Introduction
Westwell (2008) argues that “ventilation associated pneumonia (VAP) is the leading cause of death amongst hospitals-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the ventilated patients,” (p. 206). This topic is of interest to me because I have witnessed VAP in many intensive care settings (ICU) mostly 48 hours after patients are intubated.
Based on my experience, I would like to conduct this study to know the best possible strategy that can be taken to prevent the occurrence of VAP. The topic is also significant to others because “VAP prolongs the time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU,” (Grap, 2009, p. 299). The incidence of VAP ranges from 10 to 25%, with mortality of 10 to 40%. A “bundle” of ventilator care processes includes “Peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, the elevation of the head of the bed, and a sedation vacation and may significantly reduce ventilator-associated pneumonia” (Westwell, 2008, p. 205).
Prevention of VAP requires a concerted effort on the part of hospital administration, physicians, and ICU personnel. The program must be evidence-based, maintained, and accepted by ICU personnel. Continued education and feedback are crucial to maintaining a low VAP rate.
Various research studies have been undertaken to examine ways in which VAP can be prevented. Some studies focus on the use of the VAP bundle approach while others focus on general care. The studies have mixed results on which of the two strategies is better than the other. Nevertheless, the approach used currently needs to be changed because the “bundle should be modified and expanded to include specific processes of care that have been definitively demonstrated to be effective in VAP reduction or a specific VAP bundle created to focus on VAP prevention,” (Grap, 2009, p. 301).
The PICO Clinical Question
In mechanically ventilated ICU patients, does the application of a specialized Ventilation Associated Pneumonia (VAP) Bundle reduce the incidence of VAP compared to average general care?
- P – Mechanically ventilated ICU patients
- I – Ventilation associated pneumonia bundle
- Comparison – General care
- Outcome – reduction in the incidence of ventilation associated pneumonia
Search Results Table
Brief Explanation of the Search Process
It is worth noting that in cases where 0 results were found, the explanation could be the use of Boolean phrases rather than the SmartText search option. Nevertheless, the Boolean phrase search option yielded more relevant results because it gave results based on the exact phrasing of the search keywords. This is different from the SmartText search option in which results were generated based on all the keywords rather than their arrangement. Although most databases generated abundant results, only a few of those results were relevant to this particular study.
Table of Evidence.
Inclusion and Exclusion Criteria
Out of all the results found from the search process, ten articles were selected. The majority of these articles were selected from the MEDLINE and CINAHL databases due to their relevance. The inclusion criteria used include the presence of an abstract, English language, primary research articles (except for two articles), presence of all the search keywords, and the date of publication (the articles selected were published within the last five years). The exclusion criteria used included reviews (save for two articles) and commentaries.
Brief Narrative of the Evidence Table
The evidence table is composed of ten articles generated from the search process. To answer the clinical question of this study, some of the articles chosen to focus on the VAP bundle approach while the others focus on other strategies used in the general care of VAP. By including studies that focus on these two different approaches to VAP, it is possible to compare the effectiveness of the two approaches used in preventing VAP and thereby identify the better alternative.
The studies that focus on the VAP bundle approach have promising outcomes in terms of reduction of VAP rates, reduction in the length of ventilation days, and reduction in the length of the hospital once discharged to the general ward. On the other hand, the studies that focus on the general care approach have mixed results, with some showing positive results, others showing negative results, and yet others showing no difference at all. Further critical analysis of the literature and synthesis of the evidence would help to clarify the contradicting results.
Reference List
Babcock, H., Zack, J., Garrison, T., Trovillion, E., Jones, M., Fraser, V., et al. (2004). An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: A comparison of effects. CHEST, 125(6), 2224-22231.
Crunden, E., Boyce, C., Woodman, H., & Bray, B. (2005). An evaluation of the impact of the ventilator care bundle. Nursing in Critical Care, 10(5), 242-246.
El-Khatib, M., Zeineldine, S., Ayoub, C., Husari, A., & Bou-Khalil, P. (2010). Critical care clinicians’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. American Journal of Critical Care, 19(3), 272-276.
Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., et al. (2009). Reducing ventilator-associated pneumonia through advanced oral-dental care: a 48-month study. American Journal of Critical Care, 18(6), 523-534.
Grap, M. (2009). Not-so-trivial pursuit: Mechanical ventilation risk reduction. American Journal of Critical Care, 18(4), 299-309.
Grap, M., Munro, C., Hummel, R., McKinney, J., Sessler, C., et al. (2005). Effect of backrest elevation on the development of ventilator-associated pneumonia. American Journal of Critical Care, 14, 325-333.
Hawe, C., Ellis, K., Cairns, C., & Longmate, A. (2009). Reduction of ventilator-associated pneumonia: active versus passive guideline implementation. Intensive Care Medicine, 35, 1180-1186.
McCarthy, S., Santiago, C., & Lau, G. (2008). Ventilator-associated pneumonia bundled strategies: An evidence-based practice. Worldviews on Evidence-Based Nursing, 5(4), 193-204.
Tolentino-DelosReyes, A., Ruppert, S., & Shiao, P. (2007). Evidence-based practice: use of the ventilator bundle to prevent ventilator-associated pneumonia. American Journal of Critical Care, 16, 20-27.
Westwell, S. (2008). Implementing a ventilator care bundle in an adult intensive care unit. Nursing in Critical Care, 13(4), 203-207.