VentilatorAssociated Pneumonia (VAP) is one of the most common infections thatare acquired through many ways and is particularly found in theIntensive Care Unit (ICU). One of the primary risk factors that leadto the development of VAP is the availability of an endotrachealtube. In many cases, the intubation process takes place in theemergency room (ER), pre-hospital, and in the operation room. In thecurrent world, VAP has been directly associated with the increasedcosts and prolonged hospital stay. Numerous evidence-based guidelines(protocols and procedures) have been put in place to minimize theoccurrence of VAP and reduce the mortality rate of the patients.Preventive measures have also been implemented in the ICUs after thetransfer of the patient. The primary purpose of this research is toexamine the effects of the staff-training program on VAP, how toprevent it (prevention),pathophysiologyof the disease,symptoms,diagnosis,treatment,statistics,impact,and frequencyof VAP.
ProblemStatement and Statistics
Healthcare-AssociatedInfections (HAIs) have represented a high percentage of the financialburden and contributed to the huge costs of healthcare. The studiesshow that the average hospital cost in the United States due to HAIsranges from 30.8 to 36.9 billion dollars (Chalmersel, 2014).The Center for Disease Control and Prevention (CDCP) described HAIsas the disease that patients need high attention duringhospitalization while being in treatment. So far, CDCP has identifiedfive HAIs that include Catheter-Associated Urinary Tract Infection(CAUTI), Central Line Associated Bloodstream Infection (CLASBI),Clostridium Difficile Associated Infection (CDAI), Surgical SiteInfection (SSI), and (VAP).
Hospitalstaff has a direct impact on the patient care results as far as HAIsis concerned, embracing VAP, and inadequate currentprotocolsand procedures used to prevent contraction of VAP infection. TheInstitute for Healthcare Improvement (IHI) came up with theventilator bundle constituting interventions whose main objective isto reduce the VAP incidences, such as oral care with about 0.13%chlorhexidine, 30 to 40 degrees of elevation of head in bed,administration blockers, prophylaxis of vein thrombosis, vacation ofdaily sedation, and subglottal suction. The education of the hospitalstaff concerning these interventions and procedures has depicted apositive effect in the process of reducing the incidents of VAP(Marik,2006).
IncreasedER duration has led to delays in commencing the preventive measuresin the VAP patients. The role of ER and ICU nurses is to treatpatients, move the patients to the conditioned rooms, and stabilizethe worse conditions of VAP. Moreover, protocols and procedures areinitiated in the ER before the transfer of the patients to thenecessary level of care. Today, there is the little existence of theliterature pertaining early initiation of VAP preventive measuresstarting in the ER. In this study, the researcher interviewed severalER nurses and the hospital staff at large and established lack ofseriousness in following the protocols and procedures that have beenput aside to prevent VAP.
Theresearcher conducted a literature review using the following websitesand Database: CINAHL, Up-to-Date, IHI, CMS, PUBMED, and Proquest. Inthe study, the keywords included VAP, ER, ICU, preventive measures,staff’s knowledge, protocols and procedures of VAP. The articlesand journals used were published within the past 15 years.
Thecost of health in the US has been the talk of every part of thatcountry for many years. Infections associated with health are themajor sources of the increased human and material costs in the USdespite the developed protocols and procedures in an attempt todecrease the HAIs incidents. VAP is one of the HAIs that takes placein mechanically and intubated ventilated patients. The wide spread ofVAP in the US is controversial because there is an insufficiency ofrational definitions and standardized diagnostic criteria. VAP hasbeen evaluated as the first most common HAI and accumulates anadditional $60,000 to the total costs and secondary to increasedduration of hospital stay and treatment. The VAP occurrence averagesat 13-16% in intubated patients who receive mechanical ventilation.VAP is classified as early and late onsets. The early onset takesplace within 50-70 hours after intubation, and the late onset occursafter 70 hours. The appropriate average diagnosis time is estimatedto be three days.
