Ventilator associated pneumonia (VAP) is a hospital acquired infection occurs in the intensive care unit (ICU) for the patients who are on mechanical ventilator. It further complicates the hospital course by extending the length of stay, increase the cost of treatment, and increases the mortality rate. It is estimated that about 1% to 3% patients on mechanical ventilator develops VAP per day. Compared to the previous years, the Chlorhexidine mouth care and other ventilator bundle strategies decreased the VAP rate. Evidence based research studies proved that almost 89.7% reduction in VAP occurs after the implementation of ventilator bundle and other care related to it (Hutchins et al, 2009). Ventilator care bundle was introduced in 2005 by the Institute of Healthcare Improvement with the aim to increase nursing compliance with evidenced-based actions to decrease the VAP rate (Sedwick et al, 2012). Problem identification and its description
One of the most common problems identified in the ICU is VAP. According to Patricia, VAP is a hospital acquired infection occurs within 48-72 hours of post intubation. The microorganism enters the lower respiratory tract and lung parenchyma via the Endo Tracheal Tube (ETT) or tracheostomy tube and cause infiltration of the tissues which causes pneumonia (Arrolga et al, 2012). Studies proved that the introduction and use ventilator bundle significantly decreased the VAP rate. VAP accounts more than eighty percentage of the hospital acquired pneumonia. Studies proved that the introduction and use ventilator bundle significantly decreased the VAP rate. VAP accounts more than eighty percentage of the hospital acquired pneumonia (Patricia et al, 2012). Evidence proved that VAP is caused by inadequate oral hygiene and poor management of the ventilated patients by the registered nurses and respiratory therapist. Adequate and timely oral care decreased the number of VAP in United States (Arrolga, et al., 2012). A few years back, the VAP rate was relatively high due to lack of education and awareness of the Repertory therapist and registered nurse and other health care providers. Lack of adequate knowledge and understanding about the VAP, its causes and management of patients on mechanical ventilator are considered as a major cause of VAP. Solutions to the Problem Ventilator Associate Pneumonia
The solutions to decrease the VAP rate is following strict adherence to the ventilator bundle and ventilator patient care guide lines. The major components in the ventilator bundle are sedation vacation, daily assessment for readiness for extubation, head of the bed elevation more than thirty degrees, peptic ulcer disease (PUD) and deep vein thrombosis (DVT) prophylaxis. Other components in the guidelines for management of ventilator care patients are increase the frequency of oral care and suction, mouth care with Chlorhexidine, and the head of the bed elevated to more than thirty five degree to decrease the aspiration risk. Regular screening of organisms by the sputum to analysis the bronchial lavage analysis will help for early determination organism and treating it on time. Regular mouth care helps to keep the mouth clean and oral suction prevent aspiration of secretions in the back of throat. Changing the ventilator circuit in a timely manner and when required also decreased the VAP rate. Aggressive pulmonary toileting also decreased the VAP rate. Evidence based studies proved that keeping head of the bed elevated more than thirty degree will prevent the micro aspiration of secretions (Prendergast et al, 2009). Education and continuing education increased the knowledge and awareness of the health care providers about the VAP. Following the evidence based protocols and the clinical application of ventilator bundle can decrease the VAP rate. Regular follow up.
PICOT
For adult patients on ventilator(p) performing mouth care with Chlorhexidine (I) decreases number of ventilator associated pneumonia (O) compared with patients who receives oral care with tooth brush(C) with in first 48 hours or even after intubation and on ventilator (T)? Review of Literature
Arroliga, A. C., Pollard, C. L., Wilde, C. D., Pellizzari, S. J., Chebbo, A., Song, J., Ordner, J., Cormier, S., & Meyer, T. (2012). Reduction in the Incidence of Ventilator Associated Pneumonia: A Multidisciplinary Approach. Respiratory Care, 57(5). 688-696. DOI: 10.4187/respcare.01392 VAP is one of the common hospitals acquired infections, which got significant importance in following evidence based practice to prevent it. The authors of this study used a retrospective single center observational cohort study, done in the ICU at Scott and White Hospital, Temple, Texas. The study took almost two years for its completion. The research team implemented the ventilator bundle about 258 patients in mechanical ventilator. The limitations of the study were its retrospective nature, single center study and the database does not have metrics for severity, such as Acute Physiology and Chronic Health Evaluation (APACHE) score. The research team identified there was a significant decrease in the number of VAP rate and the use of antibiotic rate in the treatment of VAP was also decreased in patients who received evidence based oral care. The team concluded by stating that the VAP rate is relatively low when the respiratory therapist is giving mouth care at least twice a day with Chlorhexidine. Following the simple evidence based practice like oral care can prevent or decrease the VAP rate, nurses and respiratory therapist should work aggressively with the oral care protocol to decrease the VAP.
Along with oral hygiene, following the other recommendations in the vent bundle like HOB elevation, frequent suctioning of the secretions, daily sedation vacation and weaning trials will decrease the VAP rate. Cindy, M., Mary, G., Deborah, J., Donna, M. (2009). Chlorhexidine, tooth brushing, and Preventing early ventilator-associated pneumonia in critically ill adults. American Association of Critical-Care Nurses 18(5), 428-438. doi: 10.4037/ajcc2009792 This study was conducted with the purpose of describing the relationship of the health status of oral cavity and VAP. The study was done at the twelve bedded medical respiratory ICU at Virginia Commonwealth University Health Systems in Richmond. According the study team about 1000 patients are admitting in this ICU and more 50% of people were required mechanical ventilator. The research team used non experimental, longitudinal, and descriptive design was used. All the patients who intubated in the ICU were enrolled in the study within 24 hours. Team excluded the re-intubated patients and patients already with pneumonia prior to intubation. Initially team assessed the oral health status of the people by obtaining a baseline count about the dental carries, repaired and missed teeth in the oral cavity and assessment of the oral cavity.
