Infection factors related to nursing procedures in Intensive Care Units: a scoping review

Rev Bras Enferm. 2021;74(1): e20200731 http://dx.doi.org/10.1590/0034-7167-2020-0731 6 of ABSTRACT Objectives: to identify and map the invasive procedures performed by nursing that can cause Healthcare-Associated Infections in patients in Intensive Care Units. Methods: this is a scoping review carried out in the first half of 2018, based on search for studies in national and international databases, in which 2,209 studies were found, of which 35 constituted the final sample. The data were analyzed and organized by simple descriptive statistics. Results: among the invasive procedures performed by nursing that provide Healthcare-Associated Infections, delayed bladder catheter was indicated in 34 (66.67%) studies, the nasogastric catheter in 10 (19.61%) and the nasoenteral catheter in two (03.92%). Conclusions: in the face of such problems, better nursing planning and guidance for care in these invasive techniques becomes relevant and thus minimizes the incidence of infections. Descriptors: Healthcare-Associated Infections; Intensive Care Units; Care; Nursing; Patients.


INTRODUCTION
Currently, Healthcare-Associated Infections (HAIS) are considered a global health problem, due to rising hospital costs and morbidity and mortality rates (1) .
These consequences occur due to the length of hospital stay, the high rate of invasive procedures, both diagnostic and therapeutic, the severity of the underlying disease, the site of infection and the sensitivity to the antibiotics used (2)(3) .
With that being said, a survey (1) found that of the 1,048 patients admitted to an Intensive Care Unit (ICU), about 17.65% had infectious events such as ventilation-associated pneumonia (VAP), urinary tract infection (UTI) related to bladder catheterization and primary bloodstream infection linked to the central catheter.
Thus, it is clear that HAIS are associated with several factors, including invasive procedures, namely: insertion of central and/or peripheral venous catheters, bladder catheters (BCC), mechanical ventilation, tracheal aspiration, wound care, chest tube removal, among others (4)(5) .
Among these techniques are those performed by nursing, which are performed with high frequency according to patients' needs, presenting diagnostic and/or therapeutic purposes, in order to contribute to their recovery (4,(6)(7)(8) .
Thus, it becomes pertinent to identify the risk factors that contribute to the development of HAIS, associated with invasive procedures performed by nurses in ICUs, in order to encourage measures that may reduce the incidence of HAIS damage and impairment, and, therefore, reduce the number of adverse events (AE) and mortality due to AE.
Therefore, this study has the guiding question: which invasive procedures performed by nursing can cause HAIS in patients in ICUs and how does it occur?

OBJECTIVES
To identify and map the invasive procedures performed by nursing that can cause Healthcare-Associated Infections in patients in Intensive Care Units.

Ethical aspects
There was no need for ethical assessment because the material used is in the public domain and does not involve human beings.

Type of study
This is a scoping review, with a protocol registered in the Open Science Framework (DOI 10.17605/OSF.IO/ZMUQ4), structured according to the international guide PRISMA-ScR recommendations (9) and the Joanna Briggs Institute, Reviewers Manual method (10)(11) , using a theoretical framework based on Arsey and O'Malley.
This investigation is based on an exploratory review which aims to map content associated with the theme investigated and point out gaps in the literature. It is described in five stages: I -research question formulation; II -identification of relevant studies; III -selection of studies; IV -data analysis; V -data synthesis and presentation (10) .

Research question development
For the first stage, the research question, the study objective and the descriptors were listed according to PCC (10)

Data selection
To select the studies and sample composition, Boolean operators AND and OR were used, as described in the search strategy: (Patients AND cross infection OR nosocomial infection) AND (Nursing care OR critical care Nursing OR Nursing protocols OR evidence -based nursing OR Nursing interventions OR pratice guideline) AND (intensive care units OR critical care).
The following inclusion criteria were defined: studies published in full in Portuguese, Spanish or English; that dealt with invasive procedures performed by nursing as possible HAIS factors in ICUs; manuals and protocols published by regulatory agencies. As for exclusion: duplicate searches; editorials; experience reports; theoretical essays; reflection studies; books; other revisions. It should be noted that there was no temporal delimitation. Figure  1 presents the selection process synthesis.

Data analysis and organization
The selected studies were observed regarding the type of material, study method, year of publication, country of origin, population and invasive procedure performed by nursing. The results (step V) were organized by simple descriptive statistics (relative and absolute), presented in graphs and/or table if discussed with literature support.

RESULTS
From an analysis of the 2,209 studies identified in the initial search, only 35 (100.0%) were about the theme addressed, corresponding to the final sample. Of these, 30 (85.71%) were articles, two (05.71%) were dissertations, one (02.87%) was a thesis and two (05.71%) were manuals. It was noted that the years 2007,2010, 2012, 2013, 2016 and 2017 stood out with three (08.57%) publications in each one ( Figure 2).
Among the invasive procedures performed by nursing that can cause HAIS in ICU patients, BCC is indicated in 34 (66.67%) studies, the nasogastric tube (NGT), in 10 (19.61%) and the nasoenteral tube (NET), in two (03.92%). The main findings of research related to infections linked to invasive procedures are in Chart 1.  The nasogastric tube -Significant risk factor for Acinetobacter baumannii infections infections; -Considered an extrinsic risk factor acquired in a hospital environment; -Risk factor for cross infection.
Nasoenteral tube -Risk factor for cross infections.
Note: *More than one procedure was present in the same study.
In relation to the countries of origin of the studies, Brazil stood out with eight (22.86%), Serbia with four (11.43%), Italy, Australia and Taiwan with three (08.57%), Turkey with two (05.71%) followed by Germany, Slovenia, USA, Finland, France, Greece, India, Republic of Ireland, Jamaica, Portugal, United Kingdom and Republic of Korea with one (02.86%).
Although total parenteral nutrition (TPN) is not a procedure, it has been observed in studies as a risk factor for bloodstream infection (BSI) acquisition because it is necessary to install it intravenously.

