SALINE INSTILLATION BENEFICIAL TECHNIQUE OR HARMFUL PROTOCOL

1. SALINE INSTILLATION BENEFICIAL TECHNIQUE OR HARMFUL PROTOCOL Christina Campbell Yuri Casasola Leslie Ireland Amanda Kramer Faculty � Jenny Barnhouse

3. In critically ill patients does the instillation of normal saline in comparison to not instilling normal saline prior to endotracheal suctioning increase negative outcomes? PICO Question

4. Reasons for Current PracticeAssumed Benefits Lubricates the suction catheter Breaks up solid secretions for removal Loosens thick airway secretions within the endotracheal tube Stimulates cough reflex

5. Identification of the Problem Negative outcomes Respiratory related infections Decreased oxygen saturation level Increased intracranial pressure/arterial blood pressure Increased anxiety/pain Cardiac dysrhythmias Dyspnea Atelectasis Increased heart rate During presentation, clarify the negative outcomes are associated with instilling normal saline prior to endotractheal suctioning. -Increased ICP and arterial blood pressure are not directly related to instilling NS, but are r/t the stimulation of the cough reflex.During presentation, clarify the negative outcomes are associated with instilling normal saline prior to endotractheal suctioning. -Increased ICP and arterial blood pressure are not directly related to instilling NS, but are r/t the stimulation of the cough reflex.

6. Identification of the Problem Other problems Lack of up to date information and research Knowledge deficit Inconsistent protocols among institutions and practitioners Compliance among healthcare professionals Compliance or resitance to change as the last bullet ptCompliance or resitance to change as the last bullet pt

7. Identification of the Problem Prevalence 74 % of hospitals follow protocols that include the use of normal saline prior to suctioning (Caruso et al., 2009) Hospital-acquired pneumonia (HAP) accounts for 15% of all nosocomial infections (Caruso et al., 2009) Pediatric critical care nurses frequently instill normal saline prior to suctioning (Rauen et al., 2008) 74% refrnce: (Caruso, 2009) HAP reference: Hospital-Acquired Pneumonia* Risk Factors, Microbiology, and Treatment (2001). By Joseph P. Lynch III, MD, FCCP retrieved from: http://www.chestjournal.org/content/119/2_suppl/373S.full Original report: Intensive Care Antimicrobial Resistance Epidemiology (ICARE) Surveillance Report, data summary from January 1996 through December 1997: a report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control 1999; 27:279�284 (http://www.chestjournal.org/content/119/2_suppl/373S.full) Pedtrc cc nurses ref: (Rauen et al 2008)74% refrnce: (Caruso, 2009) HAP reference: Hospital-Acquired Pneumonia* Risk Factors, Microbiology, and Treatment (2001). By Joseph P. Lynch III, MD, FCCP retrieved from: http://www.chestjournal.org/content/119/2_suppl/373S.full Original report: Intensive Care Antimicrobial Resistance Epidemiology (ICARE) Surveillance Report, data summary from January 1996 through December 1997: a report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control 1999; 27:279�284 (http://www.chestjournal.org/content/119/2_suppl/373S.full) Pedtrc cc nurses ref: (Rauen et al 2008)

8. Identification of the Problem Costs Possible harm to the patients Increased pain/discomfort/anxiety The mortality rate for HAP exceeds 30% HAP results in longer hospital stays leading to increased cost for institution and patient Lost hospital revenue HAP mortality rate ref (not in APA): Hospital-Acquired Pneumonia* Risk Factors, Microbiology, and Treatment (2001). By Joseph P. Lynch III, MD, FCCP retrieved from: http://www.chestjournal.org/content/119/2_suppl/373S.full Lost hospital revenue is result of ins not paying for entire amount. Will only pay for so much and anything acquired over that patient will be responsible for and hospital will have to write off- Not sure about this , the info I found online didn�t mention HAP being included in this medicare change see: http://content.nejm.org/cgi/reprint/357/16/1573.pdf However we can justify the lost hosptal revenue the same way the sample ppt does slide #5 HAP mortality rate ref (not in APA): Hospital-Acquired Pneumonia* Risk Factors, Microbiology, and Treatment (2001). By Joseph P. Lynch III, MD, FCCP retrieved from: http://www.chestjournal.org/content/119/2_suppl/373S.full Lost hospital revenue is result of ins not paying for entire amount. Will only pay for so much and anything acquired over that patient will be responsible for and hospital will have to write off- Not sure about this , the info I found online didn�t mention HAP being included in this medicare change see: http://content.nejm.org/cgi/reprint/357/16/1573.pdf However we can justify the lost hosptal revenue the same way the sample ppt does slide #5

9. Review of the Literature Effects of endotracheal suctioning (Akgul & Akyolcu, 2002) Suctioning patients with pneumonia (Young-Ra et al., 2002) Endotracheal suctioning in children (Ridling et al., 2002) Instilling saline, harmful or helpful (Halm & Krisko-Hagel, 2008) Endotracheal suctioning in adults (Thompson, 2000)

10. Literature Review Akgul & Akyolcu (2002) Experimental design of 20 adult ICU patients Increase in pH following suctioning and heart rate Alterations in O2 saturation and arterial blood gases Authors� conclude the use of saline results in undesirable outcomes and recommend using humidification as an alternative to saline

