Steven Talbert

Oropharyngeal Secretion Volume in Intubated Patients: The Importance of Oral Suctioning

BACKGROUND Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown. OBJECTIVES To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning. METHODS A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals. RESULTS Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05). CONCLUSIONS A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.

Too much information: research issues associated with large databases.

Purpose: The purpose of this article was to discuss common issues associated with large databases and present possible solutions to improve the quality and usefulness of large database research. Background: The volume of electronic healthcare-related data is growing exponentially. Some of these data are being stored in registries and administrative databases. These data repositories are increasingly common and can serve as sources of nurse-driven research and quality improvement activities. Although these large databases have a wealth of useful information, they have limitations that may bias results. These include missing data and cases, data accuracy and validity, and the statistical effect of large samples. Description: Researchers using large databases to address quality, safety, clinical, or systems issues have a variety of available techniques to deal with data issues. Proper data cleaning activities such as screening, visualization, and outlier/inlier identification are essential for addressing inaccurate values within large data sets. Common methods for addressing missing data include case analyses and various imputation techniques. Statistical approaches such as risk reductions and effect size are also useful when working with large sample sizes. Conclusion/Implications: Registries and administrative databases provide healthcare researchers with increasing opportunities to address a wide variety of important practice and patient care questions. Healthcare researchers are encouraged to explore large data sets as they look for ways to improve patient safety and quality care, develop evidence-based practice guidelines, and fulfill regulatory and accreditation requirements.

Comparison of Respiratory Infections before and after Percutaneous Tracheostomy

BACKGROUND A tracheostomy is often performed when patients cannot be weaned from mechanical ventilation. Respiratory infections (ventilator-associated pneumonia and infection of the lower respiratory tract) complicate the course of hospitalization in patients receiving mechanical ventilation. OBJECTIVES To evaluate respiratory infections before and after a percutaneous tracheostomy and to describe their outcomes. METHODS Medical records of adults who had percutaneous tracheostomy during a 1-year period at a tertiary care hospital in the southeastern United States were reviewed retrospectively. RESULTS Data for 322 patients were analyzed. Patients were predominately male (63.0%) and white (57.8%), with a mean age of 57.4 years. Ventilator-associated pneumonia or infection of the lower respiratory tract was identified in 90 patients (28.0%); the majority of infections were lower respiratory infections. Of all infections, 52% occurred before the tracheostomy, and 48% occurred after the procedure. Respiratory infections were associated with longer stays and higher costs, which were significantly higher in patients in whom the infection developed after the tracheostomy. Gram-negative organisms were responsible for the majority of infections. CONCLUSIONS Data related to respiratory infections that occurred before a tracheostomy were similar to data related to infections that occurred after a tracheostomy. Most infections were classified as lower respiratory infection rather than pneumonia. Infection, before or after a tracheostomy, resulted in longer stays and higher costs for care. Interventions focused on preventing infection before and after tracheostomy are warranted.

1090: ASSOCIATION BETWEEN INTUBATION FACTORS AND ASPIRATION AND VENTILATOR-ASSOCIATED CONDITIONS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Tracheal intubation in the prehospital setting has been associated with increased risk for aspiration. Using data from an ongoing study, we evaluated tracheal intubation variables with tracheal amylase and pepsin A (aspiration), and ventilatorassociated conditions (VAC). We hypothesized that subjects intubated in the field would have higher rates of aspiration and VAC. Methods: Intubation and outcome data were collected as part of an ongoing oral suction trial in ventilated patients. Consent was obtained from patient or legal proxy. Adult subjects (≥ 18) were enrolled within 24 hours of oral intubation and followed while intubated, up to 14 days. Documented aspiration at time of intubation was an exclusion criterion. Primary outcomes were tracheal amylase and VAC (NHSN criteria). Tracheal pepsin A values were evaluated in a subset (n = 84). Data were analyzed with chi-square and ANOVA. Results: Data were analyzed from 368 subjects: mean age 57.7 (18.7) years, 56.3% male, 74.2% white, 19.3% Hispanic. Intubation location was study site (82.9%), other hospital (9.2%), and field (7.9%). The ICU (39.9%) and ED (37.8%) were the most common units. Most patients (76.4%) had a positive amylase (≥ 396 IU/L) while 16.7% had a positive pepsin A (≥ 6 ng/mL) in baseline tracheal specimens. Although not significant, mean tracheal amylase values were highest for field intubations (p = 0.64); mean tracheal pepsin A values were highest for intubations at the study site (p = .61) and if more than one intubation attempt was required (p = .11). VAC rates were significantly higher for other hospital intubations (29.4%) compared with study site (11.1%) or field (10.3%, p = 0.009), and for those that required more than one intubation attempt (21.3% vs 10.0%; p = .02). Conclusions: Aspiration of oral and gastric contents was observed despite exclusion criterion of no documented aspiration during intubation. Strategies to ensure successful intubation with one attempt are needed. Further research is warranted to identify clinical implications of aspiration and explore VAC rates associated with interhospital transfers. (1R01NR014508)