Althoughprotocols and procedures have been published, most of the hospitalstaff members are not ready to use them perhaps because of lack ofknowledge of their presence. Also, some nurses lack the knowledgethat is related to such evidence-based guidelines and protocols,which may lead to non-adherence of the rules and regulations. Thehealth service providers have a direct impact on the occurrence ofthe HAL and VAP in particular. They have the ability to perform therecommended pharmacological measures and preventions independently.Interventions such as oral care with about 0.13% chlorhexidine, 30 to40 degrees of elevation of the head in bed, administration blockers,prophylaxis of vein thrombosis, vacation of daily sedation, and subglottal suction are some of the frequent tasks that should be carriedout to the ventilator patients. In some cases, the nurses performingsuch measures are not aware of the scientific reasoning. For thisreason, following the protocols and procedures and educating nursesto help them to deliver optimal care to the ventilated patients.Moreover, adherence to the institutional protocols and procedures forVAP prevention is the chief factor that creates the required impacton the occurrence of such fatal disease.
VAP,as an HAI, is mainly wreaked by the presence of Endotracheal Tube(ETT). ETT can be placed either, during surgery, pre-hospital, or inthe ICU. The reason for the placement of this tube is to help themaintenance of the airway. Intubation, one of the risk factors, is aninvasive procedure, and it exposes the patient to the development ofHAI. Intubation process decreases the natural response of thepatient’s body to the infection by disturbing the capability ofinitiating a gag reflex that helps in dispelling the secretion ofhormones in the body and as a result, the hormone secreted stagnantaround the posterior part of the pharynx and finally micro-aspirationensues. The inflation of the ETT cuff is not the major action thatcan prevent the process of micro-aspiration. It does not preventbecause there is a small tunnel that enables the easy and quickleakage of secretions from the glands to where they are used (Yakoub,2008).
Researchershave identified that the polyvinyl surface of the ETT has contributedto the secondary colonization of severe bacteria that is calledbiofilm (Webb,2014).The correct definition of this term has created an immensecontroversy among the scholar whereby some say that it is the clusterof microorganisms bundled together in the material that containsproteins, DNA, and polysaccharides that establish the mechanicalscaffold around such living organisms (Fein,2006).Biofilm forms very fast within the duration of intubation. Positivepressure and suction from the mechanical ventilation leads todetachment of bacteria from the ETT and moves to the interior sectionof the lower respiratory tract. Some of the pathogens that lead toVAP include Enterobacteriaceae, Acinetobacter baumannii, Pseudomonasaeruginosa, Candida albicans, and Enterococci. Some pathogens can beidentified by culture from secretions, the trachea, and the ETT.Acinetobacter baumannii, Pseudomonas aeruginosa are highly infectiousbacteria that are directly related to the increased rates ofmortality among the intubated patients. Treatment and early discoveryof VAP can diminish the length of hospital stay, patient mortality,and morbidity (Yunen& Frendl, 2012).
Oneof the US national patient safety objectives is the reduction of VAP.In the current conditions, there is no steadfast standard for VAPdiagnosis, as due to this, multiple criteria and definitions havebeen developed through the year. Such lack of reliable standard ofdiagnosis of VAP has created a significant variability in the ratesof VAP among the health care contexts. The recommendations about thereliable criterion from the CDC that comprises of the clinicalpresentation, diagnostic results and the laboratory regulations havebeen printed in several books (Pramuan,2011).
Therates of VAP vary according to the criteria that the nurses usedduring the diagnosis stage. The clinical criteria depend on twopositive results from the following signs and symptoms: fever shouldbe greater than 38 degrees, leucopenia (Increased or decreased whiteblood cell count), and infectious secretion combined with theoutcomes of the x-ray covering the chest part. Microbiology isanother method that can be used in the diagnosis of VAP based on thebroncho-alveolar lavage findings. New infiltrates that are absentbefore intubation forms the important part of the diagnosis criteriato justify the presence of VAP. However, some chest x-rays may lackspecificity because some conditions, such as congestive heart attack,atelectasis, and pulmonary embolism can impersonate an infiltrate.Most of the health organizations like CDC are striving to change thesurveillance definitions of VAP. The following part of literatureexplores various diagnostic criteria that are currently used bydifferent institutions and ICUs.
