Ventilator-associated pneumonia
Abstract
The intensive care unit in most hospitals plays the role of providing care to patients dealing with life-threatening conditions. The technological and other set ups in these hospital units are vital in ensuring that these patients continue to receive the best regarding care while with the intentions of having them emerge with desirable outcomes. There are however challenges relating to the care that these patients receive since, in most cases, they are usually under mechanical ventilation. A patient under this condition faces the risk of developing ventilator-associated pneumonia if the ventilators are not handled with the required care. This condition has been proven to affect a sizeable number of patients who are currently being taken care of in intensive care units with statistics pointing at about a quarter of all patients that are currently under intubation. The condition can, however, be satisfactorily addressed if necessary steps are taken to relieve the patients of the ailments that they may be going through. The employment of ventilator-associated bundles like stress ulcer management, taking care of oral hygiene using chlorhexidine as the recommended mouthwash and elevating the heads of the beds that these patients use are some of the evidence-based measures which can be used to address this condition adequately. Therefore, this paper will provide a description of the condition (VAP), a review of literature concerning the disease, the measures that can be taken to address it, an evaluation plan aimed at assessing the gains that would have been made concerning the management of the condition, a dissemination plan and a concluding part.
Technological advancements in the field of nursing have seen significant progress in terms of providing proper care to terminally ill patients. Most of these advancements are evident in the Intensive Care Units. Patients suffering from pneumonia are examples of individuals that can be found in critical care units. This is due to the challenges they go through regarding breathing hence they have to be provided with assistance in order to breathe properly. For this reason, they are equipped with a mechanical ventilator (Amanullah&Mosenifar, 2013). Additionally, it is important to emphasize utilization of standard care practices like reduction of bacteria and improving caregivers’ knowledge on how to address this condition using evidence based practices.
The Intensive Care Unit is an area within the hospital where patients with critical health conditions are provided with the optimal care which is essential for their well-being. The main challenge that these patients usually face relates to the performance of their physiological functions. As such, there is the need to support their wellness with life supporting aids such as mechanical ventilators. If these aids are not handled correctly, patients have a risk of developing hospital-acquired infections, VAP being one of them.
VAP is a lung infection that specifically affects individuals who have been mechanically fitted with mechanical ventilators. VAP has been estimated to account for 9% to 27% of all patients that have been mechanically ventilated. This illness can be early onset or late onset depending on the factors that predispose a person to it. Early-onset VAP has been linked with antibiotic-sensitive pathogens and usually develops within four days of being fitted with tracheal plastic tubes, whereas late-onset VAP develops after four days. It occurs when a tracheostomy tube allows passing of bacteria into the lower regions of a patient that has got immune or lung problems. Once the bacteria have reached the lungs, they multiply easily by capitalizing on any immune system deficiencies. The common bacteria that are responsible for VAP include; Staphylococcus aureus, Streptococcus pneumonia, and Hemophilus influenza. The diagnosis for this condition depends on clinical signs, radiography, and tests from the laboratory. Therefore, if the white blood cell count is less than 4000/mm3 or greater than 12,000/mm3, it is a clear indication that such a person is developing VAP conditions. Additionally, temperatures less than 36°C or above 38°C also indicate VAP development (Amanullah&Mosenifar, 2013. This condition can be addressed using standard care or by employing VAP prevention practices. The standard practice entails the use of antibiotics in treating the condition while preventive measures include; observing proper oral care, elevating the head of the bed, preventing pulmonary aspiration amongst others.
The specific impacts that this disease has on patients include; increased length of stay in the hospital, rising costs of healthcare, increased morbidity rates, and death in the worst cases scenario. Statistics indicate that the mortality rates from contracting this disease stand at 20% to 30% (Amanullah&Mosenifar, 2013). Additionally, in the event that patients die from VAP, the morale levels of the nurses taking care of them will eventually go down. As such, the compounding effects that come along with the development of VAP are patients emerging with undesirable outcomes.
The gravity that this condition has on the nursing practice is very profound. In most healthcare settings where reimbursements of Hospital Acquired Infections are done, it may be challenging to a health facility in getting payments due to the high prevalence of VAP (IDSA, 2016). On the other hand, high cases of VAP indicate that patients in the ICU are not receiving optimal care; therefore, this shows that nurses are failing in discharging their duties of providing quality care to patients. Additionally, if patients die due to VAP, there are possibilities of care providers being sued which impacts negatively on their output resulting in nurse shortages. The resultant effect because of the shortage is that the levels of VAP are likely to rise.
Solution description
The DVT program involves employing anticoagulants like heparin and graduated compression socks which play the role of lessening the possibilities of a patient being affected by pulmonary embolism. This condition ahs been established to be effective in checking on VAP incidences. Thirdly, stress ulcer prophylaxis using Sucralfate is an important step towards reducing gastric bleeding in intubated patients (Cal, 2015). This preventive measure becomes effective if the oxygen that an individual is provided with is reduced which is an effective method that is directed at tracheal de-canulation. Fourthly, daily sedation holds have also been proven to be helpful in boosting the levels of patient comfort in addition to facilitating interventions which are directed at decreasing the anxiety levels of the patients.
