Of principal concern is the prevention and control of ventilator-associated pneumonia (VAP) by medical practitioners in intensive care units (ICUs). VAP is one of the most frequently reported infections acquired by patients under mechanical ventilation healthcare. Ventilator-associated pneumonia (VAP) persists to be a frequent and potentially deadly complication of ventilator care (Chulay, 2005), often occurring within environments characteristic of the intensive care unit (ICU) that are high-tech and high touch. Patients who are ventilated and intubated present the unique challenge for critical care registered nurses (RNs) to incorporate evidence-informed practices concerning the delivery of high-quality care (Crunden, 2005).
Ventilator-Associated Pneumonia Bundled (VAPB) practices comprise of preventive strategies that are individual-based for mitigating the occurrence and prevalence of VAP and improving on patient outcomes (Pruitt & Jacobs 2006). Ventilator-associated pneumonia (VAP) poses a continuing challenge for critical care nurses since they rely on existing evidence-based practices to reduce its incidence and prevalence (O’Keefe-McCarthy et al., 2008). Apart from negating effective cough reflexes, mechanical intubation hinders mucociliary clearance of secretions, thus, causing lung infection through the leakage and the micro aspiration of virulent bacteria (Koeman, 2005). For patients who are mechanically ventilated, bundled strategies were developed as a way of enhancing the delivery of evidence-based health care in a coordinated and systematic and approach while offering the pathway to assess delivery of the health care and results (Pronovost & Holzmueller 2004; Crunden et al. 2005). Therefore, it is vital to evaluate and analyze the relationship that exists between ventilator care bundles and VAPB.
VAP accounts for about ninety percent of nosocomial infections and arises within forty-eight hours of intubation (Garcia et al., 2009). In terms of mortality, the high costs of health care, extended length of days in the ventilator and length of hospital stay; VAP is a major cause of health care burden (Prendergast et al., 2009). Recent evidence reveals that the VAPB practices lead to the reduction of VAP rates. Bundled practices by ICU personnel result in a reduction in ventilator days, duration of stay in the intensive care unit, and mortality rates.
A strong correlation was observed, with a stricter clinician compliance with VAPB protocols with reduced VAP rates (Torres & Ewig, 2011). VAP can arise either early or late in the course of a patient’s intubation and mechanical ventilation period. Early onset happens within two to four days of intubation (Pruitt & Jacobs 2006). Most familiar microorganisms consist of Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae. Delayed indications of VAP take place five or more days after the period of intubation. Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacter, Acinetobacter baumannii and Klebsiella pneumoniae are some of the most rampant microorganisms reported for late occurrence of VAP (Pruitt & Jacobs 2006).
The transmission of pneumonia can take place when airborne microbes from an infected individual are taken in by someone else (Pruitt & Jacobs, 2006). However, Resar et al. (2009) argue that many cases of pneumonia are associated with self-infection with at least one microbes; originating in the mouth and nose. In healthy individuals, typical upper airway bacterial inhabitants, for example, Streptococcus pneumonia (also commonly known as “pneumococcus”) and Hemophilus influenza are the most widespread bacteria causing community-acquired pneumonia (Schleder et al., 2002). Hospital-acquired pneumonia is typically caused by bacteria that are more resistant, for example, Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae and Escherichia coli (Sheldon, 2001). People exhibiting a serious deficiency of their immune system become vulnerable to pneumonia caused by so-called “opportunistic” microbes, which comprise of certain fungi, viruses, and bacteria attributed to tuberculosis (mycobacteria), which would not ordinarily cause disease in normal individuals (Munro et al., 2006).
In order to adjust to its persistent exposure to potentially infectious microbes, the lung relies on a hierarchy of defense mechanisms. Physical mechanisms that can prevent microbes from getting to the alveoli comprise of the structure of the upper airway, the hair-like cilia that propel mucus upward, the branching of the bronchial tree, the reflex of the cough, the sticky mucus layer lining the airways. Through immune cells of various types, the microbes that do manage to get to the alveoli are wiped out; explaining why numerous cases of pneumonia arise in people who exhibit at least one deficiency in either their immune or mechanical defense mechanisms. There are several VAP risk factors that have been identified. The major ones constitute of lack of proper hand washing by ICU personnel, ventilatory circuit management practices, and lack of backrest elevation during supine positioning of patients, previous antibiotic therapy, gastric alkalinization and presence of a nasogastric tube.
