INTRODUCTION

The World Health Organization (WHO) defines patient safety as reducing the risk of unnecessary harm associated with health care to an acceptable minimum. Risk is the possibility of an incident, which is an event or circumstance that can result in unnecessary damage. Damage is the impairment of the body’s structure or function that causes physical, social, or psychological disability or dysfunction⁽¹⁾.

Patient safety in health services must be guided by safety evidence⁽²⁾. The main challenge for professionals working in critical care units is to ensure patient safety, given their exposure to risks with possible damage resulting from the various procedures of point-of-care testing. A critical patient is one who requires intensive care from a multidisciplinary team in specialized units⁽³⁾.

To minimize these risks and promote safe care, WHO encourages the adoption of various guidelines related to proper care practices, among them the six International Goals for Patient Safety (IPSG). These goals aim to reduce risks and incidents regarding patient safety in health services, to correctly identify the patient, to improve effective communication, to improve the safety of high-alert medications, to ensure safe surgery, site procedure, and correct patient, to reduce the risk of health care-associated infections through frequent hand hygiene, to reduce the risk of patient harm resulting from falls and pressure injuries in hospital environments, to ensure quality in care environments^(4-5).

The specialized units have different equipment for carrying out diagnoses and treatments, including hemodynamic monitoring, which is one of the most critical procedures for patient care in a critical unit, as it allows for accurate data that assist in rapid intervention, avoiding complications to the patient and failures in assistance⁽⁶⁾.

Although monitoring is a non-invasive procedure, most procedures performed on critically ill inpatients are invasive, such as orotracheal intubation, tracheostomy, nasogastric or orogastric catheter, bladder, central or peripheral access. Hospitalization abruptly interferes with the subject’s way of life, who is unable to exercise their autonomy, nor their attitudes, such as personal hygiene, food, eliminations, and others⁽⁷⁾.

In this sense, it is possible that, in addition to invasive procedures, patients are subjected to point-of-care testing. The number of diagnostic tests has increased significantly in recent years, including computed tomography, magnetic resonance, hemodynamics, interventional procedures, and X-rays⁽²⁾, being the X-rays and ultrasonography (US) frequently used at point-of-care testing for their portability and accessibility⁽⁸⁾.

Critical patients are subjected daily to various point-of-care testing, which has an inherent risk to the procedure. These risks, as well as the complexity of the patients, demand specific attention and care from the professionals.

Given the technology used in critically ill patients, a trained, agile team capable of predicting risk situations is necessary, avoiding injuries to the patient⁽⁹⁾. The nurse who works in critical units must ensure safe and humanized care with the team, being in charge of evaluating the patient and the situations to which he/she is exposed and systematizing the assistance, choosing the most appropriate resource or care⁽⁶⁾. A prepared professional is required, able to attend to physiological changes, complications, and the patient’s needs during treatment⁽¹⁰⁾.

The investigation of the theme emerged from the identification of the knowledge gap regarding the necessary care for point-of-care testing in critically ill patients.

OBJECTIVE

To Identify the scientific evidence on safety care for critically ill patients undergoing point-of-care testing.

METHODS

Work stages

The initial search found 5,175 articles. After reading all titles, abstracts, 101 articles were selected for full reading, resulting in 23 articles suitable for analysis.

Two researchers stated the relevance of the selected evidence concerning the research objective. For data extraction, an instrument containing: article title, authors, periodical (volume, number, page and year), objective, method, main results and conclusion, showing the care to be applied to critical patients submitted to bed image was created, and these were recorded in a Microsoft Office Excel® spreadsheet.

Figure 1 illustrates the selection process for the articles in this integrative review.

Figure 1 Diagram of identification, selection and inclusion of integrative review studies 

RESULTS

The 23 selected articles were published in the following years: nine, in 2018; five, in 2017; four, in 2016; four, in 2015; and one publication in 2013.

