Improving health outcomes by preventing intensive care related infection in Malaysia Intensive Care Unit (INVEST study)

Abstract

Ventilator-associated pneumonia (VAP), catheter-related blood stream infection (CRBSI) and pressure ulcers (PU) are well recognized complications in intensive care units (ICUs). Many of these are preventable but can also complicate patient recovery, prolong length of stay, increase costs, morbidity and mortality. In Malaysia, the majority of studies investigating VAP and CRBSI in Malaysia have focussed on identifying risk factors, diagnostic criteria and treatment of ICU-related complications. Further, in spite of the burden of PU there are limited studies undertaken in Malaysia and few of these have been nurse-led. Importantly, to date there has been limited investigation of the efficacy and effectiveness of quality improvement initiatives and the contextual issues impacting on clinical practice improvement in Malaysia.In spite of the increasing emphasis on quality assurance in Malaysian ICUs there has been a limited focus on nurse-specific interventions and the majority of projects have been initiated by physicians. This study has evaluated the utility of a nurse-led action research project to drive clinical practice improvement in the ICU and is significant in demonstrating the capacity of nurses to critique and control their practice. The project conducted for this thesis was called the Improving health outcomes by preveNting intensiVe care related infEction in Malaysia intenSive care uniT - INVEST study. The INVEST Study as reported in this thesis has been undertaken using an action research approach to improve the uptake of evidence-based strategies to prevent infection in the ICU in the Malaysian cultural context.The aims of this thesis were to identify best practices, evaluate the current nursing practice in prevention of VAP, CRBSI and PU in ICU patients in a single Malaysian ICU, and evaluate the impact of the evidence-based interventions to improve patient outcomes. The specific and research objectives of this study were to:1. Identify best practice interventions for preventing VAP, CRBSI and PU in the ICU. 2. Document the current rates of VAP, CRBSI and PU in an ICU in Malaysia. 3. Implement an action research intervention to collaboratively develop and implement strategies for improvement 4. Assess the impact of the intervention on clinical outcomes, staff dynamics, work place culture and sustainability of practice change An action research approach was used in this study to involve and empower nurses and drive practice change. A literature review identified that many action research studies conducted in the ICU were mainly most focused on process measures and not outcomes. In this study the data were collected in three phases following the action research cycles which comprised of a period of planning, acting, observation, reflecting and re-planningIn Phase I of the thesis current best practice interventions for the prevention of VAP, CRBSI and PU in ICU are described. A literature search was conducted to identify evidence-based practices (EBP) that were recommended by bodies to improve the prevention of VAP, CRBSI and PU. A core set of nursing activities was identified in preventing the complications of VAP, CRBSI and PU. These were hand washing, hygiene care, positioning of patient, elevation of the head of bed and providing adequate nutrition.Pre- intervention data collection consisted of an environmental scan, including interview with the key stakeholders, patient profiling and a nurse survey. Twenty-one cases of ICU complications were identified in 18 of the 91 patients (19.8%) admitted in December 2009. Of the patients, three developed two complications - PU and VAP (two patients) or CRBSI (one patient). The findings indicated that this ICU had a high case load due to the high ICU bed demand. Patients needing ICU care were being nursed in general wards due to the unavailability of ICU beds.Nurses reported a good knowledge of prevention strategies with a mean score of 124.84 ±SD14.66 and reported a high level of positive regard for their professional practice environment based on the results of Revised Professional Practice Environment (RPPE). Three components had mean scores of ≥3 and five <3 within the eight components. Three components of RPPE subscales with highest mean scores were Internal Work Motivation (M 3.24; SD 0.3), Relationship With Physician (M 3.22; SD 0.53) and Cultural Sensitivity (M 3.04; SD 0.24). The two lowest mean scores were for Handling Disagreement and Teamwork with 2.77 (SD 0.16) and 2.45 (SD 0.47), respectively. Nurses also showed positive attitudes toward the sustainability of the change process. The Sustainability Indices ranged from 13.4 to 100 with a mean of 75.21 (SD 21.71).In Phase 2 the intervention was conducted over six months from February to July 2010. The Center of Disease Control and Prevention (CDC) criteria for diagnosis of VAP and CRBSI, and the Waterlow Pressure Ulcer Risk Assessment Scale were promoted in the unit. Nurses were exposed and encouraged to implement evidence-based nursing interventions as identified in care criteria. All nurses were invited to the unit nursing education to increase their knowledge and awareness about evidence-based practice in prevention of the ICU complications. Nurses were encouraged to gain control of their practice. Evidence-based practice articles were also provided to increase their knowledge level and posters were distributed and placed in the unit to increase nurses awareness of the quality improvement initiativesFocus group discussions were conducted in Phase 2 and found that nurses in the unit were unaware of the importance of standardized assessment in their daily practice. They had a lack of understanding regarding the importance of standardised risk assessments. Despite the reluctance of many nurses to embrace the EBP, due to a perception of their workload, the focus groups also revealed nurses were optimistic that change will get easier and could be eventually achieved. Participants were positive about the change that could take place in the future. The hierarchical relationships with medical doctors were also identified as a factor limiting nurses from adopting the guidelines.Phase 3 of the project, the post-intervention phase was conducted from March to May 2011. The data collection process was repeated as Phase 1 and Phase 2. There were 11 cases of ICU complications identified during the post-intervention phase in 10 (8.7%) of the 115 patients admitted during March 2011. One patient developed both VAP and PU, while four developed VAP and another five PU. In the post-intervention group, no cases of CRBSI were detected. The total mean score of nurses’ knowledge was 121.45±SD16.85. An independent-samples t-test was conducted to compare nurses’ knowledge pre and post intervention, and found no significant differences, t (150) =1.32, P 0.189. The Sustainability Indices ranged from 41.3 to 100 percent with a mean of 76.81±SD21.45.Approximately 84% of the nurses in pre-intervention and 70% in post-intervention scored >55%. The nurses reported a positive regard for their practice environment in the pre- and post-intervention groups. The mean scores for each component were comparable for both the pre- and post-intervention groups except for Internal Work Motivation, Control Over Practice and Staff Relationship With Physician. The highest mean scores within the eight components for the post-intervention group were for Internal Work Motivation (M 3.13; SD 0.27), Relationship With Physician (M 3.04; SD 0.33) and Cultural Sensitivity (M 3.01; SD 0.23). The three lowest were for Handling Disagreement and Conflict (2.80; SD 0.20), Control Over Practice (2.71; SD 0.34) and Teamwork (2.48; SD 0.31).There was a reduction in overall complications from 19.8% to 8.7%. Few nurses in the focus group were optimistic that at least some changes had taken place, and positively improving their knowledge on assessment of patients and some of their common practices in the ICU. The challenge, which they were presently facing was the implementation of hospital information system because most of them were not knowledgeable in information technology.The main outcome of this study was that there was a reduction in number of patients with PU from 16 to 6 in pre and post intervention groups. This reduction of PU was statistically significant (χ[superscript]2=8.14, df=1, p=0.04).In conclusion whether there was a real improvement in patient care provided due to the interventions given was not able to be determined due to methodological considerations and inability to control for confounders. These data underscore the importance of considering cultural factors, both organisational and societal in quality improvement initiatives and empowering nurses for practice change. A risk management system which acknowledges competing demands in dynamic, real world environments is important to consider in future quality improvement studies. The series of studies presented in this thesis have contributed to understanding of factors influencing implementation and sustainability of quality improvement initiatives in a Malaysia ICU. Information acquired from the thesis will be useful information for further improvement targeting education, services, research, policy and future quality improvement project plans in Malaysia.