Improving nurse led eye care on the Paediatric Intensive Care Unit

Publication: 09/03/2010  
Next review: 03/07/2023  
Clinical Guideline
CURRENT 
ID: 1968 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Improving nurse led eye care on the Paediatric Intensive Care Unit

The aim of this project is to improve the care of patient’s eyes within a Paediatric Intensive Care Unit (PICU) by creating a nurse-led assessment process. Focusing on staff knowledge, understanding and assessment of the eye will be key. This will hopefully influence other healthcare workers in the sphere of decision making as they will be empowered with the relevant information.

Historically eye care has been performed alongside the VAP care bundle, however prior to this project eye care compliance has been questionable and become a tick box exercise. Patients who have had serious complications with the health of their eye haven’t received effective care as per national guidelines (The Royal College of Ophthalmologists 2017). The increase in long term critically ill children on PICU has prompted me to improve the care and provide staff with current up to date guidance to prevent unnecessary procedures and also ensuring necessary care is followed correctly. There previously has been a guideline for eye care on PICU however this is out of date and as we want to ensure we offer the best care to our patients and try to eliminate any further health conditions I feel this change management project will provide patient’s with up to date evidence based care.

The health of the eye surface especially the cornea depends on a normal ability to produce tears, blink and have a period of rest fully closed. Whilst on a Paediatric Intensive Care Unit (PICU) this can be impaired due to illness required ventilation or high flow or due to reduced conscious levels, facial oedema but particularly due to muscle relaxants or sedation. Muscle relaxants reduce the tonic contractions of the ocular muscle which normally keeps the lids closed and sedation reduces the ability to blink at the normal rate and reduces the blink reflex. This inability to close the eye effectively or blink to clear the eye are at high risk of causing damage to the front of the eye and patients also requiring mechanical ventilation are at a higher risk as they will have a longer stay, require more sedative or paralysis medication and the effects of positive pressure ventilation.

Vision is one of our main senses and means of communication for most people. Impaired vision, therefore, can contribute to delirium. Treatments for critical illness, especially sedation and muscle paralysis cause impaired blink reflexes and loss of eyelid muscle tone, while fluid balance and positive pressure ventilation may lead to chemosis. Ocular health needs and risks should be assessed to identify whether or not interventions are needed (Woodrow, Elliot & Beldon, 2013). Evidence based research on eye care within the PICU setting is sparse; there is very little guidance for Paediatric care nationally or locally however, due to children now surviving conditions and diseases that once were life ending, which are now resulting in longer PICU stay generally in a critically ill condition for longer periods of time. Maintaining patient stability is paramount and patients with significant impairment of major organs, primary treatment is focused on their management; the effects the associated interventions have on the health of the patient’s eye will not immediately be at the forefront of care until there are noticeable complications which could cause permanent damage (Grixti et al 2012).

There is very little research specifically on eye care in PICU and the available information is either out of date or of poor literature status. A literature search on eye care within a PICU setting using the NICE(2019) healthcare database advanced search which allows you to search PubMed, CINAHL, Medline and many more databases (see appendix 3 for literature search) it was found that the most reliable information was from Adult Intensive Care units (ICU) and The Royal College of Ophthalmology guidance produced in June 2017. Telephone contact with half a dozen PICU’s staff members across England revealed the consensus that specific guidance for paediatric specific care was limited and a lot of the care provided remains historical and inconsistent.

As practitioners we are committed to always putting the patient first. This can be done by empowering staff with up to date knowledge and guidance, ensuring all staff are working collaboratively to provide the same care to each patient in the correct way. Having a generic assessment tool and up to date evidence-based guidance will ensure fair and harm free care is given that is evidence-based. Always having the patient and their families at the centre of all care ensuring they are given accurate and timely information along with rationale for procedures. Accurate documentation is a vital component of an ethical, safe and effective nurse who can be held accountable for their actions (NMC 2015), as once was said by Kimberley (2003) “if it wasn’t documented, it wasn’t done” it remains essential for a clear time line of all patient care. Improving quality is about making healthcare safe, effective, timely, patient-centred, efficient and equitable. Never in the history of the NHS has there been as much focus on improving the quality of the healthcare that is provided. All staff have a role to play in ensuring healthcare services continue to improve and with the current evidence showing that heath care is not always safe this can lead to bad patient experience there is even more pressure to improve care given to create a more effect and harm free service.

