Ventilator Associated Pneumonia in the Adult Critical Care Setting

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Problem Statement

In health care settings, infections occurring from medical procedures are ongoing, constant concerns for healthcare providers. Intubated, critically ill patients are more vulnerable to secondary infections. “Ventilator-associated pneumonia (VAP) is the leading cause of mortality due to nosocomial infections and is that with a greater impact on morbidity of patients hospitalized in the intensive care unit (ICU)”(Maselli, 2011, para. 1). APIC (2009) stated ventilator-associated pneumonia is a type of pneumonia particular to the healthcare setting. It is contracted usually within a 48-hour period after mechanical intubation. Ventilator-associated pneumonia rates fluctuate between 8% and 28%. 

According to Maselli (2011), the problem of ventilator-associated pneumonia is associated with high death rates and expenses in patient care. For patients that contract ventilator-associated pneumonia, costs can increase by $40,000 USD for each patient. If the cause of the ventilator-associated pneumonia was preventable, this reflects a needless waste in expenses and in human life.

There are preventable and unpreventable causes of ventilator-associated pneumonia. According to Maselli (2011), unpreventable factors include age of patient, gender (male patients over 60 years of age are at higher risk of infection), respiratory illness, multiple organ dysfunction syndrome (MODS), coma, chronic bronchitis or emphysema, tracheostomy, repeated intubation, head injuries, and surgery of the nervous system. Other unpreventable factors are “Patient has received hemodialysis, wound, or infusion therapy as an outpatient; patient was previously hospitalized for at least 3 days within the past 90 days prior to current admission; or the patient is immunocompromised due to underlying disease or therapy (HIV, chemotherapy” (APIC, 2009, p. 10), along with many other factors, such as psychological (mental state), lifestyle factors (smoking), and environmental (inhalation of caustic substances) (APIC, 2009).  However, there are factors that are controllable within the healthcare setting that can and do lower the risk of a patient contracting ventilator-associated pneumonia. 

As Maselli (2011) stated, controllable factors within intensive care units include the elevation position of the patient, gas buildup in the intestines, “contamination of ventilator circuits, frequent patient transfers and low pressure of the endotracheal tube (ETT) cuff” (para. 2). Other controllable factors include hospital staff hand washing recording and procedures and patient oral care (infection can occur while brushing the teeth of patients). 

According to APIC (2009), antibiotic resistance of certain strains of pneumonia factor into the treatment of ventilator-associated pneumonia. Nonfermentative Gram-negative bacilli are associated with higher rates of mortality. Providing the shortest course of antibiotics is desirable to reduce antibiotic resistance of ventilator-associated pneumonia.

Nursing assessment plays a vital role in patient care. The first forty-eight hour window is most critical in the diagnosis and prevention of ventilator-associated pneumonia (APIC, 2009). Maselli (2011) stated, a proactive approach to care has been associated with lower risks of infection, a decrease in expense and deaths associated with ventilator-associated pneumonia. A program to prevent ventilator-associated pneumonia should be multifaceted, incorporate a staff educational program, and intubation and extubation procedures must be strictly followed to prevent infection, improve survival rates, and lower contamination. 

Instructional Setting

A nurse’s job is in patient care and to educate, both other nurses and the patients. Nurses most likely will train other nurses within the ICU or CVICU units, or any long-term critical care setting. They are the front line in patient care and can do the most to decrease the incidences of preventable ventilator-associated pneumonia. In educating hospital staff, nurses must know the components of an infection prevention protocol, reporting procedures, and how to measure a protocol’s success.

APIC (2009) recommends certain guidelines to follow in the development of a protocol for ventilator-associated pneumonia: 

APIC recommends a protocol that is targeted specifically to prevent infection in intubated patients.

Education for at-risk populations, high-risk procedures, and other factors associated with increased risk of infection.

Ensure methodological and consistent data collection for accuracy, and determine an appropriate reporting procedure (monthly, quarterly, annually).

