Tracheal Tubes in Intensive Care: Implementation Plan

Summary

Tracheal suctioning is now a common procedure for many patients with artificial airways. The process, however, presents risks and may cause deterioration in patients if not used effectively. Current literature suggests that suctioning procedure can be improved through evidence-based practices. An implementation plan, therefore, relies on the best available literature to improve the adoption and application of suctioning to improve patient outcomes.

Background and Literature Review

Tracheal suctioning involves mechanical aspiration to enhance permeability of the artificial airway for patients who are unable to perform pulmonary secretions without interventions due to physical impairment or being unconscious (Pedersen, Rosendahl-Nielsen, Hjermind, & Egerod, 2009; Ania, Martínez, Eseberri, Margall, & Asiain, 2004). For intubated patients, therefore, tracheal suctioning is essential for reducing potential atelectasis and consolidation that may cause blockage and pneumonia.

Current literature has shown that suction procedure could be risky for patients notwithstanding competence of nurses. Pedersen et al. (2009) noted that risks were related to “bleeding, infection, atelectasis, hypoxemia, cardiovascular instability, elevated intracranial pressure and lesions to the tracheal mucosa” (p. 21).

Does literature identify barriers and/or suggest how these might be overcome (e.g. frameworks and models?

At the same time, studies have demonstrated significant evidence of good clinical practices and trials concerning various approaches to the suctioning procedure (Pedersen et al., 2009; Morris, Whitmer, & McIntosh, 2013). In this context, there are widely evaluated, accepted and published recommendations from available studies that depict best practices (Chau et al., 2007). Such studies offer clinical experiments that aim to improve patient care outcomes (Zhu, Das, Brereton, Roberson, & Shah, 2012), but with elements of limitations which require further evaluation. Best practices require health care workers to observe the procedure; in particular, according to Pedersen et al. (2009) the parameters to be monitored are “the timing of suctioning, catheter size, vacuum pressure, insertion depth, duration of suction and hyper-oxygenation” (p. 21). In addition, there is always a room for improving best practices and evidence-based outcomes when providing care to patients, who require tracheal suctioning.

Aims of the Implementation

What improvement or outcomes are expected?

It is expected that the implementation plan will encourage the use of evidence-based practices when caring for patients who require tracheal suctioning; provide intensive care nurses with best practices to guide their activities when caring for intubated patients; and account for critical factors that may influence the implementation of recommendations on tracheal suctioning.

How will these outcomes be evaluated?

Health care workers who implement the plan will collect data for analysis with the aim of evaluating these outcomes. It is imperative to compare outcomes with the hospital-specific standards or against previous practices observed before the implementation of the plan.

Identification of Stakeholders, Champions and Targets

It is intended that this implementation plan will be useful for all intensive care health care workers who are responsible for tracheal suctioning of patients. The primary stakeholders in this case are the patients, both adults and children; and thus, the approach of this implementation plan is patient-centred. Generally, the implementation plan targets users who are assumed to have deep knowledge in respiratory conditions, anatomy, physiology and the need for patient intubation. In this regard, health care workers, such as advanced practice nurses, physicians and their assistants, nurses and respiratory care practitioners remain at the forefront. Therefore, they are primary target groups for this implementation plan.

These key stakeholders have specific duties when providing care for patients who require a tracheal suctioning event. For instance, health care workers will participate during anaesthesiology processes, critical care, administration of internal, emergency and pulmonary medicine, control of infectious diseases, surgery and in paediatrics care.

Identification of Barriers

Studies have identified several barriers to implementation of evidence-based practices that aim to enhance quality of care and patient outcomes. For instance, one study found that the primary barrier was resistance from nursing leadership (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Hospital culture and politics may also have negative impact on the implementation of the tracheal suctioning plan.

Nurses, physicians and other health care workers, especially experienced nurses, may resist implementation of the plan because they were not trained on such practices during their courses. Thus, they are the part of hospital culture and politics that resist implementation of evidence-based practices.

One must recognise that such health care workers also strive to improve patient quality of care and outcomes, but a lack of education, training, resources, support and access to relevant information has hampered their efforts.

Implementation of evidence-based plan may require resources to support various activities, such as patient preparation, shallow suctioning technique, sterile technique during open suctioning, lung recruitment manoeuvres and monitoring the duration of suction event and breathing.

A lack of training and education could also affect the implementation plan.

The researcher will ensure that health care workers received the necessary education and training on tracheal suctioning before the implementation process. Moreover, there would be adequate resources to support all the necessary stages during the suctioning event.