Sedatives like clonidine and benzodiazepines are essential as they help in preventing the patient from waking up in the event that they get agitated. The use of 0.12% chlorhexidine has also been established to be an effective method of taking care of the oral cavity since in most cases; it is in the mouth that the bacteria which cause this condition have been established to multiply (Cal, 2015). All these methods have been proven to play a significant role in addressing the problem of VAP amongst mechanically ventilate patients.
Incorporating Theory
The theory of goal attainment which was developed by Imogene Kings, it focuses on the interaction between patients and the care providers taking care of them. The goals that are focused on desirable patient outcomes are developed by ensuring that there is an existing communication process which ensures that a mutual interaction between nurses and their patients exists (Current Nursing, 2012). This theory can be used as a basis the assessment and the maintenance of desirable, healthy systems that which overall result in patients achieving their wellbeing goals.
This theory is made up of a series of interactions between the nurse and the patient. These interactions are personal, interpersonal and social system. The personal system involves self-growth and development, perception, and body development. Interpersonal interaction involves communication, stress, and role while the social system entails the authority, status power, and decision making. If there are perceptual accuracies in the way the nurse and patient interact, proper transactions will occur. These transactions are vital for goal achievement. From these goals, patient satisfaction, and efficient nursing care can be achieved. On the contrary, conflicts between the nurse and the patient result in stress. The rationale for utilizing this theory is that it provides a framework through which patients can express their concerns regarding care provision which is essential for their wellbeing.
This approach is critical in making sure that the needs of a patient having problems with VAP can be satisfactorily addressed since it provides a comprehensive assessment of such a patient. From the assessment, it can be easy to plan for the interventions that can be employed regarding the prevention of VAP incidences occurring to a patient under critical care (Current Nursing, 2012). Thirdly, the implementation of the interventions is made so that they can result in required transactions. To achieve this objective, it is crucial that the critical care nurses consider the perceptions that patients have concerning the proposed care. Finally, an evaluation of whether the VAP prevention practices have been effective is done. This process ensures that the treatment goal which is the reduction of VAP rates is achieved.
Incorporating this theory in my practice will mean that I have a clear understanding of my patient’s needs so that I can be able to develop a care plan that is suited for them. My first step will be to carry out an assessment on my intubated patients concerning their perceptions of VAP prevention practices. This step is important since it is through proper communication that I can have a thorough understanding of their desires. Secondly, after clearly understanding the perceptions of the patient regarding the various VAP prevention practices, I will be better placed in developing a care plan that meets their specific needs bearing in mind that I will have chosen an intervention directed at achieving treatment goals (Current Nursing, 2012). My plan will also incorporate patient and family education on how to well to handle the patient. This education plan will include providing the necessary information to the patient’s family regarding the different VAP prevention practices like bundle of care. This education is essential for taking care of the patient after being discharged from the hospital. After planning for the proposed care, it now becomes easier implementing the care plan by employing the correct combination of VAP prevention practices depending on the needs and perception of the patient and the efforts directed at attaining the goals. Finally, I will carry out an evaluation to determine whether the VAP prevention mix that I will have chosen has been active. This is in line with ensuring that the treatment goals have been achieved.
4. Implementation Plan - VAP
Implementation of the VAP project is a significant step aimed at ensuring that the objectives of giving patients outmost care, improvement of nursing practices and achieving desirable patient’s outcomes on the mechanically ventilated patients in the critical care unit are realized. Nevertheless, there is the need for making sure that all the relevant implementation stages have been followed and adequately taken into consideration. This will ensure any possible hitches that may affect project execution along the way are equally addressed. Additionally, it will be imperative that well-informed decisions are made with the intentions of ensuring that all the steps in the implementation of VAP project are addressed and that there is no wastage of resources. Therefore, in order to have a clear framework for rolling out the VAP project, there is the need for approval from the organization’s management.
The initial step towards realizing the goals of this undertaking is making sure that the approval from the management is given for the stakeholders responsible for carrying out the program can be able to proceed with their roles. Therefore, I will write a letter to the management requesting a meeting with them. This session will also feature other stakeholders in the hospital like physicians, nurses, respiratory therapists and critical care unit specialists. The letter will be accompanied by a proposal that clearly outlines the statement of the problem and the budget allocation for all the activities that will be carried out. In the meeting, I will bring the management and the staff members up to speed concerning the need for operational changes on the management of VAP. The meeting will provide a sneak preview on the need for utilizing VAP bundles in addressing VAP and will be shown to be more helpful in comparison to the standard care practices.
It is imperative that critical care patients receive the best care for them to emerge with desirable outcomes which will not have a toll on their well-being in the long run. Patients in these healthcare units are usually under constant scrutiny for their good being, and if they are not provided with the required attention, the chances are that they will likely fall victims of VAP. This condition specifically affects patients that have been fitted with mechanical ventilators. It has been proven to be found in a quarter of all patients under mechanical ventilation (Bagi, 2015). These bacteria thrive in the lungs of a mechanically ventilated patient since they have got weak immune systems.
