Evidence-Based Practice: Use of the Ventilator Bundle to Prevent Ventilator-Associated Pneumonia

Knowledge of intensive care nurses' towards prevention of ventilator-associated pneumonia in North West Ethiopia referral hospitals, 2021: A multicenter, cross-sectional study

Introduction

Ventilator-associated pneumonia is a common nosocomial infection that occurs in critically ill patients who are on intubation and mechanical ventilation. Nurses' lack of knowledge may be a barrier to adherence to evidence-based guidelines for preventing ventilator-associated pneumonia. This study aimed to assess the knowledge of intensive care nurses' towards the prevention of ventilator-associated pneumonia.

Methods

A multicenter cross-sectional study was conducted among nurses working in the intensive care unit from April to July 2021. A pre-tested and structured questionnaire was used to collect data. All intensive care nurses working in the study area were included in the study. Data was entered into Epi-data 4.1 version (EpiData Association, Denmark) and transferred to STATA version 14 (College Station, Texas 77845-4512 USA) statistical software for analysis. Both bi-variable and multivariable binary logistic regression analysis was used to identify factors associated with knowledge of intensive care unit nurse. Variables with a p-value less than <0.2 in the bi-variable analysis were fitted into the multivariable logistic regression analysis. Both Crude and Adjusted Odds Ratio with the corresponding 95% Confidence Interval was calculated to show the strength of association. In multivariable analysis, variables with a p-value of <0.05 were considered statistically significant.

Result

A total of 213 intensive care nurses were included in the study, with a response rate of 204(95.77%). The mean knowledge score of intensive care nurses regarding the prevention of ventilator-associated pneumonia out of 20 questions is (10.1 ± 2.41). There are 98 (48.04%) of the participants have been found to have good knowledge and 106 (51.96%) of them are rendered poor knowledge about the overall knowledge related to the prevention of ventilator-associated pneumonia. Higher academic qualifications and taking intensive care unit training were significantly associated with good knowledge of ventilator-associated pneumonia prevention in multi-variable logistic regression.

Conclusion

Our study indicates that the knowledge of intensive care nurses about ventilator-associated pneumonia prevention is not sufficient. Higher academic qualifications and taking intensive care unit training are significantly associated with a good level of knowledge. Therefore it shows the necessity for thorough training and education.

Assessment of knowledge and compliance to evidence-based guidelines for VAP prevention among ICU nurses in Tanzania

BACKGROUND

Implementation of evidence-based guidelines (EBGs) related to VAP is an effective measure for the prevention of ventilator-associated pneumonia (VAP). While low knowledge regarding the EBGs related to VAP prevention among ICU nurses is still a major concern among nurses in ICUs globally, the situation in Tanzania is scarcely known. This study aimed to assess the ICU nurses' knowledge, compliance, and barriers toward evidence-based guidelines for the prevention of VAP in Tanzania.

METHODS

A cross-sectional study, involving ICU nurses of major hospitals in Tanzania, was conducted. A structured questionnaire was administered among 116 ICU nurses. Data analysis included descriptive statistics and the independent sample t-test.

RESULTS

The mean knowledge score was 3.86(SD = 1.56), based on ten questions (equivalent to 38.6%). Nurses with a degree or higher level of nursing education performed significantly better than the nurses with a diploma or lower level of nursing education (p = 0.004). The mean self-reported compliance score for EBGs for the prevention of VAP was 15.20 (SD = 0.93) which is equivalent to 60.8% based on 25 questions. The main barriers to the implementation of EBGs for VAP prevention were lack of skills (96.6%), lack of adequate staff (95.5%), and lack of knowledge (79.3%).

CONCLUSION

Considering the severity and impact of VAP, and the higher risks of HAIs in resource-limited countries like Tanzania, the lower level of knowledge and compliance implies the need for ongoing educational interventions and evaluation of the implementation of the EBGs for VAP prevention by considering the local context.

A Scoping Review of Implementation Science in Adult Critical Care Settings

OBJECTIVES

The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation.

DATA SOURCES

A librarian-assisted search was performed using three electronic databases.

STUDY SELECTION

Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included.

DATA EXTRACTION

Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system.

DATA SYNTHESIS

Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes.

CONCLUSIONS

The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.

Nurses' Perceptions of a Care Plan Information Technology Solution With Hundreds of Clinical Practice Guidelines in Adult Intensive Care Units: Survey Study

Background

The integration of clinical practice guidelines (CPGs) into the nursing care plan and documentation systems aims to translate evidence into practice, improve safety and quality of care, and standardize care processes.

Objective

This study aimed to evaluate nurses’ perceptions of the usability of a nursing care plan solution that includes 234 CPGs.

Methods

A total of 100 nurses from 4 adult intensive care units (ICUs) responded to a survey measuring nurses’ perceptions of system usability. The survey included 37 rated items and 3 open-ended questions.

Results

Nurses’ perceptions were favorable with more than 60.0% (60/100) in agreement on 12 features of the system and negative to moderate with 20.0% (20/100), to 59.0% (59/100) in agreement on 19 features. The majority of the nurses (80/100, 80.0% to 90/100, 90.0%) agreed on 4 missing safety features within the system. More than half of the nurses believed they would benefit from refresher classes on system use. Overall satisfaction with the system was just above average (54/100, 54.0%). Common positive themes from the narrative data were related to the system serving as a reminder for complete documentation and individualizing patient care. Common negative aspects were related to duplicate charting, difficulty locating CPGs, missing unit-specific CPGs, irrelevancy of information, and lack of perceived system value on patient outcomes. No relationship was found between years of system use or ICU experience and satisfaction with the system (P=.10 to P=.25).

Conclusions

Care plan systems in ICUs should be easy to navigate; support efficient documentation; present relevant, unit-specific, and easy-to-find information; endorse interdisciplinary communication; and improve safety and quality of care.

Knowledge level of nurses in Jordan on ventilator-associated pneumonia and preventive measures

BACKGROUND

Ventilator-associated pneumonia is the most prevalent infection in Intensive Care Units, with the highest mortality rate; crude mortality rates may be as high as 20-75%. Many practices such as prevention measures (e.g. hand washing, wearing gloves, suctioning, elevated head of bed between 30° and 45°) have demonstrated an effect of reducing the incidence of this infection.

