Treatment Of Ventilator Associated Pneumonia Research Papers Example

Treatment of Ventilator Associated Pneumonia 5 pages – 1375 words

Ventilator-associated pneumonia (VAP) is a nosocomial infection developing in the lungs of a patient receiving assisted breathing from a ventilator (CDC.gov, 2015). Oxygen is generally delivered through a tube in the nose, mouth, or a tracheostomy. The infection is a result of contamination from the tubing, although not necessarily from initial insertion. Ventilator associated pneumonia is the most frequently occurring nosocomial infection in intensive care units.
There are several methods for attempted prevention of VAP. These include elevation of the head of the bed 30 to 45 degrees if patient’s condition allows, evaluation of ability to independently breathe daily, hygiene by care staff, patient oral hygiene, and adequate cleansing or replacement of equipment between patient use
Treatment of VAP is use of antibiotics. Aside from administration of the medications as prescribed by the physician, nursing staff assists with treatment by maintaining adequate hygiene with hand-washing as dictated by hospital policy. However, the topic of the most effective oral hygiene measures has been explored extensively in studies and publications. Dental biofilm production increases secondary to decreased salivation and absence of chewing activity. The purpose of this paper is to conduct a literature review to determine the best outcomes for patients with a diagnosis of ventilator associated pneumonia in terms of oral hygiene. In addition, data will be assessed supporting a hypothesis that including an oral rinse of 0.12% chlorhexidine gluconate to tooth brushing decreases incidences of VAP while assisting in the treatment of existing VAP. It is thought that manual cleaning with swabs soaked in the chlorhexidine rinse in combination with suctioning promotes bacterial removal from the buccal cavity through antibacterial action against both gram-positive and gram-negative organisms.

Literature Review

Studies concerning the effectiveness of oral hygiene in the reduction of ventilator associated pneumonia include references to staff compliance. O'Keefe-McCarthy, Santiago, and Lau (2008) conducted an entire study based on the aspect of oral hygiene in patients with VAP and that research is discussed in this paper. Lawrence and Fulbrook (2011) conducted reviews of two literature reviews and ten research studies to conclude that bundles of oral hygiene measures are recommended for the population studied. Silva, Nascimento, and Salles (2012) conducted studies using various combinations of oral care approaches and coordinated the results with interviews from nursing care staff. The results lead to the same recommendations as the studies previously cited. Nicolosi, del Carmen Rubio, Martinez, Gonzalez, and Cruz (2013) found that the incidence of developing VAP was three times greater in the control group of historical patients not receiving care with chlorhexidine drenched swabs than the patients that did. Roberts and Moule (2011) addressed different types of oral solutions including water, colistine, and chlorhexidine. The results with the use of chlorhexidine were judged to be best. Majid et al. (2011) also conducted a study addressing the use of chlorhexidine drenched swabs and concluded brushing with chlorhexidine was the protocol recommended .

Methods

Design
The study conducted by O'Keefe-McCarthy (2010) collected data from October 2008 to December 2009. Approval was received from the Ethics Committee of the single Pennsylvania hospital used. The design also included placement of signs reminding staff of compliance and staff education. The compliance goal was 100% with reduction of the incidence of VAP in the adults in Intensive Care Units on ventilators to 0. The hospital used for the study had 105 nurses in the ICUs and 4709 ventilator days were used. The design was non-experimental, pulling data from previous patient information and comparing it to data resulting of inclusion of an oral rinse of 0.12% chlorhexidine gluconate to tooth brushing. The information was statistically analyzed quantitatively with Fisher’s test and Chi square test.

