From Medscape for Nurses-Evidence Based Best Practice for ETT suctioning-Is Saline Instillation Beneficial?

Instilling Normal Saline With Suctioning: Beneficial Technique or Potentially Harmful Sacred Cow?
Margo A. Halm, RN, PhD, CNS-BC; Kathryn Krisko-Hagel, RN, MS
Am J Crit Care. 2008;17(5):469-472. ©2008 American Association of Critical-Care Nurses
Posted 10/28/2008
Introduction
Normal saline has been widely used in acute care settings during endotracheal and tracheostomy suctioning. Clinicians have held fast to this long-standing tradition because many were taught that normal saline breaks up secretions and aids in their removal (especially tenacious secretions). In this clinical review, we summarize current evidence related to the following questions: Does instilling normal saline during suctioning increase sputum yield? Alternatively, is this practice associated with adverse physiological and psychological effects?
Methods
The strategy included searching MEDLINE, CINAHL, Cochrane Library, Joanna Briggs Institute, and TRIP databases. Key words included endotracheal tubes, tracheostomies, normal saline, and suctioning. All types of evidence (nonexperimental, experimental, qualitative studies, systematic reviews) were included.
Results
In the past 2 decades, investigators have studied the physiological and psychological effects of instillation of normal saline. The impact of the instillation of normal saline on sputum recovery, oxygenation, subjective symptoms, hemodynamic alterations, and infection was measured in 14 studies[1-14] ( Table 1 ). The effects of 2, 5, or 8 mL of normal saline on physiological parameters were evaluated at intervals of 5, 10, or 20 minutes (5 minutes most common). In one study,[1] researchers investigated saline deposition by radioactively labeling normal saline with technetium (Tc 99m). Samples included anesthetized dogs and ventilator-dependent patients in general, coronary artery bypass, and neurological intensive care units (ICUs). In addition to these studies, a guideline on tracheal suctioning from the Joanna Briggs Institute[15] was retrieved.
Sputum Recovery
Sputum volume or weight was measured in 5 of the 14 studies (36%).[1-5] In 3 of those 5 studies (60%), instillation of normal saline was associated with significantly increased retrieval of sputum. The difference in sputum volume ranged from 1 to 2 g, which may not be of clinical importance. In another study,[1] radioactively labeled normal saline was noted near the bottom of the endotracheal tube within 1 minute of instillation (rather than mixing with secretions) and was then rapidly absorbed by the cardiopulmonary system, providing evidence that normal saline and secretions do not mix. Furthermore, suctioning recovered a mean of only 18.7% of normal saline instilled in humans.
Oxygenation
Arterial blood gas analysis and measurement of the nadir and recovery time of oxygen saturation (most common) or mixed venous oxygen saturation were done in 9 studies.[2-6,9,10,12,13] Results of 56% of those studies indicated that use of normal saline was significantly associated with decreased oxygenation and desaturation that worsened over time after suctioning. Oxygen saturation was a mean of 1% to 2% lower when normal saline was used, which may, in itself, not be clinically significant. However, instillation of normal saline may impair gas exchange as evidenced by continued desaturation. More clinically impressive was the 6-point decrease in mixed venous oxygen saturation that Kinloch[10] observed in patients suctioned 5 minutes after instillation of normal saline (compared with controls), as well as the doubled recovery time. These findings demonstrate the detrimental effect of normal saline on global tissue oxygenation.
Subjective Symptoms: Pain, Anxiety, Dyspnea
Subjective symptoms associated with instillation of normal saline were explored in 2 studies[8,11] (14%). Exploring the experience of being suctioned with normal saline, Jablonski[8] found that patients reported anxiety and dread, as well as increased pain. In another study, O'Neal et al[11] found increased perceived dyspnea in patients over age 60 that persisted for up to 10 minutes after suctioning, a finding that may be related to decreased pulmonary compliance with aging.
Hemodynamic Alterations
Hemodynamic effects were investigated in 3 studies[4,9,12] (21%). Results of 1 of these studies[12] demonstrated that instillation of normal saline was associated with increased heart rate 4 to 5 minutes after suctioning; however, no effect on blood pressure or respiratory rate was uncovered. The increased stimulation of the cough reflex associated with instillation of normal saline may have other detrimental effects such as increased mean arterial pressure and intracranial pressure.[15,16]
Infection
Risk of infection was investigated in 2 studies[7,14] (14%). Hagler and Traver[7] found sputum cultures that showed growth due to the dislodgment of bacterial colonies. Up to 5 times as many colonies were dislodged when normal saline was instilled, and therefore this practice may contribute significantly to lower airway contamination. Newer evidence from a randomized controlled trial[14] suggests that instillation of normal saline was associated with a lower incidence of ventilator-associated pneumonia. It is unclear from this abstract whether the researchers controlled for other standard interventions to avoid ventilator-associated pneumonia[17,18] such as oral care, aspiration of subglottic secretions, maintenance of cuff pressure on the endotracheal tube, and prophylaxis of peptic ulcer and deep vein thrombosis.
Recommendation Based on Current Evidence
Collectively, these studies provide class III evidence of the adverse physiological and psychological effects of instillation of normal saline, and therefore, support against the routine use of normal saline with suctioning ( Table 2 ). Normal saline and mucus do not mix. Therefore, normal saline does not thin or mobilize secretions. Rather, ensuring adequate hydration is one way that nurses can facilitate removal of secretions.[15] The best-known interventions for managing thick tenacious secretions and preventing mucus plugs in ventilator-dependent patients are hydration, adequate humidification, use of mucolytic agents, and effective mobilization.[16,18,20]
In addition to an unappreciable increase in sputum recovery, use of normal saline adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies, thus contributing to lower airway contamination. Because no solid scientifically based benefits for routine use of normal saline have been shown, it is highly recommended that this potentially harmful "sacred cow" be abandoned. Instead, treatment considerations should center on ways to prevent the development of thick, tenacious secretions.[20]
Normal saline may be indicated in situations where it is necessary to elicit a cough,[4,18] and normal saline may be useful for clearing the catheter after suctioning to avoid reintroducing pathogens into the airway.[21] Good handwashing is essential to reduce infection when opening vials of normal saline because increased contamination has been documented when clinicians use the nongloved thumb to twist off the tops of the vials.[22]
Despite these recommendations, organizational change toward best suctioning practices has not been without challenges. In a recent multisite study,[23] three large institutions had policies that recommended instilling normal saline for thick secretions. Suctioning surveys[23,24] also indicate that 2 to 3 times as many respiratory therapists as nurses report continued use of normal saline—a finding that is not so surprising given that the American Association of Respiratory Care's guideline[25] has not been updated since 1993 (and still advocates that normal saline dilutes and mobilizes secretions).
Promisingly, among nursing circles, researchers in the United Kingdom reported that although observed suctioning practices were contrary to many research recommendations,[26] educational interventions proved effective in advancing the knowledge and translation of research-based suctioning practices of critical care nurses at the bedside.[27]
Others have also reported high compliance rates of nurses with evidence-based guidelines recommending avoidance of normal saline.[28] More studies are needed to document clinical adherence to evidence-based guidelines so that we can better connect processes of care to outcomes for patients.
I think that this evidence says it all-No Saline!
And here is the link to the same article-
http://www.medscape.com/viewarticle/581620_print

