Cuidado para la prevención de la extubación no planificada: análisis de la validez del contenido de un instrumento

Torres, Giovanna Mercado; Nascimento, Eliane Regina Pereira do; Hermida, Patrícia Madalena Vieira; Malfussi, Luciana Bihain Hagemann de; Galetto, Sabrina Guterres da Silva

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Brasil

Revista Brasileira de Enfermagem

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Sumário

ORIGINAL ARTICLE • Rev. Bras. Enferm. 74 (1) • 2021 • https://doi.org/10.1590/0034-7167-2018-0998 copiar

Cuidado para la prevención de la extubación no planificada: análisis de la validez del contenido de un instrumento

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivos:

analizar la validez de contenido de un instrumento de cuidados de enfermería para la prevención de extubación no planificada en una Unidad de Cuidados Intensivos.

Métodos:

estudio metodológico, con 40 enfermeras, conteniendo 26 intervenciones distribuidas en los componentes: manejo de la agitación/delirio/dolor; estabilidad del dispositivo respiratorio; destete de la sedación, evaluación de la respiración espontánea; gestión de recursos humanos. Se aplicaron Índice de Validez de Contenido, proporción media y universal y Coeficiente Kappa.

Resultados:

destacaron las especialistas brasileñas, con edad promedio de 44,9 años, y desviación estándar de 7,75 años. Dos intervenciones no alcanzaron un Índice de Validación de Contenido válido (≥ 0,78), al considerar el conjunto de criterios evaluados. Se identificó concordancia universal de 4.0% entre brasileños y 26.6% entre extranjeros.

Conclusiones:

el instrumento es relevante y representa el contenido “prevención de extubación no planificada en una Unidad de Cuidados Intensivos”, que puede ser implementado en Brasil y en países latinos, en versiones brasileñas y extranjeras.

Descriptores:
Cuidados Críticos; Extubación Traqueal; Unidades de Cuidados Intensivos; Seguridad del Paciente; Estudio de Validación