AIMS

To identify the level of nurses' knowledge of ventilator-associated pneumonia and prevention measures before an educational programme, identify the level of nurses' knowledge on ventilator-associated pneumonia and prevention post an educational programme and identify the reasons for not applying ventilator-associated pneumonia prevention measures among nurses in Jordan.

DESIGN

Pre- and post-intervention observational study.

METHOD

Data based on a self-reported questionnaire from 428 nurses who worked in intensive care units were analysed. PowerPoint lectures, videos, printed materials and electronic materials were used in the intervention. Paired t-tests were used to test research questions.

RESULTS

More than three-quarters of nurses had a low knowledge level regarding pathophysiology, risk factors and ventilator-associated pneumonia preventative measures. Nurses showed significant improvements in mean scores on the knowledge level of ventilator-associated pneumonia and prevention measures after an educational programme (p < 0.05). The main reasons for not applying prevention measures were the lack of time and no followed protocols in the units.

CONCLUSION

Health education programmes about ventilator-associated pneumonia must be conducted among nurses in Jordan through continuous education.

RELEVANCE TO CLINICAL PRACTICE

Hospital and nursing administrators should be actively involved in educational programmes and in assuring support for continuing education. Protocol for ventilator-associated pneumonia prevention should be developed based on current evidence-based guidelines.

Use of Ventilator Bundle and Staff Education to Decrease Ventilator-Associated Pneumonia in Intensive Care Patients

BACKGROUND

Ventilator-associated pneumonia (VAP), one of the most common hospital-acquired infections, has a high mortality rate.

OBJECTIVES

To evaluate the incidence of VAP in a multidisciplinary intensive care unit and to examine the effects of the implementation of ventilator bundles and staff education on its incidence.

METHODS

A 24-month-long before/after study was conducted, divided into baseline, intervention, and postintervention periods. VAP incidence and rate, the microbiological profile, duration of mechanical ventilation, and length of stay in the intensive care unit were recorded and compared between the periods.

RESULTS

Of 1097 patients evaluated, 362 met the inclusion criteria. The baseline VAP rate was 21.6 per 1000 ventilator days. During the postintervention period, it decreased to 11.6 per 1000 ventilator days (P = .01). Length of stay in the intensive care unit decreased from 36 to 27 days (P = .04), and duration of mechanical ventilation decreased from 26 to 21 days (P = .06).

CONCLUSIONS

VAP incidence was high in a general intensive care unit in a Greek hospital. However, implementation of a ventilator bundle and staff education has decreased both VAP incidence and length of stay in the unit.

Ventilator Associated Pneumonia in Children

Ventilator associated pneumonia (VAP) is a common complication in mechanically ventilated children and adults. There remains much controversy in the literature over the definition, treatment and prevention of VAP. The incidence of VAP is variable, depending on the definition used and can effect up to 12% of ventilated children. For the prevention and reduction of the incidence of VAP, ventilation care bundles are suggested, which include vigorous hand hygiene, head elevation and use of non-invasive ventilation strategies. Diagnosis is mainly based on the clinical presentation with a lung infection occurring after 48hours of mechanical ventilation requiring a change in ventilator settings (mainly increased oxygen requirement, a positive culture of a specimen taken preferentially using a sterile sampling technique either using a bronchoscope or a blind lavage of the airways). A new infiltrate on a chest X ray supports the diagnosis of VAP. For the treatment of VAP, initial broad-spectrum antibiotics should be used followed by a specific antibiotic therapy with a narrow target once the bacterium is confirmed.

Predictors of nosocomial pneumonia in intracerebral hemorrhage patients: a multi-center observational study

BACKGROUND

Nosocomial pneumonia (NP) is a frequent complication among spontaneous intracerebral hemorrhage (sICH) patients. This study was aimed at identifying in-hospital risk factors that predispose sICH patients to NP.

METHODS

We identified 591 consecutive sICH subjects admitted to six tertiary care hospitals between 2008 and 2012. Information regarding patients' demographics, admission data, laboratory tests, medical history, diagnostic imaging, in-hospital treatments, complications, and outcomes were collected. Using a competing risks analysis, we assessed risk factors associated with NP.

RESULTS

Mean age of the subjects was 68 years; 51 % were female and 76 % were white. One-hundred sixteen (19.6 %) of the sICH patients had NP. In the univariate analysis, variables including age, non-white race, early hospital admission (<6 h after onset), larger hematoma volume, basal ganglia or intraventricular hemorrhage, multisite hemorrhage, in-hospital aspiration, intubation, nasogastric tube placement, hematoma evacuation, high ICH score, ventricular drainage, and tracheostomy had a positive association with NP. However, in the multivariate analysis, only early hospital admission, in-hospital aspiration, intubation, and tracheostomy remained statistically significant predictors (p < 0.05). For patients who survived hospitalization, the median length-of-stay (LOS) with or without NP was 20.0 and 4.0 days, respectively (p < 0.0001). For patients who did not survive to discharge, the median LOS with or without NP was 10.5 and 2.0 days, respectively (p < 0.001).

CONCLUSIONS

Independent predictors of NP included early hospital admission, in-hospital aspiration, intubation, and tracheostomy. NP was associated with prolonged hospital LOS.

Trends in ventilator-associated pneumonia: impact of a ventilator care bundle in an Italian tertiary care hospital intensive care unit

BACKGROUND

The impact on ventilator-associated pneumonia (VAP) occurrence of a multifaceted program, including progressive strategies for VAP prevention, implemented in an Italian intensive care unit (ICU) is reported.

METHODS

All adults admitted to the ICU in 2004-2010 with a length of stay ≥72 hours and mechanical ventilation time ≥48 hours were included in the study. Demographics, clinical information, and data on VAP were extracted from the ICU-acquired infection surveillance dataset. A standardized bundle for VAP prevention was implemented in 2004. In 2008, selective digestive tract decontamination (SDD) was added to the protocol. Changes in VAP incidence were evaluated.

