Reduction of VAP - Research Paper Example

Reduction of VAP Mortality and Morbidity of Ventilator-Associated Pneumonia Ventilator-associated pneumonia is one of the nosocomial infections, which affects intensive care unit patients. The greatest risk factor for VAP is invasive devices that include mechanical ventilators, intra-tracheal accesses, and catheters. The mortality of VAP ranges from 25%-76%. Underlying Conditions Which Lead To Development of VAP Age, immune incompetence, presence of rapidly fatal disease are some of the most common risk factors for the development of VAP. Microorganisms Associated With VAD (Microbial Etiology of VAP) It depends on patient's characteristics, geographical location, and duration in hospital, etc. The most common pathogens associated with the infections include Enterobacter species, S. aureus, P. aeruginosa, Klebsiella species, Acinetobacter species, and S. marcescens. Burkholderia (Pseudomonas) cepacia This is an aerobic gram-positive, rod-shaped bacteria. Its risk factors include patients with mechanical ventilation, cystic fibrosis, debilitation, impaired immune responses intravenous drug abuse and multiple administering of antibacterial drugs. Contaminated disinfection solutions, nebulizers, and topical anesthetics have been associated with sporadic outbreaks of the bacterial disease. Sporadic outbreaks of the infection have been noted in ICU and burn unit. Stenotrophonomas (Xanthomonas) maltophilia Non-fermenting gram-negative bacteria with a rod shape. The predisposing factors for infection or colonization are: central venous catheters; mechanical ventilation; ICU location; invasive devices; organ transplant; immunosuppressed patients; neutropenia; cytotoxic chemotherapy; prior antibiotic therapy; tracheotomies. The bacteria can be isolated the surrounding such as ventilator tubing, suction equivalent, water sources, spirometers, disinfecting solutions, hospital sinks and nebulizers. Legionella or Aspergillus The two most common microorganisms associated with ventilator-associated pneumonia and other healthcare associated pneumonia (HAP). The pathogens can arise secondary to environmental surrounding rather than from the patient's indigenous flora. Legionella growth is optimal at temperatures between 25° and 42°. Legionella species is found mostly aquatic environments. Legionella has also been isolated from evaporative condensers, cooling towers and heat portable water distribution systems. Transmission occurs through inhalation of aerosols. Consequences of VAP The consequences of varies between two episodes. Pseudomonas VAD is characterized by increased organ dysfunction. Patients with VAP do not develop systemic inflammatory responses. How to prevent VAP Prevention of ventilator-associated pneumonia focuses on reducing the risk of aspiration of oropharyngeal secretions, reducing the duration of mechanical ventilation, preventing gastric and pharyngeal colonization by microorganisms. The use of a sedation algorithm that adjusts both sedative and analgesic doses to enhance the intensive care unit environment's tolerance while at the same time maintaining wakefulness was shown to reduce the duration of mechanical ventilation (De Jonghe, 2005) Patients on mechanical ventilator sometimes aspire oropharyngeal secretions. Maintaining patients in semirecumbent position declines the likelihood of aspiration, and later the patient can develop pneumonia. Subglottic suctioning of secretions that pool above the endotracheal tube cuff can delay or decrease the likelihood of occurrence of ventilator-associated pneumonia. Reducing the time of mechanical ventilation in intubated patients by minimizing sedation and using spontaneous breathing trials may reduce the incidence of pneumonia. Other interventions aimed at preventing and controlling Ventilator-associated pneumonia is based on preventing and eradication oropharyngeal colonization by microorganisms. Oropharyngeal colonies can be destroyed with a topical antimicrobial paste. The paste should consist of colistin, gentamicin, and vancomycin. The paste to be applied after 6 hours can lower the incidence of ventilator-associated pneumonia by 10%. Oral application of topical chlorhexidine results to 30% relative reduction in the risk of ventilator-associated pneumonia. The performance of chlorhexidine may be better with 2% chlorhexidine solution than with preparations containing lower concentrations. There exists the claim that the routine use of chlorhexidine shows a little trend in the prevention of VAP, but evidence has increased indicating that it is more effective in patients with cardio surgical attention, at a strength of 2%. Oral care To effectively control ventilation-associated pneumonia, a comprehensive oral care regime should be followed. Which include deep suctioning every 6 hours, tooth brushing at least twice daily and oral tissue cleaning every 4 hours. With the adherence to the oral program, the incidence of the infections will reduce. Daily oral care with chlorhexidine has recently been added to the ventilator care options due to its preventive properties on the onset of gingivitis and dental plaques as proven by recent evidence (Institute for Health Care Improvement, 2012). Drugs and medications Antiseptics are antibacterial agents of a broad spectrum that control plaque formation and inhibit the growth of bacteria (Grap et al., 2004). Antimicrobial prophylaxis has been used to control oral and gastric colonization while maintaining the anaerobic intestinal flora untouched. Selective oropharyngeal decontamination and selective decontamination of the digestive tract are essential in the decrease of Ventilator associated