Chart 1 show the main results of the 23 selected publications, highlight the characterization of the evidence, the methodological aspects, and the results.

DISCUSSION

The different interventions resulting from the search were grouped according to the care used to perform imaging tests at the bedside, which contribute to safe care in terms of communication, patient identification, device care, prevention, and infection control.

In this sense, several actions when carried out properly transform care and prevent damage. Identifying patients correctly⁽²⁹⁾ and improving the effectiveness of communication⁽³⁰⁾ between healthcare professionals are the first two international goals for patient safety⁽³⁶⁾.

Among the main failures in the care of critically ill patients is the transfer of information related to the care provided, which affects the quality of care, resulting in delayed, duplicated, or wrongly performed interventions⁽³⁰⁾. It is frequent to cancel exams for not having the necessary fasting time or to keep the patient’s fasting even after the cancellation of these procedures⁽³⁷⁾. Thus, having effective communication techniques, such as the use of clear and structured language, guarantees these curity of information and the continuity of assistance⁽³⁸⁾.

Likewise, patient identification is necessary to avoid misunderstandings due to lack of documents, namesake names, names of another nationality, changes, or difference in the date of birth and failures to include data in the system. Such situations hinder the correct identification of patients and favor the exchange of exams, procedures, and exchange of information passed on during the shift change⁽³⁸⁾. It is crucial to ensure that an individual undergoing treatment is the one who is hospitalized in a particular unit or subjected to a specific examination or procedure, thus preventing failures, errors, or mistakes⁽³⁹⁾.

Several factors are involved in the identification process that makes it a great challenge for health institutions. To develop strategies that promote continuous improvement of the process, proposing and implementing the promotion of the institutional safety culture, such as the involvement of managers, assistance teams, if necessary⁽²⁹⁾.

This review allowed the identification of care with devices, whether invasive or not^{(3,15-17,20,22-26,34-35)} and care performed with positioning in the bed^(14,19). Among the devices used as resources for the treatment of critically ill patients are orotracheal tubes, tracheostomy tubes, central venous catheter, peripheral venous catheter, arterial catheter, nasogastric tube, or nasoenteric tube, catheter-delay bladder and drains⁽³⁾. And the inappropriate handling of these devices place the clientele at risk⁽²⁵⁾.

The actions listed in studies that discuss the protocol of care with drains⁽¹⁶⁾ and bypasses⁽¹⁵⁾ propose actions and suggest the appropriate management with the devices, the use of specific materials and equipment, which reduce the damage and decrease the associated morbidity to the method used^(15-16). Making a checklist that works as a care guide is proposed as a strategy that allows nurses to detect earlyproblems with the procedure, preventing the occurrence of adverse events⁽²⁰⁾.

The removal of the ventilatory device in an unplanned way, called accidental extubation, can cause complications to the treatment and damage the patient’s health, mainly if it occurs in patients with a decreased respiratory stimulus, sedated patient, or with neurological injuries⁽⁴⁰⁾.

For this, a study⁽⁴¹⁾ demonstrates that careful positioning is essential, with the patient’s decubitus change or mobilization being the main situations considered critical associated with accidental extubation, and that must be continuously observed.

In one of the studies⁽¹⁹⁾, a positioning protocol for the newborn was created which is essential for these patients, as it assists in the neuromuscular development of the patient and reduces changes and complications. Positioning is also crucial during the X-ray for confirmation of the chest drain, a technique that requires mobilization of the patient immediately after the insertion of the drain and whenever traction is suspected⁽¹⁶⁾. In addition to the risk of traction and accidental removal, it can still cause pain during the imaging exam⁽¹⁹⁾.

Another important aspect analyzed was the performance of echocardiography exams in bed, which despite this modality eliminates the risk of transporting the patient to the exam sector, the result may be impaired due to inadequate images, as positioning is crucial to obtain good exam images. Thus, the left lateral decubitus position is recommended for bed echocardiography exams⁽¹⁴⁾.