RESULTS

There were 1,372 subjects included in the study. Overall, 156 (11.4%) developed VAP. In the second part of the study VAP incidence decreased from 15.9% to 6.7% (P < .001). Reductions both in early-onset VAP (6.6% to 1.9%; P < .001) and late-onset VAP (9.3% to 4.7%; P = .001) incidence were observed. Multivariate analysis showed a significant reduction in the risk of developing VAP from multidrug-resistant pathogens in the bundle plus SDD period as well (odds ratio, .54; 95% confidence interval, .31-.91).

CONCLUSION

The implementation of a standardized approach to patient care, including a number of key reduction interventions, was associated with a significant reduction in the risk of developing VAP.

Tracking and sustaining improvement initiatives: leveraging quality dashboards to lead change in a neurosurgical department

Increasingly, hospitals and physicians are becoming acquainted with business intelligence strategies and tools to improve quality of care. In 2007, the University of California Los Angeles (UCLA) Department of Neurosurgery created a quality dashboard to help manage process measures and outcomes and ultimately to enhance clinical performance and patient care. At that time, the dashboard was in a platform that required data to be entered manually. It was then reviewed monthly to allow the department to make informed decisions. In 2009, the department leadership worked with the UCLA Medical Center to align mutual quality-improvement priorities. The content of the dashboard was redesigned to include 3 areas of priorities: quality and safety, patient satisfaction, and efficiency and use. Throughout time, the neurosurgery quality dashboard has been recognized for its clarity and its success in helping management direct improvement strategies and monitor impact. We describe the creation and design of the neurosurgery quality dashboard at UCLA, summarize the evolution of its assembly process, and illustrate how it can be used as a powerful tool of improvement and change. The potential challenges and future directions of this business intelligence tool are also discussed.

Development and psychometric testing of ventilator bundle questionnaire and observation schedule

BACKGROUND

There is a current lack of valid and reliable instruments that can be used to examine critical care nurses' knowledge and skills in adhering to ventilator bundles. The aim of this study was to develop and psychometrically test a ventilator bundle questionnaire (VBQ) and ventilator bundle observation schedule (VBOS).

METHODS

The VBQ and VBOS consisted of a list of pharmacologic and nonpharmacologic nurse-led interventions taken from the literature and supported by various levels of evidence. After content validation, stability and equivalence reliabilities of the VBOS were determined in a randomly selected sample of critical care nurses from a single academic center in Finland.

RESULTS

The final VBQ contained 49 multiple-choice questions, and the VBOS had 86 dichotomous items, whose overall content validity ranged from 0.99 to 1.0. The overall intraclass correlation coefficient of the VBOS ranged from 0.93 to 1.0.

CONCLUSIONS

The VBQ and VBOS have acceptable psychometric properties and could be used to objectively assess whether evidence-based guidelines regarding ventilator bundles are being used in clinical practice. Further testing with diverse samples is needed to strengthen the validity and reliability of these instruments.

Oral Care in Trauma Patients Admitted to the ICU: Viewpoints of ICU Nurses

Background:

Many patients with severe traumatic injuries are admitted to intensive care units (ICU). These patients usually require prolonged mechanical ventilation. These interventions require oral intubation and leave the mouth open which consequently impairs the natural antimicrobial activity in the mouth and airways. These patients are also prone to ventilator-associated pneumonia (VAP). Evidence shows that paying attention to oral hygiene in patients under mechanical ventilation is important in helping to prevent VAP.

Objectives:

The present study was conducted to assess the viewpoints and performance of ICU nurses at Birjand hospitals towards oral care of patients under mechanical ventilation.

Patients and Methods:

A cross-sectional study was conducted at ICUs of Imam-Reza and Vali-Asr hospitals, Birjand, Iran. Sampling was done through a census in which 53 ICU nurses participated. Descriptive statistics, Kolmogorov-Smirnov test, Mann-Whitney U tests and Kendall's correlation coefficient were used to analyze the data.

Results:

A total of 53 nurses participated in this study. Most of the nurses had been trained to provide oral care during their university education. According to the participants' opinions, oral care with an average score of 5.72 ranked second among the 10 nursing care domains. The most frequent oral care provided was oral suctioning, normal saline irrigation, and chlorhexidine rinse with 95%, 90%, and 81.3% frequency, respectively.

Conclusions:

Nurses participating in this study considered oral care to be of prime importance. Most of the participants although trained in this area felt the need for continuing training courses.

Oral care and ventilator-associated pneumonia: an integrated review of the literature

The purpose of this study was to review evidence-based research studies specific to oral care in critical care and its relationship to ventilator-associated pneumonia. Twenty articles were analyzed. Results showed a pattern of 4 themes: (1) oral care practices, (2) deviation from practices, (3) interventions, and (4) documentation. Results are varied across the articles reviewed, although some pattern of essential oral care was revealed as crucial to the prevention of ventilator-associated pneumonia.

The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study

BACKGROUND

For prevention of ventilator-associated pneumonia (VAP), a bundle approach was applied to patients receiving mechanical ventilation in intensive care units. The incidence of VAP and the preventive efficacy of the VAP bundle were investigated.

METHODS

A quasi-experimental study was conducted in adult intensive care units of 6 university hospitals with similar VAP rates. We implemented the VAP bundle between March 2011 and June 2011, then compared the rate of VAP after implementation of the VAP bundle with the rate in the previous 8 months. Our ventilator bundle included head of bed elevation, peptic ulcer disease prophylaxis, deep venous thrombosis prophylaxis, and oral decontamination with chlorhexidine 0.12%. Continuous aspiration of subglottic secretions was an option.

RESULTS

Implementation of the VAP bundle reduced the VAP rate from a mean of 4.08 cases per 1,000 ventilator-days to 1.16 cases per 1,000 ventilator-days. The incidence density ratio (rate) was 0.28 (95% confidence interval, 0.275-0.292).

CONCLUSIONS

Implementing the appropriate VAP bundle significantly decreased the incidence of VAP in patients with mechanical ventilation.

Knowledge translation interventions for critically ill patients: a systematic review*

OBJECTIVE

We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care.

DATA SOURCES

We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews.

