Abstract
Background
Nurses in the Intensive Care Unit (ICU) play a critical role in recognizing patients who are at risk of deterioration by conducting continual assessments and taking suitable measures in response to changing health status. The validity of the cluster nursing intervention has been studied previously, but its use among ICU patients with tracheal intubation and extubation has not been examined. This study assessed the effectiveness of cluster nursing intervention in ICU patients with tracheal intubation and extubation.
Material/Methods
In this retrospective study, 80 patients on mechanical ventilation in the ICU ward were randomly assigned to control and intervention groups (40 patients each). The control group received the routine nursing mode, while the intervention group was given 5 sessions of cluster nursing intervention. Tracheal intubation and extubation-associated complications, blood gas analysis, patient nursing satisfaction, and changes in patients’ negative emotions were compared before and after the intervention.
Results
After the nursing intervention, the levels of PaO2 were higher, while PaCO2 levels were lower in the intervention group compared to the control group (P<0.05). Importantly, anxiety and depression scores in the intervention group were lower than in the control group (P<0.05). Moreover, the overall incidence of complications in the intervention group was lower than in the control group, whereas patient satisfaction with nursing services was higher (P<0.05).
Conclusions
Cluster nursing intervention can effectively reduce the incidence of complications and improve patients’ physiological and psychological conditions. Moreover, it enhances patient satisfaction with nursing services, thus improving patients’ clinical symptoms.
Keywords: Intensive Care Units; Airway Extubation; Intubation, Intratracheal; Critical Care Nursing; Psychology
Introduction
The Intensive Care Unit (ICU) is a special area for critically ill patients. Mechanical ventilation is widely used in the ICU [1], which is an important means to rescue patients with respiratory arrest or respiratory failure. Orotracheal intubation is the most commonly used emergency respiratory method for invasive mechanical ventilation [2]. As soon as the underlying condition that eventually requires mechanical ventilation is stabilized and the patient can sustain spontaneous breathing and appropriate oxygenation and ventilation, extubation and rapid liberation from mechanical ventilation are critical. Complications that can arise after extubation include laryngeal spasm, asphyxia, bronchospasm, cough, and hypoxemia. These complications can be caused by long-term compression of the oropharyngeal, tracheal mucosa, and vocal cord by a catheter or airbag, secondary infection in the dead space above the airbag, or aspiration of oropharyngeal secretions or vomit into the trachea and lungs due to airbag leakage [3]. In addition, tracheal extubation can even induce heart failure and cardiac arrest, which is associated with high mortality rates of 25–50% [4].
Extubation is a critical decision in the ICU since mortality is particularly high when extubation fails, thus resulting in re-intubation [5,6]. The general rate of re-intubation following planned extubation is about 10%, but it can be as high as 20% in particular patient subgroups [7]. Identification of patients at high risk of re-intubation warrants consideration to of specific procedures that can prevent the need for re-intubation [8].
Intensive care nursing focuses on all aspects of basic nursing care and life support. It combines the essence of nursing with observation, insightful and even intuitive interpretation, and responses to even the slightest change in a patient’s condition [9]. The cluster nursing intervention combines evidence-based medical theory with nursing interventions to deliver centralized and focused patient care in light of the rapidly developing field of evidence-based medicine and the introduction of novel nursing concepts [10,11]. Cluster nursing intervention is a well-established concept. Previously, it was reported that clustering care interventions can dramatically lower stroke patients’ anxiety levels and have a major impact on neurological recovery in ICU stroke patients [12]. Moreover, it has been shown that cluster nursing intervention can effectively reduce negative emotions such as depression and anxiety in ICU patients with delirium [13]. Similarly, Huang et al [14] demonstrated that cluster nursing intervention could lessen the occurrence of delirium, shorten the duration of mechanical ventilation and ICU stays, and improve the prognosis of patients. However, it has not been reported whether the cluster nursing intervention can prevent complications associated with tracheal intubation and extubation and reduce patients’ negative emotions. Therefore, the primary aim of this study was to determine the clinical effectiveness of cluster nursing intervention in ICU patients with tracheal intubation and extubation.
Material and Methods
Participants
In this retrospective study, from June 2019 to December 2020, 80 patients with mechanical ventilation in the ICU of our hospital were randomly divided into control and intervention groups using a computer-generated randomization list, with 40 patients in each group. On enrolment, demographic and clinical data were gathered, including age, sex, admission diagnosis, number of days intubated before enrolment, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The APACHE II score is a severity-of-disease classification system that is applied within 24 h of admission of a patient to the ICU. When data were missing, we used the complete-case analysis method. This study was approved by the Ethics Committee of the principal investigator’s institution and informed consent was obtained from the participants or family members.