Then the team obtained the oral specimen for culture, measured the salivary volume and finally analyzed the immunoglobulin A and lactoferrin in the saliva. One of the limitations was that the study was done only while the patient is intubated. Early extubation and death related to the critical illness also affected the study. The study came to the conclusion that the presence of dental plaque increases the possibility for VAP. A good salivary flow will ensure the prevention of growth of microorganisms. Furthermore, removal of dental plaque by oral care enhances good salivary flow. Since oral health, salivary volume and dental plaque have a significant effect in developing VAP the assessment of the oral cavity is essential. According to the study the major cause of VAP is colonization of bacteria in the oral cavity. Feider, L., L., Mitchell, P., & Bridges, E. (2010). Oral Care Practices for Orally Intubated Critically Ill Adults. American Journal of Critical Care, 19(2). 175-183. doi: 10.4037/ajcc2010816 The authors of this research study discuss about the oral care policies performed by the critical care nurses and compare it with the AACN procedure manual for critical care.
A descriptive cross sectional study with web based survey was used for this study. The survey included 31 questionnaires which are obtained from randomly selected 352 critical care nurses. Use of different oral care tools like tooth brush, foam sponge, and chlorhexidine, assessment of the oral cavity, and suctioning the patient at different times were a part of the survey. The survey was sent to 2000 nurses and sent reminder cards to complete the survey. Only 352 nurses were responded for it. It was one of the major limitations of the study. Apart from this, nurses were not interested in the topic oral care.
The research team concluded that oral care policies were present and most of the nurses are aware of it. The compliance to the protocols was poor. Experienced nurses showed more compliance to the oral care than the nurses with less experience. There was a great difference between the policies and practices followed by the nurses. The study further proved that the use of tooth brush decreased the dental plaques. VAP is one of the life threatening conditions in the critical care unit. Strict adherence to the oral care protocols and policies by the nurses are essential to prevent the occurrence of VAP. Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing Ventilator Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study. American Journal of Critical Care, 18(6). 523-534. doi: 10.4037/ajcc2009311 The study was performed in the 14 bedded Medical ICU at Brookdale University Hospital and Medical Center. The study was done on patients who are mechanically intubated and admitted between admitted between January 1, 2001, and December 31, 2004. The team used certain criteria to select the patient for the study. The initial 24 months of the study was considered as the prevention period in which two expert people from infection control interview staff to identify the barriers for best practice in the prevention of VAP. Physicians, nurses and the respiratory therapist were interviewed to collect the data. Education to the staff was provided at this time. The second half of the time was the intervention period. The initial group has not followed any protocols for preventing VAP. But the research team has followed all the policies and protocols to prevent VAP.
Team identified that the compliance of the staff to the policies and protocols were more than 80% and the VAP rate with the research team was very low compared to the initial control group who hasn’t followed the protocol. The team concluded with evidence that strict compliance and following the protocols will prevent the VAP Ka Yi, Y., & Ying Yu, C.. (2010). An Exploration of Factors Affecting Hong Kong ICU Nurses in Providing Oral Care. Journal of Clinical Nursing, 19(3). 3063-3072. doi: 10.1111/j.1365-2702.2010.03344.x Providing oral care is the integral part of the nursing care team to prevent VAP. This research discuss about a study done in one of the hospitals in Hong Kong with the purpose of identifying the factors that affect in the oral care practice in the critical care unit. The research team used an exploratory qualitative study to analysis the data obtained from the audio interviews of the selected experienced staff. There were limitations in this study. Since study was done in a government hospital and done only with the experienced nurses a full range of different perspectives of the topic was not explored. Furthermore the sample size used for this study was also small to collect adequate data required for the study The study team identified that the main factors that affect the oral care practices are the perceptions of the purpose of oral care, their fears about providing it, the priority of oral care; and inadequate support for oral care.
Besides this the oral care practice followed was not evidence based. The study recommended to follow the evidence based protocol in thehospitals by changing the policies. Apart from this, research team encouraged adequate education to the staff about the importance of evidence based oral care practice and adherence to it. Since oral care is the basic practice to prevent the VAP more detailed study is recommended. Kjonegaard, R., Fields, W., & King, M. L. (2010). Current Practice in Airway Management: A Descriptive Evaluation. American Journal of Critical Care, 19(2). 168-174. doi: 10.4037/ajcc2009803 This research article discuss about the difference between the care delivered to a patient in mechanical ventilator by a respiratory therapist and the nurse in the sense of prevention of VAP. The team used a descriptive comparative method was used to analyze the study outcome. The study was conducted at Sharp Grossmont Hospital, La Mesa, in California. 41 ICU nurses and 25 respiratory therapists were participated in the study. A descriptive and inferential statistics were used to analyze the data obtained from the survey conducted regarding suctioning techniques and airway management. The study identified that both nurses and respiratory therapist are strong and weak in certain areas of management of mechanically ventilated patients. For instant, the respiratory therapist is strong and nurses are weak in suctioning system and washing the tube with saline after the suction. Nurses are strong and respiratory therapist were in the case of giving oral care, oral and nasal suctioning. In the case of hyperventilating the patient there is no significant difference between the nurses and respiratory therapist.
The research team recommended that both nurses and respiratory therapist must follow the evidence based best practice for the purpose of prevention of VAP. Kim Lam Soh, Kim Geok Soh, Japar, S., Rosna A Raman, R. A., & Davidson, P. M. (2010). A Cross-Sectional Study on Nurses’ Oral Care Practice for Mechanically Ventilated Patients in Malaysia. Journal of Clinical Nursing, 20(1). 733-742. doi: 10.1111/j.1365-2702.2010.03579.x The authors of this article did a detailed study regarding the nurse’s knowledge in oral hygiene and attitude towards the Ventilator Associated Pneumonia (VAP). The study also discussed the master plan, methods and how often the mouth care is doing in the Malaysians critical care units (ICUs). The research team used a cross sectional study which includes conducting a survey in between 284 nurses in the ICU and direct observation of the oral care done on ventilated patients by the trained nurses. The team used the mechanically ventilated patients and nurses in medical, surgical and cardiology ICUs of three different hospitals in Malaysia. There were limitations in the study. Since the study was done in government hospital set up which cannot be compared with the standards of general or private hospitals and reliability of the observation was questionable are the two main limitations of the study. The result of the study was that majority of the people participated in the study agreed that they have a standard protocol for mouth care with gauze and forceps. The rest of them were either not sure or unaware that they have an oral care protocol.
