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Assessment
Evidence-based practices to reduce VAP have been known to critical care nurses for some time. Unfortunately, these widely prescribed guidelines do not all the time result in alterations in performance. The reason is that critical-care nurses are not repeatedly integrating the evidence into their practice. As a result, VAP reduction persists to be a challenge in health care.
To reduce VAP, critical care nurses have been trained on the strategies especially on evidence-based practices. Majority of professionals caring for the patients in mechanical ventilation agree on the intensity of evidenced based training particularly on protocols to be incorporated in the daily care for critical patients. The problem is that these protocols are barely implemented. In fact, poor implementation od ventilator bundles protocol occur in almost all hospitals not only around the US but also in UK and Australia. Nurses cite workload as the impediment to the implementation of evidence-based practices.
To ensure that nurses implement and adhere to the ventilator bundle procedures, various interventions have been proposed. Most importantly, the independent compliance audit and the collaboration with other departments to ensure that the ventilator bundles procedures are followed to the later. the compliance to the ventilator bundles procedures will be evaluated through the feedback systems provided by the nurses and other critical care staff.
Literature review
A number of studies have shown that if properly implemented, evidence based practices drastically reduces the chances of VAP infections. In their study, Lawrence and Fulbrook (2011) observe that there is positive relationship between the evidence based ventilator care bundle and the reduction of VAP. Lawrence and Fulbrook (2011) argue that if ventilator care bundle are implemented appropriately, the VAP occurrences are reduced by 90%. Lawrence and Fulbrook (2011) study indicate that appropriate implementation of ventilator care bundles results in considerable clinical outcome in VAP improvement.
Gatell et al. (2012) observe that VAP results from the lack of implementation of evidence-based practices by critical care nurses. Gatell et al. (2012) argue that though current nurses have knowledge about the specific procedures to prevent VAP, transferring the knowledge to the practice has not received due attention. Gatell et al. (2012) study indicated that compliance with the VAP preventive measures are affected by many factors including the nurses workload. Further, the study findings indicate that though nurses may have advanced knowledge on preventive measures such knowledge does not result in improved compliance.
Studies done by Sedwick et al. (2012) assert that strict adherence to the evidence based practices for the prevention of VAP increases the protocol accountability, the utilization of feedback system as well as the interdisciplinary collaborations in the improvements of patients outcomes. It has also led to remarkable reduction in the hospital costs.
According to Wip and Napolitano (2009), head of bed elevation is effective method of reducing rates of VAP in ICUs. Wip and Napolitano (2009) examine the effectiveness of head of bed elevation in the study of 86 critical patients. In that study, the occurrence of VAP as was determined through the use of clinical pulmonary infection reduced from 48% on day one to 24% on day four for those patients whose elevation was between 35 degrees to 45 degrees. However, for trauma patients whose elevation was below 30 degrees the incidence of pneumonia rose from 21.1% on day one to 42.2% on day four. The study further showed that patients with pneumonia are pepsin-positive compared to those exclusive of pneumonia. Further, Wip and Napolitano (2009) study indicated that low backrest elevation less than 30 degrees were a significant risk factor for the development of VAP.
Wip and Napolitano (2009) further observe that semi-recumbent positioning is difficult to maintain in mechanically ventilated patients and therefore may not be very effective in the VAP reduction if not properly implemented. Therefore, the procedure must be adhered to enhance its effectiveness. The evidence-based practices should be combined with traditional practices in the reduction of VAP including oral care and hygiene as well as other methods such as chlorhexidine at the pharynx posterior and more specialized endotracheal tubes.
Reductions of DVT and PUD through prophylaxis are major evidence based practices in the reduction of VAP. In fact, studies indicate that PUD/DVT prophylaxes are standard practices within the critical care units. Sedwick et al. (2012) further examined the effectiveness of semi-recumbent positioning together with other evidence-based practices in the prevention and reduction of VAP. In the study of 66 critically ill patients, Sedwick et al. (2012) concluded that providing medications including histamine that increases the PH of the patients gastric juices as well as ensuring that there is no further aciditation of the gastric contents protect the patients against pulmonary inflammations. This reduces the risk of VAP by 89.1%. Therefore, the DVT prophylaxes using the thrombotic medications are warranted for the critical patients.
The other important components of the ventilator bundles are the interruptions of the daily sedation and evaluations of the patients readiness for extubation. Conventionally, critical care experts including physicians and nurses curtail the mechanical ventilation period through the manipulation of ventilator modes and gradually lessening ventilator hold. However, studies done by Mucedere et al. (2008) indicate that proper management of sedation effectively reduces the extent of mechanical aeration as well as other patient outcomes more than manipulating the respirator frequencies.