There is however concerns regarding the strategies that have been put in place to address this condition. The standard care which is aimed at restoring the health of these patients is not sufficient which calls for alternative means of addressing the problem. As such, it is imperative that proper critical care is provided to this portion of patients with the objectives of making sure that they come out of this hospital unit satisfied with the services that they have received. There is the need to shift the focus from standard care to the use of VAP prevention bundles which have been proven to be effective in addressing this problem satisfactorily. This realization has got the advantage of ensuring that the patients emerge with desirable outcomes.
The use of sedatives is a major factor in the critical care unit directed at improving patient comfort, facilitate interventions, permit mechanical ventilation and decrease anxiety levels. Examples of sedatives that can be used include benzodiazepines, clonidine, and propofol. Sedation hold is important in preventing the patient from waking up due to agitation. Secondly, the performing a deep vein thrombosis prophylaxis is also a crucial step towards addressing the development of VAP in intubated patients. DVT Prophylaxis plays the role of reducing possible pulmonary embolism incidences (Rello et al., 2013). This regimen includes the use of mechanical methods like graduated compression socks or anticoagulants like weight heparin. The two prophylaxis measures are aimed at addressing any possible emergence of VAP incidences to the patient.
Thirdly, the use of stress ulcer prophylaxis has been proven to play a significant role in reducing the risk factors that have been associated with the development of VAP. The usage of Sucralfate has been shown to be effective in reducing gastric bleeding in mechanically ventilated patients which eventually translates to lowered incidences of the condition (Rello et al., 2013). In this direction, therefore, it is imperative that patients have a gradual reduction in ventilator support which is achieved through cutting back on the oxygen that they are supplemented with and eventually ending with tracheal de-canulation.
The fourth point concerning the use of VAP bundles is the prevention of pulmonary aspiration. As such, it is imperative that critical care nurses help patients in placing the head of their beds at an angle of between 30 degrees and 45 degrees. At this position, it becomes easy to prevent patients from inhaling oropharyngeal contents which eventually prevents any possible pulmonary aspiration incidences from occurring (Rello et al., 2013). Finally, proper oral hygiene is an essential step aimed at addressing VAP. Utilizing 0.12% chlorhexidine during the brushing of teeth has been to be an effective method of preventing cases of the condition. Proper rinsing of the mouth after a thorough cleaning session using the toothpaste has played a significant role in curbing the disease in mechanically ventilated patients.
These VAP prevention bundles have been proven to be effective in controlling VAP incidences since they address the problems from the cause. By comparing these techniques to the standard care practices, there are many problems which are associated with the use of antibiotics in treating VAP. The comprehension that the bacteria responsible for VAP are constantly mutating may pose a threat on how to effectively address the problem since these pathogens will eventually become antibiotic resistant. As such, utilizing VAP bundles is the most efficient method of preventing the chances of this condition occurring in mechanically ventilated patients.
A study done by Guterres et al (2012) shows that by critical care nurses making use of VAP bundles; the resultant effect have always led to desirable patient outcomes. By combining care with the aspiration of tracheal discharges, endotracheal cuff pressure ranging from 20 to 30 cm parts of water, headboard elevation of between 30 degrees to 45 degrees and oral hygiene involving 0.12% chlorhexidine, it eventually led to improvements in VAP rates. Another research done by Al-Thaqafy et al (2014) on the association between utilizing VAP bundles and the incidences of VAP showed that by effectively sticking to these practices, VAP rates reduced from 3.6 to 1 within a period of four years whereas the use of ventilators on such patients reduced to 0.59 from 0.73. These outcomes were as a result of a bundle compliance of 7%.
According to Nicolosi et al (2014), proper oral hygiene through the use of 0.12% chlorhexidine gluconate has got profound effects on addressing the problems brought about VAP. This study showed that patients who brushed their teeth with the toothpaste had shorter hospital stays compared to those who used traditional oral care techniques. Finally, Jansson et al (2013) posit that nurses have got limited knowledge concerning how to address adequately the challenges that are brought about by VAP condition. They proposed that critical care nurses need to be provided with the resources regarding skills, time, and guidance on how to utilize VAP bundles to reduce the rates of the condition amongst critically ill patients.
The implementation process for this program will entail the integration of different stakeholders from the organization. Since many factors that need to be addressed in this situation, it is important that different professionals be involved in this process with the intention of coming up with a team that will satisfactorily address all the issues involved. As such, critical care nurses, nurse informaticists, an accountant, and physicians will be included in the process of overseeing these changes. To ensure that the project is a success and met with minimal resistance, there will be the need for incorporating hands-on experience training to all the stakeholders in the program. The training will be done in agreement with the organization’s mission, vision, and values which are important steps towards ensuring that the organization’s culture has been taken into consideration in the process. The nurse manager in charge of the critical care unit will be responsible for initiating change, overseeing the implementation process and making sure that workflow is maintained.
The nursing informaticists will be responsible for marinating patients’ records in an electronic manner. The accountant will play the role of budgeting and addressing the costs involved in the implementation process. Physicians will play the role of making sure that the correct medication measurements are adhered to. The role of staff education will be done by a critical care nurse who has got more than ten years experience in taking care of mechanically ventilated patients using VAP bundles. The education will be done by the use of pamphlets touching on areas concerning the working of the VAP bundles. The information contained in the pamphlet will include; daily sedation hold, elevating the head of the patient’s bed to between 30 degrees and 45 degrees, the administration of deep vein thrombosis medication, oral hygiene involving 0.12% chlorhexidine and gastric ulcer prophylaxis.
