Ventilator-Associated Pneumonia, Capstone Project Example
Words: 14526Capstone Project
Intensive care units (ICU) serve as the site where gravely ill individuals recuperate from their perilous afflictions. However, it is in this very “care” unit where seemingly careless regard for the patients accounts for the “second most common nosocomial infection in critically ill patients.” Ventilator-associated pneumonia (VAP) is this disease. VAP is a lung infection that is caused by prolonged (two days or more) reliance on a ventilation machine (Koenig, & Truwit, 2006). If the ventilation tubes that provide oxygen to the patient become contaminated with pathogens, then VAP develops when these organisms find their way to the patient’s pulmonary organs (Ventilator-Associated Pneumonia (VAP), 2012). Also referred to as hospital-acquired pneumonia (HAP), this preventable sickness has been known to increase hospital stay and hospital costs—the former by at least a week, the latter by at least $40,000 per patient (Amanullah, & Posner). Ventilator-associated pneumonia occurs in 28% of mechanically ventilated patients with a mortality rate ranging from 27-76%—increasing if “appropriate and adequately dosed antibiotic therapy” is not rapidly applied (Amanullah, & Posner.
I would like to take this opportunity first and foremost to give thanks to my God, without Him the requirements to complete this project would be futile. This journey would not have been possible without the support of my family, professors, mentors, and friends. I give special thanks to my husband and three children who supported me every inch of the journey and to my mom and dad, sisters and brothers my pastor and family who inspired me. Their optimism drives me every day; they support me in every aspect. I would like to express my deepest appreciation to my Capstone Chair and mentor; Dr. Rivers who have provided much direction for me when I was totally lost. You have given your time, expertise, untiring support and guidance throughout my journey. Thanks so much for all the support that you gave me, the endless e-mails back and forth, clarification of misunderstood information, your prompt and professional responses to my questions, your motivation, and the care and concern you have shown me throughout the course. Last but definitely not least, I must thank my course mentor. Rovina Billingslea simply the best. You have motivated me, my e-mails and phone calls were always answered promptly, you were there to guide me through, and it is greatly appreciated. The journey was long and tedious, there were ups and downs but through it all, I made it with all of your support. Thanks to all.
Chapter 1: Introduction to the Problem
Background and Overview
Intensive care units (ICU) served as the site where gravely ill individuals recuperated from their perilous afflictions. However, it is in this very “care” unit where seemingly careless regard for the patients accounted for the “second most common nosocomial infection in critically ill patients” (Koenig & Truwit, 2006, p. 637), ventilator-associated pneumonia (VAP). Most cases of VAP developed as a direct result of clinic practices. Therefore, was is important to understand the progression of the illness.
According to Koenig and Truwitt, VAP is a lung infection caused by prolonged (two days or more) reliance on a ventilation machine and is known as a “healthcare-associated infection” (Center for Disease Control and Prevention (CDC), 2012, Title). The CDC stated that VAP develops when the ventilation tubes providing oxygen to the patient become contaminated with pathogens and find their way to the patient’s pulmonary organs. Often the cause of 90% of hospital-acquired infections, VAP arises within 48 hours of intubation (Lau, O’Keefe-McCarthy, & Santiago, 2008). Ventilator-associated pneumonia is usually suspected when the individual develops a new or progressive infiltrate on chest radiograph, leukocytosis, and purulent tracheobronchial secretions. Unfortunately, and unlike the criteria for community-acquired pneumonia, accepted clinical criteria for pneumonia are of limited diagnostic value in definitively establishing the presence of VAP (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004). In most cases, VAP is a preventable disease, and its occurrence in preventable cases has potentially severe clinical and economic losses for the patient, the hospital, and the healthcare system.
The clinical consequences of preventable VAP occurrences were substantial. When clinical consequences were realized, they most often translate into economic costs and needless loss of life. A type of hospital-acquired pneumonia (HAP), this preventable sickness was known to increase hospital stay and hospital costs—the former by at least a week, the latter by at least $40,000 per patient, Amanullah (2013) conveyed. As Amanullah (2013) stated, VAP occurs in 28% of mechanically ventilated patients with a mortality rate ranging from 27-76%—increasing if it is not immediately recognized and treated.
In addition, having to treat a case of preventable VAP produced other consequences that result in loss of life. “Increasing drug-resistance rates among gram-negative pathogens that frequently cause ventilator-associated pneumonia” according to Amin (2009, p. S36) have resulted in increased healthcare cost as well as longer hospitalization for patients and higher mortality rates in healthcare settings, explained Amin.
According to Vima Medical (2011), despite the fact that the medical field knew the importance of having a protocol to follow and implement in the prevention of VAP, these programs have not been applied with consistency:
The key components of the Ventilator Bundle are: Elevation of the Head of the Bed (HOB >30°), Daily ‘Sedation Vacations’ and Assessment of Readiness to Extubate, Peptic Ulcer Disease Prophylaxis, Deep Venous Thrombosis Prophylaxis and Daily Oral Care with Chlorhexidine. (Vima Medical, para. 4).
Mechanical intubation inhibited the patient’s ability to yield to his or her cough reflexes, hindering the effective eviction of built-up mucus that can seep infectious bacteria into the lungs, according to Lau et al. (2008). The result of mechanical intubation was often the inability of the patient to yield to his or her cough reflexes, hindering the effective eviction of built-up mucus that can seep infectious bacteria into the lungs, according to Lau et al. (2008). Recognized as a continuous dilemma for critical care nurses, VAP was often approached by the “use [of] current evidence-based strategies to decrease its incidence and prevalence” (Lau et al., 2008, p. 193).
In the prevention of VAP, many educational training programs were introduced to train nurses and healthcare workers in practices that were thought to prevent VAP. People opposed to these training programs claimed the typical points of training were not validated in research, and might even be detrimental to the patient (O’Grady, Murray, & Ames, 2012). If groups of healthcare workers questioned the practices conventionally thought to prevent VAP, there was not any motivation to follow them if the practices were called into question. Therefore, it was the intention of this study to test if the Association for Professionals in Infection Control and Epidemiology’s (APIC) protocol was effective in lowering the cases of VAP in an ICU setting.
Investigation into the background and overview of VAP revealed many occurrences of VAP arise from a failure to follow infection prevention protocol. Maselli (2011) described certain causes of VAP as inherent; risk factors patients arrived with, including depressed immune systems due to severe illness such as cancer and HIV, and external factors, such as a failure of hospital staff to sanitize their hands after each patient. This study concentrated upon how adherence to a consistent protocol could reduce the number of preventable cases of VAP. The problem statement and the rationale and significance of the study explained the importance of finding ways to lower the amount of incidences of preventable VAP.
As healthcare professionals are extensively trained to ensure that patients heal rather than worsen after a stay at the hospital, the ill afflicted trust them with their lives. Ventilator-associated pneumonia (VAP) is an ailment a dependent patient acquires when the nurses and Respiratory therapists are responsible for their recovery do not sufficiently abide by the protocols to prevent infection. Whilst losing the trust of the patient and his or her family, the healthcare provider responsible for the full manifestation of the preventable disease also costs his or her place of employment a fraction of its credibility. For the sake of the betterment of the medicinal field, the researcher chose this topic as a way to raise awareness about the importance of proper preventative procedures regarding VAP so that patients would no longer have to suffer because of incompetence and inconsistency in their healthcare giver’s craft.
Rationale and Significance of the Study
The importance of this project to the researcher’s discipline resided in the name of improvement. The medicinal field was always in need of enhancement; if it were not so, VAP would not be a detrimental factor that plagues the hospital setting’s existence and reliability. This project sought to discover the most efficient way of reducing if not completely eliminating this infection (and others possibly acquired in a hospital setting) by developing a structured regimen that aimed to discipline healthcare givers into wholly complying with hospital standards without having to face debasing consequences on their and the hospital’s behalves.
Purpose of the Study
The purpose of this study was to assess the success of using a protocol, such as the procedures and documentation proposed by The Association for Professionals in Infection Control and Epidemiology (APIC) in decreasing the amount of reported cases of VAP within an ICU setting.
The theoretical framework that was utilized in this study involveed a quantitative case study method in order to determine how specific teaching strategies play a role in facilitating education for ICU nurses who otherwise might not possess sufficient knowledge regarding VAP and its impact on their patients.
- This research study intended to utilize a quantitative case study method. The study’s research questions were detailed below:
- What were teaching strategies implemented in the Intensive Care Unit to care for patients that were intubated?
- How did implementing VAP teaching strategies in the ICU compare in terms of learning outcomes and performance to traditional classroom programs?
- What were some possible solutions for developing a more effective practice to ensure VAP prevention coursework and training programs for future nurses?
What would be the experience of VAP if the ICU did not have VAP prevention programs?
- This experiment did not involve any form of human experimentation or testing.
- This study did not include children (individuals under the age of 18) among the study’s respondents.
- In order to minimize any risk to the study’s respondents all participation was completely confidential with the researcher being the only individual with access to identifying information. Furthermore, after five years, all records pertaining to study respondents would be destroyed by members of the department and the researcher. Finally, This study’s survey respondents would not include any members of a vulnerable population participation in the study itself was completely voluntary and can be withdrawn at any time during the study including requesting the final results to omit a respondent’s information if requested.