Nursing Interventions	REL		CON		CLA		OBJ		SIM		FEA		ACCU		CVI interventions
	CVI		CVI		CVI		CVI		CVI		CVI		CVI		CVI interventions
	BN	FE	BN	FE	BN	FE	BN	FE	BN	FE	BN	FE	BN	FE	BN	FE
Agitation/delirium/pain management
1. Detecting delirium using validated scales: ICDSC or CAM-ICU.	0.98	0.98	0.94	0.97	0.88	0.92	0.85	0.97	0.78	0.92	0.82	0.95	0.86	0.93	0.87	0.95
2. Assessing pain with BPS.	0.99	0.93	0.95	0.93	0.89	0.90	0.87	0.93	0.79	0.88	0.82	0.85	0.86	0.83	0.88	0.89
3. Monitoring the level of sedation and agitation with RASS.	0.99	0.97	0.95	0.90	0.92	0.98	0.91	1.00	0.89	0.92	0.87	0.98	0.93	0.97	0.92	0.96
4. Useing standardized protocol for assessment and management of pain, agitation, delirium.	0.96	1.00	0.90	0.98	0.94	1.00	0.95	0.98	0.88	1.00	0.99	0.97	0.70	0.92	0.90	0.98
5. Maintaining continuous surveillance of patients during bathing, transportation, changing positions and in the weaning process.	0.95	0.85	0.95	0.90	0.96	0.92	0.96	0.88	0.94	0.92	0.98	0.88	0.98	0.90	0.96	0.89
6. Identifying and modifying non-pharmacological risk factors for developing delirium.	0.89	0.87	0.93	0.92	0.96	0.98	0.89	0.90	0.82	0.97	0.83	0.92	0.86	0.88	0.88	0.92
7. Using mechanical restraint in appropriate clinical situations assessed by the team and based on current legislation.	0.95	0.83	0.89	0.92	0.96	0.97	0.97	0.90	0.93	0.90	0.96	0.93	0.96	0.92	0.95	0.91
8. Detecting asynchrony during mechanical ventilation.	0.93	0.87	0.98	0.92	0.94	0.82	0.96	0.85	0.82	0.87	0.94	0.93	0.89	0.87	0.92	0.88
Respiratory device stability
9. Using standardized technique and material when fixing an OTT.	0.94	0.95	0.91	0.97	0.97	0.93	0.97	0.98	0.97	0.98	0.99	0.97	0.97	0.95	0.96	0.96
10. Changing attachment whenever needed and when it is evidently damaged.	0.93	0.97	0.87	0.97	0.95	0.98	0.95	0.98	0.93	0.98	0.95	1.00	0.87	0.93	0.92	0.97
11. Checking cuff pressure, keeping 20-30 cm of H2O.	0.91	0.85	0.92	0.95	0.97	0.98	0.94	0.90	0.99	0.98	0.91	0.98	0.94	0.90	0.94	0.93
12. Monitoring OTT numbering at the level of the labial commissure.	0.98	0.97	0.98	0.98	0.94	1.00	0.95	0.93	0.98	1.00	0.99	1.00	0.99	0.98	0.97	0.98
13. Assessing OTT positioning with chest X-ray.	0.93	0.75	0.91	0.73	0.94	0.88	0.95	0.77	0.98	0.88	0.90	0.80	0.98	0.82	0.94	0.80
14. Performing MV pulmonary auscultation and checking lung expansion.	0.98	0.83	0.97	0.85	0.98	0.92	0.93	0.85	0.91	0.90	0.96	0.90	0.95	0.92	0.95	0.88
15. Assessing OTT permeability through the progression of aspiration probe and the presence of respiratory effort.	0.88	0.60	0.86	0.72	0.86	0.87	0.92	0.73	0.92	0.88	0.91	0.85	0.90	0.75	0.89	0.77
16. Checking changes in the capnograph curve.	0.87	0.80	0.88	0.90	0.89	0.95	0.92	0.87	0.92	0.88	0.88	0.92	0.93	0.88	0.90	0.89
17. Avoiding pulling OTT through the MV circuit, and positioning the circuit carefully during bathing, changing positions and transport.	0.97	0.98	0.97	1.00	0.99	0.98	0.96	0.98	0.98	0.98	0.99	0.98	0.94	0.95	0.97	0.98
18. Center the patients' head during bathing, changing positions and transport.	0.87	0.82	0.89	0.85	0.94	0.85	0.88	0.80	1.00	0.92	0.99	0.82	0.95	0.87	0.93	0.85
Weaning from sedation and spontaneous breathing assessment
19. Stoping using sedatives daily using standardized protocols.	0.81	0.93	0.83	0.90	0.85	0.98	0.81	0.95	0.94	0.93	0.93	0.90	0.92	0.93	0.87	0.93
20. Using the spontaneous wake-up test.	0.91	0.87	0.95	0.88	0.88	0.86	0.85	0.88	0.77	0.87	0.77	0.83	0.85	0.88	0.85	0.87
21. Using the spontaneous breathing test.	0.93	0.92	0.95	0.90	0.88	0.83	0.85	0.92	0.77	0.85	0.77	0.85	0.85	0.90	0.86	0.88
22. Assessing daily the need for early weaning.	0.89	0.98	0.85	0.98	0.93	0.97	0.88	0.98	0.96	0.95	0.97	0.93	0.96	0.95	0.92	0.96
23. Monitoring alarms related to airway pressure and graphical analysis of volume-time, flow-time and pressure curves.	0.93	0.82	0.92	0.82	0.93	0.95	0.91	0.88	0.89	0.87	0.97	0.85	0.96	0.80	0.93
Human resource management
24. Maintaining enough nur. Staff per patient in critical health situation according to workload.	0.94	0.97	0.86	0.92	0.88	0.97	0.87	0.98	0.93	0.87	0.88	0.88	0.87	0.95	0.89	0.93
25. Determining nur. sizing according to the technical standards in force in each institution.	0.74	0.98	0.71	0.90	0.80	0.97	0.79	0.92	0.79	0.88	0.86	0.97	0.70	0.97	0.77	0.94
26. Conducting/providing continuing education and training for nur. staff.	0.95	0.95	0.91	0.92	0.95	1.00	0.92	0.97	0.88	0.87	0.90	0.95	0.96	0.97	0.92	0.95
All interventions	0.92	0.89	0.91	0.91	0.92	0.94	0.91	0.91	0.90	0.92	0.91	0.92	0.91	0.90	0.91	0.91

