RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA BANGALORE

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the candidate and address(in block letters) / MR. JOSEPH MATHEW,
I YEAR M Sc. NURSING,
KARAVALI COLLEGE OF NURSING,
KULOOR,
MANGALORE.
2. / Name of the institution / KARAVALI COLLEGE OF NURSING,
KULOOR,
MANGALORE
3. / Course of study and subject / M Sc. NURSING (Medical Surgical Nursing)
4. / Date of admission to the course
5. / Title of the Topic
STUDY TO ASSESS THE CRITICAL CARE NURSE'S COMPLIANCE AND KNOWLEDGE ABOUT THE USE OF VENTILATOR CARE BUNDLE TO PREVENT VENTILATOR ASSOCIATED PNEUMONIA AMONG THE SELECTED HOSPITALS IN MANGALORE.
6. / Brief resume of the intended work
6.1 Need for the study
Nosocomial pneumonia is a leading cause of death from hospital-acquired infections, with an associated crude mortality rate of approximately 30 percent. Ventilator-associated pneumonia(VAP) refers specifically to nosocomial bacterial pneumonia that has developed in patients who are receiving mechanical ventilation. Ventilator-associated pneumonia that occurs within 48 to 72 hours after tracheal intubation is usually termed early-onset pneumonia; it often results from aspiration, which complicates the intubation process.Ventilator-associated pneumonia that occurs after this period is considered late-onset pneumonia
Between 5-15% of hospital in-patients develop infection during admission to intensive care unit(ICU). ICU patients are 5-10 times more likely to acquire nosocomial infections than patients in the wards and approximately 86% of hospital associated pneumonia is linked with mechanical ventilation.
Approximately 10-28% of critical care patients develop VAP and is the most common and fatal infection of ICU. In India it affects 9-27% of intubated patients and doubles the risk of mortality as compared with similar patients without VAP. VAP may account for up to 60% of all Healthcare-Associated Infections. VAP prolongs ICU length of stay and increases the risk of morbidity and mortality in critically ill patients. Nurses' knowledge of evidence based practice help to reduce the risk of ventilator-associated pneumonia.
Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy.
Despite the prevalence of VAP and its associated high mortality rate, there is little guidance for VAP prevention in India. The Centers for Disease Control and Prevention (CDC) in the United States of America (USA) published a guideline (Part 1) for the prevention of VAP in 1994 (Tablan et al 1994), updated in 2003 (Tablan et al 2004). This guideline addresses the common problems encountered by infection control practitioners in VAP prevention and control in hospitals. The CDC guideline had been implemented in 98% of 179 USA hospitals surveyed by Manangan et al (2000). Among these hospitals the VAP rate decreased significantly after implementation of the guideline. The CDC Guideline for Prevention of VAP can be an important resource for educating health care workers regarding prevention and control of NP and was chosen as the benchmark for this study.
Critical care nurses (CCNs) have an important role in preventing VAP by decreasing risk factors, recognising early symptoms, and assisting in diagnosis (Myrianthefs et al 2004; Hixson et al 1998).
Centres for Disease control and Prevention (CDC), 2003 guidelines for the prevention of VAP recommends hand washing, elevation of head end of bed, suctioning of subglottice secretions, use of hand gloves and implementation of comprehensive oral hygiene programme. The guidelines specify that an antiseptic agent be used as part of the oral care programme and oral chlorhexidine gluconate rinse is solely recommended for adults undergoing cardiac surgery.The prevention of ventilator Assisted Pneumonia (VAP), a hospital acquired infection, among intensive care patients is a major clinical challenge. It is a condition that is associated with high rates of morbidity, mortality, length of stay and hospital costs.
Current best practices for patients at risk of VAP can be established by conducting systematic literature reviews on the ventilator bundle and factors related to VAP and by communicating evidence-based findings through education sessions. Supported by current research and scientific evidence, this clinical project was aimed at examining critical care nurses’ knowledge of the ventilator bundle and its applications for preventing VAP.