The study also found there was no supply of tooth brush in the hospitals. Apart from this, team identified that about 75% of the nurses are giving oral care at least five times or even more to the patients on ventilator. Furthermore, study identified that nurses have a positive attitude towards oral care in terms of prevention of VAP. The study could provide insight to the nurses about the importance of oral care in terms prevention of VAP and the importance of implementing evidence based protocols to prevent hospital acquired infection like VAP. Krein, S. L., Kowalski, C. P., Damschroder, L., Forman, J., Kaufman, S. R., Saint, S. (2008). Preventing Ventilator-Associated Pneumonia in the United States: A Multicenter Mixed-Methods Study. Infection control and hospital epidemiology 29(10). 933-940. DOI: 10.1086/591455 This panel’s study offers an insight on hospital practices and processes used in preventing and diagnosing VAP. The study team used a qualitative and quantitative approach by sending surveys to 719 hospitals to identify the type of practices used in each hospital in terms of preventing VAP. The team selected both Veterans Affairs (VA) and non-VA hospitals for the study. Among this 14 hospitals were selected for deep analyzes for determining the knowledge about VAP, its occurrence, mode of transmission, treatment and prevention. This research team used statistical analysis to identify the mouth care protocols followed by the nurses in the intensive care unit care unit and compare these practices with the recommendations from best practice and evidence based practice. A descriptive, cross sectional design with web-based survey was used to display the oral care done for mechanically ventilated patients by the critical care nurses in one of the hospital in United States.
The results of the survey display that nurse’s makes discrepancy in doing proper oral care for the patients on ventilator. Further this study identify that the VAP rate is decreased in patients who received 2% Chlorhexidine mouth care at least 3 times a day. According to research team, even though the hospital has standard protocol for the oral care, the compliance of the nursing team towards the preventive measures for VAP in also low. About more than 75% of the people who returned the survey recommended a semi recumbent position to prevent the micro aspiration which leads to VAP. Furthermore, the research study revealed that there is a noticeable decrease in the VAP rate for who had at least two to three times a day. Although VAP has multiple risk factors, many nursing interventions can reduce the incidence of this disease .Positioning patients in a semi-recumbent position with the head of the bed elevated 30° to 45° prevents reflux and aspiration of bacteria from the stomach into the airways. Munro, C. L., Jo Grap, M., Elswick, R. K., McKinney, J., Sessler, C. N., & Hummel R. S. (2006). Oral Health Status and Development of Ventilator Associated Pneumonia: A Descriptive Study. American Journal of Critical Care, 15(5). 453-460. Retrieved June 23, 2013, from http://www.ajcconline.org. VAP is one of the nosocomial infections that can be prevented by following the evidence based practices. The research team did the study and discuss about the impact of tooth brushing, oral Chlorhexidine in the development of VAP in mechanically ventilated patients.
Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. The study group designed three different methods; mouth care with Chlorhexidine, mouth care with tooth brush and a combination of both tooth brush and Chlorhexidine. Team developed a control group for the detailed analysis. There were limitations in the sample size especially on day five to seven. Besides this, it was hard for the team to obtain consent from the family in the stressful situation. After a detailed descriptive analysis team came to the conclusion that tooth brushing alone did not reduce ventilator-associated pneumonia, and combining the tooth brushing with Chlorhexidine did not provide additional benefit over Chlorhexidine alone. Study also found that, the use of Chlorhexidine has made a marked decrease in the VAP rate in surgical, medical, trauma, and Neuro ICU.
Furthermore, the VAP rate was high in patients who received regular tooth brushing than the one who used Chlorhexidine. Presence of VAP increased the cost of treatment, length of stay in hospital, and increased the mortality as well as morbid rate. Use of Chlorhexidine, a pharmacological management with minimum cost will prevent the development of VAP and its huge treatment expense. Prendergast, V., Hallberg, I. R., Jahnke, H., Kleiman, C., & Hagell, P. (2009). Oral Health, Ventilator-Associated Pneumonia, and Intracranial Pressure in Intubated Patients in A Neuroscience Intensive Care Unit. American Journal of Critical Care, 18(4). 368-376. doi: 10.4037/ajcc2009621 In this research article the authors discuss about the oral health and development of VAP in patients in the Neuro ICU and its effect on the intracranial pressure. According to the research team the Neuro Science ICU patients are at high risk for developing VAP than patients any other ICUs. Data on 45 consecutive intubated patients admitted to a neuroscience intensive care unit during 1 year were collected by using oral cultures and the Oral Assessment Guide throughout intubation and 48 hours after extubation. The main limitation of this study was small size in sample and the study was limited to a single hospital.
The findings of the research team were that, neuroscience patients are at greater risk for aspiration pneumonia associated with acute changes in mental status, dysphagia, and traumatic brain injury. During intubation, occurrence of oral gram-negative bacteria and yeast increased. The team came to the conclusion that the intubation is worsening the oral health in Neuro Science patients will return to the normal stage by 2-3 days after the extubation. Furthermore, team identified that the oral care do not affect the intracranial pressure. Roncolato da Silva, L. T., Maria Laus, A., Marin da Silva Canini, S. R., Hayashida, M. (2011). Evaluation of prevention and control measures for ventilator associated pneumonia. Rev, Latino-Am, Enfermagem 19(6). 1329-36. Retrieved June 23, 2013, from www.eerp.usp.br/rlae This article describes about a research study for evaluating the quality of the nursing care and the adherence to the clinical guidelines provide for the prevention of VAP. The study was done between November 2009 and January 2010 with 839 mechanically ventilated patients. Descriptive, exploratory and quantitative methods were used for this study. The study analyzed that strict compliance and following the clinical guidelines of evidence based practice will prevent the VAP. The main limitation of the study was that team did not evaluate any other major care or factors which prevent pneumonia such as oral care, oral suction, hands hygiene, assessment of oral cavity, ventilator circuit, and changing the humidifier and filter which may have a marked impact in the development of VAP. The research team found that the adherence to the preventive measures of VAP was very low as 26.94%.The team recommended that evaluation of the adherence of staffs to any preventive measures implemented.
