Evidence-Based Practice and Applied Nursing

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Table of Contents

Article Critique
Literature Search
Annotated Bibliography
Tools used and Efficacy of the Therapeutic Approaches
Evidence Summary of the Articles
Recommendation of a Nursing Strategy
Importance of Theoretical Model for Nursing Research
Reference List

Article Critique

From the analysis of the five areas, I can say that the evidence presented supports the conclusion made by Babcock et al. (2004). Specifically, the researchers found that in three of the four hospitals that took part in the study, the infection rates of ventilator-associated pneumonia fell by between 38 and 61 percent following the educational intervention program. These results were observed in both adult children’s hospitals as well as community hospitals. Hence, the results could be generalized to different health settings. This conclusion was arrived at following the data analysis and results from the analysis which supports the conclusion.

The major ethical issue that arose from the study was access to personal health information of the participants. Specifically, the researchers needed to gain access to the common database kept by the Infection Control and Hospital Epidemiology Consortium of the health system where the information about ventilator-associated pneumonia is kept (Babcock et al., 2004). Gaining access to the health records of patients is a very sensitive issue because health records are confidential and should only be used by professionals who provide direct care to patients. Thus, the researchers had to obtain permission from the institutional review board and the hospitals’ administrations so as to access the patients’ health records.

The study was purely quantitative in nature. A qualitative research would also have been appropriate in a similar situation. Specifically, a qualitative study would entail in-depth interviews with the health practitioners working in the intensive care units to determine how the educational program has benefitted them and what knowledge and skills they gained from the intervention that helped them to better reduce the rates of ventilator-associated pneumonia. A qualitative study would enable the researchers to go beyond collecting numbers and instead to gain a deep understanding of the problem. The researchers would have understood the problem from the point of view of the medical staff. Such information is impossible to obtain through quantitative research yet it is important for any study.

Literature Search

Identification of a Nursing Care or Management Problem for a Therapeutic Nursing Situation

The problem requiring a therapeutic nursing situation is the use of general care versus specialized ventilation associated pneumonia (VAP) bundle in the reduction of ventilation associated pneumonia among mechanically ventilated ICU patients.

Matrix of Primary Research Sources

The matrix of primary sources is attached as a separate document.

Annotated Bibliography

Babcock, H., Zack, J., Garrison, T., Trovillion, E., Jones, M., Fraser, V., et al. (2004). An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: A comparison of effects. CHEST, 125(6), 2224-22231.

Babcock et al. (2004) studied adult and pediatric patients admitted in two teaching and two community hospitals located in Midwestern United States. They then tracked ventilator-associated pneumonia in each of the hospital through the use of infection control experts and surveillance. Incidences of VAP were reported in a common database at the Infection Control and Hospital Epidemiology Consortium. The educational program was introduced to all the patients admitted in the four participating hospitals and a follow up done throughout the study period. A statistical software (SPSS) was used to analyze data. Chi-square analysis was used to compare the rates of VAP. The combined annual rate of VAP with intervention was 7.81/1,000 ventilator days compared to 8.75/1,000 ventilator days without the intervention, hence no statistically significant difference. On individual basis, three out of the four hospitals recorded a statistically significant difference in the VAP rates following the intervention, with the largest decrease recorded in a community hospital.

Crunden, E., Boyce, C., Woodman, H., & Bray, B. (2005). An evaluation of the impact of the ventilator care bundle. Nursing in Critical Care, 10(5), 242-246.

The researchers studied patients admitted at the combined Intensive and High Dependency Care Unit at East Surrey Hospital. The study design involved an audit of the hospital’s compliance with evidence-based protocols followed in care bundles and if the protocols reduced ventilation length of the patients. Descriptive statistics (percentages, mean, median and standard deviation were used to describe the characteristics of the population; student’s t-test was used to compare APACHE II, length of ventilation and LOS data. The mean ICU LOS was reduced by 39%; there was a reduction in the mean duration of ventilation by 43%.

El-Khatib, M., Zeineldine, S., Ayoub, C., Husari, A., & Bou-Khalil, P. (2010). Critical care clinicians’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. American Journal of Critical Care, 19(3), 272-276.

The population entailed clinicians working in an intensive care unit of a university bed. The sample of clinicians used included only those clinicians who were not aware of similar prior studies. The researchers used a multiple-choice questionnaire design to carry out their study. Descriptive statistics (percentages and means) were used to describe the accuracy of the responses; analysis of variance and Scheffe test were used to compare the scores; Chi-square analysis was used to compare the proportion of the accurate responses; linear regression was used to establish the correlation between scores and participants’ demographics; SPSS was used to carry out the statistical tests. No differences were found in the knowledge of protocols for VAP prevention among the clinicians; no differences were found in the knowledge of protocols for VAP prevention based on ICU experience.

Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., et al. (2009). Reducing ventilator-associated pneumonia through advanced oral-dental care: a 48-month study. American Journal of Critical Care, 18(6), 523-534.

In this study, Garcia et al. (2009) studied a population of patients enrolled in a medical intensive care unit of a university medical center. The sample included patients who were 18 years and above and who were receiving mechanical ventilation for more than 2 days at the medical center. The research design used was a randomized control study in which the researchers studied two different groups of patients: the control and the intervention groups and made comparisons. Descriptive statistics were used to describe the demographic characteristics of the population; student t-test, Mann-Whitney analysis and mortality analysis were used to test the variables of the study. VAP rate was higher in the control group (8.6%) than in the intervention group (4.1%); VAP rates decreased by 33.3% during the intervention; the intervention significantly decreased the duration of mechanical ventilation and length of hospital stay.

Grap, M. (2009). Not-so-trivial pursuit: Mechanical ventilation risk reduction. American Journal of Critical Care, 18(4), 299-309.

The study conducted by Grap (2009) involved a population consisting of patients admitted in a respiratory intensive care unit. The research design used was observational in that the researcher did not control the intervention but instead made a comparison between non-randomized sequential groups. Descriptive statistics were used to describe the characteristics of the backrest elevation. The use of elevated backrest reduces aspiration and hence VAP to some extent.

Grap, M., Munro, C., Hummel, R., McKinney, J., Sessler, C., et al. (2005). Effect of backrest elevation on the development of ventilator-associated pneumonia. American Journal of Critical Care, 14, 325-333.

The researchers studied patients admitted at the respiratory intensive care unit of Virginia Commonwealth University Health Systems. A non-experimental, longitudinal, descriptive design was used in the study. Descriptive statistics were used to describe the features of the population; a forward-selection multiple regression analysis was used to predict CPIS on the fourth day. The results showed no direct correlation between the height of backrest and VAP. VAP was highly likely to occur in more seriously ill patients who spent more time at backrest elevations.

Hawe, C., Ellis, K., Cairns, C., & Longmate, A. (2009). Reduction of ventilator-associated pneumonia: active versus passive guideline implementation. Intensive Care Medicine, 35, 1180-1186.

Hawe, Ellis, Cairns and Longmate (2009) conducted their study using a sample of patients admitted at the intensive care unit of Stirling Royal Infirmary. The sample used included patients who were admitted at the unit between September 1, 2005 and December 31, 2007. The research design used was a quasi-experimental design that was used to assess the effects of a bundle of evidence-based approaches to VAP. Passive implementation was correlated with poor compliance with VAP prevention bundle; active implementation was correlated with a substantial improvement in compliance with VAP bundle.

McCarthy, S., Santiago, C., & Lau, G. (2008). Ventilator-associated pneumonia bundled strategies: An evidence-based practice. Worldviews on Evidence-Based Nursing, 5(4), 193-204.

McCarthy, Santiago and Lau (2008) studied patients admitted in intensive care units of different hospitals. The research design used in the literatures reviewed was observational in that the researchers did not control the intervention but instead made a comparison between non-randomized sequential groups. Results from the literature review varied widely and include: a decrease in the ventilator days following the intervention; a strong correlation between VAP rate and compliance rate; non-development of VAP with the intervention.

Tolentino-DelosReyes, A., Ruppert, S., & Shiao, P. (2007). Evidence-based practice: use of the ventilator bundle to prevent ventilator-associated pneumonia. American Journal of Critical Care, 16, 20-27.

The study by Tolentino-DelosReyes, Ruppert and Shiao (2007) involved nurses working in the coronary care unit and surgical ICU of a large hospital located in a large metropolitan city. The research design was a clinical education project that was used to evaluate the knowledge of nurses concerning the use of ventilator bundle to prevent VAP. Descriptive statistics were used to describe the characteristics of the population; independent t test and chi-square analysis were used to measure and compare the pretest and posttests scores of the nurses. An education program lasting as little as 30 minutes can help to enhance the nurses’ knowledge concerning VAP prevention strategies.

Westwell, S. (2008). Implementing a ventilator care bundle in an adult intensive care unit. Nursing in Critical Care, 13(4), 203-207.

The study involved patients admitted at an adult ICU of a district general hospital. The research design was an audit of the hospital’s compliance with evidence-based protocols followed in care bundles. Descriptive statistics were used to describe the hospital’s compliance rate and the rate of VAP reduction following different interventions. Daily audit of care bundles is strongly correlated with compliance which in turn is correlated with VAP reduction rates.