- The researcher has ensured complete confidentiality by assembling the sample frame and the sample pool independently. Additionally, the final record of survey respondents were placed in a sealed envelope or file and retained only for a period of five years after which they were destroyed
The researcher hypothesized that if the nurses comply with the health precautions and the procedures in place, then the occurrences of VAP within the hospital setting would drastically decline because of improving adherence to VAP protocols. Due to the fact that VAP is a preventable disease, if the preventions were executed, then the disease would be annihilated. This rationale wasthe foundation for the following research question:
Did establishing and implementing APIC’s VAP prevention protocol produce lower occurrences of VAP in intensive care units?
The following were the null and alternate hypotheses for the study. The null hypothesis reflected no effect once the VAP prevention program was established. If the alternate hypothesis was proven, the establishment of the VAP prevention program was effective in reducing the incidences of VAP in an ICU setting. The independent variable was the APIC training and guidelines. The dependent variable was the number of VAP related illnesses and deaths in an ICU setting.
H0: The implementation of the APIC training and guidelines decreased the occurrences of VAP in an ICU setting.
H1: The implementation of the APIC training and guidelines decreased the occurrences of VAP in an ICU setting.
In chapter one, the overview and background of the problem of VAP was presented. The problem statement, rationale of the study, purpose, and hypotheses were presented. Terms that will be used throughout the paper were defined.
Chapter 2 presented the literature review. After a brief introduction, the two types of factors thought to contribute to the progression of VAP were explained. Best practices to prevent VAP progression were described in general, followed by a detailed description of APIC’s VAP prevention protocol and the summary and conclusion for the chapter.
Chapter 2: Literature Review
Approach to the Literature
The literature review consisted of various studies that that were completed on implementation of an education initiative use of evidence-based practice and guideline recommendations. The literature review explained the preventable and unpreventable factors that contributed directly to the development of VAP and best practices in the prevention of VAP. Anticipatory measures and best practices were vital characteristics of nursing care for patients who received mechanical ventilation.
Causes and Factors of VAP
A review of the literature revealed two types of factors that were found to contribute to the occurrence of VAP. Maselli (2011) found there were some factors that could be controlled for within a healthcare setting, and some factors were inherent in the condition of the patient.
Inherent Patient Risk Factors
Some patients were naturally at higher risk to develop VAP than other patients. Some factors, conveyed Maselli (2011), contributed to the development of VAP that were outside the control of hospital staff were if the patient is above the age of 60 and male, if the patient had an upper respiratory infection, multiple organ dysfunction syndrome (MODS), coma, chronic bronchitis or emphysema, a tracheotomy, multiple intubations, injuries to the cranium or brain, and neurosurgery. Other factors that can put a patient at risk for infection are: “Patient has received hemodialysis, wound, or infusion therapy as an outpatient; patient was previously hospitalized for at least 3 days within the past 90 days prior to current admission; or the patient is immunocompromised due to underlying disease or therapy (HIV, chemotherapy” (APIC, 2009, p. 10).
However, there are many factors that contributed to the development of VAP that healthcare workers can control to reduce the incidences of VAP within the health care setting, if not all cases despite inherent factors. The following section described hospital-associated causes of VAP.
Hospital-Associated Causes of VAP
There was more motivation than ever to reduce HAIs from occurring. Insurance companies ceased payments on “preventable” diseases, basically diseases that were acquired in hospitals, stated Paciella (2009). The costs for these diseases now come directly out of the pocket of the hospital, because the hospital does not receive reimbursement for treating the illness and the hospital is not allowed to charge the patient for the care (Paciella, 2009).
Research has established that many causes of VAP are caused by factors that are directly linked with the care of the intubated patient. There are several possible contributing factors for the development of VAP as Pitett (2003) outlined. Hand hygiene is considered the primary measure to reduce the transmission of nosocomial pathogens. Noncompliance with hand hygiene remains a major problem in hospitals. Due to poor hygiene, more and more patients are being exposed to various types of nosocomial pathogens and infections. These infections range from a common cold to life threatening illnesses. Following recent improvements in our understanding of the epidemiology of hand hygiene compliance, new approaches were suggested. Guidelines for hand hygiene were revisited and improved the standards and practice in healthcare settings.
Another source of infection was the condition created by the tracheal tube. John Hopkins Medicine (n. d.) explained that when a breath of air is inhaled, it is naturally heated, cleansed, and moistened. A tracheal tube circumvents the natural breathing process, and the forced oxygen is colder, lacks moisture, and not as sterile. The body creates an increased amount of mucus. The tracheostomy tube is suctioned to remove mucus from the tube and trachea to allow for easier breathing and mitigate the chances of pulmonary infections. Normally, a patient would be suctioned every 4 to 6 hours and as needed to reduce the risk of bacterial infections in the pulmonary tracheostomy. It was imperative patients are suctioned within the appropriate time periods set forth by the hospital to mitigate various pulmonary infections and reduced hospital cost.
Williams, Chan, and Kelly (2008) highlighted problems that can arise from improper head elevation: “Elevation of the head-of-bed (HOB) of intubated patients is an effective method for reducing rates of aspiration pneumonia.” (para. 9). Williams et al. expressed a patient elevated at less than a 30-degree angle is one of the leading preventable causes of contracting the illness. Williams et al. found if other non-modifiable risk factors are controlled within a study, such as advanced age, recently taking prescription antibiotics, and massive organ failure, as well as other modifiable contributions, such as hand washing and tracheal tube maintenance, head positioning was identifiable in its role in the development of VAP within 24 hours of intubation.
Maselli (2011) expressed healthcare workers can make a big difference in the reduction of VAP through factors associated with the direct care of the patient. These factors include maintenance of a head elevation position between the 30 and 45 degree angle, which decreases the amount of hydrogen, carbon dioxide, or methane collecting in the digestive system, “contamination of ventilator circuits, [and] frequent patient transfers and low pressure of the endotracheal tube (ETT) cuff” (Introduction, para. 2). Other hospital procedures shown to reduce incidences of VAP include consistent hand sanitation, adherence to reporting requirements for washing hands, and patient dental hygiene maintenance (if a certain protocol is not followed in teeth cleaning, bacterial contamination can take place).
However, various gaps exist between what was expected of healthcare workers to be practiced and what actual care patients receive. The next section identified best practice, examined current health care practice, and evaluated compliance after educational involvement. The best way to achieve the ambitions of this study was to utilize a comprehensive program that helped track progress and generated data for research.
In the APIC (2009) system for VAP prevention, there were some core concepts that drove the concepts behind best practices. The core concepts were discussed along with the APIC practices to demonstrate the features of the protocol.
Best Practices for the Prevention of VAP
In this section, The Association for Professionals in Infection Control and Epidemiology (APIC) was described in terms of their goals and their activities in order to understand their authority in the subject of infection prevention, followed by a description of their VAP prevention program and how its features align with best practice procedures.
APIC (n. d.)
APIC described their association as a collective consensus of health care professionals such as nurses, emergency care workers, doctors, scientists, and “medical technicians who” (Para. 2):
- Collect, analyze, and interpret health data in order to track infection trends, plan appropriate interventions, measure success, and report relevant data to public health agencies.
- Establish scientifically based infection prevention practices and collaborate with the healthcare team to assure implementation.
- Work to prevent healthcare-associated infections (HAIs) in healthcare facilities by isolating sources of infections and limiting their transmission.
- Educate healthcare personnel and the public about infectious diseases and how to limit their spread. (APIC, n. d., para. 2)
Their role in policy-making and ties to Congress are noteworthy and influential, serving as a source of information for policy makers as they create legislation to ensure public safety (APIC, n. d., Public Policy and Advocacy). The following sections described the features of the APIC (2009) VAP prevention system that coincided with concepts behind best practices in nursing. These concepts aligned with widely accepted nursing research and projects that sought to improve current practices.
Evidence Based Practices (EBP)
APIC (2009) stated their Guide to the Elimination of Ventilator-Associated Pneumonia is based upon EBPs. EBP is not just a buzzword. EBP is defined as “innovative interventions that are based on best practices as well as solid research-based evidence” (Majid, Foo, & Mokhtar, 2011, p. 229), and has become an increasingly integral part of the nursing field.
Evidence-based practice explores the empiric way of knowing, focusing on Methods of critically appraising and applying available data and research to understand and inform clinical decision-making better. Although it clearly is not the only way of knowing, evidence-based practice provides a way to frame and address questions about how to provide the best patient care. For the Purpose of this article, the following definition of evidence-based practice has been selected: “the integration of best research evidence with clinical expertise, and patient values”. (Pipe, Wellik, Buchda, Hansen, & Martyn, 2005, p. 365)
Kempnich (2011) explained a gap analysis is used to analyze, then express current policies and nursing practices in order to find gaps between existing practices and best practices, gaps in knowledge, adherences to best practices, and gaps in patient outcomes (desired health outcomes versus present health outcomes). According to Devo (n. d.), gap analysis process begins with a self-assessment. Then the self-assessment is compared to the standards usually provided from governmental organizations aiming to improve safety and adherence to regulations and standards. For this study, a gap analysis is used and will be described in detail in the methodology section.
Learning as a Collaborative Effort
According to Kempnich, (2011), collaboration as a team optimizes learning efforts. The APIC bundle for VAP prevention utilizes the concept of a team effort in training, education, practices, and prevention, expounding upon the collaborative effort, equal appreciation for respect, and team member responsibility..