Quality can be defined as measured, evidence based, safe, standardised, robust, valued, fit for purpose, consistent, effective and sustainable. There needs to be clear, focused goals with achievable measurable targets so that improvements can be monitored. This change project aims to improve eye health for patients on the PICU by 75% before November 2019. Staff education and guidance will ensure the delivery of correct eye care to the appropriate patient groups. Having evidence-based guidance will ensure staff provide harm free care that is effective, efficient, safe and sustainable.

Having a structured approach for nurse led assessment of eye care will allow staff to develop positive behaviours and encourage the opportunity to work outside their core roles and contribute to the health and decision making of the eye care plan. SMART objectives (Ambler 2010) were formulated to ensure there was a structured approach to the project.

Change management theories were evaluated to ensure the most suitable model was selected for the project and the setting to which it will be held. Change management is a continual re-assessment. The change model that was selected was the PDSA cycle (ACT Academy 2017). This was the most appropriate cycle for the project and environment due to the small cycles of change. Other change models like Lewin’s change model (1947) didn’t feel appropriate as the project directly involved patient care and specific guidance is available in this area that needed to be implemented, Lewin’s model (1947) appeared to be more a trial and error model. ADKAR (Hiatt 2003) again although a very good change model and one that was nearly chosen felt this didn’t offer the ability to re-assess only reinforce.  

As with any change ownership is the key to implementing the improvement successfully, not just practical making a change but changing people’s perception of the change (Bevan 2010). If you involve a range of colleagues in trying something out on a small scale before it is fully operational, you will reduce the barriers to change.

Limited research surrounding eye care for PICU patients, however the paediatric research that is available suggests that the vast amount of research for Adult ICU and the effects of critical illness and mechanical ventilation with an impaired blink reflex are the same. The Royal College of Ophthalmologist published updated guidelines in 2017 giving very clear guidance on caring for patients’ eyes in an ICU using a grading system. The PICU has previously has guidelines produced in 2010 and updated since however are not in date now nor practiced on the unit. ICU guidelines.

Having chosen an area of change it was required to obtain support from the ward manager. Change is never easy in any environment, it is assumed that change implies that something has been done incorrectly previously, however change is a positive action especially in healthcare if it is necessary to improve patient care or experience. Using the PDSA change theory within the planning stage SMARTER objectives were utilised so the project for change was recognised as necessary for both patients and nursing staff ensuring the best evidence-based care is provided, also ensuring it is measurable and so was it achievable. If a project isn’t measurably then it cannot be achievable, without data the change can only be a matter of opinion rather than evidence based. Brainstorming using a mind map was the preferred way to separate the objectives from the goals and what resources were required to achieve the desired result. During the DO stage of the PDSA cycle, Data was then collected from a staff questionnaire aimed at gathering pre change data on staff knowledge, this was given to a variety of staff with a variety of experience across all nursing bands. Data was requested from the medical team as to how many ophthalmology referrals have been made over the last twelve months however referrals are not logged or currently documented, so this information is not available. However, the Paediatric Ophthalmologist agreed to source this data for the project and information on patient’s ocular health following outpatient’s appointment. The study process was analysing the data collected, however data from the ophthalmologist was still outstanding due to time constraints. This did not affect the project moving forward at this point and the questionnaires were analysed an overview of staff knowledge was obtained.

Staff questionnaire to assess the current knowledge of eye care. This information will act as pre change data and will be used to compare later. 

 

 

At this point it needs to be noted that only thirty questionnaires were returned so this is not a true reflection of all staff and there has been opportunity to falsify the information provided to seem more accurate. The data collected still displays a problem with staff knowledge of identifying what equipment to use and when to use it. This strengthens the need for change and has provided raw data to compare once the change is in place.

