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Nursing Care Time Required Providing the Care to the Patients on Adult Mechanical Ventilator Admitted in ICU of BPKIHS

Mehta*1 RS, Bhattari*2 BK. B.P. Koirala Institute of Health Sciences, Nepal

Email: ramsharanmehta@hotmail.com

Abstract: Background: The primary goal of aggressive care in the ICU is to stabilize and restore patients to their prior state of health. However, an increasing number of patients are receiving terminal care in ICU settings, contrary to the original intent of an ICU. Objectives: The objective of this study was to explore the time required to perform the various nursing activities regarding care of patients on Adult Mechanical Ventilation admitted in ICU of BPKIHS. Materials and Methods: It was hospital based descriptive exploratory study conducted among the patients admitted in ICU on adult mechanical ventilation. Total 60 patients were selected during the study period of 3 months (May to June, 2010) using random sampling (lottery) method. The data was collected by the nurses involved in the direct care of those assigned selected cases. Results: It was found that the average time spent on each patient on ventilator in critical care unit in morning shift was 329 minutes; evening shift 317 minutes, night shift 356 minutes and in all the shift total time spent was 1002 minutes out of 1440 minutes. For administrative activities total time spent was 244 minutes, monitoring vital signs 92 minutes, providing personal hygiene care 104 minutes, providing respiratory care 63 minutes, providing ventilator care 1oo minutes, prevention and care of bedsore 82 minutes, management of nutrition and diet 39 minutes, dispensing drugs 48 minutes, and performing specific nursing procedures was 165 minutes. Conclusion: It can conclude that the nurses working in critical care unit spent most of the time in the care of patient on ventilator. Note: *1Ram Sharan Mehta, Associate Professor, Medical-Surgical Nursing Department, Email: ramsharanmehta@hotmail.com , *2 Prof. Dr. Bal Krishna Bhattari, HOD, Department of Anesthesiology and Critical Care Unit.

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Introduction: The incidence of death in intensive care units (ICUs) is increasing. In the United States, approximately 2.5 million people die each year, with over 60% of these deaths occurring in hospitals,1 with half of those deaths involving ICU care.2 A retrospective study reported that 1 in 5 Americans died using ICU services.3 Moreover, recent studies indicate that the majority of these ICU deaths involved withholding or withdrawing life-sustaining treatments.4 Complicating matters, the decision to withhold or withdraw life support has dramatically increased, from 51% of all ICU deaths in 1987 to 90% in 1993. 1 The primary goal of aggressive care in the ICU is to stabilize and restore patients to their prior state of health. However, an increasing number of patients are receiving terminal care in ICU settings, contrary to the original intent of an ICU.5 Anyone entering an intensive care unit can feel bombarded by the huge array of sensory stimuli. Family members in ICU are typically in a state of fear and shock. Studies have shown that caring for the families of patients who are critically ill is believed to be an essential component of the nurse's role.4 Nursing care must address not only the needs of the patient, but those of the whole family. The needs of patients in intensive care and those of their families are especially complicated by the physical and emotional demands on all concerned. Families experience severe stress and anxiety, and may feel helpless and unable to cope. Accurate assessment of their needs is one of the first steps in providing appropriate care to ICU patients and their families.3 Study conducted by Dodck6 reported, out of 205 of total 308 ventilator patients 67% achieved ventilator dependence during ICU admission and among those 83% met the set criteria. The most frequent reason for failing criteria before ventilator independence was PaO2/FiO2 ratio less than 24 KPa (49% of Cases). Study conducted by Eckerblad 5 reported Mechanical Ventilation withdrawal can amount up to 40% of total ventilator time. Study conducted by David7reported, it is effectively implemented the guidelines may decrease the morbidity, mostly and cost of ventilator associated pneumonia in mechanically ventilated patients. Objectives: The objective of this study was to explore the time required to perform the various nursing activities regarding care of patients on Adult Mechanical Ventilation admitted in ICU. Methodology: It was descriptive exploratory study, conducted among the patients on adult mechanical ventilation admitted in ICU. The data was collected by the nurses (Staff-Nurses) involved in the direct care of the patients admitted in ICU, on adult mechanical ventilation. All the 35 nurses working in ICU had filled the pre-tested questionnaire during their duty period to their selected assigned patients. Nurses were explained the purpose of the study prior to data collection and their informed verbal consent was obtained. The confidentiality of information was assured to the nurses. Nurses were requested to recall and note the time of activities during their duty hour. At the end of their duty in each shift i.e. morning, evening and night they complete the tool and handover to the shift in-charge nurse.

