Abstract
Ventilation Associate pneumonia is a nosocomial infection that affects immobile patients, especially those admitted in the Intensive Care Unit. The management of these patients has been challenged and it triggered numerous studies on the most efficient ways of managing such patients. In the ward care of a patient that is ambulant and can describe changes in their condition it is easy not to pay attention to the positions of the patients. However, in the acute wards, the positioning of such patients is significant in prevention of complications. One of the main challenges is pneumonia. The positioning of the head and the torso in an upright angle is what is referred to as semi recumbent position. The studies done in this paper were done by six different groups of authors, to give direction on the possibility of it reducing the risk of aspiration which is the primary cause of ventilation associated pneumonia in unconscious patients in the care unit (Cocze, et al., 2013).
Introduction
With ICU care taking up 30% of the gross domestic product amount in the United States. It is important that the health sector creates ways that can be used to accelerate recovery from the unit as well as reduce the chances of patients landing in it in the first place Sedwick et al. (2012), the occurrence of healthcare –associated infections occurs frequently. The author’s further report that the mortality rate of VAP is usually more than that of infection-associated pneumonia in hospitals. Mechanical ventilation is critical in the management of patients especially in the intensive care unit. Which positions are most efficient for nursing ICU patients? With the contradiction mainly being between 30 and 45 degrees.
This paper seeks to find out if the use of semi recumbent position can help to reduce the incidences of VAP. The condition occurs to a high percentage of machine supported patients. The quality of care is determined by the control protocol that guides the particular diagnosis. In the case of pneumonia induced by the use of the machines, positioning the patient is just as important. Many hospitals are still doing their research to identify
Research Questions:
Compare and contrast the available practices by different units on the positioning of patients
PICOT QUESTION OF PATIENTS ON MECHANICAL VENTILATION.
P- Population:
The studies done by the authors mainly dealt with a given number of patients in different countries and different hospitals. The patients ranged from admissions in post-operative care unit to intensive care units of the hospitals to identify if the elevation of the patient’s backrest is significant in the reduction of chances of contracting Pneumonia while on ventilation.
I-Intervention:
In the study done by Cocze et al., the different angles that were adopted were 0, 30 and 45 degrees. In a random research study. Unit and Multivariable logistics regression methods were used to find out what are the risk factors of hypotension in the case that a patient is set on head bed elevation process known as MAP and has the values <65mmhg (2013). The patients studied by the researchers were given the different intervention only similar in that they were all position related. Change from the normal practice to elevation of the bed. Although different facilities used different angles which gave particular results.
C-Comparison:
The control group for the studies was the interchange in the bedrest elevation angles to identify which of the three was prone to give a better prognosis. The researchers made sure to have other measures such as weight, age, and height as a control plan for the patients. The group control used in the research was multifactorial VAP reduction approach. A different study by Rose et al. (2010), was used on 371 patients from 32 ICU in Australia and New Zealand. Contrary to the previous one the hospital policy dictated that the patients should be nursed on 30 degrees’ elevation. The other control technique used was the placement of 37 patients in the semirecumbent position, which was at 45o, and 47 of them is a supine position. The consideration of alternative position was necessary to determine the actual rate of VAP.
O-Outcomes:
The 45 degrees’ elevation was noted to reduce the MAP significantly. The risk factor that was present was realized to be the pressure exerted to the patient during ventilation. According to Rose et al., the positions that were more prevalent in Australia and New Zealand, (2010), the position is determined by the condition of the patient. The most dominant being 30 degrees unlike the study by Cocze et al., (2013), which indicated 45 degrees as the most used angle. 45 degrees was highly associated with patients that are at later recovery stages of their illness. Mainly used for weaning and feed introduction to the patients. Therefore, the conclusion from the studies is that positioning the patients in semi recumbent position reduces the chances of getting ventilation associated pneumonia.
Meta-Analysis/ Systematic Review
Studies from different database have revealed that Ventilator-Associated Pneumonia can prove to be morbid in patients that are critically ill. This systematic review is meant to reveal how elevation of the head of the bed can reduce the prevalence and incidence of the disease. It is however already evident that the studies have all focused on a single mode of prevention controlled by same alternative measures. In the first case, the population was made up of 200 patients who had been placed in an ICU (Rose et al., 2010). The second case involved 371 patients from different Australian ICUs. The inclusion criteria had been patients over the age of 16 who had been under mechanical ventilators. The duration of the study was 7 days. The first case however had a differing inclusion criteria since it only accepted those above 18 years. Those excluded entailed patients with pump-driven respiratory and cardiovascular support (Gocze et al., 2013). The information gathered from patients in both cases was extracted using criteria that were pre-established. The research revealed that out of the suggested preventive criteria, and the need to prove that elevation was the best mode to select, the strongest outcome that was supported by ample evidence in both cases had been the semi-recumbent placement of the patient. A scoring system was employed when assessing the quality of the studies and 1 point assigned to each relevant criterion, and if failed to meet the quality standard it is awarded 0 points.
