Healthcare Team Interventions in ICU for Patients With Acquired-Brain-Injury: A Pilot Study Using Participant Observation

Background and Purpose: The patients with adquired brain injury (ABI) are frequently cared for in many ways, day and night. This care include interventions that are made with the aim to benefit the patient, bed-bathing, suctioning of respiratory secretions and repositioning in bed are examples. Despite this, several researchers have suggested some kind of relationship between the interventions that are performed in the care of the patients with ABI and the occurrence of clinical events that cause secondary brain injury (SBI) like increase or decrease of blood pressure, intracranial pressure, cerebral perfusion pressure and heart rate. The aim of this study was to develop observation guides (checklist) for the interventions bed-bathing, suctioning of respiratory secretions and repositioning in bed, in order to identify factors that could influence the neurocritical patients’ outcome.

Methods: To carry out the objectives set out in this pilot study, Participant Observation was used as a data collection tool. A total of nine interventions were observed in patients with isquemic and hemorrhage stroke and Traumatic Brain Injury in the ICU: four repositioning in bed, three bed-bathing and two suctioning of respiratory secretions. Two activities were planned to achieve the objective: 1. Elaboration, review and evaluation of the checklists and 2. Calculation of the percentage of compliance of the items in the checklists and identification of relevant variables in the patient with ABI.

Results: the results of this pilot study are exposed in the order of the activities mentioned above.

Activity 1: Elaboration, review and evaluation of the checklists.

A literature review (books, guides, protocols) was conducted to identify and determine how these interventions are executed according to standardized management guidelines. Six checklists resulted from this revision: 1. Bed bathing, 2. Oronasopharyngeal suction, 3. Tracheal suctioning, 4. Closed system tracheal suctioning, 5. Positioning the patient supine in bed, 6. Positioning the patient side-lying in bed; which were subject to experts review and a practical check.

• Experts review: the objective was to review the content and use of the language of the checklists. For this, two evaluators with clinical experience analyzed each item on the checklists and determined if they had all the important and relevant contents for each procedure. They also reviewed the spelling, punctuation, and grammatical errors.
• Practical check: the insertion into the field was started with the objective of reducing the "reactivity" (acting in a special way when they notice that they are being observed) and carrying out the observation of the interventions, guided by the checklists.

Activity 2. Calculation of the percentage of compliance of the items in the checklists and identification of relevant variables in the neurocritical patient.

The percentage of compliance was between 85-100% in all interventions, however the items that were not fulfilled are mostly clinically related to unfavorable results in patients with acquired brain injury. The items that were not met in each intervention and that may be related to the outcome of the patient are listed below:

Bed bathing	Suctioning of respiratory secretions	Repositioning in bed
· Leaves the patient totally uncovered. · Delay in finalizing the intervention. · Head of the bed less than 15 degrees or greater than 30 degrees. · Additional sedation prior to the procedure.	· Suction pressure higher than 120 mmHg · Head of the bed less than 15 degrees or greater than 30 degrees. · Hyperoxygenation at 100% prior to the start of the procedure. · Perform more than two suction events. · Additional sedation prior to the procedure.	· Head of the bed less than 15 degrees or greater than 30 degrees.

These items are now variable in the principal study.

Conclusion: This pilot study examined the feasibility of the main study. The insertion into the field using participant observation decrease the reactivity of the ICU staff at the moment of being observed. The elaboration, evaluation and testing of the checklists make possible that new intervening variables were obtained and now are part of the principal study.

ETHICAL CONSIDERATIONS: This project was approved by the Ethics Committee of the Universidad Nacional de Colombia.