11. Literature Review Young-Ra et al. (2002) Repeated measure design study involving 16 adult patients in a neuro-trauma ICU Significant decrease in oxygen saturation lasting longer than five minutes Authors� conclude instillation of saline could have adverse effects on oxygen saturation

12. Literature Review Ridling et al. (2003) A convenience sample study performed on 24 endotracheally intubated children in a pediatric ICU Oxygen saturation decreased significantly at one and two minutes after suctioning Authors� concluded the instillation of saline had an adverse effect on oxygen saturation

13. Literature Review Halm & Krisko-Hagel (2008) Clinical evidence review of 28 studies No significant increase in sputum recovery Saline is significantly associated with decreased oxygenation Increased anxiety, pain, dyspnea, & heart rate May contribute to lower airway contamination The review concluded no discernible benefits in breaking up and removing secretions, as well as potential for adverse effects. If you feel it is pertinent, mention that article references that normal saline and secretions do not mix.If you feel it is pertinent, mention that article references that normal saline and secretions do not mix.

14. Literature Review Thompson (2000) Systematic review of 95 studies published by the Joanna Briggs Institute (11 studies were specific to saline instillation) Additional negative outcomes included: Possibly triggering cardiac arrhythmias Atelectasis Pulmonary infections Damages to the bronchial tree No definitive evidence of saline breaking up secretions The author suggests a change in practice of routinely instilling saline prior to suctioning

15. Summary of Literature No standardized practice exists for the instillation of NS prior to ET suctioning No empirical evidence exists to support the use of NS to thin out and remove secretions The use of NS prior to ET suctioning is associated with adverse patient outcomes Is this what you had in mind CC? Its basically just reiterating what follows- which is what the EMLA group did also?Is this what you had in mind CC? Its basically just reiterating what follows- which is what the EMLA group did also?

16. Recommendation We recommend discontinuing the current practice of instilling normal saline prior to endotracheal suctioning.

17. Additional Recommendations Use of ongoing humidification Maintain patient hydration Patient acuity dependent interventions: Chest physiotherapy Deep breathing, coughing, turning Q2 Give Christina and Yuri copy of clinical review: airway hygiene�Give Christina and Yuri copy of clinical review: airway hygiene�

18. Reasons for Recommendation Evidence supports that the use of normal saline prior to suctioning may lead to adverse effects. Pneumonia/ nosocomial infections Decreased oxygen saturation level Increased intracranial pressure/arterial blood pressure Increased anxiety/pain Cardiac dysrhythmias Dsypnea Atelectasis Increased heart ratePneumonia/ nosocomial infections Decreased oxygen saturation level Increased intracranial pressure/arterial blood pressure Increased anxiety/pain Cardiac dysrhythmias Dsypnea Atelectasis Increased heart rate

19. Patient Outcome Evaluations Measure oxygen saturation levels Monitor patients for pain, anxiety, and stable heart rates during suctioning Observe patient for dyspnea or other signs of distress Continual assessment for pneumonia or other respiratory related infections When giving presentation be sure to include these are evaluations post practice change of not instilling normal saline prior to ET suctioning.When giving presentation be sure to include these are evaluations post practice change of not instilling normal saline prior to ET suctioning.

20. Evaluating Practice Change Periodic staff surveys Unit meetings Evaluation cycle consisting of pre- and post-implementation audits Monitor nursing documentation

21. Suggestions for Further Study Further controlled clinical trials Multi-site locations with varied population Standardized interventions Larger sample size New studies on Use of mucolytic agents and other solutions Obtaining up to date research, including larger population, diverse patient population, more defined study parameters Study effects of hydration and humidification on the effectiveness of suctioning Parameters meaning � eliminating reasons behind other cause of negative outcomesObtaining up to date research, including larger population, diverse patient population, more defined study parameters Study effects of hydration and humidification on the effectiveness of suctioning Parameters meaning � eliminating reasons behind other cause of negative outcomes

22. New Questions Should suctioning be performed on a scheduled basis or based on patient assessment? Is there a difference in the techniques and effects of suctioning pediatric and adult patients? How well do nurses adhere to new evidence based guidelines?

23. References: Akgul, S., & Akyolcu, N. (2002, November). Effects of Normal Saline on Endotracheal Suctioning. Journal of Critical Nursing, 11(6), 826-830. Retrieved March 1, 2009, from CINAHL Plus with Full Text database. Halm, M. & Krisko-Hagel, K. (2008, September). Instilling Normal Saline With Suctioning: Beneficial Technique or Potentially Harmful Sacred Cow? American Journal of Critical Care, 17(5), 469-472. Retrieved March 1, 2009, from CINAHL Plus with Full Text database. Ridling, D., Martin, L., & Bratton, S. (2003, May). Endotracheal suctioning with or without instillation of isotonic sodium chloride solution in critically ill children. American Journal of Critical Care, 12(3), 212-219. Retrieved March 9, 2009, from CINAHL Plus with Full Text database. Thompson, L. (2000). Suctioning Adults with an Artificial Airway. The Joanna Briggs Institute for Evidence Based Nursing and Midwifery. Systematic Review No. 9. Retrieved April 1, 2009 from http://www.joannabriggs.edu.au/pubs/systematic_reviews.php Young-Ra, J., Hee-Seung, K., Jeong-Hwan, P. (2002, August). Instillation of Normal Saline before Suctioning in Patients with Pneumonia. Yonsei Medical Journal, 43(5), 607-612. Retrieved March 1, 2009, from CINAHL Plus with Full Text database. �