Ventilator-Associated Pneumonia and Practice Change

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Introduction

Ventilator-associated pneumonia (VAP) is a sub-category of hospital-acquired pneumonia (HAP), which occurs in patients exposed to technical airflow/ ventilation for more than 48 hours. VAP is not recognized by the causative agents; rather, as indicated through its name, the meaning of VAP is limited to patients exposed to mechanical airflow while at the medical center. A good culture following intubation is a sign of ventilator-associated pneumonia and is clinically diagnosed as such.

To be able to properly classify the causative mechanism or agent, it is usually suggested to acquire culture, before the start of technical ventilation, as a reference procedure. Many patients under mechanical ventilation are most times sedated, therefore, rarely capable of communicating. As a result, many of the characteristic symptoms of pneumonia will either be non-existent or not recordable. These include low body temperature, fever, hypoxemia, and new purulent sputum.

The condition is diagnosed and detected; in case a patient registers increasing white blood cell count during a blood test, after exposure to the ventilation process (American Thoracic Society and the Infectious Diseases Society of America, 2005, pp. 388-412).

This condition is the most prevalent nosocomial contamination among ICU patients. Systematic reviews have shown that VAP affects 10-20% of the patients exposed to mechanical ventilation for over forty-eight hours. The approximate mortality rate among patients suffering from VAP is between 24-50%, rising to 76% in cases where the infection is caused by a multi-resistant agent.

The patients who suffer from VAP are twice, as likely to die, as opposed to those not affected by it. The condition also leads to increased ICU stay and costs. Therefore, addressing the incidences of VAP will aid in improving healthcare efficiency, and the outcomes registered among patients.

This report is drawn to present an evidence-based change process, to address the problem of ventilator-associated pneumonia, through identifying the safety concerns of the patients, presenting the plan of the evidence-based change, and the setting of measurable objectives, towards the realization of the change (American Thoracic Society and the Infectious Diseases Society of America, 2005, p. 388-412).

Problem Statement

Ventilator-associated pneumonia is a prevalent problem in intensive care units (ICUs) globally, which results in increased mortality and morbidity rates, among mechanically aerated patients. It is the most prevalent infectious condition among patients at ICUs. When a patient suffers from VAP, their ICU stay is lengthened, which results to increasing hospital stays as well as the possibility of death, among critically ill ICU patients (Tablan et al., 2004; George, 1993, pp. 164-165).

Epidemiological surveys show that the condition leads to cumulative incidence levels of 10-25% approximated mortality levels among 10-40% of critically ill patients, and attributable death rates of 5-27% among ICU patients (Kollef, 1999, pp. 627-634). VAP is the principal cause of death, among the varied hospital-acquired infections (HAI), registering more than the rate of deaths resulting from central line infectivity, respiratory tract contamination among non-intubated patients, and severe sepsis. Possibly, the most concerning facet of VAP is the high level of related mortality, which goes to an approximated 46% as compared to 32% among those who do not develop the condition (Ibrahim et al., 2011).

Project statement: goal for the planned change

Although two of the bundled strategies are aimed at the reduction of VAP, the other two are aimed at preventing other likely complications, resulting from mechanical ventilation, including stress ulcers and DVTs. The intent of the planned change is the realization of a healthcare design, which can replicate the success expressed through the literature on bundled practices.

This area of planned change is based on the review of literature, sourced from evidence-based studies, applied in the practice of bundled practices. The study will focus on exposing the interventions in ventilator bundles. VAP planned change areas include identifying the strategies necessary towards the implementation of change to bundled practice and exposing the implications of the shift, which are expected to reduce the prevalence and incidences of VAP.

The goals for the planned change include the realization of an incorporated collection of interventions related to ventilator care, which presents better outcomes, as opposed to when the strategies are implemented individually. The utilization of the integrated component should result in a reduction in the prevalence of VAP (Hatler et al., 2006).

Objectives of the study and practice

The objectives of the study include taking an observational role in the administration of healthcare, where investigators do not control the intervention in a direct manner but focus on the comparison of the sequential study groups. The studies to be incorporated into the inquiry should be prospective and retrospective cohort studies, as the samples are defined before the start of the study as well as at the end of the observation duration.

The investigators should administer a follow-up study in real-time after their identification as cohorts, to evaluate the impacts of VAPBs on the declining VAP rates and the velentilatory days registered (Crunden et al., 2005). The study should also feature theory-guided project execution, encompassing prospective observation and self-reports.

There is also the objective to ensure adherence to treatment protocols, bridging the differences in staff competency and the variable nature of bundle implementation. However, due to the focus on historical controls in a non-randomized way, selection bias may become a risk, towards the internal validity of the inferences drawn from the study (Sheldon, 2001).

Agency and the identified need: practice site requiring change

St. Michaels medical Center (SMMC) has identified that there is the problem of the failure to realize patient outcomes, among patients exposed to mechanical ventilation. There is also the problem of congestion at the ICU center, mainly because the patients going in are registering long durations of stay; average count of days spent under ventilation. Lengthy durations are registered at the ICU and the prevalence of ventilator-associated pneumonias is also very high.

Due to the need for the change of ventilation exposure models and processes, aimed at the reduction of the adverse effects of these challenges, the center collaboratively operating with the OSF system-wide protocol on patient safety, set out for the implementation process. The efforts were crowned by the guidelines presented by the Institute for Healthcare Improvement (IHI) on ventilator bundles at the ICU, to increase the outcomes for patients and improve the care offered (Altman et al., 2001).