This checklist will be maintained in an electronic format which will make it easier to make any corrections concerning the changes that will be occurring on the condition of patients. The documentation of bundle of practice will be done by nurses on a daily basis and will be reviewed each month for the compliance of the bundle of care. The nurse manager in charge of the critical care unit will be charged with making sure that the checklists are collected. The reviewing of the chart will be the responsibility of the key stakeholders in the program including the nurse manager, critical care nurses, the nurse informaticist and physicians. The responses from the chart information will be used to gauge the success rates of the program. This strategy will form the basis of the reviewing process.
5. Evaluation Plan
For the objectives of a particular project to be achieved, there is the need for carrying out an assessment of how far the program has moved. In this direction, therefore, it is important that program evaluation be done which is a crucial step towards checking on the efficiency and the effectiveness of that project. Program evaluation is an essential step in any program since it produces timely, credible, relevant and objective findings of a project by making use of reliable and valid data collection and analysis (Posavac, 2015). Additionally, carrying out program evaluation lays down the framework for which the program can be improved, check whether there are alternatives to the established procedures, and confirm whether the program is worth the cost outlay, whether there are other unintended results and generally whether the objectives of the project are in line with its progress.
The assessment program that a particular organization picks in trying to address its needs is based on the specific requirements of the organization. As such, the commonest program evaluation methods in accordance with the demands of making sure that the VAP bundles work towards lowering VAP rates include goal-based, process-based and outcomes-based evaluation. Goal based evaluations are useful in assessing the extent to which the project is meeting its objectives of addressing VAP rates amongst intubated patients. This method aims at assessing whether the project has been rolled out according to the resources, priorities, and timelines and future projections of the undertaking (Posavac, 2015). The process-based evaluation on the other hand takes into consideration the efforts put in achieving the required results. The primary focus is on the role that nurses need to play in realizing the objectives of the program, the different mix of bundles that each patient needs to be provided with to address the cases of VAP and the possible complaints from the care providers. This process is fundamental to achieving the program’s overall objectives. Lastly, the outcomes-based approach puts a lot of focus on whether the critical care unit is adhering to the VAP bundle regimen which is a significant step in realizing the outcomes of the intervention. The outcomes that are expected in intubated patients are whether they experience faster discharge rates from the critical care unit in addition to improved VAP rates. These efforts are geared towards having patients emerging with desirable outcomes.
Since this program is aimed at reducing VAP rates amongst mechanically-ventilated patients, the items that need to be evaluated will be the effectiveness of the VAP bundles. Therefore, the first assessment in line with the needs of the addressing VAP is determining whether sedation holds have been effective in addressing the conditions of the patient. The anxiety levels of the patient in addition to their comfort will form the yardsticks on which VAP rates will be addressed (Speck et al., 2016). Secondly, the extent to which graduated compression stockings and weight heparin will have addressed the problem of pulmonary embolism will show the effectiveness of this bundle.
The dosages of Sucralfate that a patient requires in a day will determine the success of stress ulcer prophylaxis. The lower the levels of this drug used, the higher the success rate of this intervention. Fourthly, in the event that the critical care nurses report reduced oropharyngeal contents in the lungs of an intubated patient, it will mean that the adoption of the head of the bed at an angle of between 30° and 45° will have played a significant role in improving VAP rates amongst mechanically ventilated patients. As such, this realization will serve as a yardstick for determining the workability of the program (Speck et al., 2016). The last variable to be assessed is whether using 0.12% chlorhexidine has achieved its objective of improved oral hygiene in intubated patients. Improved rates of VAP from a patient under this care are an indication that the process has been successful.
6. Disseminating Evidence
It is imperative for the outcomes of the program to be presented to the primary stakeholders that have been involved in the program all through the implementations phase. As such, it is essential that the information be disseminated to the relevant authorities which are significant steps towards having it supported in the event that it has proved to be successful (Royse et al., 2015). Additionally, by making the project to be well known to many individuals, it will serve as a way of increasing the impact that the program will have in different healthcare settings thereby resulting in desirable outcomes on the side of patients. Furthermore, by sharing out the results of the VAP prevention program, it makes it easy to point out any possible shortcomings by the general public thereby making it easy to correct any inconsistencies.
In this direction, therefore, the most appropriate method of disseminating the results of the project to the key stakeholders in the program is through setting up workshops and seminars where healthcare practitioners involved in rolling out the program will be brought up to speed on the gains and challenges that the VAP prevention program has faced. This meet ups also provide an opportunity where possible problems for the program can be identified and solutions proposed. To the general public, the significance of the using VAP bundles in addressing VAP can be achieved through holding community awareness open days, publishing papers and reports concerning the gains of the program on scientific literature and using the mass media in publicizing the outcomes of the program (Royse et al., 2015). Such a channel is paramount as it helps in reaching a wider following. It is through these publicity efforts that the benefits of utilizing VAP bundles in improving VAP rates can be felt on a larger scale.