Significance of the Project

Today, tracheal suctioning has become a common procedure for several medical conditions in both children and adults (Garner, Shoemaker-Moyle, & Franzese, 2007). Health care providers must comprehend implementation processes of evidence-based practices in order to offer safe and competent care. This will ensure that they can provide optimal postoperative and long-term care for intubated patients. An implementation plan, therefore, would ensure that health care providers understand their hospital policies and procedures involved in caring for such patients.

Overall, the implementation plan would ensure that nurses understand critical outcomes expected in best practices for intubated patients. These include improvements in breath sounds, low rates of peak inspiratory pressure (PIP) accompanied with diminishing PIP-plateau pressure, low airway resistance or high rate of dynamic compliance, elimination of pulmonary secretion and enhanced arterial blood gas values (ABGs).

Method of Knowledge Transfer: Planned Staging of Implementation Activities

There are chances that implementation of the tracheal suctioning could meet resistance from nurse managers and nurse leaders. This is a critical problem because the implementation plan requires support from managers to succeed. In this context, the researcher will educate and train people who are likely to resist the implementation of evidence-based practices for improving health outcomes in patients. It is imperative to recognise that nurses who trained earlier did not learn about evidence-based practices and implementation (Wallis, 2012). Hence, it is necessary to demonstrate the relevance of research findings to such people.

How will barriers be addressed?

Various stakeholders will be engaged in different phases of implementation related to their roles in the tracheal suctioning. These stakeholders, however, require a behavioural change, which is tough. Wallis (2012) observed that it was vital to create “a context and support system under which EBP efforts could be sustained” (p. 12). Specifically, training and workshop programmes are likely to create sustainable change and encourage health care workers to support evidence-based practices in tracheal suctioning.

The researcher would encourage the use of nurse mentors to work with other health care workers and encourage them to learn new skills and implement them in practice.

Overall, nurses would require continuing education programmes to support the implementation of evidence-based practices as they learn new skills.

Proposed Evaluation

Data will be collected for evaluation before and after the implementation of the programme. The researcher will analyse data and identify any statistically significant changes due to the implementation of the tracheal suctioning. The outcome will be used to improve tracheal suctioning practices regularly.

Ethical or Resource Implications

Tracheal suctioning is a required procedure for patients with artificial airways (Pedersen et al., 2009). There are, however, many contraindications associated with its usage. A patient faces risks of developing serious reactions or of deterioration of their clinical condition due to tracheal suctioning. In addition, patients have a right to request the procedure themselves. (Atman, 2009).

A decision to withhold from tracheal suctioning for patients who require it could be lethal to their health. In some instances, physicians could refuse to give tracheal suctioning to avoid adverse outcomes, but this could be unethical practice when patients request for it.

Another limitation that could raise ethical issues is a lack of strong evidence to support the recommendations made for adopting tracheal suctioning evidence-based outcomes.

The researcher will select the “best current evidence” by relying on the available current guidelines and literature to overcome the challenge of strong evidence that supports tracheal suctioning outcomes. This would also ensure that physicians recommend tracheal suctioning for patients who require it rather than opting not to perform the procedure because of the potential adverse outcomes. While many interpretations of the research findings could be based on the authors’ experience and research outcomes, there are certain limitations of the findings, which require further studies that can provide additional reliable evidence.

The researcher believes that the “best current evidence” used in this implementation plan is reliable and could be used for making informed decisions on the usage of tracheal suctioning. The literature review used for developing the recommendations aims to present the best practices that can improve tracheal suctioning and, therefore, a step towards safe interventions. Given the need for hospital-specific practices, the researcher encourages nurses to collect data for updating their guidelines on tracheal practices regularly.

The researcher also urges health care workers to implement the proposed recommendations once they have accounted for the needs of specific patients. This approach is necessary due to various conditions and possible reactions of different patients.

Budget

(Is the schedule completed?) – This is a budget schedule and it is completed with related activities and costs.

