Clinical Inquiry on Ventilator-Associated Pneumonia Essay

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Clinical Inquiry on Ventilator-Associated Pneumonia Essay.

Evidence-based practice (EBP) requires that all interventions that are used in the healthcare setting be backed by scholarly scientific evidence for efficacy. This is what is referred to as best practice (Melnyk & Fineout-Overholt, 2019). Current professional nursing practice recommends the adoption of EBP in place of common practice. With common practice, some interventions are just used as a matter of course because they have always been used that way.Clinical Inquiry on Ventilator-Associated Pneumonia Essay.

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It has however been proven that the use of EBP is beneficial in bringing about the best patient outcomes, assuring patient safety, and reducing healthcare costs. One clinical area where EBP is crucial is in critical care. For critical patients on mechanical ventilation, the rate of ventilator-acquired pneumonia (VAP) is an outcome measure that must be kept in check. This paper details a clinical inquiry into the efficacy of semi-Fowler’s or semi-recumbent position versus the supine position in the prevention of VAP in critical care.Clinical Inquiry on Ventilator-Associated Pneumonia Essay.

Problem Statement

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection (HAI) in critical care patients. It is estimated to affect up to 28% of the patients on mechanical ventilation in intensive care units. In the US, it is the second most common HAI. VAP is defined as a HAI that occurs in patients who are receiving mechanical ventilation for more than 48 hours in a critical care setting. The occurrence of VAP will increase the duration of time the patient is on mechanical ventilation.Clinical Inquiry on Ventilator-Associated Pneumonia Essay. It will also increase the hospitalization costs and the risk of mortality (Ghezeljeh et al., 2017). In this case study scenario at the Big City Hospital’s ICU, the rate of VAP as a HAI among the critically-ill patients on mechanical ventilation is rising. There is an urgent need to find evidence-based nursing interventions that can help reduce this rise in the rate of VAP. It is a problem that is causing many complications and threatening to increase the mortality rate. One of the nurse-led interventions expected to become part of the VAP prevention bundle is the aspect of patient positioning. This clinical inquiry sought to determine which position is efficacious in VAP prevention between semi-Fowler’s (semi-recumbent) position and supine position.Clinical Inquiry on Ventilator-Associated Pneumonia Essay.

The PICO Statement

To effectively carry out the clinical inquiry, the author used the PICO model to guide the search for evidence from research databases. The following were the PICO elements.

Table: PICO elements for patient positioning as a VAP prevention measure

P Patient or population Mechanically ventilated intensive care patients
I Intervention or program to be done Semi-Fowler’s or semi-recumbent position while on mechanical ventilation
C Comparison intervention Supine position
O Outcome expected Lower incidence of VAP

This gives the following PICO statement: In mechanically ventilated ICU patients (P), does putting the patient in semi-Fowler’s or semi-recumbent position (I) compared to supine position (C) result in a lower incidence of ventilator-associated pneumonia or VAP (O)?Clinical Inquiry on Ventilator-Associated Pneumonia Essay.

The Search Strategy

The search for evidence was conducted in electronic databases to retrieve current published scholarly peer-reviewed articles that provide evidence in support of the intervention. The databases were the Cochrane Database of Systematic Reviews, CINAHL Plus with Full Text, PubMed, and ProQuest Nursing and Allied Health Database. The search terms were “ventilator-associated pneumonia”, “prevention”, “semi-Fowler’s position”, and “supine position”. These were connected with the Boolean operator “AND” and entered in the database’s search engine. Further filtering was achieved by entering the period of publication as the last five years and also study type (like randomized controlled trial, RCT).Clinical Inquiry on Ventilator-Associated Pneumonia Essay.

Evidence Appraisal/ Analysis and Results

Selected article and DOI.

Article #1 Article #2 Article #3 Article #4 Article #5
Ghezeljeh et al. (2017) Ghezeljeh et al. (2018) Gunay et al. (2018) Hassankhani et al. (2017) Wang et al. (2016)
Evidence Level *
(I, II, or III)

Level I Level I Level III Level I Level I
Study Design/Method Randomized controlled trial (RCT) RCT Prospective survey RCT Systematic review
Sample/Setting

120 patients hospitalized in the ICU and on mechanical ventilation. 80 patients on mechanical ventilation hospitalized in the ICU. 3,466 patients in intensive care. 25 patients in intensive care. 10 RCTs involving 878 patients/ participants.
Major Variables Studied
List and define dependent and independent variables

Independent variable: Semi-Fowler’s or supine position on mechanical ventilation for a period of 48 hours or more.
Dependent variable: Development of VAP or not.

