Physicians' and nurses' opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey

Thirteen ICUs participated in the study, differing in size and teaching status and covering all levels of ICU in the Netherlands. Physicians assessed the eligibility of patients for the trial and when eligible confirmed trial medication in the patient chart. Nurses applied oral paste during SDD and SOD and administered suspension and systemic antibiotics during SDD. Furthermore, in all study periods, nurses applied oral hygiene consisting of teeth brushing and cleaning the oral cavity with a dental swab (Table 1).

Oral presentations were held at the start of every study period in each of the participating hospitals to inform nursing and medical staff about the trial and the study protocol. Furthermore, posters containing information about the study period were placed visibly in each unit. Both presentations and posters contained non-biased information about the aim of the trial and practical consequences of the next study period (oral hygiene, administration of study medication). Personnel from ICUs that had not used SDD before were invited to observe oral care and application of oral paste in another 'SDD-experienced' ICU.

A survey was used to determine expectations concerning and experience with SDD, and compliance to the study protocol. The survey to determine compliance to the study protocol was defined as the self-reported level at which nurses performed oral care according to the study protocol. Experience was focused on past and current experience with SDD. In the last week of each six-month study phase, all nurses and physicians working during a day (including night, day and evening shifts) received the questionnaire, which could be filled in anonymously [see Additional files 1 and 2]. With this single-day approach we expected to maximize response rates, because questionnaires could not be put aside but had to be returned the same day. In the second and third questionnaires (at the end of these study periods) it was also asked whether the nurse or physician had filled in a previous questionnaire. In the third questionnaire, nurses and physicians who participated in all three study periods were asked to grade workload, patient friendliness and effectiveness for SDD, SOD and standard care on a scale of 1 (low) to 10 (high). Patient friendliness was described as ease of application of oral hygiene and oral paste, and patient endurance of oral paste (taste, structure) to minimize additional stress in patients. Of note, nurses and physicians were not aware of the outcome results of the SDD-SOD trial at the time of the questionnaires.

A comprehensive literature search in Medline and Cumulative Index to Nursing and Allied Health Literature was performed in August 2004. The following keywords were used: questionnaires [MeSH], attitude of health personnel [MeSH], intervention studies [MeSH], and SDD [free text]. The search did not reveal questionnaires on the attitudes of nurses and physicians towards a new intervention. Therefore, qualitative techniques were used to identify items, that is, problems encountered when executing the study protocol. The questionnaires were developed on observations of oral care and semi-structured interviews with seven nurses from four different hospitals at the start of the trial: four in a SDD-period, one in a SOD and two in a standard-care period. The observations revealed that nurses did not comply entirely with the oral hygiene protocol. During subsequent interviews the interviewer (IJ) pursued and clarified information on problems encountered during oral care and solutions to resolve reasons for non-compliance. Interviews were audio taped and transcribed verbatim. Transcripts were read and nurses' views regarding experience with SDD and problems met during oral care were identified and coded (by IJ and AS). Codes were continuously compared within and between transcripts. Agreement was reached between the researchers as to the major themes to be used in the questionnaires (concerning experience with and expectations of SDD), that is problems encountered during oral hygiene, non-compliance with the protocol, duration of oral care and expectations of SDD efficacy.

To maximize response rate, we designed a short questionnaire. For nurses, it contained four (standard care-period) to six (SDD and SOD-period) mostly closed questions, with a possibility to add comments in free text sections [see Additional file 1]. The nurses' questionnaire was pre-tested on three nurses (one research nurse and two ICU nurses), which resulted in a few linguistic changes only.

The questionnaires for physicians consisted of four closed and one open question in all study periods [see Additional file 2], addressing perceived clinical efficacy of SDD. Physicians were also asked to estimate ICU mortality rates in their standard care and SDD population, which were used to calculate the presumed relative reduction in mortality (PRRM), being the estimated mortality in SDD divided by the estimated mortality in standard care. The physicians' questionnaire was not pretested.

Data were analyzed using SPSS15.0 (SPSS Inc, Chicago, IL, USA).