6.2 Review of Literature
Rello et al (2006) explored type and frequency of oral care practices in European ICU’s and the attitude, beliefs and knowledge of health care workers. An anonymous questionnaire was distributed one questionnaire per ICU, in seven countries. Ninety One percent of the respondents were registered nurses. Of the respondents 77 % reported that they had received adequate training on providing oral care and 93% expressed the desire to learn more about oral care.88% responded oral care as a high priority in mechanically ventilated patients. Cleaning the oral cavity was considered difficult by 68%. The study concluded that oral care was considered very important in European ICU’s , it was experienced as a task that was difficult to perform, and that did not necessarily succeed in ensuring oral health in patients with prolonged intubation. The limitations of this study were unequal distribution of participating ICUs across Europe and from some countries no single unit responded. Secondly the questionnaire was developed to explore oral care practice and attitudes in individual nurses, while in this survey it was used to investigate practices among European ICUs. Although the survey was anonymous it was expected that unit in which oral care was considered of high importance where more likely to participate in the study.
Mori et al (2006) examined the contribution of oral care in preventing ventilator associated pneumonia in ICU patients. Design used was Nonrandomized trial with historical controls. Study was conducted in 1666 mechanically ventilated patients admitted to the ICU.Oral care was provided to 1252 patients who were admitted to the ICU during period between January 1997 and December 2002 (oral care group), while 414 patients who were admitted to the ICU during period between January1995 and December 1996 and who did not receive oral care served as historical controls (non-oral care group).The result showedincidence of VAP(episodes of pneumonia per 1000 ventilator days) in the oral care group was significantly lower than that in the non-oral care group (3.9 vs 10.4). The relative risk of VAP in the oral care group compared to that in the non-oral care group was 0.37, with an attributed risk of −3.96%. Furthermore, length of stay in ICU before onset of VAP was greater in the oral care than in the non-oral care group. However, no significant difference was observed in either duration of mechanical ventilation or length of stay between the groups. Number of potentially pathogenic bacteria in oral cavity was significantly reduced by single oral care procedure. Mori et al identified the incidence of VAP in ICU patients was decreased significantly by oral care.There were many limitations to this study as it was limited to one hospital where the characteristics of patients were nearly the same. Secondly the study was conducted for a longer duration so that the improvements in the treatment strategies might have influenced the rate of incidence of VAP in the later part of this study.
Grap et al (2003) carried out a qualitative study on oral care interventions, frequency and documentation. Study used questionnaire and medical records data. 170 nursing care providers from different categories were included in the study, patient’s age group was above 18 years of age, and 5 randomly selected data collection days during a month period were included in the sample. 77 health care providers responded from three ICUs. 75% reported carrying out oral care 2 or 3 times per day for non intubated patients and 72% reported providing care 5 times per day for intubated patients. This study found that the frequency of mouth care was dependent on the work load and staffing levels; mouth care was done more frequently when work load was less and staffing level was good.
Dodek et al (2004),developed evidence based clinical practice guidelines for prevention of VAP in Canada. The authors systematically searched for relevant randomized, controlled trials and systematic reviews that involved mechanically ventilated adults. Physical, positional, and pharmacologic interventions that may influence the development of VAP were considered and recommended semi-recumbent positioning in the absence of contraindications as one of the guidelines if effectively implemented, may decrease the morbidity, mortality, and costs of VAP in mechanically ventilated patients
Institute of Health Care improvements (2006), The Centre for Disease Control and Prevention (2004) with the Joint commission on Accreditation of health care organisations (2003) also advocate elevating the head of the patients’ bed to 45 degree to prevent aspiration of secretions unless contraindicated.
Grap et al (2005) used a non experimental, longitudinal, descriptive design to describe the relationship between backrest elevation and development of ventilator associated pneumonia. The Clinical Pulmonary Infection Score was used to determine VAP. Backrest elevation was measured continuously with a transducer system. Data were obtained from laboratory results and medical records from the start of mechanical ventilation up to 7 days. Sixty-six subjects were monitored (276 patient days). Subjects spent the majority of the time at backrest elevations less than 30 degrees. This study identified that only the combination of early, low backrest elevation and severity of illness affected the incidence of VAP.