7. Conclusion
This paper has given a description of VAP as a clinical problem which needs to be addressed since it has been proven to be an issue in most critical care units. The use of VAP prevention bundles has been established to be effective in preventing the emergence of the condition in the ICU. In addition to the solution of the problem, the implementation plan and the steps taken in evaluating the program have also been given the required attention. A method used to report the findings to the key stakeholders has also been discussed making it easy to share the information with a larger audience.
8. Review of the Literature
Sedwick, M. B., Lance-Smith, M., Reeder, S. J., &Nardi, J. (2012). Using evidence-based practice to prevent ventilator-associated pneumonia. Critical Care Nurse, 32(4), 41-51.
This study was done with the aim of developing a care bundle that will assist in preventing the cases of VAP cases for patients in critical care units. The strategies to be used will include subglottic suctioning, hand washing, using electronic compliance feedback system and head of bed alarms. It was established that sticking to these practices improved patients’’ outcome and also cut on costs. The study included a combination of 105 nurses employed during the study period within a period of 4709 days. Study participants worked in interdisciplinary teams with the objective of coming out with precise data about the problem. The participants were provided with materials like flagged order sheets and checklists for them to achieve 100% compliance with the bundles. The strengths of the study period off 4,709 ventilator days were also enough to carry out a comprehensive study. Employing the use of interdisciplinary teams was an important step towards the success of the projects. The weakness of the survey includes the problem of bias since the study was only done in a single hospital. Additionally, the study population was little which compromises the validity and reliability of the survey.
Complying with the prevention practices led to an increase in oral care by 20.8%, extubation readiness to 92.4% while VAP cases reduced from 9.47 to 1.9. It resulted in savings on treatment costs by 1.5 million dollars. Nurses can include the bundles in daily care to improve patient outcomes since they are evidence based. Constant observations ensure that nurses can deliver high-quality patient care. Team working is also important in achieving improved patient care.
Ranjan, N., Chaudhary, U., Chaudhry, D., &Ranjan, K. P. (2014). Ventilator-associated pneumonia in a tertiary care intensive care unit: Analysis of incidence, risk factors, and mortality. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine,18(4), 200-204.
The goal of this research was to establish whether different pathogens are responsible for VAP in critical care patients and the duration of mechanical ventilation that exposes an individual to the condition. This study confirmed that Pseudomonas aeruginosa and Acinetobacter spp are the striking causes of high fatalities in VAP patients. This study was carried out using a prospective observational design over a period of one year. Patients under mechanical ventilation were selected to be included in the survey. ETA and BAL samples were collected from these patients and analyzed by the use of Fisher’s exact test. By applying ETA and BAL methodologies in the study made sure that ensured that better comparable results were produced which forms the strength of this study. The sample size of 105 was not enough to come up with comprehensive data regarding the problem at hand.
The study indicated that the more a patient stayed under mechanical ventilation, the higher were their chances of developing VAP. Overall death cases reported from the survey stood at 48.33%. Nurses are obliged to have a better understanding of the primary bacteria that are responsible for increasing VAP, which is an essential step towards addressing the problems of VAP and also reduce deaths related to this condition.
Al-Thaqafy, M. S., El-Saed, A., Arabi, Y. M., &Balkhy, H. H. (2014). Association of compliance of ventilator bundle with the incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over four years. Annals of thoracic medicine, 9(4), 221.
This study was conducted with the intentions of ascertaining whether the Institute of Healthcare Improvement ventilator bundles were effective in reducing VAP rates. It was established that utilizing these strategies led to reduced levels of VAP in hospitals. The study design employed was a quantitative one with data being collected through cross-sectional surveillance. The study sample was developed from a 900-bed facility in Saudi Arabia which admits 900 patients per year. Data analysis was done by the use of the Z-test and chi-square tests. The strength of the study is based on the longer duration of the study and a large number of ventilator days were critical in ascertaining the validity and reliability of the survey. The limitation of the review is based on the realization that there was no causal link in the study, therefore, translating to no generalizability.
The results of the study indicated that VAP rates reduced significantly during the four-year study period by 2.6 in 1000 ventilation days. Additionally, ventilator compliance rose by 7% during the study period. The nursing profession is supposed to make sure that IHI Ventilator bundles are implemented in critical care units as they help in reducing VAP rates translating to desirable patient outcomes.
Yeung, K. Y., & Chui, Y. Y. (2010). An exploration of factors affecting Hong Kong ICU nurses in providing oral care. Journal of clinical nursing, 19(21‐22), 3063-3072.
The goal of this research was to carry out an assessment of the factors that affect critical care nurses in providing oral assistance to patients in Hong Kong. The primary focus was on their perceptions, fears, the priority that they give and the support that they get in the process.
This study was carried out using an explanatory qualitative design. The participants in the study came from a sample of 10 nurses with between 3 to 15 years experience in critical care. It was carried in a 24-bed ICU unit. Data was collected through transcribed interviews while data analysis was done by Morse and Field. The strengths of the study were achieved through proven validity where fellow researchers were involved in data analysis. There was also informed consent of the participants before the study. A limitation was the small sample size and only one study setting which would have created a situation of biases.
It was established that the critical care nurses’ practices were seldom evidence-based regarding cleansing the oral cavity, assessing the health of the mouth and take care of the surrounding regions. This study presents the need for training of critical care nurses to improve their knowledge concerning oral care. It is vital that adequate levels of staffing, appropriate material, and evidence-based protocol to be followed in providing care to the patients.