Ensuring “Safe and Reliable Care” (Vanderbilt University Medical Center, n. d.)
Vanderbilt University Medical Center associated safe and reliable care with forming teams of qualified nurses who have mutual respect for their areas of expertise and skills to reduce hospital-acquired infections (HAI). The following standards are also incorporated into the APIC bundle:
- Consistently achieve and exceed all of the publicly reported and internally developed core measures targets as well as comply with all regulatory standards
- Reduce hospital acquired condition rates to be at or below the established target for all state and CMS reported conditions.
- Support the deployment and use of evidence based order sets and decision making where applicable.
- Reduce the potential risk for known high-risk processes
The Role of Hospital Administration
Clarke and Donaldson (n. d.) and Vanderbilt University Medical Center (n. d.) agreed that the hospital administration molds the attitude, work culture, procedures, and safety measures within the healthcare setting. Employees take their cues from hospital administration. APIC account for the roles the hospital administration plays and strives to involve them by establishing reporting systems based on hardcore data for job fulfillment and unit goals department goals.
Capturing Relevant, Timely Data to Improve Patient Care
As Clarke and Donaldson (n. d.) stated, “Clearly, capturing data about patient outcomes prospectively (i.e., as care is delivered) is the best option for obtaining precise, comprehensive, consistently collected data. This approach is the most challenging because of practical, ethical, and financial considerations” (p. 10). The APIC (2009) system has built into it data charts that help to capture relevant data, tracking progress on keeping down infections in critical care units.
Providing a Uniform Training Protocol
The Critical Care Nurse Training Standards Task Group (n. d.) cited the importance of having a standardized, evidence-based training protocol to educate ICU nurses and staff. The APIC system contains the elements one needs for adequate training. Adequate training, stated the Critical Care Nurse Training Standards Task Group (n. d.), starts with providing standard and consistent guidelines and procedures on how to perform the duties necessary that fulfill the job of ICU nurse, which in turn will adhere to standards that promote patient safety.
Description of the Guide to the Elimination of Ventilator-Associated Pneumonia (APIC, 2009)
Nurses play a large role in the care of patients. Since nurses are the ones that have the most contact with patients, they can make the most difference in decreasing preventable incidences of VAP. Having a comprehensive program to follow and track results will help nurses in their practice and in the prevention of VAP.
Programs to prevent the occurrences of VAP were created to encompass everything from direct patient care to documentation to keep track of the occurrences of VAP, adherence to protocols, and administrative tracking of all aspects of the program to reduce VAP and help nurses in their practice and care of ICU patients.
APIC (2009) offered a comprehensive program free of charge on their website. The program offered all the necessary paperwork for all departments within a hospital setting, which made the implementation of their program and the recording of the results after the program is instilled traceable, and generated data that could be used in course of research. APIC’s comprehensive program for the prevention of VAP included nurse education and follow up in adherence to procedures. The aspects of this program were outlined below.
APIC (2009) recommended beginning with an initial risk evaluation of a hospital’s current practice in VAP prevention to see what documentation procedures were in place to track the occurrences of VAP in the health care setting and in the prevention of VAP, such as tracking hand sanitation, sedation cessation at intervals, periodic weaning evaluations, keeping patients at the required 30 degree head elevation, and periodic tooth brushing. In the evaluation process, the health care staff should determine if their present practices are evidence-based, are reported to hospital management, and if there is an established, evidence-based educational program to train staff to prevent VAP.
Once the evaluation has been completed, APIC (2009) recommends a list of procedures and educational materials on how to maintain trachea tubes to prevent the spread of bacteria, such as the best intubation equipment to use to minimize the risk of infection, appropriate patient head elevation, and equipment cleaning procedures, the recognition of factors that put some patients at higher risk of developing an infection, and how to collect data consistently to track the implementation of the VAP prevention program.
Reporting is also an essential part of the program according to APIC (2009). Health care facilities should establish reporting protocols for hospital administrators to track progress, according to APIC (2009). Health care workers should be encouraged to keep thorough, detailed records, and use the forms provided by APIC to translate the compliance program’s success into data to track progress in the prevention of VAP within the facility.
The APIC (2009) manual for VAP prevention is included in Appendix A. All procedures, concepts, practice, and training protocols are described within the manual and serves as a source of reference for this study.
Threats to Adherence to Protocol
As the Agency for Healthcare Research and Quality (n. d.) observed: “No matter how good the bundle that you develop is, if it is not used by the staff it will not be successful” (para. 1). Clarke and Donaldson (n. d.) expressed that factors in the workplace can drastically affect the quality and delivery of care to a patient. Some possible causes of failure to adhere to protocol are understaffing, rate of nurse burnout due to understaffing issues and a stressful environment. Other causes are personal attitudes and lack of cultural cultivation of safety vigilance, a united effort for VAP prevention of best practices within ICU units, a lack of a protocol, and time restrictions (Majid, Foo, & Mokhtar, 2011).
Research Demonstrating Successful VAP Reduction Outcomes Using Ventilator Bundles
Several studies in recent years proved the effectiveness of ventilator bundling. The studies conducted in an ICU setting all contained many of the features of the APIC system explained above.
The Pennsylvania Patient Safety Advisory (2009) named a few hospitals that were able to bring down their VAP occurrences using ventilator bundles. One of these hospitals was the Roxborough Memorial Hospital (n. d). Before the study, according to the Roxborough Memorial Hospital, the hospital reported steady and increasing numbers of VAP cases for the years 2002 through 2004. After applying a ventilator bundle, they decreased their numbers to only one per year for the following three years, achieving zero cases of VAP in 2007. The success of decreased numbers of VAP cases was due to the implementation of a ventilator bundle protocol.
Some of the factors Roxborough Memorial Hospital (n. d.) that were thought to contribute to the success of the bundle program were teams of healthcare workers from different disciplines worked collectively as a team and provided input into the program implementation and tracking. Moreover, in addition to the preventative measures commonly associated with bundle programs, Roxborough Memorial Hospital reported that keeping, tracking, and analyzing data was pertinent to lowering their numbers for three years.
Korn, Burke, Burke, and Agarwal (2010) reported similar results upon implementation of a VAP prevention program. For their baseline assessment, Korn et al stated their rate of VAP infection was one case of VAP for every 100 hours. After the implementation of the bundle, their occurrences of VAP dropped 60%. “Initiation of a VAP bundle protocol is an effective method for VAP reduction when compliance is maintained” (p.466).
Even when reports on using ventilator bundle to prevent and decrease occurrences of VAP are not as rosy as one would like, one can still look to these studies to find areas of improvement, possible research design flaws, and other matters that might have skewed the results. One such example is a study by Bouadma, Deslandes, Lolom, Le Corre, Mourvillier, Regnier, Porcher, et al. (2010). When they implemented and tested a multifaceted bundle, they almost seemed to be disappointed their results were not close to or at zero cases of VAP for the duration of their research. Cadena, Tierney, and Restrepo (2011) attributed this to missing data in Bouadma’s et al. report. Also, observed Cadena et al., “The authors also included organisms not commonly associated with VAP, such as coagulase-negative Staphylococcus, Enterococcus species, and fungus. Given that microbiological confirmation was required for a VAP diagnosis, these organisms should have been excluded” (p. 1084). In addition, depicted Cadena et al., Bouadma et al. used proton pump inhibitors, which are associated with contributing to the occurrences of VAP. Mistakes like these are valuable lessons for future research designs and other valuable lessons negative or not-as-good-as-anticipated results can bring.
Why VAP Bundles Work
There are still some doubters who question the effectiveness of VAP bundles, claiming they are oversold as a solution, observed Darves (2005). They cite the reasons for their lack of faith to be that some of the individual practices are not proven as a “stand alone”, evidence-backed measure. However, as Darves pointed out, while some are weakly associated as preventative measures, such as hand washing, one cannot ignore the common sense of the practice, plus when associated with other measures such as head-of-bed elevation, assessment for early weaning, and other practices, the bundles are powerful as a package and have validity as a group. Perhaps it does not even make sense to test each measure in isolation, and it’s unethical, because it would bring the patient harm to use only one measure to improve care rather than use an entire comprehensive system. It makes sense that each measure is weakly associated as stand-alone because strategies starring a single preventative measure could not possibly be as effective as addressing all the possible causes of infection comprehensively.
While each patient arrived with an array of challenges and factors that contributed to their placement within the ICU, there were many factors that are within a nurse’s control that could decrease a health care facility’s incidences of VAP. Where patients were more prone to develop VAP, nurses made a significant contribution in decreasing occurrence of VAP even in the most challenging cases, even bringing VAP numbers to zero – “Many hospitals have achieved significant reductions in VAP rates in their critical care units, some even reaching zero by taking a comprehensive and multidisciplinary approach to ventilator care” (Institute for Healthcare Improvement, 2013, para. 1). Having a comprehensive VAP prevention program in place that includes the education of nurses and other staff most closely associated with the patient ‘s care, compliance to safe practice procedures aimed to reduce risk of infection, and meticulous record keeping by staff to keep track of compliance to procedures were essential elements within a comprehensive VAP prevention program. APIC’s program contains all of these elements, and is therefore a good program to use to track results and achieve the goals of this study. Moreover, more validation was needed for these protocols, and the APIC protocol in particular is understudied.
