key: cord-0988785-t9hdmpmx authors: Yujiao, Yan; Juan, Ding; Xurui, Zeng; Hong, Wang title: Establishment of evidence‐based nursing review indicators for airway management of adult critical patients and analysis of obstacle factors date: 2021-05-18 journal: Nurs Open DOI: 10.1002/nop2.898 sha: 6283281ab76833b19683ad59a0f77513872ceb5b doc_id: 988785 cord_uid: t9hdmpmx AIM: To select and obtain relevant evidence of airway management in adult critically ill patients at home and abroad, formulate clinical quality review indicators based on evidence and analyse obstacle factors and promoting factors in evidence‐based nursing practice. To promote standardized ICU airway management evidence‐based nursing practice to provide the basis. DESIGN: Obstacle factor analysis. METHODS: Take the Joanna Briggs Institute (JBI) evidence‐based healthcare model as theoretical guidance, establish evidence‐based problems, form a team, systematically search for literature, evaluate quality and summarize evidence, establish quality review indicators and review methods, analyse obstacles and facilitating factors based on the review results and formulate corresponding action strategies. RESULTS: According to the 29 best evidences, 21 review indicators were developed. Through the results of clinical quality review, the main barriers to evidence‐based practice were analysed: the lack of nurse training and relevant evidence‐based knowledge at the practitioner level, the lack of standardized procedures for airway management and the lack of materials at the system level. CONCLUSION: There is a big gap between airway management evidence and clinical practice in critically ill adult patients. Therefore, improvement measures should be formulated for obstacle factors to promote effective transformation of evidence into clinical practice. Artificial airway refers to the insertion of a catheter into the trachea through the mouth/nasal or tracheotomy site to establish a smooth gas exchange channel, improve the ventilation function and thereby correct the body's hypoxic state (Juan, 2017) . In clinical practice, poor quality of airway management in critically ill patients can lead to related complications, aggravate the patient's original condition, prolong the patient's hospital stay and increase treatment costs (Branson et al., 2014 , Umobong et al., 2018 and Feng D et al., 2019 . Prospective studies have been carried out on the main complications of airway management in intensive care units abroad, and relevant data show that the quality of airway management is not optimistic (Cook et al., 2011) . According to domestic literature, among patients with artificial airway in the intensive care unit, the incidence of lung infection is 40.6% (Yi et al., 2018) , and the cuff pressure compliance rate is an average of 35.29% (Lirong et al., 2018) . Only 9.2% of ICU nurses met the requirements of the guidelines for sputum suction operations (Zheng et al., 2015) and cannot follow the clinical practice guidelines well (Guihua et al., 2015) , and there is still a big gap between theory and clinical practice. Evidence-based health care is the core guiding ideology of medical and healthcare decision-making in the 21st century, and it plays an important role in promoting the scientificity, effectiveness and standardization of global medical and healthcare decision-making. However, most of the current clinical practice and decision-making are not based on the best evidence, but based on clinical experience, which makes the clinical practice have greater variability, resulting in poor results, inefficiency and unfair use of resources. Evidence-based nursing is beneficial to improve the clinical outcome of patients and improve the quality of clinical nursing. The evidence-based practice of scholars such as Chan et al. (2017) and Yan et al. (2019) (Pearson et al., 2005) and updated in 2016 (Jordan et al., 2016) . In 2009, it was introduced into China by Professor Hu Yan of JBI Evidence-based Nursing Cooperation Center of Fudan University, providing theoretical guidance and methods for domestic nursing staff to carry out evidence-based nursing practice (Yan & Yufang, 2018 ). The JBI model of evidence-based health care aims to promote global health through evidence-based practices and is its core value. The key steps of evidence-based practice in this mode mainly include Evidence Generation, Evidence Synthesis, Evidence Transfer and Evidence Implementation. This paper aims to analyse the obstacle factors and promoting factors before the application of evidence and formulate action strategies to facilitate the subsequent clinical practice of evidence. The clinical problems of airway management were structured to establish evidence-based problems based on the PIPOST model of JBI Evidence-Based Healthcare Centers (Dang et al., 2017; Jordan et al., 2016; Pearson et al., 2005; Yan & Yufang, 2018) . P (Population) is the evidence application population: critically ill patients with tracheal intubation or tracheotomy; I (Intervention) refers to intervention measures: intervention measures for airway management; P (Professional) is a professional who applies evidence, including medical staff and clinical managers; O (Outcome) is the outcome: the incidence of lung infection in adult critically ill patients with tracheal intubation or tracheotomy, sputum characteristics, NICU length of stay, nurses' compliance with evidence-based airway management in critically ill adults, nurse-related knowledge awareness rate; S (Setting) is the place of evidence implementation: neurosurgical intensive care unit (NICU) in a level III first-class hospital in Hubei Province, China; T (Type of evidence) is the type of evidence: highest clinical decision-making, guidelines, systematic reviews, expert