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Using random sampling technique (lottery method) all the 60 patients were selected during the study period of three months (May, June and July 2010). Using lottery method subjects were selected in each shift on Sunday. On each Sunday five patients were selected randomly. The selected patients were accessed in all the three shifts. If the observation was not completed in all the three shifts that patient was excluded. If the required number was not adequate on Sunday, the number of subjects was increased on next Sunday. The patients on ventilator selected for study using lottery method is used for data collection purpose. The allocated nurses were given the questionnaire and requested to complete at the end of their shift duty hour. The tools were collected from the staffs and used for analysis. The data collected was entered in Excel and analyzed using SPSS 11.5 software package. Results: Most of the patents (56.7%) were of age below 40 years, male (53.3%), belongs to villages (56.7%), illiterate (51.7%), Hindus (90%), married (81.7%), and they were from Sunsari (41.7%), Jhapa (25%), Morang (21.7%), and Saptari (11.7%). The mean duration of stay of patients on the date of data collection was 21.85, with range 1 to 79 days. Most of the patients (96.7%) were on SIMV mode and on ETT (56.7%). The major diagnosis of selected patient was Organophosphorus poisoning (48.3%), GB Syndrome (16.7%), Acute Coronary Syndrome (10%), Diabetic Keto-Acidosis (6.7%), Tetanus (6.7%) and others (11.9%). It was found that the average time spent on each patient on ventilator in critical care unit in morning shift was 329 minutes; evening shift 317 minutes, night shift 356 minutes and in all the shift total time spent was 1,002 minutes out of 1,440 minutes. For administrative activities total time spent was 244 minutes, monitoring vital signs 92 minutes, on personal hygiene care 104 minutes, providing respiratory care 63 minutes, providing ventilator care 100 minutes, prevention and care of bedsore 82 minutes, management of nutrition and diet 39 minutes, dispensing drugs 48 minutes, and performing specific nursing procedures was 165 minutes. Discussion: The average time spend by nurses on morning duty was 329 minutes (5.48 hrs), in evening duty317 minutes ( 5.28 hrs) and in night duty 356 minutes( 6 hrs) and in total 1,002 minutes ( 16.7 hrs) out of 1,040 minutes (24 hrs). Many studies in the literature have indicated that nurses feel frustrated with their limited role in decisions regarding the withdrawal or withholding of life support. 1, Study conducted by Angus8, describes comparable struggles with medication administration. The nurses express feeling of abandonment and powerlessness, which may further contribute to difficulties in the delivery of terminal care. It is hard to deal with death9. Study conducted by Eckerblad5, reported mechanical ventilation withdrawal can amount up to 40% of total ventilator time. This picture clearly illustrate that patient on mechanical ventilator is time consuming nursing job. Nursing care must address not only the needs of the patients, but those of the whole families are especially complicated by the physical and emotional demands on all concerned10. An exploratory study can be conducted to calculate the total time required to care of patient on mechanical ventilator, taking adequate sample in multicentre.

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Conclusion: It can conclude that the nurses working in critical care unit spent most of the time in the care of patient on ventilator and limited time was available for counselling and other professional activities. References:

1. Azoulay E, Pochard F, Chevret S, Lemaire F, Mokhtari M, Fall JL et al. Meeting the needs of intensive care unit patient families: A multicenter study. Am. J. Respir. Crit. Care Med. 2002; 163: 135-139.

2. Espinosa L, Young A, Symes L, Haile B, Wsalsh T. ICU Nurses’ experiences in providing terminal care. Critical Care Nurse. 2010; 33(3): 273-28.

3. Molter NC. Needs of relatives of critically ill patients. Heart Lung. 1979; 8: 332-339. 4. Hardcer J. Meeting the needs of families of patients in intensive care units. Nurse Times. 2003;

99(27): 26-7. 5. Eckerblad J, Kriksson H, Kamer J, Edeu GU. Nursess’ Conceptions of facilitative strategies of

weaning patients from mechanical ventilation: a phenomenographic study. Intensive Critical Care Nurses. 2009; 25(5): 225-32.

6. Dodck P, Keenan S, Cook D et al. Evidence-based clinical practices guidelines for the prevention of ventilator associated pneumonia. British Journal of Anesthesia. 2004; 92(6): 793-9.

7. David J, Monique W, Brenda C, Candice B, Debra G, Otto M. Measuring the ability to meet family needs in an intensive care unit: Clinical Investigations. Critical Care Medicine. 1998; 26(2): 266-271.

8. Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004; 32(3):638–643.

9. Akinci SB, Salman N, Kanba KM, Ayparu. Assessement of family satisfaction in the ICU. European Journal of Anesthesiology. 2004; 21:7-8.

10. Colleen EG, Diane IC, Jeanne SE, Patricia AF. Heather JV. Visiting presence of patients in the ICU and in a complex, care medical unit. Americal Journal of critical. 2004; 13: 194 – 198.

Table 13

Average Total Time Spend by Nurses while Providing Care to the Patient on Ventilator n=60

SN Activities

Time Spend for Each Shift Duty Total Time Spend

(T=1440)

Morning (8am-2pm)

(T=420)

Evening (2pm-9pm)

(T=420)

Night (9pm-7am)

(T=600)

1 Administrative activities 87 64 93 244 2 Monitoring vital Signs 31 29 32 92 3 Personal hygiene care 34 32 38 104 4 Respiratory care 21 19 23 63 5 Providing ventilator care 35 30 35 100 6 Prevention and care of Bed Sore 28 26 28 82 7 Providing nutrition and Diet 11 13 15 39 8 Treatment/Drug Dispensing 15 12 21 48

9 Performing specific nursing procedures

47 62 56 165

10 Miscellaneous activities 20 30 15 65 Total Time Spent 329 317 356 1002