ENDOTRACHEAL SUCTIONING KNOWLEDGE AND PRACTICE AMONG CRITICAL CARE PRACTITIONERS IN INTENSIVE CARE UNITS IN UNIVERSITY OF CALABAR TEACHING HOSPITAL, CALABAR, CROSS RIVER STATE

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ABSTRACT
This study was carried out to determine endotracheal suctioning knowledge and practice among critical care practitioners in intensive care units of University of Calabar Teaching Hospital. The objectives of the study were to identify critical care practitioners’ knowledge of endotracheal suctioning, evaluate adherence to  procedure in endotracheal suctioning, assess their competence in performing endotracheal suctioning, determine if there is an association between knowledge and competence in performing endotracheal suctioning and determine if there are differences in knowledge and practice between the critical care practitioners. A descriptive survey and observational designs were adopted for the study .A total population study of 96 respondents was used for the study. The instrument for data collection was a structured questionnaire and observational checklist. The face and content validity were determined by the supervisor, and two consultant Anaesthetists in UCTH. The results were presented in tables as percentages. Pearson Chi-square test was used to determine the association between the knowledge distribution for doctors and nurses, a Chi-Square Test of Association revealed no significant difference between them, p = .803 at 0.05 level of significance. Majority of practitioners Age between 31-35 years (85.2%) had low knowledge while few (14.8%) had high knowledge. Likewise, practitioners between 36-40 years, (85.2%) had low knowledge while few (14.8%) had high knowledge and those above 40 years, (48.8%), had low knowledge while (51.2%) had high knowledge. However, findings from the study revealed that few physicians, (21.7%) had inadequate adherence to practice of endotracheal suctioning procedure while majority (78.3%) had moderately adequate adherence. Likewise, nurses, (40.7%) had inadequate adherence while (59.3%) had moderately adequate adherence. Out of the 50 critical care practitioners that were assessed using the check-list, all had poor competence in endotracheal suctioning procedure. In conclusion, the overall knowledge of practitioner was low and there was no difference between knowledge and practice among practitioners. However, knowledge did not significantly influence practice of critical care practitioners. It was recommended that a fully equipped modern laboratory be put in place for continuous practice and simulation.
 
CHAPTER ONE
INTRODUCTION
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.
 
Specific Objectives            
The specific objectives of the study are to:

  1. Identify knowledge of endotracheal suctioning procedure among critical care practitioners’ in University of Calabar Teaching Hospital (UCTH), Calabar.
  2. Evaluate adherence to step by step (practice) procedure in endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
  3. Assess level of competence in performing endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
  4. Determine association between knowledge and competence in performing endotracheal suctioning among critical care practitioners in University of Calabar Teaching Hospital (UCTH), Calabar.
  5. Determine differences in practice between the critical care practitioners.

 
Hypotheses
The following hypotheses were formulated to guide the study:

  1. There is no significant relationship between socio-demographic characteristics and knowledge of endotracheal suctioning among critical care practitioners.
  2. There is no significant relationship between socio-demographic characteristics of respondents and competence in performing endotracheal suctioning among critical care practitioners.
  3. 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.
 
Operational Definition of Terms
Critical Care Practitioners: Physicians (doctor anaesthetists) and nurses working in the critical care units of UCTH, Calabar. They are referred to in this work interchangeably with dependent nurse/physician care agent.
Endotracheal Suctioning: A procedure to clear the airways by mechanically removing accumulated pulmonary secretions in patients with endotracheal tube.
Intensive Care Units (ICU): Are unit in the hospital where patients with life threatening conditions are cared for by specially trained staff. Here it includes ICU and recovery rooms
Endotracheal Intubation:  A procedure in which endotracheal tube is placed into the trachea in order to maintain an open airway in patients who are unable to breathe on their own.
Competence: Ability to perform endotracheal suctioning according to recommended guidelines.
Knowledge of endotracheal suctioning: The ability of critical care practitioners to identify information concerning clinical procedures employed to clear the airways by mechanically removing accumulated pulmonary secretions in patients with artificial airways The responses to questions on knowledge of endotracheal suctioning will be rated as high for scores above 50%, 49% and below as poor/ low. The questionnaire has 22 items. To calculate the % score thus; Total score obtain divided by numbers of item multiply by 100. High Knowledge: Are those who scored above 50% on answering questions on knowledge of endotracheal suctioning. Low/poor Knowledge: Are those who scored between 0- 49% on answering questions on knowledge of endotracheal suctioning.
Practice: The act of removing accumulated pulmonary secretions in patients with artificial airways by doctor anaesthetists and nurses that work in the critical care unit according to recommended guidelines. Observational checklist on practice was scored over 23 and rated as follows: scores less than 13 will be inadequate practice, scores from 14 -18 as moderately adequate while scores from 19- 23 will be rated as adequate.

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