Adjustments performed
Component: Agitation/delirium/pain management Interventions 1, 2 and 3 were combined. The Ramsay Scale was added to intervention 3, joined to 1 and 2. The verb "detect" was changed to "identify" in intervention 6. Non-pharmacological risk factors for delirium development in intervention 6 were mentioned. The term "evaluation" was eliminated and "institutional" was inserted in the intervention 4. "Maintain continuous surveillance" was replaced by "continuously monitor" in intervention 5. "Modify" was changed to "prevent" in intervention 6.
Component: Respiratory device stability Interventions 9 and 10 were combined into one. In intervention 10, the situation in which OTT fixation should be changed was changed, so that it occurs once per shift according to skin conditions. "Adventitious noises" was added in intervention 14, and it was specified that it should be performed at least once per shift. The verb "check" was replaced by "detect" and "capnograph" by "capnography" in intervention 16. Interventions 17 and 18 were combined and synthesized.
Component: Weaning from sedation and spontaneous breathing assessment The writing was changed to "use a standardized protocol to stop the use of sedatives" in intervention 19. The test was specified to assess patients' awakening and that it should be used after suspending sedatives using the RASS or Ramsay Scale in intervention 20. The spontaneous breathing test was explained using T-tube in intervention 21. The word "need" was changed to "possibility" in intervention 22, and it was specified that standard protocols should be used in this intervention.
Component: Human resource management The component's name was changed to "in-service education". The term "continued" was replaced by "permanent" and the words "provide" and "training" were excluded from intervention 26.

Components and Interventions
Component: Agitation/delirium/pain management
1 - Identify and evaluate delirium with the ICDSC or CAM-ICU scales, pain with the behavioral pain scale - BPS, and the level of sedation and agitation with the RASS or RAMSAY scale. 2 - Using standardized institutional protocol for pain, agitation and delirium management. ^* * Intervention eliminated from the Brazilian version instrument; 3 - Monitoring patients continuously during bathing, transportation, changing positions and in the weaning process. 4 - Identifying and preventing non-pharmacological risk factors for developing delirium, such as noise, isolation, lack of communication, sleep deprivation, visit deprivation, absence of daylight, physical restraint and late mobilization. 5 - Useing mechanical restraint in appropriate clinical situations, assessed by the team and based on current legislation.
Component: Respiratory device stability
6 - Performing OTT fixation replacement using standardized technique and material, once per shift according to the skin conditions around OTT/faces. 7 - Assessing OTT positioning with chest X-ray. ^ Intervention suppressed from the foreign version instrument. T.N. - this instrument was freely translated, as it has not been validated in English yet. 8 - Identifying the presence of adventitious sounds, breath sounds and lung expansion, at least once per shift. 9 - Detecting changes in capnography curves. 10 - Avoiding moving the OTT through the MV circuit, position the centralized breathing device carefully during bath, changing its position, transporting and changing its fixation.
Component: Weaning from sedation and spontaneous breathing assessment
11 - Using standardized protocol to stop using sedatives. 12 - Using the SAT test to assess patients' awakening, after suspending sedatives, using the RASS or RAMSAY scale. 13 - Using the spontaneous breathing SBT test, using the T-tube. 14 - Assessing daily the possibility of early weaning, using standardized protocols.
Component: Human resource management
15 - Maintaining a sufficient number of nursing staff per patient in a critical health situation, according to the workload. 16 - Determining nursing staff sizing according to the technical standards in force in each institution.^* * Intervention eliminated from the Brazilian version instrument; 17 - Carrying out nursing staff permanent education.

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[1] Corresponding author: Giovanna Mercado Torres. E-mail: vannia_27@yahoo.es