My primary diagnosis leads to a condition known as Community-Acquired Pneumonia (CAP). CAP is one of the respiratory conditions that are closely related to Hospital Acquired Pneumonia (HAP). While HAP affects individuals in healthcare facilities, CAP is common amongst individuals outside medical facilities. Some of the factors that substantiate my diagnosis espouse the symptoms associated with CAP.
Prina, Ranzani, and Torres (2015) allude that tachypnea, crackles, and high fever are signed, which indicate that the patient is suffering from CAP. In this regard, the symptoms presented by Leroy on his second visit to the clinic are similar to those associated with CAP. The symptoms advanced by Leroy are linked to respiratory issues, a phenomenon that guides medical practitioners to the conclusion that he is suffering from CAP. As such, the conclusion that Leroy suffers from CAP emanates from the similarity of his experiences and the symptoms of CAP.
The tests that I will perform
To ascertain fully that the patient suffers from CAP, I will need to undertake several tests. Some of the tests comprise CBC that represents a complete blood count, chest X-ray, and sputum. By testing the blood count, I will be in a position of analyzing and assessing whether Leroys blood has additional white blood cells. It is fundamental to explain that the presence of additional or extra blood cells is one of the predisposing factors, which confirm that the patient has CAP. Consequently, a chest X-ray helps reveal whether the lungs have fluids that lead to CAP (Feldman & Anderson, 2015). To get near precise results, I will use Computed Tomography (CT) X-ray because the common x rays may not give clear results. Furthermore, I will test Leroys sputum and the amount of oxygen in his blood.
Sputum tests are very important in examining the presence of bacteria or other causatives that may have initiated the eventuality of the disease. Besides, sputum tests help in establishing the presence of fluids in the respiratory system of the patient. For a clear examination of the bacteria or fungi that may have triggered the infection, I will undertake blood tests through the process referred to as blood culture.
Another important test that I will engage in is auscultation. Wunderink and Waterer (2014) explain that auscultation tests help medical practitioners listen keenly to the internal process of the body such as heartbeat rate and breathing using a stethoscope. Through the test, I will be in a better place to reaffirm the presence of pulmonary crackles and tachypnea that indicate the presence of the CAP.
Pharmacological treatment and its mechanism of action
Since Leroy appears fit and UT infections have diminished, I will provide medication that he will take at home. It is important to state that CAP is a condition that is treated using antibiotics. Some of the antibiotics that are useful in treating CAP include Doxycycline, Macrolide, and Quinolone. Therefore, with knowledge of Leroys health and age, I will use an antibiotic that best suits his condition. I will choose azithromycin, a macrolide, which addresses CAP by ensuring that mRNA translation does not materialize.
Musher and Thorner (2014) highlight that azithromycin is an antibiotic that interferes with the growth of bacteria because it hampers the synthesis of proteins that are vital in bacterial development. The dosage that I will prescribe espouses an oral intake of the antibiotic for five days. The patient will commence his medication by taking a single dose of 500mg and then proceed with a regular intake of 250mg per day for four days. Besides advising Leroy to continue taking water about eight glasses per day, I will also have him visit the clinic after 3 days so that I can check his progress.
References
Feldman, C., & Anderson, R. (2015). Community-acquired pneumonia: Pathogenesis of acute cardiac events and potential adjunctive therapies. CHEST journal, 148(2), 523-532.
Musher, D., & Thorner, A. (2014). Community-acquired pneumonia. New England journal of medicine, 371(17), 1619-1628.
Prina, E., Ranzani, O., & Torres, A. (2015). Community-acquired pneumonia. The lancet, 386(9998), 1097-1108.
Wunderink, R., & Waterer, G. (2014). Community-acquired pneumonia. New England journal of medicine, 370(6), 543-551.
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
Altman, D et al. (2001). The revised CONSORT statement for randomized trials: Explanation and elaboration. Annals of Internal Medicine, 134 (8), 663694.
American Thoracic Society and the Infectious Diseases Society of America. (2005). ATS/IDSA Guidelines: Guidelines for the management of adults with HAP, VAP, and HCAP. Am J Respir Crit Care Med., 171 (4), 388412.
Crunden, E et al. (2005). An evaluation of the impact of ventilator care bundle. British Association of Critical Care Nurses, Nursing in Critical Care, 10 (5), 242246.
