Ventilator Associated Pneumonia (VAP) occurs when endogenous bacteria from the nose, throat, and mouth accumulates in the subglottic space and eventually moves into the lungs. When patients are intubated, bacteria begin to create a biofilm on the endotracheal tube and cuff which may result in microaspiration into the lungs. While the causative bacteria are endogenous in nature, it becomes problematic when these bacteria migrate to the lungs, causing inflammation and fluid accumulation, which may result in respiratory compromise (Kalanuria, Zai, & Mirski, 2014).
While the cause of (VAP) is well understood and preventative interventions are strictly enforced, hospitals nationwide are still dealing the incidence of VAP and attempting to find ways to decrease its occurrence. Studies have shown that VAP accounts for approximately 50% of hospital-acquired pneumonias, which results in increased length of hospital stay, mortality rates, and cost. The diagnosis of (VAP) can be made when patients develop pneumonia 48-72 hours post endotracheal intubation, signs of which include leukocytosis, fever, and/or alteration in sputum characteristics. While many hospitals work diligently to reduce the incidence of VAP, it is still considered one of the top two nosocomial infections acquired by hospitalized patients in Intensive Care Units. In fact, it is estimated that anywhere from 9-27% of intubated and mechanically ventilated patients develop VAP, and of those patients, mortality is noted in approximately 9-13% (Kalanuria et al., 2014).
The purpose of this project was to investigate additional interventions that can be implemented at Mercyhealth System to reduce the incidence of VAP, specifically focusing on the use of subglottic suctioning endotracheal tubes (SSETTs). Currently, Mercyhealth System implements all notably recognized VAP prevention procedures including: The awakening and breathing coordination, delirium monitoring and management, and early mobility (ABCDE) bundle, elevation of head of bed to at least 30 degrees, peptic ulcer prevention, weekly ventilator circuit changes, patient turning every two hours, and oral care with chlorhexidine every two hours. Despite their implementation of recommended policies, VAP continues to occur in about ten patients yearly, contributing to increased mortality rates and hospital costs.
After meeting with the Clinical Nurse Educator of the Adult Critical Care (ACC) department at Mercyhealth System, it was decided that SSETTs should be researched as an additional intervention to implement in the reduction of VAP, in addition to investigating further evidence-based research recommendations. Initial research investigation began with an extensive literature search which consisted of various methods of VAP reduction including various ETT types and the importance of Registered Nurse (RN) continuing education (CE). A literature review was then performed to explore various types of ETTs and their role in the reduction of VAP (see appendix A).
Next, it was important to examine Mercyhealth System’s current VAP preventions measures, including their policy regarding the ABCDE Bundle (see Appendix B). While Mercyhealth System’s policy discusses the ABCDE Bundle, which incorporates the use of widely recommended and extensively researched interventions for use in VAP reduction, it does not integrate the importance of ETT selection or RN education requirements in ongoing VAP prevention, specifically for Adult Critical Care RNs (ACCRNs).
After reviewing recent literature on the topic of VAP prevention, the unit was observed to monitor for RN implementation of VAP prevention measures. While on unit, appropriate hand hygiene, patient turning, and aseptic/sterile technique was observed in patient care. Additionally, a questionnaire was created to assess the ACCRNs opinions on VAP prevention measures as well ascertain their judgement on the importance and compliance of interventions that are currently put in place. Lastly, I sought to determine how often the ACCRNs attend CE regarding VAP prevention measures (see Appendices C-D).
As the fight against VAP continues, researchers will continue to study improved methods of prevention, with goals of markedly decreasing its occurrence. When researching the use of SSETTs, pros and cons were found in literature. While they have been found to decrease the incidence of VAP by providing the ability to remove subglottic secretions that lead to microaspiration, they have also been found to cause tracheal injury in patients with minimal secretions (Mao et al., 2016). While VAP is a major concern, both for mortality and cost, tracheal injury is a much more serious implication; therefore, the use of continuous subglottic suctioning would be recommended with caution. Based on the literature review performed (see Appendix A), it is recommended that SSETTs be used in practice for the prevention of VAP, with the intent to suction when subglottic secretions are observed, expected, or measured to be elevated or just prior to extubation.
The second recommendation is to institute a hospital-wide policy enforcing the use of polyurethane cuffed ETTs, as they have been shown to decrease the incidence of VAP through the reduction of microaspiration that is possible due to the decreased cuff leakage demonstrated in research (Mao et al., 2016). Often, patients are intubated in emergency departments or various units in the hospital, and it is not recommended to exchange ETTs upon arrival to ACC, as reintubation may exacerbate the patients’ risk for VAP, laryngeal injury, or inflammation and edema (Hyzy, 2017). Therefore, a hospital-wide policy instituting the use of polyurethane cuffed ETTs would ensure that the majority of patients who are transferred to ACC have that intervention in place upon arrival.
The final recommendation comes from the questionnaire results, in addition to research on the importance of RN education in the prevention of VAP. The VAP questionnaire yielded eight results, of which 100% of the RNs indicated that they had either rarely or never attended CE regarding the prevention of VAP . Given this information, it would be recommended to institute a policy mandating that critical care RNs, as well as multidisciplinary team members, attend regular CE meetings or education that specifically discusses VAP prevention measures, including uncommon interventions found in research. Ongoing educational sessions are important in that they reinforce policies and procedures and overall have even been shown to increase compliance. Educational endeavors can incorporate tactile learning through workshops or through visual aids such as power point presentations. Integrating various learning styles will ensure that all types of learners gain knowledge in these sessions (Klompas et al., 2014). Lastly, once VAP specified education is implemented, it would be suggested to do quarterly or bi-annual reviews to determine any change that results due to this institution.
It is with hope and determination, that all healthcare professionals continue to incorporate research and evidence-based practice to improve patient outcomes. While the incidence of VAP is a frustrating problem, the continuity of research and clinical trials performed to prevent its occurrence shows the strength, endurance, and motivation that healthcare teams have in ensuring safe and high-quality deliverance of patient care.
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