The knowledge level of the ICU staff must be updated with current clinical practice guidelines. Health education to the staff about the diagnosis, treatment and preventive measures should be given by the hospital and timely evaluation to be done to deliver qualitative care. High quality high standard care delivery is essential to prevent VAP. Sedwick, M, B., Lance-Smith, M., Reeder, S. J., & Nardi, J. (2012). Using Evidence-Based Practice to Prevent Ventilator- Associated Pneumonia. American Association of Critical-Care Nurses, 32(4). 41-51. doi: 10.4037/ccn2012964 Ventilator associated pneumonia is the second most common and complicated infection in the United States. In this article the authors discuss about the VAP, its etiology, complications, preventive measures and a detailed description of the components in the ventilator bundle. The team did this study with the aim of developing an ideal ventilator bundle for the purpose of prevention of VAP. The research study was conducted in the ICUs at Lankenau Hospital in Pennsylvania. The research team designed an interdisciplinary team which included physician, nurses and respiratory therapist with shared responsibility for implementing the ventilator bundle.
The nurses and other team members were educated about VAP, and each aspects of the ventilator bundle. A ZAP VAP sign also attached at bedside as a sign of reminder. The result of the study was that the team introduced the ventilator bundle for critical care nurses. The team further introduced protocols for mouth care, and hand washing, head of-bed (HOB) alarms, subglottic suctioning, and use of and electronic compliance feedback tool. Compliance to the program was strictly monitored and immediate feedback was given to the participants. For the success of the program peptic ulcer prophylaxis (PUP), deep vein thrombosis prophylaxis (DVTP), sedation vacation, and HOB also implemented. The research study came to the conclusion that strict adherence and compliance to the ventilator bundle prevent VAP to a certain extent. The team found that VAP is a preventable hospital acquired infection the insurance companies may take of the reinforcement. The patients who develops VAP has an additional stay of 4 to 19 days. Since VAP increases the hospital stay, cost of treatment. So the nurses and other health care providers must strictly adhere to the ventilator bundle. Shu-Pen Hsu., Chao-Sheng Liao., Chung-Yi Li, & Ai-Fu Chiou.(2009). The Effects of Different Oral Care Protocols on Mucosal Change in Orally Intubated Patients from an Intensive Care Unit. Journal of Clinical Nursing, 20(5), 1044–1053. doi: 10.1111/j.1365-2702.2010.03515.x This research study was done with the purpose of comparing the effectiveness of three different oral care protocols in different patients in the sense of prevention of VAP. It discusses the effects of each oral care protocols in patients for preventing VAP. A quasi-experimental design was used for this study. The study excluded patients with any kind of oral issues or if the oral mucosa is not intact. Oral mucosa assessment was done prior to the study to obtain baseline data.
The team used a control and every four hour mouth care with samples such as routine oral care, routine oral care along with green tea and the third one is routine oral care and care with boiled water. The team was not able to do a random study since the staffs were following different oral care protocol was one of the limitations of the study. There were no significant differences between the oral care protocols in the case prevention of VAP. The injury and infection rate was low with the patients who received oral care with green tea and boiled water. So the team recommended a combined use of this. Study recommended oral hygiene at least six times of a day to prevent VAP. Since the count of mechanically ventilated patients is increasing it is very important to develop evidence based protocols in critical care unit to prevent the development of infections like VAP. Wolken, R. F., Woodruff R. J., Smith, J., Albert, R. K., & Douglas, I. S. (2012). Observational Study of Head of Bed Elevation Adherence Using a Continuous Monitoring System in a Medical Intensive Care Unit. Respiratory Care, 57(4). 537-547. DOI: 10.4187/respcare.01453 Keeping the head of the bed (HOB) elevation is one of the simple interventions required to prevent VAP. This study describes a detailed study done about the importance of HOB elevation in patients on ventilator and monitored the compliance of the staff was monitored in different way. According to the team continuous monitoring, visual cues, and audible alerts will help to improve the compliance and adherence to the program HOB elevation. The team used these three methods to analyze and identify the compliance and adherence of the staff. Manual bedside monitoring was done twice daily. The team did the statistical analysis of the data collected to identify the adherence. There were limitations in this study. Team did not obtain data throughout; unable to provide sufficient alerts on time due to the circumstances, and the data was obtained only from one unit were some of them.
The statistical data of this study highlighted that intermittent in room checks and continuous monitoring of the HOB with an electronic device will increase the compliance and adherence to the HOB elevation. Even if HOB elevation is a simple intervention for the prevention of VAP the study results proved that implementation of HOB elevation in the vent bundles helps to prevent VAP. Yann-Fen C Chao, Yin-Yin Chen, Kai-Wei Katherine Wang, Ru-Pin Lee & Hweifar Tsai (2007). Removal of Oral Secretion Prior to Position Change can reduce the Incidence of Ventilator-Associated Pneumonia for Adult ICU Patients: A Clinical Controlled Trial Study. Journal of Clinical Nursing, 18(1). 22-28. doi: 10.1111/j.1365-2702.2007.02193.x Through this article, the research team discuss about the importance of oral care and suctioning prior to position change. The team used a comparison study and was conducted in a 48 bedded general ICU of a medical center in Taipei city. The research group team has received routine oral care and suctioning prior to positioning or any kind of movements the other group in the study was the control group which received only the routine oral care. Prior to the study the staff was educated about the implementation of suctioning protocol. A descriptive statistical analysis was used to evaluate the result of the study. While comparing the results of the study, the VAP rate in the research group is comparatively low than the control group in this study. Since the research team has suctioned the secretions prior to positioning the micro aspiration of the contaminated secretion is prevented and thus prevented the occurrence of VAP.