Put down the Penlights...Neuro assessment

Changes in behavior are an early sign of neurologic compromise. They are not specific to neurologic problems, but they are the earliest sign. Keep a close eye on the patient for problems with speech and disorientation. Many nurses start assessing neurologic function by pulling out their penlight and checking the patient's pupils. This is very stimulating to your neuro patient and is not the first thing that is going to change.
If your patient is alert and oriented and you are just trying to follow him to see if his condition is getting worse, the first thing that is going to change is his behavior. Behavior is the highest level of function. Next the patient will have changes in his speech. Speech patterns and the ability to perform speech tell you a lot about the patient's neurologic function. The third level down is content of arousability, and this is what is referred to as orientation. The forth level is arousability; whether or not the patient wakes up when you walk into the room or you have to touch him or use painful stimuli.
If your patient is already unconscious, assess systolic blood pressure as an indicator of intracranial pressure. As intracranial pressure increases, systolic pressure has to increase to continue to perfuse the brain. The very lowest level is the pupil reflex. Changes in pupils do not tell you much about the patient. Pupil changes indicate a very small lesion that is right around the optic nerve or a huge lesion that is causing the patient to herniate.
Check speech first. Put down the penlights and watch the patient's behavior changes.
Best wishes,David W. Woodruff, MSN, RN-BC, MSN, CENPresident, Ed4Nurses, Inc.www.Ed4Nurses.com www.dwoodruff.com

Amiodarone Competency~for RN's

You will find in your mailboxes a competency for Amiodarone. Each RN needs to complete the quiz and return it to Vilma's mailbox outside the office and while you are there sign the Attendance sheet posted there also.

AHRQ and You-Evidences Based Best Practice Handbook

You just never know what you find when you are surfing the net these days but looky here a handbook developed from the Agency for Healthcare Research and Quality (AHRQ) for nurses. Sponsored by the Robert Wood Johnson Foundation this is a virtual (literally) treasure trove of best practices from the nurses point of view and get this...researched as best practice, not just "we do it that way because that's how we've always done it" reasons.
The whole book can be accessed.....online-for nothing...and you can order your own 3 volume printed copy or a researchable CD if you so desire but why when this will be updated periodically long before the printed stuff will be available.
http://www.ahrq.gov/qual/nurseshdbk/

What a treat! Take a gander around and see what we can improve on to keep our patients safe and well cared for.
We all have a hand in this so read on McDuff !! :)
Tracy

And they're on their own..

