Does frequency of providing stoma and inner canula care reduce rate of VAP in patients with tracheostomy?

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Bottom line:  There is not much evidence available on this question.  Most recommendations are based on expert opinion.

A search of PubMed and CINAHL for these concepts–tracheotomy, tracheostomy, ventilator-associated pneumonia, prevention–revealed one study specifically examining care of the tracheostomy–Eid RC, et al.  Successful prevention of tracheostomy associated pneumonia in step-down units.  Am J Infect Control. 2011 Aug;39(6):500-5.
Intervention included “drainage and discarding of condensate” in the tubing at least 3 times per day, but this doesn’t say specifically changing the tubing. No additional studies identified that evaluated care of the tracheostomy in preventing outcome of ventilator-associated pneumonia.

Tracheostomy: Stoma Care.  Joanna Briggs Institute, 2010.  States that evidence regarding tracheostomy is mostly based on expert opinion as there are not many published studies on tracheostomy procedures and care.

Tracheostomy:  Management – references guideline that relies on expert opinion in recommendation

Cites this small study that found no statistically significant difference in bacterial colonization between patients who had canula changed daily versus those who did not.

Burns SM, et al.  Are frequent inner cannula changes necessary?: A pilot study.  Heart Lung. 1998 Jan-Feb;27(1):58-62.
This small study that found no statistically significant difference in bacterial colonization between patients who had canula changed daily versus those who did not.  Did not look at ventilator-associated pneumonia rates.

What is the standard for changing the inner cannula and performing stoma care in tracheostomies?

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Bottom line:  Recommendations for tracheostomy management include daily cleaning of inner canula, as well as routine cleaning and daily inspections of the stoma.

Summary: 
Tracheostomy: Stoma Care.  Joanna Briggs Institute.  April 26, 2010.
Recommends routine cleaning and daily inspection for signs of infection in the skin around the stoma.  Evidence based on expert opinion.

AACN Procedure Manual, 6th ed, 2011 .
Recommends monitoring skin around stoma for breakdown.

Tracheostomy:  Management.  Joanna Briggs Institute, October 29, 2010.  
Recommends cleaning inner cannula daily based on guidelines that did not cite studies, but relied on expert opinion.

Patient and family centered care

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Bottom Line: PFCC is an original approach to p health care that is mutually beneficial among patients, families, and providers.

Digioia Care Experience-based Methodologies: Performance Improvement Roadmap to Value-driven Health Care. Clinical orthopaedics and related yr:2011

Vermoch Benchmarking patient- and family-centered care: highlights from a study of practices in 26 academic medical centers. Journal of healthcare risk management yr:2010 vol:30 iss:2 pg:4 -10

Guion Development of a concept map to convey understanding of patient and family-centered care. Journal for healthcare quality yr:2010 vol:32 iss:6 pg:27 -32

Brown Patient and family-centred care for pediatric patients in the emergency department. CJEM. Canadian journal of emergency medical care yr:2008 vol:10 iss:1 pg:38 -43

O’Malley Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department. Annals of emergency medicine yr:2006 vol:48 iss:5 pg:643 -645

Boise The family’s role in person-centered care: practice considerations. Journal of psychosocial nursing and mental health services yr:2004 vol:42 iss:5 pg:12 -20

Hooper Patient-family centered care: are we there yet? Journal of perianesthesia nursing yr:2008 vol:23 iss:6 pg:440 -442

In-patient handoffs

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Goldsmith D, Boomhower M, Lancaster DR, Antonelli M, Kenyon MA, Benoit A, Chang F, Dykes PC.Development of a nursing handoff tool: a web-based application to enhance patient safety.
AMIA Annu Symp Proc. 2010 Nov 13;2010:256-60. PMID: 21346980

Benham-Hutchins MM, Effken JA.Multi-professional patterns and methods of communication during patient handoffs. Int J Med Inform. 2010 Apr;79(4):252-67. Epub 2010 Jan 15.
PMID: 20079686

Apker J, Mallak LA, Applegate EB 3rd, Gibson SC, Ham JJ, Johnson NA, Street RL Jr.Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Ann Emerg Med. 2010 Feb;55(2):161-70. Epub 2009 Nov 27. PMID: 19944486

Benham-Hutchins M, Effken JA.Multi-professional communication during a patient handoff. AMIA Annu Symp Proc. 2008 Nov 6:875.
PMID: 18998774

Andrews C, Millar S.Don’t fumble the handoff. Inpatient providers, specialists, and the primary care physician: a medical care delivery system with benefits and complex risks.
J Med Assoc Ga. 2007;96(3):23-4. No abstract available. PMID: 18203554

Apker J, Mallak LA, Gibson SC.Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007 Oct;14(10):884-94.
PMID: 17898250

From JBI+

Nursing: Clinical Handover

A systematic review of nurses’ inter-shift handoff reports in acute care hospitals

For inpatients, are skin assessments by two staff more accurate than skin assessments by one staff at detecting pressure ulcers and areas at risk for ulcers?

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Bottom line:  Practice guidelines recommend having a standard procedure for assessing and documenting skin and training staff who will be making these assessments, but there is no specific recommendation for the number of staff required for assessing skin.

DynaMed topic on Pressure Ulcers includes a section on prevention screening and section on guidelines.  Prevention/screening section summarizes data on utility of specific structured assessment tools.  There are numerous guidelines, which should document studies on which they base recommendations.  One guideline is Institute for Clinical Systems Improvement (ICSI) guideline on pressure ulcer treatment.

JBI+COnNECT – There are several evidence summaries, but the most relevant ones (ex: Pressure Ulcers: Prevention and Management, seem to  reference the guidelines included in DynaMed, such as that of the Royal College of Nursing.

No identifed recommendations or mention of using more than one person to assess a patient’s skin in the DynaMed or JBI+ information.

PubMed search:  pressure ulcers AND (rater* OR observer*) AND (accura* OR reliabl*)

Yielded studies such as these two that compare use of one nurse to two nurses in documenting skin and found no difference in the number of pressure ulcers documented.  These studies did not address assessment for risk.

Kottner J, Tannen A, Dassen T. Hospital pressure ulcer prevalence rates and number of raters. J Clin Nurs. 2009 Jun;18(11):1550-6.

Kottner J, Tannen A, Halfens R, Dassen T. Does the number of raters influence the pressure ulcer prevalence rate? Appl Nurs Res. 2009 Feb;22(1):68-72.