Running head: Prevention of Ventilator
1
Prevention of Ventilator Associated Pneumonia
Nicole Rea
Concordia University, Nebraska
Introduction
Much research has been done to determine the best practice for preventing ventilator acquired pneumonia in critically ill patients while hospitalized. Ventilator associated pneumonia is an important topic because it poses increased health risks for critically ill patients and major health care cost concerns for the nursing profession if not prevented or controlled. Critically ill patients with multiple comorbidities spend far too many days in the hospital so we need to do the best we can to minimize VAP to improve patient outcomes, reduce patient care days and healthcare costs.Can simple nursing interventions be used to prevent chronically/critically ill patients from ventilator associated pneumonia?
P: chronically/critically ill patients hospitalized on ventilators
I: Patients getting better oral care, head of bed elevation and prevention of peptic ulcer disease and deep vein thrombosis
C: Ventilator bundle interventions versus standard of care interventions
O: Improved patient outcomes with ventilator bundle interventions; decreased healthcare costs and decreased ventilator/hospital days.
According to a quantitative study reviewed in the article “Adoption of a Ventilator-Associated Pneumonia Clinical Practice Guideline” changing nursing behaviors to prevent VAP can be very difficult. In this study the Academic Center for Evidence based Practice (ACE) Star Model was used to implement the clinical practice guidelines necessary to prevent VAP. The intent was to change behaviors of nurses and lower health care costs and patient care days by using low cost evidenced based methods to prevent VAP. The study reviewed 2 hospitals with five ICU’s with a total of 106 ventilator patients. Both hospitals initiated the new clinical practice guidelines with various learning methods. The VAP rates were documented for 3 months before and after the implementation of the CPG. There were five clinical practice guidelines initiated in both hospitals: a) head of bed elevation b) oral care, c) emptying condensate from ventilator tubing, d) hand washing and, e) glove use. For all 5 ICU units the rates of VAP declined initially but after a few quarters the rates seemed to increase dramatically and the adoption of the CPG were fairly low for all units as well. The “Particularly noteworthy is the low adoption rate of hand washing and oral care for all units at both hospitals.” (Abbott, 2006, p.146). The strengths of this study were that there was a lot of support from management and team leaders, good education on the CPG to help minimize VAP but some barriersto this study were the insufficient initiation time frame, nursing and leadership turnover during CPG changes, delay in equipment needed to follow CPG’s, weaning protocols not considered, and two different sites compared which could pose some variations in outcomes due to risks, culture, structure, and buy in.
According to a study done at Brookdale University Hospital reducing the risk of VAP can be accomplished by increasing the oral-dental care provided to ventilator patients. The study was a 48 month study to “determine the effect of implementing a comprehensive oral and dental care system and protocol on the rate of ventilator-associated pneumonia.” (Garcia, 2009). The control group was the group studied before the interventions and which had no oral care done whatsoever and the study group was the group reviewed during the implementation of a comprehensive oral care protocol. Each group was reviewed over a 24 month period. Rates of VAP decreased with the use of consistent oral care treatments but there was some inconsistency with length of stay and mortality rates in both groups. Compliance with the new protocol was about 80% which makes this a pretty good strength. A limitation for this study were that it was nonrandomized design which means that seasons and patient population can vary altering VAP rates and outcomes of the study. Overall I felt this would be a pretty good review of how to implement CPG and get the buy in from staff and direct care givers.
The third article I want to review talks about increasing the head of bed elevation to about 45 degrees to prevent VAP. This was a quantitative pilot study that reviewed the results of two groups of patients, the control group had head of bed set at 45 degrees and the study group was set at 25 degrees. This study did show some decline in VAP with head of bed elevation at 45 degrees but because of the small sample size it was difficult to validate the results. The data was collected over a period of 3-5 months and the sample size was only 30 patients. While these limitations are present I feel that if we could get a larger sample size or lengthen the time of the study we may be able to validate the lower incidence of VAP with head of bed elevation.
The literature review written by Lawrence and Fulbrook reviews evidence in the decrease of VAP with use of the ventilator care bundle. “The VCB is a group of four evidence based procedures, which when clustered together and implemented as an ‘all or nothing’ stratedgy, may result in substantial clinical outcome improvement.” (p.222). The four procedures include head of bed elevation, daily interruption of sedation and assess readiness to wean, gastric ulcer prevention and deep vein thrombosis prevention. This article reviews the literature from randomized control trials yielded from 10 different research studies. All studies were used non-randomized samples and had no concurrent controls for comparison and may be limited because of this. “However, it is argued that this would be unethical because the VCB is known to improve outcomes.” (p231). All studies showed improved outcomes with the use of VCB such as decreased ventilator days, and decreased ICU length of stay. Due to the limitations based on the observational design of the studies the link between VAP and VCB could not be proven in this review but I believe there is a significant amount of data to prove a strong relationship between the two.
In a literature review written by T. Oshodi and S. Bench there may be clinical evidence reducing the risk of VAP with the use of chlorhexidine in critically ill patients with liver dysfunctions. Several studies were critiqued to see if there was some effectiveness to using chlorhexidine solution with oral cares in patients that were mechanically ventilated. None of the reviewed studies specified whether or not their patients had liver dysfunction but other populations groups alluded to the fact that these patients may be of equal value due to their immunosuppression and increased risk of bleeding. There was really only one side effect to the CHX and that was tooth staining, but it seems as though the benefits outweighed the disadvantages in this situation. Limitations to this study were that there was not sufficient evidence about CHX associated with liver disease. I think there is sufficient data here to suggest that the use of CHX could not be of harm, but with the review we also learned that there is some limitations to accurate nursing assessments of the oral cavity in those that are intubated suggesting that there is a lack of knowledge and skill preventing the outcome of the CHX if done appropriately.
In conclusion I still think that there is sufficient evidence out there that suggests that VAP can be reduced significantly by following some very low cost, and simple clinical practice guidelines. I felt like the review of the above articles all had some great information and a trend of findings suggestive of positive outcomes for all involved with some minor, yet critical changes in nursing practice. I’m not sure I can just choose one or two articles with the best EBP, I feel that they all pose some great info and strengthen each other with the information that is provided. They all support the same theory of improving patient outcomes by improving EBP guidelines, education and continued review of policies and procedures.
References
Abbott C., Dremsa T., Stewart D., Mark D., Swift C. Adoption of a ventilator-associated pneumonia clinical practice guideline. Worldviews on Evidence-Based Nursing. (December 2006);3(4): 139-152. Available from: CINAHL Plus with full text, Ipswich, MA. Accessed September 16, 2013.
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 Cricical Care,18(6): 523-534.doi: 10.4037/ajcc2009311
Keeley L. (2007). Reducing the risk of ventilator acquired pneumonia through head of bed elevation. British Association of Critical Care Nurses, Nursing in Critical Care, 12(6), 287-294.
Lawrence P., Fulbrook P. (2011). The ventilator care bundle and its impact on ventilator-associated pneumonia: a review of the evidence. British Association of Critical Care Nurses, Nursing in Critical Care. 16(5), 222-234. doi: 10.1111/j.1478-5153.2010.00430.x
Oshodi T., Bench S. (2013). Ventilator-associated pneumonia, liver disease and oral chlorhexidine. British Journal of Nursing, 22(13), 751-758.