Ventilator-Associated Pneumonia - Proposed Solution, Implementation and Evaluation - Essay Example

?Proposed Solution, Implementation and Evaluation XXXXX Grand Canyon HLT 490V Capstone Project Proposed Solution, Implementation and Evaluation In this paper, the solution, implementation and evaluation of the use of ventilator care bundle to reduce the risk of ventilator associated pneumonia will be presented. Ventilator Associated Pneumonia (VAP) refers explicitly to nosocomial bacterial pneumonia that has developed in patients who are under mechanical ventilation. VAP can be segregated into two types – early onset pneumonia and late onset pneumonia. One that occurs within 48 to 72 hours after tracheal intubation and is mostly the result of aspiration is termed early onset VAP and the one that occurs after this period is termed late-onset pneumonia (Kollef, 2005). VAP is associated with increase in morbidity and mortality, hospital length of stay and costs. It has been found that the mortality rate as a result of VAP is 27% and has been as high as 43% when the contributing agent was antibiotic resistant. When a patient is diagnosed with VAP, the length of his stay in the Intensive Care Unit (ICU) is increased by 5-7 days and the duration of hospital stay is increased by 2-to-3 folds. Moreover, the cost of VAP has been projected to be an additional $40, 000 per hospital admission per patient and a projected $1.2 billion per year. The level of risk occurrence, increased costs and mortality necessitates implementation of measures to prevent VAP, everywhere feasible (Augustyn, 2007). A number of strategies have been proposed for VAP prevention however, only a few of them have proved their efficacy; others still need evaluation in large randomized clinical trials before accurate references can be made. In any case, antibiotic therapy will always remain the main stay of initiating VAP treatment and should be started as soon as the patient has been diagnosed with VAP and admitted to the hospital; other treatments whether single treatment or combination treatment should be initiated soon after. However, the varied amount of researches on VAP is often overpowering and contradictory. In some research, single treatment or monotherapy has been found to be a useful alternative to combination therapy, with the same achievement rate and without any superinfections or colonization by multiresistant pathogens. However, it was noted that most of these conclusions were arrived after observing patients who were diagnosed with VAP on merely clinical basis. Moreover, the efficiency of the treatment was simply based on information from tracheal aspirate instead of more explicit methods. In addition, on clinically studying 200 patients with P. aeruginosa bacteremia, it was revealed that the mortality rates for VAP patients undergoing monotherapy was 88% (7 out of 8 patients) whereas rate for those undergoing combination therapy was 35% (7 of 20 patients). Thus, it was concluded that the mortality rates in combination therapies are much lower than in the case of monotherapies (Chastre & Fagon, 2002, p. 892). Proposed solution The Ventilator care bundle is one of the six major programs that has been introduced and proven effective to prevent VAP. This approach includes a string of evidence based interventions associated to ventilator care, which when implemented together will achieve significantly better results than when applied separately. These evidence based strategies minimizes endotrachael intubation, the duration of mechanical ventilation and the risk of aspiration of oropharyngeal pathogens thereby leading to prevention of VAP to a great extent (Gillespie, 2009,p. 48). The Centers for Disease Control Guidelines and Pugin’s Clinical Pulmonary Infection Score criteria simultaneously noted that analyzing VAP needs a amalgamation of clinical signs, impaired gas exchange, radiological changes and positive microscopy to distinguish an occurrence of VAP from simple colonization. Specific guidelines have been developed to both prevent VAP and treat it appropriately as soon as possible. The guidelines provide targeted strategies and the additional management of VAP comprises the provision of essential care, psychosocial support, ventilator support, enteral feeding and relevant medication including deep-vein thrombosis prophylaxis, and the prevention of complications (Gillespie, 2009, p. 44). Indeed, the combination or the care bundle approach provides an interventional means to execute the strategies explicitly directed towards the avoidance of VAP and the facilitation of a team approach to reduce the incidence of VAP in the critical care units (Gillespie, 2002, p. 48). Implementation The Canadian critical care society (CCCS) has synthesized evidence based clinical practice guidelines which provide a reliable evidence for application in practice. According to them, successful implementation of the ventilator care bundle requires a team approach that embraces an active strategy to improve patient care, participation by all team members, periodic review of guidelines, and a continuous process to effect change in behavior where required. The format for the implement plan is as follows (Gillespie, 2002, p. 48-50): I. Assemble a team (Who) A) Medical Directors B) Nursing Managers C) Administrators D) Respiratory therapy staff E) ICU Nurses F) Adequate ICU Staff G) Outcome managers II. Resources for facilitating the implementation process A) Written Guidelines B) Daily goal worksheet C) Checklists D) Audit tools E) Regular Feedbacks III. Physical Strategies According to CCCS, VAP can be reduced through the implementation of a care bundle approach with three vital strategies – 1. Staff Education 2. Colonization Reduction 3. Aspiration Avoidance 1. Staff Education A) Education of the staff is absolutely necessary for a successful VAP prevention program. Therefore, firstly an educational program should be organized for respiratory care programs and ICU nurses which accentuate correct practices for the avoidance of VAP. Such a program should include a self-study unit on risk factors for, and approaches to prevent VAP, and education based .in-services. Moreover, factsheets and posters consisting of this valuable information should be posted throughout the ICU and respiratory care departments. (Bablock et al., 2002) B) The accurate application of all the clinical guidelines for the treatment of this disease should be encouraged as it has been found to enhance the preliminary management of adequate antimicrobial treatment and reduce the overall length of antibiotic treatment (Gillespie, 2009, p. 49). C) Most importantly, all ICU nurses and staffs should be strictly instructed to wash hands with alcohol based hand disinfectants before as well after all contact with patients. In addition, gloving and gowning of the health care workers should be a routine practice as it minimizes the transmissions of pathogens between patients (Gillespie, 2009, p. 49). 