Denise Miyuki Kusahara

Oral Care Interventions and Oropharyngeal Colonization in Children Receiving Mechanical Ventilation

BACKGROUND Recent progress in identification of oral microorganisms has shown that the oropharynx can be a site of origin for dissemination of pathogenic organisms to distant body sites, such as the lungs. OBJECTIVE To compare the oropharyngeal microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit of children receiving mechanical ventilation who had pharmacological or nonpharmacological oral care. METHODS A randomized and controlled study was performed in a pediatric intensive unit in São Paulo, Brazil. A total of 56 children were randomly assigned to an experimental group (n=27, 48%) that received oral care with use of 0.12% chlorhexidine digluconate or a control group (n=29, 52%) that received oral care without an antiseptic. Oropharyngeal secretions were collected and cultured on days 0, 2, and 4, and at discharge. RESULTS The 2 groups had similar demographic characteristics, preexisting underlying diseases, and pharmacological, nutritional, and ventilatory support. Gram-negative bacteria were the predominant pathogens: Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enter-obacter species. The 2 groups did not differ significantly in the colonization of normal (P= .72) or pathogenic (P= .62) flora, in the duration of mechanical ventilation (P= .67), or in length of stay in the intensive care (P= .22). CONCLUSION Use of chlorhexidine combined with nonpharmacological oral care did not decrease the colonization profile, duration of mechanical ventilation, or length of stay in critically ill children receiving mechanical ventilation.

Oral care with 0.12% chlorhexidine for the prevention of ventilator-associated pneumonia in critically ill children: Randomised, controlled and double blind trial §

PURPOSE To test the effectiveness of oral care with 0.12% chlorhexidine in decreasing ventilator-associated pneumonia in critically ill children. METHODS Prospective, randomised, controlled, double-blind clinical trial performed in a paediatric critical care unit at a university hospital. The sample was composed of 96 mechanically ventilated children randomly allocated to the chlorhexidine group (oral care with a toothbrush and an antiseptic gel twice a day) and the placebo group (oral care with a toothbrush and a non-antiseptic gel twice a day). Microbiological analyses of oropharyngeal and tracheal secretions were performed 24, 48 and 96h after intubation. Chi-square, Fischers exact and Mann-Whitney tests were applied (p≤0.05). RESULTS The chlorhexidine group was composed of 46 children, and the placebo group consisted of 50 children. Within these samples, 15 (32.6%) children in the chlorhexidine group and 16 (32.0%) children in the placebo group developed ventilator-associated pneumonia (p=0.949). Children in the chlorhexidine group without potentially pathogenic microflora in their oropharynx 24h after mechanical ventilation presented with fewer episodes of ventilator-associated pneumonia (p=0.019). The pathogen colonization profile of children with ventilator-associated pneumonia in the chlorhexidine group included Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa. In the placebo group, Pseudomonas aeruginosa and Escherichia coli were the predominant potentially pathogenic microorganisms. The intervention did not influence paediatric intensive care unit mortality (p=0.425), hospital length of stay (p=0.143), or paediatric intensive care unit length of stay (p=0.177). CONCLUSIONS The use of 0.12% chlorhexidine did not significantly modify the VAP incidence in a sample of mechanically ventilated children.

Evaluation of the patient safety culture in neonatal intensive care

Estudo quantitativo, tipo survey, cujo objetivo foi analisar a cultura de seguranca do paciente na perspectiva das equipes de enfermagem e medica de hospitais publicos de Florianopolis. Participaram 141 profissionais, com dados coletados entre fevereiro/abril de 2013, com o instrumento Hospital Survey on Patient Safety Culture, avaliando 12 dimensoes da cultura de seguranca, apos aprovacao pelo Comite de Etica. Realizou-se analise descritiva, classificando as dimensoes em areas de forca ou criticas. Apesar de nao ocorrer uma area de forca especifica, destacaram-se como areas melhor avaliadas as expectativas e acoes do supervisor/chefia para promocao da seguranca do paciente e o aprendizado organizacional - melhoria continua. Como area critica, identificou-se: Resposta nao punitiva ao erro e Apoio da gestao hospitalar para seguranca do paciente. A cultura de seguranca nas Unidades de Terapia Intensiva Neonatal apresenta areas potenciais para se tornarem fortes. Conclui-se que sao necessarias mudancas culturais, principalmente na abordagem dos erros.This quantitative, survey type study aimed to analyze the patient safety culture of the nursing and medical teams of public hospitals of Florianopolis. A total of 141 professionals participated, with data collected between February/April 2013, after approval by the Ethics Committee. The Hospital Survey on Patient Safety Culture was used and the 12 dimensions of the culture were evaluated. Descriptive analysis was performed, classifying the dimensions into areas of strength or critical areas. Despite not verifying a specific area of strength, the dimensions with the best evaluation were Supervisor/manager expectations and actions promoting safety and Organizational learning - continuous improvement. The dimensions with the highest percentage of negative responses, identified as critical were: Non-punitive response to errors and Management support for safety. The safety culture in the Neonatal Intensive Care Units presented aspects that could potentially become areas of strength. Cultural changes are necessary, especially in addressing errors. DESCRIPTORS: Patient safety. Organizational culture. Neonatal nursing. Intensive Care Units Neonatal.