Eligibility Criteria
The inclusion criteria were: (1) The study’s participants were all critically ill patients who qualified for ICU admission; (2) The duration of the hospital stays, and the mechanical ventilation in the ICU were ≥24 h; (3) Patients who were sufficiently conscious to cooperate; (4) Patients or families who knew the research objectives and voluntarily signed informed consent.
Exclusion criteria were: (1) Patients with severe hemodynamic instability or arrhythmia; (2) Patients with pregnancy; (3) Those with mental illness; (4) Having respiratory tract infection before intubation.
Development of Evidence-Based Cluster Nursing Intervention Plan
To identify the clinical issues, a cluster nursing intervention team was formed. The team was composed of 1 head nurse, 5 experienced nurses having more than 7 years of ICU experience, and 3 systematic evidence-based training personnel. The evidence-based issues were raised in accordance with international evidence-based medical standards [15,16], and then the cluster nursing intervention was constructed answer the following: (1) whether implementation of isolation measures such as a quiet environment in the ICU can improve patients’ psychological condition associated with intubation and extubation; (2) whether proper body positioning can reduce the incidence of intubation and extubation-associated complications; (3) whether timely evaluation of patient consciousness and swallowing function can reduce the incidence of intubation and extubation-associated complications; (4) whether timely avoidance of aspiration refluxes can improve patients’ physiological condition associated with intubation and extubation in the ICU.
Implementation of Cluster Nursing Intervention
The control group was given routine nursing intervention measures, including strictly monitoring blood pressure, blood gas levels, heart rate, and other physiologically vital indicators.
The study group was given 5 sessions of cluster nursing mode measures in addition to the routine nursing intervention. The specific measures were: (1) An intervention team composed of a chief physician and a head nurse as the core was established to train the ICU nursing staff and ensure that each nursing staff member understood the cluster nursing intervention program’s specific implementation requirements. After completing the training program, the qualified nurses could join the cluster nursing intervention team. (2) According to the cluster nursing intervention plan, team members adopted tailored nursing measures based on each patient’s circumstance and influencing factors, convened a monthly group meeting to summarize and discuss each measure’s implementation during the nursing process.
Sample Size
This sample size was assessed based on the t test (α=0.05) for cluster-randomized controlled studies by Murray [17] with an expected effect of a critical difference of 6 points (SD 12.5), an intracluster correlation of 0.05, and a power of 80%.
Blinding
Nurses who provided the interventions and assessed the results were aware of group allocation due to their involvement in the cluster nursing intervention training program. Although patients were not told of their group assignment, they may have been made aware of it because of unmasking information from nurses.
Measurement Indicators
Primary outcome
(1) Clinical complications, including bleeding of soft-tissue injury, glottic edema, cough, and upper respiratory tract obstruction, were recorded and compared between the 2 groups. The overall incidence rate was measured as:
Secondary Outcomes
(2) The patient’s anxiety and depression scores of the 2 groups were evaluated by the hospital anxiety and depression assessment scale. The Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith [18], is a self-report questionnaire specifically designed to screen anxiety and depression of patients in non-psychiatric settings. It is a 14-item scale with 7 questions in each of 2 subscales for assessing anxiety and depressive symptoms. Each item is classified on a scale of 0 to 3, and the scores in each subset range from 0 to 21. The cut off scores were 10/11 for anxiety and 7/8 for depression subscales, as described previously [19]. According to these findings, scores of ≥11 and ≥8 suggest a significant risk of anxiety and depression, respectively.
(3) Patient satisfaction with nursing care services was evaluated using the Newcastle Satisfaction With Nursing Scale (NSNS) [20], Chinese version [21]. The NSNS comprises 2 subscales: the Satisfaction with Nursing Care Scale (SNCS) and the Experience of Nursing Care Scale. These 2 subscales can be utilized either separately or together. In this study, the SNCS was used with slight modifications, consisting of only 3 items, including nursing care quality, nursing professionalism, and nursing attitude, and using a 3-point Likert scale. For assessing the degree of satisfaction, ‘barely satisfied,’ ‘satisfied,’ and ‘very satisfied’ were scored from 0 to 10 points, with 8–10 points representing very satisfied, 5–7 points showing satisfied, and 0–4 points indicating barely satisfied. The overall satisfaction ratio was calculated as:
(4) The blood gas analysis, including PaO2, PaCO2, and blood pH 24 h after extubation was performed using an ABG analyzer (Siemens Medical Solutions Diagnostics, Shanghai, China).
The reliability and validity of all the tools used in the present study were analyzed and compared with the established standards and benchmarks.
Statistical Analysis
SPSS version 20.0 software was used to analyze the data. The measurement data of the 2 groups of patients was tested using t test and expressed as x±s. The count data of the 2 groups of patients were assessed by χ2 test and expressed by [n (%)]. Statistical significance was assumed at P<0.05.
