الفهرس 
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Abstract
Ventilator associated pneumonia (VAP) is associated with increased mortality and morbidity. Although the impact of VAP on mortality is still a matter for debate, its negative impact on duration of mechanical ventilation, length of intensuve care units (ICU) stay, and cost was repeatedly reported in several studies. Microaspiration of contaminated secretions around the tracheal cuff is the main mechanism for entry of bacteria into the lower respiratory tract. Tracheobronchial colonization, resulting from microaspiration, could progress to ventilator-associated tracheobronchitis or pneumonia. Improving the design of endotracheal tubes (ETT) (subglottic suction ETT) is a key issue in the prevention of microaspiration (Rouze et al., 2017).
Research design
A quasi-experimental design (one group pre/ immediately post and follow- up) was used in the current study. Intervention on its target nurses without random assignment. Therefore, the design is most appropriate to investigate the effect of the educational program on nurses’ performance regarding subglottic suction and clinical outcomes of patients.
Research setting
This study was conducted at the General Intensive Care Unit (ICU) at Beni -Suef University Hospitals, ICU located at 3rd floor in hospital, capacity of beds 19 beds, 12 ventilators, 19 monitors and 3 emergency carts, it were distributed in 4 rooms, ICU also contains one room for nurses, one class room and room for medication storage, ICU received monthly from 20 to30 patients with different diagnosis.
Research subject
A convenient sample (No=35 nurses), who working in ICU and care for patients inserted of subglottic suction ETT and accepted to participate in the study from both gender with different qualification, different age,training courses and years of experiences were recruited to this study.
Based on power analysis apurposive sample of eightieth mechanically ventilated patients from both gender. They were selected using the sensitive analysis according to number of ICU patients in the year 2017/2018 at Beni-Suef University Hospital = 300 is the coefficient factor = 0.05. Total number of patients = 80.
Inclusion criteria:
Adult Patients’ from both genders ≥18 years old.
Orally intubated with subglottic suction ETT.
Intubated Patients’who has anticipated mechanical ventilation (MV) from 48-96 hours.
Exclusion criteria:
Patients’ extubated before 48hours of ventilation.
Patients’ with chest infections.
History of aspiration on admission or before intubation.
Patients’ who were transferred from another hospital or had already connected with mechanical ventilator before the admission.
Leukocytes count less than 1000 cells/mm3.
Patients’with solid or hematological tumor.
Tools of data collection and techniques:
Five tools were used to collect the study data as follows:
Nurses’ Self-administered Questionnaire: (Appendix I).
It was used to assess nurses’ level of knowledge regarding subglottic suction. It was include two parts:
First part: it was concerned with the demographic characteristics of nurses under study such as age, gender, education level, experience, VAP prevention and subglottic suction courses.
Second part: Second part: It was adapted from (Mohamed, 2017; Hassan et al., 2018 and Qurany et al., 2018), and modified by the researcher to suite the study aim. It was written in Arabic language and included 40 questions in the form of multiple choice and true/false questions. It was categorized into 5 sections.
Nurses’ practice observational Checklist (Appendix II): This tool adapted from (Mohamed, 2017; Wiegand, 2017; Perry et al., 2021 and Tomaszek et al., 2021) and modified by the researcher to suite the study aim. It was written in English language and used to assess nurses’ level of practice regarding subglottic suction. The checklist consisted of five procedures each procedure included preparation, procedure and post procedure.
First procedure: is concerned with subglottic suction endotracheal tube (ETT) care that included 30 steps as follows:
1. Preparation (6 steps).
2. Procedure (18 steps).
3. Post procedure (6 steps).
Second procedure is concerned with deflation and inflation of endotracheal tube cuff which included 20 steps as follows.
1. Preparation (5 steps).
2. Procedure (10 steps).
3. Post procedure (5 steps).
Third procedure is concerned with endotracheal tube cuff measurement which included 26 steps as follows:
1. Preparation (12 steps).
2. Procedure (5 steps).
3. Post procedure (9 steps).
Fourth procedure is concerned with continuous subglottic suction drainage which included 42 steps as follows:
1. Preparation (16 steps).
2. Procedure (13 steps).
3. Post procedure (13 steps).
Fifth procedure is concerned with intermittent subglottic suction which included 30 steps as follows:
1. Preparation (16 steps).
2. Procedure (3 steps).
3. Post procedure (11 steps).
Nurses’ attitudes assessment scale (Appendix III):
This tool adapted from (Hadgu et al., 2015; Yaseen & Salameh, 2015; Qurany et al., 2018 and Abd El-Gawad et al., 2019) and modified by the researcher to suite the study aim. It was written in Arabic language and used to assess nurses’ attitude regarding subglottic suction. It consists of fourteen statements. Participants were asked to respond on a 3-point Likert scale.
