Abstract
Ventilator-associated pneumonia is a common nosocomial infection that occurs in patients admitted to the intensive care unit (ICU). It is associated with increased mortality of up to 70%. VAP is defined as pneumonia that occurs 48 hours after admission in those patients put on mechanical ventilation. We elaborate the process of initiation through to implementation of VAP prevention protocols collectively referred to as the VENT bundle that entails procedures such as a change in the bed angle, sedation holiday, proper oral care, and prophylaxis against DVT and Gastrointestinal ulcers.
The systematic procedure of implementing the protocol is analyzed in detail from literature review, implementation of the protocols, and evaluation of the whole program to decision making regarding the outcome of the whole prevention program. The process is based on evidence-based protocols obtained through extensive research on programs aimed at the reduction of mortality rates associated with VAP in America.
Decision Making
Evidence shows that by implementing various strategies, VAP can be prevented resulting in decreased morbidity and mortality in those patients at risk. After initiation of the VAP protocol, there comes the need to freeze the current status quo and initiate a change mentality in all the stakeholders. To achieve this, the management needs to ensure that the healthcare team in the ICU is given Continuing Education (CE) on the Ventilation Acquired Pneumonia Prevention Protocol (VAPP). Furthermore, the hospital management should lay down procedures to follow when handling those patients that are at risk of VAP. To maintain adequate care, adequate staff needs to be employed to avoid job-related stress that may lead to laxity in the management of these patients hence putting them at risk of infection (Bouadma, Deslandes, Lolom, Le Corre, Mourvillier, Regnier, et al, 2010).
In addition, extending this program will need increased allocation of resources to the ICU in the hospital to ensure seamless management of patients at risk of VAP. Increased resources will ensure the staff is kept up to date with current evidence-based protocols in the prevention of VAP and are utilizing appropriate equipment in carrying out various duties such as brushing patients teeth aimed at preventing VAP (Bouadma, Deslandes, Lolom, Le Corre, Mourvillier, Regnier, et al, 2010). The program should be made part and parcel to any new nursing staff joining the team so that is well entrenched and passed over to the next generation of healthcare workers to ensure continuity in proper care.
Other risk factors associated with VAP should be mapped out and extension protocols formulated to ensure the continuity of care to those patients at risk. These include the period under which the patient is under mechanical ventilation, any form of antibiotic therapy instituted before admission, and any contacts within or without the hospital. With increasing research in the causative organisms of VAP, there is a need to lay down new protocols in terms of disinfectants used before and after making contact with the patient. All members working in the ICU should be trained and be fully versed with the pathogenesis of hospital-acquired pneumonia and its prognosis without proper intervention. This understanding of pathogenesis will be the guiding light in the formulation of proper working preventative strategies and policies. Comorbidity should be considered in designing additional protocols.
There may come a time when a program does not meet the set goals and fails to achieve the desired goals. In this case, if this program fails to prevent the occurrence of VAP in hospitalized patients on mechanical ventilation, it necessitates the need for review. The review process entails assessing each recommended procedure thoroughly to rule out loopholes that may be associated with failure (Escobar, Fireman, Palen, Gardner, Lee, Clark, et al, 2008).
This involves a thorough dissection of each procedure by both internal and external qualified health professionals to identify what went wrong with the program. After going through each stage, and identifying the root cause of the problem, appropriate measures are initiated immediately to correct the situation. Such measures may include re-training of personnel, change in equipment or even change in some protocols based on evidence through new research (Chastre, 2005).
The need for change should be impressed upon from the highest level of the organization through the involvement of all stakeholders from patients, nurses, and any other member of the healthcare team. Furthermore, newer advances in terms of evidence-based research need to be reviewed to facilitate the addition of more methods aimed at improving the situation (Escobar, Fireman, Palen, Gardner, Lee, Clark, et al, 2008). Healthcare workers should be immunized against conditions like influenza to reduce the risk of transmission of pathogens to vulnerable patients. The clinicians working in ICU should be continuously trained on proper medication use especially antibiotics such that strict policies are laid down to ensure narrow-spectrum antibiotics are used unless the situation demands broad-spectrum antibiotics. As such the risk of development of resistance is averted (Chastre, 2005).
In cases where the plan is deemed unsuccessful, after a thorough review of the process by qualified practitioners such as when the rate of patients developing VAP after admission increases instead of decreasing; an appropriate strategy needs to be followed in discontinuing the program (Bouadma, Deslandes, Lolom, Le Corre, Mourvillier, Regnier, et al, 2010). This will entail communicating information to all parties involved in the program explaining in detail the reasons behind such a move. At the same time, protocols that have worked before need to be initiated immediately. Furthermore, new research needs to be reviewed in preparation for initiating a new workable program (Chastre, 2005).
The further review should include research that showed high clinical significance rather than relying on data that shows statistical significance. Clinicians should aim at visiting other centers that have initiated similar protocols that have shown positive results and get to learn what is it that they are doing wrong and can be changed for successful implementation of the VAP prevention protocol (Escobar, Fireman, Palen, Gardner, Lee, Clark, et al, 2008).
After the failure is confirmed, there comes a need to re-analyze the protocols step by step with all stakeholders and identify points of weakness. Workable solutions need to be proposed as research projects for the future and the information submitted to peers in the field to be reviewed and disseminated to the wide healthcare community for further analysis. This can be done by publishing the information in reputable journals with high impact factors detailing the program, especially the drawbacks that may have led to the failure of the whole process, and asking for further review of the process to encourage the formulation of new policies and strategies (Chastre, 2005). Appropriate authorities should be notified of the failure of the program and any steps taken thereafter.
References
Bouadma, L., Deslandes, E., Lolom, L., Le Corre, B., Mourvillier, B., Regnier, B., et al. (2010). The long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Journal of Clinical Infectious Diseases, 51(10), 1115-1122.
Chastre, J. (2005). Conference Summary: Ventilator-associated pneumonia. Journal of Respiratory Care, 50(7), 975-982.
Escobar, G.J., Fireman, B.H., Palen, T.E., Gardner, M.N., Lee, J.Y., Clark, M.P., et al. (2008). Risk adjusting community-acquired pneumonia hospital outcomes using automated databases. American Journal of Managed Care, 14(3), 158-166.