The research team came to the conclusion with evidence that removal of oral secretion prior to position change is cost effective to reduce the incidence of VAP. Since the cost for this remedy is less expensive nurses should practice it as a routine care along with other care for the patients in ventilator. Developing an Implementation Plan
Ventilator associated pneumonia (VAP) is one of the life threatening and second most common cause of death among the hospital acquired infections. Interventions are developed in timely manner to overcome this situation and proved with evidence that those remedies actually help to decrease the mortality rate. Since VAP is a complex condition, it is essential to focus on prevention of this condition rather than treatment. Prevention of VAP reduces the mortality rate, total costs of the treatment, and reduces the length of hospital stay (Zilberberg et al, 2011). The proposed solution for this plan is implementation of the VAP-Bundle and ensuring the compliance of the staff with the implemented plan. Brief Description of the Problem
Prior to introducing the VAP bundle, the awareness of the staff about the VAP was poor. There were no standard policies for the VAP prevention. Routine oral care was performed for the patients. Use of Chlorhexidine was not popular. Providers were not paying special attention to Deep Vein Thrombosis (DVT) and peptic ulcer disease (PUD) prophylaxis. It was ordered not ordered for all the patients or it was ordered by some physicians only. The number of occurrences of VAP, DVT and PUD was high. Staffs were not aware about the importance of gastric decompression and Head of the Bed (HOB) elevation. Thus the study decided to develop a standard protocol and implementing VAP bundle. Nurses have the responsibility to provide maximum care to the suffering patients with discrimination. Sincere care in the intensive care unit without any discrimination and compliance to the protocols can prevent the VAP.
The proposed plan VAP-Bundle is implementing with the aim of reduces the VAP rate, promotes the cost effectiveness, and enhances the services affordable to combat VAP. For the successful implementation of the VAP-Bundle, a group of trained nurses are selected to participate in the implementation program. About 70 nurses were actively involved in the program by giving education to the public as well as other nurses about the VAP and the importance of compliance to the VAP Bundle for prevention of VAP. Details of the Proposed Plan and Rationale
The new proposed solution for the VAP is the introduction of the VAP Bundle. The VAP Bundle includes HOB elevation, daily sedation vacation, spontaneous breathing trial (weaning), Chlorhexidene oral care at least four times a day, DVT prophylaxis and PUD prophylaxis (). Apart from this the implementation committee recommended for the gastric decompression, turning and repositioning the patient every two hour. The team highlighted the importance of hand hygiene, suctioning, and changing the circuits and humidifier to decrease the VAP rate (Mendez et al, 2013). The research and evidence proved that strict compliance to the VAP bundle and the strong recommendations of the committee ensure a significant decrease or no VAP rate, decreases the cost of treatment and mortality rate. Once the study plan was designed it should be approved by the stakeholders. This proposed plan is submitted to the stakeholders and the members followed the chain of command to submit the plan for its approval. The plan is reviewed and approved by the clinical practice committee (CPC), quality improvement committee (QIC), and the institutional review board (IRB) for protocol and policy. Stages of Implementation Process of the proposed plan
The research team has to go through multiple steps to implement a plan successfully. The initial step is obtain adequate back up support and approval from the coworkers, unit manager and the education department by exchanging the idea of VAP Bundle, the contents in the VAP Bundle, and the rest of the plan. A good presentation about VAP is done in the Unit based Council (UBC). This helps to identify and obtain the taste, interest and opinion of the staff to the proposed plan and collected their suggestions too. Then the implementation team conducted another meeting with the stake holders and formal leadership members and presented the plan by highlighting its necessity for implementation. The presentation further highlighted the steps of the plan for the better understanding. Since VAP is a crucial issue in the intensive care unit, the plan was supported by the manager and education department. The response from the workers was also positive and amazing. The next step was submitting the problem to the IRB, QIC and CPC for the approval. These committees did a detailed review of the plan. While reviewing the plan, the committee was paid special attention to the patient safety and rights and ethical issues. The plan was reviewed with all the members in the IRB up on their monthly meeting. It took almost a month to get the approval from the IRB. In order to understand the logistic and objectives of the plan the formal leadership members and stake holders took the copies of the plan. According to them this helped them for the easy adoption. A copy was given to the CPC and QIC for review. This enhances the support to the plan and maintains the standard practices.
Since the plan is undergoing the evaluation of the QIC, it ensures a high quality care in an affordable rate. There are multiple solutions to prevent the VAP. Some of them are expensive and some are cost effective. A cost effective and high quality plan is always appreciated by the hospitals and insurance companies in the health care field. Sending the approved plans to the different departments in the facility for their opinion, suggestions, and approval is the next step in the implementation plan. Once all the approval is obtained the next step is develop a safe, cost effective standard protocol which would be affordable to all the patients who seeks treatment. It took almost 2-3 months for the approval since it aims to reduce overwhelming threat to the human being and supports their wellbeing. The implementation committee decided to do a trial of the developed protocol for all the mechanical ventilator patients admitting in the intensive care unit for a time period of eight months. The implementation of the VAP Bundle protocol, showed a great result in the first month of implementation. Education of the staff and educational tools
Education of the staff is essential component in successful implementation of a plan. It took approximately a moth for developing the education tools, education and training of the staff. Educational classes, seminars and workshops with hands on work to educate and update the knowledge of the staffs that comes across in the care of patients on mechanical ventilator. Understanding of the VAP, VAP Bundle and the importance of compliance to its program ensure no VAP. Apart from this, the implementation committee prepared laminated posters and posted in different areas of the unit a reminder. PowerPoint presentations, medical journals and articles, computers and internet system, projectors, posters (See sample poster attached) and boards are some of the tools used for the education. The attached poster is actually a copy of the poster posted in each room of the intensive care unit as a reminder for all the nurses. Interactive sections, seminars and workshops with door prizes were made the educational program more effective.