Oral care and oropharyngeal and tracheal colonization by Gram-negative pathogens in children

BACKGROUND Critical care nursing interventions to oral care can reduce microorganisms in the oropharynx available for translocation. OBJECTIVES To analyse the effect of 0·12% chlorhexidine digluconate on the colonization of oropharyngeal and tracheal secretions by Gram-negative pathogens in mechanically ventilated children. METHODS A randomized, controlled and double-blinded study was performed in the paediatric intensive care unit (PICU) of a Brazilian university hospital. Exclusion criteria included child age under 28 days, pneumonia diagnosis at admission, use of tracheostomy, PICU length of stay (LOS) less than 48 h and refusal to participate. Children were randomly allocated to the interventional group (IG), in which oral care with chlorhexidine was administered, or to the placebo group (PG), which received oral care without antiseptic use. The data were analysed through Pearsons χ(2) test, Fishers exact and ANOVA tests with significance levels set at 0·05. RESULTS The demographic characteristics of the 74 children were not statistically different between groups. No between-group differences in oropharyx colonization by Gram-negative pathogens were identified (p = 0·316). Pathogens were isolated in the tracheal secretions of two (10·0%) children in the PG and four (19·0%) children in the IG (p = 0·355). CONCLUSION The use of chlorhexidine did not significantly influence the colonization of oropharyngeal and tracheal secretions by Gram-negative pathogens of the studied sample. RELEVANCE TO CLINICAL PRACTICE This study demonstrated no influence of a specific antiseptic agent on colonization profile of mechanically ventilated children in PICU. Further research in this field is necessary to promote evidence-based nursing practice on oral care of critically ill children.

Risk Factors for Ventilator-Associated Pneumonia in Infants and Children: a Cross-sectional Cohort Study

BACKGROUND The epidemiology of ventilator-associated pneumonia is well described for adults, but little information is available on risk factors for this disease in children. OBJECTIVE To identify predisposing factors for ventilator-associated pneumonia in children. METHODS A cross-sectional prospective cohort study of 96 patients in a 9-bed pediatric intensive care unit was performed. Variables examined were demographic characteristics, inpatient care, medications, nutrition, invasive procedures, and characteristics of mechanical ventilation. Data were analyzed by using Pearson χ(2) analysis, Fisher exact and Mann-Whitney tests, odds ratios, and forward stepwise logistic regression. RESULTS Occurrence of ventilator-associated pneumonia correlated positively with use of nasoenteral tubes (odds ratio, 5.278; P < .001), intermittent administration of nutritional formula (odds ratio, 6.632; P = .005), emergency reintubation (odds ratio, 2.700; P = .02), use of vasoactive drugs (odds ratio, 5.108; P = .009), duration of mechanical ventilation (P < .001), and length of stay in the pediatric intensive care unit (P < .001) and in the hospital (P = .01). CONCLUSION Use of vasoactive drugs, presence of a nasoenteral tube, and duration of stay in the pediatric intensive care unit were independent risk factors for ventilator-associated pneumonia.

Compreensão de alunos de cursos de graduação em enfermagem e medicina sobre segurança do paciente

OBJECTIVE: Prospective and exploratory study in order to identify the comprehension of nursing and medicine students from a public university of Sao Paulo regarding human error and patient safety. METHODS: It was investigated variables concerning the characterization of students and, attitudinal and conceptual aspects. The study sample was composed by 109 students who answered an electronic form. RESULTS: The majority of students answered that they had had formal learning about patient safety and show actions that demonstrate uncertainty about what would be correct in some practices. CONCLUSION: It is concluded that students understand and associate some aspects from formal learning about the theme patient safety to experiences during curricular stages.