Another device that is widely used and requires specific care is the nasogastric or nasoenterictubes. A study⁽³⁾showed that these devices removed in an unplanned manner, being removed by the patient, due to obstruction, accidental loss or damaged device.

The use of venous catheters in critical units is common and avoiding infections is extremely important, therefore, it is necessary to clean hands, perform insertion maintenance, carry out daily monitoring, observe phlogistic signs, perform dressing, handle the catheter carefully follow-up infusions such as the use of contrast for exams^(25-26,35). A study⁽²²⁾ suggests that, to avoid contrast leakage, the professional should use strategies for patient safety, including reducing the injected volume and quickly detecting the leakage.

The nurse plays a central role in maintaining the surgical dressing, in the evaluation of the surgical wound⁽²³⁾ and in the evaluation of signs of urinary tract infection, as well as the need for urinary catheterization and when to remove the catheter⁽²⁴⁾. Care with the fixation and traction of these devices are essential to avoid infection and complications for the patient.

In this perspective, the analysis shows that hand hygiene^(18,27,32), the use of personal protective equipment (PPE)⁽²⁸⁾ and the cleaning of equipment and surfaces^(21,33) are relevant regarding to the safety of the care provided, although often ignored by professionals.

Data from a survey⁽²⁷⁾ showed that in 56.2% of the procedures observed, hand hygiene was not performed, and professional nurses, nursing technicians and doctors had less than 50% adherence in the observed behaviors. Another study⁽¹⁸⁾ revealed that out of the 793 observations, 56.2% of them did not have hand hygiene, resulting in an adherence rate of 43.7%. In a third study⁽³⁵⁾ of 1107 patients/day with Central Venous Catheter (CVC), 14 were infected with S. aureus, which are removed with simple measures such as hand hygiene.

Professionals are often careless and exposed to occupational risks, either due to non-adherence to the use of Personal Protective Equipment (PPE) or due to poor hand hygiene⁽²⁵⁾.

Hands are the primary source of contamination and the spread of infection. Despite being a simple measure and inserted in the daily routine of health professionals, most professionals do not perform hand hygiene at the moment after contact with areas close to patients⁽³²⁾.

The decontamination of surfaces, materials, and equipment is part of the provision of care, as they are always in contact with patients and the professionals involved in the assistance. The presence of dirt or organic matter on surfaces, equipment, and materials contributes to the transmission of microorganisms. Therefore, in addition to hand hygiene and the use of PPE, cleaning, and disinfecting surfaces is of paramount importance to prevent health-related infection⁽³³⁾.

Adherence to the five moments of hand hygiene is recommended by the World Health Organization (WHO) which must be carried out: before contact with the patient; before performing the procedure; after risk of exposure to biological fluids; after contact with the patient; and after contact with areas close to the patient, even if he has not touched the patient, caring directly or indirectly for the patient^(42-43).

Care for critically ill patients undergoing point-of-care testing must be based on scientific evidence, finding strategies that promote the efficient and safe management of the procedure is necessary to significantly decrease the practice and behaviors not recommended by the guidelines⁽²⁷⁾. The entire multidisciplinary team must promote an appropriate intervention to guarantee the quality of care delivery to bedridden patients⁽³¹⁾.

FINAL CONSIDERATIONS

Safe care is a challenge for institutions and health professionals, and it is relevant to carry out procedures that prevent adverse events in point-of-care testing.

It is necessary to train professionals concerning the safety of actions related to bedridden care, the involvement of the patient throughout their hospitalization, and the strengthening of strategies based on the evidence and permanent education of the team.

The prevention and management of risk incidents in health institutions and the encouragement of reporting them, aim to improve the quality and safety of care processes.

Although the care described in the selected evidence has provided subsidies for the validation of a safe care protocol for critical patients undergoing bed imaging, specific studies are needed on the patient’s safety undergoing point-of-care testing and on the competence of professionals from the multidisciplinary team involving care.