Mucedere et al. (2008) used multicenter randomized control studies of 360 critically ill patients within five tertiary care hospitals. The conclusion was that the intervention saved at least one life for every seven patients treated. The researchers also concluded that daily spontaneous wake-up-and-breath protocol trials resulted in the improved patient outcomes compared to the current standard approaches. Therefore, sedation interruptions or the daily spontaneous awakening and breathing are the best approaches for the patients in mechanical ventilations.
Intervention
Nurses should undergo improved training on the VAP preventing strategies. The results obtained on several studies particularly by Gatell et al. (2012) and the CDC recommendations reinforce this invention measure. Training on the improved adherence to the preventive measures of VAP would result in the reduction of the VAP occurrences by almost 87%. However, improved training alone would not help achieve the results. It should also be emphasized that adherence to the stated procedure is critical in the attainment of the goals. In other words, training should be based on the activities and protocols of evidence-based aimed at improving the quality of care and helping nurses to turn their scientific knowledge into actual performance.
As indicated in the studies done by Muscedere et al. (2008), preventive measures should also be supplemented with diagnostics. In as much evidence-based ventilator care bundles are critical in the reduction of VAP, timely treatment of the disease is also important. VAP results from the growth and multiplication of pathogens particularly bacteria at the lower end of the respiratory tract. Once diagnosed, quick treatment using appropriate drugs are critical preventive measure from the spread of the disease. Evidence-based ventilator care bundles targets only the uninfected. However, for the infected ventilator patients, treatment remains to be necessary measure.
Secondly, a team comprising personnel from various disciplines are crucial in the attainment of reduction of the VAP rates. Interdisciplinary team including the nurse, respiratory therapists, physicians, quality personnel as well as the information technology specialists are important to the success of the implementation of the VAP evidence based ventilator care bundles. In fact, all members of the team are normally present at the ICU and their involvement in the maintenance of hygiene and the full implementation of the ventilator care bundles are crucial.
Moreover, the assistance from other departments such as the respiratory department is important in the implementation process. The unconventional duties of such department allow the nurses to conserve extra time and other resources that are critical in the management and compliance with VAP bundles.
Third, self-regulating assessors should appraise nurses on the compliance with the VAP best practices. The nursing staffs are normally committed with the success of the patient outcomes. Therefore, independent auditor is normally perceived as unbiased in its compliance ratings. As none of the nursing staff will accept unwelcomed changes in the VAP rates, attaining zero defect quality are important goal to be attained.
The implementation of the interventions
For these intervention measures to succeed, the SMART approach would be used. The independent audit team would develop SMART (specific, measurable, achievable, relevant, and time-bound) tools to address the interventions. The nurses would be required to select precise objectives that accurately characterize and measure the preferred results. In addition, departmental managers are supposed to check the personnel observance to the evidence-based protocols and present feedback on the staff members progress on the conformity with the set up procedures.
SMAR approach will be implemented through the provision of direction to all nurses as well as specific people working within critical care units on the procedures to be followed on all facets of the evidence-based practices. The interdisciplinary team together with independent audit will have to develop measurable goals to ensure success. These measurable goals will ensure a hundred percent compliance and reduction of VAPs to zero. Moreover, to achieve the required goals the nurses must be provided with resources including flagged order sheets, checklists that would aid in their feedback. Finally, enough time must be provided to meet the required goals.
Re-evaluation
Nurses will be held accountable and evaluated on the improvement of the patient care outcomes. The key component in the improvement of the patient care outcomes is the nurses accountability for the everyday patient care. To achieve this, nurses will be evaluated from time to time on the implementation of the compliance procedures. in addition, the nurses feedback will be used to assess the outcome of the interventions and whether the interventions put in place are attainable. To provide the required feedback, nurses will be required to use feedback systems, daily trend, and evaluation reports. In essence, the ICU patient caregivers must comply with care protocols and in essence develop strategies that will end up improving the patients care. The documented feedback systems, daily trend, and evaluation reports should be provided to the independent auditors as well as the compliance officials.
References
Gattel, M., Roig, M., Vian, O., Santin, E., Duaso, C., Moreno, I. & Daunis, J. (2012). Assessment of a training programme for the prevention of ventilator-associated pneumonia. British Association for Critical Care Nurses, 17(6), 285-292.
Lawrence, P. & Fulbrook, P. (2011). The ventilator care bundle and its impact on ventilator-associated pneumonia: A review of the evidence. Nursing in Critical Care Nurse, 16(5), 222-234.
Muscedere, J., Dodek, P., Keenan, S., Foeler, R., Cook, D. & Heyland, D. (2008). Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. Journal of Critical Care, 23(1), 138-147. Web.
Sedwick, B., Lance-Smith, M., Reeder, S. & Nardi, J. (2012). Using evidence-based practice to prevent ventilator associated pneumonia. Critical Care Nurse, 32(4), 41-50.
Wip, C. & Napolitano, L. (2009). Bundles to prevent ventilator-associated pneumonia: How valuable are they? Critical Care Nurse, 38(6), 159-166.
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