George, D. (1993). Epidemiology of nosocomial ventilator-associated pneumonia. Infect Control Hosp Epidemiol, 14, 164-165.
Hampton, D et al. (2005). Evidence-based clinical improvement for mechanically ventilated patients. Rehabilitation Nursing, 30 (4), 160165.
Hatler C.W et al. (2006). Using evidence and process improvement strategies to enhance healthcare outcomes for the critically ill: A pilot project. American Journal of Critical Care, 15 (6), 549554.
Ibrahim, E. H et al. (2001). The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest, 20 (2), 555-561.
Kollef, M. (1999). The prevention of ventilator-associated Pneumonia. NEJM, 340, 627- 634.
Lewin, K. (1958). Group decision and social change. New York: Holt, Rinehart and Winston.
Rello, J et al. (2012). A care bundle approach for prevention of ventilator-associated pneumonia. Clin Microbiol Infect, 10, 11-23.
Resar, R et al. (2005). Using a bundle approach to improve ventilator care processes and reduce ventilatorassociated pneumonia. Journal on Quality and Patient Safety, 31 (5), 243248.
Sheldon, T. (2001). Biostatistics and study design for evidenced-based practice. American Association of Critical Care Nurses Clinical Issues, 12 (4), 546559.
Tablan, O et al. (2004). CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep, 53 (RR-3), 1-36.
In medicine, prevention is one of the management options for controlling diseases. In the case of pneumonia, the pneumococcal conjugate vaccine (PCV 13) is endorsed for adults who are 65 years old and above, children less than two years old, and babies (John Hopkins Medicine, n.d.). Moreover, the vaccine is indicated for people aged between 2 to 64 years old who are highly susceptible to pneumonia infections because of specific medical issues. According to Grief and Loza (2018), PCV 13 has resulted in a 46% reduction of community-acquired pneumonia cases, and the protection lasts for four years. The pneumococcal polysaccharide vaccine (Pneumovax 23) is specified for cigarette smokers between 19 and 64 years, adults above 64 years old, and people between 2 and 64 years old with medical conditions.
Bacteria cause most pneumonia infections, and they are managed using antibiotics. Empirical therapy should be the best option for treating pneumonia and should be chosen depending on the etiology and efficacy (Mantero et al., 2017). The prevalence of antibiotics differs among different classes of patients, including inpatients, outpatients, and intensive care unit patients. There is a need for starting early treatment using antibiotics as it helps to reduce 30-day mortality. Antibiotics are administered via the oral route for outpatients, while the endo-venous route is preferred for inpatients until they gain clinical stability, after which oral administration is used. Clinical stability is determined by monitoring respiratory rate, fever, hemodynamic parameters, and inflammatory biomarkers.
Macrolides and doxycyclines should be used in previously healthy patients who lack risk factors for resistant Staphylococcus pneumonia. Examples of these drugs are erythromycin, azithromycin, and clarithromycin. Respiratory fluoroquinolones such as moxifloxacin and levofloxacin are indicated in cases of comorbidities such as diabetes; chronic renal, heart, liver, or lung disease; and compromised immune system. They are also used in cases of resistant Staphylococcus pneumonia, or where patients have used antibiotics within the last three months (Mantero et al., 2017). Moreover, combined therapy of macrolides and beta-lactam antibiotics is directed. High doses of cefuroxime, ceftriaxone, cefpodoxime, amoxicillin, or amoxicillin-clavulanate are used in this treatment. Patients who are allergic to penicillin are managed using respiratory fluoroquinolone. The inpatients who are not in the intensive care unit are treated using either respiratory fluoroquinolones or beta-lactams and macrolides. For intensive care patients, beta-lactams and azithromycin, and beta-lactams and fluoroquinolones are used.
Adequate antimicrobial therapy has positive outcomes; however, it is not sufficient in some cases. For instance, even with sufficient antibiotic treatment, patients with two or more of the following risk factors, arterial blood with a pH of less than 7.35, hypoalbuminemia, high urea levels, needing hospitalization, have a higher probability of 30-day mortality (Mantero et al., 2017). Such patients should be identified early and provided with supportive therapy for better management of their health. The main complication that requires supportive treatment is respiratory failure. There are several non-invasive respiratory support options. Examples include high flow nasal cannula oxygen therapy, non-invasive therapy, and Helmet Continuous Positive Airway Pressure.