consensus and summary of evidence. Set up an evidence-based nursing team consisting of 12 members. Among them, there is a director of the nursing department and a project tutor, who is responsible for the development of the evidence-based practice programme. One deputy head nurse who • Most of the clinical practices and decisions of airway management in adult patients with critical illness are not based on the best evidence, but on clinical experience, and there is still a big gap between theory and practice. Based on the guidance of evidence-based theory model, this paper analysed the barriers and promoting factors of evidence-based airway management practice for adult critically ill patients, promoted the development of evidence-based best practices and continuously improved clinical quality. participated in the workshop training of evidence transformation project of Fudan University Evidence-based Nursing Center was responsible for overall planning, coordination and guidance. The deputy chief physician of the department and the head nurse were responsible for guiding and supervising the implementation of the programme. Three graduate students who have participated in the training of Fudan University Evidence-based Nursing Center are responsible for evidence retrieval, quality evaluation and evidence collection. There are 4 specialist nurses in the department, who are responsible for collating and analysing expert opinions, clinical data collection and baseline investigation together with graduate students. This study is based on JBI evidence-based healthcare model, struc- (Yan & Yufang, 2018) to determine whether the evidence was included. The review indicators should involve structure, process and result levels (Zhou Yingfeng,et al., 2016) . (1) Structural indicators: refer to the various resources needed in the process of practice; (2) Process indicators: refer to the action strategies adopted in the process of practice; (3) Result indicators: refer to the effects produced in the process of practice; at the same time, it should be credible, effective and measurable characteristics to comprehensively evaluate the status of clinical practice and best practice implementation (Cao et al., 2019; Donabedian A, 1988; Zhou Yingfeng,et al., 2016) . Based on the best evidence and after two rounds of discussion, the members of this research group and the expert group determined the localized quality review indicators and developed the review methods to conduct a baseline review of the clinical practice of airway F I G U R E 1 Literature search flow chart management for adult critically ill patients in the Department of Neurosurgery, a level III first-class hospital in Jingzhou City, Hubei Province, China. This study was summarized from seven aspects: airway assessment, airway attraction timing, cuff pressure management, airway humidification, airway attraction, tracheotomy care, oral care and so on, and a total of 44 best evidences were included . A total of 15 stakeholders in the hospital were invited to conduct evidence FAME evaluation (Yan & Yufang, 2018) , including feasibility, appropriateness, clinical significance and effectiveness. The evidences were selected and 29 evidences were obtained, as shown in Table 1 . Based on the 29 best evidences finally determined, the evidencebased nursing team developed 21 quality review indicators, including 3 structural indicators, 15 process indicators and 3 outcome indicators, and determined the object of review and data collection methods for each review indicator, as shown in Table 2 . The baseline was to understand the current situation of airway management in the department. A total of 36 adult patients with artificial airway were included in the review, who were admitted to the neurosurgical intensive care unit of a level III first-class hospital in Jingzhou, Hubei Province, China, from 30 June to 31 July 2020. At the same time, 25 NICU nurses were included as the subjects of baseline review. Questionnaire survey was conducted to evaluate the degree of mastery and implementation of airway management knowledge in critically ill patients. The baseline results show that, except for the compliance of review indicator 10 which is 71.43%, the compliance of most of the review indicators is low. The compliance of specific clinical review indicators is shown in Table 3 ; the qualified rate of airway management knowledge test was 44%, and the scores of knowledge, behaviour and attitude questionnaires are shown in Table 4 . Based on the results of the baseline review, the evidence-based team members performed obstacle factor analysis for the review indicators with low compliance and conducted obstacle analysis seminars, listed the review indicators with compliance <60%, analysed obstacle factors through the method of brainstorming and formulated corresponding action strategies, as shown in Table 5 . According to the FAME principle of evidence (Yan & Yufang, 2018) in the early stage of the study, 29 pieces of evidence were finally included from 7 aspects of airway management in adult critically ill patients. The content to be considered in the FAME principle mainly includes the following four aspects: (1) In standardized evidence-based practice, the formulation of review indicators should be based on the best available evidence in various fields, and the review indicators should be effective, relevant, feasible and flexible and closely fit with various stakeholders (Pearson & Jordan, 2007; Yingfeng et al., 2016) . Scientific, normative and implementable review indicators will provide clear goals for researchers and practitioners and provide the basis for further development of action reform strategies (Boult et al., 2007) . The review indicators should correspond to the summary of