Background to the Study
Endotracheal suctioning is a clinical procedure that helps to clear airways in the respiratory system by mechanically removing accumulated pulmonary secretions in patients with artificial airways (Sharma, Sarin & Bala, 2014). Critically ill patients with artificial airways require endotracheal suctioning to remove secretions and prevent airway obstruction, without which the patient may experience inadequate oxygenation and ventilation. Endotracheal intubation is an artificial airway that inhibits cough reflex and interferes with normal muco-ciliary function, therefore increasing airway secretion production and decreasing the ability to clear such secretions (The Royal Children’s Hospital Melbourne, 2012). Although endotracheal suctioning is an essential way of maintaining ventilation and oxygenation in patients with such artificial airways, it can result in adverse effects and serious complications when performed inappropriately or incorrectly (Kelleher & Andrews, 2008).
Patients on mechanical ventilation are vulnerable to disease complications such as alveolar hypoventilation, alveolar hyperventilation, fluid and electrolyte imbalance, pneumothorax and ventilator associated pneumonia, a most common infectious complication accounting for about 47% of all infections among critical care patients (Sharma, Sarin & Bala, 2014). In spite of the fact that most of the technical aspects of managing mechanical ventilator is the responsibility of respiratory care practitioners (physiotherapist who specialized in respiratory care), nurses provide holistic care to patients, including the management of clinical symptoms and responses to mechanical ventilator support (Chlan, 2011).
Critical care practitioners (anesthetists and nurses) are professionals that provide evidence-based assistance in critical care units of healthcare facilities in order to promote quality healthcare services to clients. Such practitioners monitor client’s responses to ventilation intervene to maintain oxygenation and ventilation and ensure that the complex needs of critically ill patients are met. It is very important that critical care practitioners are aware of endotracheal suctioning procedure and are able to practice according to current evidence based recommendations. Knowledge and experience can determine a critical care practitioner’s ability to adequately perform endotracheal tube suctioning. However, some researchers have documented that some critical care practitioners do not have sufficient knowledge about the current recommendations for endotracheal suctioning and, their practice is often based on rituals and traditions (Frota, Loureiro & Ferreira, 2013). Others observed that the critical care practitioners do not often adhere to the recommended procedures by the World Health Organisation and their level of competence in endotracheal suctioning practices is below expectation (Akram, Negin, Mohsen & Mohammadreza, 2012; Bighamian, Zarkeshan & Rafieeano, 2010; George & Sequiera, 2010).
Also, it was reported in a multisite survey of suctioning techniques and airway management practices by Sole, Byers and Ludy (2009) that the management practices were inadequate; compliance with hand washing guidelines was 82%, wearing gloves was 75%, elevating head of bed was 50%, and proper oral care protocol was 50%. Day, Farrell and Hayes (2012) observed that the mean score for knowledge was 11.1 and 10.3 for practice among critical care practitioner; and majority of the subjects failed to perform suctioning as accurately as they had claimed.
Similarly, in Cairo, a study by Nahla (2013), revealed that less than half of the nurses recognized closed system suctioning as recommended, while the rest were unfamiliar with closed system suctioning. Heyland, Cook and Dodek (2012) also reported on prevention of ventilator associated pneumonia practice in Canadian critical care units that nurses were familiar with closed suctioning practices because such practices were common in 88% of the ICUs. Sierra (2010) reported that in Spain open tracheal suctioning was reported in 96% of the ICUs and added that closed suction systems are not commonly used, and thus nurses were unfamiliar with those systems. More than half of the nurses in the study knew that frequent change in suction systems, and kinetic beds decrease the risk and occurrence of pneumonia. While only 48% of nurses knew that semi-recumbent positioning help in prevention of pneumonia.
Despite the recognition that endotracheal suctioning is an effective technique that clears the airways by mechanically removing accumulated pulmonary secretions in critically ill patients with artificial airways, the adherence to established guidelines on endotracheal suctioning by critical care practitioners is not impressive. Studies by Day, Farnell, Haynes, Wainwright and Wilson-Barnett (2012); Negro, Ranzani and Manara (2014) have shown that critical care practitioners’ lack of adequate knowledge about endotracheal suctioning may be a barrier to adhere to evidenced based guidelines.
The researcher is unaware of any empirical evidence of endotracheal suctioning knowledge and practices of critical care practitioners and has not come across any study on endotracheal tube suctioning in Nigeria. Hence, this research was undertaken to evaluate the effectiveness of endotracheal suctioning in terms of knowledge and practices of critical care practitioners in University of Calabar Teaching Hospital, Calabar.
Statement of the Problem
Hospital acquired infections such as Ventilator Assisted Pneumonia (VAP) among critical care patients is a major healthcare challenge. Incidence of hospital acquired infections has continued to rise, especially in the developing countries, despite advancements in health technology (Ulu-Kilic & Ahmed, 2013). Although they account for fewer than 10% of total beds in most hospitals, more than 20% of all nosocomial infections are acquired in ICUs (Ulu-Kilic & Ahmed, 2013).
In clinical practice in the critical care unit of the University of Calabar Teaching Hospital, the researcher has observed that some critical care practitioners do not adhere strictly to endotracheal suctioning procedure, according to recommendations and guidelines. Among the poor practices observed were: poor insertion of catheter, poor positioning of the patient and poor infection control practices during and after suctioning. These observations made the researcher to ponder and ask: why is there lack of adherence to best-practices and lack of competence in performing endotracheal suctioning among critical care practitioners? Could it be related to lack of knowledge? Does it cut across all critical care practitioners? This study will therefore assess endotracheal suctioning knowledge and practices among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
Purpose of the Study
The purpose of this study is to assess endotracheal suctioning knowledge and practice among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
The specific objectives of the study are to:
- Identify knowledge of endotracheal suctioning procedure among critical care practitioners’ in University of Calabar Teaching Hospital (UCTH), Calabar.
- Evaluate adherence to step by step (practice) procedure in endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
- Assess level of competence in performing endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
- Determine association between knowledge and competence in performing endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
- Determine differences in practice between the critical care practitioners.
The following hypotheses were formulated to guide the study:
- There is no significant relationship between socio-demographic characteristics and knowledge of endotracheal suctioning among critical care practitioners.
- There is no significant relationship between socio-demographic characteristics of respondents and competence in performing endotracheal suctioning among critical care practitioners.
- There is no significant differences in practice of endotracheal suctioning between critical care practitioners
Significance of the Study
This study would be of immense benefit to health personnel/workers (physicians and nurses), researchers and the entire society.
Physicians and nurses working in ICU in conjunction with hospital management would through the findings of this study prepare protocol for endotracheal suctioning in UCTH, Calabar. This will enable them adhere to recommended suctioning techniques.
Stakeholders in health and policy makers such as the WHO would understand the level of knowledge and practice of endotracheal suctioning among critical care practitioners, thereby formulating policies that will bring about efficiency in the practice by critical care practitioners. They will strategize towards ensuring that factors militating against good suctioning are overcome; and this will promote quality healthcare delivery in critical care units through efficient utilization of endotracheal suctioning in critical care units.
Researchers would benefit from this study because it will serve as a reference material and it will add to existing literature on knowledge, practice and competence of endotracheal suctioning in the management of patients in critical care units.
Scope of the Study
The focus of this study is to evaluate endotracheal suctioning knowledge and practices among critical care practitioners in Intensive Care Unit of University of Calabar Teaching Hospital (UCTH), Calabar. It will involve both nurses and physicians that work in the critical care unit of UCTH, Calabar. As well as assess their adherence to best practices in endotracheal suctioning and competence in performing endotracheal suctioning.