Chapter 2, the literature review was presented. Hospital-associated causes of VAP were explained, as well as a patient’s inherent characteristics that could increase susceptibility to VAP. Best practices to prevent VAP progressions were described followed by a detailed description of APIC’s VAP prevention protocol, the summary, and conclusion for the chapter.
In chapter 3, the methodology for the study was introduced and explained. The following elements of chapter 3 were described in detail: the setting, participants, research design, instrument or research tools, data collection, data analysis, human subjects’ protection, and summary.
Chapter 3: Methodology
This chapter contains the methodology for this study. The study setting will be described, as well as the participants. The research design, data collection, and data- analysis will be explained. The measures taken to protect human subjects will be stipulated.
The setting for this study occured within an intensive care unit (ICU), where gravely ill patients were most likely to be intubated. The training for the nurses took place in part in an available room in the hospital. The rest of the training occurred in the ICU. The establishment of the APIC record keeping system was established throughout appropriate recommended areas throughout the hospital setting.
The Role of the Researcher
According to APIC (2009), a person playing the role of infection preventions’ should be the key person to educate the faculty and be the person to facilitate communication across faculty and hospital administration channels. The researcher was the person who garnered the participation of any and all hospital staff responsible for the care of the patients. The researcher was also the person to ensure compliance of all staff to protocol, gather relevant documentation, and analyze the results of the study.
This proposed study would stress the importance of highlighting VAP guidelines in order to reinforce the preliminary procedures that were put in place to minimize, if not eliminate, the occurrences of ventilator-associated pneumonia (VAP) in the hospital setting. For this proposed study, sixteen nurses worked in the ICU setting in this researcher’s hospital and participated in the study. Since the APIC system-suggested guidelines included a systemic support system for the establishment and implementation of a comprehensive infection prevention protocol, the researcher approached recruitment for the study from the top down. The researcher sought the approval of the ICU department and the IRB of the hospital to conduct the study within the ICU setting, and obtained permission of all supervisory personnel. Not only did hospital administration approve the study, but they agreed to participate. It was the researcher’s goal to garner as many people as possible from other departments for their expertise in their field and input to form a committee to implement the APIC guidelines. While the numbers of people were not determined at this time, it was the hope of the researcher to seek out a committee of ten people to include different experts and different members of the hospital administration to stay true to the APIC protocol and benefit from the education and learning collaboration offers, an important part of the study. It was the hope of the researcher to have every person working in the ICU who had direct contact with ventilator patients to agree to a least participate in the assessment, which would amount to 16 nurses working in the ICU participants in addition to the 16 nurses and any supervisory and administrative personnel relevant to the study and implementation of the APIC.
With the implementation of the APIC protocol, all nurses, regardless of years on the job, training, and ethnicity, received identical training on the APIC system of record keeping and procedures for VAP prevention, and had an equalizing effect upon participant variations that could affect the study’s produced data.
The seriously ill patients also played a part in this study. They suffered from a variety of illnesses that resulted in their stay in the ICU. They came from all walks of life, are various ages, and had a variety of health problems. The one aspect they had in common was they were ill enough to require care in an ICU setting. The inherent factors of the patients discussed in the literature review could produce variations upon the results. However, variations in inherent factors that could leave some patients more vulnerable to infection than others were part of the realistic nature of caring for gravely ill patients, and added to the valuable experiences of this study. As past studies have shown, it was possible to have a year with zero cases of VAP if protocol is followed closely. Therefore, all patients who entered the ICU setting participated in the study. The number of participating patients was undetermined at this time.
A quantitative analysis generates data that can be manipulated (Howell, 2011) to discover if a change in procedures produces a discernible effect upon the occurrences of VAP in an ICU setting. This study will utilize the quantitative framework to discover if the implementation of the APIC protocol will reduce the amount of VAP cases in an ICU setting. A quantitative study will be used for this study to generate hard data that will either prove or disprove the null hypothesis.
Quantitative studies are important for the field of nursing. It produces the data the field needs to decide which practices should be acceptable, which to discard because of ineffectiveness, and which practices to incorporate or supplant older practices because it has been proven they are more effective and have a benefit for the patient. It was the hopes of the researcher that this study added to the literature and generated the data needed for other hospitals and nursing professionals to make informed decisions based upon valid research.
One saw elements of action research design in this study because of the collaborative nature of APIC VAP prevention bundle. However, because the researcher was leading the study and performed all calculations and was solely responsible for the generation of the results and subsequent write up of the research, this remained a quantitative research design with community and team learning and education aspects built into the APIC program.
Validity and Reliability
This study was designed with the implementation of the APIC protocol it emphasis on these protocols which show the reliability and validity of this design. The emphasis on these dimensions in this approach was to enhance the study’s validity through a process of survey studies specifically meta-analysis of relevant studies which occurs in those quantitative studies in which validity is achieved through establishing the credibility of the source material, which, in this case, involved the existing research and literature on the subject of ventilator associated pneumonia. This tool was implemented in the Intensive Care Unit where new nurses in training would be educated. The survey tools leading to credibility within the study involved the integration of existing research that was subject to peer review and criticism, the unique critical analysis by the researcher, and the inclusion of primary data. This research design wasdisplayed in the figure below:
Description of Instruments or Research Tools
All research tools were provided with the APIC protocol for VAP prevention, which was an evidence-based system of collecting and analyzing data (APIC, 2009). A variety of methods were utilized to gather data – questionnaires, surveys, historical gathering of data from patient files, and reports on observations from participating supervisory hospital staff.
SPSS was used to generate the dependent t-tests, the normality assumption, and generate the confidence intervals to see if the results of the test were significant. Harvard-MIT Data Centers (n. d.) stated that SPSS is a little limited for complicated analyses. However, for t-tests, it was known as a reliable tool for analysis.
For the baseline assessment, the researcher acquired the historical data from patient records. Each hospital patient’s records, ethnic background, course of illness, and other information pertinent to the APIC protocol and study were used solely for informational purposes. Each name on the record was dedacted and replaced with a case number.
The researcher sought compliance information from the hospital staff participants. Each participant was asked to fill out the required paperwork provided in the APIC bundle.
Integrity of Data
The integrity of the data was maintained on a removable storage device for a desktop or laptop computer. The device was stored in a locked draw, for which the researcher had the key to ensure safety and integrity of the data.
A t-test is a method of analysis that is beneficial to use when hardcore data is needed to gauge the effectiveness of implemented protocols. T-tests have validity and are the most widely used analysis (Howell, 2011).
The analysis technique utilized a dependent t-test. The rationale for the use of the dependent t-test was the experiment took a preliminary data assessment. The experimental situation, the establishment of the protocol, was instilled into the practices of the ICU unit. After a predetermined segment of time, the data was measured at the end. The ending data set was compared with the first data set. Since there will be a beginning data set, the protocol was administered, then a collection of data from the same ICU at the end of the experiment, a dependent t-test was desirable to use, according to Howell, to discover if a made a significant contribution to the reduction of VAP for the month of study. This analysis contrasted independent t-tests, where the origins of the two sets of data were provided from two separate groups, such as a control group and an experimental group, stated Howell. Since this study looked for a change in data from the same setting, a dependent t-test was more appropriate.
The baseline assessment was performed. Another assessment was conducted once a month for six months to see if VAP death and acquisition rates had fallen. The data was tested for normality, and was reported with a confidence interval of 95%.
Other calculations were important to understand the success or failure of the implementation of the APIC bundle. The researcher used the APIC (2009) guidelines for conducting a baseline assessment of the ICU unit. A combination of nominal and ordinal data responses were used on the questionnaires for the researcher to complete. The subjects covered are present compliance to VAP protocols (hand washing, sedation vacations/readiness to wean, head-of-bed elevation, and oral brushing/cleaning). The next step was to conduct the assessment. Historical data, the different types of infections and occurrences, was used to generate meaningful data. After selecting length of time for data examination (which will be one year for this study), financial costs generated from illness and mortality rates per 1000 hours were generated. The assessment helped generate a supervision plan for the execution of the protocol. Moreover, the baseline assessment data, the death rates, were used as part of the methodological part of the study as the preliminary data for the dependent t-test.
Human Subjects Protection
Minimizing harm of the participants was built into the research design. This study was conducted with the permission of the IRB at the hospital. The IRB reviews research proposals and had a set of standards research must meet in order for the study, including the ethical protection of the participants.
In this study, the researcher took extra measures to protect the participants from harm. Permissions were sought for nurses’ and other healthcare workers’ participation in the program to ensure they were participating freely. Their willingness to participate was part of the collaborative environment APIC suggested and ensured adherence to protocol, personal responsibility, and free will to participate, minimizing harm. Moreover, the education and training was applied equally to all hospital staff, so risk of emotional and mental harm was minimized. Any feedback they provided would be anonymous, so their truthfulness would not produce fear of supervisory discipline.
The study’s entire purpose was to protect the patients from harm, minimizing harm to the patients. Moreover, when patients were signed into the hospital, they or their relatives were informed that the facility was a teaching hospital. Since the study’s purpose was to minimize harm to the patient and improve upon present services using a prevention bundle based upon evidenced-based practice from an authoritative organization dedicated to the prevention of HAPs, harm was minimized to the patient. This in addition to IRB approval reduced the risk of harm to the patient.