Hollander& Tytgat(2005) performed a literature review regarding the diagnosis of VAP.In the study, about sixty-five articles and journals that werepublished between 1967 and 2008 met the intended requirements of thestudy. The main objective of the study was to compare differentdiagnosis criteria in the ICUs. In the research, the primary focuswas the clinical diagnosis, biomarkers of the patient responses, andthe microbiological culture concepts. The researcher scrutinized theclinical criteria, a quantitative culture that aims at assessing theaccurate diagnosis of VAP, and the bacteriologic data. In theresearch, it was concluded that there is no even one tool that was inthe study that can be used to diagnose VAP.
TheSystematic Inflammatory Response Syndrome (SIRS) is another methodthat has an extensive use in the ICUs in the process of VAPdiagnosis. SIRS is the technique that includes the temperatures thatare more than 38 degrees or less than 35 degrees, more than 90 beatsper minute in the matters regarding heart rate, 25 breaths per minuteregarding the respiratory rate, and white blood cells count thatshould range from 4000cells/mm to 12000 cells/mm. Clinical PulmonaryInfection Score (CPIS) is another criteria used in VAP diagnosis thatis based on other six criteria. Such criteria include trachealaspirates, fever, oxygenation, radiographic infiltrate, leukocytosis,and semi-quantitative cultures (Moriartyel, 2013).
BetweenJune 2010 and January 2011, the mechanically ventilated patients’database was used to in Virginia to perform a retrospectiveevaluation. The main objective of this study was to evaluate variouscriteria that are used in the diagnosis of VAP by the bacteriacontrol committee and the trauma services. The trauma servicediscovered VAP after using the SIRS criteria. On the other hand, thebacterial control committee diagnosed VAP based on NNIS criteria. Theresults of the research showed that the NNIS criteria led to theincidents of VAP under-reporting. The study included some limitationswhere it was conducted in only one institution. The rates of VAP werenot calculated in per 100 ventilator days, and the x-rays presentedwere not standard, which is one of the algorithms in NNIS (Torres& Menendez, 2008).
Inrecapitulation, the gold standard for the diagnosis of VAP has notbeen reached upon, but several diagnostic tools available haveprovided a worthwhile contribution to the process of diagnosing VAP.VAP through clinical diagnosis has led to increased usage ofantibiotic therapy that can cause a Multiple-Resistance Drug Therapy(MRDT). In the cases of high suspicion of the patients with VAP basedon the clinical results, more examination with diagnostic culturesand tests should be carried out to help the justification ofdiagnosis.
ICUs,ER, and VAP
VAP’simportant care interventions commence right from the Emergency roomand the protocols and procedures for various conditions are put inplace for the patient. If early interventions are conducted, themortality rate and ICU duration are highly decreased. InHui el (2016)reviewed a journal regarding the application of protocols andprocedures to reduce VAP, with his major goal being to evaluate theimportance of early intervention of VAP in the ER. He found out thatthere is a need of initiating early intervention in the ER, includingoral care with about 0.13% chlorhexidine, 30 to 40 degrees ofelevation of the head in bed, administration blockers, prophylaxis ofvein thrombosis, vacation of daily sedation, sub glottal suction, andprophylaxis of ulcers. He also gave the evidence that supports hisargument about how ER creates a direct impact on the mortality of VAPpatient. However, there are no studies that give the rationalevidence whether such early interventions in the ER decrease the VAPincidences (Soleel. 2013).
Traumapatients are highly vulnerable to high-stake patients for VAP. Inmany cases, trauma patients are emergently intubated in theprehospital environments or the ER. The research that carried out byMcCance& Huether (2014) accomplishedthe study about the retrospective case-control of such patients andhow they are exposed to VAP. The research was carried out at a660-bed level 2 trauma health care center in Philadelphia. The aim ofthe study was to examine if the prolonged duration in the ERincreased the risk for VAP individuals. The study also evaluated therelationship between the length of time in the ER and ICU (Vincent,2010).VAP was observed in the patients with fever that was greater than 38degrees Celsius, chest x-rays that confirm infiltrate, andleukocytosis. The patients included in the study confirmed that theyhad experienced blunt trauma that needed an agent intubation.Clinical and demographic data collected included gender, age, headinjury score, chest injury score, and injury severity score (N=150).