Guterres da Silva, S., Pereira do Nascimento, E. R., & Kuerten de Salles, R. (2012). Bundle to prevent ventilator-associated pneumonia: a collective construction. Texto&ContextoEnfermagem, 21(4).
The aim of research was to create a prevention bundle for VAP. The key areas of focus were oral; hygiene, headboard elevation, care with the aspiration of tracheal secretions and endotracheal cuff pressure. These bundles were established to contribute to a reduction of VAP cases. The study employed a qualitative convergent care research technique. The study population comprised of 21 nurses and four physiotherapists. Data collection was done by the use of semi-structured interviews and discussion groups with each data collection session durations going for 60 minutes. Data analysis was conducted using the Morse and Field framework. The strength of the study is that information was recorded by the utilization of a micro-recorder which ensured the reliability of the survey. The weakness of the study was that by care providers having little knowledge of the bundles did not translate to them applying it in their practice.
The results indicated that utilizing the VAP prevention bundles was effective in supporting healthcare and reducing the rates. Such a realization resulted in better patient outcomes. The implication that this study on the profession is that it results in better patient outcomes due to the ease with its applicability. As such, nurses need to incorporate them in their care provision process for patients under mechanical ventilation.
Silva, S. G. D., Nascimento, E. R. P. D., &Salles, R. K. D. (2014). Ventilator-associated pneumonia: discourse of professionals about prevention. Escola Anna Nery, 18(2), 290-295.
This study was carried with the intentions of establishing the level of knowledge of nurses and physiotherapists concerning the prevention of VAP in ICUs. The research design employed in this study was qualitative primarily focusing on a description. Data collection was done using semi-structured interviews from 25 medical professionals in one public hospital for five months. Data analysis was done using Collective Subjective Discourse. The use of several independent variables was crucial in achieving reliable results. The study period and the number of participants was limited thus compromising the validity of the research and may also lead to biases.
The results of the survey indicated that focusing on hands and oral hygiene, prevention of pulmonary infections, assessment of extubation and taking care of aspiration and secretions was vital in lessening VAP rates. It is crucial that medical practitioners have a better understanding of the VAP prevention bundles and incorporate them into practice so that the patients can emerge with desirable outcomes.
Nicolosi, L. N., del Carmen Rubio, M., Martinez, C. D., González, N. N., & Cruz, M. E. (2014). Effect of oral hygiene and 0.12% chlorhexidine gluconate oral rinse in preventing ventilator-associated pneumonia after cardiovascular surgery. Respiratory care, 59(4), 504-509.
This study assessed the effect that brushing teeth with 0.12% chlorhexidine gluconate had on the wellbeing of patients with VAP after undergoing cardiovascular surgery. It was established that utilizing these methods resulted in shorter hospital stays and lessened the VAP rates. The study employed a quasi-experimental study in which patient that were under heart surgery care were recruited in the process. The study participants involved two groups of 150 participants each in which one used 0.12% chlorhexidine gluconate while the other employed regular oral care. Data was analyzed using chi-square technique. The study used two groups of participants which generated better results because of the comparisons made thus resulting in generalizability. The limitation of the survey is that it is not a prospective RCT thus did not collect substantive data.
The group that used recommended oral care reported decreased VAP incidences of 2.7% in addition to lower shorter hospital stay of 3 days compared to the control group which focused on standard oral care. It is vital that care providers incorporate the use of 0.12% chlorhexidine gluconate in maintaining the oral hygiene of VAP patients under critical care.
Cutler, L. R., &Sluman, P. (2014). Reducing ventilator-associated pneumonia in adult patients through high standards of oral care: A historical control study. Intensive and Critical Care Nursing, 30(2), 61-68
This research was conducted to assess the effect that maintaining proper oral hygiene using oropharyngeal suction in addition to chlorhexidine gluconate at the rate of one percent had on addressing the prevalence of VAP rates and the effects it had on the treatment expenses. It was established that employing these two strategies led to reduced VAP cases and also cut on costs of care. A quantitative design involving a study population of 1087 participants was conducted for 30 months. The setting of the survey was in one hospital in England. The number of participants and study period present the strengths of the review since they reduced cases of biases and also boosted the reliability and validity aspects of the study. Limitation of the study was based on the restriction of literature which resulted in little generalizations of results.
The study showed that 91% compliance rate was achieved which translated to a mean VAP incidence by 8.9% for the control group. The intervention group observed a 4.1% incidence rate which was a significant step in preventing VAP rates. Treatment costs were also reduced by 6319 pounds. Risk reduction also reduced to 0.53. It is vital that nurses incorporate the use of chlorhexidine in taking care of VAP patient since it has been established that they play the role of reducing VAP rates and also cut on treatment costs.
Leblebicioglu, H., Yalcin, A. N., Rosenthal, V. D., Koksal, I., Sirmatel, F., Unal, S., &Ulusoy, S. (2013). The effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC). Infection, 41(2), 447-456.