In this chapter, the methodology of the study was explained. The setting, participants and protection of the participants were described. The data analysis, storage, and reliability and validity were explained, as well as the tools used for data collection and calculation was explained. Chapter 4 will explain the findings, if the APIC VAP prevention protocol was effective for reducing VAP incidences and deaths in an ICU setting.
Chapter 4: Findings
A comprehensive systematic bibliographic search of medical literature published between 2008 and 2012 was conducted for this research project. The search included four different types of studies as follows: 1) randomized controlled trials (RCTs); 2) non-randomized controlled trials (NRCTs); 3) controlled before-after (CBA) studies; and 4) interrupted time series (ITS) studies. In addition, all of the studies had to comply with the Cochrane EPOC (Effective Practice and Organization of Care) Group methodological criteria (McCauley & Ramsey, 2002). The purpose of each search was to locate literature specifically related to the evaluation of interventions designed to improve professional adherence to guidelines for the prevention of VAP.
The initial search resulted in the discovery of 132 relevant published articles, of which 114 were excluded since they were either duplicate studies or for various other reasons (e.g., simple reviews, studies with unclear designs, or studies not relevant to the current analysis). This selection was based on a review of the title and the available abstract. The remaining eighteen articles were retrieved so the researcher could make a complete review of the text. Following the reviews of the complete articles, nine of the articles were excluded for specific reasons. For example, five studies did not report outcomes of interest, one article pertained to the prevalence of VAP rather than prevention techniques, two studies were currently ongoing, and three articles reported duplicated data. Therefore, nine studies were included in the final meta-analysis for this literature search study. These nine studies are identified in Table 1.
Analysis of Data
In order to evaluate the information derived from the dataset known as “Epidemiology PMR – FY 2013,” it was important to conduct basis analyses that will evaluate an existing dataset and determine if compliance to the VAP protocol has changed or improved over a period of time, such as one year or four quarters. Based upon the utilization of the dependent t-test for this study, it was important to recognize that this test is basic in nature but provided significant information regarding the validity of a given problem and whether or not the results changed over time (Howell, 2011). By using patient records that have been generated for a given fiscal year, the statistical significance of the VAP protocol was determined and quantified. The dataset used for the t-test did not include any specific patient identifiers and instead, included the implementation of the VAP protocol in experimental form in the ICU for data analysis and evaluation.
Research Question 1
What teaching strategies were implemented in the Intensive Care Unit to care for patients that are intubated?
This research question was reflected in the statistics that compared the different quarters of the research study, and it was determined that education does not have a significant impact on VAP compliance in many areas. This issue remains weak as there were substantial cases of VAP that remained across the different ICUs. Based upon the findings, additional work was required in order to determine how teaching strategies were implemented, if there were consistencies in these teaching practices, and whether or not these differences had an impact on educational outcomes and protocol implementation. This was critical to the ability of nurses to be successful in their efforts to prevent VAP infections as frequently as possible.
Research Question 2
How did implementing VAP teaching strategies in the ICU compare in terms of learning outcomes and performance to traditional classroom programs?
Overall, the implementation of VAP education in the ICU had a positive impact and was more favorable than traditional classroom instruction, as demonstrated in the responses to the nurse questionnaire. However, there was a continued need to improve upon existing VAP teaching strategies to determine if they would have a long-term impact on education for nurses working in the ICU. There was a higher favorability for ICU education rather than classroom instruction because of the approach and context of the education protocol; therefore, this practice should be improved and expanded on a continuous basis.
Research Question 3
What were some possible solutions for developing a more effective practice to insure VAP prevention coursework and training programs for future nurses?
The implementation of VAP education in the ICU is essential to enable nurses to improve their understanding of the risks of VAP and its impact on ICU patients. This was encouraged through feedback from nurses such as the information provided in the questionnaire instrument. Nurses provided feedback and also addressed their concerns related to VAP education in the ICU because this played a critical role in the development of strategies for educators to expand the impact of this approach to promote knowledge retention for nurses working with ICU patients at risk of VAP.
Research Question 4
What would be the experience of VAP if the ICU did not have VAP prevention programs?
VAP cases would likely increase if there was no formalized education program in place to accommodate nurses in obtaining education regarding this important issue. They must be educated in order to take the steps necessary to prevent VAP under different circumstances and through the implementation of new approaches to reduce VAP across all ICUs. This form of education was critical to the success of nurses and their ability to implement protocols that would be effective in treating patients and in reducing the risk of VAP for this population. It was also relevant because it supported the growth of the knowledge base for nurses working in the ICU.
Quarter 1 – Quarter 2
In comparing the first and second quarter statistics, the following data was derived using a dependent t-test:
|Jul||Aug||Sep||1st Qtr||Oct||Nov||Dec||2nd Qtr|
|Adult VAP-AICU||339||292||308||939||Adult VAP-AICU||203||254||348||805|
|Adult VAP – CCU||43||35||6||83||Adult VAP – CCU||40||63||123||226|
|Adult VAP – CVICU||165||163||125||435||Adult VAP – CVICU||185||128||205||518|
|Adult VAP – RCU||163||147||93||403||Adult VAP – RCU||37||84||90||211|
|Adult VAP – TSS||0||0||0||0||Adult VAP – TSS||0||0||0||0|
|VAP – PICU||54||95||107||256||VAP – PICU||103||56||50||209|
|VAP – NICU||412||365||368||1145||VAP – NICU||342||30||252||964|
Based upon the results derived from the t-test, the P-value derived from comparing the first and second quarters was 0.128908886, which was deemed statistically insignificant because it was above the commonly used threshold of 0.05. This data demonstrated that in adopting the protocol from the first quarter into the second quarter, there was no statistical difference in compliance rates because the cases of VAP continued to be high overall across all ICUs. Although some areas have declined, such as the AICU, the RCU, the PICU, and the NICU, others actually increased, such as the CCU and the CVICU. Therefore, the protocol implementation was met with mixed results from quarter one to quarter two.
In the transition from quarter two to quarter three, the results indicated a P-value of 0.211931817, which remained statistically insignificant. However, this comparison was important because the two quarters demonstrated an increase in VAP cases in all but two units, the RCU and the NICU. All other units experienced an increase in VAP cases, which signified that the VAP protocol as implemented by nurses was not properly utilized and was not well understood, or compliance was poor. The movement from quarter two to quarter three also signified a potential set of challenges in implementing the VAP protocol over the long term because it did not provide any significant reductions in VAP cases within the majority of the units that were surveyed.
In the transition from quarter three to quarter four, the results indicated a P-value of 0.542958689, which was also statistically insignificant, based upon the threshold for standard P-values:
|Jan||Feb||Mar||3rd Qtr||Apr||May||Jun||4th Qtr|
|Adult VAP-AICU||292||246||329||867||Adult VAP-AICU||234||266||280||780|
|Adult VAP – CCU||59||124||132||315||Adult VAP – CCU||49||56||72||177|
|Adult VAP – CVICU||177||244||231||652||Adult VAP – CVICU||176||183||172||531|
|Adult VAP – RCU||77||67||38||182||Adult VAP – RCU||99||81||58||238|
|Adult VAP – TSS||0||0||0||0||Adult VAP – TSS||0||0||0||0|
|VAP – PICU||51||68||136||255||VAP – PICU||107||180||72||359|
|VAP – NICU||198||260||299||757||VAP – NICU||319||373||439||1131|
This dataset was somewhat different than the comparison of the prior quarters because there was a general decrease in the number of VAP cases in the AICU, the CCU, and the CVICU. However, there was an increase in cases in the PICU and the NICU, which demonstrated that there was another type of circumstance that might have occurred in both of these pediatric units that led to an increased number of VAP cases between these two quarters. This dataset was relevant because it supported the assumption that the method in which the protocol was administered and the training provided to nurses might be different between the adult ICU units and the pediatric ICU units. This was an important assumption because the manner in which pediatric patients were treated is generally different due to the vulnerability of this patient population. Nonetheless, the VAP protocol response and compliance rates were mixed, based upon the statistically insignificant results of the t-test alone.
From a researcher’s perspective, the evolution of the VAP protocol was considered in greater detail because based upon the t-test values, there was little significance and change in the administration of the protocol within the ICU in both pediatric and adult units. Therefore, it was important to recognize that there were other factors at work. The value of the dataset and the administration of the protocol appeared to be ineffective in reducing overall VAP cases. At the same time, other factors were considered, such as the period in which the data was derived, as different months of the year demonstrated a marked increase in the number of VAP cases, based upon weather and other factors leading to increased illness within a given patient population. Furthermore, other protocols or policies might have been implemented in the different units that nurses followed, which had an impact on the ability of this protocol to be successful in reducing VAP cases within these units.
Based upon the data provided and the P-values generated using the dependent t-test method, the hypothesis was null because the data had not demonstrated any real change in the number of VAP cases, in spite of VAP protocol implementation directly in the ICU. Although some results were mixed and had increased/decreased on a random basis that were difficult to measure, this study did not indicate that there was any real benefit to the VAP protocol implementation in its current form in the various ICU units under consideration. In spite of the recommendations provided by the Association for Professionals in Infection Control and Epidemiology (APIC), there was no real benefit to the implementation of this protocol using the case data provided for analysis. However, there was room for interpretation and a possible weak implementation protocol, based upon the dataset that had been provided.