Patients’ interview questionnaire (Appendix IV)
It was divided into two parts:
• First Part: It was concerned with demographic characteristics of patients under study such as patient’s age, gender.
• Second Part: Health-Related Data:
It was adapted from (Elpasiony et al., 2018; Diab et al., 2021; and Triamvisit et al., 2021) to suite the study aim. It was concerned with patient’s present and past history from the patients’ medical record. It was concerned with data related to smoking, current diagnosis, past medical history, arterial blood gases result before intubation, indication for mechanical ventilation (MV), duration on MV, and hemodynamic parameters (respiratory rate, oxygen saturation and heart rate).
Modified Clinical Pulmonary Infection Score (MCPIS) (Appendix V)
It was adopted from (Elpasiony et al., 2018). It was concerned with the assessment of patient for VAP.
Pilot study
Pilot study tools was carried out on group of 8 patients (10%) and group of 4nurses (10%) to test applicability of the study and to test clarity of the designed questionnairs, as well as to estimate the time needed to conducted the study. Some modification on tools were done based on pilot study, some statements were omitted, rephrased and then the final forms were developed. Subjects included in the pilot study were excluded from the main two study group.
The ethical research considerations in the study included the following:
The research approval was obtained from scientific research ethical committee in faculty of nursing in ain Shams University before initiating the study work.
The researcher clarified the objective and aim of the study to the nurse’s and patients included in the study.
The researcher assured maintaining anonymity and confidentiality of the subjects’ data.
Nurses and patients were informed that they allowed choosing to participate or not in the study and that they had the right to withdraw from the study at any time without giving any reasons.
Ethics, values, culture, and beliefs were respected.
The findings of the study can be summarized in the followings:
• According to demographic data the mean age of the studied nurses is 25.14±3.28, and (65.7%) of them are males. Concerning educational level, the result revealed that (68.6%) of the studied nurses are technical institute graduates.
• According to level of knowldege among studied nurses the present study revealed that 0, 42.9%, 34.3% had unsatisfactory level of knowledge pre programwhile increase of satisfactory level of knowledge immediately post program and slightly decrease in follow up.
• According to level of practice among studied nurses the present study revealed that, there was reduction in the total score of practice pre program most nurses had unsatisfactory and increase of satisfactory level of practice immediately post program and and slightly decrease in follow up.
• According to level of attitude among studied nurses the present study revealed that negative attitude regarding subglottic suction and VAP pre porgram, while postive attitude regarding subglottic suction and VAP immediately post and follow up.
• Regarding patients selected all sample according to inclusion and exclusion crtiteria before study and 98%of patients not diagnosis with VAP post program implementaiom.
Conclusion
Based on the result of the current study; it can be concluded that.
The results revealed that the nurses’ performance regarding subglottic suction was improved after implementation of the educational program, whereas there is statistically significant difference through three phases of study. The results also showed that there was insignificant difference regarding ventilator associated pneumonia (VAP) score which indicate decrease number of cases with VAP. Finally, the present study concluded that the application of educational program had a positive effect on studied nurses’ performance and patients’ outcome and this support the research hypothesis.
Recommendations
Based on results of the present study the following recommendations can be suggested:
Research
Replication of the current study on a larger sample is recommended to achieve generalization of the results and wider utilization of the designed program.
Education
• An orientation program for newely staff nurses regarding subglottic suction should be done to increase awareness about the use of r subglottic suctioning ETT and its benefits to prevent VAP.
• Continuous in-service training programs about subglottic suction for the purpose of refreshing, updating the nurses knowledge and practice regarding subglottic suction.
• The importance of establishing booklet guideline for critical care nurses regarding subglottic suction.
• The importance of establishing subglottic suction procedure in nursing students’ curriculum.