Evidence-based practice for ICU sedation, central line infections, and early feeding: Are you up to date?
By Anna Ver Hage, MSN, RN, AG-ACNP, CCRN, CNRN
This course is 1 contact hour
Course must be completed by February 15, 2020
Goals and objectives: The goal of this continuing education program is to provide evidence-based recommendations for sedation, central line-associated blood stream infections (CLABSIs), and early enteral feeding so nurses can better care for critically ill patients. After studying the information presented here, you will be able to:
  1. Describe “sedation vacation” protocols for mechanically ventilated ICU patients
  2. State the nurse’s role in decreasing CLABSIs
  3. Discuss current recommendations for early initiation of enteral feedings in critically ill patients
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
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You’re assigned to care for a 69-year-old man who was admitted to the ICU three days ago with a diagnosis of acute heart failure. William Haney is on mechanical ventilation, has both subclavian and femoral central line access, and has not been fed since admission
During report, the nurse going off duty tells you that Mr. Haney failed the spontaneous awakening trial and is currently on full ventilator support. You wonder if research supports performing spontaneous awakening trials or initiating early enteral feedings. Also, you wonder about the latest recommendations for preventing central line-associated blood stream infections (CLABSIs) in critically ill patients. You decide to review the evidence behind these three common practices and develop a plan of action.
Evidenced-based practice (EBP) is a common term used among clinicians and long considered the standard of care, continues to be practiced inconsistently by clinicians.1 There continues to be long delays in research findings and implementation of those findings to patient care.1 Fortunately, critical care is a specialty that thrives on using the latest scientific research to drive every intervention. Critical care nurses are constantly pushing limits and integrating the newest medical and nursing advances into patient care. Advances in technology give healthcare professionals easy access to a wealth of information to support EBP. By accessing these resources, nurses can provide patients with the best evidence-based interventions and treatments. This continuing education module reviews the evidence behind three practices: breathing trials for patients on mechanical ventilation, preventing CLABSIs, and early feeding of critically ill patients.
Time to wake up
Mechanical ventilation is a common, effective treatment in the ICU, but prolonged time on a ventilator can harm the patient and be costly for the institution. Researchers have sought ways to reduce time on the ventilator.2,3 Clinical trials performed over the last two decades have shown the importance of performing daily spontaneous breathing trials, adjusting ventilator settings to allow the patient to perform more work of breathing on his or her own, and decreasing the duration of time on the ventilator.2-4

About a decade ago, the focus shifted to combining spontaneous breathing trials with adjusting sedation requirements. A growing body of research supports spontaneous awakening trials, also referred to as “sedation vacations” or “daily wakeups,” in mechanically ventilated patients. Spontaneous awakening trials consist of a daily interruption of continuous sedative infusions to help determine the patient’s sedation requirements.2 In many patients requiring ventilator support, continuous infusion of IV sedation is used to alleviate discomfort and agitation. Compared to intermittent boluses of sedation, disadvantages of continuous infusion include increased time on the ventilator, fewer clinical examinations of neurological status, and complications such as ventilator-acquired pneumonia that contribute to increased morbidity and mortality.3 To mitigate these disadvantages, many hospitals have adopted sedation protocols to help nurses with measuring the amount of sedation a mechanically ventilated patient requires.2 Randomized control trials that measured interrupting sedative infusions found that decreasing the dose of sedation after a failed spontaneous awakening trial allowed patients to be extubated sooner than those receiving standard care — defined as reducing sedation according to nurse or physician judgment, only lowering sedation during weaning, and not completely stopping sedation infusions2-4 (Level A) Primary endpoints of these studies included number of ventilator-free days in the first 28 days, duration of mechanical ventilation, and time to discharge from the ICU and hospital.2-3
Wake up and breathe
Hospital policies and protocols regarding ventilator weaning vary widely, and few patients are managed according to the current scientific research.4 In 2008, several researchers conducted a multicenter study to assess a protocol termed “wake up and breathe,” which combines spontaneous breathing trials and spontaneous awakening trials. This pivotal study remains the basis for current guidelines and recommendations in effect today. The Society of Critical Care Medicine recommends a protocol, which consists of daily safety screenings, readiness assessment of the patient for spontaneous awakening and spontaneous breathing trials, and what to do if the trial fails.2 For patients who meet established criteria, such as those without active seizures, alcohol withdrawal, and agitation, and those not receiving neuromuscular blockade, the nurse stops all infusions of sedatives and analgesics used for sedation and performs a spontaneous breathing trial.2 Analgesics required for pain control are continued during the test.4 (Level A) Failure of the spontaneous awakening trial occurs when the patient shows symptoms, such as increased agitation, anxiety, or pain, or signs of respiratory distress. The nurse then restarts sedation at half of the previous dose and titrates the medications until the patient is comfortable.4 (Level A) Patients who pass the spontaneous awakening trial but fail the spontaneous breathing trial are placed back on full ventilator support and reassessed the next day.2 Extubation is considered for patients who tolerate the spontaneous awakening trial and pass the spontaneous breathing trial.2 The pivotal multicenter study found that a protocol combining spontaneous awakening trials with spontaneous breathing trials improved outcomes when compared to using standard weaning methods. For instance, patients who received the trials were a third less likely to die within the first year.4 (Level A) Based on these results, researchers recommended the protocol become a standard of care for mechanically ventilated patients.4 (Level A) It should be noted that these studies were performed in a medical ICU, so results may not be generalizable to trauma, postoperative, or neurological critically ill patients. A more recent multicenter trial evaluating 322 mechanically ventilated patients was performed in a general intensive care unit and, again, reported sedation overuse as a common practice.3 This study cited a correlation between early deep levels of sedation with adverse outcomes and was an independent predictor of hospital mortality among patients who were mechanically ventilated.3 (Level 3)
EBP recommendations
Current expert opinion and research suggest the best method for weaning a patient from the ventilator is to combine spontaneous awakening and breathing protocols.2-4 (Level A) This practice helps achieve earlier planned extubation, results in potentially fewer complications, decreases length of stay in the critical care unit and total hospitalization time, and improves survival rate at one year after hospital discharge compared to standard care.4 Nurses should take a multidisciplinary approach to implementing a spontaneous awakening trial and spontaneous breathing trial protocol. Talk about the research findings with other nurses, physicians, pharmacists, and respiratory therapists. Work as a team to develop preprinted order sets that make the protocol clear and easy to follow.