Although as previously stated the PICU has previously had guidelines and taught procedures but these are historical and out of date. The need for more visual reference is required along with re-education. This will be first trial in the form of a bedside nurse-led assessment flow chart along with guidelines and rationale for eye hygiene.  

The implementation of this documentation with be addressed in the next cycle of PDSA.

There have been a variety of barriers that have been obstructive throughout the project, initially deciding on how to gather the raw data was difficult due to shift patterns, time constraints and patient demand so a basis questionnaire to gauge staff knowledge was the best idea. This itself was time-consuming process as encouraging staff to fill out and return them is difficult. I utilised the nurse in charge to promote completion in my absence. With winter pressure and reduced staffing levels, progressing with the project implementation was difficult and this has led to a reduction of staff participation to promote the forth coming change and has also prevented any available work time to inform, discuss and update staff on the changes that are been going to be implemented.  Possible reason for non-compliance in correct eye care may be due to a reduction in experienced staff and the consistency and quality of care may be affected. Lack of any data from PICU as to referrals made to ophthalmology, however this is currently been sourced from an ophthalmology registrar this data can be used along side the questionnaire data to compare in the future.   

It was advised that the nurse led assessment flow chart that I produced needed to be overlooked and approved by a PICU Consultant to ensure that it was appropriate to publish for use on the PIC unit and this had caused a delay due to annual leave and unit pressures. Also, time was restricted due to other educational commitments with high demands.

For the future of the project a decision needs made in the next plan stage of the cycle the most effective way to deliver to new flowchart and guidance information. There is a variety of resources available that can be utilised to convey the new process. All staff have an NHS email address however ensuring all staff check and read the emails is difficult, teaching boards have had previous success on the PICU and during downtime are often read and feedback given but again this will only be in one specific area and not visual to all nursing staff. Personal Development Groups (PDG) are a good time to bring new information to small clusters of staff, having the opportunity to attend these groups will be difficult due to the ward demands. Considerations also need to be made for the variety of learning styles and understanding that people learn and retain information differently and unfortunately there will be some nursing staff that may struggle with the format choice. This will give the opportunity for a variety of leadership styles helping people retain and utilise the information by been a transformational leader and not allowing learning style to be a barrier to change. Making a change is very rewarding however time consuming, ensuring that the change you are making is for the improvement to the patients foremost and for the staff and the trust.

The personal learning points from conducting this project are that things don’t happen overnight, planning and visualising the change is key and learning that not all research is good research. I have always known that people learn in different ways and at different speeds and on an individual basis this can be managed adequately, having to plan implementation of a change whilst considering a vast group of different learners is difficult and frustrating, this reaction reflects my own activist learning style and something I have worked on to overcome throughout this project.

Nurse Led Eye Care Assessment

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Rationale for Eye care on the Paediatric Intensive Care Unit (PICU)

Equipment required for Eye care:

  • Sterile gauze
  • Sterile water ampoules (water for injection)
  • PPE
  • Prescribed ocular lubricant (if required)
  • Micropore (if required)

Action

Rationale

Explain procedure to patient and/or their family

To alleviate fear and gain consent, however difficult to gauge understanding from young children/ critically ill.

Hand hygiene using 7 step process, PPE and maintain ANTT

Reduces the risk of infection and cross contamination

Apply sterile water to sterile gauze ensuring it is not over saturated

Limits irritation to the eye tissue and to maintain patient comfort.

With minimal pressure wipe from the inside to the outside ensuring no contact with the cornea. Single wipe and discard, repeating until eyes are clean.

To prevent fibres entering the eye causing surface scratches and reduces the risk of infection.

Dry eyes with a further piece of dry sterile gauze removing excess water, separate gauze for each eye.

To maintain skin integrity and patient comfort.

If required instil ocular lubricant as prescribed, identifying to correct tube for the correct eye, taking care not to touch the eye in any way.

To help restore the natural environment of the eye.
Preventing cross contamination of infection and damage to the surface.

