Benefits and harms of normal saline instillation before endotracheal suctioning in mechanically ventilated adult patients in intensive care units: A systematic literature review and meta-analysis

OBJECTIVES

This systematic review aimed to identify the effects of normal saline instillation before endotracheal suctioning on clinical outcomes in critically ill patients on a mechanical ventilator.

RESEARCH METHODOLOGY

This review was based on the guidelines of the National Evidence-based Healthcare Collaborating Agency in Korea and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Six electronic databases were searched for relevant literature. Other sources were also searched, including the reference lists of identified reports and previous systematic reviews. After the initial literature search, a two-step retrieval process was performed to select eligible studies. Then, data were collected using a newly developed form, and the risk of bias was assessed using the checklists of the Joanna Briggs Institute. Data were analyzed using both narrative syntheses and meta-analyses.

RESULTS

In total, 16 studies: 13 randomized controlled trials and three quasi-experimental studies, were included. From the narrative syntheses, instilling normal saline before endotracheal suctioning was associated with a decrease in oxygen saturation, prolonged time for oxygen saturation to recover to baseline, decreased arterial pH, increased secretion amount, reduced incidence of ventilator-associated pneumonia, increased heart rate, and increased systolic blood pressure. Meta-analyses showed a significant difference in heart rate at five minutes after suctioning but no significant differences in oxygen saturation at two and five minutes after suctioning and heart rate at two minutes after suctioning.

CONCLUSION

This systematic review indicated that instilling normal saline before performing endotracheal suctioning has more harmful effects than benefits.

IMPLICATIONS FOR CLINICAL PRACTICE

As recommended in the current guidelines, it is necessary to refrain from routine normal saline instillation before endotracheal suctioning.

An Estimate of Severe Harms Due to Screening Colonoscopy: A Systematic Review

OBJECTIVE

This study aims to comprehensively assess the direct, severe harms of screening colonoscopy in the United States. Whereas other investigators have completed systematic reviews estimating the harms of all types of colonoscopy, this analysis focuses on screening colonoscopies that had adequate follow up to avoid undercounting delayed harms.

DATA SOURCES

PubMed and Embase were queried for relevant studies on screening colonoscopy harms published between January 1, 2002, and April 1, 2022.

STUDY SELECTION

English-language studies of screening colonoscopy for average risk patients were included. Studies must have followed patients for adequate time post procedure, defined as 30 days after colonoscopy.

MAIN OUTCOMES

The primary outcome was the number of severe bleeding events and gastrointestinal (GI) perforations within 30 days of screening colonoscopy.

RESULTS

A total of 1951 studies were reviewed for inclusion; 94 were reviewed in full text. Of those reviewed in full, 6 studies, including a total of 467,139 colonoscopies, met our inclusion criteria and were included in our analysis of harms related to screening colonoscopies. The rate of severe bleeding ranged credibly from 16.4 to 36.18 per 10,000 colonoscopies; the rate of perforation ranged credibly from 7.62 to 8.50 per 10,000 colonoscopies.

CONCLUSIONS

This study is the first to estimate direct harms from screening colonoscopy, including harms that occur up to 30 days after the procedure. The risk of harm subsequent to screening colonoscopy is higher than previously reported and should be discussed with patients when engaging in shared decision making.

The Impact of Nursing Skill-mix on Adverse Events in Intensive Care: A Single Centre Cohort Study

BACKGROUND

The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed.

OBJECTIVE

To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE.

DESIGN & SETTING

We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient.

RESULTS

A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003).

CONCLUSION

An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable

BACKGROUND

Knowing the frequency and characteristics of adverse events is key to implementing actions that can prevent their occurrence. However, reporting systems are insufficient for this purpose and epidemiological studies are also required. Currently, the reviewing of clinical records is the gold standard method for knowing the frequency and characteristics of adverse events.Research on adverse events in primary care setting have been limited and primarily focuses on specific types of events (medication errors…) or patients. Large studies that search for any kind of adverse event in all patients are scarce.This study aimed to estimate the prevalence of adverse events in the primary care setting and their characteristics.