CLABSIs: We are our own worst enemy
Critically ill patients are breeding grounds for infections. CLABSIs have been the focus of many quality improvement initiatives throughout hospitals in the U.S. because they are among the leading causes of nosocomial sepsis that causes morbidity and mortality.5 It’s estimated that CLABSIs are associated with about 84,551 to 203,916 preventable infections, contributing to an estimated 10,426 to 25,145 preventable deaths.5 Additional negative effects include avoidable costs estimated to be between $1.7 to $21.4 billion dollars, given the increased length of stay in a critical care unit which increases the overall hospital stay.5 An old saying goes, “We are our own worst enemy.” This is certainly the case with blood stream infections. Skin organisms from the patient or providers can migrate into the patient’s body through the insertion site of a central line, colonizing on the catheter, and causing an infection. The good news is that research supports the use of simple interventions to decrease and potentially eliminate CLABSIs.5-7 Most of this research is not new, and the interventions are surprisingly basic — handwashing sits at the top of the list. From the time we were children, we have been reminded to wash our hands. The Centers for Disease Control and Prevention reiterate the important role of proper hand hygiene and aseptic technique when managing central venous catheters (CVCs).6 The most recent CDC guidelines for preventing CLABSIs were released in 2011. The agency also has produced a checklist.
Nurses are in a prime position to initiate and lead quality improvement projects. Assess your unit’s CLABSI rates. If they are higher than the national benchmark, look at the standard of practice. Involve your management and infection prevention team. Start by auditing standard recommended measures, such as maintaining aseptic technique during insertion of central lines, adherence to dressing and IV tubing change recommendations, and handwashing compliance. Educate, provide literature, and put guidelines into action. Use a central-line checklist and cart. Measure compliance and assess how these interventions have affected your unit’s CLABSI rates. The Joint Commission offers an interactive tool that helps identify barriers to performance measures and gives evidence-based solutions to common healthcare problems, such as reducing hospital-acquired infections. It offers Targeted Solutions Tool for Hand Hygiene.
EBP Recommendations:
Use a designated cart containing all items needed for CVC placement
Use a catheter checklist to monitor compliance with aseptic CVC insertion
Perform proper hand hygiene before CVC insertion and with any subsequent catheter contact
Use a sutureless securement device for the CVC
Avoid the femoral route for central access whenever possible
EBP recommendations for preventing CLABSIs are as follows:8 (Level ML)
Use a twisting motion to vigorously scrub the injection port with an alcohol/chlorhexidine preparation before accessing
Use aseptic technique when inserting or replacing a CVC. All those involved in the procedure must wear a mask, cap, sterile gown, and sterile gloves
Remove CVCs when they are no longer needed
Note: Prophylactic antibiotics and routine replacement of catheters are NOT recommended as standard of care for preventing CLABSIs.
How to earn continuing education
THIS COURSE IS 1 CONTACT HOUR
1.
Read the Continuing Education article.
2.
This continuing education course is FREE ONLINE until September 1, 2018, courtesy of Nurse.com. To take the test for FREE, go to https://www.nurse.com/ce/evidence-based-practice-for-icu-sedation-central-line-infections-and-early-feeding. After that date, you can take the course for $12 at the same link. If you have a CE Direct login and password (generally provided by your employer), please login as you normally would at https://cedirect.continuingeducation.com and complete the course on that system.
3.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
5.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.
ONLINE
You can take this test online or select from the list of courses available. Prices subject to change.
