Ventilator-associated pneumonia (VAP) is one of the most widespread hospital-acquired infections among American patients. VAP can cause increased mortality rates, length of stay, and health care costs both for the facility and the patient. However, there is no accurate reference definition of VAP, as it is usually suspected if the patient was intubated and ventilated within 48 hours before the onset of ventilation (Andrews & Steen, 2013).
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Other radiological, clinical, and laboratory characteristics are used for the diagnosis of VAP. In the following literature review, seven articles from the nursing journals (including Nursing in Critical Care, Critical Care Nurse, and Intensive and Critical Care Nursing) will be reviewed. All of the articles are no older than five years and were published in peer-reviewed journals.
The focus of the Review
The focus of the review is the prevention of VAP by various methods, including high-quality oral care, nursing knowledge and awareness, and a training program. The review aims to examine the findings of the researches and indicate what strategies are effective and how they can be implemented in clinical care. Additional attention will be paid to VAP in children and strategies for its prevention, as Cooper and Haut (2013) provide an evidence-based protocol for the prevention of VAP in the pediatric population.
Student’s interest in VAP can be explained by the high prevalence of the infection in hospital patients and its severe and adverse influence on the health care costs for patients and hospital facilities. Furthermore, VAP can also lead to fatal outcomes in 46% of patients (Sedwick, Lance-Smith, Reeder, & Nardi, 2012). It is possible that the reimbursement for VAP in hospitals will be discontinued; in this case, hospitals will face severe financial losses (Sedwick et al., 2012). Therefore, future and current nursing professionals need to pay particular attention to VAP and strategies of its prevention; if these strategies are followed, it is possible to significantly reduce the number of fatal outcomes in patients with VAP and hospital expenditures of those who acquire VAP during their stay.
Sedwick et al. (2012) provided a specific “VAP bundle” to hospital staff where the research was conducted and measured the effectiveness of these interventions. Compliance of 100% was reached for PUD prophylaxis, DVT prophylaxis, HOB elevation, daily interruption of sedation, and assessment of readiness for extubation (Sedwick et al., 2012). The protocols for oral care were followed less precisely and never reached 100%. Nevertheless, the use of the VAP bundle (strategies described above) resulted in increased hospital savings and better patient outcomes.
Other data is provided by Andrews and Steen (2013), who argue that mechanical hygiene and oral decontamination are effective, whereas electronic tooth brushing is more effective than a manual one. Furthermore, the use of chlorhexidine is also associated with the reduced incidence of VAP; its effect is the strongest in cardiovascular patients. Andrews and Steen (2013) notice that a 2% concentration of it is more effective than lesser ones.
Due to the lack of official guidelines in the prevention of VAP in children and infants, Cooper and Haut (2013) provide their VAP bundle. They argue that after the implementation of the bundle, “VAP rates decreased from 5.6 to 0.3 infections per 1000 ventilator days” (Cooper & Haut, 2013, p. 26). The bundle includes oral hygiene, endotracheal suctioning, and circuit changes; overall, it provides more than fifteen interventions that can be implemented in a nursing unit.
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Some of the suggested interventions are to perform hand hygiene before and after contact with the patient or the ventilator, brush teeth every 12 hours (for children <6 years old and with teeth), coat lips with petroleum jelly, rinse the mouth with 1% chlorhexidine (Cooper & Haut, 2013). Particular attention is paid to oral hygiene in adults by Cutler and Sluman (2014), who argue that the use of oral care bundles for VAP prevention can significantly lower VAP-incidents (47 of 528 patients developed VAP before the intervention, 24 of 559 patients developed VAP after it).
A high level of compliance (91%) and high-standard oral care caused a reduction in the incidents of VAP. Gatell et al. (2012) argue that to prevent ventilator-associated pneumonia in adults, nurses need to be attentive to the intervention routines and show compliance with suggested procedures. Nurses who underwent additional training demonstrated improved knowledge about VAP-prevention techniques; they also used various strategies (use of chlorhexidine, hand washing, specific headboard positioning) more often after the training program. The authors confirm that not all nurses demonstrated compliance with guidelines, possibly due to high workload and time pressure (Gatell et al., 2012).
To increase adherence to guidelines, training activities and evidence-based protocols are suggested as suitable tools. Valuable information about the relation between guidelines adherence and VAP is reported by Jansson, Ala-Kokko, Ylipalosaari, Syrjälä, and Kyngäs (2013). Nurses with more ICU experience (>5 years) tend to adhere to guidelines more often than their less experienced colleagues. Additional barriers include a high workload, as well as a lack of knowledge and resources. Some of the nurses adhered to preventive strategies only if they found them necessary (e.g., washed hands, use of protective gowns, etc.).
Akın Korhan, Hakverdioğlu Yönt, Parlar Kılıç, and Uzelli (2014) provide findings that support the arguments of Jansson et al. (2013) and Gatell et al. (2012). Lack of knowledge, lack of training programs, and lack of sufficient information on VAP prevention led to poor adherence to evidence-based guidelines among ICU nurses. Multifaceted educational programs are suggested as tools for the improvement of clinical care.
Akın Korhan, E., Hakverdioğlu Yönt, G., Parlar Kılıç, S., & Uzelli, D. (2014). Knowledge levels of intensive care nurses on prevention of ventilator‐associated pneumonia. Nursing in Critical Care, 19(1), 26-33.
Andrews, T., & Steen, C. (2013). A review of oral preventative strategies to reduce ventilator‐associated pneumonia. Nursing in Critical Care, 18(3), 116-122.
Cooper, V. B., & Haut, C. (2013). Preventing ventilator-associated pneumonia in children: An evidence-based protocol. Critical Care Nurse, 33(3), 21-29.
Cutler, L. R., & Sluman, P. (2014). Reducing ventilator associated pneumonia in adult patients through high standards of oral care: A historical control study. Intensive and Critical Care Nursing, 30(2), 61-68.
Gatell, J., Rosa, M., Santé Roig, M., Hernández Vian, Ó., Carrillo Santín, E., Turégano Duaso, C., & Vallés Daunis, J. (2012). Assessment of a training programme for the prevention of ventilator‐associated pneumonia. Nursing in Critical Care, 17(6), 285-292.
Jansson, M., Ala-Kokko, T., Ylipalosaari, P., Syrjälä, H., & Kyngäs, H. (2013). Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia – A survey study. Intensive and Critical Care Nursing, 29(4), 216-227.
Sedwick, M. B., Lance-Smith, M., Reeder, S. J., & Nardi, J. (2012). Using evidence-based practice to prevent ventilator-associated pneumonia. Critical Care Nurse, 32(4), 41-51.