Despite antibiotics being the cornerstone of pneumonia treatment, resistance limits their use. For instance, in pneumococcal pneumonia, a monotherapy using beta-lactams will not manage the infection even though the bacteria are susceptible. Staphylococcus pneumoniae has a 20% to 40% resistance against macrolides, and the resistance is still on the rise (Nayar et al., 2019). As bacteria develop resistance against antimicrobials, it may become difficult to manage them in the future. Therefore, there is a need to use the correct antibiotics and dosages to avoid increased resistance cases.
Ventilator-associated pneumonia is a common nosocomial infection that occurs in patients admitted to the intensive care unit (ICU). It is associated with increased mortality of up to 70%. VAP is defined as pneumonia that occurs 48 hours after admission in those patients put on mechanical ventilation. We elaborate the process of initiation through to implementation of VAP prevention protocols collectively referred to as the VENT bundle that entails procedures such as a change in the bed angle, sedation holiday, proper oral care, and prophylaxis against DVT and Gastrointestinal ulcers.
The systematic procedure of implementing the protocol is analyzed in detail from literature review, implementation of the protocols, and evaluation of the whole program to decision making regarding the outcome of the whole prevention program. The process is based on evidence-based protocols obtained through extensive research on programs aimed at the reduction of mortality rates associated with VAP in America.
Decision Making
Evidence shows that by implementing various strategies, VAP can be prevented resulting in decreased morbidity and mortality in those patients at risk. After initiation of the VAP protocol, there comes the need to freeze the current status quo and initiate a change mentality in all the stakeholders. To achieve this, the management needs to ensure that the healthcare team in the ICU is given Continuing Education (CE) on the Ventilation Acquired Pneumonia Prevention Protocol (VAPP). Furthermore, the hospital management should lay down procedures to follow when handling those patients that are at risk of VAP. To maintain adequate care, adequate staff needs to be employed to avoid job-related stress that may lead to laxity in the management of these patients hence putting them at risk of infection (Bouadma, Deslandes, Lolom, Le Corre, Mourvillier, Regnier, et al, 2010).
In addition, extending this program will need increased allocation of resources to the ICU in the hospital to ensure seamless management of patients at risk of VAP. Increased resources will ensure the staff is kept up to date with current evidence-based protocols in the prevention of VAP and are utilizing appropriate equipment in carrying out various duties such as brushing patients teeth aimed at preventing VAP (Bouadma, Deslandes, Lolom, Le Corre, Mourvillier, Regnier, et al, 2010). The program should be made part and parcel to any new nursing staff joining the team so that is well entrenched and passed over to the next generation of healthcare workers to ensure continuity in proper care.
Other risk factors associated with VAP should be mapped out and extension protocols formulated to ensure the continuity of care to those patients at risk. These include the period under which the patient is under mechanical ventilation, any form of antibiotic therapy instituted before admission, and any contacts within or without the hospital. With increasing research in the causative organisms of VAP, there is a need to lay down new protocols in terms of disinfectants used before and after making contact with the patient. All members working in the ICU should be trained and be fully versed with the pathogenesis of hospital-acquired pneumonia and its prognosis without proper intervention. This understanding of pathogenesis will be the guiding light in the formulation of proper working preventative strategies and policies. Comorbidity should be considered in designing additional protocols.
There may come a time when a program does not meet the set goals and fails to achieve the desired goals. In this case, if this program fails to prevent the occurrence of VAP in hospitalized patients on mechanical ventilation, it necessitates the need for review. The review process entails assessing each recommended procedure thoroughly to rule out loopholes that may be associated with failure (Escobar, Fireman, Palen, Gardner, Lee, Clark, et al, 2008).
This involves a thorough dissection of each procedure by both internal and external qualified health professionals to identify what went wrong with the program. After going through each stage, and identifying the root cause of the problem, appropriate measures are initiated immediately to correct the situation. Such measures may include re-training of personnel, change in equipment or even change in some protocols based on evidence through new research (Chastre, 2005).