METHODS

Setting: all 262 primary healthcare centres in the Madrid region (Spain) during the last quarter of 2018.Design: cross-sectional descriptive study.Eligible population: subjects over 18 years of age who attended medical consultation over the last year (N=2,743,719). Randomised sample stratified by age.Main outcomes: age, sex, occurrence of an adverse event, number of consultations in the study period, avoidability, severity, place of occurrence, type of event, and contributory factors. The clinical records were reviewed by three teams, each composed of one doctor and one nurse trained and with expertise in patient safety.The SPSS software package (version 26) was used for the statistical analyses.

RESULTS

The evaluators reviewed 1,797 clinical records. The prevalence ofadverse events over the study period was 5.0%[confidence interval (CI) 95%:4.0%‒6.0%], with higher values in women (5.7%;CI95%:4.6%‒6.8%;P=0.10) and patients over 75 years of age (10.3%;CI95%:8.9%‒11.7%;P<0.001). The overall occurrence per hundred consultations was estimated to be 1.58% (CI95%:1.28%‒1.94%).Of the detected adverse events, 71.3%(CI95%:62.1%‒80.5%) were avoidable. Additionally, 60.6%(CI95%:50.7%‒70.5%) were categorised as mild, 31.9%(CI95%:22.4%‒41.4%) as moderate, and 7.4%(CI95%:2.1%‒12.7%) as severe. Primary care was the occurrence setting in 76.6%(CI95%:68.0%‒85.2%) of cases. The overall incidence of adverse events related to medication was 53.2%(CI95%:50.9%‒55.5%). The most frequent types of AE were prescription errors (28.7%;CI95%:19.5%‒37.9%), followed by drug administration errors by patients (17.0%;CI95%:9.4%‒24.6%), and clinical assessment errors (11.7%;CI95%:5.2%‒18.2%). The most common contributory factors were those related to the patient (80.6%;CI95%:71.1%‒90.1%) and tasks (59.7%;CI95%:48.0%‒71.4%).

CONCLUSION

A high prevalence of adverse events (1 in 66 consultations) was observed, which was slightly higher than those reported in similar studies. About three out of four such events were considered to be avoidable and one out of 13 were severe. Prescription errors, drug administration errors by patients, and clinical assessment errors were the most frequent types of adverse events.

Physiological abnormalities and adverse events during physical therapy in the intensive care unit after cardiac surgery: A prospective observational study

BACKGROUND

After cardiac surgery, physiological abnormalities or adverse events might occur in patients in the intensive care unit (ICU) during physical therapy care. Identifying these events may help improve patient safety and care.

OBJECTIVES

To estimate the incidence and the degree of severity of physiological abnormalities or adverse events during physical therapy interventions provided in the ICU after cardiac surgery. To explore the relationship between these events and patients' characteristics and clinical outcomes.

METHODS

Prospective observational study of adult patients in the postoperative period of cardiac surgery admitted to the ICU of a referenced university hospital. Physical therapy interventions were observed by a team trained to evaluate and register the occurrence of physiological abnormalities or adverse events and grading their consequences. We compared baseline characteristics and outcomes of patients with versus without these events.

RESULTS

We observed 935 physical therapy interventions in 323 patients, of which 189 (20%, 95% confidence interval: 18, 23%) resulted in physiological abnormalities or adverse events. The highest incidences of these events were observed during endotracheal suctioning (44%), walking (40%), and noninvasive ventilation (37%). Hemodynamic changes were the most frequent events accounting for 74% of all events. Only 2% of interventions resulted in mild harm and 0.2% in moderate harm. The presence of comorbidities was associated (p = 0.03) with the occurrence of these events.

CONCLUSION

Physiological abnormalities or adverse events occurred in 20% of physical therapy interventions in patients in the ICU after cardiac surgery, with 10% of those resulting in negative effects. Only the presence of comorbidities was associated with the occurrence of these events.

Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands

OBJECTIVE

Numerous studies have shown that a substantial number of patients suffer from adverse events (AEs) as a result of hospital care. However, specific data on AEs in acute cardiac care are scarce. The current manuscript describes the development and validation of a specific instrument to evaluate patient safety of a predefined care track for patients with acute myocardial infarction (AMI).

DESIGN

Retrospective patient record review study.

SETTING AND PARTICIPANTS

A total of 879 hospital admissions treated in a tertiary care centre for an AMI (age 64±12 years, 71% male).

MAIN OUTCOME MEASURE

In the first phase, the medical records of patients with AMI warranting coronary angiography or coronary intervention were analysed for process deviations. In the second phase, the medical records of these patients were checked for any harm that had occurred which was caused by the healthcare provider or the healthcare organisation (AE) and whether the harm that occurred was preventable.

RESULTS

Of all 879 patients included in the analysis, 40% (n=354) had 1 or more process deviation. Of these 354 patients, 116 (33%) had an AE. Patients with AE experienced more process deviations compared with patients without AE (2±1.7 vs 1.5±0.9 process deviations per patient, p=0.005). Inter-rater reliability in assessing a causal relation of healthcare with the origin of an AE showed a κ of 0.67 (95% CI 0.51 to 0.83).

CONCLUSIONS

This study shows that it is possible to develop a reliable method, which can objectively assess process deviations and the occurrence of AEs in a specified population. This method could be a starting point for developing an electronic tracking system for continuous monitoring in strictly predefined care tracks.

Predicting Harm Scores from Patient Safety Event Reports

The identification of the severity of patient safety events promotes prioritized safety analysis and intervention. The Harm Scale developed by the Agency for Healthcare Research and Quality is widely used in the US hospitals. However, recent studies have indicated a moderate to poor inter-rater reliability of the Harm Scale across a number of US hospitals. Although the reasons are multi-folded, biased human judgments are recognized as a prominent factor. We proposed that key information to identify and refine the severity of harm is contained in the narrative data in patient safety reports. Using automated text classification to categorize harm scores is intended to provide reduced subjective judgments and much improved efficiency. We evaluated different types of classification algorithms using a corpus of patient safety reports from a US health care system. The results demonstrate the effectiveness and efficiency of the proposed methods. Accordingly, human biases on the application of harm scores are expected to be largely reduced. Our finding holds promise to serve as a semi-supervised tool during the process of manually reviewing and analyzing patient safety events.

Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the Literature

OBJECTIVE

The purpose of this study was to review the literature for cases of adverse events in infants and children treated by chiropractors or other manual therapists, identifying treatment type and if a preexisting pathology was present.

METHOD

English language, peer-reviewed journals and non-peer-reviewed case reports discussing adverse events (ranging from minor to serious) were systematically searched from inception of the relevant searchable bibliographic databases through March 2014. Articles not referring to infants or children were excluded.

RESULTS

Thirty-one articles met the selection criteria. A total of 12 articles reporting 15 serious adverse events were found. Three deaths occurred under the care of various providers (1 physical therapist, 1 unknown practitioner, and 1 craniosacral therapist) and 12 serious injuries were reported (7 chiropractors/doctors of chiropractic, 1 medical practitioner, 1 osteopath, 2 physical therapists, and 1 unknown practitioner). High-velocity, extension, and rotational spinal manipulation was reported in most cases, with 1 case involving forcibly applied craniosacral dural tension and another involving use of an adjusting instrument. Underlying preexisting pathology was identified in a majority of the cases.

CONCLUSION

Published cases of serious adverse events in infants and children receiving chiropractic, osteopathic, physiotherapy, or manual medical therapy are rare. The 3 deaths that have been reported were associated with various manual therapists; however, no deaths associated with chiropractic care were found in the literature to date. Because underlying preexisting pathology was associated in a majority of reported cases, performing a thorough history and examination to exclude anatomical or neurologic anomalies before applying any manual therapy may further reduce adverse events across all manual therapy professions.