Reduction of Ventilator-Associated Pneumonia

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

Database Search Keywords Limited by: Results
Date Full text Peer-reviewed
EBSCOHOST Ventilation Associated Pneumonia;
VAP bundle;
Benefits of ventilator bundle in ventilator associated pneumonia;
VAP bundle approach
2000 – 2010 26

1010000

2207044

1

PROQUEST Nursing Ventilation Associated Pneumonia;
VAP bundle;
Benefits of ventilator bundle in ventilator associated pneumonia;
VAP bundle approach
2000 – 2010 314

3

0

2

MEDLINE Ventilation Associated Pneumonia;
VAP bundle;
Benefits of ventilator bundle in ventilator associated pneumonia;
VAP bundle approach
259154

261220

1288026

81449

CINAHL Ventilation Associated Pneumonia;
VAP bundle;
Benefits of ventilator bundle in ventilator associated pneumonia;
VAP bundle approach
2000 – 2010 3

0

931663

55204

COCHRANE Ventilation Associated Pneumonia;
VAP bundle;
Benefits of ventilator bundle in ventilator associated pneumonia;
VAP bundle approach
2

0

24615

3327

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.

Citation Population Sampling method Research design Data analysis Results/outcome
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. Adult and pediatric patients admitted in two teaching and two community hospitals located in Midwestern United States None used The researchers tracked ventilator-associated pneumonia in each of the hospital through the use of infection control experts and surveillance. Incidences of VAP were reported in a common database at the Infection Control and Hospital Epidemiology Consortium. The educational program was introduced to all the patients admitted in the four participating hospitals and a follow up done throughout the study period. A statistical software (SPSS) was used to analyze data.
Chi-square analysis was used to compare the rates of VAP
The combined annual rate of VAP with intervention was 7.81/1,000 ventilator days compared to 8.75/1,000 ventilator days without the intervention, hence no statistically significant difference.
On individual basis, three out of the four hospitals recorded a statistically significant difference in the VAP rates following the intervention, with the largest decrease recorded in a community hospital.
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. Patients admitted at the respiratory intensive care unit of Virginia Commonwealth University Health Systems. Purposive sampling was used to include patients who were not diagnosed with pneumonia at the time of intubation. A non-experimental, longitudinal, descriptive design was used in the study. Descriptive statistics were used to describe the features of the population; a forward-selection multiple regression analysis was used to predict CPIS at the fourth day There was no direct correlation between height of backrest and VAP; VAP was highly likely to occur in more seriously ill patients who spent more time at backrest elevations
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. Patients admitted at the combined Intensive and High Dependency
Care Unit at East Surrey Hospital
Purposive sampling was used to incorporate only those patients who had been ventilated at some point during their ICU stay and who were to be discharged to a hospital ward The study design involved an audit of the hospital’s compliance with evidence-based protocols followed in care bundles and if the protocols reduced ventilation length of the patients Descriptive statistics (percentages, mean, median and standard deviation were used to describe the characteristics of the population; student’s t-test was used to compare APACHE II, length of ventilation and LOS data The mean ICU LOS was reduced by 39%; there was a reduction in the mean duration of ventilation by 43%;
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. Nurses working in the coronary care unit and surgical ICU of a large hospital located in a large metropolitan city Not mentioned The research design was a clinical education project that was used to evaluate the knowledge of nurses concerning the use of ventilator bundle to prevent VAP Descriptive statistics were used to describe the characteristics of the population; independent t test and chi-square analysis were used to measure and compare the pretest and posttests scores of the nurses An education program lasting as little as 30 minutes can help to enhance the nurses’ knowledge concerning VAP prevention strategies
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. Population encompassed patients admitted in intensive care units of different hospitals Not identified The research design used in the literatures reviewed were observational in that the researchers did not control the intervention but instead made a comparison between non-randomized sequential groups Systemic reading of the identified literatures to identify the interventions used, the similarities, disparities and weaknesses of the studies Results varied widely and include: a decrease in the ventilator days following the intervention; a strong correlation between VAP rate and compliance rate; non-development of VAP with the intervention
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. The population of the study entails patients admitted at the intensive care unit of Stirling Royal Infirmary. The sample used included patients who were admitted at the unit between September 1, 2005 and December 31, 2007. The research design used was a quasi-experimental design that was used to assess the effects of a bundle of evidence-based approaches to VAP. The VAP rate was measured per 1,000 ventilation days; SPC analysis was carried out and incorporated time series analysis and graphical presentation. Passive implementation was correlated with poor compliance with VAP prevention bundle; active implementation was correlated with a substantial improvement in compliance with VAP bundle
Grap, M. (2009). Not-so-trivial pursuit: Mechanical ventilation risk reduction. American Journal of Critical Care, 18(4), 299-309. The population entailed patients admitted in a respiratory intensive care unit. The sample used was 52 patients but no mention was made of the sampling technique used. The research design used was observational in that the researcher did not control the intervention but instead made a comparison between non-randomized sequential groups Descriptive statistics were used to describe the characteristics of the backrest elevation The use of elevated backrest reduces aspiration and hence VAP to some extent
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. The population involved patients enrolled in a medical intensive care unit of a university medical center The sample included patients who were 18 years and above and who were receiving mechanical ventilation for more than 2 days at the medical center. The research design used was a randomized control study in which the researchers studied two different groups of patients: the control and the intervention groups and made comparisons. Descriptive statistics were used to describe the demographic characteristics of the population; student t-test, Mann-Whitney analysis and mortality analysis were used to test the variables of the study VAP rate was higher in the control group (8.6%) than in the intervention group (4.1%); VAP rates decreased by 33.3% during the intervention; the intervention significantly decreased the duration of mechanical ventilation and length of hospital stay
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. The population entailed clinicians working in an intensive care unit of a university bed The sample of clinicians used included only those clinicians who were not aware of similar prior studies The researchers used a multiple-choice questionnaire design to carry out their study. Descriptive statistics (percentages and means) were used to describe the accuracy of the responses; analysis of variance and Scheffe test were used to compare the scores; Chi-square analysis was used to compare the proportion of the accurate responses; linear regression was used to establish the correlation between scores and participants’ demographics; SPSS was used to carry out the statistical tests. No differences were found in the knowledge of protocols for VAP prevention among the clinicians; no differences were found in the knowledge of protocols for VAP prevention based on ICU experience
Westwell, S. (2008). Implementing a ventilator care bundle in an adult intensive care unit. Nursing in Critical Care, 13(4), 203-207. Patients admitted at an adult ICU of a district general hospital Not applicable The research design was an audit of the hospital’s compliance with evidence-based protocols followed in care bundles Descriptive statistics were used to describe the hospital’s compliance rate and the rate of VAP reduction following different interventions Daily audit of care bundles is strongly correlated with compliance which in turn is correlated with VAP reduction rates

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.