The need for change should be impressed upon from the highest level of the organization through the involvement of all stakeholders from patients, nurses, and any other member of the healthcare team. Furthermore, newer advances in terms of evidence-based research need to be reviewed to facilitate the addition of more methods aimed at improving the situation (Escobar, Fireman, Palen, Gardner, Lee, Clark, et al, 2008). Healthcare workers should be immunized against conditions like influenza to reduce the risk of transmission of pathogens to vulnerable patients. The clinicians working in ICU should be continuously trained on proper medication use especially antibiotics such that strict policies are laid down to ensure narrow-spectrum antibiotics are used unless the situation demands broad-spectrum antibiotics. As such the risk of development of resistance is averted (Chastre, 2005).
In cases where the plan is deemed unsuccessful, after a thorough review of the process by qualified practitioners such as when the rate of patients developing VAP after admission increases instead of decreasing; an appropriate strategy needs to be followed in discontinuing the program (Bouadma, Deslandes, Lolom, Le Corre, Mourvillier, Regnier, et al, 2010). This will entail communicating information to all parties involved in the program explaining in detail the reasons behind such a move. At the same time, protocols that have worked before need to be initiated immediately. Furthermore, new research needs to be reviewed in preparation for initiating a new workable program (Chastre, 2005).
The further review should include research that showed high clinical significance rather than relying on data that shows statistical significance. Clinicians should aim at visiting other centers that have initiated similar protocols that have shown positive results and get to learn what is it that they are doing wrong and can be changed for successful implementation of the VAP prevention protocol (Escobar, Fireman, Palen, Gardner, Lee, Clark, et al, 2008).
After the failure is confirmed, there comes a need to re-analyze the protocols step by step with all stakeholders and identify points of weakness. Workable solutions need to be proposed as research projects for the future and the information submitted to peers in the field to be reviewed and disseminated to the wide healthcare community for further analysis. This can be done by publishing the information in reputable journals with high impact factors detailing the program, especially the drawbacks that may have led to the failure of the whole process, and asking for further review of the process to encourage the formulation of new policies and strategies (Chastre, 2005). Appropriate authorities should be notified of the failure of the program and any steps taken thereafter.
References
Bouadma, L., Deslandes, E., Lolom, L., Le Corre, B., Mourvillier, B., Regnier, B., et al. (2010). The long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Journal of Clinical Infectious Diseases, 51(10), 1115-1122.
Chastre, J. (2005). Conference Summary: Ventilator-associated pneumonia. Journal of Respiratory Care, 50(7), 975-982.
Escobar, G.J., Fireman, B.H., Palen, T.E., Gardner, M.N., Lee, J.Y., Clark, M.P., et al. (2008). Risk adjusting community-acquired pneumonia hospital outcomes using automated databases. American Journal of Managed Care, 14(3), 158-166.
The evidence-based project entails the implementation of bundled practices to prevent ventilator-associated pneumonia, which is a common occurrence in intensive care settings (Sedwick, Lance-Smith, Reeder, & Nardi, 2012).
Readiness Level
Survey results show that the readiness level is high because the organization views EBP as central to the realization of its mission and philosophy, allows the practice of EBP, and puts in place mechanisms for nurses, physicians, and other healthcare professionals to use EBP in the provision of quality of care. Other survey indicators that confirm the organizations readiness level is high include the presence of EBP champions, the entrenchment of EBP across the organization, and the availability of a critical mass of nurses with strong EBP knowledge and skills. These indicators show that the prevailing culture is supportive of EBP, which in turn translates to the fact that nurses will show more confidence in implementing the proposed project (Kaplan, Zeller, Damitio, Culbert, & Bayley, 2014).
Barriers and Facilitators
The low score on the use of fiscal resources to support EBP presents a monetary barrier due to the fact that successful EBP implementation may require significant financial investments (Melnyk & Fineout-Ouerholt, 2015). This barrier is nested in a lack of support from senior management. Another barrier concerns the low use of computers and library resources to support EBP, with the justification being that ICU nurses lack adequate time and skills to engage in research due to their ever-busy schedule (Sedwick et al., 2012). Lastly, the organization demonstrates an inability or unwillingness to generate decisions from direct care providers. Project facilitators include responsive organizational culture, dedicated EBP champions, alignment of the organizations philosophy with EBP, and commitment shown by nurses in implementing EBP. These indicators scored highly in the survey, with the justification being that the organization has embraced a culture of evidence-based practice (van Patter Gale & Schaffer, 2009).
