Intensive and Critical Care Nursing (2005) 21, 119—122

ORIGINAL ARTICLE

Development of a new eye care guideline forcritically ill patients

Deborah Dawson ∗

General ICU St. George’s Hospital, 9 Monks Way, Reigate, Surrey RH2 055, UK

Accepted 11 January 2005

KEYWORDS Summary Ventilated, critically ill patients have an increased risk of corneal expo-

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Eye care;lubrication;eyelid closure;keratitis;corneal exposure

sure and microbial keratitis; however there is evidence that eye care is a neglectedarea of patient care. An audit of eye surface disease and eye care documentationrevealed a problem within one general intensive care unit (GICU). An educationprogramme was developed to highlight the incidence of eye surface disease andimportance of eye care in the ventilated patient.© 2005 Elsevier Ltd. All rights reserved.

ntroduction

ritically ill patients frequently have poor eyelidlosure and a reduced ability to use the protectivelink reflex due to the effects of sedative agentssed to enable other aspects of care. In addition,atients requiring artificial ventilation may sufferecreased tear production, decreased resistanceo infection and a decrease in venous return lead-ng to conjunctival chemosis. These factors lead ton increased risk of eye surface disease includingorneal exposure and microbial keratitis (Hilton etl., 1983; Hutton and Sexton, 1972; Ommeslag etl., 1987; Wincek and Ruttum, 1989). The actualncidence of eye surface disease is difficult to quan-ify (JBIEBNM; Joanna Briggs Institute, 2002), how-ver four prospective studies have published ratesanging between 37.5% and 60% in critically ill pa-

* Tel.: +44 20 8 725 3129.E-mail address: deborah.dawson@stgeorges.nhs.uk.

tients (Hernandez and Manis, 1997; Imanaka et al.,1997; McHugh et al., 2004; Mercieca et al., 1999). Itis also difficult to quantify how many patients whosuffer eye surface disease progress to eye infec-tions such as conjunctivitis and keratitis; althoughof those patients who develop keratitis, the evi-dence suggests that they suffer a significant reduc-tion in visual acuity (Hilton et al., 1983; Parkin etal., 1997).

Eye care guidelines have been shown to reduceeye surface disease (Suresh et al., 2000). Eye careis therefore an important aspect of care to maintainthe integrity of the ocular surface, however thereis evidence to suggest that this is a neglected areaof care (Farrell and Wray, 1993; JBIEBNM, 2002;Laight, 1996). Within one general intensive careunit, it had been observed that adherence to lo-cal unit guidelines based on Suresh et al. (2000)was poor. An audit was undertaken to identify theincidence of eye surface disease and adherence tothe local guideline. This also involved a literaturesearch of the published eye care literature.

964-3397/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.oi:10.1016/j.iccn.2005.01.004

120 D. Dawson

Literature review

The literature suggests practice is varied and thatthe evidence base for developing guidelines is lim-ited, however there is sufficient evidence on whichto base care. Further studies are required to as-sess the effectiveness of various eye care regimes(Farrell and Wray, 1993) and to establish keratitisrates. The eyes should be kept lubricated (JBIEBNM,2002; Suresh et al., 2000) although there is no ev-idence to suggest frequency or the most effectivesolutions. Lid position has shown to be of impor-tance, as any corneal exposure will lead to epithe-lial drying increasing the risk of keratitis and ep-ithelial erosion (Suresh et al., 2000). It is thereforeimportant to assess and maintain lid closure in pa-tients with incomplete closure to reduce the risksof infection, drying and ulceration. Eye closure us-ing tape placed horizontally across the eye, reducesepithelial changes (Suresh et al., 2000). Eye lid tap-ing is unpopular with nursing staff as there is a po-tential risk of damage to the eyelid and surround-ing skin and it is also thought to increase the rela-tives’ distress (Farrell andWray, 1993; Suresh et al.,2000). In an attempt to find an alternative method

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was correlated to the degree of corneal erosion al-though was not statistically significant (p = 0.09).Documentation of eye assessment revealed thatonly 25.5% (n = 12) patients had an eye assessmentand only a further 14.9% (n = 7) had any details ofthat assessment documented. Eye care was docu-mented in 55.3% (n = 26) of patients, with only a fur-ther 4.3% (n = 2) of patients having details of the eyecare they received reported. This suggested thatthe guideline was not widely adhered to (McHughet al. 2004).

Discussion

This local audit identified a rate of eye surface dis-ease in ventilated patients comparable to previousstudies. In addition it identified a problem withadherence to current evidence based guidelines forthis group of patients. The literature search did notprovide any further evidence on which to base newguidelines, but supported the requirement for eyelubrication and closure. Therefore a discussion tookplace between the multi-disciplinary team to de-cide the best practice for lubrication and closure.AtepatF

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of closure polyacrylamide gel (e.g. Geliperm ) hasbeen commonly used (Farrell and Wray, 1993) butto date has not been evaluated (Ezra et al., 2004;Farrell and Wray, 1993). Polyethylene covers whencompared to lubrication, have been shown to re-duce the incidence of eye surface disease (Corteseet al., 1995; Koroloff et al., 2004), however thesestudies have compared polyethylene covers againsteye lubrication alone rather than lubrication andeyelid closure.

Audit

A prospective audit was conducted by two juniorintensive care doctors to assess the adherence tothe eye care guideline and the prevalence of eyesurface disease in ventilated patients on the gen-eral intensive care unit. This was conducted overtwo months and included all patients in the gen-eral intensive care unit who were ventilated andsedated for more than 24 h. This resulted in a to-tal of 31patients, providing 47 examinations whichwere validated by an ophthalmologist on 24 occa-sions. At each assessment the ICU chart and nurs-ing notes were examined to assess documentationof assessment and care. Using a portable slit lampexamination, a rate of 37.5% (n = 18) of corneal ero-sion was found. In addition 20.8% (n = 10) patientswere found to have incomplete lid closure, this

s the previous guidelines were not being adheredo it was decided to update them by producing anasy to follow algorithm. In addition an educationrogramme was developed using the results of theudit and literature search to clearly demonstratehe problem. The guidelines are presented inig. 1.The audit highlights two common issues with

he development and utilisation of evidence baseduidelines. Firstly how can evidence guidelines beeveloped without robust evidence and secondlyow evidence is translated into practice. The ev-dence for eye care is scanty. There are however aumber of common themes, by using these as a ba-is for developing practice guidelines and auditingre and post implementation, effectiveness of anyuideline implemented can be evaluated. Moreovery raising the awareness of eye surface disease in-erest has been generated in creating the evidencease via a research project.The nursing literature is littered with authors

ointing to the difficulties of translating researchnto practice (English, 1994; Funk et al., 1991;unt, 1981; LaPierre et al., 2004). Various barri-rs have been described including nurses not feel-ng the results are relevant to their practice set-ing (Bryer et al., 2003; Funk et al., 1991; LaPierret al., 2004), therefore providing education to theeam is a vital part of any successful change pro-ess (Thurston and King, 2004). The education pro-

Development of a new eye care guideline for critically ill patients 121

Figure 1.

gramme not only highlighted the problem of eyesurface disease in ventilated patients, but throughthe audit results indicated a link between the re-search and the incidence in the local patient pop-ulation. Having provided an education programmeand implemented a change in practice, it is im-portant to maintain practice change through con-tinuing education and monitoring the outcomes(Rosswurm and Larrabee, 1999), to this end a re-

audit is planned to assess any change in practiceand whether there has been a reduced incidence ineye surface disease.

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122 D. Dawson

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