Prevention of Ventilator-Associated Pneumonia - Research Paper Example

Clinical Practice Summary- Prevention of Ventilator-Associated Pneumonia: Health Care Protocol affiliation Clinical Practice Summary- Prevention of Ventilator-Associated Pneumonia: Health Care Protocol Pneumonia associated with ventilation is one of the major infections acquired mainly in hospitals. It is responsible for the high mortality rates in patients who get the pneumonia from the ventilation. It is because of this that various strategies are in place to help curb the disease. The pneumonia associated with ventilation is under observation to prevent it from further affecting the patients. Various strategies are in place to reduce the exposure of the bacteria and the time a patient stays on the mechanical ventilation. The bacteria spread very much like a communicable disease. Therefore, there is a need to create health care protocols to help curb the spread of the disease. Scope and Purpose The scope of this document is on the ventilator-associated pneumonia together with other complications like stress ulcers, venous thromboembolism among patients on ventilators. The purpose of this clinical practice guideline is to come up with ways of preventing, managing and monitoring the risk assessment of the ventilator-associated pneumonia. The main objective of the guideline is to ensure that the prevalence of pneumonia in ventilated patients reduces (Institute for Clinical Systems Improvement (ICSI), 2011). The guideline dedicates its services in the use of a bundle for patients in intensive care. However, the admission orders are restricted in the protocol even for patients outside the ventilator management. The populations in the clinical practice are the patients already on ventilators in intensive. The adult patients in intensive care especially those on the ventilators are the major beneficiaries of the services in the guideline. The major consumers or the anticipated users will include the nurses with advanced knowledge in the field, linked health personnel, the paramedics, stakeholders providing health care solutions, hospitals, care organizations, nurses, physicians and respiratory care specialists (Institute for Clinical Systems Improvement (ICSI), 2011). Stakeholder involvement Various clinical specialists from the different professions were present during the implementation of the guideline. It involved professions like physicians, nurses, pharmacists and any other professional from the healthcare industry and at least one staff implementer from Institute for Clinical Systems Improvement (ICSI) (Institute for Clinical Systems Improvement (ICSI), 2011). Among the physicians, one got selected as the leader and if there is a profession not represented, other members from selected medical groups and hospital are chosen to be part of the team. Ventilator-associated pneumonia is a new field and there is no much information about it. Specialists are trying to come up with new ways of preventing it but people are afraid that we are far from the solution. The members of the targeted population were not part of consultation in the development of the document. The members from the medical community were the only ones involved in drafting the document. This brings a conflict of interest because the patients need to be included in the consultations to help understand the infection. Instead, other people make the decisions for them concerning the preservation of their lives. Rigor of development To test and assess the credibility of the articles in the guidelines, a rating scheme evaluates how good and strong the evidence is. The rating scheme uses randomized controlled trial for data collections (Institute for Clinical Systems Improvement (ICSI), 2011). The scheme also includes cohort-study, non-randomized controls and cross-sectional study. The non-randomized trial incorporates the case-control study, understanding and explanation of a diagnostic test and population based descriptive study. The qualitative studies come in terms of systematic reviews, decision analysis and cost-effectiveness analysis. Everything about ventilator-associated pneumonia is elaborate in this article. The target population, through the specialists, is aware of the benefits and risks the ventilator-associated pneumonia brings. Recommendations The major recommendations for the clinical practice include nursing and respiratory care and the medications. Under nursing and respiratory care, various approaches apply to ensure that the patients receive the best treatment. The first approach is Head of bed whereby the head of bed is elevated at angle for a patient who is at a high risk for aspiration and the enteral tube fixed for respiration. The angle of elevation surpassing 30 degrees may prove difficult to maintain and lower elevation may help the situation either compared to a controlled elevation of 10 degrees. Another approach is on the cuff pressure. The recommended cuff pressure is 20-25 cm H2O and there should be no minimal leak techniques (Institute for Clinical Systems Improvement (ICSI), 2011). Studies have revealed that maintaining low intracuff pressure is risky for ventilator-associated pneumonia. The pressure in the cuff along the endotracheal tube should be above 20 mm Hg. The study explains that patients who did not receive antibiotics and had low cuff pressures usually ended up with the risk of contracting the pneumonia. The stationary oropharyngeal secretions at the cuff can end up in going into the airway when cuff pressure reduces unexpectedly. The accumulated secretion in the endotracheal cuff is the most probable cause of aspiration and ventilator-associated pneumonia. Currently, no recommendations exist for endotracheal cuff pressures. The question of how humidifiers or heat exchangers and moisture exchangers are used is still in doubt on whether it is the cause for the changes in ventilator-associated pneumonia rate in patients. The CDC has still made no recommendation on the technology used in the circuits of both exchangers. CDC is strict on how heat and moisture exchangers are used requiring them not changed regularly or when they can be unused or malfunctioning. Heat and moisture exchangers removed for around 48 hours or to approximately 12 hours as compared to 24 hours showed no increase in the disease (Institute for Clinical Systems Improvement (ICSI), 2011). Further results showed nothing for the pneumonia, any bacteria colonization or variable for ventilator sustenance found in the comparison of heat exchanger and moisture exchanger fluctuations after a day or even after a week. The studies was only done on adults and therefore, to ensure safe prolonged heat exchangers and moisture