Overview of the Problem
Ventilator-associated pneumonia (VAP) is a nosocomial infection that starts after 72 hours of endotracheal intubation of patients’ in intensive care units. This type of pneumonia is linked with a high mortality rate, increased cost of care, and length of hospitalization. The disease incidence in a critical care setting is about 65 %, it also increases the client’s stay in the hospital for about 4.3 days and accounts for an increase in mortality rates to about 70% from 20% (Álvarez-Lerma et al., 2018). Currently, this hospital-acquired disease is the leading cause of death for people discharged from intensive care units.
Star memorial hospital needs to adopt a ventricular bundle, the hospital has a capacity of 1000 patients and it has 18 beds in the intensive care unit. Approximately 80 % of patients in ICU are usually mechanically ventilated. Ventilator-associated pneumonia continues to be an important infection affecting critically ill patients in this hospital. This disease has increased morbidity, and mortality, thus, there is a need to implement evidence-based guidelines in critical care to reduce VAP incidence in the clinical setting.
Significance of Quality Improvement in the Organization
VAP has negative impacts on critically ill patients and is linked to the high cost of care. For this reason, its incidence should be reduced by creating a patient safety intervention to be deployed by health care professionals, patient care, and hospital leaders. A standardized care delivery model called the ventilator bundle, which combines several care delivery strategies for patient care optimization needs to be adopted. The bundle consists of five activities, which are daily goals, education, day to day management, team meetings, and structured oral care.
The inclusion of several interventions during implementation produces better outcomes as compared to one intervention. The ventilator bundle lays emphasis on a specific aspect of treatment required by the patient before initiating groundwork for the care team. It also improves guidelines and protocols to bring out ideal patient outcomes. The package activities are deep vein thrombosis prophylaxis, target head-of-the-bed (HOB) elevation, daily sedation vacations, structured oral care, peptic ulcer disease prophylaxis, and daily assessments for extubate. Expected outcomes include a reduction in mortality, morbidity, sedation days, length of hospital days, and reduction of patients in need of subsequent mechanical ventilation.
Evidence-based Healthcare
Evidence-based care is the explicit, judicious conscientious utilization of the most recent suggestion with a better outcome in making decisions for individual-based care. This practice has gained momentum in the healthcare system and it has forced nurses to update their skills and knowledge to augment a provider-client decision making process. There are six steps involved in the evidence-based practice which are; asking clinical guiding question, searching for evidence, critically appraising the evidence, integrating evidence with clinical expertise, evaluating the outcome, and disseminating the outcome.
The clinical guiding question for this initiative follows the PICOT format, which stands for the patient, problem of interest, intervention, comparison outcome, and finally time period. Thus, the focus question is: In critically ill patients admitted in ICU, is using a ventilator bundle efficient in reducing VAP complications such as increased morbidity, mortality, and length of stay in hospital as compared to one type of intervention over seven months period.
In the second step, the best evidence is tracked down, nurses and doctors assess the outcomes of a practice based on the ability to undertake routine activities and life quality. Evidence is obtained from the Cochrane Collaboration database and papers with systemic randomized control trials are reviewed. Prior to using the evidence, an appraisal is conducted to determine whether the evidences are valid followed by a meta-analysis of the results in the third phase.
The fourth step involves changing practice to align with the evidence and convincing staff to adopt the initiative. Patients admitted in ICU and interventions used on them are audited in the fifth stage to determine the success of the project. Outcome dissemination is the last step, it is done by making evidence-based protocols to be used as a reference in and out of the hospital. In addition, the findings are disseminated through lectures, conferences, manuscripts, and online media.
Previous Research Supporting the quality improvement initiative
Evidence of ventilator bundle’s effectiveness in controlling VAP has been demonstrated by Parisi et al., (2016). These authors examined the effects of staff education and VAP implementation on disease incidence, mechanical ventilation duration, length of stay in the hospital, and the period between incidences in the multidisciplinary intensive care unit. They discovered that VAP incidence and duration of hospitalization decreased in units using the ventilator bundle intervention.
A Meta-Analysis of published randomized controlled trials article conducted by Su et al., (2020) showed that probiotics are effective and safe in controlling VAP in patients who received mechanical ventilation. This is because the disease incidence reduced in the studies pooled, however, there was no significant difference in ICU mortality and the length of stay in hospitals between the patients using probiotics and those not. The results obtained from this research implies that one intervention is not effective in the management of VAP.
Oral cavity contamination increases the colonization of pathogens responsible for the dissemination of pulmonary infection such as pneumonia. In ICU, prophylaxis with topical antibiotics is used to induce bacteria resistance. Rabello, Araújo, & Magalhães, (2018) conducted seven systemic reviews on the prevention of ventilator-associated pneumonia using chlorhexidine. The drug is effective in controlling VAP in the cardiothoracic intensive care unit only. Thus, there is a need to include other interventions in intensive care units as a bundle.