Results
Baseline Clinical Characteristics
The control group consisted of 21 females and 19 males, with a mean age of 44.31±5.24, ranging from 24 to 64 years. There were 20 males and 20 females in the intervention group, with an average age of 45.23±6.46 years (range, 26–68 years). Table 1 demonstrate that the 2 groups did not differ significantly regarding gender, age, number of days intubated before enrolment, admission reason, diagnosis on admission, and APACHE score (P>0.05).
Table 1.
Demographic and baseline characteristics of the 2 groups.
| Groups | Control group | Intervention group | P |
|---|---|---|---|
| N | 40 | 40 | >0.05 |
| Gender | |||
| Male | 19 | 20 | >0.05 |
| Female | 21 | 20 | >0.05 |
| Average age (years) | 44.31±5.24 | 45.23±6.46 | >0.05 |
| Days in hospital | 15.5±6.46 | 13.6±10.4 | >0.05 |
| Diagnosis | |||
| Sepsis | 14 (36.86) | 18 (47.37) | >0.05 |
| Respiratory failure | 14 (36.84) | 12 (31.58) | >0.05 |
| Surgery | 12 (31.58) | 10 (26.32) | >0.05 |
| APACHE score | 25.2±4.6 | 23.7±5.2 | >0.05 |
| Admission reason | |||
| Medical | 15 | 17 | >0.05 |
| Surgical | 25 | 23 | >0.05 |
The difference between the 2 groups was estimated using the t test.
Anxiety and Depression Outcomes
The psychological state (anxiety and depression) of the patients in the control group and the intervention group after the specified nursing intervention was much better than before the nursing intervention, and the difference was significant (P<0.05). Interestingly, the anxiety and depression score of the patients after giving the cluster nursing intervention in the intervention group was much lower than that in the control group, and the difference was noticeable (P<0.05), as shown in Table 2.
Table 2.
Comparison of anxiety and depression scores between the 2 groups.
| Groups | N | Anxiety score | Depression score | ||
|---|---|---|---|---|---|
| Before nursing intervention | After nursing intervention | Before nursing intervention | After nursing intervention | ||
| Control group | 40 | 15.94±2.36 | 8.131±3.64# | 12.43±2.58 | 8.37±3.41# |
| Intervention group | 40 | 14.41±5.24 | 5.26±3.71#,* | 12.15±6.85 | 5.12±2.54#,* |
The difference between the 2 groups was estimated using the χ2 test.
P<0.05 indicates a comparison between before and after the nursing intervention;
P<0.05 indicates a comparison between the control and intervention groups after the nursing intervention.
Blood Gas and pH Indexes
Before the nursing intervention, no apparent difference was observed in the PaCO2 and PaO2 levels and blood pH between the control and intervention groups (P>0.05). However, after the nursing intervention, the PaCO2 level of the intervention group was lower, and the PaO2 blood level was higher compared to the control group. There was a statistically significant difference between the 2 groups (P<0.05). After the nursing intervention, the blood pH of the 2 groups was comparable (P>0.05), as shown in Table 3.
Table 3.
Comparison of arterial blood gas indexes between the 2 groups before and after the nursing intervention.
| Groups | N | PaCO2 (mmHg) | PaO2 (mmHg) | Blood pH | |||
|---|---|---|---|---|---|---|---|
| Before nursing intervention | After nursing intervention | Before nursing intervention | After nursing intervention | Before nursing intervention | After nursing intervention | ||
| Control group | 40 | 57.61±2.35 | 48.24±4.29# | 53.27±5.27 | 76.17±6.81# | 7.29±0.18 | 7.12±0.14 |
| Intervention group | 40 | 56.73±2.57 | 37.41±2.73#,* | 54.13±3.47 | 91.5±4.52#,* | 7.34±1.05 | 7.09±0.05 |
The difference between the 2 groups was estimated using the χ2 test.
P<0.05 indicates a comparison between before and after the nursing intervention;
P<0.05 indicates a comparison between the control and intervention groups after the nursing intervention.
Patients’ Satisfaction with Nursing Services
Patients in the intervention group reported significantly higher levels of satisfaction with nursing services following the nursing intervention compared to those in the control group (P<0.05), as shown in Table 4.
Table 4.
Comparison of patient satisfaction between the 2 groups.
| Groups | N | Very satisfied | Satisfied | Barely satisfied | Overall satisfaction |
|---|---|---|---|---|---|
| Control group | 40 | 21 (52.50%) | 5 (12.50%) | 14 (35.00%) | 26 (65.00%) |
| Intervention group | 40 | 32 (80.00%) | 6 (15.00%) | 2 (5.00%) | 38 (95.00%)* |
The difference between the 2 groups was estimated using the χ2 test.
P<0.05 indicates a comparison with the control group after the nursing intervention.