Integrating Clinical Inquiry
Research demonstrates that rules for mouth care and hand washing, installing bedside alarms, training ICU nurses on effective use of subglottic suctioning, and utilizing an electronic compliance feedback system can prevent ventilator-associated pneumonia in intensive care settings (Sedwick et al., 2012). Nurses within the unit need to be taught about these best practices to improve patient care outcomes (Melnyk & Fineout-Ouerholt, 2015). Based on the weaknesses identified in the survey, it is important to come up with strategies that ensure nurses recognize the value of research-based knowledge by, for example, funding and facilitating them to undertake research studies and share findings with the organization. Additionally, successful integration of the identified best practices requires the management to train nurses on effective use of library resources, empower them on the use of computers to search for information, and include them in making decisions (van Patter Gale & Schaffer, 2009).
Conclusion
This paper has used the results of the survey to address the units readiness level, possible project barriers, and facilitators, as well as how the best practices for the prevention of ventilator-associated pneumonia could be successfully integrated into the unit.
References
Kaplan, L., Zeller, E., Damitio, D., Culbert, S., & Bayley, K.B. (2014). Improving the culture of evidence-based practice at a magnet hospital. Journal of Nurses in Professional Development, 30, 274-280. Web.
Melnyk, B.M., & Fineout-Ouerholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins.
Sedwick, M.B., Lance-Smith, M., Reeder, S.J., & Nardi, J. (2012). Using evidence-based practices to prevent ventilator-associated pneumonia. Critical Care Nurse, 34, 41-50. Web.
van Patter Gale, B., & Schaffer, M.A. (2009). Organizational readiness for evidence-based practice. Journal of Nursing Administration, 39, 91-97. Web.
Acute illnesses are especially dangerous for human health as they occur suddenly and have a substantial effect on the body. For this reason, patients who were hospitalized with this type of disease need a quick response, an accurate examination, and constant care. Bacterial pneumonia is an illness for which older people have high susceptibility; thus, its research helps to understand acute diseases and features of nursing care (Palleschi, Galdi, & Pedone, 2018). Consequently, pathophysiology and susceptibility factors of bacterial pneumonia in the elderly will be considered then a synergy model will be applied in this paper to determine the features of most effective treatment and care.
Characteristics of the Causes and Course of Bacterial Pneumonia in the Elderly
Characteristics and Variables
Bacterial pneumonia is an infectious disease that affects a persons lungs by causing inflammation. Common symptoms include coughing, difficulty breathing, sputum production, chest pain, and fever (Miyashita & Yamauchi, 2018). Older people usually have less physical and muscle strength to fight diseases, weaker immunity, and age-related ailments. For this reason, representatives of this group may not identify typical symptoms from chronic diseases, age-related changes, or cognitive impairment, and anorexia, malaise, and confusion may be atypical symptoms (Miyashita & Yamauchi, 2018). The main variables that increase susceptibility to pneumonia are the persons age, comorbidity, lung disease, and reduced physical activity (Palleschi, Galdi, & Pedone, 2018). All these features lower the peoples immunity and make their body more vulnerable to infections.
Factors That Influence Rehabilitation
The physiological factors also affect the recovery of a patient with bacterial pneumonia. However, psychological features and social factors are also added to them (Palleschi, Galdi, & Pedone, 2018). The physiological determinants directly affect the treatment process as it requires a comprehensive selection of medications and nutrition to reduce the risk of all concomitant diseases. The presence of mental dysfunctions can limit the ability to follow the rules of treatment and self-care.
Depression and sociological factors affect the patients desire to participate in the treatment and fulfill the nurses appointments. Sociological aspects also can affect the quality of post-hospital care if the patient cannot follow nutritional rules or if there is no support for every-day procedures. For example, according to studies, patients with poor quality of life are less likely to undergo rehabilitation to a previous level after acute illness (Bornet, Truchard, Rochat, Pasquier, & Monod, 2017). Therefore, physiological, social, and psychological factors have almost the same effect on the rehabilitation of elderly patients.
