IMPACT OF REAL TIME COMPLIANCE TO CERTAIN INTERVENTIONAL METHODS INCLUDING VAP BUNDLE ON VENTILATOR ASSOCIATED PNEUMONIA AMONG PATIENTS
ON MECHANICAL VENTILATOR IN APOLLO HOSPITALS AT CHENNAI.
A Thesis submitted to
THE TAMILNADU MGR MEDICAL UNIVERSITY, CHENNAI
for the award of the degree of
DOCTOR OF PHILOSOPHY IN NURSING
By
Ms. D.SASIKALA, M.Sc. (NURSING) Under the Guidance of
DR. N.CHIDAMBARANATHAN, M.D., D.M.R.D., Ph.D., D.N.B., F.I.C.R., RESEARCH GUIDE & HEAD OF THE DEPARTMENT,
RADIOLOGY AND IMAGING SCIENCES, APOLLO HOSPITALS, CHENNAI.
JANUARY 2018
CERTIFICATE
This is to certify that the thesis entitled “Impact of Real Time Compliance to Certain Interventional Methods Including VAP Bundle on Ventilator Associated Pneumonia Among Patients on Mechanical Ventilator in Apollo Hospitals at Chennai” submitted by Ms. D. Sasikala, M.Sc.(N)., for the award of the degree of Doctor of Philosophy in Nursing, is a bonafide record of research done by her during the period of study, under my supervision and guidance and that it has not formed the basis for the award of any other Degree, Diploma, Associateship, Fellowship or other similar title. I also certify that this thesis is her original independent work. I recommend that this thesis should be placed before the examiners for their consideration for the award of Ph.D. Degree in Nursing.
Signature of the Principal
Dr. Latha Venkatesan.,
M.Sc.(N)., M.Phil.(N)., Ph.D(N)., M.B.A., Ph.D(HDF&S)., Apollo college of Nursing,
Ayanambakkam, Chennai- 600095
Place:
Date:
CERTIFICATE
This is to certify that the thesis entitled “Impact of Real Time Compliance to Certain Interventional Methods Including VAP Bundle on Ventilator Associated Pneumonia Among Patients on Mechanical Ventilator in Apollo Hospitals at Chennai” submitted by Ms. D. Sasikala, M.Sc.(N)., for the award of the degree of Doctor of Philosophy in Nursing, is a bonafide record of research done by her during the period of study, under my supervision and guidance and that it has not formed the basis for the award of any other Degree, Diploma, Associateship, Fellowship or other similar title. I also certify that this thesis is her original independent work. I recommend that this thesis should be placed before the examiners for their consideration for the award of Ph.D. Degree in Nursing.
Signature of the Research Guide
Dr. N.Chidambaranathan, M.D., D.M.R.D., Ph.D., F.I.C.R., M.A.M.S., Head of the Department and Ph.D. Research Guide,
Radiology and imaging sciences, Apollo Hospitals, Chennai.
Place:
Date :
CERTIFICATE
This is to certify that the thesis entitled “Impact of Real Time Compliance to Certain Interventional Methods Including VAP Bundle on Ventilator Associated Pneumonia among Patients on Mechanical Ventilator in Apollo Hospitals at Chennai” submitted by Ms. D. Sasikala, M.Sc.(N)., for the award of the degree of Doctor of Philosophy in Nursing, is a bonafide record of research done by her during the period of study, under my supervision and guidance and that it has not formed the basis for the award of any other Degree, Diploma, Associateship, Fellowship or other similar title. I also certify that this thesis is her original independent work. I recommend that this thesis should be placed before the examiners for their consideration for the award of Ph.D. Degree in Nursing.
Signature of the Research Co – Guide
Dr. Lizy Sonia. M.Sc. (N)., Ph.D. (N)., Research Co – Guide &Vice Principal, Apollo College of Nursing,
Vanagaram to Ambattur Main Road, Ayyanambakkam,
Chennai – 95
Date:
Place:
DECLARATION
I hereby declare that the present study on “Impact of The Real Time Compliance to Certain Interventional Methods Including VAP Bundle on the Incidence of Ventilator Associated Pneumonia among the Patients on Mechanical Ventilator in Apollo Hospitals at Chennai” is the outcome of original research work undertaken and carried out by me under the guidance of DR.N.Chidambaranathan, M.D., D.M.R.D., Ph.D., D.N.B., F.I.C.R., Head of the department, Radiology and imaging sciences, Apollo Hospitals, Chennai. And under the co – guidance of Dr. Lizy Sonia., M.Sc.(N)., Ph.D.(N)., Vice Principal Apollo College of Nursing, Chennai. I also declare that the material of this has not found in any way, the basis for the award of any degree in this university or any other universities. I further declare that to the best of my knowledge the thesis does not contain any part of any work which has been submitted for the award of any degree either in this University or in any other University / Deemed University without proper citation.
Date : D. Sasikala Time : Research scholar
ACKNOWLEDGEMENT
I bow with profound gratitude to God almighty for showering His blessings and enabling me to envision the correct way to conduct this study with the spirit of enthusiasm throughout the study.
I dedicate my heartfelt thanks and gratitude to our esteemed, enigmatic leader Dr. Latha Venkatesan M.Sc.(N).,M.Phil.(N).,Ph.D (N).,M.B.A.,Ph.D (HDF&S), Principal, Apollo college of Nursing, Ayanambakkam, Chennai- 600095 for her ambitious vision in initiating Ph.D programmeme in Apollo College of nursing, continuous support, enormous auspice, valuable suggestions and tireless motivation to carry this study without which my dream of acquiring Ph.D would not have been materialised.
The researcher extends the earnest gratitude to The Tamilnadu Dr. M.G.R.
Medical University, Chennai and the Apollo Hospital Educational Trust for the fathomless oppurtunities they provide for the professional growth and development.
I express my heartfelt gratitude to the present and past Vice Chancellor, The Registrar, Academic Officer of The Tamilnadu Dr. MGR Medical University for providing this opportunity to pursue the doctoral degree in the esteemed university.
I take this opportunity to express my great pleasure and deep sense of gratitude to our guide Dr.N.Chidambaranathan, M.D., D.M.R.D., Ph.D., D.N.B., F.I.C.R., Head of the department, Radiology and imaging sciences, Apollo Hospitals, Chennai, for his kind support, open doors, valuable guidance, enlightening ideas, willingness to help at all times for successful completion of this research work.
My bouquet of thanks to my co-guide Dr. Lizy Sonia, M.Sc. Nursing, Ph.D.
Nursing, Vice Principal and Head of the Medical Surgical Nursing Department, Apollo College of Nursing, for her valuable guidance and support rendered by her to bring this task to completion.