Incidence of Complications
There was a statistically significant reduction in the overall incidence of complications in the intervention group following the nursing intervention compared to the control group (2.50% vs 15.0%) (P<0.05; Table 5).
Table 5.
Comparison of complications between the 2 groups.
| Groups | Laryngospasm | Laryngeal edema | Aspiration | Overall incidence |
|---|---|---|---|---|
| Control group | 2 | 3 | 1 | 6 (15.00%) |
| Intervention group | 1 | 0 | 0 | 1 (2.50%)* |
The difference between the 2 groups was estimated using the χ2 test.
P<0.05 indicates a comparison with the control group after the nursing intervention.
Discussion
The results of the present study suggest that a cluster nursing intervention might be an effective strategy in ICU patients with tracheal intubation and extubation. It reduces patients’ anxiety and depression, improves patients’ physiological condition, promotes patients’ satisfaction with the nursing services, and lowers intubation and extubation-associated complications.
In the ICU, invasive mechanical ventilation such as tracheal intubation (TI) is a common and life-saving technique. A significant proportion of procedures result in life-threatening complications, making TI one of the most common but underappreciated airway emergencies in the ICU [22]. TI is associated with several hazards, including broncho-aspiration, barotrauma, ventilator-related pneumonia, reduced cardiac output, and respiratory muscle dysfunction [23]. Similarly, extubation of the patient from mechanical ventilation is crucial due to the risks involved with prolonged invasive mechanical ventilation as well as the fact that it is a sign that the patient is regaining their ability to breathe on their own [24]. Extubation failure rates are 15–18% after 48 h, necessitating endotracheal re-intubation, which increases hospital stay and mortality in the ICU [5].
Nursing care for patients who need invasive mechanical ventilation is complex and diverse [25]. Nurses are responsible for giving continuous care to help patients progress in a favorable way. Although traditional nursing interventions can accomplish specific nursing results, mechanical ventilator-related complications in ICU patients still cannot be reduced [26]. The cluster nursing intervention program, which is based on evidence-based medicine, combines fundamental nursing practices with targeted preventive intervention to address issues that nurses may face, such as the complex problems currently related to mechanical ventilation [14,27]. In our study, this program was based on evidence-based research on the factors influencing mechanical ventilator-associated complications and targeted nursing measures. Our results demonstrated that the incidence of complications was 15.79% in the control group and 2.63% in the intervention group to which cluster nursing intervention was given, indicating the importance of this program in the prevention and management of complications in ICU patients with artificial airway intubation and extubation. These results are in accordance with a previous publication showing similar results in ICU patients with breathing difficulties [28].
Patient satisfaction with nursing care is a reliable predictor of good patient prognosis and is a key indication of hospital healthcare quality [29,30]. Hence, assessing the level of patient satisfaction with nursing care is essential for improving the standard of care [31]. In the present study, we investigated patients’ satisfaction with the nursing care services after receiving the cluster nursing intervention. We found that patients’ satisfaction regarding nursing care services was 65.79% in the control group and 94.74% in the intervention group, similar to previous studies [32,33].
Most individuals with chronic illnesses have psychological issues that impede recovery of the disease [11]. The cluster nursing mode prioritizes psychological nursing, assesses patients’ psychological requirements, and then implements targeted psychological nursing to alleviate patients’ negative psychological feelings and maintain their psychological well-being [34]. In our study, we also found that the anxiety scores and depression scores of the intervention group were lower than those of the control group, which agrees with the results of other studies [35–37]. This improvement in patients’ negative emotions might be attributed to the introduction of health education, psychological counselling, and other nursing services for patients through one-on-one counselling and communication.
Study limitations
Our study has a few limitations that needs to be addressed. First, the study was carried out in the ICU of a single representative public hospital. Individuals who use private hospitals may differ greatly from those utilizing public hospitals, hence necessitating additional research before drawing broad conclusions. Second, nurses who participated in the present work were aware of the group allocation and interventions; therefore, potential data collection bias cannot be excluded, and the findings should be interpreted with caution. Third, due to the small sample size and absence of evidence-based conversion studies in the present research, additional evidence-based data are needed to give a more reliable foundation for improving patient clinical prognosis by merging evidence-based information with clinical reality.
Conclusions
In this study, the efficacy of a cluster nursing intervention for tracheal intubation and extubation in ICU patients was evaluated. We found that the cluster nursing intervention can effectively lower the incidence of complications associated with artificial airway intubation and extubation. This intervention can also enhance patient satisfaction regarding nursing care services and significantly reduce depression and anxiety in ICU patients.
Footnotes
Conflict of interest: None declared
Ethical Statement: Ethics approval was obtained from the Institutional Review Board Ethics Committee of the Shenzhen Longhua District People’s Hospital.
Publisher’s note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher
Financial support: None declared
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