Steps Necessary to Implement the Quality Improvement Initiative
The implementation process begins with planning for staff education, results tracking, data collection, outcome reporting, and creation of a team that will spearhead the initiative. The critical care nursing manager, medical director, chief quality officer, and nurse director are the key administrative champions that will supervise the project.
A goal sheet containing prioritized ventilator bundle interventions will be utilized each day in the intensive clinical care unit. In the daily rounds, the nursing care coordinator, nursing staff, and the attending physician will record the interventions used. The goal sheet aids in facilitating and tracking progress, encouraging fast response to arising patients’ problems and it also ensures that key issues are addressed. The sedation vacation will be effected by giving continuous sedation infusion when a patient is fully awake. However, in patients requiring continuous sedation after a vacation, the nurses will have to administer bolus sedation prior to restarting the infusion of sedatives.
Before executing the standardized care delivery process, staff will be familiarized with evidence-based information concerning VAP through training. Additionally, they will be introduced to the ventilator bundle and daily goal sheet in the staff meetings through on one sessions and poster presentations. Staff will be given a chance to voice their concerns and air their feedback on the initiatives during the meetings, which will take place weekly.
The ventilator bundle and daily goal sheet will be applied first on a few patients, it will then be refined based on the outcome through a plan do study act cycle. Thereafter, the goal sheet will be utilized during the daily nursing care routines. The program will be audited weekly by the quality data coordinator to track staff progress on bundle compliance and to address issues that may arise. Furthermore, an appraisal step will provide an opportunity for reinforcement, staff reeducation, and overall support.
Evidence and Rationale
Evidence suggests that oral care is critical in deterring pneumonia in an intensive care setting. Therefore, oral secretion decontamination and reduction of risk factors associated with VAP will be implemented. Good oral hygiene intervention using a structured oral care method done every 3 hours will be introduced to the bundle. In Intensive care unit, failure to utilize standardized processes in sedation, ventilator-associated pneumonia (VAP) prevention, blood transfusion, and venous thromboembolism (VTE) prophylaxis may result in poorer outcomes such as increased mortality and length of hospitalization. Thus, it is critical to implement all interventions that have been effective in controlling the nosocomial infection.
Evidence of effective interventions will be generated using the critical appraisal program. Additionally, credibility, and reliability of the indicators and articles used should be ascertained to ensure that the results used is valid enough for the new practice. It wise to adopt the ventilator bundle because it is cost-effective and simple to implement, in addition, this intervention has the potential of positively influencing the staff, patients, and hospital resources utilization. According to Parisi et al., (2020) study, the application of the package in a medical intensive care unit, resulted in the culture change that led to remarkable patients’ outcomes. Furthermore, the process of implementing a new protocol gave the healthcare team a sense of ownership and pride, which contributed to the success and quality improvement.
Process and Outcomes Measurement
The compliance rate will be utilized to indicate a ventilator bundle implementation degree, it will be calculated by dividing the number of all patients mechanically ventilated in the intensive care unit by patients under the ventilator bundle. The outcome measured in the intervention will include the rate of VAP incidence and the days between outbreaks. Reduction of VAP rate and increase in days between episodes after ventilator bundle implementation will signify the success of the initiative.
The quality improvement project targets ventilator-associated pneumonia, sedation, and length of stay in the hospital. The process will measure different variables such as the head of bed elevation, mouth care, early appropriate diagnostic measure and antibiotic therapy, compliance with individual processes, and daily interruption of sedative infusions. Descriptive statistics like standard deviation, means, and frequencies will be used to describe the population. Bivariate analyses such as chi-square statistics and Mann-Whitney U analyses will be utilized to compare the outcomes of the control group and that of patients undertaking ventilator bundle treatment. This quality improvement project hypothesis is: using a ventilator bundle is not efficient in reducing VAP incidence and other complications such as increased morbidity, mortality, and length of stay in the hospital.
References
Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., Álvarez-Rodríguez, J., Lorente, L., & Jam-Gatell, R. (2018). Prevention of ventilator-associated pneumonia: the multimodal approach of the Spanish ICU “Pneumonia Zero” program. Critical Care Medicine, 46(2), 181.
Parisi, M., Gerovasili, V., Dimopoulos, S., Kampisiouli, E., Goga, C., Perivolioti, E., & Nanas, S. (2016). Use of ventilator bundle and staff education to decrease ventilator-associated pneumonia in intensive care patients. Critical Care Nurse, 36(5), e1-e7.
Rabello, F., Araújo, V. E., & Magalhães, S. M. S. (2018). Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilator‐associated pneumonia in intensive care units: Overview of systematic reviews. International Journal of Dental Hygiene, 16(4), 441-449.
Su, M., Jia, Y., Li, Y., Zhou, D., & Jia, J. (2020). Probiotics for the prevention of ventilator-associated pneumonia: A meta-analysis of randomized controlled trials. Respiratory Care, 65(5), 673-685.