Item Participants Training period Estimated costs per head Total costs
Data collection and analysis before implementation 5 4 days $ 200 $ 4,000
Training and education 100 5 days $ 250 $25,000
Implementation 100 6 months $100,000 $ 600,000
Data collection and analysis in evaluation phase 5 4 days $ 200 $ 4,000
Training materials $3,000
Miscellaneous costs $ 4,000
Total $ 640,000

Justification

Chau et al. (2007) concluded that, “Implementing best practice guideline education could help nurses deliver safer care for patients requiring tracheal suctioning in an intensive care setting” (p. 354). Implementation of the recommended best practices in tracheal suctioning would result in cost benefit to the organization and to the patient in terms of improved health care and outcomes. Adoption of best practices in tracheal suctioning would ensure that patients have major outcomes related to improved breath sounds, namely: (1) low rates of peak inspiratory pressure (PIP) accompanied with diminishing PIP-plateau pressure; (2) low airway resistance or high rate of dynamic compliance; and (3) elimination of pulmonary secretion and enhanced arterial blood gas values (ABGs). In addition, the costs of health care would be lower for patients when certain complications and risks are eliminated through tracheal suctioning.

On the other hand, hospitals will save costs and improve the quality of health care outcomes for their patients. Health care workers will also gain new skills required in evidence-based practices.

Time line

Note that the time line for the project is six months with evaluation outcomes done in December as the last item.

Time -2014 July August September October November December
Programmes Initial data collection and analysis Implementation of the recommendations on tracheal suctioning – activities involved:
Patient preparation
  • Catheter selection
  • Pre-oxygenation when preparing for suctioning event
  • Evaluating negative pressure of the unit
  • Setting suction pressure
  • Learning suctioning technique for specific patient categories
  • Suctioning
  • Pulse oximetry
Implementation
  • Shallow suctioning technique
  • Sterile technique during open suctioning
Implementation
  • Lung recruitment manoeuvres
Implementation
  • Monitoring duration and breath of suctioning events
Programme evaluation, data collection, analysis and result comparison with previous findings

Conclusion

Current studies have recognised that tracheal suctioning procedure has become a critical practice in health care provision to patients with artificial airways (Morris et al., 2013). Effective implementation of optimal nursing practice on tracheal suctioning however requires intensive research on clinical standards. Guidelines used in the clinical practices rely on some of the best studies and findings available in a given area. The implementation plan accounts for all needs of the patient and resources required to ensure that the implemented practices improve the patient outcomes. One, however, should recognise that there are barriers that can affect effective implementation of the plan. Thus, it is necessary to account for such challenges and potential limitations, including ethical issues that may arise during programme implementation. Nurse managers and nurse leaders should support the process to ensure its success.

It is imperative for an implementation plan to have a long-term evaluation and sustainability strategy. Such an approach could eliminate certain barriers related to resistance to change and enhance behaviour change. The implementation plan should be patient-centred, as well as account for all other stakeholders; it should also improve decision-making, provide a wide range of alternatives, address barriers, required resources, expected outcomes and ensure that patients receive care of high quality (Damschroder et al., 2009).

References

Ania, G., Martínez, M., Eseberri, S., Margall, C., A., & Asiain, M. (2004). Assessment of practice competence and scientific knowledge of ICU nurses in the tracheal suctioning. Enferm Intensiva, 15(3), 101-11.

Atman, G. (2009). Fundamental and advanced nursing skills. Mason, OH: Cengage Learning.

Chau, J.,Thompson, D. R., Chan, D., Chung, L., Au, W., Tam, S.,… Chow, V. (2007). An evaluation of the implementation of a best practice guideline on tracheal suctioning in intensive care units. International Journal of Evidence Based Healthcare, 5, 354-359.

Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1), 50.

Garner, J. M., Shoemaker-Moyle, M., & Franzese, C. B. (2007). Adult outpatient tracheostomy care: practices and perspectives. Otolaryngology—Head & Neck Surgery, 136(2), 301–306.

Melnyk, B., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The State of Evidence-Based Practice in US Nurses: Critical Implications for Nurse Leaders and Educators. Journal of Nursing Administration, 42(9), 410–417. Web.

Morris, L., Whitmer, A., & McIntosh, E. (2013). Tracheostomy Care and Complications in the Intensive Care Unit. Critical Care Nurse, 33(5), 18-30. Web.

Pedersen, C. M., Rosendahl-Nielsen, M., Hjermind, J., & Egerod, I. (2009). Endotracheal Suctioning of the Adult Intubated Patient — What Is the Evidence? Intensive Crit Care Nursing, 25, 21-30.

Wallis, L. (2012). Barriers to Implementing Evidence-Based Practice Remain High for U.S. Nurses. American Journal of Nursing, 112(12), 15. Web.

Zhu, H., Das, P., Brereton, J., Roberson, D., & Shah, R. K. (2012). Surveillance and management practices in tracheotomy patients. Laryngoscope, 122, 46–50.