Change: the end product results

The process to be involved in affecting the change, include the review of literature for evidence-based support of the changes to be implemented, so as to determine and explore their success and their applicable nature to the case of the medical center. From the review, the major guides of the change process will have insights on the approach to use during the implementation of the changes in a successful manner, which works best for its case.

The next step is the consultation between the patient safety personnel, respiratory therapy personnel and the ICU nurses, who will deliberate upon the components of the SMMCs bundle, which will fit into the respiratory usage and the ventilator package protocol for ICUs. The next change implementation procedure is the training of the staff from the different departments, instructing them on interventions and the protocols to be observed (Resar et al., 2005).

The successful usage of the ICU ventilator bundles presents the need for the ownership and acceptance of the project among the respiratory therapy personnel, and the department in general, as well as the ICU personnel and the ICU department (Hampton et al., 2005).

The results anticipated by the center included the reduction of ventilator-associated pneumonia, a reduction in the average duration of stay at the ICU and the ventilator machine. At the onset, the objective of SMMC was to register 90% compliance with the instructional directives of the vital components of the ventilator management.

These included the elevation of the head section of beds at 30 degrees, dealing with peptic ulcer disease (PUD), deep venous thrombosis (DVT), oral care, hand hygiene, suctioning after every 2 hours or as the case may require, respiratory checking of the airway status on a two-hourly basis, and the assessment for readiness to exubate on a daily basis. Through the ventilator bundle implementation, SMMC realized 100% compliance from each of the intervention models (Altman et al., 2001).

The change Agents: implementation team at the agency

The implementation/ change agents team included the researchers observing the implementation of SMMCs ventilation bundle, who took a conservative role; they were not actively involved in the implementation of the change process throughout the implementation process. The second group of agents is the ICU charge nurses and the nursing team in general, as it offered support to the implementation of the change process. The third group is respiratory therapy personnel, who play a key role in aiding the implementation areas directly linked to respiratory measures. The last agent is the patient safety officer, who is responsible for maintaining the safety of the processes for the advantage of the patients.

Theory: the planned change theory

The planned change theory will be affected on the basis of Lewins three-step change theory, which explains that human behavior is dynamic, reaching a balance of forces working against each other. The driving forces aid change, as they push the parties to the implementation process, towards the desired direction of change. The restraining forces impede change, as they push employees against the direction against the desired change.

According to this model, these forces should be analyzed towards manipulating the shift, towards the planned change. The first stage is unfreezing, which is the phase of getting the medical center ready for the change; making the players experience the need for the change. At this stage, the different parties will be briefed on the positive effects of the shift. An example here will be the promise of reduced work load due to the reduced ICU and ventilation durations.

The second phase is the transition phase, which covers the change process, in case of implementation and usage of the new ventilation model. This phase will require support in the form of expecting mistakes, coaching and offering training among the different implementation teams. The third phase is freezing or refreezing, which will involve imposing stability into the change process realized (Lewin, 1958).

Project approach: strategies for accomplishing the evidence-based initiative

The strategies for the realization of the evidence-based practice for preventing VAP and its effects on patient healthcare outcomes, will take place through a continuing follow-up. The care bundle model will be based on the five interventions to be implemented at the medical center, which is to be recorded for the next sixteen months.

There are 885 subjects at the start of the implementation and the number is expected to increase. Compliance at the start of the implementation is 30%, but is expected to rise to almost 100%. After starting the program, VAP incidence reduced from 15.5 to 11.7%. The reduction so far, is associated to intra-cuff pressure control, hand hygiene, sedation control and oral hygiene (Rello et al., 2012).

Barriers: barriers to the implementation of the strategies

The barriers to the implementation of the ventilator bundles include the resistance of nursing personnel, especially in the cases they felt that the planned change compromised the comfort of the patient or risks the incidence of adverse effects. There was also the barrier of non-compliance with daily goals and required standards. There were also cases of inconsistencies during the implementation of bundle interventions.

Recommendations on addressing the barrier areas

Towards addressing these barriers, the main area of concern will be realizing the full confidence of the implementing parties, as per Lewins three-step theory of change. The address will start with the administration of further training an education on the benefits of adopting the ventilator bundles, placing emphasis on the risk-reduction strategies and the safety of the patients administered to the model. The other focus will be associating the change to rewards like recognition of the players who successfully implement the strategies.

Conclusion

Ventilator-associated pneumonia is a sub-category of hospital-acquired pneumonia, which occurs on patients exposed to technical airflow for more than 48 hours. This condition is the most common among ICU patients, leading to mortality rates of between 24-50%. VAP is the most prevalent infection among ICU patients, leading to lengthened hospital and ICU center stays, thus increased healthcare costs.

Following the adversity of the effects of the condition, it is clear that there is need to reduce the adversities and the deaths resulting from the condition. The goal for the planned change is reducing the VAP and the conditions resulting from the condition. The objectives of the study include taking an observation role to the strategies, where the subject group will be reviewed before and after the study.

The agency in need of the change is St. Michaels medical center, as it seeks to realize better patient outcomes and the conditions resulting from exposure to mechanical ventilation. The end results from the change implementation include the reduction of VAP incidences to 0, for the past 20 months and a decrease in average ventilation days to 2.98 from 4.76. The change agents include the researchers, the patient safety officer, ICU nurses, and respiratory therapy personnel among other aiding personnel.

The planned change theory is Lewins three step model, which explains change in human behavior as one that goes through unfreezing, transition phase and the refreezing phases. The project approach will be affected through a continuing follow-up. The barriers to the implementation of the strategy include the concerns of nurses over the safety of the patients, which will be addressed through re-education and further training, to affirm the effectiveness of the model and the patients safety.

References

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