STUDY SELECTION

Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies.

DATA EXTRACTION

Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care.

DATA SYNTHESIS

From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes.

CONCLUSIONS

Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Impact of education on ventilator-associated pneumonia in the intensive care unit

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a common risk among critically ill ventilated patients. This study aimed to investigate the effects of nurse-led education on: (a) knowledge of and compliance with ventilator care bundle (VCB) practices among intensive care unit (ICU) nurses; and (b) reduction in the rates of VAP post intervention.

METHODS

A quasi-experimental design with pretest-posttest evaluation and observation was used to investigate nurses' knowledge of and compliance with VCB practices, and the incidence of VAP. The study was conducted among 71 nurses, and the intervention involved structured education on VAP and its prevention using VCB in an ICU setting. Data were analysed using descriptive and inferential statistics.

RESULTS

Nurse-led education significantly increased nurses' knowledge of (t[70] = -36.19; p < 0.001) and compliance with (t[65] = -21.41; p < 0.001) VCB practices. The incidence of VAP, which was 39 per 1,000 ventilator days during the two-month period before intervention, dropped to 15 per 1,000 ventilator days during the two-month period following intervention.

CONCLUSION

Our findings show that nurse-led education on VAP and VCB significantly increased knowledge of and compliance with VCB practices among ICU nurses, and was associated with a reduction in the incidence of VAP among intubated and mechanically ventilated ICU patients. Inclusion of recent knowledge and evidence-based VCB guidelines for VAP prevention when educating anaesthetists, nurses, physiotherapists and other healthcare providers in the critical care setting is recommended.

Knowledge levels of intensive care nurses on prevention of ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia constitutes a significant concern for ventilated patients in the intensive care unit.

AIM

This study was planned to evaluate the knowledge of nurses working in general intensive care units concerning evidence-based measures for the prevention of ventilator-associated pneumonia.

METHOD

This study design is cross-sectional. It was carried out on nurses working in the general intensive care units of anesthiology and re-animation clinics. Collection of research data was performed by means of a Nurse Identification Form and a Form of Evidence-Based Knowledge concerning the Prevention of Ventilator-Associated Pneumonia. Characterization statistics were shown by percentage, median and interquartile range. Chi-square and Wilcoxon tests and Kruskal-Wallis tests were used as appropriate.

RESULTS

The median value of total points scored by nurses on the questionnaire was 4.00 ± 2.00. The difference between the nurses' education levels, duration of work experience and participation in in-service training programmes on ventilator-associated pneumonia prevention and the median value of their total scores on the questionnaire was found to be statistically significant (p < 0.05).

CONCLUSION

The conclusion of the study was that critical care nurses' knowledge about ventilator-associated pneumonia prevention is poor.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Using evidence-based practice to prevent ventilator-associated pneumonia

BACKGROUND

Strategies are needed to help prevent ventilator-associated pneumonia.

OBJECTIVE

To develop a ventilator bundle and care practices for nurses in critical care units to reduce the rate of ventilator-associated pneumonia.

METHOD

The ventilator bundle developed by the Institute for Healthcare Improvement was expanded to include protocols for mouth care and hand washing, head-of-bed alarms, subglottic suctioning, and use of an electronic compliance feedback tool. Compliance audits were used to provide immediate electronic feedback.

RESULTS

Adherence to practices included in the bundle increased. Compliance rates were greater than 98% for prophylaxis for peptic ulcer disease and deep-vein thrombosis, interruption of sedation, and elevation of the head of the bed. The compliance rate for the oral care protocol increased from 76% to 96.8%. Readiness for extubation reached at least 92.4%. Rates of ventilator-associated pneumonia decreased from 9.47 to 1.9 cases per 1000 ventilator days. The decrease in rates produced an estimated savings of approximately $1.5 million.

CONCLUSION

Strict adherence to bundled practices for preventing ventilator-associated pneumonia, enhanced accountability for initiating protocols, use of a feedback system, and interdisciplinary collaboration improved patients' outcomes and produced marked savings in costs.

Oral care education in the prevention of ventilator-associated pneumonia: quality patient outcomes in the intensive care unit

BACKGROUND

Ventilator-associated pneumonia (VAP) is associated with high morbidity and mortality rates in mechanically ventilated patients in the United States. Routine oral care has been shown to have a direct effect on reducing VAP rates.

METHODS

Intensive care unit registered nurses attended educational sessions about oral care and also used online education modules. Nursing care involving 180 intubated patients was observed, and changes were noted in practices related to oral care.

RESULTS

After the education intervention, the frequency of oral care increased significantly (p = .001) to tooth brushing every 4 hours and swabbing every 12 hours with 0.12% chlorhexidine solution. The evidence-based practice education intervention decreased VAP rates by 62.5%.

CONCLUSION

Significant reductions in VAP rates may be achieved through improved education and implementation of oral care protocols with 0.12% chlorhexidine solution.

Nursing actions for the prevention of ventilator-associated pneumonia

OBJECTIVE: To identify prevention actions of the nursing team related to ventilator-associated pneumonia (VAP). METHOD: A cross-sectional, observational study conducted in an Intensive Care Unit of a teaching hospital in Goiania/GO. RESULTS: Hand hygiene occurred, mainly, after the procedures and most of care, such as elevating the head-of-bed, bronchial and oral hygiene, diet administration, also handlingmechanical ventilator circuits were not adequate and if experienced groups such as the one in the present study are not following the recommendations emerging from evidence, it may indicate that, for some reason, the learning is not being significant. CONCLUSION: Most recommendedmeasures to reduce VAP related to positioning the head-of-bed, bronchial and oral hygiene, administration of diet and handling mechanical ventilator circuit were not followed.

Pursuing excellence: development of an oral hygiene protocol for mechanically ventilated patients

Oral hygiene in seriously ill patients is a nursing responsibility. Oral hygiene regimens in conjunction with standardized ventilator-associated pneumonia "bundles" reduce the incidence of pneumonia, length of stay, and associated costs in critical care. Following strict adherence to the recommended ventilator-associated pneumonia bundle, the ventilator-associated pneumonia rate at the Northeast Baptist Hospital intensive care units has remained 0% for 36 months. Oral care in this patient population, however, has remained vague based on ritual and nurse preference. This article describes the development of an oral care protocol based on best evidence, providing a rationale for standardization of oral hygiene and the plan for surveillance and updating.

Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program

PURPOSE

Healthcare-associated infections (HCAIs) impact 10% of hospitalized patients. Some of these infections result from bacterial cross contamination and poor compliance with guidelines (Pittet D: Compliance with hand disinfection and its impact on hospital-acquired infections. J HospInfect 48 Suppl A:S40-S46, 2001); (Watanakunakorn C, Wang C, Hazy J: An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 19:858-860, 1998). Contamination of provider hands may be a modifiable risk factor. We instituted a novel multimodal system designed to improve hand hygiene by ICU providers.

MATERIALS AND METHODS

A before and after study design was used to evaluate the impact on the incidence of CRBSI and VAP of a multi-modal program incorporating education, performance feedback, and a body worn hand hygiene device. Compliance was communicated quarterly. Primary outcomes were CRBSIs and VAPs per 1,000 line days or per 1,000 ventilator days and compliance rates. Secondary outcomes were hospital length of stay and mortality.

RESULTS

A total of 1, 262 and 1,331 patients were evaluated during consecutive 12 month periods. VAP per 1000 vent days were significantly reduced after introduction of the program [3.7 vs. 6.9] P < .01. The reduction in CRBSI per 1000 line days was not significant [1.5 vs. 2.6], P = .09. Observed hand hygiene increased during the study period. There was no significant difference in mortality.

CONCLUSIONS

A novel multi-modal hand hygiene system resulted in a reduction in VAP. Provider hand contamination during patient care in the ICU is a modifiable risk factor for reducing ventilator associated pneumonias.

Critical care issues in managing complex open abdominal wound

Over the past 30 years, surgical specialties have introduced and expanded the role of open abdominal management in complicated operative cases, necessitating an intensivist's understanding of the indications and unique intensive care unit (ICU) issues related to the open abdomen. When presented with the open abdomen, resuscitation to correct shock is of primary concern. This is accomplished by correction of hypothermia, acidosis, and coagulopathy in trauma and adequate resolution of intra-abdominal hypertension or source control in general surgery. These patients typically require deep sedation and often paralysis and benefit from low-volume ventilatory strategies to prevent and treat acute lung injury. Antibiotics must be tailored to the clinical situation, but in most cases, 24 hours of perioperative treatment is all that is required. In cases of gross contamination and peritonitis, a 5- to 7-day course of broad-spectrum antibiotics may be of benefit.Adequate source control has been demonstrated to have the greatest impact on outcome and when the patient's clinical milieu dictates, bedside washouts. Enteral nutrition should be instituted as early as possible after intestinal continuity has been reestablished. Additional protein is required to account for losses from the open abdomen. Reconstruction may require staging, but in general, should proceed following resolution of shock and control of sepsis. Elevated multiorgan dysfunction score, Acute Physiology And Chronic Health Evaluation II (APACHE II), and a rise in peak inspiratory pressure portend poor source control and could result in failure of fascial closure. If unable to proceed to fascial closure, then considerations should be made for planned ventral hernia and subsequent abdominal wall reconstruction.

[Nursing care in the prevention of ventilator-associated pneumonia]

INTRODUCTION

Certain nursing interventions reduce the incidence of ventilator-associated pneumonia (VAP).

OBJECTIVES

a) to analyze in patients with more than 24 hours of invasive mechanical ventilation how frequently oral hygiene, oropharyngeal suction, turning and evaluation of the tolerance of enteral nutrition were performed according to established protocols; b) to record in these same patients endotracheal tube cuff pressures and the degrees of elevation of the head of the bed (HOB); c) to determine over the three months of the study the incidence density of VAP.

METHOD

This descriptive study was carried out in 26 patients. The nursing interventions of interest were recorded daily. Furthermore, endotracheal tube cuff pressures and the degrees of elevation of HOB were measured 3 times a day. Compliance with the established protocols was considered good when it reached ≥80%. Cases of VAP were determined using CDC criteria. The incidence density was calculated including all the patients (122) with mechanical ventilation during the study period.

RESULTS

Good compliance with the established protocols was achieved for oral hygiene in 23 patients, for oropharyngeal suction and for turning in 19 patients, and in all patients for the evaluation of the tolerance of enteral nutrition. In 214 measurements endotracheal tube cuff pressure was ≥ 20cm H20 and in 121 lower. In 79 measurements elevation of HOB was ≥30° and in 256 lower. The incidence density of VAP was 7.43/ 1.000 days of mechanical ventilation.

CONCLUSIONS

: For these nurse interventions aimed at preventing VAP, levels of compliance with established protocols were satisfactory. The incidence density of VAP was low and well within internationally established ranges. Nevertheless, the incidence of VAP could be further reduced with a better control of cuff pressures and by elevating the HOB to between 30° and 45°.

Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative

AIMS

To investigate perceived factors relating to the reliable application of four clinical care practices targeting ventilator-associated pneumonias, in the context of a patient safety improvement initiative called the Safer Patients Initiative (SPI).

METHODS

Qualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programme's critical care work stream during its pilot phase. The interviews had a focus on perceived aspects pertaining to the reliable implementation of the four clinical practices, promoted by the Institute for Healthcare Improvement as the 'ventilator care bundle'.

RESULTS

Thematic analysis of the verbatim transcripts revealed three overarching themes experienced by the participants during the implementation of the clinical practices included in the SPI ventilator care bundle: the power of measurement, feedback to peers and experts and improvement tools specific to SPI. Consistent measurement of compliance with the four elements of the bundle and outcomes made the staff realize that their engagement in previous improvement work for ventilated patients was inadequate and motivated them to apply the introduced clinical practices more reliably. Feedback to experts and peers of staff compliance with the four clinical practices and outcome improvement was perceived as a very influential aspect of SPI. Small tests of change (Plan-Do-Study-Act cycles), teaching sessions and daily goal sheets were quoted as particularly useful tools throughout the implementation of the four clinical care practices.