It was important to identify areas where there were significant challenges in protocol implementation and in determining the protocol’s effectiveness in reducing VAP cases in this group. For example, the results were influenced by underlying factors such as poor hand hygiene, which has contributed to poor patient outcomes in the ICU (Pitett, 2003). Furthermore, the tracheal tube might have contributed to the statistics derived during the four-quarter period due to mucus development and limited suctioning (Johns Hopkins Medicine). Other challenges included poor head elevation, which contributed to increased cases of pneumonia (Williams, Chan, and Kelly, 2008), in addition to employee-based methods that increased comfort and reduced the risk of VAP within this patient population over a period of time (Maselle, 2011). Each of these factors contributed to the variances that were observed in VAP cases across the different ICU units and the statistical insignificance of the VAP protocol for patients.
It was also possible that the study results were distorted as a result of other unknown factors. Nonetheless, the results generally indicated that the implementation protocol was not successful on a consistent basis in reducing the number of cases of VAP within the ICU setting. The term “inconsistent” was essential to this discussion because it indicated that some nurses had not implemented the protocol in the desired manner and therefore, led to inconsistencies between quarters in the number of measured VAP cases. This information was relevant because it supported the need to potentially expand education in regards to the existing protocol or to consider other alternatives to modify the protocol as necessary to support the desired objectives and reduce the number of VAP cases over time. These efforts demonstrated if the protocol in its current form was effective with additional training, or if the protocol needed modification to better accommodate patient needs.
With respect to the nurse questionnaire, the findings suggested that the VAP protocol as implemented in the ICU introduced favorable results, thereby enabling the protocol to be a success within the implementation environment. These findings also demonstrated that it was important to utilize the protocol on a widespread basis in order to provide other nurses with the same type of education, based upon its favorability index as determined by the questionnaire results. It was expected that in future settings, similar feedback would be provided in order to accomplish the desired objectives of the protocol in the ICU setting.
Perhaps the most significant area to consider with the lack of effectiveness of the current protocol was the lack of understanding of the need for the protocol and whether or not it would make any real difference in patient-related outcomes. Some nurses perceived that the protocol would not make a difference and was ineffective and therefore, would not fully comply with its requirements. Others took a different approach and recognized the need for the protocol in spite of the relatively simple risks associated with VAP, yet supported its continuation through compliance with the required methods. In either case, nurses who were required to implement the protocol had to be on the same page and demonstrate their commitment to providing optimal patient care in critical care settings, even when there was a risk that the chosen methods would not be effective. Compliance was key in supporting this process and the eventual reduction of VAP cases in ICUs throughout the world.
As a researcher, it was important to identify other obstacles or barriers that had influenced outcomes and the t-test results. However, it was also possible that environmental factors and general poor or non-compliance with the protocol objectives played a role in these outcomes. It was important to identify the challenges that existed with this protocol and the potential that existed to overcome these challenges and to improve VAP protocol implementation in the future, along with any modifications to the existing protocol as necessary to ensure that greater compliance was achieved and VAP cases were reduced within this patient population. It was important to recognize these conditions because they represented an opportunity to explore the serious nature of VAP and its impact on patient care in ICU settings, particularly when patients possessed critical needs and may be in extreme danger, facing death or other complications.
Adherence to protocol requirements, however, may not tell the entire story. Therefore, additional evaluations in other healthcare organizations using the same protocols in a similar context were also considered as a feasible alternative to ensure that nurse compliance is maximized and patient care quality was improved through the use of this protocol on a consistent basis. These elements played an important role in shaping the future directives of ICUs and in supporting the development of new approaches to manage patient outcomes in an effective manner. The implementation of a VAP protocol was explored for its value and significance in supporting a reduced number of VAP cases and in achieving the desired results within the framework of the ICU patient care setting, as this type of protocol must achieve greater effectiveness within this environment.
Educating nurses regarding VAP teaching strategies in the ICU required an effective understanding of the challenges that they face with this process. Therefore, in order to accommodate these needs, it was necessary to develop strategies that encompassed the challenges of VAP education through a survey instrument. The scale of 1-5 was defined with the following markers: 5 = extremely satisfied, 3 = neutral, and 1 = extremely dissatisfied; therefore, it was important for nurses to be honest with their responses to the protocol and to determine how to best move forward and apply the protocol in a manner that is consistent with the education provided in the ICU setting.
The questions that were raised in the survey addressed the concerns that were associated with current VAP education and knowledge, as well as other factors that contributed to this practice. The survey incorporated questions regarding the efficacy of VAP education for nurses in order to achieve effective results. The nurses recruited for the study demonstrated their knowledge and understanding of the chosen protocol through their responses. Many of the nurses preferred a method whereby there was significant understanding of the challenges of VAP and its implementation. The survey also questioned the impact of VAP strategies in the ICU versus those in other settings, such as the classroom. Finally, recommendations were sought regarding the efficacy of the proposed solutions and the potential for future outcomes. The survey instrument demonstrated that there was variable knowledge regarding the impact of VAP education in the ICU, but that with additional insight, this practice could be largely effective in producing adequate knowledge and training in this area. Furthermore, some nurses recommended that the chosen educational strategy should be unique yet appropriate for the study population. These efforts are important in establishing a precedent for future studies and the examination of future protocols for application in the nursing environment.
Results and Interpretation
The main characteristics of the studies were included here. These studies were published between 2008 and 2011. The sample sizes of all the studies examined for this study ranged from as few as 53 to as many as 60,000 patients. The selected studies utilized several populations for inclusion in the trial (primarily ICU), including surgical, medical, trauma, and neuroscience. All the patients included in the studies were intubated and remained on ventilation for periods of no less than 24 continuous hours.
Table 1. Most relevant clinical studies applicable to this study
|First Author (Ref)||Journal, Year||Implemented Strategy||Summary|
|Morris||Crit Care Med, 2011||VAP Bundle||Before-and-after study, showing that implementation of a 4 item bundle (head elevation, oral chlorhexidine gel, sedation interruptions and a ventilator weaning protocol) reduced VAP rate|
|Terragni||JAMA, 2010||Tracheostomy||Randomized trial showing that VAP incidence was not significantly different comparing early (7 days after intubation) to late (14 days) tracheostomy|
|Nseir||Am J Respir Crit Care Med, 2011||Control of ETT cuff pressure||Randomized trial showing VAP rate reduction using a pneumatic device Care Med, 2011 to maintain ETT cuff inflating pressure constant|
|Lacherade||Am J Respir Crit Care Med, 2010||Intermittent SSD system||Randomized trial; the use of a SSD system resulted in a significant Care Med, 2010 reduction of VAP incidence, including late-onset VAP|
|Kollef||JAMA, 2008||Silver coated ETT||Randomized trial showing that VAP rates were lower with silver coated
ETTs, as compared to standard ETTs
|Miller||J Crit Care, 2011||Polyurethane ETT cuff||Retrospective assessment of VAP rate with polyurethane vs. PVC cuffed ETTs, favoring the use of polyurethane ETT cuff|
|Siempos||Crit Care Med, 2010||Probiotics||Meta-analysis of randomized controlled trials showing an association between the use of probiotics and reduced VAP incidence|
|Bird||Arch Surg, 2010||VAP Bundle||CBA study indicating that initiation of a VAP bundle protocol is an effective method for VAP reduction when compliance is maintained.|
|Wip||Cur Opinion in Infec Dis, 2009||Ventilator bundle||Randomized clinical study found the Ventilator Bundle is an effective method to reduce VAP rates in ICUs.|
Additionally, none of the patients that participated in any of the studies were diagnosed with pneumonia prior to admission. It must be noted that the exact definition of VAP was not consistent across all of the included studies, in spite of a standard definition being accepted in the literature. The recorded Jadad scores for the articles based on RCTs were 2 or 3, with a median of 3. When risk-of-bias was analyzed, it was found that that one study did not satisfactorily report the randomization protocol, but seven studies described a method used to obscure the allocation sequence sufficiently enough to exclude selection bias.
Outcomes for VAP with RCT Studies
All five articles that included RCTs reported VAP in the patients included in the study. The aggregated results suggest that the protocols followed were associated with a significant reduction in the incidence of VAP (Relative Risk [RR] 0.77, 95% CI 0.50 to 1.21; P = 0.26). It is also important to determine heterogeneity, and the initial test for that also proved to be significant (P for heterogeneity = 0.05; I2 = 21.6%). Afterward, sensitivity analyses were performed to determine what the source of heterogeneity might be. One possibility was to exclude the meta-analysis article (the Siempos article, which was included in this group due to a significant number of RCT studies included in its analysis), which was carried out. This action did indeed take care of heterogeneity, and the results remained similar as above (RR 0.85, 95% CI 0.75 to 1.22; P = 0.41; P for heterogeneity = 0.21; I2 = 0%). Therefore, the findings indicate that the protocols followed in the RCTs were associated with a significant reduction in the incidence of VAP among those patients.