The new grads are off orientation and are all doing great! We also had a great weekend at ACLS and I am happy to say that Susan Plissey passed without a speck of nerves showing, Dorothy, Jen and I all recerted successfully! The next ACLS is December 6 & 7th. The new grads will be scheduled in the spring class(es) once the dates are annouced I'll post them here.

Just a couple pix of the preceptors with their new grads...

Thank you to all who attended the Wound Update on Monday...if you missed it there will be more at the skills fair in November also. Remember the new regs go into effect today so let the providers know if there are any pressure ulcers on your patients so they can assess and document them in their admission work. Thanks for all you do!

Wound Ulcer Staging and New Standards for Documentation

Inservice: September 29th every hour on the hour in McCain B with Rhonda Bossie starting at 0700 with the last session starting at 1600.

Starting October 1st there are new CMS regulations going into effect that will effect repayment on pressure ulcers. The long and short of it is that if a pressure ulcer isn't documented at the time of admission(POA or present on admission) by the provider then payment is not guarenteed for the care of this ulcer. i.e. patient A admitted for CHF and hyperglycemia and has a stage II on his heel if the provider doesn't dictate or document the ulcers presence and the ulcer either gets worse or we have treatments to administer (lets say we order an air mattress) it's won't be reimbursed. Since the doctors rely heavily on our documentation of these items we need to be certain that the admitting provider is aware of these as soon as possible to ensure that money is captured by the coding folks.

Here are the staging guidelines for review.
http://www.medicaledu.com/staging.htm
and let's be measuring these-I have found that the white boards are helpful for communication of this info to any provider (wound/ostomy nurses and MD's) in addition to our coworkers who may be changing the dressing after you.

Rhonda will be reviewing some of this info also but I figured having it here too will be a resource for you also. And some of you have already attended the webcast Sept. 9th. This is not a repeat presentation of that information.

So attend 1 session with Rhonda on September 29th for one hour-it starts at 0700 until 1600-if you aren't working that day you have some latitude on what time to attend and if you are working we will do our best to get everyone there.

Questions and answers from the presentation on Sept. 9th; some of you had some questions and I poised them to Rhonda after the session I attended.

Q: Are the physicians being trained?
A: Yes at their monthly meeting this month.

Q: Can we take pcitures of wounds to document them?
A: Not at this time-there is alot of training necessary for this plus obtaining cameras for each unit and only specific formats are allowed by Medical records.

Q: Are we going to purchase/use the "Solutions Algorithms" mentioned in the webinar?
A: Not at this time but the Wound/Ostomy Affiliate group is working on standardized treatments based on the products we use in the system.

One more time: September 29th for an hour in McCain B-Wound updates with Rhonda Bossie.

Thanks for reading!
Tracy

Back to School time SCIP= Core Measures=Best Practice

Surgical Care Improvement Project

What does this mean to us-well similar to Core Measures it provices a framework of researched best practices only instead of it being about CHF, MI & Pneumonia that Cores target these are specific to pre and post op measures. You may have already seen them as part of ordersets-for instance stopping antibiotics after a set number of doses or VTE prophylaxis/screening. Other measures that we already know work were researched by other studies and are integrated into these measures-like all the respiratory measures SCU staff will recognize as IHI's 100,000 Lives Campaign; having the HOB greater than 30 degrees in a ventilated patient and Ulcer prophylaxis.

Here is a link to all the SCIP measures-and yes this is monitored and reported since repayment is contingent on our completing each step in the process and like Cores if we miss one measure of the whole surgical experience then we fail the whole"bundle" and payment.

http://www.premierinc.com/quality-safety/tools-services/safety/topics/scip/downloads/scip-final-10-14-05.pdf

One to note especially for SCU staff who commonly recover the big bowel cases is #7 :

Colorectal surgery patients with immediate postoperative normothermia.

Translation: We have 15 minutes to get the postop colorectal patients temp above 96.8.

Everyone is working hard to meet this measure, but even I was unaware that this was the standard until we had already missed one-unfortunate since it decreases the patients risk negative post op issues but now that I know I want you all to be in to make our patients safer also.

Please take the time to read through the measures on the link so that you ar aware also and we can all help each other to facilitate giving our patients the best care research says works.

Thanks for all you are doing for Cores-I went to the meeting on Friday and we were 100% for all measures in June-YEAH US!!!

So if we can do it for Cores-SCIP should be a breeze with a little attention to detail.