CONCLUSIONS

Future initiatives that aim to improve the adherence of clinical staff with clinical practice guidelines in intensive care units could benefit from integrating in their methodology consistent measurement and feedback practices of both process compliance and outcome data.

Ventilator-associated pneumonia: the importance of oral care in intubated adults

Ventilator-associated pneumonia (VAP) occurs within 24 hours of intubation and mechanical ventilation. Health care costs related to increased patient mortality, extended length of stay, and patient well-being make treatment of VAP a priority in all health care settings. The Institute for Healthcare Improvements has developed the Ventilator Bundle as a group of interventions linked to ventilator care with demonstrated outcome improvements; removal of subglottic secretions is one of these recommendations. Dental plaque and bacterial colonization of pathogens is directly related to microaspiration of bacteria into the lungs. A moist environment in the mouth maintains normal oropharyngeal bacteria, preventing overgrowth of pathogenic bacteria. Frequent oral care to include twice-a-day brushing of the teeth found a 69% reduction in respiratory tract infections.

[Evaluation of the compliance of semirecumbent position between 30-45° in intubated patients]

AIMS

To determine compliance of the standard "semirecumbent position between 30-45° in patients with artificial airway (AA)". To know the opinion of the professionals on this issue.

MATERIAL AND METHODS

An observational, prospective study was carried out in December 2009 in the ICU department of a tertiary hospital that excluded the limitation of therapeutic effort, prone position and antitrendelemburg.

DATA COLLECTED

headrest angle, professional experience of the nurse, shift, perception of the auditor, diagnostic, type of AA (tracheostomy or endotracheal tube), mechanical ventilation (MV) (yes/no) and enteral nutrition (EN). Nurses were surveyed to verify if they knew the standard, if they complied with it, the method used and their suggestions. We used the Student's t test and ANOVA for multivariable analysis, and Fisher's χ2; p<0.05=significant.

RESULTS

A total of 546 valid measurements were obtained from 53 patients, of which 40.9% had the correct semirecumbent position (30-45°). Professionals with <1 year of experience were those who raised the headrest the least, with only 26.4% of these measurements over 30°. The standard was met in only 34.8% of the neurocritical patients (NC) vs non NC (46.7%) (p<0.05). It was <30° in 29.2% of patients with tracheostomy vs 44% measurements performed on patients with TOT (p<0.05). There were no differences between shifts, the use of MV or EN. Diagnostic accuracy of the auditor: sensitivity: 91.6%; specificity: 72.5%; positive predictive value: 70.2%; negative predictive value (NPV): 92.4%. 97.9% of responders know the standard. Visual judgment was used in 97.2% of the cases.

CONCLUSIONS

Measured compliance was less than 50% although the standard is well known by the nursing team. Even though the subjective perception has a high NPV, it does not achieve the standard.

[Southern European intensive care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia]

OBJECTIVES

To assess Southern European intensive care unit nurses' knowledge about evidence-based guidelines for the prevention of ventilator-associated pneumonia and to compare these findings with a pan-European perspective.

DESIGN

A sub-analysis from an observational study performed using a 9-questions, multiple-choice questionnaire performed during the period October 2006 - March 2007.

SETTING

Six Southern European countries, selected from 22 participant European countries.

PARTICIPANTS

Volunteer nurses from intensive care units.

RESULTS

3329 questionnaires were obtained, 1182 of them belonging to Southern European countries with a 75.8% response rate. Global average score was 45.1%, being it significantly better in the South of Europe (46.6%, P<.001). A linear multiple regression analysis showed that years of working experience (per class of increase) (B=0.154 ± (SD) 0.045) (95% CI (0.066-0.242))(p=0.001) and working in a smaller intensive care unit (B=-0.210 ± (SD) 0.059)((95% CI) -0.326-0.094)(P<.001) was independently associated with better test scores.

CONCLUSIONS

Southern European critical care nurses' knowledge about ventilator-associated pneumonia prevention is poor, but significantly better than in the pan-European countries.

Critical care clinicians' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia is the most common hospital-acquired infection among patients receiving mechanical ventilation in an intensive care unit. Different initiatives for the prevention of ventilator-associated pneumonia have been developed and recommended.

OBJECTIVE

To evaluate knowledge of critical care providers (physicians, nurses, and respiratory therapists in the intensive care unit) about evidence-based guidelines for preventing ventilator-associated pneumonia.

METHODS

Ten physicians, 41 nurses, and 18 respiratory therapists working in the intensive care unit of a major tertiary care university hospital center completed an anonymous questionnaire on 9 nonpharmacological guidelines for prevention of ventilator-associated pneumonia.

RESULTS

The mean (SD) total scores of physicians, nurses, and respiratory therapists were 80.2% (11.4%), 78.1% (10.6%), and 80.5% (6%), respectively, with no significant differences between them. Furthermore, within each category of health care professionals, the scores of professionals with less than 5 years of intensive care experience did not differ significantly from the scores of professionals with more than 5 years of intensive care experience.

CONCLUSIONS

A health care delivery model that includes physicians, nurses, and respiratory therapists in the intensive care unit can result in an adequate level of knowledge on evidence-based nonpharmacological guidelines for the prevention of ventilator-associated pneumonia.

Clinicians' perception of head-of-bed elevation

BACKGROUND

Head-of-bed elevation of 30 degrees to 45 degrees is important in preventing ventilator-associated pneumonia, but clinicians' perception and determination of head-of-bed elevation are not widely reported.

OBJECTIVES

To (1) document the accuracy of clinicians' perception of head-of-bed elevation, (2) document methods clinicians use to determine the head-of-bed angle, and (3) assess knowledge of recommended head-of-bed elevation.

METHODS

Clinicians (n = 175) viewed a simulated patient with head of bed elevated 30 degrees and elevation gauge concealed. They answered 3 questions: What is the level of the head of the bed? What head-of-bed elevation is associated with decreased incidence of ventilator-associated pneumonia? When providing care, how do you routinely determine the head-of-bed elevation?