pneumonia. The decontamination of the digestive tract selectively is not recommended because using the method routinely may increase the tendency of antimicrobial resistance (Collard, 2003 [M]). In an aim to prevent or delaying bacteria colonization of the oropharynx, Silver-coated endotracheal tubes have been studied as an option. They significantly reduce the instances of VAP (Dallas and Kollef, 2009). According to The Institute for Healthcare Improvement, (IHI) promotes the use of ventilator bundle that is a collection of care processes aimed at reducing the incidence of ventilator-associated pneumonia. The package consists of four elements, which are: maintaining the head of the bed elevated greater than 30°, readiness to wean and the daily interruption of sedation, peptic ulcer prophylaxis and deep vein thrombosis prophylaxis. Maintain gastric acidity to prevent VAP Gastric colonization with potentially pathogenic microorganism increases with the decline in acidic levels. Drugs used for the treatment of ulcers that alters gastric pH include H2 antagonists, antacids, and proton pump inhibitors. Sucralfate a gastric cytoprotective agent that promotes natural mucosa barrier is an alternative prophylaxis agent in preventing VAP. This medication increases bacterial colonization into the gastrointestinal tract and may significantly increase the risk of VAP. Future directions New innovative methods of preventing and controlling VAP should be investigated. The Development of new and more effective antimicrobial agents. That prevents adhesion of microorganisms like pathogenic bacteria to the gastric mucosa and oropharyngeal. This will help control the incidence of VAP. Contradictions and inconsistencies in Prevention of Ventilator-Associated Pneumonia in Adult Intensive Care Unit Research analyzing the effectiveness of chlorhexidine in reducing VAP suffers from a number of methodological issues. Currently, the recommended chlorhexidine concentration chlorhexidine for use in patients is 0·12%, and there is the need for revision of the indicating guidelines (Institute for Health Care Improvement, 2012). Contrasting the statement above, Pileggi et al. (2011) showed a significant 31% reduction in VAP when using the lowest chlorhexidine concentration but with lower levels of efficacy in non-specialized intensive care units (ICUs). The effectiveness of 0·12% chlorhexidine formulations remains equivocal with studies reporting the absence of effect, reductions as well as upsurges in anaerobic Gram-negative bacilli. Formulations of 0·12% chlorhexidine at frequencies reaching three times per day come out to be uniformly ineffective (Lam et al., 2012). The possible explanation for these inconsistencies is inadequate research on the recommended effective concentration ratio of chlorhexidine. Proper analysis and evaluation concerning this issue should be adequately worked upon. Preliminary Conclusions The evidence in the literature review provides sufficient proof to conclude that there is the need to change the various nursing practices and abide by the above literature in order to prevent and control ventilator-associated pneumonia (VAP). Literature Review Summary Table The most effective way for preventing VAP is by mechanical ventilation and decreasing the duration of intubation (Rebmann and Greene, 2010). ISSUE INFORMATION REFERENCES Mortality and morbidity of ventilator-associated pneumonia Mortality of VAP ranges from 25%-76%. Richard D. Wunderink, Jordi Rello. ( 2001). Ventilator-Associated Pneumonia. New York: Springer science+ business media Underlying conditions which leads to development of VAP Age, immune incompetence presence of rapidly fatal disease Richard D. Wunderink, Jordi Rello. ( 2001). Ventilator-Associated Pneumonia. New York: Springer science+ business media Microbial etiology of VAP Entero-bacter species, S. aureus, P. aeruginosa, Klebsiella species, Acinetobacter species, and S. marcescens. Burkholderia (Pseudomonas) cepacia, Xanthomonas, Legionella or Aspergilus Keith Kaye. (2014). Infection Prevention and Control in the Hospital, An Issue of Infectious. Detroit: Elsevier Health Sciences. Consequences of VAP Increased organ dysfunction, lack of systemic inflammatory responses How to prevent VAP Reducing the risk of aspiration of oropharyngeal secretions, reducing the duration of mechanical ventilation, preventing gastric and pharyngeal colonization by microorganisms. Craig L. Scanlan, Albert J. Heuer. (2013). Comprehensive Respiratory Therapy Exam Preparation Guide. Burlington: Jones & Bartlett Publishers Inconsistencies in prevention of VAP 2% chlorhexidine solution considered effective. Keith Kaye. (2014). Infection Prevention and Control in the Hospital, An Issue of Infectious. Detroit: Elsevier Health Sciences. What is the most effective intervention to decrease VAP in terms of using antiseptic chlorhexidine oral care versus standard toothbrush oral care? The significance of the findings from these questions to nursing practices is that the nurse will acquire knowledge on how to prevent the occurrence of ventilator-associated pneumonia and gain the best expertise in providing best possible healthcare services. Some of the evidenced based protocol includes the use of antiseptic rinse, brushing teething teeth at least twice daily (after 12 hours) and use of oral swabs every 4 hours. Deep oral pharyngeal suctioning every 12 hours ventilated neuroscience patients. Summary of Findings: Articles in Literature Review VAD is a nosocomial infection that is associated with significant mortality and morbidity. It is also linked to increased length of stay and consequently increased costs of treatment.VAD mortality rates have