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Item type Presentation

Format Text-based Document

Title Patients Being Weaned From the Ventilator: PositiveEffects of Guided Imagery

Authors McVay, Frank; Spiva, Elizabeth; Hart, Patricia L.

Downloaded 18-Jun-2018 11:03:04

Link to item http://hdl.handle.net/10755/621471

Frank McVay, BS, BSN, RN LeeAnna Spiva, PhD, RN

Tricia Hart, PhD, RN Karen Malley, MSN, RN, CCRN, CNL

Marsha Kadner, MBA, BSN, CCRN, CNML, RN Angela Segars, BSN, RN, CCRN

Betsy Brakovich, DNP, RN Sonja Y. Horton, M.Div

Erin Gallagher, BS Melida Garcia, BSN, RN, CCRN Novlette Smith, BSN, RN, CCRN

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Patients Being Weaned from the Ventilator: Positive Effects of Guided Imagery

Not-For-Profit 11-Hospital System ~ 2,775 Beds

Integrated Health System: 2 Health Parks, 3 Nursing Homes, 3 Hospices, 8 Urgent Care Centers, 19 Imaging Centers, 1 Pediatric Center

240 Medical Offices (2,900 Medical Group Providers)

69,900+ Discharges/year

9,500+ Deliveries/year

20,000+ Team Members

Revenues $3 Billion

$427 Million in Annual Community Benefits

WellStar Health System

Background

Mechanical ventilation (MV) estimated $27 billion a year representing 12% of hospital costs

Patients requiring MV may experience anxiety, inability to relax, psychological and emotional distress (unable to communicate), and delusional memories

Analgesic and sedatives are administered to reduce these symptoms; interventions have notable side effects, prolong MV, and contribute to longer length of stays

As MV duration increases, risk of hospital-acquired complications increases contributing to higher mortality & morbidity rates

[1-14]

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Guided Imagery

Guided imagery is used to focus on pleasant mental images to promote healing, relaxation, manage symptoms and contribute to well-being

Guided imagery is used in a variety of patient populations to

o Reduce pain, fatigue, stress and anxiety levels

o Reduce length of stay

o Lower (improve) respiratory rate (RR), heart rate (HR), blood pressure (BP)

o Reduce musculoskeletal pain and medication usage, including analgesics, in osteoarthritis patients

[15-30]

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Study Design & Study Aims

Study Design

o Quasi-experimental, repeated measures design

Study Aims o To determine effects of guided imagery in mechanically ventilated

patients undergoing active ventilator weaning on sedation levels, sedative and analgesic volume consumption, and physiological responses

o To assess nurse perception of feasibility and satisfaction of using guided imagery as an intervention

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Setting

Two community acute care hospitals with seven intensive care units (ICUs)

o One hospital served as comparison group and provided routine care (no intervention), while the other hospital provided guided imagery (intervention)

o The two hospitals were chosen based on similar patient population (age, reason for ICU admission, illness severity, etc.); evidence-based MV order set was followed to decrease practice variation

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Sample

Patient inclusion: (a) age greater than 18 years; (b) actively weaning from MV (process of gradual reduction of ventilator support) per hospital weaning criteria; and (c) no hearing impairment

Nurse inclusion: directly caring for patient receiving intervention

34 patients (power .80, alpha .05, medium effect of 0.25)

Approval obtained from Institutional Review Board

Informed consent obtained at beginning of study by researcher from each patient’s surrogate due to patient consumption of sedatives and analgesics

Participant assigned a unique identifier to protect confidentiality

[31-32]

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Intervention

Prior to session, patient sedation level assessed before weaning to ensure patient rested and not lethargic when weaning started

Two separate sessions 60 minutes each held on two consecutive days during AM weaning trials

Guided imagery delivered via PLAYAWAY® device, 5x7 inch plastic case, with 4-track pre-loaded 60-minute audio book with disposable earphones

Guided imagery narrated with faint, soft voice, instructing patient to relax

Started 20 minutes prior to weaning; patients listened to content 60 minutes during trial

Intervention time based on hospital average duration of weaning trial (30 to 120 minutes)