This study was done to establish the effects that International Nosocomial Infection Control Consortium (INICC) strategies had in addressing VAP amongst hospitalized adults. It was determined that utilizing the strategies led to a 46% decrease in VAP incidences amongst these group of patients. This a quantitative research which involved surveillance carried out before and after the study. It was divided into two phases which utilized data from INICC and the CDC. The areas of focus were outcome surveillance, a bundle of infection control, patient education and feedback concerning VAP rates. The strength of the research is that it used time series in data analysis which is a comprehensive method of analyzing multiple sources of data. The limitation of the study is that it was not generalized in all ICUs in Turkey in addition to having a very short study period that would have resulted in an overestimation of variables.
The results indicated that the VAP rates were lower in the second phase of the study compared to the first one. The study resulted in 46% VAP reduction over the 1000 mechanical ventilation days. Healthcare practitioners are required by to incorporate INICC practices while caring for ICU patients since it is important in taking resulting in better patient outcomes concerning VAP.
Jansson, M., Ala-Kokko, T., Ylipalosaari, P., Syrjälä, H., &Kyngäs, H. (2013). Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia–A survey study. Intensive and Critical Care Nursing, 29(4), 216-227.
This research was conducted to assess the factors that affect the knowledge of nurses regarding how they adhere to evidence-based VAP prevention practices and the barriers that they face in this process. Factor that prevented from achieving better VAP rates were established to be a lack of adequate time and resources. The study employed a quantitative cross-sectional survey with a study sample of 10 nurses. It was done in an academic center in Finland in 2010 during the autumn season. Questionnaires were used in data collection. Data analysis was done using t-tests. Getting approval from the responsible board and participants giving the consent for the study are the strengths of this study. The sample size was, however, small thus poses a limitation regarding validity and reliability of the survey.
The levels of knowledge that the nurses in the survey stood at 59.9% which is an indication that very few nurses understand how to provide care to ICU patients. Only 84% of the nurses adhered to the care provision strategies. This study is important in the nursing profession since there is the need for improvements regarding education and adequate adherence strategies. Such moves are aimed at reducing VAP rates.
Chow, M. C., Kwok, S. M., Luk, H. W., Law, J. W., & Leung, B. P. (2012). Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: A pilot randomized controlled trial. International journal of nursing studies, 49(11), 1333-1341.
This study was done to establish whether saliva ejectors used in continuous oral suctioning was an effective method for reducing VAP incidences in patients. These devices were found out to play a critical role in reducing the length of hospital stay, cutting VAP rates and decreasing the duration of mechanical ventilation. This study was a randomized control test that was conducted in a 400-bed space hospital providing medical care to critical care patients. Patients in the experimental group were assigned with saliva ejectors and conventional endotracheal tubes which were connected to a 100mmHg for continuous saliva drainage. The strength of this research is that it involved the use of an experimental and control groups of participants which were important for comparison purposes. The limitation, however, is that the sample size was small which may have led to compromised reliability.
There were higher rates in the control group regarding VAP compared to the experimental groups with ten patients accounting for the control faction while three patients accounted for the experimental cluster. There was also a remarkable difference between the two groups regarding mechanical ventilation standing at 3.7 days on average. The number of ICU days differences was 5.It is essential for nurses to ensure that they include saliva ejectors when providing care to their ICU patients. These strategies result in shorter hospital stays, lower mechanical ventilation days and reduced VAP rates.
Krag, M., Perner, A., Wetterslev, J., &Møller, M. H. (2013). Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review. ActaAnaesthesiologicaScandinavica, 57(7), 835-847.
This study was aimed at addressing the role that stress ulcer prophylaxis plays in addressing problems that are associated with hospital-acquired pneumonia, gastrointestinal and mortality rates. It was established that there is no enough evidence showing the role that SUP plays in addressing these patients’ problems. This was a qualitative study that utilized data from nursing databases like MEDLINE, EMBASE, and Cochrane Library. The study population was patients being taken off in the ICU. The strategies employed were both pharmacological and non-pharmacological. Separate reviews concerning the study were done which was an important step in ensuring the strength of the survey. A limitation of this study is that it has not specified the period of study which compromises its validity.
Results from the study indicated that the level of mortality rates in addition to the hospital-acquired pneumonia was not in line with the use of SUP in patients. Applying the use of TSA likewise confirmed the absence of effectiveness of SUP. This study is crucial in the nursing profession since there is the need for nurses to have a better understanding of how SUP functions to ensure that adult ICU patients are well taken care .
Kahraman, B. B., &Ozdemir, L. (2015). The impact of abdominal massage administered to intubated and enterally fed patients on the development of ventilator-associated pneumonia: A randomized controlled study. International journal of nursing studies, 52(2), 519-524.
This study was aimed at determining the role that abdominal massages play in ensuring the mechanically ventilated patients does not develop any VAP. This strategy proved beneficial in reducing residual gastric volume in patients who were enterally fed and also reduced VAP incidences. A randomized controlled trial was used in this test in an intensive care unit university hospital in Turkey. The sample size was 32 whereby 16 were in the study group and another sixteen in the control group. Participants received massages on their abdomen for five minutes every day. The strength of this study is that it used two groups of participants which are an important factor in ensuring generalizability of the results. The limitation of the survey is the small sample size which will compromise the reliability of the inferences made.