The researcher owes her deepest appreciation to Director of Medical education and Assistant Nursing Director, Apollo Hospitals, Greams Road, Chennai and Medical Superintendent and Nursing Superintendent, Apollo Speciality Hospital, Teynampet for granting permission to conduct the study in the esteemed institution and continuous support rendered throughout the research.
Heartfelt gratitude to Dr. Ramesh, Senior Critical Care Consultant with a bounteous experience in the research field, for his valuable suggestions in formulating tool for data collection. It is noteworthy to acknowledge the constant support and open doors provided by Dr.Vijayalakshmi, M.Sc. Nursing, Ph.D.
Nursing Head of the Psychiatric Department, research coordinator in finishing this study. My heartfelt gratitude to the Mrs. Shobana, M.Sc.(N)., Head of the Department, Community Health Nursing for constant support and help throughout the study.
A special word of note, thanks to all the experts for validating the tool and offering worthy suggestions to make it effective. I express my immense gratitude to the biostatistician Mr. Pitchai Arumugam, for his timely support and untiring help in compiling the data and for computing statistical analysis.
A sincere thanks to Mr. E.S. Chandrasekaran, M.A., M.Phil., B.Ed., a senior faculty in English for editing the report. My genuine gratitude to Ms. Jaslina.,
M.Sc.(N) and the all the other faculty of the medical surgical nursing department for their enormous concern and support throughout the process. I am obliged to all my participants of the study for their cooperation and willingness to participate in the research.
I am extremely thankful to the Intensive Care Unit Incharges and the Infection Control Nurse for their immense support in data collection and arranging for reinforcement programme.
A whole hearted thanks to Mr. Kannan, Office superintendent, the entire faculty, office and Administrative staff and students of Apollo College of nursing for extending support throughout the study. Immense thanks to the librarian Mr.S.Sivakumar and Mr.B.Gopinath for helping in literature search in our college library.
I would fail in my duty if I forget to thank my beloved ones behind the scene. I am thankful to my late father Mr. Dhakshinamoorthy for his blessing to enable me in fulfilling his wish for me to complete Ph. D. I am grateful to my mother Ms.Kuppabai, my husband Mr. Jaiganesh, my daughter J. Dhanyalakshmi for their continuous moral support and forbearance in enduring hardships with pleasure and my brothers and sister for their continuous support and prayers and help rendered to me in completing the study.
Date:
Place: Signature of the Candidate
INDEX
Chapter No Title Page No
I. Introduction 1
Background of the study 1
Significance and Need for the Study 6
Statement of the Problem 9
Objectives of the Study 9
Operational Definitions 11
Assumptions 14
Null Hypothesis 14
Delimitations 15
Conceptual Framework Based on Kurt Lewin‟s Model 16
Projected Outcome 20
Summary 20
Organisation of Research Report 20
II Review of Literature 21
Literature reviewed related to work 21
Development of Nursing Evidence Based Protocol 45
Summary 55
III Research Methodology 56
Research Approach 56
Research Design 57
Variables of the Study 60
Research Setting 60
Population 61
Sample and Sample Size 63
Sampling Technique and Criteria for Sample Selection 63 Selection and Development of Study Instruments 63 Psychometric Properties of the Instruments 67
Intervention Protocol 68
Pilot Study 71
Data Collection Procedure 72
Protection of Human Rights 74
Problem faced during data collection 75
IV Data Analysis and Interpretation 77
Presentation of Data Analysis 77
Summary 113
V Discussion 114
Summary 148
VI Summary and Recommendations 149
Summary of the Study 149
Nursing Implications 161
Recommendations for Future Research and Conclusions and limitations
165
Reference 166
Annexure 187
LIST OF TABLES
S. No. Title
Page No.
1
Individual Evidence Summary of Clinical Trial Based on
Effectiveness of VAP Bundle Care in Reducing VAP 50
2 Reliability of the Tools Used 68
3 Statistics Used for Data Analysis 75
4
Frequency, Percentage and Chi Square Values of Demographic Variables of Pre-intervention and Post-intervention Group of Patients on Mechanical Ventilator.
79
5
Frequency, Percentage and Chi Square Values of Clinical Variables of Pre – intervention and Post-intervention Group of Patients on Mechanical Ventilator.
82
6
Mean, Standard Deviation and„ t‟ Value of the Continuous Variables of Pre – Intervention and Post-intervention Group of Patients on Mechanical Ventilator
89
7
Description of Demographic Variables of the Nurses taking Care of Patients on Mechanical Ventilator
90
8
Incidence of VAP among Pre – Intervention and Post-intervention
Group of Patients on Mechanical Ventilator 91
9 Comparison of Incidence of VAP between Pre – Intervention and Post-intervention group Patients on Mechanical Ventilator
92
10
Comparison of CPIS Score between Pre – Intervention and Post- intervention Group of Patients on Mechanical Ventilator
93
S. No. Title
Page No.
11
Assessment of Knowledge Scores of Nurses Taking Care of Patients on Mechanical Ventilator Regarding Certain Interventional Methods Including VAP Bundle.
94
12
Comparison of the Pretest and Posttest Knowledge Scores of Nurses Regarding Certain Interventional Methods Including VAP Bundle.
95
13
Frequency and Percentage Distribution of the Practice Scores of Nurses Regarding Certain Interventional Methods Including VAP Bundle
96
14
Comparison of Practice Scores of Nurses Regarding Certain Interventional Methods Including VAP Bundle Between Pre- intervention and Post-intervention Group of Patients on Mechanical Ventilator.
98
15
Correlation between Practice Scores of Certain Interventional Methods Including VAP Bundle and Clinical Pulmonary Infection Score
100
16
Proportional Hazard Ratio (Cox Regression Analysis) of Incidence of Ventilator Associated Pneumonia and Practice Scores of Nurses Regarding Certain Interventional methods Including VAP bundle
103
17
Association between the Selected Demographic Variables and the Incidence Rate of VAP among the Pre – Intervention and Post- intervention Group of Patients on Mechanical ventilator.
105
S. No. Title
Page No.
18
Association between the Selected Clinical Variables and the Incidence Rate of VAP among Pre – Intervention and Post- intervention Group of Patients on Mechanical Ventilator
107
19
Association between the Demographic Variables of the Nurses Taking Care of Patients on Mechanical Ventilator and their Knowledge Score.
111
20
Levels of Acceptability on Certain Interventional methods Including VAP Bundle among Nurses Taking Care of Patients on Mechanical Ventilator.
112
LIST OF FIGURES
S. No Title Pg. No.
1 Conceptual Framework Based on Kurt Lewin‟s Model 19
2 PRISMA Flow Chart 49
3 Schematic Representation of Research Design 59
4.
Percentage Distribution of Habit of Smoking among the Patients on mechanical Ventilator
81
5.
Percentage Distribution of Reason for Admission among the Pre – intervention and Post-intervention Group of Patients on Mechanical Ventilator
85
6.