Handouts were given to the staff to keep with them for the easy reference (See Appendix-A) The second phase of the educational part of the implementation plan focused on testing the knowledge acquired from the classes about VAP. To ensure the participation of all the members in testing, program offered continuing education (CE) contact hours. To simplify the testing, implementation committee used multiple choice questions. Team used the same questions for the pre and posttest. The cost of the education was covered by the facility. Since VAP is a nosocomial infection it is essential to prevent its occurrences. The facility was willing to take all the expenses needed for the education and purchasing the tools necessary for the education and implementing the VAP bundle. Incorporating Theory
According to the author, Kurt Lewin’s change theory model is the most appropriate theory for the prevention of VAP. This framework is used for proper implementation of the solution for decreasing the VAP rates in mechanically ventilated patients in critical care units. Kurt Lewin’s nursing theory frame work is a three-stage model of change which is also known as the unfreezing-change-refreeze model that requires prior learning or practice to be removed and replaced with new one (Lewin, 2011) The author choose this theory because the previous practice of cleaning the mouth with tooth brush or tooth tee must be removed and replaced with evidence based practice of mouth care with Chlorhexidine. Furthermore, the attitude of nurses must be changed and replaced with giving priority in mouth care and suction and use other resources such as hand washing to prevent VAP. In Lewin’s nursing theory the first stage is unfreezing.
In this stage, change the old practice model which is outdated, or do not make any significant benefit to the patient to be stopped (Hover, 2013). In the case of VAP, use of tooth brush, toothetee and cotton balls for the mouth care is outdated fashion of mouth care. The number of VAP case reported with this practice is high. The second stage is moving to a new level or changing. In this moving stage, nurses and other staff members need to change their thoughts, feeling and attitude to the new changes in a positive way. The staff must updates their knowledge and work in regards to the process of undergoing change (Hover, 2013). Giving information to the staff about the change in practice, education of the staff about the proposed intervention and getting feedback from the staff must be done this stage.
In the proposed problem VAP, implementing ventilator bundle with interventions like oral care with Chlorhexidine, head of the bed elevation, sedation vacation and dialing weaning is recommended (Morris, et al., 2011). The third stage is refreezing, which is implementing the desired change in practice, thus it becomes an in evitable procedure in the clinical practice (Lewin, 2011). According to Lewin, if this stage is missing then the implemented practice change will return to the old practice. Furthermore, it is advised to do the concepts of theory, the driving and restraining forces must be analyzed before implementing a planned change.
This author recommends Lewin’s theory for the proposed problem VAP because, the refreezing steps of this theory will ensure that the old practice is vanished and the new practice is working well. For instance, it is proved with evidence that the practices in ventilator bundle decreased the VAP rate. VAP itself and the complications associated with it can lead to death. It is one of the requirements of the critical care nurse that, they should know about VAP, its etiology and predisposing causes, prevention, complication and management. The application of ventilator bundle shortens the critical care stay and hospital stay, decreased the cost of treatment and the VAP rate. Developing an Evaluation Plan
Evaluation is an essential component in the evidence based practice program to assess the effectiveness and outcome of the implemented project. It further helps to identify the strong and weak areas of the program and the areas in which the staff needs more training and education. Education to the staff, periodic evaluation, and provision of adequate supplies are essential components of the successful implementation of the ventilator bundle. To assess the effectiveness of the ventilator bundle this author used feedback from staff, physicians, and respiratory therapist, patient’s medical records, lab values and reports from ventilator bundle committee as evaluation tools. Implementation of ventilator bundle; an evidence based best practice, decreased the rate of ventilator associated pneumonia (VAP) a healthcare-associated infections (HAI).
The component in the ventilator bundle decreased the VAP rate as well as the complications associated with it (Pogorzelska et al, 2011). This author obtained the feedback from the registered nurses, respiratory therapist and the physicians by conducting a survey. A sample of the survey is attached (Appendix-2). The survey obtained randomly at different time. The data collected from the survey proved that implementation of the ventilator bundle was effective. The effectiveness of the implemented project ventilator bundle was assessed by conducting biweekly meeting with the all the staff who involves in the care of a ventilator patient. All the questions and concerns about the ventilator bundle project is discussed and clarified at this time. Any necessary changes were made at this time after a discussion with the team members to correct the errors and weakness. A ventilator bundle project team was formed at this time. The team make daily bedside rounds, monitor for the compliance of the staff who took care of the patients on mechanical ventilator. Furthermore, the team evaluates the recording of the staff to assess whether the patient met all the criteria of VAP bundle.
The committee members obtained feedback from staff and checked their knowledge and attitudes towards the newly implemented ventilator bundle. Variables assessed for the evaluation plan VAP rate, perception of the patient, family and staff about the ventilator bundle and VAP, staffs attitude and compliance before and after the implementation of ventilator bundle project. The attitude of staff to accept the changes in their daily practice are also essential for the success of the evidence based practice change. For instance, the staff needs to change the oral care practice of the ventilator patients to chlorhexidine. A survey was conducted immediately after the implementation of the program. A follow up surveys was conducted in every three to six months. The responds to the survey was 100% and all the staffs shows a positive attitude towards the newly implemented plan ventilator bundle. The only concern about the staff was the availability of supplies.