2. Colonization Reduction A) The duration of mechanical ventilation should be minimized, the sedative administration should be reduced, and a standardized protocol for ventilator weaning should be implemented as it will lead to the reduction in the days of ICU stays as well as in the days of intubation thereby preventing VAP. In addition, intubation can be avoided by an early use of non-invasive ventilation, especially in case of weak patients (Gillespie, 2009, p. 49). B) Secondly, Circuit changes should be done only if the circuit becomes soiled or damaged. Moreover, heat-moisture exchangers should be altered every 5 - 7 days or as clinically indicated (clogged with secretions) if in use (Gillespie, 2009, p. 49). C) It is acceptable to use water bath humidification or a heated humidifier when needed (Gillespie, 2009, p. 49). D) It has been suggested that bacterial filters should be used only in patients with infectious diseases such as TB (Gillespie, 2009, p. 49). 3. Aspiration Reduction A) Endotracheal intubation (ETT) should be minimized where possible; orotracheal route should be preferred to nasotracheal route. The orotracheal cuff pressure should be maintained at >20cm H2O (but 72 hours. It has been found that a closed endotracheal suctioning system used for safety considerations only does not prevent VAP; therefore such a system should be changed between patients, or as clinically indicated (Gillespie, 2009, p. 49). B) Kinetic Therapy The patients should be rotated mechanically with 40 degree turns since it results in much better improvement of pulmonary function in comparison to standard care. Moreover, kinetic therapy has been found to improvise the movement of secretions and also avoid the accretion of mucus in the dependent lung zones (Coppadaro, Bitter & Berra, 2012). C) Semi-recumbent positioning, that is keeping the patient’s head up at an angle of 30? - 45? has been observed to be very protective, especially during enteral feeding. The elevation of the head above the stomach decreases the gastro-oesophageal reflux and aspiration which is the main reason for keeping patients in a semi-recumbent position (Coppadaro, Bitter & Berra, 2012). D) The physicians should start enteral feeding slowly, particularly during the 48 hours after initiating mechanical ventilation for minimizing gastric reflux and possible aspiration threat (Gillespie, 2009, p. 49). E) Moreover, the post-pyloric route for feeding is recommended in place of gastric route (Gillespie, 2009, p. 49). F) Oral care Oral sanitization with chlorhexidine has been found to diminish the occurrence of VAP in patients who have been undergoing cardiac surgery, most probably by reducing oropharyngeal colonization. Furthermore, several studies have revealed that oral decontamination done with antibiotic paste only or along with systemic antibiotics leads to a reduction in early VAP (Koenig & Truwit, 2006). IV) Pharmacological strategies A) It has been recommended to use povidone-iodine oral antiseptic only for oral decontamination of patients with severe head injuries (Gillespie, 2009, p. 49). B) It is important to limit stress ulcer prophylaxis to high-risk patients (avoid antacids and histamine type 2 antagonists, sulcralfate and proton pump inhibitor preferable) (Gillespie, 2009, p.49). C) Patients suffering from trauma or critically ill patients should be made to undergo limited red blood cell transfusions (Gillespie, 2009, p. 49-50). D) The physicians should always remember that targeted antibiotic management strategies such as de-escalation and antibiotic rotation or ‘cycling’ are maintained on a regular basis (Gillespie, 2009, p. 49-50). V) Review progress of the VAP program with all the ICU heads, reassessment of the clinical guidelines, assessment of any problems or barriers in the implementation of treatment or patient referrals and regular maintenance of a checklist is deemed necessary. VI) Review program and procedures to evaluate the success of the treatment course and any follow-up treatments that may be necessary to ensure the success of the treatments. Regular feedbacks of the VAP care bundle approach should be obtained from ICU staffs, the patients and their families so that improvisations in the treatment can be made, if needed and also a complete success of the program can be ensured. Evaluation Most of the hospitals that have approved and implemented the bundle care approach have reported vital enhancement in quality indicators and patient results. A recent study of a UK hospital, where an organized and meticulous implementation of the ventilator care bundle intervention was done, revealed a reduction in patients’ ICU stay as well as ventilator days, and a raise in the unit patient throughput. It was found that constant delivery of evidence based strategies and improved care in the ICU using the bundle approach had made these results possible. Indeed, the VAP rates which was reported in 35 units reduced by an average of 44.5% during the 2 year study period (Gillespie, 2009, p. 50). Another study of VAP patients conducted from 2006-2008 in a Saudi Arabia hospital that had implemented the VAP bundle have reportedly been successful in reducing the VAP rates from a mean of 9.3 cases per 1000 ventilator days in the year 2006 to 2.3 cases per 1000 ventilator days in 2007, and ultimately to 2.2 in 2008 (P Read More