In consideration of another empirical study, the aim had been to test how best prone positioning would aid in the prevention of VAP. Unlike the first two, this research was based on the research carried out by other authors. There seems to be no guidelines in the current medical practice relating to the best practices relating to prone positioning. The secondary sources used had been gathered from academic websites such as Medline, and Cochrane library database among others. The selection mode used was relevance in terms of title of the article whereas the inclusion criteria in this case had been the date of the article. If it were published earlier than 2000, or be written in English and had to present an outcome. The exclusion criteria on the hand entailed considerations of publishing date, anything before 2000 would not be in. Dwight and Flynn (2011) also conducted a study on the same and used secondary sources as well. 6 had based their data on a trial, meaning that the information provided was not statistically viable. The strength of this article is that it incorporates the opinions of 14 different researchers, meaning that there is substantial information for a definitive conclusion.
Despite these articles attempting to achieve the same result they all concluded differently. Sedciwk et al. (2012) suggested that the primary treatment was the administration of bundle increase, for the elevation of the head of the bed (HOB) and reduced sedative interruption. The height was monitored using a system called transducer. The mean backrest height was 21.7o. Registered critical and intensive care nurses, Critical and Intensive care unit and Ventilator-associated pneumonia (VAP) patients. Pediatric and animal research were however excluded in the study (Sedwick et al., (2012). While according to Safdar, Collard & Saint, (2005). The in-service training program led to high rates of compliance for the module which in turn showed a decrease in VAP rates. VAP incidence rate declined from 8.75 to 4.74 per 1000 ventilator-days this signified 46% drop. The self-study module was completed by 89.9% of respiratory therapists and 80.1% of ICU nurses. An educational program for the nurses resulted in improvement of hand hygiene practices and posted an increase of 31.2% to 57%. The mortality rate due to VAP also declined from 12.3 to 8.7. Both pre and post-intervention phases displayed no difference in the bacteria causing VAP (Ylipalosaari, Ala‐Kokko, Laurila, Ohtonen, and Syrjälä, 2006).
There was no clear indication whether the negligible change in degree of positioning could change the result of the preventive measure.
Both authors have presented their research well and they recommend that there are numerous methods that could be applied to reduce cases of VAP, however the most specific one is the positioning of the patient in a semi-recumbent manner. Positioning the patient in semi-recumbent position contributes to preventing reflux of gastric contents significantly and therefore improve the prognosis of the condition. Increased elevation also, leads to a gravitational shift of blood pressure levels. This movement to the central system then induces retention of blood in the extremities hence the cardiac output reduces and the patient is at risk of hypotension (Rose et al., 2010).
Validity
The validity of a study is the ability it has to give the results that indicate that the study measured what it is said to have. The given studies all gave patients in intensive care their study population. The patients were real life subjects who suffered from conditions that influence them to contract pneumonia after surgical operations (Cocze, et al., 2013). A multicenter population used by Rose et al., was also valid because the patients gave different perspectives of the hospitals they were in (2010). Reviews of information from different sources was also a considerable area (Jansson, Kaariainen & Kyngas, 2012) and (Wright & Flynn, 2011), It gives the researchers a more objective study as the raw data is already available from other people. Grap, et al., 2012)
In the instance that the same study is done on a different set of patients with similar conditions. There is a high chance that 30 degrees’ elevation would be preferred for acute patients while 45 degrees would be better for recovering patients who can report a change in their condition.
Limitations
One of the main challenges faced by researchers in this study was lack of resources. Not all hospitals visited were adequately supplied with the require kinds of bed that could maintain the patients in the positions and at the same time remain ventilated. The results depended on the time that the patients spent in the machine support, in case of extubating then the studies became invalid (Rose et al., 2010). The knowledge available to the nursing team that managed the patients was also a problem. Those who had prior training were well placed to help in the studies. However, training was necessary for those who had none (Jansson, Kaariainen & Kyngas, 2013).
Conclusion
The studies done by all the authors have the same aim in mind. To identify the impact of bed rest elevation on unconscious patients. To concluded, the semi-recumbent position is important in the management of patients. However, as the patients recover the angle can be increased to 45 degrees for the sake of feeding and other medical procedures when the patient can tolerate the position. A bundled evidence-based practice is the best mode of care (Sedwick et al., 2012). By ensuring that documentation is used as the primary method of accountability, it is possible for the caregivers to
Supervise the progress of the patients. Although further studies are necessary to ensure that all the aspects of patient management are met. The current findings can be utilized to a large extend and the reduction rate be registered as significant with intubated patients not being at risk of mortality due to this nosocomial infection.
References
Cocze et al. (2013). Critical Care. A Research Paper. Retrieved from http://cforum.com/17/2/R80
Dwight, A. D., and Flynn, M. (2011). Using the Prone Position for Ventilated Patients with Respiratory Failure: A Review. Nursing in Critical Care 16(1), 19-26
Jansson, M., Kaariainen, M., & Kynga¨s, H. (2013). The effectiveness of educational programs in preventing ventilator-associated pneumonia: a systematic review. Journal of Hospital Infection, 206-214. Retrieved from www.sciencedirect.com
Mary Jo Grap, Cindy L. Munro, Unoki, T., Hamilton, V. A., & Kevin R. Ward. (2012). Ventilator-Associated Pneumonia: The Potential Critical Role Of Emergency Medicine In Prevention. The Journal of Emergency Medicine, 352-362. doi:10.1016/j.jemermed.2010.05.042
Rose et al. (2010). Positioning in Ventilator-Department Patients: A Multicenter, Observational Study. American Journal of Critical Care. Doi: 10.4037/ajcc2010783
Sedwick et al. (2012). Using Evidence-Based Practice to Prevent Ventilator-Associated Pneumonia. Critical Care Nurse, 32(4), 41-50
