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Nurses’ Role in the Prevention of Ventilator-Associated Pneumonia:

Megan Kreifels , Ali Pearson, Mara Sloan & Briahna Stofferson Creighton University School of Nursing Summer 2012 Nurses’ Role in the Prevention of Ventilator-Associated Pneumonia

PowerPoint Presentation:

What is the association between oral care and ventilator associated pneumonia (VAP) among critically ill patients?

Significance of the problem:

Significance of the problem VAP accounts for nearly 15% of all hospital-acquired infections 1 Highest risk populations include >70 years old, patients with decreased LOC and the immunocompromised 2 Increased costs of patients of $30,000-$40,000 per hospitalization in VAP cases alone 2

Clinical Outcomes3:

Clinical Outcomes 3 Special focus on prevention in critically ill patients Maintain baseline weight and nutrition to prevent aspiration Reduce fatigue Open, clear tracheobronchial airways for optimal gas exchange Structural intactness, normal function of skin and mucous membranes

Quality Outcomes4:

Quality Outcomes 4 Benchmarking Adherence to best practice protocols Patient’s perceived well being and involvement in care

Cost Outcomes2:

Cost Outcomes 2 Direct: length of stay in the ICU and hospital, resources used, cost of care Indirect: time and wages lost as a result of hospitalization

Level & Quality of Evidence:

Level & Quality of Evidence Synthesizing our research, two of our four articles have an evidence level of three 5,6 , while the other two had an evidence level of six. 7,8 The quality of evidence is more often than not moderately well-controlled. 5,7,8

Sample Description:

Sample Description The sample size ranged from 57 subjects 6 to 347 subjects. 8 The population consisted of nurses caring for mechanically ventilated patients 7, 8 , or mechanically ventilated patients in intensive care units (ICU). 5, 6 The studies reviewed geographically ranged from the United States 6,8 to Malaysia 7 and Taiwan. 5

Summary of the Findings:

Summary of the Findings The synthesized findings validate that there is some improvement in oral mucosal health with regular oral care implementation 5 and that oral care is necessary for critical care nurses to practice in order to decrease the morbidity of VAP cases 6,7,8

Practice Implications/Recommendations:

Practice Implications/Recommendations RECOMMENDATIONS: Implementing oral care protocol into hospital policies for mechanically ventilated patients based on evidence-based practice 5,6,7,8 Evaluate effectiveness of implemented oral care protocol 7,8 The first recommendation was found to be consistent in our three Level 3 studies 5,6,7 as well as the Level 6 study 8.. Our analysis of the quality of evidence of the studies the this specific recommendation is based on our interpretation of all of the reviewed article’s information as moderately- well controlled. The second recommendation was found to be consistent in the articles by both Feider , Mitchell & Bridges, 2010, a level 3 study and Soh et al., 2011, a level 6 study. As stated above, over all, all of the reviewed articles were found to be moderately well-controlled. IMPLICATIONS Oral care is paramount for the reduction of VAP and frequent, as well as thorough, oral care that follows either a specific oral care protocol or standardized oral care protocol, such as the AACN Procedure Manual for Critical Care 8 , are various implications for the practice of implementing an oral care protocol 5,6,7,8

Impact of Recommendations’ on Clinical Outcomes :

Impact of Recommendations’ on Clinical Outcomes Clinical Outcomes Impacted: Less change in structural intactness, normal function of skin and mucous membranes Adequate prevention of VAP in critically ill patients

Impact of Recommendations’ on Quality Outcomes:

Impact of Recommendations’ on Quality Outcomes Quality Outcomes Impacted: Development of standard oral care policies, protocols & assessment tools Improved adherence to best practice protocols Improved health care provider collaboration and satisfaction Improved patient satisfaction and perception

Impact of Recommendations’ on Cost Outcomes:

Impact of Recommendations’ on Cost Outcomes Cost Outcomes Impacted: Direct: decreased length of stay in the ICU and hospital, resources used, cost of care Indirect: less time and wages lost as a result of hospitalization

Future Research:

Future Research Research concerning the development of a more globally standardized oral care protocol should be conducted. Evaluation of the effectiveness of individual protocols, as well as future standardized protocols should also be included in prospective research. Future studies should include the evaluation of nurses’ knowledge regarding oral care assessment and implementation, prior to instruction on a specific or standardized oral care protocol, as well as after the education has been completed. Nursing documentation of oral care , compared to actual oral care implementation, which includes both duration and frequency, is another area of future research that is recommended.

References:

References Center for Disease Control and Prevention. (2003). Guidelines for preventing healthcare-associated pneumonia. http://www.cdc.gov/ncidod/dhqp/gl_hcpneumonia.html . Accessed February 10, 2012 McCoy , T., Fields, W., Kent, N.(2012). Evaluation of emergency department evidence-based practices to prevent the incidence of ventilator-acquired pneumonia . Journal of Nursing Care Quality, 27 (1), 83-88. Goss, L. (2011). A close up view of pneumococcal disease . The Nurse Practitioner, 36 (12), 41-45. Bonello , R.S., Fletcher, C.E., Becker, W.K., Clutter, K.L., Arjes , S.L., Cook, J.J., Petzel , R.A. (2008). An intensive care unit quality improvement collaborative in nine department of veterans affairs hospitals: reducing ventilator-associated pneumonia and catheter-related bloodstream infection rates . The Joint Commission Journal on Quality and Patient Safety,34 (11), 639-645. Hsu, S., Liao, C., Li, C., & Chiou , A. (2010). The effects of different oral care protocols on mucosal change in orally intubated patients from an intensive care unit. Journal of Clinical Nursing, 20 ,1044-1053. Ross, A., & Crumpler , J.(2007). The impact of an evidenced-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia. Intensive and Critical Care Nursing , 23 , 132-136. doi:10.1016/j.iccn.2006.11.006 Soh , K. L., Soh , K. G., Japar , S., Faman , R. A., & Davidson, P. M. (2011). A cross-sectional study on nurses' oral care practice for mechanically ventilated patients in Malaysia. Journal of Clinical Nursing , 20 , 733-742.doi: 10.1111/j.1365-2702.2010.03579.x Feider , L.L., Mitchell, P., & Brides, E. (2010). Oral care practices for orally intubated critically ill adults. American Journal of Critical Care , 19 , 175-183. doi : 10.4037 /ajcc2010816

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