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EDITOR’S NOTE: Anna Ver Hage, MSN, AGACNP-BC, CCRN, CNRN, is a nurse practitioner in the division of stroke and neurological critical care at Banner Desert Medical Center in Mesa, Arizona. She has authored numerous articles on stroke and coauthored national guidelines on the care of the neuroscience patient.
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OnCourse Learning guarantees this educational activity is free from bias.
Follow the guidelines
Several single hospital and multicenter studies report that following CDC guidelines significantly decreases CLABSIs. One systematic review and meta-analysis of 43 studies, including 584 adult ICU, examined implementation of evidence-based recommendations identified as having the maximum effect on infection rate while also being easy to implement.7 This meta-analysis provided evidence that quality improvement initiatives to reduce CLABSIs are beneficial, and appeared to be most noticeable among settings that instituted bundles or checklists.7(Level ML) These initiatives included implanting interventions such proper hand hygiene, maximum sterile barrier precautions during insertion of CVCs, cleaning the CVC insertion site with a chlorhexidine preparation, avoiding femoral access, and removing unneeded catheters.7 Many studies found discussions held daily during multidisciplinary rounds were beneficial so that unnecessary catheters were removed. One study formed a team of nurses to evaluate a reported increase in infection rates, and after implementing a change in practice, they reported a decrease in infection rate from 1.5 to 0 CLABSIs per 1,000 catheter-days.7 Interventions also include educating clinicians so they adhered to the recommendations, use of a central-line cart equipped with supplies needed for sterile insertion, and a checklist to monitor compliance.6 Best practices for preventing infections post-catheter insertion include disinfecting all injection ports with an alcohol preparation before accessing the catheter.8 (Level ML) Based on results from several randomized trials, transparent dressings placed on nontunneled central catheters should be changed using aseptic technique up to every seven days or earlier if integrity has been compromised.8 (Level ML) In addition, replace IV administration sets no more often than every 96 hours (but at least every seven days) or more frequently for lines infusing blood products or lipids.8 (Level ML) Total parenteral nutrition infusions require special care. TPN is a hyperosmolar glucose-containing solution that provides an ideal environment for bacteria to multiply. Although CDC guidelines don’t make a recommendation for using a designated lumen; be aware that patients receiving TPN infusions are associated with an increased infection risk.8 Observational studies suggest an adequate nurse-to-patient ratio of one to two nurses in ICU settings where nurses are managing central lines has been associated with decreased infection rates.8
Special situations
A 2008 meta-analysis on use of antimicrobial-coated CVCs suggests these catheters be reserved for those areas or patient populations whose CLABSI rates remain high even though standard interventions are being performed.6,8 (Level ML) No studies to date have shown a benefit from routinely replacing CVCs to decrease infection.6 (Level ML), 8 (Level ML) If infection is suspected, the CVC should be removed and not exchanged over a guidewire.6 (Level ML) If an emergency situation precluded use of aseptic technique, the CVC should be removed or replaced within 48 hours of insertion.6 (Level ML) Additional special approaches for decreasing CLABSIs if infection rate remains high — regardless of other interventions tried — may include daily bathing of critically ill patients with a chlorhexidine solution, use of a chlorhexidine-containing sponge dressing, and installation of antimicrobial locks into the lumens of the CVC.8 (Level ML)
ICU sedation practices are all about the evidence
Earn 1 credit hour with this free continuing education course
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Contents
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Be a driving force behind EBP
Learn why evidence is a must when it comes to quality patient care.
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evidence-based practice
Nurses cross into research
Nurses are doing the digging to find answers to their practice questions.
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Get to the root of it
Master the basics of EBP and learn how to start your own project.
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Research feeds good practice
Turn a patient care idea into practice by starting with solid research.
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You hold the power
Bedside nurses have the ability to make significant practice changes.
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Making the grade
Evidence is a moving target. Be ready to adjust EBP policies.
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Protect the children
Pain management is a big deal when it comes to the littlest patients.
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evidence-based practice
Meet a wound care expert
RN Nancy Morgan tells you what really works wound care.
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evidence-based practice
FREE CE: What's new in EBP?
Learn the latest about ICU sedation, CLABSIs, and more.
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EBP blasts make an impact
A nurse successfully expands healthcare access for her patients.
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Fuel career satisfaction
Use new evidence to transform your old practices.
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CE Catalog
Boost your knowledge of EBP with these education modules.
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Follow the evidence
You know EBP is important; now grasp the strategies behind it.
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The journey continues
Driving interest in EBP is not always easy, but it’s worth the effort.
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An unacceptable risk
Periop nurses are striving to decrease pressure ulcers.
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Training days
Patient-centered care plus team science equals dazzling results.
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Pregame practice
Nursing students are being to appreciate the value of EBP.
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Poor self-care is a safety issue
Nurses who do not address fatigue can jeopardize patients.
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Create a dream team
A children's hospital shows how interdisciplinary care pays off.
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It's all about the team
Learn how the TeamSTEPPS strategy took shape.
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Patient care gets revamped
A cancer center reboots bedside reporting and improves care.
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