Through colonization of the oropharynx by potential pathogens such as Streptococcus pneumoniae, gram-negative rods and Staphylococcus aureus, there is a major risk exposure to acquire VAP. A number of factors affect the significance of oral health condition in the development of VAP (Munro et al., 2006). The causes VAP risk exposure constitute agents that can disrupt the defense system of the patient and those that have the potential to increase the aspiration of oral secretions. Nasogastric, endotracheal, and enteral feeding tubes; impaired mental status; supine positioning; and sedation can result in an increase, in the risk of colonization of the oropharynx and the subsequent shift of oral secretions to the subglottic section, causing pneumonia.
Combating of bacterial organisms colonizing the oropharynx is not a typical but a new practical intervention. The findings of a study by Garcia et al. (2009) add more weight to the notion that oropharyngeal colonization is fundamental in the etiology of VAP. Attempts to reduce bacterial colonization are principally imperative, given that oral care is often viewed to be challenging and does not always constitute tooth-brushing for ICU patients. According to O'Keefe-McCarthy et al. (2008), treatment methods, for instance, gastric alkalinization with regular use of H2 receptor blockers act as another source of risk. For example, cases of an overgrowth of virulent organisms extended use of antibiotics, improper hand washing, and prolonged durations of mechanical ventilation, invasive procedures, and contact with other patients are all possible risk factors for VAP (Schleder et al. 2002; Pruitt & Jacobs 2006).
Munro et al. (2009) argues that several factors contribute to the linkage between oral health and VAP development. Before the expiry of two days of intensive care unit (ICU) admission, the oral flora of seriously ill patients transforms into predominantly gram-negative flora that comprises of organisms that are more virulent (Munro et al., 2006). Mechanical ventilation, when needed, is a life saving process within the intensive care unit when needed. However, the risk of exposure to VAP has been revealed to be directly attributed to its period, and a collective occurrence of between 10-25 percent has already been reported (Dezfulian et al., 2005). The sedation required can lead to a number of negative health effects such as prolonging intubation (Koeman, 2005). Therefore, it is constantly recommended within existing evidence based strategies that there should be a review on a daily basis and interruption of sedation except clinically contraindicated.
Recent research shows that the microbial colonization in the mouth increases the risk of VAP. The previous oral health of the patient is an important risk factor that affects intubated patients, thus, pre- exposing them to risk of acquiring VAP. Any interference in the oral health of a patient can lead to the acquisition of VAP (Resar et al., 2004). There is sufficient proof of evidence to warrant the institution of regular oral care routines for patients who are mechanically ventilated. Critical care nurses need to be informed about patient outcomes emanating from the omission of oral health, the gains of rendering oral care in a timely manner, and pro-scaling healthy oral care immunity to who are mechanically ventilated (O’Keefe-McCarthy 2006). Implementing oral care routines decreases the extent of dental plaque. Hatler et al. (2006) comprised oral care as a basic constituent of the VAPB.
The period of intubation is associated with a greater risk of VAP. Thus, one of the easiest methods of decreasing the risk exposure of patients is to ensure that they are extubated as soon as clinically achievable. In addition, along with a re-assessment of sedation, there should be a re-assessment of willingness to wean, and this should be carried out daily. The clinical interventions, however, do not constitute a particular care action associated with extubation or weaning. Many researchers have reported the likelihood of merging the ventilator and sedation weaning protocols. Nonetheless, more research work still needs to be done regarding this notion.
The detection and adaptation of factors causing risk exposure among patients have resulted in the establishment of preventive methods meant to decrease VAP rates. Such methods involve strategies that tackle the causes of VAP, its effective treatment, and infection control-related steps that have led to the decline of VAP rates (Schleder et al., 2002). A myriad of risk factors in patients who are critically ill and the surfacing of organisms that are resistant to antibiotics bring about the need for an aggressive stance toward prevention strategies to reduce the prevalence of VAP. Eventually, the effective implementation of such practices will better the quality of patient health care and culminate into lower costs.