There are many ways and established protocols that are effective in reducing the risk of infection in ventilated patients. APIC (2009) suggests the first step to be an assessment of risk at a hospital. The following guidelines are suggested for risk assessment:

Is there a data collection process for ventilator-associated pneumonia, such as compliance to and documentation for hand washing, periodic sedation breaks, weaning evaluation, maintenance of a semi-elevated patient position, and patient teeth cleaning?

Are these practices compliant with proven protocols?

Are records reported to senior hospital staff?

Is there an established training program in the prevention of ventilator-associated pneumonia?

APIC (2009) recommends the following procedures to reduce the incidences of pneumonia in intubated patients:

A face and nasal mask should be used instead of an invasive intubation tube.

If tubes have to be used, oral tubes are preferred over nasal tubes to prevent sinusitis, more common with nasal tubes.

Minimize ventilator equipment contamination, such as removing condensation from tubes, which can wash back into the ventilator machine when the patient shifts and changes positions. Follow equipment-cleaning protocols.

Educate staff for early weaning procedures to decrease the risk of infection and decrease patient care costs.

Elevate head and chest of patient between thirty and forty-five degree angle to prevent aspiration.

Staff must wash hands before handling patients and equipment, as well as wearing gloves to handle contaminated equipment.

Develop and follow oral and dental disinfecting and cleaning procedures.

Observed intestinal flow and observe feeding tubes for signs of regurgitation, which can increase risk of aspiration.

Monitor patient PH levels to decrease peptic ulcers. Not enough stomach acidity can increase risk of infection.

APIC suggests that a timeline is established for reporting data once a program is implemented, such as monthly or bi-monthly, for protocol compliance. Every healthcare professional that comes into contact with the intubated patient should follow the protocol. The number of times professionals comply with the protocol is observed, and expressed out of 100 incidences. The compliance is recorded as a percentage. Hospitals should aim for an increase of compliance every month until 100% compliance is reached.

APIC (2009) also recommends that hospitals keep meticulous records to track the success of their infection prevention in intubated patients, both in cost effectiveness and decreases in mortality rates. APIC provides worksheets for hospitals to use. The staff fills in the data, and the costs are calculated. This will show how effective a ventilator-associated pneumonia prevention program is. 

Antibiotics should not be used as a preventative measure because it increases the development of antibiotic-resistant strains of bacteria, according to Chastre et al. (2003). Also helpful is decreasing the course of antibiotics from two weeks one day to eight days (Chastre et al., 2003). 

Research Questions

1. Do ICU/CVICU nurses have sufficient expertise on prevention of ventilator-associated pneumonia?

2. Are ICU/CVICU nurses utilizing their knowledge of preventive procedures of ventilator-associated pneumonia?

3. Are years of education, ICU/CVICU training, years of working in the ICU/CVICU, and expertise of ICU/CVICU nurses on prevention of ventilator-associated pneumonia correlated?

4. Does understaffing affect ICU/CVICU nurses’ ability to apply their knowledge in the prevention of ventilator-associated pneumonia?  

References

APIC (2009). Guide to the elimination of ventilator-associated pneumonia. Retrieved from http://www.apic.org/Resource_/EliminationGuideForm/18e326ad-b484-471c-9c35-6822a53ee4a2/File/VAP_09.pdf

Chastre, J., Wolff, M., Fagon, J. Y., Chevret, S., Thomas, F., Wermert, D., Clementi, E., … Aubas, S. (2003). Comparison of 8 vs. 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: A randomized trial, JAMA, 290(19), 2588-2598. doi:10.1001/jama.290.19.2588.

Maselle, D. J. (2011). Therapeutic advances in respiratory disease strategies in the prevention of ventilator-associated pneumonia. Ther Adv Resp Dis., 5(2),131-141. Retrieved from http://www.medscape.com/viewarticle/739619