Outcomes for Non-RCT Studies
Similar findings were obtained regarding the other studies that were not RCT. In all included studies, the control groups did not receive the treatment protocol that was later administered to the experimental group. In each case, the introduced protocol decreased the incidence of VAP in the ICU. For example, one of the protocols introduced into a VAP bundle was oral hygiene. This action was associated with a reduction of VAP in the sample group of patients (RR 0.68, 98% CI 0.30 to .60; P = 0.06; P for heterogeneity = 0.21). Head elevation was another factor studied, and those results are also included here (Weighted mean difference [WMD] 95% CI -2.58 to 0.82; P = 0.31; P for heterogeneity = 0.88). Use of polyurethane ETT cuffs was the focus of one study, which resulted in the following findings (95% CI -3.40 to 0.45; P = 0.13; P for heterogeneity = 0.75). Siempos addressed the use of probiotics in multiple studies and the findings indicate a reduction in the occurrence of VAP in ICUs (WMD 95% CI -2.82 to 1.79; P = 0.66; P for heterogeneity = 0.75). The use of a VAP bundle, including several elements in the prevention of VAP was also found to be beneficial (WMD -0.43 days, 95% CI -1.23 to 0.36; P = 0.29; P for heterogeneity = 0.56). There was no evidence of heterogeneity for any of the studies in this latter group (all P values > 0.56; I2 = 0%).
This meta-analysis suggests that following specifically-designed protocols (including the VAP bundle techniques) may reduce the incidence of VAP in adult patients who require mechanical ventilation. The nine articles included in this meta-analysis—including five RCTs—indicated the benefits to ICU patients who require ventilators if the hospital staff follow basic protocols for reducing VAP. All of these studies are considered of high quality. The fact that, regardless of the selected study design, a reduction of VAP was discovered provides beneficial information for nurses who assume great responsibility for meeting these protocols.
Chapter 5: Discussion and Conclusions
Overview of Research Project
The research project that was conducted provided an investigation of the implementation of a protocol to address the significance of Ventilator-Acquired Pneumonia within the Intensive Care Unit. This protocol was designed by the Association for Professionals in Infection Control and Epidemiology (APIC) in order to reduce the incidence of VAP in ICU patients. This protocol was implemented in a hospital environment with several units, including pediatric, neonatal, and adult intensive care units. Therefore, the protocol implementation was applied across the organization to ensure consistency in executing the selected APIC protocol. The study analyzed the data observed regarding the incidence of VAP cases in quarterly intervals for up to one year after protocol implementation. In addition, a questionnaire was distributed to nurse participants in order to determine if the protocol was effective and if it achieved the desired purpose within the ICU framework.
Summary of Findings
The research study sought to implement a protocol that could potentially reduce the incidence of VAP in patients requiring mechanical ventilation. This protocol represented an opportunity for nurses to adhere to a specific set of requirements and to demonstrate their knowledge, understanding, and level of compliance with the chosen protocol. Based upon the implementation of the protocol, it was determined that from one quarter to the next, there were inconsistencies in the number of VAP cases per unit, with some units experiencing increases and others experiencing decreases. This demonstrated that in its current state, the VAP protocol was ineffective in providing the desired reduction of VAP diagnoses across the different units on a quarterly basis. These findings suggest that there are significant factors associated with the implementation of a given protocol within a patient care setting that may be influenced by environmental conditions or other forces, such as low compliance with every aspect of the chosen protocol.
How Results were Obtained
The results were derived by using a data collection process in order to identify the frequency of VAP cases within the different ICU units at the selected hospital. The data collection was derived from case records and was recorded on a quarterly basis in order to determine if there were any patterns or changes to the number of VAP cases across the different ICUs. This information was useful because it provided greater insight into the effectiveness of the VAP protocol and whether or not it could have a significant impact on the outcomes of patients who are dependent on mechanical ventilation. Under these conditions, if the protocol was effective, there would be a marked decrease in the incidence of VAP cases across the different ICUs that were evaluated. If the protocol was not deemed effective, then it would not have a significant impact on reducing the number of VAP cases within the ICUs. The data collection method was necessary in order to capture an understanding of the number of VAP cases and why there is a continuous risk of VAP for patients who require mechanical ventilation. An effective protocol is necessary to reduce the number of cases and to promote nurse effectiveness in adhering to the protocol guidelines. This provides an opportunity to explore the different dimensions of a protocol and to determine if it will be effective in achieving its stated objectives in a successful manner.
The nurse questionnaires were disseminated in order to determine if the VAP protocol used in the ICU setting was effective and sufficient to improve outcomes for nurses. It was determined that this protocol provided greater insight into the extent of VAP and its impact on ICU patients. Nurses were able to obtain a clearer understanding of the problem in a live setting so that implementation efforts would be positive and meaningful to ICU nurses as the protocol is rolled out to a larger audience. With the results of the questionnaire demonstrating favorability towards this strategy so that nurse knowledge regarding VAP is expanded on a gradual basis and VAP cases are gradually reduced.
Solutions to the Research Problem
The research problem in question is challenging and complex for many reasons. Therefore, it is necessary to identify possible solutions that will have a favorable impact on patient outcomes and on the ability of nurses to achieve maximum compliance with the protocols that they are given. These practices will ensure that nurses are able to understand the protocol and adhere to its requirements at all times. However, the protocol must be appropriate for the given population and must address as many areas as possible that will enhance the quality of care and reduce the risk of infection for this patient population. Due to the precarious health of these patients and their weakened immunity, all possible measures must be taken in order to achieve effective outcomes. Therefore, in the absence of an effective protocol as demonstrated in the research study, other possibilities must be explored, which may include this protocol along with other guidelines or a combination thereof.
Implications and Limitations
This research study provided an important step towards the discovery of new concepts in order to implement protocols that might be effective in reducing the incidence of VAP in patients. It is important to identify areas where VAP infections are likely to occur and to determine the types of patients that might be affected by this condition within their lives. This study has significant implications for the area of VAP research because additional protocols must be considered that may have a greater impact on patient outcomes. These elements are critical because they contribute to the effectiveness of a given VAP protocol and the success rate that it provides in the form of reduced numbers of VAP cases. Based upon the information provided in this VAP protocol, additional measures must be considered in other protocol forms in order to accomplish the desired objectives and to provide patients with a minimal risk of infection. This is an important step towards the discovery of new techniques and strategies to accommodate patients who require mechanical ventilation so that their recoveries are not compromised in any way during their time in the ICU.
The research study provided a strong basis for evaluating a VAP protocol upon its implementation in a number of ICUs. The use of a single facility with several different types of ICUs that serve a number of populations from neonates to adults represents an opportunity to utilize the protocol in a number of different patient care environments.
It is important to recognize the value of the VAP protocol as a means of establishing benchmarks for nursing compliance in order to determine if additional frameworks or protocols must be identified. In this instance, it is necessary to expand the protocol to other sites in order to determine if the problems are related to that specific organization or if the protocol is weak to stand on its own. These elements pose a challenge to the integrity of the protocol and its potential impact on the ability to reduce VAP-related infections in ICU patients who require mechanical ventilation.
Problems Noted with the Project
The protocol implementation in the research study was relatively smooth; however, based upon the study results, it is necessary to expand the protocol to a larger population in order to determine its effectiveness in meeting the desired outcomes. In this context, the study was limiting, but did not pose any real problems for the researcher or the organization as a whole.
Factors that Skewed Findings
The limiting nature of the study in a single facility was challenging for the researcher and might have played a role in the limited results that were derived. It was important for the researcher to conduct the study in a single facility to gauge its probability for success in a larger number of facilities. Nonetheless, the study was not entirely successful in its approach or its scope. Furthermore, the possibility of external environmental factors played a role in the outcomes of the study and its limited impact on VAP infections. Therefore, the findings of this study were not as comprehensive and as effective as anticipated.
How Study Could be Improved
The study could be improved in a number of ways, including a more precise evaluation of nursing compliance with the VAP protocol. In addition, an expansion of the study to additional sites may have an impact on the study results that are derived in the future. This may also have an impact on long-term outcomes for patients who are at risk of VAP in ICU settings.
Areas for Further Investigation
It is expected that patients in the ICU will be most impacted by this study. However, nurse perspectives, knowledge, and education must also play a role in shaping these outcomes in future studies. The retention of nursing knowledge is critical to this process. It also supports the development of an approach that will aim to reduce VAP infections in ventilator-assisted patients in the ICU. In the future, the following issues should be addressed regarding VAP education in the ICU:
- Expand upon existing VAP educational tools in larger settings where there is a greater number of ICU nurses to utilize the education
- Require nurses to take a post-course quiz with a passing score of 80 percent
- Require nurses to take a post-course survey to provide feedback regarding their experiences
- Offer continuing education credits for the course
- Require mandatory participation for the VAP course for all ICU nurses
What to do Differently in the Future
For future variations of this study, it is important to attempt to overcome any possible issues regarding compliance that are likely to occur with this study. If the same protocol is implemented elsewhere, lessons should be learned that will accommodate the needs of ICU patients in other settings. It is most important, however, to address the most relevant criteria across all protocols and to utilize the ICU as the primary teaching environment in order to attract the appropriate audience of ICU nurses and to determine how to best move forward in providing a comprehensive course that encompasses many important areas of VAP education. By using the feedback that was provided through the questionnaire instrument, future VAP education sessions will be more specific and will provide the information that is most important to encourage nurses to adhere to protocol-specific requirements. Furthermore, it will emphasize the importance of VAP prevention in greater detail so that all possible measures are taken by nurses to accommodate patients in the ICU with a greater risk of a VAP diagnosis.
Justification of Differences
It is also important to modify the study as necessary to ensure that future outcomes are successful. This may include the development of new additions to the existing protocol in order to achieve improvements in the form of reduced VAP cases. The differences that must be implemented in future versions of the VAP education protocol must provide a basis for exploring new approaches to VAP education and providing nurses with a protocol that is interesting and informative. Engaging nurses through participation in the VAP education discussion will play an important role in this process and provide a basis for advancing VAP knowledge to improve patient outcomes and reduce VAP cases. This may include case studies and other real-life examples that will support and enhance the patient care experience more effectively.