been very high 30-70% and may account for 15% of all deaths in ICU. VAP mostly arises from exposure to environmental pathogens such as Aspergillus, Xanthomonas, Acinetobacter spp, Pseudomonas. Frequently the infection comes from the patient’s indigenous flora. This text reviews most aspect pertaining ventilator-associated pneumonia. This article addresses the mortality and morbidity of ventilator-associated pneumonia. It probes the underlying conditions, which leads to the development of VAP, microorganisms associated with VAD and association between septic shock and VAP. It furthure enquires how to prevent VA, the appropriate management of VAP and its emerging issues. Prevention, which is the key aspect in the management and control of VAP, has several points. The points focus on reducing the risk of aspiration of oropharyngeal secretions, reducing the duration of mechanical ventilation, preventing gastric and pharyngeal colonization by microorganisms. VAP is the most formidable of all infections that are dealt with in ICU and needs aspect in the multi-faceted approach. A nursing practice supported by the evidence in the articles Based on the principle of physiological, behavioral and biological aspect in the literature review seen in above the performance of activities requires substantial specialized skills, knowledge and sound judgment. The nursing practice supported by the evidence in the article is the positioning of the patients in ICU with an aim of preventing or delaying the onset of VAP. Elevating the bed head between 30°- 45° unless contraindicated reduces the incidence of VAP significantly. This is also in line with The Institute of Healthcare Improvement (IHI) VAP bundles. How the identified evidence-based practice contributes to better outcomes and how potential adverse outcomes could result from the failure to use the evidence-based practice Patients on mechanical ventilator sometimes inhale oropharyngeal secretions or inspiration of gastric reflux contents after gastrointestinal reflux. Maintaining patients in semi-recumbent position declines the likelihood of aspiration secretions being retained in the pharynx, and the mouth will be reduced. Failure to do so increases the incidence of not only acquiring VAP but also other severe bacterial infections. Increased length of stay in hospital and consequently increased costs of treatment. Strategy for disseminating the evidence-based practice of elevating the bed’s head to prevent occurrence of VAP The incorporation the findings in medics organized seminars and workshops so that the information be made known. Adding the information to the nursing guidelines practice manuals. Teaching the findings in nursing and medical institutions. Organizing update talks with medics to make them familiarize with the new information. How to communicate ‘the importance of elevating the bed’s head to prevent VAP’ with colleagues. There are several avenues useable in communicating the importance of the above practice. They include one to one communication, lecturing, giving out fliers containing the information, organizing a health talk, etc. How to move from disseminating the information to implementing the evidence-based practice within the organization Implementation of the new updates is by ensuring all beds in the critical care unit section are functional and can be adjusted to raise and elevate the patient's head any angle. Elevating all bed head by 30°- 45° of all patients in ICU as long as there is no contraindication that can bring other medical complications. How to address concerns and opposition to the change in practice Concerns arising from the change in practice can be addressed appropriately by consulting the person in charge for information update for clarification of the same. Giving references so that one can check on more information on the topic Opposition to the change in practice can be addressed by explaining the importance of the new practice based on evidence. Involving the responsible groups in all processes before and during implementation can also be used to tackle the opposition. References Andrews, Tom; Steen, Colin. (2013). Nursing in Critical Care. 18 (3) 116-122. 7. Bekaert M, Timsit JF, Vansteelandt S, Depuydt P, Vesin A, ´ Garrouste-Orgeas M, Decruyenaere J, Clec'h C, Azoulay E, Benoit D. (2011). Attributable mortality of ventilator associated pneumonia. A reappraisal using causal analysis. American Journal of Respiratory Medicine, 184, 1133–1139. Craig L. Scanlan, Albert J. Heuer. (2013). Comprehensive Respiratory Therapy Exam Preparation Guide. Burlington: Jones & Bartlett Publishers Dodek P, Keenan S, Cook D, et al. (2004). Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Int Med. 141, 305-13. D. Wunderink, Jordi Rello. ( 2001). Ventilator-Associated Pneumonia. New York: Springer science business media. Hixson S, Sole ML, King T. (1998). Nursing strategies to prevent ventilator-associated pneumonia. AACN Clin Issues 9,76-90. Keith Kaye. (2014). Infection Prevention and Control in the Hospital, An Issue of Infectious. Detroit: Elsevier Health Sciences. Kress JP, Pohlman AS, O'Connor MF, Hall JB. (2000). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 342, 1471-77. MH. (2004) .Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. 32, 1396-1405. Vincent JL. (2003). Nosocomial infections in adult intensive-care units. New York: Lancet. Safdar N, Crinch C, Maki DG. (2005). The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Respiratory Care, 50, 739–741. Yao LY, Chang CK, Maa SH, Wang C, Chen CC. (2011). Brushing teeth with purified water to reduce ventilator-associated pneumonia. The Journal of Nursing Research, 19, 289–296. Read More