Mitchell Ruff and Stacy Steiner
University of Kansas School of Nursing

July 1999

Executive Summary

In conducting this research utilization project, the Stetler/Marram model (1994) is utilized to guide application of research findings to practice to fit the assignment criteria.

Phase I: Preparation

With clinical relevance to critical care, instillation of a 3 to 10ml bolus of normal saline prior to endotracheal suctioning is an unsubstantiated, traditional intervention performed by nurses. Little empirical evidence supports this nursing practice, which is thought to loosen secretions, improve oxygenation status, and elicit a cough reflex (Schwenker, Ferrin, & Gift, 1998). An increasing amount of research discourages this controversial practice. The empirical evidence notes the disadvantages of normal saline instillation (NSI); such as patient discomfort, the adverse effects on oxygenation, and the increased risk for infection due to the release of bacteria into the lower airway (Ecklund & Ackerman, 1995). Therefore based on research findings, arbitrary use of NSI prior to endotracheal suctioning might worsen patient outcomes. This prompts possible revision needs of the current nursing procedures. This revision has great potential in producing positive patient outcomes for decreasing the amount of patient discomfort associated with suctioning, maintaining improved oxygen saturation, and decreasing the risk of infection related to NSI, while reducing hospital costs.

Phase II: Validation

Research findings did not demonstrate advantages to using NSI. Selected studies actually demonstrate adverse effects of NSI on oxygenation. Although some studies suggest an increase in secretion removal with the use of NSI, there are no feasible tools to measure secretion content. Only one study offered empirical evidence that normal saline instillation (NSI) may enhance secretion clearance through cough stimulation (Gray, MacIntyre, & Kronenberger, 1990). However, as pointed out by Ackerman & Mick (1998), insertion of the suction catheter alone stimulates the cough reflex. The research as a whole offers both probability and nonprobability sampling in diverse, controlled research designs. Appropriate and reliable measures and instruments were utilized. Identified weaknesses of current research findings include the inability of the researchers to measure the percent of normal saline in the secretions recovered. Small sample sizes and selective patient populations restrict the generalizability of the research findings. The research is lacking qualitative data describing patient discomfort related to NSI. Although studies suggest that NSI increases the risk of infection, further investigation is recommended. Refer to Table 1: Summary of Studies.

Phase IV: Decision Making

Substantiated evidence applicable to the current setting and knowledge noted in Phase III supports the consideration for revision of nursing procedures regarding the routine use of NSI. Application at the cognitive and action levels are necessary for utilization of current research findings due to the need for developing a new knowledge base and revising a common nursing procedure.

Phase V: Translation/Application

Critical care nursing implications can be extracted from the available research data on NSI. Utilization of empirical evidence is necessary to standardize existing nursing procedures related to NSI. By keeping up with and applying current research finding nurses can minimize potential hazards and improve patient outcomes. A number of studies provide adequate support to eliminate routine use of NSI.

Planned change is required in the revision of the nursing procedure. Lewin’s change theory is utilized to guide this process.

driving forces - scientific evidence, positive patient outcomes, and medical director support

restraining forces - routine and tradition, lack of knowledge/acceptance of recent evidence, attitudes

Reinforcing the driving forces and confronting the restraining forces is essential in promoting stabilization of the change.

Phase VI: Evaluation

As noted in the preparation phase, outcomes relative to not using NSI include increased patient comfort, improved oxygenation, decreased infections, and decreased hospital costs. Methods of evaluation may include ongoing patient satisfaction surveys, observable SVO2 affects, pre- and post chart audits, cost savings evaluation, and informal staff satisfaction surveys/discussions. As noted above, the change agent will continue to monitor compliance with the revised procedure and support staff in change maintenance.

Summary and Conclusions:

In summary, nurses needed to be aware of current research findings in order to substantiate nursing practice. Research needs to be considered and serve as the basis for revision of nursing procedures. Specifically noted in this research utilization project and clinically relevant to critical care, routine use of normal saline instillation prior to endotracheal suctioning should be abandoned. Using the revised Stetler model and Lewin’s change theory assisted efforts aimed at increasing knowledge base regarding NSI and implementing change. In conclusion, the available research suggests that NSI is ineffective and potentially harmful to patients. By revising the accepted nursing suctioning procedure based on research findings, the desired outcomes are expected to be met.

References

Ackerman, M. H. & Mick, D. J. (1998). Instillation of normal saline before suctioning in patients with pulmonary infections: A prospective randomized control trial. American Journal of Critical Care, 7(4), 261-266.

Bostick, J. & Wendelgass, S. T. (1987). Normal saline instillation as part of the suctioning procedure: Effect on PaO2 and amount of secretions. Heart & Lung, 16(5), 532-537.

Ecklund, M. M. & Ackerman, M. H. (1995). Ask the experts. Critical Care Nurse, 15(1), 88.

Gray, J. E., MacIntyre, N. R., & Kronenberger, W. G. (1990). The effects of bolus normal saline instillation in conjunction with endotracheal suctioning. Respiratory Care, 35(8), 785-790.

Kinloch, D. (1999). Instillation of normal saline during endotracheal suctioning: Effects on mixed venous oxygen saturation. American Journal of Critical Care, 8(4), 231-240.

Schwenker, D., Ferrin, M., & Gift, A. G. (1998). A survey of endotracheal suctioning with instillation of normal saline. American Journal of Critical Care, 7(4), 255-260.

Stetler, C. B. (1994). Refinement of the Stetler/Marram model for application of research findings to practice. Nursing Outlook, 42, 15-25.

Swansburg, R. C. (1990). Management and leadership for nurse managers. Boston: Jones & Bartlett.