Evidence-basedGuidelines and Protocols
Thedevelopment of evidence-based Guidelines and protocols aimed atdecreasing the rates of HAI, optimizing the outcomes of the patients,and provision of optimal care to the VAP individuals through the bestresearch present (Marti& Ewig, 2011).The Institute for Health Improvement (IHI) provided the ventilatorguidelines that originally had four evidence-based interventionsproven to decrease the VAP incidents and other HAIs like a vacationof daily sedation, subglottal suction, and prophylaxis of ulcers.Oral care was added later to the list because the dental plaque hashighly contributed to the risks of VAP. The other measures that wereincluded in such procedures and protocols are hand-washing protocoland the tools used for staff feedback. Because VAP is a conditionthat can be reported, The Joint Commission (JC) is advising hospitalsto ensure that they have embraced the necessary procedures andprotocols. However, due to the increased costs of the exceptionaltools, that is, subglotting suctioning, many hospital amenities andfacilities have not adopted the whole procedure (Rello,2007).
Loeb& Smieja(2009) conducted a retrospective study from August and October 2010(control group)and August through October 2011 (experimental group) with the mainpurpose of measuring the rates of VAP after the introduction of theevidence-based guidelines and protocols. Implementation of theinterventions as part of the research included washing hands, anincrease of HOB to 30 degrees, checking the angle and direction ofthe ventilator tubing for adequate condensation, sedation vacation,breathing trials, ulcer and DVT prophylaxis, and oral care. In thestudy, VAP was observed as a new consolidation on x-ray from thechest in conjunction with the temperature that is greater than 38.7degree Celsius, the white blood cells of count that was greater than10000 cell/mm, and the pathogens from bronchus. In this case, thecontrol group constituted thirty-eight patients that received thenormal care. Moreover, there was an intervention in the educationalbackgrounds of the nurses that comprised of online learning (Marrie,2001).
Apartfrom intubation, VAP has other risk factors that include lungdiseases, trauma, neurologic disease, modifiable risk factors likewhether the head of the bed is raised or flat, whether the patientexperience some aspiration event before intubation and other factorslike prior exposure to antibiotics. Individuals in the ICU for headtrauma, neurologic disease, and penetrating trauma are at a high riskof developing VAP. Moreover, patients who have been admitted forblunt trauma are vulnerable to the development of VAP compared to thepatients suffering from penetrating trauma.
Individualson mechanical ventilation are usually sedated and cannot be able toconverse with any person. Because of this reason, most of the typicalsymptoms of are either unable to beobserved or are absent. The following are some of the signs that canbe easily observed by the person suffering from Ventilator AssociatedPneumonia.
Fever:It is also called febrile response or pyrexia. It is defined ashaving the temperature that is higher than the normal range becauseof an increase in the set point of the body temperature. Fever isusually caused by several medical conditions that range from not direto potentially dire. Such conditions include bacterial, viral, andtract infections. Because VAP is a bacterial disease, should not beastonishing when the patients develop the temperatures higher thannormal. In the case of VAP, the temperature recorded are normallymore than 38.7 degrees Celsius (Wilde,2009).
Hypothermia:It is the condition where the body temperature is below 36 degreesCelsius. In the case of small hypothermia, the Ventilator AssociatedPneumonia patient shivers and they become mentally confused. In highhypothermia, the patient develops a paradoxical undressing, thesituation where the person removes their clothes. Therefore, theperson suffering from VAP can be in the hypothermia condition.
Hypoxemia:It is the medical conditions when a person has a low level of oxygenin their blood. Apart from causing VAP, hypoxemia also causeshypoxia. However, hypoxia can be caused by other mechanisms likeanemia. A person suffering from VAP has low contents of hemoglobin intheir red blood cells. Such condition hinders some physiologicalprocess, such as gas exchange and respiration, in the human body. Onthe other hand, the immune system of the body is likely to beimpaired because the white blood cells have been reduced in number.Due to this condition, the VAP patients may develop other diseasesapart from VAP.