RESULTS

Fifty percent of 89 registered nurses and 53% of 39 physicians identified head-of-bed elevation correctly (+/-5 degrees ). Head-of-bed elevation was perceived accurately by 86% of 21 respiratory therapists, 63% of 16 medical assistants, and 50% of 10 physical/occupational therapists. Ninety-five percent of nurses and respiratory therapists, 79% of physicians, 90% of physical/occupational therapists, and 46% of medical assistants correctly identified the head-of-bed angle associated with decreases in occurrence of ventilator-associated pneumonia. Techniques for determining the angle varied; 58% of respondents reported using the gauge.

CONCLUSIONS

Head-of-bed angle was perceived correctly by 50% to 86% of clinicians. Nurses tended to underestimate the angle, whereas other clinicians tended to overestimate. Nurses, respiratory therapists, and physical/occupational therapists showed the best understanding of the correct angle for minimizing occurrence of ventilator-associated pneumonia. Elevation gauges were most often used to determine the angle.

Systems initiatives reduce healthcare-associated infections: a study of 22,928 device days in a single trauma unit

BACKGROUND

"Implementation research" promotes the systematic conversion of evidence-based principles into routine practice to improve the quality of care. We hypothesized a system-based initiative to reduce nosocomial infection would lower the incidence of ventilator-associated pneumonia (VAP), urinary tract infection (UTI), and bloodstream infection (BSI).

METHODS

From January 2006 to April 2008, 7,364 adult trauma patients were admitted, of which 1,953 (27%) were admitted to the trauma intensive care unit and comprised the study group. Tight glycemic control was maintained using a computer algorithm for continuous insulin administration based on every 2-hour blood glucose testing. Centers for Disease Control and Prevention definitions of nosocomial infections were used. Evidence-based infection reduction strategies included the following: a VAP bundle (spontaneous breathing, Richmond Agitation-Sedation Scale, oral hygiene, bed elevation, and deep vein thrombosis/stress ulcer prophylaxis), UTI (expert insertion team and Foley removal/change at 5 days), and BSI (maximum barrier precautions, chlorhexidine skin prep, line management protocol). An electronic dashboard identified the at-risk population, and designated auditors monitored the compliance. Infection rates (events per 1,000 device days) were measured over time and compared annually using Fisher's exact test.

RESULTS

The study group had 22,928 device exposure days: 6,482 ventilator days, 9,037 urinary catheter days, and 7,399 central line days. Patient acuity, demographics, and number of device days did not vary significantly year-to-year. Annual infection rates declined between 2006 and 2008, and decreases in UTI and BSI rates were statistically significant (p < 0.05). These decreases pushed UTI and BSI rates below Centers for Disease Control and Prevention norms.

CONCLUSIONS

Over 28 months, a systems approach to reducing nosocomial infection rates after trauma decreased nosocomial infections: UTI (76.3%), BSI (74.1%), and VAP (24.9%). Our experience suggests that infection reduction requires (1) an evidence-based plan; (2) MD and staff education/commitment; (3) electronic documentation; and (4) auditors to monitor and ensure compliance.

Intervenção e atividades propostas para o diagnóstico de enfermagem: ventilação espontânea prejudicada

Este estudo teve como objetivo investigar as intervenções e atividades de enfermagem propostas pela literatura para o diagnóstico de enfermagem ventilação espontânea prejudicada. Trata-se de uma revisão integrativa da literatura, nos bancos de dados MEDLINE e LILACS, utilizando os unitermos: Ventilação Mecânica, Diagnóstico de Enfermagem, Cuidados Intensivos e Cuidados de Enfermagem. A amostra foi constituída de 15 artigos, em oito deles foram identificados 20 cuidados que poderiam se relacionar às intervenções e atividades de enfermagem aplicadas ao paciente em ventilação mecânica, propostas na Classificação das Intervenções de Enfermagem. Entre esses cuidados, apenas oito equivaleram-se às intervenções prioritárias. Mas, nas intervenções sugeridas existem atividades para praticamente todos os cuidados desta revisão. Este estudo demonstrou que, apesar da importância dos cuidados aplicados aos pacientes em ventilação mecânica, estes, não são considerados como específicos da enfermagem, e a maioria não está presente na literatura.

ICU nurses' oral-care practices and the current best evidence

PURPOSE

The purpose of this study was to describe the oral-care practices of ICU nurses, to compare those practices with current evidence-based practice, and to determine if the use of evidence-based practice was associated with personal demographic or professional characteristics.

DESIGN

A national survey of oral-care practices of ICU nurses was conducted using a convenience sample of 218 practicing ICU nurses in 2004-05. The survey instrument included questions about demographic and professional characteristics and a checklist of oral-care practices. Nurses rated their perceived level of priority concerning oral care on a scale from 0 to 100. A score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the current best evidence. This score was then statistically analyzed using ANOVA to determine differences of EBP based on demographic and professional characteristics.

FINDINGS

The most commonly used equipment was gauze pads (84%), followed by tongue depressors (55%), and toothbrushes (34%). Chlorhexidine was the most common solution used (75%). Less than half (44%) reported brushing their patients' teeth. The majority performed an oral assessment before beginning oral care (71%); however, none could describe what assessment tool was used. Only 57% of nurses reported documenting their oral care. Nurses rated oral care of intubated patients with a priority of 67+/-27.1. Wide variations were noted within and between units in terms of which techniques, equipment, and solutions were used. No significant relationships were found between the use of an evidence-based protocol and demographic and professional characteristics or with the priority given to oral care.

CONCLUSIONS

While nurses ranked oral care a high priority, many did not implement the latest evidence into their current practice. The level of research utilization was not related to personal or professional characteristics. Therefore attempts should be made to encourage all ICU nurses to introduce and use evidence-based, oral-care protocols.

CLINICAL RELEVANCE

Practicing ICU nurses in this survey were often not adhering to the latest evidence-based practice and therefore need to be educated and encouraged to do so in order to improve patient care.