The managers and the research team encouraged the unit secretaries and central supply department to get the necessary supplies. Continuing education to the staff regarding VAP and ventilator bundle is essential to decrease the VAP rate. During the time of education, the importance of hand hygiene, and each components of the ventilator bundle were discussed well. Evaluation of an educational program can essentially lead to desired changes in the objectives, course contents or teaching methods. The research team used both pre and posttest to assess the knowledge of the staff and effectiveness of the education respectively (Kalra et al, 2011). Ventilator bundle was included to the staff competency list as a part of the annual evaluation to assess the staff and thus it became another tool for evaluating the knowledge level of the staff. The research team also assessed the effectiveness of successful implementation of the bundled strategies, staff satisfaction and participation, systematic structural change includes preprinted order sets for ventilator management, sedation management, and oral care of the patients on mechanical ventilator (Wip & Napolitano, 2009). The main tool used for evaluating the assessment of the ventilator bundle was obtaining the VAP rate in both surgical and medical intensive care unit.
The clinical education coordinator working along with the intensive care unit physician gets the data required for the study and posted the results in the unit as well as in the staffs break room and sent it to all the staff in the unit through intranet. Usually it is in the form of a graph with the results VAP rate of three to four months. All the results were reviewed in the monthly unit based meeting too. A specially assigned team closely monitored the staff for the compliance to the ventilator bundle and hand hygiene. Further evaluation was done by the data obtained from the medical records. The evaluation outcome showed a zero VAP rate in the medical and surgical ICU after the implementation of ventilator bundle. Dissemination and implementation (D&I) research is increasingly recognized as an important function of academia and is a growing priority for major health-related funders (Rabin et al, 2008). Most of the time, any changes in the medical and nursing projects are not recognized and remained as isolated due to lack of dissemination of the outcome. It is essential to disseminate the study findings to the stakeholders, nursing community and all levels of healthcare professionals. Dissemination is an active approach of spreading evidence-based interventions to the target audience via determined channels using planned strategies (Rabin et al, 2008). The dissemination of the outcome of the ventilator bundle by the stake holders is beneficial to the entire intensive care unit team who take care of the patients on ventilator. The research committee and the facilities clinical guidelines committee must be updated about the changes and effectiveness of the implemented project in a weekly or bi weekly manner.
There are several methods in which the stake holders can be used for the dissemination of ventilator bundle measures. The initial step of this is by getting approval from the respiratory therapist, nurses, physicians, supervisors, managers, administrative members, stake holders, financial managers, quality improvement committee, and infection control team. This can be done by conducting a meeting with this team members and distribute the handout about ventilator bindle. All questions and concerns about the project were discussed and cleared well at this time. The expected outcome of the project ventilator bundle is swipe the ventilator associated pneumonia from the facility. The outcome of the project evaluation started from the bedside nurses and respiratory therapist. The next level of evaluation goes to the management and other committee level. The feedback can be obtained through questionnaires, suggestion sheets, and vocal reports from nurses. Weekly or biweekly gathering of the team and continuous monitoring of the practices is essential for the success of the project. Any noncompliance from staff must be addressed and take necessary corrective action and education must be provided. Ventilator bundle is included to the annual skill fair of the staff to keep their knowledge and skills updated with the evidence based practice.
Once the project is implemented successfully, monitor the effectiveness in a quarterly basis and provide adequate recognition to the staffs involved for the success of the program. The author’s current facility was recognized with zero VAP for past five years and all the staff got a pizza party (Lawson, 2005). Initiation of the Ventilator bundle significantly reduced incidence of VAP. The completion of checking the ventilator bundle order is done daily at the time of multidisciplinary rounds with the critical care team (Bird et al, 2010). The team further discuss about the weaning protocols and sedation orders at this time. An effective dissemination of the project can be achieved by publishing it through reputed journals and magazines of associations like American Association of Critical care Nurses (AACN), central of disease control (CDC) and World Health organization (WHO). Publishing it through internet and intranet is also do good dissemination of the evidence based project. Disseminating Evidence
Dissemination and implementation (D&I) research is increasingly recognized as an important function of academia and is a growing priority for major health-related funders (Rabin et al, 2008). Most of the time, any changes in the medical and nursing projects are not recognized and remained as isolated due to lack of dissemination of the outcome. It is essential to disseminate the study findings to the stakeholders, nursing community and all levels of healthcare professionals. Dissemination is an active approach of spreading evidence-based interventions to the target audience via determined channels using planned strategies (Rabin et al, 2008). The dissemination of the outcome of the ventilator bundle by the stake holders is beneficial to the entire intensive care unit team who take care of the patients on ventilator. The research committee and the facilities clinical guidelines committee must be updated about the changes and effectiveness of the implemented project in a weekly or bi weekly manner. There are several methods in which the stake holders can be used for the dissemination of ventilator bundle measures. The initial step of this is by getting approval from the respiratory therapist, nurses, physicians, supervisors, managers, administrative members, stake holders, financial managers, quality improvement committee, and infection control team. This can be done by conducting a meeting with this team members and distribute the handout about ventilator bindle. All questions and concerns about the project were discussed and cleared well at this time.
The expected outcome of the project ventilator bundle is swipe the ventilator associated pneumonia from the facility. The outcome of the project evaluation started from the bedside nurses and respiratory therapist. The next level of evaluation goes to the management and other committee level. The feedback can be obtained through questionnaires, suggestion sheets, and vocal reports from nurses. Weekly or biweekly gathering of the team and continuous monitoring of the practices is essential for the success of the project. Any noncompliance from staff must be addressed and take necessary corrective action and education must be provided. Ventilator bundle is included to the annual skill fair of the staff to keep their knowledge and skills updated with the evidence based practice. Once the project is implemented successfully, monitor the effectiveness in a quarterly basis and provide adequate recognition to the staffs involved for the success of the program.