evidence, and the review indicators should be decomposed or combined according to the corresponding evidence, so as to make the quality review operable (Pearson & Jordan, 2007; Yan & Yufang, 2018) . For example, evidence 1: the skin condition of the patient's tracheostomy should be TA B L E 1 Best evidence for airway management in critically ill adults after FAME evaluation B 0.9% sodium chloride solution and 0.45% sodium chloride solution had the same effect on airway humidification, but 0.45% sodium chloride solution is significantly lower in the incidence of complications and the proportion of viable sputum after humidification, indicating that hypotonic solution had better humidification effect than isotonic solution, and was more suitable for airway humidification with a low incidence of adverse events A 11. Heat-and-moisture exchangers are most commonly used, in which gas flow is directed through a heated water bath prior to inspiration. (Fong, 2017) A 12. There was no difference between HMES and HHS in terms of artificial airway obstruction, pneumonia, and mortality. the choice of humidifiers should be made according to the clinical context, trying to avoid possible complications and reaching the appropriate performance at lower costs (Vargas et al., 2017) A 13. The use of either active heated humidifier or passive heat moisture exchange (HME), saline nebulizers, sprays humidification in all patients with a tracheostomy tube is recommended (Fong, 2017) B 14. The airway humidification effect of continuous oxygen atomization inhalation is better than that of micro pump or infusion pump continuous dripping of humidifying liquid (Xinyang et al., 2015) A 15. Continuous airway humidification can reduce the incidence of pneumonia in patients with tracheotomy (Jing & Hongying, 2016) B 16. The effect of 0.45% sodium chloride solution on airway humidification is similar to that of water for sterilization injection, but the incidence of adverse events is low, and 0.45% sodium chloride solution is more suitable for airway humidification (Ruijuan, Wenjie, et al., 2015; Ruijuan, Zhe, et al., 2015) A (Continues) assessed daily and cleaned according to the patient's needs. If there is redness, tenderness, swelling, inflammation, smell, high skin temperature, yellow-green discharge around the stoma or fever in the patient, the clinician should be notified. If there are obvious signs of infection, it is recommended to provide culture/sensitive specimens (see Table 1 ). It can be broken down into 3 review indicators: 1. the patient's tracheostomy wound appears red, tender, swollen, inflammation, smell, high skin temperature and yellow-green secretions can be seen around the stoma, or the patient has fever. 2. The patient showed signs of infection at the tracheotomy, and the nurse followed the doctor's order to do a bacterial culture. 3. When the patient has decreased blood oxygen saturation, decreased blood oxygen partial pressure and frequent coughing and respiratory distress, the nurse should perform airway suction for the patient (see Table 2 ). For example, evidence 2: when blood oxygen saturation or partial pressure of oxygen decreases and evidence 3: when frequent coughing or respiratory distress syndrome occurs (see Table 1 ), these two pieces of evidence can be combined into one review indicator, that is review indicator 3: when the patient has decreased blood oxygen saturation, decreased blood oxygen partial pressure, and frequent coughing and respiratory distress, the nurse should perform airway suction for the patient. And so on, the team It can be seen from the review results that, except for the review indicator 17, which is 71.43%, the compliance of the other 20 review TA B L E 2 Evidence-based nursing review indicators and review methods for airway management in adult critically ill patients Indicator 1. The patient's tracheostomy wound appears red, tender, swollen, inflammation, smell, high skin temperature and yellow-green secretions can be seen around the stoma, or the patient has fever, the nurse immediately informs the doctor. Indicator 2. The patient has signs of infection at the tracheostomy site, follow the doctor's advice for bacterial culture. Indicator 3. When the patient has decreased blood oxygen saturation, decreased blood oxygen partial pressure and frequent coughing and respiratory distress, the nurse should perform airway suction for the patient. Indicator 4. When the patient needs to suck sputum, the airway pressure is low and the spontaneous breathing is weak, increase the cuff pressure appropriately. Indicator 5. After the patient turns over, wipes the bath, and transfers, the nurse should re-measure the cuff pressure. Practice is the only way to implement evidence-based reform, as a process of systematic reform, the application of evidence is bound to encounter obstacles at different levels. Therefore, it is necessary to evaluate the obstacles in the application of evidence and then formulate targeted action strategies. It can be seen from the system level that the department lacks the airway management process specification and medical equipment, and the air- will be implemented in the next step in practice, complete the clinical application of the best evidence and ultimately achieve the goal of improving the clinical outcome of critically ill patients and improving the quality of clinical care. Ethical approval or individual consent was not applicable. The [DATA TYPE] data used to support the findings of this study are available from the corresponding author upon request. The authors thank the evidence-based nursing team, critical care management experts, hospital and NICU medical staff who participated in this study. No conflict of interest. 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