Hospital-acquired pneumonia: pathophysiology, diagnosis, and treatment

Hospital-acquired pneumonia (HAP) is one of the most common causes of nosocomial infection, morbidity, and mortality in hospitalized patients. Many patient- and disease-specific factors contribute to the pathophysiology of HAP, particularly in the surgical population. Risk-factor modification and inpatient prevention strategies can have a significant impact on the incidence of HAP. While the best diagnostic strategy remains a subject of some debate, prompt and appropriate antimicrobial therapy in patients suspected of having HAP has been shown to significantly decrease mortality. Because the pathogens responsible for HAP are frequently more virulent and have greater resistance to commonly used antimicrobials than other pathogens, clinicians must have knowledge of the resistance patterns at their institutions to choose appropriate therapy.

Ventilator-associated pneumonia in paediatric intensive care: a literature review

BACKGROUND

Ventilator-associated pneumonia (VAP) has been identified as the most common nosocomial infection in intensive care units (ICUs) with associated health and financial costs. To date, more research has been carried out in adult ICUs than in paediatric units, thus prompting a review and investigation of the implications for paediatric practice.

AIMS

To identify relevant paediatric literature surrounding VAP and use this in association with research carried out in the adult environment to establish the implications of VAP and possible management strategies.

SEARCH STRATEGIES

A literature search was undertaken using databases within DialogDatastar to identify the extent to which VAP has been researched in both paediatric and adult centres. This information was used to try and gain a clearer concept of the impact and management of VAP in the paediatric setting. Key words and combinations included VAP, intensive care, paediatric, antibiotics, positioning, suction, economics, management, nosocomial and morbidity and mortality. RESULTS OF ANALYSIS: Despite the documented significance of VAP in terms of its financial and health implications, discrepancies and inconsistencies exist surrounding the identification and treatment of VAP. This is reflected in paediatric centres by a dearth of literature on the subject and the lack of a national standard as to the management and prevention of VAP. Inappropriate management of VAP plays an important role in the development and spread of multiresistant bacteria within hospitals.

CONCLUSIONS

While inadequate paediatric research exists, extrapolating from adult research suggests that the financial and health costs of VAP are substantial and can be reduced by introducing simple low-cost measures. Such measures include improving education surrounding VAP and its implications and making small changes in practice to improve and maintain oral hygiene standards.

IMPLICATIONS

With a growing cohort of paediatric patients requiring short- and long-term ventilation, progress must be made in identifying the extent and impact of VAP in paediatric ICUs and among the community ventilated patients. This will require changes in practice and attitudes towards VAP for which an appropriate knowledge base would need to be established using audit and research. These issues are particularly relevant in the current environment given the links with multiresistant strains of bacteria within hospitals and the community.

Nursing involvement improves compliance with tight blood glucose control in the trauma ICU: a prospective observational study

INTRODUCTION

The importance of tight glycaemic control has gained acceptance over the last 5 years as a critical component of routine intensive care unit (ICU) measures. In an environment already strained for resources and staffing, however, effective strategies providing for increased input and responsibility of bedside nursing personnel are paramount to successful implementation.

HYPOTHESIS

Increasing input and responsibilities of ICU nursing staff in tight glycaemic control policies improves glucose control in the trauma ICU.

METHODS

After Institutional Review Board approval, we conducted a prospective "before-after" trial examining the effect of nursing education and input on outcome of a tight (goal 80-120 mg/dL) glycaemic control protocol. After a three month assessment of compliance with a previously physician-developed protocol, an educational in-service was conducted for all trauma ICU nursing staff. Nursing staff were then asked to provide input on the development of a new protocol using multiple-choice ballots to define 7 components of protocol criteria. Using nursing input, we developed and implemented a new glycaemic protocol that shifted much of the responsibility for initiation and subsequent adjustment of insulin infusion to the bedside nurse, allowing them to more liberally utilise their bedside clinical judgment and knowledge of the specific patient.

RESULTS

Nursing input on seven factors of protocol criteria did not differ significantly from the previously existing protocol, except with reference to nursing desire for increased responsibility in the implementation and maintenance of tight glycaemic control. After three months implementation of a new protocol developed utilising nursing input, both mean blood glucose levels achieved (137.8 mg/dL vs. 128.2mg/dL, p=0.028) and time to first hourly blood glucose within goal range (<120 mg/dL) was improved (36 h vs. 9h). The number of hypoglycaemic (BS <60) episodes increased slightly after revision (1 event vs. 5 event), with no hypoglycaemic seizures or coma occurring during either period.

CONCLUSION

Nursing input and increased responsibility improved the results of a tight glycaemic control in our trauma ICU. Increasing nursing input in the development and implementation of a tight glycaemic policies can result in safe and effective improved glucose control in the trauma ICU.

Implementing a ventilator care bundle in an adult intensive care unit

BACKGROUND

Ventilator-associated pneumonia (VAP), in addition to causing distress to patients, is associated with increased length of stay in intensive care, higher rates of morbidity and mortality and pressure on critical care capacity and costs. A care bundle approach for the management of ventilated patients can reduce the risk of VAP.

AIM

This paper aims to appraise the implementation of a series of high impact intervention care bundle components directed at preventing the development of VAP, within an adult intensive care unit of a district general hospital.

INTERVENTION

Subsequent to the implementation of care bundle components, evidence from audit data revealed that compliance fell below standard. To address this, Department of Health staff who were visiting the hospital recommended that the frequency of audit activity should be increased to facilitate the rapid identification of areas of poor compliance, which could then be rectified.

CONCLUSION/IMPLICATIONS

Daily care bundle audits showed a positive impact on compliance. However, without a robust method to collect data on prevalence of VAP, the impact of the care bundles on improving outcomes for this aspect of care is unknown.

Basic concepts in mechanical ventilation

Mechanical ventilatory support is a major component of the clinical management of critically ill patients admitted into intensive care. Closely linked with the developments within critical care medicine, the use of ventilatory support has been increasing since the polio epidemics in the 1950s (Lassen 1953). Initially used to provide controlled mandatory ventilation, today with advances in technology, most mechanical ventilators are triggered by the patient, increasing the awareness of the complexity of patient/ventilator interaction (Tobin 1994). Though ventilator appearance and design may have changed quite significantly and the variety of options for support extensive, the basic concepts of mechanical ventilatory support of the critically ill patient remains unchanged. This paper aims to outline these concepts so as to gain a better understanding of mechanical ventilatory support.