Percentage Distribution of Reason for mechanical ventilation among the Pre-intervention and Post-intervention Group of Patients on Mechanical ventilator
86
7.
Percentage Distribution of History of Diabetes Mellitus among the Pre – Intervention and Post-intervention Group of Patients on Mechanical Ventilator
87
8. Percentage Distribution of Risk factors among the Pre – Intervention and Post-intervention Group of Patients on Mechanical Ventilator
88
9
Trend Graph of Practice Score of Nurses and VAP Rate Among Patients on Mechanical Ventilator
102
10
Hazard Ratio of Incidence of VAP among Patients on Mechanical Ventilator among Pre – Intervention and Post-intervention Group
104
LIST OF APPENDICES
S.No Description
I Part Time Provisional registration certificate - Ph.D. Degree Programme
II Confirmation of Provisional Registration
III Constitution of Doctoral Advisory Committee - certificate IV Institutional Ethics Committee Approval Certificate
V Plagiarism check certificate, Plagiarism Analysis report by Urkund, Screenshot of Plagiarism Analysis Report
VI Certificate of English Editing
VII Letter seeking setting permission for conducting Study VIII Letter to Granting Permission to Conduct Study
IX Grant of Permission to use the John Hopkins Evidence Based Practice Models and Tools
X Evidence of permission to Use Clinical Pulmonary Infection Score from the Author
XI Request for Content Validity XII List of Experts for Content Validity XIII Content Validity Certificate
XIV Content Validity Index XV Intervention Protocol
XVI Certificate For assessing Intervention Fidelity
XVII Certificate for Participating/Presenting in Research/
Conference
XVIII Certificate of Research Articles Published by the Researcher XIX Tools used in this Research
XX Master Code Sheet
XXI Ph.D Synopsis Submission Application Form XXII Ph.D Thesis Submission Application Form
ABBREVIATIONS
1 VAP Ventilator Associated Pneumonia
2 VAT Ventilator Associated Tracheobronchitis 3. CPIS Clinical Pulmonary Infection Score
4 APACHE Acute Physiology and Chronic Health Evaluation II 5 CDC Center for Disease Prevention
6 JCIA Joint Commission of International Accreditation 7 ICU Intensive Care Unit
8 CAUTI Catheter Associated Urinary Tract Infection
9 CLABSI Central Line Associated Blood Stream Infection CLABSI 10 INICC International Nosocomial Infection Prevention Consortium 11 ARDS Acute Respiratory Distress Syndrome
12 IHI Institute for Healthcare Improvement
13 DVT Deep Vein Thrombosis
14 SSD Supraglottic Secretion Drainage 15 PUD Peptic ulcer disease prophylaxis
16 DA-HAIs Device-Associated Hospital Acquired Infection 17 CI Confidence Interval
18 MDR Multidrug Resistant
19 EDTA Ethylene Diaminetetraacetic Acid
20 EDS EDTA Disk Synergy
21 MRSA Multidrug Resistant Staphylococcus Aureus 22 BALF Bronchoalveolar Lavage Fluid
23 BAL. Broncho Alveolar Lavage 24 VOCs Volatile Organic Compounds 25 VAEs Ventilator-Associated Events
26 IVAC Infection-Related Ventilator Associated Complications 27 NSHN National Health Safety Network
28 IBMP Immunodeficiency, Blood, Multipolar Infiltrates on a Chest Radiograph and Platelet count
29 XDR AB Drug-Resistant Acinetobacter baumannii 30 CTSS Closed Tracheal Suction System
31 OTSS Open Tracheal Suction System
32 FAST HUG Feeding/fluids, Analgesia, Sedation, Thromboprophylaxis Head Up Position, Ulcer prophylaxis, Glycemic control 33 VARI Ventilators Associated Respiratory Tract Infection
34 LOS Length Of Stay
35 PVAP Probable Ventilator Associated Pneumonia
ABSTRACT
A Quasi Experimental Study to Assess the Impact of Real Time Compliance to Certain Interventional Methods Including VAP Bundle on Ventilator Associated Pneumonia among the Patients on Mechanical Ventilator.
Objectives of the Study Primary
1. To assess the incidence rate of Ventilator Associated Pneumonia among the pre-intervention and post-intervention group of patients on mechanical ventilator.
2. To determine the impact of real time compliance to certain interventional methods including VAP bundle on the Ventilator Associated Pneumonia by comparing the incidence rate of Ventilator Associated Pneumonia between the pre – intervention and post-intervention group of patients on mechanical ventilator.
3. To assess and compare the pretest and posttest knowledge scores regarding certain interventional methods including VAP bundle among nurses taking care of patients on mechanical ventilator
4. To assess and compare the practice scores of nurses regarding certain interventional methods including VAP bundle among the pre-intervention and post-intervention group of patients on mechanical ventilator.
Secondary
5. To find the correlation between the practice scores of nurses regarding certain interventional methods including VAP bundle and the incidence rate of
Ventilator Associated Pneumonia among the pre – intervention and post- intervention group of patients on mechanical ventilator.
6. To find the association between the selected demographic variables of patients on mechanical ventilator and the incidence rate of Ventilator Associated Pneumonia among the pre-interventionand post-intervention group of patients on mechanical ventilator.
7. To find the association between the selected clinical variables of patients on mechanical ventilator and the incidence rate of Ventilator Associated Pneumonia among the pre-intervention and post-intervention group of patients on mechanical ventilator.
8. To find the association between the selected demographic variables of nurses taking care of patients on mechanical ventilator and their knowledge scores regarding certain interventional methods including VAP bundle.
9. To assess the level of acceptability regarding certain interventional methods including VAP bundle among nurses taking care of patients on mechanical ventilator.
Methods
The conceptual framework for study was developed on the basis of Kurt Lewins Change Model (1947), which has been modified for the present study. An intensive review of literature and guidance from expert laid the foundation for the development of tools such as demographic and clinical variable proforma of the patients on mechanical ventilator, the demographic variable proforma of the nurses taking care of patients on mechanical ventilator, structured knowledge questionnaire and observation checklist of the practice regarding certain interventional methods including VAP bundle among nurses taking care of patients on mechanical ventilator
and Clinical Pulmonary Infection Score. The data collection tools were validated and the reliability was established.
In this study a quasi experimental time series design was adopted to assess the incidence rate of VAP during the twelve month period of data collection in the intensive care units of Apollo main hospital, Greams Road and Apollo specialty hospital, Teynampet in Chennai. The feasibility and researchability of the study were assessed by conducting a pilot study. After obtaining ethical clearance, setting permission and consent of the research participants, the samples ( 382 patients on mechanical ventilator and 163 nurses ) were selected in the pre-intervention period by purposive sampling technique.