Koenig and Truwit (2006) who noted that back rest elevation to asemirecumbant position do not translate into practice. In reality nurses position and reposition patients through out their shift and anecdotal evidence suggests this as to maintain patient comfort to prevent pressure ulcers, yet elevating the bed head to prevent VAP is not a recognized practice. In addition Grap et al (2003) noted that the majority of patients are nursed supine within an intensive care setting, even though there is no evidence or indication of the benefit of this. Cook et al (2002) identified abarrier to correct patient positioning to be that nurses perceived the physician’s orders to be determinant, whereas the physicians felt the main determinant to be the nurses’ preferences. Nurses’ preferences can also be afactor where nurses are influenced by hospital norms and what has been done previously. This supports the use of anecdotal evidence instead of research based evidence when attempting to shed light on the dynamics affecting patient care.
The development in nurse led practice is noted to be of great international importance (Grap et al, 2003) and all nurses should be developing their scope through further education and development, as advocated by Indian Nursing council. The desire to develop professionally should encourage nurses to perform education sessions in relation to patient positioning, thereby informing other members of staff of its benefits. Education sessions were used by Cook et al (2002) and the majority of the health carers within this study believed education to be most effective method for promoting semirecumbancy. Some staff noted that unit policies including specific patient position orders would be encouraging. This point was further utilized by Helman et al (2003) which used electronic reminders regarding positioning at bed spaces. They also used education sessions and reviewed the position of the head of the bed six months after the formal education session had stopped. Improvements were continued, showing the results to be statistically different from the baseline group (P<0.01). Even with this noted improvement, only twenty eight per cent of the patients were lying at a45 degree angle.
6.3 Statement of the problem
Assesment of critical care nurse's knowledge about the use of the ventilatOr bundle to prevent ventilator associated pneumonia among the selected hospitals in Manglore
6.4 Objectives of the study
1. Learning Objective 1: Identify the existing knowledge of critical care nurses’ regarding evidence based practices for the prevention of ventilator associated pneumonia (VAP). Learning Objective 2: Learn the evidence based guidelines for the prevention of ventilator associated pneumonia (VAP).
6.5 Operational definition
1.Ventilator-associated pneumonia(VAP) refers specifically to nosocomial bacterial pneumonia that has developed in patients who are receiving mechanical ventilation.
2.Mechanical ventilation
Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing.
3.Compliance
The nurse's adherence to a recommended guideline.
In this study compliance refers to critical care nurses adherence to ventilator care bundle.
4.Ventilator care Bundle
Refers to a health-care program implemented by Centres for Disease control and Prevention (CDC), 2003. Guidelines for the prevention of VAP recommends hand washing, elevation of head end of bed, suctioning of subglottice secretions, use of hand gloves and implementation of comprehensive oral hygiene programme.
5.Critcal care nurse
In this study critical care nurserefers to the nurse who is s registered nurse, prsently working in intensive care units, and having more than one yeae experience in the same area.
6.6 Assumption
The study assume that
1. There is a noncompliance with ventilator care bundle and practice among critical care nurses.
2. Non-compliance to ventilator care bundle and practice can have effect on developing VAP among the ventilated patients.
6.7 Delimitations
The study is delimited to
·1 Critical care nurses working in intensive care units.
·2 Critical care nurses who has moe than one year experience in intensive care units.
6.8 Hypothesis
H1 :Education sessions designed to inform nurses about the ventilator bundle and its use to prevent ventilator-associated pneumonia have a significant effect on participants’ knowledge and subsequent clinical practice.
7. Material and Methods
45 critical care nurses were selected for the study from critical care area. Knowledge was assessed through a self-developed tool, consisting of multiple choice questions (MCQs), based on Centers for Disease Control and Prevention (CDC) guide lines.
7.1 Sources of data
Critical care nurses working in intensive care units