Segurança na administração de medicamentos em Pediatria

Errors or failures can occur at any phase of the medication administration system. In children, factors such as age, weight, height, medical conditions, metabolic characteristics and lack of targeted drugs for the pediatric population contribute to the occurrence of medication errors. This article presents relevant aspects of the medication system and recommendations for reducing medication errors in children, with a foundation in the principles of patient safety in pediatrics.Errors or failures can occur at any phase of the medication administration system. In children, factors such as age, weight, height, medical conditions, metabolic characteristics and lack of targeted drugs for the pediatric population contribute to the occurrence of medication errors. This article presents relevant aspects of the medication system and recommendations for reducing medication errors in children, with a foundation in the principles of patient safety in pediatrics.

Vivências de enfermeiros intensivistas na avaliação e intervenção para alívio da dor na criança

Descriptive survey of daily practical experiences of pediatric nurses in the assessment and intervention to pain relief in children, during nursing care provided in pediatric and neonatal intensive care units, and the influence of the infrastructure of care and system organization. The sample was made up of 109 nurses. The principal results indicated that the majority of the nurses considered the academic training obtained as insufficient to support this aspect of nursing care; that they had not received local training in evaluating pain or in relief interventions; that the staff ratio is inadequate and as well as the availability of institutional guidelines to improve the quality of analgesia. It was concluded that nurses value the assessment and intervention to pain relief in children, but describe aspects which compromise practice: lack of collaborative practice, lack of processes definition, lack of formal and continuing education and lack of infrastructure. These aspects compromise the implementation of scientific evidences capable of improving practical aspects of analgesia in children under intensive care.

The experiences of intensive care nurses in the assessment and intervention of pain relief in children

Descriptive survey of daily practical experiences of pediatric nurses in the assessment and intervention to pain relief in children, during nursing care provided in pediatric and neonatal intensive care units, and the influence of the infrastructure of care and system organization. The sample was made up of 109 nurses. The principal results indicated that the majority of the nurses considered the academic training obtained as insufficient to support this aspect of nursing care; that they had not received local training in evaluating pain or in relief interventions; that the staff ratio is inadequate and as well as the availability of institutional guidelines to improve the quality of analgesia. It was concluded that nurses value the assessment and intervention to pain relief in children, but describe aspects which compromise practice: lack of collaborative practice, lack of processes definition, lack of formal and continuing education and lack of infrastructure. These aspects compromise the implementation of scientific evidences capable of improving practical aspects of analgesia in children under intensive care.

Variabilidade na determinação do ponto externo de referência para a medida de pressão venosa central em crianças

OBJECTIVE: To investigate the variability in the establishment of the midaxillary line as external reference point (ERP), by different healthcare workers, for the measurement of central venous pressure in children. METHODS: Descriptive and correlational study carried out in a pediatric intensive care unit of a teaching hospital. During the establishment of the midaxillary line as ERP for central venous pressure measurement, five assessments of the same patient made by healthcare workers and one assessment made by a trained evaluator were compared. A total of 120 assessments were made by 44 healthcare workers, 17 (38.6%) by nursing assistants and nursing technicians, 16 (36.3%) by nurses and 11 (25.1%) by physicians, in addition to 24 assessments made by the trained evaluator. The data were analyzed using the chi-square test, ANOVA, Kruskal-Wallis test and t test. Significance level was set at 5%. RESULTS: There was statistically significant difference between the assessments made by healthcare workers and by the evaluator (p < 0.001). The comparison of the variability in the measurements made by healthcare workers revealed that 56 (46.7%) measurements were lower than those obtained by the evaluator (range from -0.5 to -9), 44 (36.7%) were higher (range from 0.5 to 4) and 20 (16.7%) were concordant (zero variability). Professional category did not influence the concordance between the ERPs (p = 0.899), or the variability observed (p = 0.778). However, the measurements made by professionals with greater experience in intensive care tended to differ more sharply from those made by the evaluators. CONCLUSION: The indications of the midaxillary line as ERP presented variations when measured by the healthcare team and by the trained evaluator. Variability was not influenced by professional category, and the more experienced the healthcare worker, the greater the probability for underestimation of the ERP. According to the results of this study, such situations may compromise both the efficacy of this procedure and patient safety.