The baseline data was collected regarding the demographic variables and clinical variables of the patients on mechanical ventilator, demographic variable of the nurse and incidence rate of VAP for a period of six months. A sensitising programme regarding the real time compliance to certain interventional methods including VAP bundle was organised and implemented by the researcher for the nurses. The certain interventional methods including VAP bundle were , elevation of the head of the bed to between 300 and 450, oral care every 2 hours with 3% chlorhexidine, daily
“sedation vacation” and daily assessment of readiness to extubate, peptic ulcer disease (PUD) prophylaxis, deep venous thrombosis (DVT) prophylaxis), meticulous hand washing with 2% chlorhexidine, ryles tube aspiration every 4 hours, using separate oral suction catheter for oral and endo tracheal suctioning, subglottic suctioning every 4 hours, checking and maintaining cuff pressure every 4 hrs (>20cm of H2O), keep closed end of the ventilator circuit, suction device, mask off the bed and drain the
ventilator condensate frequently without opening the circuit. The programme was conducted for four weeks ( three days per batch of 20 – 21 nurses). Each session lasted for 55 – 60 minutes. The level of knowledge and practice regarding certain interventional methods including VAP bundle incidence rate of VAP was assessed in the post-intervention period of six months. The collected data were analysed using the appropriate descriptive and inferential statistics (frequency, percentage distribution,
„t‟ test, Mann Whiteney, Pearson correlation, Cox regression and Chi square test).
Major Findings of the Study
Among the patients on mechanical ventilator, 31.7% and 35.2% were belonging to the age group between 50 to 64years , majority of them were males (68.3%, 70.4%), moderate level workers (61.8%, 56.2%), and most of them were non smokers (78.35 and 85.2%) and non alcoholic (81.2% and 83.% ) in pre-intervention and post-intervention group respectively.
About 46.9% and 48.1% of the patients on mechanical ventilator were within the normal range of BMI, 28.3% and 33.3% of them were admitted with the diagnosis of the neurological disorder and most of the them were intubated orally (80.9% ,85.4%) for the chief reason of the respiratory problem ( 43.7%
and 48.8% ) among the pre-intervention and post-intervention group respectively as shown in fig.5.
The distribution of co morbid illnesses and other risk factors of ventilator associated pneumonia among patients on mechanical ventilator were as follows i.e. cardiovascular disease (18.3% and 22%) as shown in fig.6, diabetes mellitus (35.6% and 45.3%), hypertension (38.5 and 46.3%), respiratory disorder (12.3% and 9.1%), thyroid disorder (5% and 4.7%),
cancer (18.1% and 17.1%), immunological disorders (2.6%, 4.7%) and renal disorders (8.6% and 10.1%) among pre-intervention and post-intervention group respectively. About 41.4% and 58.9% of the patient were on treatment for co-morbidity, with past history of accident (10.6%, 7.6%), infection (2.6%, 3.5%), hospitalisation (13.6%, 6.4%) and treatment with the anti- biotic (10.7%, 7.2%) within the past six months of admission and most of them were on current treatment with antibiotic (83.8%, 77.2%) among the pre-intervention and post-intervention group of patients respectively. The mean score of the APACHE II was 20.2±7.6 in pre-intervention group and 22.3±6.9 in post-intervention group.
Most of the nurses taking care of patients on mechanical ventilator (96.3%) were in the age group between 30-39 years, females (92.6%), degree holders (88.3%) and nearly half of them had <1 year of experience in the intensive care unit (53.4%).
In the pre-intervention group 19 out of 382 (5.0%) patients developed ventilator associated pneumonia while only 3 out of 514 patients (0.6%) on mechanical ventilator developed VAP in the post-intervention group.
The VAP rate was 9.3/1000 (5.1 – 13.5/ 1000 days @ 95% Confidence interval) among the pre-intervention group that decreased to 1.2/ 1000 days (- 0.1-2.5/1000 days @ 95% CI) among post-intervention group of patients on mechanical ventilator and the difference was significant at P<0.01.
In the pre test 55.2% of the nurses had moderate level of knowledge and 43.6% of them had inadequate level of knowledge while most of the nurses (98.8%) had adequate knowledge in the post- test.
There was a significant difference in mean pre test (15.8±3.4) and post test knowledge scores of nurses (27.5±2.1) with the improvement mean score of 11.7±4.1 at P<0.001 revealing the effectiveness of the sensitising programme on real time compliance to Certain interventional methods including VAP bundle to the nurses.
The compliance scores during the post-intervention period demonstrated improvement for head end elevation from 63.6% to 99.2%, oral care from 67.3% to 75.3%, sedation vacation from 0.8% to 94.2%, peptic ulcer prophylaxis from 97.4,% to 99.8% , deep vein thrombosis prophylaxis 98.7%
to 99.4%, hand hygiene 1.3% to 75.1%, ryles tube aspiration 0.5% to 90.1%, separate catheter for oral and ET suctioning 26.2% to 86.6%, subglottic suction 2.1% to 94.4%, cuff pressure monitoring 1.8% to 98.6%, open end of the ventilator circuit off the bed 1.8% to 89.7%, draining the circuit 5.2% to 80.7%. The overall full compliance score increased to 100 % for all the components.
There was a significant difference in the mean rank of practice score of the following components : elevation of head end (397.4 and 486.5 with the Z value7.177), oral care (403.1and 482.3 with the Z value of 4.653), sedation vacation (197.9, 634.7 with the Z value 28.550), peptic ulcer prophylaxis (435.6 and458.1 with the Z value 4.206), hand hygiene (210.8 and 453.4 with the Z value 24.546), ryles tube aspiration (198.2 and 634.5 with Z value 27.065), separate catheter for suction (293.2 and 563.9 with the Z value 17.402), subglottic suctioning (198.6 and 634.2 with the Z value 28.209), cuff pressure monitoring (200.9 and 632.5 with the Z value 27.410), ventilator circuit off the bed (214.3 and 622.5 with the Z value 25.125) and draining
the circuit (246.0 and 598.9 with the z value 21.314) at P<0.001 and deep vein thrombosis prophylaxis (441.9 and 453.4 with Z value 2.378) at P<0.05 level among the pre and post-intervention group of patients on mechanical ventilator respectively.
The overall total mean rank of all the components purported a significant improvement in the post-intervention group (634.9) compared to pre- intervention group (197.6 ) with the Z value 25.040 ( P<0.001).
There was significant negative correlation between Clinical Pulmonary Infection Score (CPIS) of the patients and the practice score of ryles tube aspiration (r value -0.130) at P<0.01, separate catheter for endotracheal suctioning (r value -0.101), cuff pressure monitoring (r value -0.120) ventilator circuit off the bed (r value -143) at P<0.05.