Collecting Nursing Research Data 24 Hours a Day: Challenges, Lessons, and Recommendations

Background Research on many routine nursing interventions requires data collection around the clock each day (24/7). Strategies for implementing and coordinating a study 24/7 are not discussed in the literature, and best practices are needed. Objective To identify strategies incorporated into implementing a nursing intervention trial 24/7, including key lessons learned. Methods Strategies to facilitate implementation of a clinical trial of a nursing intervention with patients undergoing mechanical ventilation are shared. Challenges and changes for future studies also are discussed. Results Adequate planning, including a detailed operations manual, guides study implementation. Staffing is the most challenging and costly part of a study but is essential to a study’s success. Other important strategies include communication among the study personnel and with collaborators and direct care staff. An electronic method of recording study‐related data also is essential. Conclusions A nursing clinical trial that requires interventions on a 24/7 basis can be done with thorough planning, staffing, and continuous quality improvement activities.

140: THE IMPACT OF A HOME HEALTH, NURSE-DRIVEN TELEMONITORING PROGRAM ON HEART FAILURE READMISSIONS

as the ICU. Additional data was collected by sending the AAPA survey to all members of the SCCM PA section. SCCM data was combined with AAPA data with national certification numbers used to avoid duplication. CCM PA data was compared with the AAPA non-CCM PA population. Results: 302 surveys were returned. The CCM PA population was younger (36.4 vs 40.8 years p<0.0001), less experienced (8.5 vs 10.7 years p<0.0001) and had less years in specialty (6.4 vs 7.7 years p=0.0005). 90% of work in one of four environments (University Hospital, Community Hospital, Single Specialty Physician Group, and MultiSpecialty Physician Group) in contrast to 65% of the general PA population (p<0.0001). Medical ICUs (21%), Surgical ICUs (20%) and CV Surgery ICUs (14%) are the most common environment. Neonatal ICUs (11%), Neuro ICUs (10%), Pediatric ICUs (9%), and Cardiac ICUs (9%) employ most of the rest. Multi-specialty ICUs (7%) and Trauma (1%) employ the least PAs. Cardiac and Cardiovascular PAs have the most general (10.9 and 9.4 years) and specialty experience (10.5 and 9.0) years. Multi-specialty, Surgical, and Medical ICU PAs have 8.7, 7.8, and 7.1 years of general experience with 5.8, 5.1, and 4.6 years of specialty experience. Neuro and Trauma ICU PAs have the least experience with 6.7 and 4.7 years of general experience with 4.6 and 4.7 years of specialty experience. Conclusions:Overall, the average CCM PA is younger; less experienced, has less specialty experience and is more likely to work for a hospital or physician specialty group than the general PA population. Most PAs work in Surgical, Medical or CV Surgery ICUs. Given the increasing use of CCM PAs understanding the ICU PA demographics will help organizations plan for additional PAs.

Characteristics, resource utilization, and nursing care of patients who undergo percutaneous tracheostomy.

Purpose/Objectives: Many critically ill patients require a tracheostomy when unable to be weaned from prolonged ventilator support. This study describes the characteristics, resource use, and outcomes of patients who required a tracheostomy for failure to wean from mechanical ventilation. Design: A retrospective descriptive study was conducted to analyze data from the electronic medical record and hospital databases. Setting: The setting was a tertiary care hospital with a level I trauma center. Sample: Data from 363 adult subjects who underwent a tracheostomy after prolonged mechanical ventilation during a 1-year period were obtained from hospital databases. All underwent a percutaneous procedure. The majority of subjects were male (62.8%) and white (57.9%), with a median age of 59 years. Nearly half had a trauma diagnosis. Results: Hospital mortality was low (9.9%). Ventilator days, hospital/intensive care unit lengths of stay, and costs were high. Only 7.1% of subjects were discharged directly from the hospital to home. Others were transferred to long-term acute-care hospitals, rehabilitation centers, skilled nursing facilities, and other hospitals. Those who had the tracheostomy done prior to 10 days of ventilation had better outcomes; however, these same subjects had lower acuity scores. Within 1 day of the procedure, ventilator settings were reduced, airway pressures were lower, and level of sedation was improved. Conclusions: Patients requiring a tracheostomy incur high resource use, and although the majority was transferred to other facilities, the number discharged directly home was low. Improved physiological parameters and reduced ventilator settings following the tracheostomy facilitated weaning from ventilation. Implications: Knowledge of characteristics and outcomes may assist in identifying interventions to reduce the need for tracheostomy or improve outcomes. In particular, the clinical nurse specialist can lead team initiatives to promote weaning prior rather than performing a tracheostomy as well as interventions postprocedure to improve discharge outcomes.