Reflection on Master’s Degree Experience
This experience has been highly beneficial in demonstrating the importance of new perspectives regarding research and its impact on nursing practice. Prior to this experience, I did not have a full awareness of the importance of evidence-based practice objectives and their influence on patient outcomes. However, I now recognize that this process is instrumental in shaping outcomes for patients and in enhancing the quality of nursing care and treatment as derived from existing practice models. These contributions will play a critical role in supporting positive patient outcomes through the reduced risk of VAP infections. However, this model also represents a larger framework that captures the essence of patient care needs, particularly in critical care settings. These elements are critical to the Master’s Degree experience because they support student engagement and learning regarding an unfamiliar research area.
How Skills and Experience may Apply to Work Environment
This skill set and level of experience is useful because it enables nurses to acquire valuable experience in the research field from which the results may be applicable to patient care settings. These elements play an important role in the creation of a learning environment that extends beyond the classroom setting. Therefore, these skills and experiences are essential contributors to the achievement of successful patient care outcomes and the delivery of high quality care and treatment at all times. Evidence-based practice objectives as supported by the research protocol will have a lasting impact on patient care and treatment and will demonstrate the importance of new directions and approaches to encourage patient care that is conducive to greater health and wellbeing throughout the life span. This experience is critical to these objectives and in sustaining the growth of patient care objectives throughout all areas of nursing practice.
Agency for Healthcare Research and Quality (n. d.). How do we implement best practices in our organization? U. S. Department of Health and Human Services. Retrieved from http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool4.html
Amanullah, S. (2013). Ventilator-Associated Pneumonia Overview of Nosocomial Pneumonias. Medscape Reference: Drugs, Diseases, and Procedures. Retrieved from http://emedicine.medscape.com/article/304836-overview
Amin, A. (2009). Clinical and economic consequences of ventilator-associated pneumonia. Clin Infect Dis., 49(Supplement 1), S36-S43. doi: 10.1086/599814
Association for Professionals in Infection Control and Epidemiology (APIC). (n. d.). About APIC. Retrieved from http://apic.org/About-APIC/About-APIC-Overview
Association for Professionals in Infection Control and Epidemiology (APIC). (n. d.). About APIC: Public policy and advocacy. http://apic.org/Advocacy/Government-Affairs-and-Advocacy
Association for Professionals in Infection Control and Epidemiology (APIC) (2009). Guide to the Elimination of Ventilator-Associated Pneumonia. Retrieved from http://www.apic.org/Resource_/EliminationGuideForm/18e326ad-b484-471c-
Bangert-Drowns, R.L. (1986). Review of developments in meta-analytic method. Psychological Bulletin 99 (3), 388-399.
Bird et al. (2010). Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg. 145(5), 465-470.9c35-6822a53ee4a2/File/VAP_09.pdf
Bouadma, L., Deslandes, E, Lolom, I, Le Corre, B., Mourvillier, B., Regnier, B., Porcher, R., et al. (2010). Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Clin Infect Dis., 51, 1115–1122. PMID: 20936973
Cadena, J. Tierney, C. J., & Restrepo, M. I. (2011). Preventing ventilator associated pneumonia: Looking beyond the bundles. Clin. Infect. Dis., 52(8), 1083-1084.
Cohen, L., Manion, L., & Morrison, K. R. B. (2007). Research Methods in Education. Routledge: London.
Center for Disease Control and Prevention (CDC). (2012). Healthcare-associated infections (HAI): Ventilator-associated pneumonia. Retrieved from http://www.cdc.gov/hai/vap/vap.html
Clarke, S. P., & Donaldson, N. E. (n. d.). Nurse staffing patient care quality and safety. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses, 1-25. Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/ClarkeS_S.pdf
Critical Care Nurse Training Standards Task Group (n. d.). Final report: Critical Care – Secretariat. Retrieved from http://www.caccn.ca/en/files/mohltc_report_ccn_stds.pdf
Darves, B. (2005). Seven strategies to prevent VAP: a look at the evidence. Today’s Hospitalist. Retrieved from http://www.todayshospitalist.com/?b=articles_read&cnt=262
Devo, P. (n. d.) Pathway to excellence: Are you ready to apply? Retrieved from http://www.nursecredentialing.org/Pathway/PathwayResources/Pathway-AssessmentGapAnalysis.pdf
Harvard-MIT Data Centers. (n. d.). Guide to SPSS. Retrieved from http://www.hmdc.harvard.edu/projects/SPSS_Tutorial/spsstut.shtml
Howell, D. C. (2011). Fundamental statistics for the behavioral sciences. Belmont, CA: Wadsworth Cengage Learning.
Institute for Healthcare Improvement. (n. d.) Ventilator-associated pneumonia. Retrieved from http://www.ihi.org/explore/VAP/Pages/default.aspx
John Hopkins Medicine (n. d.). Suctioning. Retrieved from http://www.hopkinsmedicine.org/tracheostomy/living/suctioning.html
Kempnich, J. (2011). Utilizing decision acceleration for Magnet® gap analysis. Nursing Management, (42)2, 43–45. doi: 10.1097/01.NUMA.0000393001.11257.a5
Kollef, M. H. et al. (2008). Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA 300, 805-813.
Koenig, S. M. & Truwit, J. D. (2006). Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention. Clinical Microbiology Reviews, 19(4), 637-657. doi: 10.1128/CMR.00051-05
Korn, C., Burke, R., Burke, P., & Agarwal, S. (2010). Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit. Arch Surg., 145(5),:465-470.
Lacherade, J. C. et al. (2011). Intermittent subglottic secretion drainage and ventilator-associated pneumonia: a multicenter trial. Am J Respir Crit Care Med 182, 910-917.
Lau, G., O’Keefe-McCarthy, S., & Santiago, C. (2008). Ventilator-associated pneumonia bundled strategies: an evidence-based practice. Worldviews Evidence Based Nursing. 5(4):193-204. doi: 10.1111/j.1741-6787.2008.00140.x.
Majid, S., Foo, S., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: nurses’ perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99(3), 229-236.
Maselle, D. J. (2011). Therapeutic Advances in Respiratory Disease Strategies in the Prevention of Ventilator-associated Pneumonia. Ther Adv Resp Dis. 5(2):131-141. Retrieved from http://www.medscape.com/viewarticle/739619
McAuley, L., & Ramsay, C. (2002). Cochrane Effective Practice and Organisation of Care
Review Group (EPOC): Data Collection Checklist. Retrieved from http://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/datacollectionchecklist.pdf
Miller, M. A. et al. (2011). A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-associated pneumonia. J Crit Care 26, 280-286.
Morris, A. C. et al. (2011). Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle. Crit Care Med 39, 2218-2224.
Nseir, S., et al. (2011). Continuous control of tracheal cuff pressure and micro-aspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med 184, 1041-1047.
Paciella, M. E. (2009). “Bundle” up to prevent pressure ulcers. American Nurses Today, 4(4). Retrieved from http://www.americannursetoday.com/article.aspx?id=5886
Pennsylvania Patient Safety Advisory. (2009). Successful Reduction of Ventilator-Associated Pneumonia. Pa Patient Saf Advis, 6(2):63-8.
Pipe, T. B., Wellik, K. E., Buchda, V. L., Hansen, C. M., & Martyn, D. R. (2005). Implementing evidence-based nursing practice. Urol Nurs., 25(5),365-370.
Pittet, D. (2003). Hand hygiene: improved standards and practice for hospital care. Current Opinion in Infectious Diseases, 16, 327–335. Retrieved from http://www.intelligentm.com/articles/ArticleImprovedStandardsPractice.pdf
Roxborough Memorial Hospital. (n. d.). Ventilator-associated pneumonia trends, 2002-2008. Retrieved from http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Jun6%282%29/PublishingImages/66_fig1.JPG
Siempos, I. I., Ntaidou, T. K., & Falagas, M. E. (2010). Impact of the administration of probiotics on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. Critical Care Med 38, 954-962.
Tablan, O. C., Anderson, L. J., Besser, R., Bridges, C., & Hajjeh, R. (2004). Guidelines for preventing health-care-associated pneumonia, 2003. Center for Disease Control and Prevention (CDC), 52(RR03), 1-36. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm.
Terragni, P. P.et al. (2010). Early vs. late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 303, 1483-1489.
Wip, C., & Napolitano, L. (2009). Bundles to prevent ventilator-associated pneumonia: how valuable are they? Current Opinion in Infectious Diseases 22, 159-166
Vanderbilt University Medical Center (n. d.). Nursing quality and performance improvement plan. Retrieved from http://www.mc.vanderbilt.edu/documents/Magnet%20Website/files/Nursing%20Quality%20Plan.pdf
Vima Medical (2011). HOB Alert: VAP Background. Retrieved from http://www.hobalert.com/vap_bg.html
Williams, Z., Chan, R., & Kelly, E. (2008). A Simple device to increase rates of compliance in maintaining 30-degree head-of-bed elevation in ventilated patients. Critical Care Medicine, 36(4), 1155-1157. Retrieved from http://www.medscape.com/viewarticle/574911
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