DISCUSSION
The articles developed between 2007 and 2017 show the progress of the discussion about HAIS; therefore, they showed the development of programs and guidelines on the theme, in an attempt to assess HAI control and prevention in hospital settings, as with the creation of the Brazilian National Commission for Healthcare-Associated Infection Prevention and Control (CNIRAS -Comissão Nacional de Prevenção e Controle de Infecção Relacionada à Saúde) by Ordinance 1218/12 (12) .
In relation to the countries that published the most, Brazil stood out due to studies (5,13) pointing to the expressive occurrence of HAIS in national ICUs and for being understood as a public health concern.
As for the methodological designs used, the highest quantitative was the descriptive, which indicates the need for studies with greater methodological impact, such as experimental ones (11) .
Regarding invasive procedures, BCC stood out because it is one of the most performed in ICU based on the following guidelines: management of urinary retention, strict control of diuresis, measurement of diuresis for diagnostic tests, surgical and postoperative procedures, handling of immobilized people, neurogenic bladder carriers, terminally ill comfort, among others (14) .
Furthermore, due to BBC use time prolongation due to the severity of patients' clinical conditions and the indications mentioned above, patients have a high propensity to develop UTI (8,14) . That said, a study (13) carried out in a clinical center in Serbia points out that the bacterium Pseudomona aeroginosa is the main cause of UTI, which causes intense infections due to its multidrug resistance to antibiotics, as well as IRAB (15) . Such complications are aggravated according to the risk factors: male gender, bladder catheterization length before UTI, intra-hospital reinfection, previous penicillin use and length of hospital stay (15)(16) .
Thus, in order to prevent/reduce the number of HAIS, nursing has tools to optimize the performance of BCC, such as institutional protocols, which facilitate and guide the procedure, by indicating appropriate equipment and appropriate measures according to patient, in addition to the order of actions to be taken (17) .
Another factor that contributes to nursing work, minimizing the risk of UTI is the quality of their records, which aim to enhance communication between multidisciplinary staff members through registration of the material used, date of insertion and removal of the probe and the volume of urine drained (18)(19) .
Regarding NGT and NET, it was realized that they are possible ways to acquire infections, by providing a gateway for the growth of microorganisms in the gastrointestinal tract and being a reservoir for pathogens resistant to antibiotics (20) .
The practice of such procedures is due to the fact that some of patients in intensive care have nutritional depletion or inability to swallow due to orotracheal tube (OTT) or tracheal tube (TCT) use so that performing NGT and/or NET serves to meet nutritional needs, perform gastric drainage, collect material for examination and administer medications (21)(22) .
With regard to nursing activities towards NGT and NET, there is control of nutrition by promoting the introduction, maintenance, route of choice and adequate volume in the prevention of complications. As in performing the BCC, nurses have Standard Operating Procedures (PCOS) as devices to optimize the effectiveness of the activity and reduce the chances of infection (17,23) .
However, the scientific literature (22) indicates negligence in hand hygiene as a risk factor for cross infection in NGT and/or NET insertion. Although the WHO indicates the five moments of this practice, to be included before performing the aseptic procedure, it is noted that nursing professionals do not comply with it correctly (24)(25) .
Another risk factor for HAIs in ICUs was TPN installation and maintenance, which may favor bloodstream infection, as it is associated with the use of a central catheter. Thus, it is necessary to use appropriate techniques for its handling and passage through exclusive venous access in order to avoid infections (25) .
Thus, it is understood that nursing must have adequate knowledge for care, especially in ICUs, due to the clinical complexity of patients and greater attention in carrying out numerous invasive procedures (26)(27)(28) .
It is worth mentioning that it is up to the nurse, as a member of the health staff, and to the other multidisciplinary health staff members to participate in elaborating measures for prevention and systematic control of damages that may be caused to patients during assistance. Furthermore, they must implement and assess infection control programs and protocols in order to reduce HAI incidence and ensure patient safety. This will be achieved with the help of an updated educational process, adapted to the staff's needs (29) .

Study limitations
As limitations of the research, there is the restriction of the investigated sector and the professional category. HAIs are a problem evidenced in several areas and health services, in addition to involving the different profiles of health workers.

Contributions to nursing
It is observed that identifying the main risk factors for HAIS can contribute to developing preventive measures and training in the care environment, and thus, minimizing the incidence of preventable infections in ICU settings. Moreover, it can promote discussions in the scientific and educational scope, as it provokes other research with similar themes and associates this content with patient safety in the classroom, respectively.

CONCLUSIONS
Among the invasive techniques practiced by nursing and considered as risk factors for HAIs in patients admitted to ICUs, BCC, NGT and NET stood out.
In relation to the main reasons that cooperate for such techniques to be risk factors, there is pharmacological resistance to antibiotics, prolonged hospital stay and use of the inserted device, non-use of protocols, poor hand hygiene and the wrong way of performing activities.
Thus, there is a suggestion for carrying out future research the need for comprehensive HAIs research for numerous hospital sectors and other professional categories due to the possible occurrence in several services and health sectors, in addition to the other workers performing procedures that can favor such infection.

FUNDING
Coordination for the Improvement of Higher Education Personnel (CAPES).
National Council for Scientific and Technological Development (CNPq).