Among post-intervention group of patients there was a significant negative correlation between Clinical Pulmonary Infection Score and the practice scores of head end elevation (r value 0.089), sedation vacation (r value – 0.127), ryles tube aspiration (r value – 0.108), separate catheter for suctioning (r value - 0.104), cuff pressure monitoring (r value - 0.108) at P<0.05.
The total practice score of the nurses had significant negative correlation with the CPIS (r value -0.124 and -0.097) at P<0.05 among the pre-intervention and post-intervention group of patients on mechanical ventilator respectively.
The oral care (Wald χ2 4.045, HR 0.295) and hand hygiene (Wald χ2, 4.784 HR.182) were significantly associated with the reduction in the risk of ventilator associated pneumonia at P<0.05.
There was no significant association between the incidence of VAP rate and the demographic variables age, gender, habit of smoking and alcoholism
except the work pattern among patients on mechanical ventilator at P<0.05 level.
A significant association was found between incidence rate of VAP and the clinical variables such as the type of intubation (χ2=7.362), past history of thyroid disease (χ2=4.949) at P<0.05, APACHE level II score (χ2=16.658) of the patients on mechanical ventilator at P<0.001.
There was no significant association between the demographic variables such as age, gender, years of experience and the level of knowledge except their level of education at P<0.05 level.
Most of the nurses expressed high acceptability (84.66%) and 15.33% of the nurses demonstrated acceptability regarding time compliance to certain interventional methods including VAP bundle.
Conclusion
The findings of the study reveal that there is a reduction in the incidence rate of ventilator associated pneumonia among the post intervention group of patients on mechanical ventilator thus projecting the impact of real time compliance to certain interventional method including VAP bundle.
1
CHAPTER I INTRODUCTION
Background of the Study
The important and specific aspect of intensive care units is the utilization of advanced technologies such as invasive monitoring and mechanical support for deteriorating organ and systems, particularly the cardiovascular, respiratory and urinary system. Endotracheal intubation, tracheostomy mechanical ventilation and continuous renal replacement therapy are the most frequently performed procedures in the intensive care units. The presence of endotracheal tube in the respiratory tract is considered as a foremost risk factor for development of ventilator associated pneumonia. The process of creating an artificial respiratory tract by means of endotracheal tube would deprive the patient the likelihood of heat, humidification and purification of the inhaled air which indeed generates more interventions, contributing for the development of health care associated infection such as ventilator associated pneumonia. Moreover the patients who are admitted to intensive care units are at perceived threat to life not only due to their critical illness but also from the development of secondary course such as health care associated infection.
The nosocomial infections in intensive care units is a major concern today as they contribute to increased mortality and morbidity rate. Even though critical care unit beds constitute the minority of the entire hospital inpatients , they account for the utmost burden of nosocomial infection. It has been reported that the incidence of nosocomial infections in intensive care unit is about 2 to 5 times higher than in the general inpatient hospitals population. (1) A large cohort multicentric international
2
study has reported at least one ICU acquired infection in 18.9% of patients, with an incidence of intensive care acquired infection ranging from 2.3% to 49.2% across. (2) In a 1-day point prevalence study involving 1265 ICUs from 76 countries 51%
patients were found to have nosocomial infection. (3)
The nosocomial infections contributing to escalated morbidity and mortality rate among intensive care unit (ICU) patients are Ventilator Associated Pneumonia (VAP), Catheter Associated Urinary Tract Infection (CAUTI) and Central Line Associated Blood Stream Infection (CLABSI).(4) Among these, intensive care acquired pneumonia is the most frequently occurring infection (62.07%) followed by catheter related urinary tract infection and central line associated blood stream infection. The crude mortality rates related to nosocomial infections vary from 12% to 80%. The crude mortality rate for patients with device associated infections ranged from 35.2% (for CRBSI) to 44.5% (for VAP).(5) Ventilator Associated Pneumonia (VAP), one of the top three infections concerns of the intensivists today, develops 48 hours after intubation, accounting for up to 60% of all deaths occurring due to healthcare associated infections. (6,7)
Pneumonia, considering it as the most common nosocomial infection.(6) affects 27% of all critically ill patients and 86% of nosocomial pneumonias are related to endotracheal intubation and mechanical ventilation. Though endotracheal intubation and mechanical ventilation are considered as life saving measures, these procedures augment the risk of ventilators associated pneumonia (VAP), contributing to increased hospital mortality and morbidity rate, despite recent advances in diagnosis and accuracy of management. The mortality rate attributable to VAP has
3
been reported to range between 0 and 50%. Furthermore, the economics effects of VAP include increased length of stays (LOS) from 4 to 13 days , and incremental costs due to 3 - 5 folds increase in duration of hospitalisation, 4 – fold increase in hospital-bed cost (4-fold), and the 5 – fold increase in the total cost. (8,9)
According to the International Nosocomial Infection Prevention Consortium (INICC), the overall rate of VAP is 13.6/ 1,000 ventilator days. The incidence rate varies according to the patient group and hospital settings and it ranges from 13 to51 per 1,000 ventilation days. (10) The mortality associated with VAP is high because the intubation process itself contributes to the development of VAP. Mortality is more likely when VAP is associated with certain multidrug resistant micro-organisms (Pseudomonas, Acinetobacter), blood stream infections, and ineffective initial prophylactic antibiotics.(8,11) VAP is particularly common in people who have acute respiratory distress syndrome (ARDS).
Although there is a plethora of studies detailing the risk factors, the more commonly identified risk factors can be divided into 3 categories: host related, device related, and personnel related.
The common host related risk factors include co- morbidities such as immune suppression, chronic obstructive lung disease, and acute respiratory distress syndrome, body positioning, decreased level of consciousness, reintubation , and intake of medications such as sedative agents and antibiotics.
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The identified device related risk factors include the presence of endotracheal tube, the ventilator circuit, nasogastric or an orogastric tube. The secretions pooling above the cuff of an endotracheal tube, pilot to micro aspirations of bacteria around the cuff into the trachea due to low cuff pressures. The nasogastric tubes also disrupt the gastro esophageal sphincter closure, causing reflux of the gastric contents and increase the risk for aspiration and VAP. (12)
The personnel related risk factor for VAP include improper hand washing ensuing in the cross-contamination which is considered as the biggest risk factor. The process of suctioning or manipulation of the ventilator circuit increase the probability of cross-infection, if proper hand washing techniques are not adhered by the nurses.