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Measurements

Richmond agitation-sedation scale (RASS) used to titrate sedation & pain control

Acute Physiology and Chronic Health Evaluation (APACHE II) provided illness severity and in-hospital mortality estimate

4-item survey rated on 5-point Likert scale (1= strongly disagree and 5= strongly agree) developed to assess guided imagery feasibility/satisfaction

HR, BP, RR, oxygen (O2) saturation and RASS scores were recorded at baseline, 30 and 60-minute intervals

Total volume of continuous intravenous (IV) sedatives and analgesics administered in 24-hour timeframe converted into milliliters and recorded from electronic medical record (EMR); amounts were evaluated before and after intervention

[33-35]

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Data Analysis

SPSS 22.0 software for Windows (SPSS, Inc., IBM Company, Armonk, NY)

Independent t-test, Chi-square test, and Mann-Whitney U test- examined differences between comparison and intervention groups

Friedman test determines changes over time with RASS scores and sedative volumes followed by post hoc analysis with Wilcoxon signed-rank test with Bonferroni correction applied

One-way repeated measures analysis of variance was conducted to test effect of guided imagery on patient physiological responses during both sessions at baseline, 30 minutes and 60 minutes

To detect differences with analgesic use, t-tests were conducted

Significance level was set at P < .05

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Sample

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Comparison

(N = 21) Intervention

(N = 21) Total

(N = 42) P

Age, y

Mean (SD) 64 (14.1) 65.2 (12.7) 64.6 (13.25) 0.78

Median, range 61 35-93 66 39-89 64.5 35-93

Female sex, % 15 71.4% 8 38.1% 23 54.8% 0.03

Race, % 0.05

White 12 57.1% 17 81% 29 69%

African American 7 33.3% 1 4.8% 8 19%

Other 2 9.5% 3 14.3% 5 11.9%

Marital Status, % 0.87

Married 6 28.6% 14 66.7% 80 47.6%

Single 6 28.6% 2 9.55% 8 19%

Other 9 42.9% 5 23.8% 14 33.3%

Number of Comorbidities

Mean (SD) 5.9 (2.8) 4.7 (2.6) 5.29 (2.7) 0.14

Median, range 6 1-15 4 1-10 5 1-15

APACHE Score

Mean, SD 22.9 (8) 25.8 (6.7) 24.36 (7.42) 0.21

Median, range 24 10-39 24 9-38 24 9-39

Reason for ICU Admission, % 0.09

Respiratory 14 66.7% 11.52 52.4% 25 59.5%

Cardiac 4 19% 8 38.1% 12 28.6%

Other 3 14.3% 2 9.5% 5 11.9%

Hospital Length of Stay

Mean (SD) 21.33 (15.9) 19.9 (11.1) 20.63 (13.6) 0.74

Total days on ventilator

Mean (SD) 13.14 (15.2) 8.26 (7.3) 10.7 (12.1) 0.2

Median, range 7 2-56 7 1-29 7 1-56

Ventilator mode 0.06

Assist control, n % 18 85.7% 10 47.6% 28 66.7%

Synchronized intermittent mandatory, n % 2 9.5% 3 14.3% 5 11.9%

Pressure control, n % 1 4.8% 8 38.1% 9 21.4%

Sedation levels, sedative and analgesic outcomes for Session I

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Characteristic Comparison

(N = 21), M(SD) Intervention

(N = 21), M(SD) P

SESSION I

Baseline RASS score -.38 (1.1) -2.1 (1.4) 0.000

30 minute RASS score 0.1 (1.2) -1.57 (1.4) 0.000

60 minutes RASS score -.29 (1.2) -1.17 (1.8) 0.086

24-hour cumulative amount (mL)of sedative infused prior 133.18 (143.28) 218.66 (243.62) 0.284

(16 doses) (19 doses)

24-hour cumulative amount (mL)of analgesic infused prior 48.92 (83.77) 95.28 (128.12) 0.173

(11 doses) (14 doses)

24-hour cumulative amount (mL)of sedative infused after 111.77 (156.24) 78.59 (93.61) 0.737