Treatmentof Ventilator-Associated Pneumonia
Thereare various principles applied when selecting the suitable therapyfor VAP. Such principles include knowledge of the living organismsthat are likely to be available, resistance pattern in the ICU, aRational Antibiotic Regimen (RAR), and a Rationale for AntibioticStoppage (RAS). Although the nurse can know the sensitivities andorganisms before the development of VAP, this is not the case. Earlyefficient VAP therapy is associated with reduced death rates. In thecase of VAP, the physicians are required to direct their antibioticcoverage and diagnostic bids at this disease. Treatment of VAPrenders two strategies to the clinician to manage such suspectedcondition. The first strategy is based on the clinical criteria, andthe other one applies the quantitative culture of in the respirationprocess of the specimens. The technique of quantitative culture canbe further classified into non-bronchoscopic and bronchoscopicstrategies.
Bronchoscopyallows the clinician to directly examine the respiratory secretionsfrom PSB, PTC, and BAL to establish the percentage of the body cellswith ICOs. Some adepts use such technique as the factor favoring thebronchoscopic strategy to the management of VAP over othertechniques. Although there is no clear evidence that quantitativecultures improve the VAP condition in patients, most clinicians usesthe quantitative culture technique to manage VAP. Because thequantitative culture shows the exact part of the body that does notreceive adequate blood as compared to non-quantitative culturetechniques, the nurse is confidently allowed to discontinue theissuance of antibiotics and to avert the VAP patient complications,including their bacterial resistance. Also, such strategy helps thenurse to carry out a thorough examination of VAP before giving out aprescription to the patient (Wunderink& Rello, 2001).
Preventionof Ventilator-Associated Pneumonia
VentilatorAssociated Pneumonia can be prevented if the people observe somesimple rules and regulations. Being vaccinated is one of the ways ofpreventing . People should get a flushot yearly to prevent influenza. The flu is one of the causativeagents of . VAP vaccine is alsorecommended for all adults with the stake of such disease. Anotherway of preventing VAP is a regular washing of hands with runningwater. People should wash their hands after diapering, blowing theirnoses, visiting bathrooms and toilets, and before preparing andeating food. Another preventive measure is avoiding smoking. Tobaccodestroys lungs and people smoking are vulnerable to VentilatorAssociated Pneumonia. Lastly, people should be aware of their generalhealth.
Impactsand frequency of
Therapid increase of the drug resistance among some pathogens that causeVAP have led to hospital mortality, longer stays in the hospital, andhigh healthcare costs. Due to this, the US government has used muchof its income to carry out the research on the techniques that shouldbe used to counter this problem. By so doing, most of its economicactivities are liable to be paralyzed due to the diversion of highfunds in the healthcare sector. High frequency of VAP has beenrecorded in southern parts of the US, such as Texas and Florida.Another impact of VAP is in the clinical activities. High capital hasbeen used by most of the health care in the US to train their staffmembers on how to follow the procedures and protocols that have beenput aside for easy treatment and prevention of VAP.
Sincethe primary purpose of this research was to examine the effects ofthe staff training program on the ICU nurses` skills of VAP, how toprevent it (prevention),pathophysiologyof the disease,symptoms,diagnosis,treatment,statistics,impact,and frequencyof VAP, it has come to a conclusion that most of the hospital staffdoes not follow the procedures and protocols as slated. VAP, as anHAI, is mainly wreaked by the presence of Endotracheal Tube (ETT).Intubation, one of the risk factors, is an invasive procedure, and itexposes the patient to the development of HAI. It decreases thenatural response of the patient’s body to the infection bydisturbing the capability of initiating a gag reflex that helps indispelling the secretion of hormones in the body and as a result, thehormone secreted stagnant around the posterior part of the pharynxand finally micro-aspiration ensues. The symptoms of VAP are hightemperatures, Hypothermia, and Hypoxemia.
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