Ventilator Associated Pneumonia is a worldwide harm. As prevention is better than cure is probably more appropriate to VAP, effective evidence based approaches imply to prevent the occurrence of VAP and thereby decrease the hospital stay, cost, morbidity and mortality. Hence all the regulatory bodies continue to emphasise on the importance to reduce these nosocomial infections. The health care institutions are under force to reduce the VAP infection rates and are conducting process- improvement projects by implementing the bundle care to reduce the incidence of VAP. In view of this, Institute for Healthcare Improvement (IHI) has launched a Ventilator Bundle in 2005, which is a series of interventions related to ventilator care that, when implemented together, aimed to achieve significantly better outcomes than when implemented individually. The bundle components are, elevation of the head end of the bed, daily sedation vacations and assessment of readiness to extubate,
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peptic ulcer disease prophylaxis, deep vein thrombosis (DVT) prophylaxis, daily oral care with chlorhexidine. (13)
However, this bundle is controversial in the literature. Although there are many studies supporting this bundle care in the reduction of VAP incidence rates, still to achievement of zero percentage of VAP is difficult. Instead definitions used for surveillance and clinical diagnosis of VAP are interpreted differently that has led to under reporting of VAP rates. In an effort to achieve the zero VAP, this study using the current evidences related to VAP provides insight into implementing a suggested revision of the care of patients on mechanical ventilation considering all the risk factors, along with the five components of VAP bundle, by including certain evidence based practices like meticulous hand washing with 2% chlorhexidine, ryles tube aspiration every 4 hours, separate oral suction catheter for oral and endotracheal suctioning, subglottic suctioning every 4 hours, checking and maintaining cuff pressure every 4 hrs. (20 - 30cm of H2O), keeping closed end of the ventilator circuit, suction device, ventilation bag and mask off the bed and draining the ventilator condensate frequently without opening the circuit.
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Significance and Need for the Study
Despite major advanced techniques for the management of patients on mechanical ventilator and the routine use of effective based practices to disinfect respiratory equipment, Ventilator Associated Pneumonia has defied the attempt to reach the goal of zero VAP rate and continues to complicate the course of 8 to 28% of the patients receiving mechanical ventilation. The risk of pneumonia is increased to 6 to 21-folds for the intubated patient. The incidence per day varies over time, with the 3% per day for the first 5 days, 2% per day for days 6-10, and 1% per day after day 10. The crude mortality rate for VAP is 27-76%. The greatest risk appears to be during the initial days of mechanical ventilation.
Additionally, significant risk factors for early on-set VAP include cardiopulmonary resuscitation and continuous sedation. It is reported that the mortality rate for VAP, ranges from 24 to 50% and can reach upto76% if the infection is caused by certain high risk pathogens ,whereas mortality rate is low for the infection of more frequently involved organs such as urinary tract and skin, ranges from 1 to 4%. (8) Pseudomonas or Acinetobacter pneumonia in particular associated with higher mortality rates than other organisms. (9)
Wise and humane management of the patient is the best safeguard against infection. The vital role of the nurse is to prevent the infection. Prevention of VAP involves limiting exposure to resistant bacteria by following proper hand washing, sterile technique for invasive procedure, isolation precautions for individuals with known resistant organisms and discontinuing mechanical ventilation as soon as possible. A variety of aggressive weaning protocols have been anticipated to limit the
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amount of time a patient spends after intubation. One important aspect is limiting the amount of sedation that a ventilated person receives. (13) Other recommendations for preventing VAP include raising the head of the bed to at least 30 degrees and placement of feedings tubes beyond the pylorus of the stomach. Antiseptic mouth washes such as chlorhexidine may also reduce the incidence of VAP. One recent study suggests that heat and moisture exchanges instead of heated humidifiers, may increase the incidence of VAP. (14)
The American and Canadian guidelines strongly recommend the use of supraglottic secretion drainage (SSD). New cuff technology based on polyurethane material in combination with subglottic drainage (Seal Guard Evac tracheal tube from Covidien/Mallinckrodt) showed significant delay in early and late onset of VAP. (15) Pooled data on 17,347 patients showed the estimated relative risk of 1.09 (95%
confidence interval [CI], 0.87-1.37) among trauma patients and 0.86 (95% CI, 0.72- 1.04) among patients with acute respiratory distress syndrome. (16)
The Center for Disease Prevention (CDC), Joint Commission of International Accreditation (JCIA) and National Institute of Medicine have identified VAP rate as a measure of quality of care provided by the institution. In view of this, most of the hospitals implemented standardised patients care practice termed as VAP bundle care which involves the simultaneous application of the bundle components.
However, despite implementation of the bundle parameter only few studies demonstrate a reduction in VAP rate and inadequate health care team compliance rates of the guidelines varying between 30 and 64%. The vigilant compliance of the
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best cost- beneficial, preventive measure would have the following impacts on the health care system such as decreased morbidity and mortality in ICU patients, reduced costs of ICU care, improved ICU resource utilisation, improved access to scarce ICU beds since each case of VAP increases ventilator days and ICU days. These impacts on the health care system are highly relevant to health system managers and the applicability would be potentially worldwide.
The Apollo Hospital, a leading medical centre, accredited by Joint Commission International, committed to the achievement and maintenance of excellence in education, research and healthcare for the benefit of humanity with the state of art facilities for various health ailments, provides all types of care starting from primary health care up to tertiary health care. The VAP bundle was introduced in our hospital in 2010. The bundle consisted of five components as per the IHI and CDC guidelines which include elevation of the head end of the bed between 30 and 45 degrees, oral care every 4 hours with 0.12% chlorhexidine gluconate solution, daily ―sedation vacation‖ and daily assessment of readiness to extubate, peptic ulcer disease (PUD) prophylaxis, deep venous thrombosis (DVT) prophylaxis.
Despite implementation of the ventilator bundle and intermittent compliance monitoring by the nurse manager, we observed difficulty in achieving a sustainable target of zero VAP. Recent studies have suggested that the success of the VAP bundle is dependent on nurse – physician collaboration (17) and continuous educational initiatives as well as practitioner compliance with the bundle parameters. Hence the investigator, being an educator, felt the necessity to contribute to increase the
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compliance rate of the bundle components and to effect significant change in the incidence of VAP though continous educational activities
In view of this, the investigator has done an extensive review of current evidence based practice related to VAP and provides insight into implementing a suggested revision of the care of patients being treated with mechanical ventilation.
After seeking approval from the critical care team and infection control team members, the researcher incorporated certain interventional methods in the bundle, which are meticulous hand washing with 2% chlorhexidine, ryles tube aspiration every 4 hours, separate oral suction catheter for oral and endo tracheal suctioning, checking and maintaining cuff pressure every 4 hrs. (20 - 30cm of H2O), subglottic suctioning every 4 hours, keep closed end of the ventilator circuit, suction device and keeping ventilation bag and mask off the bed. The nurses were sensitized regarding the revised bundle components and planned for a vigilance monitoring by multidisciplinary team members to improve the compliances rate.
Statement of the Problem
A Quasi Experimental Study to Assess the Impact of Real Time Compliance to Certain Interventional Methods Including VAP Bundle on Ventilator Associated Pneumonia among Patients on Mechanical Ventilator in Apollo Hospitals at Chennai.