The conclusions from the study showed that VAP rates from the intervention group had reduced at a ratio of 6.3% compared to the control group. This was as a result of the amount of residual gastric volume decreasing. The implication that study has on nursing practice is that there is the need for care providers to include massages in the VAP prevention practices. These methods have been proven to check on the level of VAP rates amongst mechanically ventilated patients.
Talbot, T. R., Carr, D., Parmley, C. L., Martin, B. J., Gray, B., Ambrose, A., &Starmer, J. (2015). Sustained Reduction of Ventilator-Associated Pneumonia Rates Using Real-Time Course Correction With a Ventilator Bundle Compliance Dashboard. Infection Control & Hospital Epidemiology, 36(11), 1261-1267.
The research was aimed at employing a program that utilizes bundles which are dashboard complaint with the intentions of reducing VAP complications. Ensuring that these practices have been adhered to made it easy significantly to reduce the cases of this condition in mechanically ventilated patients. A before-and-after quasi-experimental research was done. Time series was employed in data analysis. The development of these bundles was done in 6 different adult critical care units. The overall cumulative percentages for every patient were recorded. The fact that this study was done in multiple settings is a clear indication that data was collected from vast settings which imply that the results of the study were reliable. The probable limitation of the survey is based on the documentation process which compromises the issue of generalizability.
The application of dashboard bundles resulted in a reduction of VAP rates by 10.3 in each 1000 ventilator days. Additionally, the monthly rates of VAP also reduced to 3.28 in every 1000 ventilator days. Therefore, this study showed the important steps in reducing VAP rates amongst patients in ICUs. This study has to go significant effects on the nursing practice in the sense that nurses can get reliable information concerning the compliance to standards practice which is an essential step towards achieving desirable patient outcomes.
Liao, Y. M., Tsai, J. R., & Chou, F. H. (2015). The effectiveness of an oral health care program for preventing ventilator‐associated pneumonia. Nursing in Critical care, 20(2), 89-97.
This study sought to determine the role that evidence-based oral care plays in ensuring that patients under mechanical ventilation are well taken care of. This study showed that with improved oral mucosal care, the rates of VAP will be significantly reduced. The study design employed was quasi-experimental with a sample size of 199. The sample size was divided into two groups with a hundred patients forming the control set while ninety nine patients formed the experimental group. The intervention group used evidence-based care whereas the control group used standard care. The strength of the study is making comparisons between the two groups of participants which are vital for coming up with comprehensive interpretations. The limitation of the study is the limited study period which could have influenced the final inferences made.
The studies indicated that there was a major decrease in VAP rates amongst the experimental participants compared to the other set. The intervention group witnessed only 4% VAP rates while the control group saw 21% VAP rates. This study is vital to the nursing practice since it provides a framework through which VAP can be prevented if evidence-based oral care is observed. Such a fact leads to improved patient outcomes.
References:
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Amanullah, S., &Mosenifar, Z. Ventilator-Associated Pneumonia Overview of Nosocomial Pneumonias. 2013.
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Chow, M. C., Kwok, S. M., Luk, H. W., Law, J. W., & Leung, B. P. (2012). Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: A pilot randomized controlled trial. International journal of nursing studies, 49(11), 1333-1341.
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Jansson, M., Ala-Kokko, T., Ylipalosaari, P., Syrjälä, H., &Kyngäs, H. (2013). Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia–A survey study. Intensive and Critical Care Nursing, 29(4), 216-227.
Kahraman, B. B., &Ozdemir, L. (2015). The impact of abdominal massage administered to intubated and enterally fed patients on the development of ventilator-associated pneumonia: A randomized controlled study. International journal of nursing studies, 52(2), 519-524.
Krag, M., Perner, A., Wetterslev, J., &Møller, M. H. (2013). Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review. ActaAnaesthesiologicaScandinavica, 57(7), 835-847.
Leblebicioglu, H., Yalcin, A. N., Rosenthal, V. D., Koksal, I., Sirmatel, F., Unal, S., &Ulusoy, S. (2013). The effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC). Infection, 41(2), 447-456.
Liao, Y. M., Tsai, J. R., & Chou, F. H. (2015). The effectiveness of an oral health care program for preventing ventilator‐associated pneumonia. Nursing in Critical care, 20(2), 89-97.
Nicolosi, L. N., del Carmen Rubio, M., Martinez, C. D., González, N. N., & Cruz, M. E. (2014). Effect of oral hygiene and 0.12% chlorhexidine gluconate oral rinse in preventing ventilator-associated pneumonia after cardiovascular surgery. Respiratory care, 59(4), 504-509.
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10. Appendices
Questionnaire
1. How often do you employ these ventilation bundles in the care provision process?
2. What strategies do you use in sticking to sedation hold?
3. What methodologies do you employ in checking DVT rates?
4. Which medications do you provide to your patients to prevent stress ulcers?
5. What steps do you follow in elevating the patients’ bed?
6. What is your frequency of providing oral care to your patients?
Technology
The required technology for this program will be maintaining patients’ information in Electronic Health Record database by a nurse informaticist.
Funds
Budget
The nurse manager in charge of the critical care unit will be tasked with initiating, overseeing and the evaluation of the program.