The expected effect of SDD on patient outcome, as asked after every study period, increased during the study ( P = 0.004; Table 2). The proportion of physicians that expected SDD to have no effects on clinical outcomes decreased from 14% after the first two periods to 4% at the end of study ( P = 0.065). For nurses, these proportions were 33%, 26% and 22%, for periods 1, 2 and 3, respectively ( P = 0.017). The most frequently reported expected effect of SDD was a reduction in the incidence of ventilator-associated pneumonia (VAP), and these proportions increased during the study ( P = 0.001). Regarding improved ICU survival, both nurses and physicians tended to have increasing confidence in a positive effect of SDD on patient survival ( P = 0.062 and P = 0.059, respectively). This corroborated the median calculated PRRM, as reported by physicians, which tended to increase from 3.0% (IQR 0 to 25) after period 1 to 16.7% (IQR 0 to 28.5) at the end of the study ( P = 0.113).

The proportion of physicians that expected SDD to affect antibiotic resistance in their unit did not change significantly during the conduct of the trial. An increase in resistance was expected by 17% after period 1 and 27% at the end of study ( P = 0.25) and a decrease in resistance was expected by 13% and 18% ( P = 0.64) at these time points.

As we assumed that opinion on effect of SDD might be influenced by previous experience, we analyzed whether experience with SDD (either before or during the trial) was associated with expectations of SDD effects, which appeared not to be the case (chi-squared analysis, P = 0.74 and P = 0.98 for physicians and nurses respectively, data not shown). Trial results were not communicated, but neither intervention nor outcome were blinded for physicians and nurses. Data revealed that there was no correlation between the SDD-induced change in 28-day survival (observed effect in the trial) and the expected effect (by questionnaires) per hospital ( r = 0.24, P = 0.43), nor between the observed effect and PRRM ( r = -0.28, P = 0.36).

As additional effects of SDD, nurses mentioned better oral care, whereas physicians mostly mentioned a decrease in other infections (beside VAP), like urinary tract infections (Table 3).

Problems during oral care, as reported by nurses, occurred frequently. It was reported that in particular non-sedated patients experienced oral care as annoying (56%), disliked the flavor of the oral paste (46%) and/or suspension (22%), refused to cooperate during oral care (36%) or were nauseous (13%) (Table 4). Despite these problems, the self-reported adherence to the study protocol was 70%. Of nurses who did not comply, an average of 8% (7% in SDD, 8% in SOD) reported to have discontinued application and 6% (8% in SDD, 5% in SOD) reported to have modified the study protocol, by using a suspension instead of oral paste for oral care. The remaining 16% forgot to apply the oral paste on one occasion or at the right time point. Most modifications of the study protocol were made in non-intubated, non-sedated patients who refused the oral paste. These modifications did not seem to be influenced by expectations of nurses: the expected effect of SDD was not associated with being fully adherent to the study protocol ( P = 0.65).

The estimated median time needed to perform oral care according to the protocol (which included applying oral paste every six hours during the SDD and SOD period) was 3.0 (IQR 0 to 5) minutes for both standard care and SOD and 5.0 (IQR 2 to 5) minutes for SDD ( P < 0.001; Table 4). Estimated median additional times needed for oral care during SDD differed per center from 1.7 to 7.3 minutes. SDD was considered more time consuming than SOD and standard care in six centers and SOD was considered less time consuming than standard care in five.

Both physicians and nurses graded the estimated workload lowest for standard care and highest for SDD (Table 5). Although median differences in grades for SDD and SOD were small (5 and 4 for nurses and 5.5 and 5.0 for physicians, respectively), there was a tendency both in nurses and physicians to value workload during SDD higher as compared with SOD ( P < 0.001 for nurses and P < 0.01 for physicians). Free text from nurses revealed that removing rests of oral paste from the oral cavity (before applying new paste) and increased prevalence of diarrhea contributed to a perceived higher workload during SDD. There was no relation between expected effect of SDD and the grade given for workload during SDD, neither in nurses nor in physicians.