Objectives of the Study Primary
1. To assess the incidence rate of Ventilator Associated Pneumonia among the pre-intervention and post-intervention group of patients on mechanical ventilator.
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2. To determine the impact of real time compliance to certain interventional methods including VAP bundle on the Ventilator Associated Pneumonia by comparing the incidence rate of Ventilator Associated Pneumonia between the pre-intervention and post-intervention group of patients on mechanical ventilator.
Secondary
3. To assess and compare the pre-test and post-test knowledge scores regarding certain interventional methods including VAP bundle among nurses taking care of patients on mechanical ventilator.
4. To assess and compare the practice scores of nurses regarding certain interventional methods including VAP bundle among the pre-intervention and post-intervention group of patients on mechanical ventilator.
5. To find the correlation between the practice scores of nurses regarding certain interventional methods including VAP bundle and the incidence rate of Ventilator Associated Pneumonia among the pre-intervention and post- intervention group of patients on mechanical ventilator.
6. To find the association between the selected demographic variables of patients on mechanical ventilator and the incidence rate of Ventilator Associated Pneumonia among the pre-intervention and post-intervention group of patients on mechanical ventilator.
7. To find the association between the selected clinical variables of patients on mechanical ventilator and the incidence rate of Ventilator Associated Pneumonia among the pre-intervention and post-intervention group of patients on mechanical ventilator.
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8. To find the association between the selected demographic variables of nurses taking care of patients on mechanical ventilator and their knowledge scores regarding certain interventional methods including VAP bundle.
9. To assess the level of acceptability regarding certain interventional methods including VAP bundle among nurses taking care of patients on mechanical ventilator.
Operational Definitions Impact
It refers to the outcome of the real time compliance to certain interventional methods including VAP bundle on the ventilator associated pneumonia among the mechanically ventilated patients as evidenced by decreased incidence rate of ventilator associated pneumonia in post-intervention group than in pre-intervention group of patients on mechanical ventilator.
It is also evidenced in terms of improvement in the knowledge and practice scores of nurses taking care of patients on mechanical ventilator which is measured by structured knowledge questionnaire and observation checklist developed by the researcher.
Real Time Compliance
In this study it refers to degree of adaptability or adherence of the nurses taking care of mechanical ventilator to a set of guidelines directed for the prevention of ventilator associated pneumonia among the patients on mechanical ventilation
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admitted in the selected hospitals, as measured by the observational checklist developed by the researcher.
VAP Bundle
In this study it refers to a set of five evidence based practice, adopted as per Institute of Healthcare Improvement (18) guidelines directed for prevention of Ventilator Associated Pneumonia among patients on mechanical ventilation. It includes:
• elevation of the head end of the bed between 30 and 45 degrees
• oral care every 4 hours with 0.12% chlorhexidine gluconate solution
• daily ―sedation vacation‖ and daily assessment of readiness to extubate
• peptic ulcer disease (PUD) prophylaxis
• deep venous thrombosis (DVT) prophylaxis
Certain interventional methods including VAP bundle
In this study, it refers to a set of 12 evidence based practices, including the five components of VAP bundle, adopted as per Institute of Healthcare Improvement guidelines, implemented together to prevent the incidence of ventilator-associated pneumonia among the patients on mechanical ventilation, which includes :
• elevation of the head end of the bed between 30 and 45 degrees
• oral care every 2 hours with 0.12% chlorhexidine gluconate solution
• daily ―sedation vacation‖ and daily assessment of readiness to extubate
• peptic ulcer disease (PUD) prophylaxis
• deep venous thrombosis (DVT) prophylaxis
• meticulous hand washing with 2% chlorhexidine
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• ryles tube aspiration every 4 hours
• separate oral suction catheter for oral and endo tracheal suctioning
• checking and maintaining cuff pressure every 4 hrs (20 to 30 cm H20)
• subglottic suctioning every 4 hours
• keep closed end of the ventilator circuit, suction device, ventilation bag and mask off the bed
• drain the ventilator condensate frequently without opening the circuit
Ventilator associated pneumonia
In this study, it refers to the incidence rate of pneumonia among the patients on mechanical ventilator for more than 48 hours as diagnosed by Clinical Pulmonary Infection Score (CPIS) developed by Pugin et al (19), consisting of six parameters such as temperature, leukocyte count, tracheal secretions, radiographic findings (new infiltration and progression of the infiltration), PaO2/fiO2 ratio and tracheal aspirate culture, scoring 0- 2 for each parameter. The incidence of VAP was confirmed if the score is > 6 to 12.
The incidence rate was calculated by the formula VAP rate = No. of VAP cases x 1000 No. of Ventilator days
Patients on mechanical ventilator
In this study it refers to the adult patients admitted in the intensive care units, who were intubated and connected to mechanical ventilator for respiratory support for more than 48 hours and on closed monitoring system for early detection and management of the complications.
14 Assumptions The study assumes that
the patients on mechanical ventilator are at high risk of developing ventilator associated pneumonia, lung injury and oxygen toxicity.
ventilator Associated Pneumonia increases the mortality and morbidity rate of the patients admitted in intensive care unit.
a vigilant compliance of comprehensive preventive measure is necessary for the reduction in incidence rate of ventilator associated pneumonia.
the reduction in the incidence rate of the ventilator associated pneumonia also reduces the length of hospital stay and the health care cost for the patients.
ventilator care bundle is cost effective comprehensive preventive measure for ventilator associated pneumonia adopted by many health care institues.
a strict compliance to the comprehensive infection preventive measures is not present among health care providers.
the continuing nursing education, reinforcement programme, a vigilant surveillance and monitoring are necessary for the nurses‘ strict adherence to infection prevention measure that could prevent the ventilator associated pneumonia.
Null Hypotheses
Ho1 There will be no significant difference in the incidence rate of Ventilator Associated Pneumonia between the pre – intervention and post-intervention groups of patients on mechanical ventilator at p <0.05 level of significance.
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Ho2 There will be no significant difference between the pre-test and post-test knowledge scores of nurses taking care of patients on mechanical ventilator regarding certain interventional methods including VAP bundle at p <0.05 level of significance.
Ho3 There will be no significant difference in the practice scores of nurses regarding certain interventional methods including VAP bundle between pre-intervention and post-intervention groups of patients on mechanical ventilator at p <0.05 level of significance.
Ho4 There will be no significant correlation between the practice scores of certain interventional methods including VAP bundle and the incidence rate of Ventilator Associated Pneumonia among pre-intervention and post-intervention groups of patients on mechanical ventilator at p<0.05 level of significance.
Ho5 There will be no significant association between the selected demographic variables of patients on mechanical ventilator and the incidence of Ventilator Associated Pneumonia at p<0.05 level of significance.
Ho6 There will be no significant association between the clinical variables of patients on mechanical ventilator and the incidence of Ventilator Associated Pneumonia at p<0.05 level of significance.