exchangers, other studies need to be done to include the other type of patients especially the children. Oral care under a precise trial and meta-analysis proved the efficiency of oral decontamination for 2% chlorhexidine solution against pneumonia related to ventilation. The patient administered with a 2% dosage of chlorhexidine or the normal saline solution for four times a day until the removal of endotracheal tube. The number of cases of pneumonia after every 1,000-ventilator days improved statistically for the chlorhexidine and saline normal groups. A higher rate of irritation of oral mucous was present in the chlorhexidine group that limited the dosing effect (Institute for Clinical Systems Improvement (ICSI), 2011). However, there was a reduced rate of pneumonia from ventilation for chlorhexidine group. The use of a dedicated suction line for endotracheal tube greatly helps curb the occurrences of early pneumonia because of ventilation. The changing out of the endotracheal tube for another endotracheal tube with subglottic suction lumen cannot happen due to the high risk of secretions from subglottic. As a result, the recommendation is to use an endotracheal tube having a dorsal lumen directly above the endotracheal cuff for drainage of tracheal secretions amassing within subglottic area of the patient. The secretions should have cleared above the tube cuff before the endotracheal tube removal without a dorsal lumen. Patients with an endotracheal tube that has a removal port for subglottic secretions, experience reduced rates of pneumonia that resulted from ventilation. The tubes also moderate the time for which the mechanical ventilation takes place. The use of kinetic bed therapy considerably helps to moderate the existence of pneumonia emanating from ventilation and lobar atelectasis. It can reduce the existence of pneumonia relating to ventilation but then again cannot avoid other outcomes like death or the duration of ventilation. Since a special bed is required and intensive care unit cannot afford one, the best thing is that it not be used consistently in ventilated patients. A patient’s ability to maintain enough ventilation, oxygenation and breathing ease reduces the time for failure of acute respiration. The continuous use of sedatives reduces the period of mechanical ventilation and diagnostic testing that evaluates mental status after the intensive care admission. Reduce or discontinue sedation until the patient is awake to follow simple commands or patient becomes tense. The results of a weaning trial are important during a clinical judgment of the consciousness of the patient, airway steadiness, status of hemodynamic illness (Institute for Clinical Systems Improvement (ICSI), 2011). Various reasons can arise causing the delay of weaning trials from an increase in pressure of intracranial, serious respiratory letdown, expiratory pressure being too much or prone positioning, unsteady airways, neuromuscular blockade or predicted life support withdrawal (Institute for Clinical Systems Improvement (ICSI), 2011). The combination of both daily sedation cessation and spontaneous breathing trial can go a very long way than only performing spontaneous breathing trials alone. This may decrease the intensive care unit for about three days. The medications used include stress ulcer prophylaxis and venous thromboembolism prophylaxis (Institute for Clinical Systems Improvement (ICSI), 2011). The stress ulcer prophylaxis is clinically for prevention in the critical and intensive care patient. Studies have shown that intercessions can apply to avert hospital from experiencing any pneumonia related case. It suggests avoiding unnecessary routine of using antibiotics together with stress ulcer prophylaxis, using sucralfate to reduce stress ulcer prophylaxis, decontamination of the digestion among others (Institute for Clinical Systems Improvement (ICSI), 2011). Prophylaxis stops once the patient is extubated or gastrointestinal bleeding stops when transferred out of the ICU or even the non-existence of spinal cord injury. The Venous thromboembolism Prophylaxis is for patients in the ICU or those with risk factors of venous thromboembolism (Institute for Clinical Systems Improvement (ICSI), 2011). The ICU patients are always at risk of getting exposed to deep vein thrombosis and embolism originating from pulmonary. The ICU stay may present the different thromboprophylaxis at different times. The resources needed to accomplish the recommendations of this document include equipment and tools like special beds, training of the personnel to be involved in the program and a ventilator bundle. Implementation The implementation of the guideline recommendations has its benefits and presents a potential harm. Some of the barriers into the implementation of the documents range from lack of understanding in the interpretation of the clinical trials, inadequate resources, fear of adverse events and cost of implementation of the recommendations. The cost of implementing the recommendations is high because some of the equipment required is expensive. The kinetic bed therapy requires a special type of bed that is difficult to acquire. The benefits are that there has been an increase in the usage of pneumonia ventilator bundle for most ventilated patients in intensive care. The recommendations have achieved the goal of eradicating ventilator-associated pneumonia for adult patients in the ICU. The main potential harm is that chlorhexidine causes the irascibility of the mucus in the mouth and has a limiting effect on the dosage. Although the recommendations guarantee a positive result and hope for ventilator-associated pneumonia, some of them are risky and dangerous. The tests are still in trial phase meaning that they are not 100% full proof. Most of the recommendations are costly in terms of acquiring the necessary material and resources. Systematic review of the program is the best approach to use to measure whether the recommendations have improved. It is a good approach because it will help oversee how the program runs in case of an infection. It is evident that pneumonia associated with ventilator is common within hospitals. The healthcare providers should ensure that prevention programs are in place to help curb the infection. The program should specifically target those patients in ventilators as well as those having hospital-associated infections. The duration for mechanical ventilation should be short and some measures put in place to prevent the aspiration of contaminated secretions. References Institute for Clinical Systems Improvement (ICSI). (2011). Prevention of ventilator-associated pneumonia. Health care protocol. Bloomington (MN): Author. Read More