Ventilator associated pneumonia (VAP) is a nosocomial infection occurring in hospitalized patients who are mechanically ventilated. These infections are common in ICU settings, difficult to diagnose early, and unfortunately have a high rate of mortality and morbidity. VAP accounts for almost half of infections in ICU settings, up to 28% of mechanically ventilated patients will develop VAP and of these patients the mortality rate is between 20% and 70% (Craven & Steger, 1998). A patient that develops VAP while mechanically ventilated adds days to his recovery as well as thousands of dollars to the care costs.
Numerous studies have been conducted across the county in an effort to understand VAP, however very few of those studies focus on the nursing interventions that can prevent this deadly and costly nosocomial infection. Many of these studies focus on the “bundling” of certain interventions, so the question is does the implementation of a VAP bundle compared with the use of non-bundled interventions decrease the incidence of VAP in ventilated patients. The research that was found in nursing journals along with a related study from a medical journal follows.
Cason, Tyner, Saunders and Broome (2007) conducted a study of 1200 critical care nurses and the results demonstrate the variability in the recommended and reported care of the ventilated patient. Their study aims to identify the areas of needed improvement to comply with the CDC recommendations for prevention of VAP. The study consisted of a questionnaire distributed to nurses who attended the 2005 American Association of Critical Care Nurses National Teaching Institute, with the findings demonstrating a need for more education and research in the area of preventing ventilator associated pneumonia.
Ferrer and Artigas (2001) also noted the lack of compliance in even the most basic of preventative measures. The study focuses on non-antibiotic preventative strategies for VAP; they suggest the use of antimicrobial hand soap, clorahexidine oral rinses, stress ulcer prophylaxis, prevention of gastric over distension, providing adequate nutritional support as well as frequent position changes. The research also suggests that endotracheal tubes with an extra lumen designed to continuously suction secretions pooled above the endotracheal tube cuff would lower the incidence of VAP by reventing these secretions from being aspirated into the lower airway. The authors also suggest more research be done to further limit the number of patients who develop VAP. Siempos, Vardakas and Falagas (2008) found that after meta-analysis of nine published randomized controlled trials that a closed tracheal suction system has no benefit in reducing the incidence of VAP compared with an open tracheal suction system. The preliminary data suggests that a closed circuit would reduce the incidence of VAP, however the data and trials that were reviewed showed that there was no decrease in the rate of infection.
Due to the fact that a closed system can be used more than once, and only needs to be changed every 24 hours, it does tend to be more cost effective. Also of note, in two separate trials, a closed system was found to increase colonization of both the respiratory tract and the ventilator tubing. Obviously more research is needed to determine the best intervention when endotracheal suctioning is necessary. Ventilator associated pneumonia is both common and unfamiliar to nurses in the critical care setting, according to Labeau, Vandijck, Claes, Van Acken & Blot (2007).
They note that while nurses deal with VAP frequently their knowledge of the infection and preventative measures may be a reason that VAP is still so prevalent in the intubated patient. The research points to the idea that because many nurses are not responsible for the ventilator circuit; they rely on the respiratory therapist to manage the ventilator, they may be less informed than if they had more control and training in the interventions necessary to prevent VAP. The research suggests more training and education for nurses who work with ventilated patients.
Research done at the University of Toledo College of Medicine has shown a decrease in the incidence of VAP in its ten bed surgical ICU by implementing a “FASTHUG” protocol. Papadimos, et al, (2008) explained the interventions that the college used as a tool to educate the critical care team. “FASTHUG” stands for daily evaluation of feeding, analgesia, sedation, thromboembolic prevention, head of bed elevation, ulcer prophylaxis, and glucose control in critically ill intubated patients. The “FASTHUG” protocol was emphasized at morning and afternoon rounds and after a 2 year esearch period the incidence of VAP declined to 7. 3 VAPs/1000 ventilator days down from a historical rate of 19. 3 VAPs/1000 ventilator days. Of note, in 2007 the surgical ICU that implemented this program actually had no incidence of VAP from January to May. The research suggests that the use of bundled care processes for ventilated patients may reduce the rate of VAP. The nurse’s knowledge of the use of the ventilator bundle is crucial to the success of the protocol according to research done at the University of Texas.
Education sessions were held with pre and posttests administered as well as observation to evaluate the nurse’s understanding of the bundles. The VAP bundle focused on the elevation of the head of the bed, continuous removal of subglottic secretions, change of the ventilator circuit no more often than every 48 hours, and washing of hands before and after contact with each patient. The research done by Tolentino-DelosReyes, Ruppert and Shiao (2007) suggests that a lack of understanding and knowledge of VAP leads to a higher rates of infection.
Observation of the nurses in the study revealed that after the education sessions nurses demonstrated an increase in compliance with the established standards of care. Given the high mortality and morbidity of ventilator-associated pneumonia, compliance in the critical care unit is crucial to reducing the rate of VAP. The critical care nurse is vital to the prevention of VAP, and nurses need to initiate further research concentrating on education and prevention. References Cason, C. L. , Tyner, T. , Saunders, S. Broome, L. (2007) Nurses’ implementation of guidelines for ventilator-associated pneumonia from the Center for Disease Control and Prevention. American Journal of Critical Care, 16, 28-37. Craven, D. E. , Steger, K. A. (1998) Ventilator-associated bacterial pneumonias: Challenges in diagnosis, treatment, and prevention. New Horizons, 6(2). Ferrer, R. & Artigas, A. (2001) Clinical Review: Non-antibiotic strategies for preventing ventilator-associated pneumonia. Critical Care 2002, 6, 45-51.
Hunter, J. D. (2006) Ventilator associated pneumonia. Postgraduate Medical Journal, 82, 172-178. doi:10. 1136/pgmj. 2005. 036905. Labeau, S. , Vandijck, D. M. , Claes, B. , Van Aken, P. , Blot, S. I. & on behalf of the executive board of the Flemish Society for Critical Care Nurses (2007) Critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator- associated pneumonia: An evaluation questionnaire. American Journal of Critical Care, 16, 371-377. Morrow, L. E. Shorr, A. F. (2008) The seven deadly sins of ventilator-associated pneumonia. Chest, 134, 225-226. doi:10. 1378/chest. 08-0860. Papadimos, T. J. , Hensley, S. J. , Duggan, J. M. , Khuder, S. A. , Borst, M. J. , Fath, J. J. , Oakes, L. R. , & Buchman, D. (2008, February) Implementation of the “FASTHUG” concept decreases the incidence of ventilator-associated pneumonia in the surgical intensive care unit. Patient Safety in Surgery 2(3). doi:10. 1186/1754-9493-2-3. Siempos, I. I. , Vardakas, K. Z. & Falagas, M. E. (2008) Closed tracheal suction system for prevention of ventilator-associated pneumonia. British Journal of Anasthesia 100(3), 299-306. doi:10. 1093/bja/aem403. Tolentino-DelosReyes, A. F. , Ruppert, S. D. , Shiao, S. P. K. (2007) Evidence-based practice: Use of the ventilator bundle to prevent ventilator-associated pneumonia. American Journal of Critical Care, 16, 20-27. Ventilator-associated pneumonia. (2008). Critical Care Nurse. Retrieved from http://ccn. aacnjournals. org