Ho7 There will be no significant association between the selected demographic variables of nurses taking care of patients on mechanical ventilator and their knowledge scores at p<0.05 level of significance.
Delimitations The study is delimited to
the patients who were on mechanical ventilator for more than 48 hrs.
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patients admitted to intensive care units during the one year period of data collection.
the nurses working in the two intensive care units during the period of data collection.
a period of 12 months.
to only two intensive care units.
Conceptual Framework for the Study Based on Modified Kurt Lewins Change Model
The conceptual framework of the study was based on Modified Kurt Lewins Change Model (1947) (20) which is derived from a larger conceptual model and does not seek to explain or conceptualize the entire human experience but rather serves as a bridge between a larger conceptual framework and the practice level of nursing.
This model is very simple and practical for understanding the change process. The process of change entails in creating the perception that a change is needed, then moving toward the new, desired level of behaviour and finally solidifying that new behavior as the norm. The model is still widely used and served as the basis for many modern change models. Within the context of this theory, the goal of nursing is defined as motivating individuals and groups of nurses to attain, maintain or to re- establish the use of certain interventional methods including VAP bundle. Therefore the nurses act as a positive change to support and encourage nursing care for pursuit of essential care of patient on mechanical ventilator which is the ultimate goal of nursing. Kurt Lewins has developed a change model involving three steps:
unfreezing, changing and refreezing.
17 Unfreezing
This stage is to start creating motivation to change. Before a change can be implemented, it should go through the initial step of unfreezing. This is because many people naturally resist change and the goal during the unfreezing stage is to create an awareness of how the status qualifies or current level of acceptability is hindering the nursing care in some way. The problem for event is the catalyst that create the pressure for movement of attitude and for change to occur, while communication is the key to this unfreezing catalyst. Effective communication is important during the unfreezing stage. The current nursing care, ways of thinking process, nurses and procedures must all be carefully examined to show nurses necessity of change in current nursing care to create or maintain a competitive advantage in the intensive care units. So that nurses must be informed about the imminent change of zero VAP.
They feel the urgent necessity to adopt and comply to the certain evidence based practices including VAP bundle to achieve the goal and they are motivated to accept the change empowering the nurses to embrace new way of working.
Changing
Now that the nurses are unfrozen, they can begin to move. Lewin recognised that change is a process where the nursing care must transit or move into this new state. This changing step is also referred to as ‗transitioning‘ or ‗moving‘ stage and is marked by the implementation of the change. It is also time marked with that most of the nurse struggle with the new reality, uncertainty and fear, making it the hardest step to overcome. During this step the nurses learn about certain intervention including VAP bundle. The more prepared they are for this step, the easier it is to complete.
Hence the education, communication, support and time are critical for nurses in this
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step, as they become familiar with the change. Again, change is a process that must be carefully planned and executed. Educating / sensitising the nurses highlight the gap between the current and desired state and present a vision as it needs to be.
Throughout this process, nurses should be constantly reminded of the incidence rate of VAP, once fully implemented.
Refreezing
It is the process of sustaining the changes through criticizing and adaptation of the change. The change has to be anchored into the culture of nursing. This is necessary for creating the confidence from which to embark and on the next, evitable change. The system may revert to former ways of doing things at this point unless changes are reinforced through refreezing. Lewin called the final stage of his change model freezing but many refer to it as refreezing to symbolize the act of reinforcing, stabilizing and solidifying the new state after the change. The changes made to nursing care and goals are accepted and refrozen as the new norm. Lewin found the refreezing step to be especially important to ensure that nurses do not revert back to their old ways of nursing care or doing prior to the implementation of the change.
Efforts must be made to guarantee the change is not lost; rather, it needs to be cemented into the nursing care and maintained as the acceptable way of thinking or doing. Positive outcomes of certain interventional methods including VAP bundle acknowledged with individualised nursing efforts are often referred to reinforce the new state because it is believed that positively reinforced nursing care will likely be repeated.
19 Identifying
Assess the level of knowledge and practice regarding certain interventional methods including VAP bundle among the nurses
Assess the incidence rate of VAP
Restraining factors Inadequate knowledge Lack of awareness and motivation
Lack of positive reinforcement through feedback sessions Resistance to change Lack of time during crisis situation
Researcher acts as a change agent
Stages of change
Analyses the utilisation of certain interventional methods including VAP bundle among the nurses
Unfreezing
Creating an awareness to perceive the necessity for real time compliance to certain interventional methods including VAP bundle
Changing
Accepts and complies to certain interventional methods including VAP bundle
Refreezing
Motivating by giving positive feedback and reinforcement by displaying the degree of compliance and incidence rate of VAP
Fig 1: Conceptual Framework Based on Kurt Lewins Change Model
20 Projected Outcome
The projected primary outcome will be reduction in the incidence rate of ventilator associated pneumonia and the secondary outcome include improvement in the knowledge and practice of the nurses taking care of patients on mechanical ventilator regarding certain interventional methods including VAP bundle
Summary
This chapter has dealt with the background, need for the study, statement of the problem, objectives, operational definitions, assumptions, null hypothesis, delimitations and conceptual framework.
Organisation of the Reports
Further aspects of the study are presented in the following chapters.
CHAPTER II : Review of literature
CHAPTER III : Research methodology includes research approach, research design, setting, population, sample, sampling technique, tool description, content validity and reliability of the tools, pilot study and data collection procedure and plan for data analysis CHAPTER IV : Analysis and Interpretation of Data
CHAPTER V : Discussion
CHAPTER VI : Summary , Conclusions, Implications and Recommendations
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CHAPTER II
REVIEW OF LITERATURE
A review of literature involves the systematic identification, location , scrutiny and summary of written material that contain information on research problem. The researcher conducted an extensive search of the literature through electronic sources and hand search with the aim to develop meta synthesis of the available evidences of studies. The collected literature is organised under the following headings:
Incidence of ventilator associated pneumonia
Causes and risk factors of ventilator associated pneumonia
Diagnosis of ventilator associated pneumonia
Treatment of ventilator associated pneumonia
Prevention of ventilator associated pneumonia
VAP bundle care
Incidence of Ventilator Associated Pneumonia
Ventilator associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs after 48–72 hours of endotracheal intubation and receiving mechanical ventilation in ICU. VAP occurs in 9–27% of all intubated patients. (21) The Centers for Disease Control and Prevention (CDC) had reported a decreasing between 2002 and 2009 i.e. the mean VAP rate among medical ICUs dropped from 4.9 to 1.4 events per 1,000 ventilator-days and from 9.3 to 3.8 / 1,000 ventilator-days. (22)
In a retrospective study the incidence, clinical and microbiological features, treatment characteristics and prognosis of pneumonia was assessed following cardiac