Independent variable: Semi-Fowler’s or supine position on mechanical ventilation for a period of 48 hours or more.
Dependent variable: Development of VAP or not.

Independent variable: Semi-Fowler’s or supine position on mechanical ventilation for a period of 48 hours or more.
Dependent variable: Development of VAP or not.

Independent variable: Semi-Fowler’s or supine position on mechanical ventilation for a period of 48 hours or more.
Dependent variable: Development of VAP or not.

Independent variable: Semi-Fowler’s or supine position on mechanical ventilation for a period of 48 hours or more.
Dependent variable: Development of VAP or not.

Measurement
Identify primary statistics used to answer clinical questions (The actual tests done).

ANOVA and Scheffe ad hoc tests.

Chi-square, Fisher’s exact test, and t-tests.

Descriptive and inferential statistics. Chi-square test, Fisher’s exact test, t-tests, and Mann-Whitney U test. Mean difference and meta-analysis using random effects model.
Findings and Recommendations
General findings and recommendations of the research.

An elevation of the head-of-bed (HOB) by 45° resulted in less VAP than that of 35°. Supine position should therefore be avoided to prevent VAP in patients on mechanical ventilation. The intervention group with a HOB elevation of 45° had fewer cases of VAP compared to the control group. HOB elevation of 45° is effective in preventing VAP. The rate of VAP was lower when patients on mechanical ventilation were put in semi-Fowler’s position. VAP rate was only 20% in the intervention group but 73% in the control group. HOB elevation of 60° helps to prevent VAP. A semi-recumbent position of ≥ 30° prevents VAP than a supine position of 0° to 10°.

Recommendations

The EBP recommendations drawn from the above clinical inquiry and its findings are that:

Head-of-bed elevation (HOBE) of between 30° and 60° for mechanically ventilated patients (more than 48 hours) in intensive care is effective in reducing VAP and should therefore be practiced.
Patients on mechanical ventilation for more than 48 hours in critical care must not be put in a supine position at a degree of between 0° and 10°.

References

Ghezeljeh, T.N., Kalhor, L., Moghadam, O.M., Lahiji, M.N., & Haghani, H. (2017). The comparison of the effect of the head of bed elevation to 30 and 45 degrees on the incidence of ventilator associated pneumonia and the risk for pressure ulcers: A controlled randomized clinical trial. Iranian Red Crescent Medical Journal, 19(7), 1-10. http://dx.doi.org/10.5812/ircmj.14224

Ghezeljeh, T.N., Kalhor, L., Moghadam, O.M., Niakan, M.L., & Haghani, H. (2018). The effect of head-of-bed elevation of 45 degree on the incidence of ventilator- associated pneumonia among hospitalized patients in intensive care units. Iran Journal of Nursing, 31(111), 65-74. https://doi.org/10.29252/ijn.31.111.65

Gunay, L., Yesılbag, Z., Gedık, H., Karabela, Ş.N., Engin, G., Gunaydın, N., & Yasar, K.K. (2018). Ventilator associated pneumonia prevention experience in cardiovascular surgical intensive care. The American Journal of Cardiology, 121(8), e158–e159. https://doi.org/10.1016/j.amjcard.2018.03.344

Hassankhani, H., Akbarzadeh, S., Lakdizaji, S., Najafi, A., & Mamaghani, E.A. (2017). Effects of 60° semi-recumbent position on preventing ventilator-associated pneumonia: A single-blind prospective randomised clinical trial. Journal of Clinical and Diagnostic Research, 11(12), 36-39. http://dx.doi.org/10.7860/JCDR/2017/27443.11007

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4th ed. Wolters Kluwer.

Wang, L., Li, X., Yang, Z., Tang, X., Yuan, Q., Deng, L., Sun, X., & Cochrane Acute Respiratory Infections Group (2016). Semi‐recumbent position versus supine position for the prevention of ventilator‐associated pneumonia in adults requiring mechanical ventilation. Cochrane Database of Systematic Reviews, (1), 1-50. https://doi.org/10.1002/14651858.CD009946.pub2

Clinical Inquiry on Ventilator-Associated Pneumonia Essay.