(13 doses) (13 doses)

24-hour cumulative amount (mL)of analgesic infused after 54.69 (89.28) 18.1 (18.10) 0.111

(11 doses) (8 doses)

Sedation levels, sedative and analgesic outcomes for Session II

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Characteristic Comparison

(N = 21), M(SD) Intervention

(N = 21), M(SD) P

SESSION II

Baseline RASS score -.55 (.8) -1.67 (1.4) 0.043

30 minute RASS score -.35 (.9) -1.08 (1.4) 1.62

60 minutes RASS score -.55 (.8) 0 (1.8) 0.181

24-hour cumulative amount (mL)of sedative infused prior 109.24 (146.74) 166.54 (259.61) 0.803

(14 doses) (10 doses)

24-hour cumulative amount (mL)of analgesic infused prior 24 (52.67) 2.52 (9.13) 0.073

(6 doses) (4 doses)

24-hour cumulative amount (mL)of sedative infused after 125.93 (188.45) 38.13 (75.78) 0.024

(15 doses) (3 doses)

24-hour cumulative amount (mL)of analgesic infused after 21.14 (56.36) .49 (1.53) 0.101

(4 doses) (3 doses)

Physiological Responses

Intervention group: lower HR & RR and higher oxygen saturation compared to comparison group over three time periods

1st session only, HR differed over three time periods (F2, 80 = 3.91; P = .02)

Respiratory rate differed over time during sessions one (F2,80 = 4.45; P =.02) and two (F 2,60= 3.02; P = .05)

HR & RR for both groups increased from baseline to 60 minutes

2nd session oxygen saturation levels (F2,60 = 3.11; P =.05) differed between the two groups

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Staff Perception

Of 42 surveys distributed, 23 nurses (55%) completed survey with mean scores ranging from 4.09 to 4.83

Nurses felt guided imagery was effective nursing intervention (M = 4.83, SD = .39)

Nurses felt intervention was incorporated into weaning process (M = 4.09, SD = .95), simple to implement (M = 4.13, SD =1.0), and met intended purpose (M = 4.09, SD =1.08)

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Discussion

Patients receiving intervention had a shorter time on ventilator, shorter LOS, lower HR and RR

Significant improvement in actual sedative and analgesic volume intake despite baseline RASS score of 24% of intervention patients deeply sedated (greater -4)

Throughout intervention, HR, BP, O2 sat levels remained normal

Nurses perceived intervention as effective

Sample primarily white females admitted to ICU with respiratory problem

Sedation & analgesic use, levels, & practices may have varied between sites & affected measurements; we focused on volumes, (most weight-based medications). Comparing medication volume infused between groups is a limitation

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Discussion

Certain meds may have masked intervention effects as meds were not controlled, for example, cardiac medications

Ventilator weaning for both hospitals is assumed by respiratory therapist guided by standardized protocol; daily weaning occurred in AM and intervention effects may have been different later in day

Secondary to one hospital serving as intervention and other serving as control, any hospital outcome is potentially confounded by intervention effect; by carrying out intervention at one hospital only, researchers were hoping to lessen threat of treatment diffusion

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Discussion

Randomized controlled trial (RCT) not conducted secondary to ICU events that either occurred daily and/or were planned that researchers had no control over including, noise levels, patient volumes, renovations, and medical record transition

Patients’ surrogate consented for patient to participate a day prior to actual intervention and/or surrogate was not present during entire weaning process and intervention

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Conclusions

Guided imagery appeared to be an effective, safe and feasible intervention to use on patients being weaned from MV

Future research is needed including a larger randomized controlled trial examining guided imagery use with a larger sample using a longer tracking period in relation to patient outcomes

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Acknowledgments

Acknowledgements: The researchers acknowledge Amy Good, BSN, RN for her assistance with data collection

Funding: This research received $150 from WellStar’s Nursing Research Fund to purchase music and guided imagery devices for use in the study; researchers also received a discounted price for PLAYAWAY® device at Findaway World

References and additional information available at LeeAnna Spiva, PhD, RN leeanna.spiva@wellstar.org

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