The author’s current facility was recognized with zero VAP for past five years and all the staff got a pizza party (Lawson, 2005). Initiation of the Ventilator bundle significantly reduced incidence of VAP. The completion of checking the ventilator bundle order is done daily at the time of multidisciplinary rounds with the critical care team (Bird et al, 2010). The team further discuss about the weaning protocols and sedation orders at this time. An effective dissemination of the project can be achieved by publishing it through reputed journals and magazines of associations like American Association of Critical care Nurses (AACN), central of disease control (CDC) and World Health organization (WHO). Publishing it through internet and intranet is also do good dissemination of the evidence based project. Conclusion
Evidence based research has a vital role in improvement of patient outcomes in health care. Research results confirm that most patients undergoing mechanical ventilation are potential for developing Ventilator Associated Pneumonia (VAP). Development VAP increased the mortality and morbidity rate, increased the cost of treatment, and prolong the hospital stay. Most of the research studies about VAP came to the conclusion that VAP can be prevented by aggressive adherence to the ventilator bundle strategies. Adequate evidence based best practice care on patients who are in mechanical ventilator by nurses and other health care team members like respiratory therapist and physician can decrease the occurrence of VAP.
Education and continuing education about the VAP, and ventilator bundle practice to the staff is essential to keep them up to date about the changes in practice of ventilator bundle and other practice care for the patients on mechanical ventilator. Effective evaluation of the methods implemented to prevent VAP is essential. Early assessment and intervention can prevent or decrease the severity of VAP complications, potentiating safe and effective care. Reference
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APPENDIX-A
Ventilator associated pneumonia Bundle Practice Guidelines
A good hand washing is recommended by people who ever take care of the patients in mechanical ventilator. Hand washing must be done with soap and water and scrub the hands for at least 20 minutes or use the alcohol based hand gel. Maximum barrier precaution while attending the ventilator patients. For instance, while suctioning the patient use sterile catheters for the endotracheal tube. The oral suction catheter or tube must be kept
covered Use Chlorhexidine and give mouth wash at least every four to six hours. Give mouth care and suction every two hours and as required. Sedation vacations in each shifts and assess the readiness for weaning and extubation. Daily weaning trials. Document all care facility policy. The ETT securing tapes must be changed daily and as required. The circuit and humidifier of the ventilator must be changed as required. Head of the bed must be elevated at least thirty degree to prevent aspiration. Insert a nasogastric or oro-gasatric tube followed by intubation to prevent gastric decompression and gastric content aspiration Gastro intestinal prophylaxis (Pepcid, Protonix, Pravacid) must be initiated for all the patients on mechanical ventilator. Deep Vein Thrombosis prophylaxis either mechanical (SCD) or pharmacological ( Lovenox) must be initiated. Hold or stop the tube feeding for all ventilator patients prior to turn or position change. Check the residuals for tube feeding in a timely manner APPENDIX-B
Pre and Posttest Questionnaire Tool for VAP Education
Circle the appropriate answer
1.Does kinetic bed decreases the VAP rate?
•Yes
•No
2.The best recommended position for patients on mechanical ventilator? •Supine
•Lateral
•Semi recumbent
3.Patients with which of the following condition is not eligible for sedation vacation protocol? •Seizure patients
•Congestive heart failure patient
•Pneumonia
•Myocardial infarction
4.Is spontaneous breathing trial is part of VAP Bundle?
•Yes
•No
5.Recommended mouth wash for patients on mechanical ventilator? •Chlorhexidine
•Toothette swabs
•Regular brushing
6.Is pneumonia vaccine is a part of VAP Bundle? Does it prevent VAP? •Yes
•No
7.Is hand hygiene is important to prevent VAP?
•Yes
•No
8.Does the evidence based practice or implementation of VAP Bundle the VAP decrease rate? •Yes
•No
9.Does VAP can be prevented?
•Yes
•No
10.Does HOB elevation is a priority care for the patients on mechanical ventilator? •Yes
•No.
APPENDIX- C
Assessment for compliance to the VAP Bundle monitoring from records Name of the Unit:-
Name and Credential of the Auditor:-
CriteriaDate of Audit Date of AuditDate of Audit
HOB elevationY / NY / NY / N
DVT prophylaxisY / NY / NY / N
Daily Sedation VacationY / NY / NY / N
PUD prophylaxisY / NY / NY / N
Chlorhexidine Mouth Care Y / NY / NY / N
Spontaneous Breathing TrialY / NY/ NY / N
Gastric DecompressionY / NY / NY / N
APPENDIX- D
VENTILATOR ASSOCIATEPNEUMONIA BUNDLE PRACTICE
SAMPLE EDUCATION POSTER IN THE ICU ABOUT VAP
APPENDIX- E
Random Assessment of VAP Bundle
Name of the patient:-
Unit:-
Name of the Auditor:-
CriteriaDate of Initial AssessmentDate of Follow up AssessmentDate of Follow up Assessment
Daily Sedation VacationTolerated/ not ToleratedTolerated/ not ToleratedTolerated/ not Tolerated
Spontaneous Breathing Trial
Pass/ Fail
Pass/ Fail
Pass/ Fail
DVT Prophylaxis (mechanical/ pharmacological)Ordered/ Not Ordered Present/ Absent
Present/ Absent
PUD ProphylaxisOrdered/ Not Ordered
Present/ Absent
Present/ Absent
HOB Elevation
Present/ Absent
Present/ Absent
Present/ Absent
Gastric Decompression
Done/ Not done
Done/ Not done
Done/ Not done
Chlorhexidine oral care
Done/ Not done
Done/ Not done
Done/ Not done
APPENDIX- F
Sample of the survey questions in the evaluation phase
1
Does the ventilator bundle project was successful?
Y / N
2Does the ventilator bundle project decrease the rate of VAP? Y / N
3Does the ventilator bundle project decrease the rate of VAP? Y / N
4Does all the ventilator bundle orders were complete?
Y / N
5Is the project is cost effective?
Y / N
6Did you face any difficulty in implementing the ventilator bundle? Y / N
7Do you have any suggestions to improve the program?
Y / N
8Would you recommend ventilator bundle to implement in other facilities? Y / N