Researchers in the United States have adopted a more straightforward strategy of managing the colonization by studying how oral decontamination affects pulmonary infection (Resar et al., 2005). The methods involved the administration of antibiotic solutions or pastes into the trachea or oropharynx of patients who undergo the procedure of mechanical ventilation. Antiseptic solutions such as chlorhexidine gluconate have also acted as decolonization agents. A study conducted by Gracia et al. (2009) revealed that VAP occurred in 8.6 percent (67 out of 779) of patients in the control group and 4.1 percent (31 out of 759) of patients in the study group. During the duration of the intervention, rates of VAP declined by 33.3 percent, although the outcome was only slightly significant (P= .06). After assessment of these results, there was approval by the critical care committee for the continuing of the intervention as an integral part of MICU care. The following table indicates the outcome measures from the study:
Abbreviations: MICU-Medical Intensive Care Unit
VAP-Ventilator Acquired Pneumonia
PD-Patient Days
Oral care amongst adult patients that are fatally ill is becoming an essential contemporary issue (Munro et al., 2006). However, whether ventilated acquired pneumonia can be successfully reduced by appropriate dental care has not been extensively studied in patients other than those who are undergoing electively cardiac surgery. It is important to carry out a controlled, randomized clinical trial to examine the impacts of tooth brushing and/or chlorhexidine in reducing the risk for VAP in adult ICU patients who are under mechanical ventilation. Certainly, basic nursing practices, for example, hand hygiene, sub-glottal suctioning, semi recumbent positioning of patients, and decreasing colonization of dental plaque by respiratory pathogens play a critical role in reducing the occurrence of VAP.
Proper oral care practices would help cut on the incidence of VAP. Systematically, strong trials that are randomized and controlled are required to inspect the efficacy of VAPBs and find out causality between clinical outcomes and VAPBs. Organizational commitment is required so as to adopt a conceptual framework that facilitates effective knowledge translation, integrating factors of context, evidence, and facilitation of VAPBs into clinical settings (Garcia et al., 2009). Incorporating nurse-oriented involvement of model leaders to enable accurate, consistent and reliable and implementation of VAPBs into practice is critical. The result of data analysis by Schleder et al. (2002) will provoke present research ideas concerning oral care for mechanically ventilated patients and encourages more research on the topic.
Health facilities need to implement protocols for preventing VAP that comprise of those practices that best work for them (Garcia et al., 2009). Units charged with the responsibility to foresee the implementation of protocols targeting prevention should assess the effects of nursing actions on rates of VAP and share the results. All health care facilities should initiate programs aimed at training and educating their personnel in order to increase the amount of awareness about the prevention of VAP. It will also act to boost the extent of compliance with the evidence-based guidelines provided by the various researchers. In addition, it is vital that health care facilities encourage the involvement of their personnel in advancement of education and improvement of performance standards in projects.
In conclusion, Ventilator associated pneumonia (VAP) is one of the deadliest and most prevalent cause of healthcare related infection (HAI) within intensive care units (ICUs) environment. It leads to a high rate of mortality and morbidity. VAP can occur as a result of aspiration of microorganisms (from the stomach or oropharynx); contamination particularly within the immediate ICU environment, or through humidified unsterile water or microorganisms from other places of infection/colonization. Some of the risk factors that can add to the risk of VAP constitute prolonged length of mechanical ventilation, factors which increase the possibility of aspirations, for example, of contaminated equipment, increased gastric pH and patients lying in a supine position. Strategies aiming towards mitigation and prevention of VAP are concerned about three major dimensions for interventions that are targeted towards reducing risk of contamination of equipment, aspiration and colonization. Therefore, all ICUs should establish and implement an oral hygiene protocol that is based on the best existing research evidence. The units should carry out systematic assessments of the possible gains attributed to the use of the protocols and share the results. Further research study is required to reveal the relationship between VAP and oral care. Future research in the area will add to the existing body of evidence-based oral care protocol meant for the prevention of VAP.
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