Apply micropore tape to the eye if necessary, ensuring the lid is closed and the eye lashes are correctly positioned. Make sure the surrounding area is dry from ointment.

To protect the health of the conjunctiva and cornea from long term damage.

Assess, grade and document the condition of eye and report any changes to medical staff immediately.

Accurate documentation in line with NMC guidelines, monitor condition, information easily available when needed

 

Provenance

Record: 1968
Objective:
Clinical condition:

Eye care

Target patient group: Children aged 0 - 16 years
Target professional group(s): Secondary Care Nurses
Secondary Care Doctors
Adapted from:

Evidence base

  1. ACT Academy (2017) Plan, Do, Study, Act. (PDSA) cycles and the model for improvement. London: NHS Improvement.
  2. Alansari, M. A, Hijazi, M.H and Maghrabi, K.A (2015). ‘Making a difference in the eye care of the critically ill patient’. Journal of Intensive Care Medicine. Pp 311-317.
  3. Ambler, G. (2010) S.M.A.R.T Objectives. [Online] Available at: www.projectsmart.co.uk [Last accessed 12th April 2019]
  4. Barr, J. and Dowding, L. (2016) Leadership in Healthcare. 3rd Edition. London: Sage Publication.
  5. Berry, S.L and Douglas, L.J. (2010) Guidelines for eye care in the paediatric intensive care unit. The Leeds Teaching Hospital NHS trust guidelines.
  6. Bevan, H. (2010) From Compliance to Commitment. [Online] Available at: www.institute.nhs.uk/compliancetocommitment [Last Accessed, 12th March 2019].
  7. Brennan, E. (2017) Nurse-led eye care in the intensive Care Unit: A protocol for practice. Manchester University NHS Foundation Trust. 
  8. British National Formulary (2019) BMJ Publishing Group Limited: London
  9. Grixti, A. Sadri, M. and Edgar, J. (2012) Common Ocular Surface Disorders in Intensive Care Units. Ocular Surface: pg 26-42.
  10. Hiatt, J. (2003) ADKAR Change Model. [Online] Available at: https://www.toolshero.com/change-management/adkar-model/ [Last Accessed 9th April 2019]
  11. Honey, P. and Mumford, A. (1982) The Manual of Learning Styles. London: Peter Honey Associates. 
  12. Institute for Innovation and Improvement (2012) ‘Harm free’ care A new mind set in patient safety improvement Learning from the Safety Express. Pilot London.
  13. Jones, K. Warren, A. and Davis, A. (2015) Mind the Gap, Exploring the needs of early career nurses and midwives in the workplace. [Online] available at: www.hee.nhs.uk/files/2015/05/mind-the-gap-final. [last accessed 10th January 2019].
  14. Leading Change (2017) Adding Value summary   
  15. Leeds Teaching Hospitals NHS Trust (2014) The Leeds Way : The Leeds Teaching Hospital Trust Leeds.
  16. Lewin, K. (1947) Lewin's change management model. Understanding the three stages of change .[Online] Available at: http://www.mindtools.com/pages/article/newPPM 94.htm. [Last Accessed 21st February 2019].
  17. NICE (2019) Healthcare Database Advanced Search.[Online} www.Hdas.nice.org.uk [Last accessed 4th April 2019].
  18.  Nursing and Midwifery Council (2015) The Code. [Online] Available at: https://www.nmc.org.uk/standards/code/ [Last Accessed 5th November 2018]
  19. Paediatric Intensive Care Audit Network (2014-17) www.picanet.org.uk.(148) pg. 52.
  20. Paediatric intensive care society (2015): Quality standards for the care of critically ill children.
  21. The Royal college of Ophthalmologists (2017) Ophthalmic Services Guidance ‘Eye Care in the Intensive Care Unit (ICU). Intensive care society: London.
  22. Woodrow, P. Elliot, J. and Beldon, P. (2013) Assessment and Care of Tissue Viability, Mouth and Eye Hygiene needs in Critical Care. Manual of Clinical Procedures and Competencies. Wiley Blackwell.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

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