Tools used and Efficacy of the Therapeutic Approaches

The researchers reviewed above made use of different tools to measure the variables of the studies. However, I do not believe that the tools used affected the results of the studies in any way. This is because in the studies that appeared to be similar in the objectives and variables to be measured, the results were similar despite the fact that different tools were used. For instance, the studies that examined the effect of educational intervention programs – Babcock et al. (2004), El-Khatib et al. (2010) and Tolentino-DelosReyes (2007) – used different approaches yet got similar results.

Each of the studies reviewed above made a case for the efficacy of the therapeutic approach. This was done by highlighting the effect (either positive or negative) of the different therapies on patient outcomes mainly the development of ventilator-associated pneumonia. The major therapeutic interventions identified in the studies were: educational intervention program to increase nurses’ knowledge on preventing ventilator-associated pneumonia, the use of elevated backrest, and the implementation of a bundle of evidence-based approaches to VAP. The studies which assessed the use of educational intervention programs and a bundle of evidence-based approaches to VAP all found the therapies to be effective in reducing the incidences of ventilator-associated pneumonia. On the other hand, the studies that assessed the effect of elevated backrest had mixed results. For instance, Grap (2009) found that the use of elevated backrest reduces aspiration and hence VAP. However, Grap et al. (2005) found no direct correlation between the height of backrest and VAP. VAP was highly likely to occur in more seriously ill patients who spent more time at backrest elevations.

Evidence Summary of the Articles

The evidence table is composed of ten articles generated from the search process. In order to answer the clinical question of this study, some of the articles chosen focus on the VAP bundle approach while the others focus on other strategies used in the general care of VAP. By including studies that focus on these two different approaches to VAP, it is possible to compare the effectiveness of the two approaches used in preventing VAP and thereby identify the better alternative. The studies that focus on the VAP bundle approach have promising outcomes in terms of reduction of VAP rates, reduction in the length of ventilation days and reduction in the length of hospital once discharged to the general ward. On the other hand, the studies that focus on general care approach have mixed results, with some showing positive results, others showing negative results, and yet others showing no difference at all. Further critical analysis of the literatures and synthesis of the evidence would help to clarify the contradicting results.

Recommendation of a Nursing Strategy

Based on the evidence presented above, I would recommend a strategy that incorporates both an educational intervention program and ventilator-associated pneumonia bundle. These two strategies seem to have a significant positive effect on reducing ventilator-associated pneumonia. An educational program equips nurses with knowledge and skills on what to do and what not to do so as to minimize the chances of mechanically ventilated ICU patients developing VAP. On the other hand, a VAP bundle provides utmost care to the mechanically-ventilated ICU patients thereby reducing the risk of VAP. However, compliance with the bundle protocols is equally important.

Importance of Theoretical Model for Nursing Research

A theoretical model provides guidance to the nursing research (Houser, 2007). It forms the basis upon which researchers formulate their research questions, construct their research design, collect data, analyze data and interpret the data. Without theory to guide the research process, a researcher would produce a study and data that make no sense and which do not add value to the existing knowledge of the practice. A theory can help a researcher to conduct a study that proves whether or not the theory holds in different circumstances. A theory-guided research is thus important in providing evidence-based nursing practice (Fitzpatrick & Wallace, 2005).

Reference List

Crunden, E., Boyce, C., Woodman, H., & Bray, B. (2005). An evaluation of the impact of the ventilator care bundle. Nursing in Critical Care, 10(5), 242-246.

Fitzpatrick, J. J., & Wallace, M. (2005). Encyclopedia of nursing research. New York: Springer Publishing Company.

Grap, M. (2009). Not-so-trivial pursuit: Mechanical ventilation risk reduction. American Journal of Critical Care, 18(4), 299-309.

Hawe, C., Ellis, K., Cairns, C., & Longmate, A. (2009). Reduction of ventilator-associated pneumonia: active versus passive guideline implementation. Intensive Care Medicine, 35, 1180-1186.

Houser, J. (2007). Nursing research: reading, using, and creating evidence. Sudbury, MA: Jones & Bartlett Learning.

McCarthy, S., Santiago, C., & Lau, G. (2008). Ventilator-associated pneumonia bundled strategies: An evidence-based practice. Worldviews on Evidence-Based Nursing, 5(4), 193-204.

Westwell, S. (2008). Implementing a ventilator care bundle in an adult intensive care unit. Nursing in Critical Care, 13(4), 203-207.

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