Population and Sample

The population of the study was adult patients in the single Pennsylvania hospital ICUs on ventilators. The general population of the hospital is not appropriate for this study as the definition of the infection is a nosocomial lung infection contracted after the patient was placed on mechanically assisted ventilation. Patients on ventilators are usually cared for exclusively in the intensive care units of health care facilities. Children were not included in the same population as the variables contributing to the development of VAP and response to oral hygiene are different from those of adults and outside the scope of the studies.
Reliability and Validity The quantitative researcher attempts to place collected data into categories for analysis (Golafshani, 2003). The purpose is to apply the conclusions to a wider and similar population. Through the use of standardized measures and research design that allows for replicable studies with confirming results, the reliability and validity of the research is verified. In the case of the research conducted regarding the effect of oral care on adult ICU patients on mechanically assisted ventilation, the literature supports the reliability and validity of the findings of the articles reviewed. Results and Discussion
With satisfactory compliance rates as reported by the compliance team, the rate of pneumonia decreased from 9.47 cases per 1000 days of ventilation to 1.9 cases in the O'Keefe-McCarthy et al. (2008) study. In addition to the decreased incidences, recovery was notable faster than in cases historically recorded.
The study conducted by Majid et al (2011) also supported these findings although the data was analyzed with Morse and Field's reference framework. This study also addressed application on a basis of three times daily.
Several of the research studies not included in the review addressed the importance of nursing compliance. This is an important variable in the incidence and recovery from VAP within the population studied. The research conducted by O'Keefe-McCarthy et al. (2008) did include this variable in their design and was the reason it was the study primarily addressed in this paper. Strengths and Weakness
The strengths of the study by O'Keefe-McCarthy et al. (2008) were that an interdisciplinary team was used, there was an implementation of bundled services with oral hygiene, independent audits by a compliance team were used, and feedback was real-time. The use of a compliance team allowed an external control of nursing compliance apart from the use interviews when the variable was addressed in other studies. This verification added more reliability than self-reporting or simple documentation in patient records.
A limitation of the study was that the population, being all adults in the ICUs on ventilator assistance, was not prospective randomized case control. The ability to address this factor is beyond the ability of the study given the definition of the infection, that being a hospital-acquired lung infection for a specific type of patient in a specific area of the hospital. Moral limitations preclude excepting some patients from treatment while incorporating treatment for others. This reason prompted comparison of statistics prior to change in oral hygiene protocol. Significance to Nursing
The significant to nursing staff was that compliance resulted in measurable reduction of morbidity and mortality. Apart from addressing possible change in hospital policy using the results from the study, the importance of compliance is explicit in the attainment of the favorable results recorded. Conclusion
In conclusion, the hypothesis that inclusion of a 0.12% chlorhexidine gluconate rinse to documented routine oral care that includes tooth brushing both decreased the incidence of VAP while assisting the recovery from existing VAP. The conclusion is based on the various research articles included in a literature review involving variables involved in rates of VAP development and treatment.
Patients required ventilator assisted oxygenation are already in a state of morbidity that additional body resources for fighting VAP could mean the difference between life and death. By nursing compliance with hospital policy concerning use of oral hygiene consisting of manual brushing with swabs containing a 0.12% chlorhexidine gluconate rinse in conjunction with frequent suctioning, the outcome for the patient is improved. A professional nurse can use this information in evaluated the current oral hygiene policies of his or her place of employment; if they do not include the variables of the studies, recommendations and actions addressing policy changes may be appropriate.
Additional research for comparison of patients meeting the criteria previously treated in the ICU of the facility with those treated with the changed protocol can be conducted for confirmation for another facility. Unforeseen variable may influence the outcome of the study. Also, research is recommended for gathering data for recovery from VAP separate from incidences of development of VAP. Review of the literature failed to discern the differences.

References

Cdc.gov. (2015). CDC - VAP FAQs - HAI. Retrieved 9 February 2015, from
http://www.cdc.gov/HAI/vap/vap_faqs.html
Golafshani, N. (2003). Understanding Reliability and Validity in Qualitative Research. The
Qualitative Report, 8(4), 597-607.
Lawrence, P., & Fulbrook, P. (2011). The ventilator care bundle and its impact on ventilator-
associated pneumonia: a review of the evidence. Nursing In Critical Care, 16(5), 222-234. doi:10.1111/j.1478-5153.2010.00430.x
Roberts, N., & Moule, P. (2011). Chlorhexidine and tooth-brushing as prevention strategies in
reducing ventilator-associated pneumonia rates. Nursing In Critical Care, 16(6), 295-302. doi:10.1111/j.1478-5153.2011.00465.x
Silva, S., Nascimento, E., & Salles, R. (2012). Bundle de prevenção da pneumonia associada à
ventilação mecânica: uma construção coletiva. Texto & Contexto - Enfermagem, 21(4), 837-844. doi:10.1590/s0104-07072012000400014
Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. (2011). Adopting
evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers. Journal Of The Medical Library Association : JMLA, 99(3), 229-236. doi:10.3163/1536-5050.99.3.010
Nicolosi, L., del Carmen Rubio, M., Martinez, C., Gonzalez, N., & Cruz, M. (2013). Effect of
Oral Hygiene and 0.12% Chlorhexidine Gluconate Oral Rinse in Preventing Ventilator-Associated Pneumonia After Cardiovascular Surgery. Respiratory Care, 59(4), 504-509. doi:10.4187/respcare.02666
O'Keefe-McCarthy, S., Santiago, C., & Lau, G. (2008). Ventilator-Associated Pneumonia
Bundled Strategies: An Evidence-Based Practice. Worldviews On Evidence-Based Nursing, 5(4), 193-204. doi:10.1111/j.1741-6787.2008.00140.x