Synergy Model for Person-Centered Care
Patients Characteristics
The synergy model is one of the most successful patient care options as it takes into account the personal characteristics of patients and the competency of nurses. Two characteristics of the patient that have an impact on the treatment of pneumonia in the elderly are participation in caring and resource availability (Slota, 2018). Both features are interconnected, since resources imply personal, material, and social aspects that affect the possibility of care. For example, mental illness can interfere with adequate decision-making and implementation of recommendations, which, in the absence of social support, can be impossible. Also, the lack of money for proper nutrition and the purchase of medicines, even if participation is desired, makes it limited or impossible.
Nurses Competency
The main features of nurses have to correspond to patients needs. Consequently, these characteristics are caring practices and collaboration (Slota, 2018). The first competency includes an understanding of all the patient needs and their satisfaction, such as medicines, nutrition, physical activity, and communication. A second competency is necessary for older people who are affected by various factors. For example, interacting with a patients family can push them to participate in his or her recovery, and contacting social centers can provide financial and moral support after discharge. In this way, the patient and the nurse can achieve synergy and help the elderly recover.
The Process and Methods of Rehabilitation
The Educational Program
A nurse who is focused on the needs of the patient can better understand the options for caring and speed up the healing process. One of the strategies in rehabilitation should be the education of patients about their condition, care, and treatment. For example, elderly patients with pneumonia experience difficulty in oral intake, which negatively affects their nutrition. For this reason, Momosaki (2017) emphasizes that the nurse should choose one of the training options for swallowing depending on the patients condition, such as a pose or method, and train him or her. Besides, part of the education is the care of the oral cavity because elderly patients often neglect this procedure, which can create the accumulation of bacteria, which will cause a relapse of pneumonia (Momosaki, 2017).
Physical mobility is also essential as it reduces the possibility of complications, such as pressure sores or muscular dystrophy. For elderly patients, these complications are especially characteristic, since only 4% of them move during hospitalization (Palleschi, Galdi, & Pedone, 2018). Therefore, education on rehabilitation measures, including drug rehabilitation, should be part of the care.
Pharmacological Treatment and Nutrition
However, drug treatment and nutrition are integral elements of the rehabilitation of elderly patients. The common medicines for the treatment of bacterial pneumonia are narrow-spectrum antimicrobial drugs, such as ²-lactam, ceftriaxone, or clindamycin (Miyashita & Yamauchi, 2018). Besides, piperacillin, tazobactam, carbapenem, or a fourth-generation cephem can also be used at a high risk of resistant bacteria (Miyashita & Yamauchi, 2018).
The nutritional peculiarity of the elderly is the use of soft and liquid foods due to dental issues, and the complications of pneumonia only reinforce this secularity. However, patients in the rehabilitation process must abandon alcohol and foods that stimulate the production of mucus but replenish their diet with proteins and complex carbohydrates to restore muscle mass and vitamins to strengthen immunity.
References
Bornet, M.-A., Truchard, E. R., Rochat, E., Pasquier, J., & Monod, S. (2017). Factors associated with quality of life in elderly hospitalised patients undergoing post-acute rehabilitation: a cross-sectional analytical study in Switzerland. BMJ Open, 7(10), 18.
Miyashita, N., & Yamauchi, Y. (2018). Bacterial pneumonia in elderly Japanese populations. Japanese Clinical Medicine, 9, 14.
Momosaki, R. (2017). Rehabilitative management for aspiration pneumonia in elderly patients. Journal of General and Family Medicine, 18(1), 12-15.
Palleschi, L., Galdi, F., & Pedone, C. (2018). Acute medical illness and disability in the elderly. Geriatric Care, 4(3), 6264.
Slota, M. C. (Ed.). (2018). AACN core curriculum for pediatric high acuity, progressive, and critical care nursing (3rd edition). New York, NY: Springer Publishing Company, LLC.
This case study is focused on pneumonia diagnostics in a patient with type 2 diabetes using objective and subjective data. For pneumonia diagnostics, these types of data are crucial.
Subjective and Objective Data for Pneumonia Diagnostics
It could be assumed that the patient will share the additional subjective data in terms of cold symptoms that she presumably has. Also, it is possible to gather the verbal statements of the type of chest pain she has during cough as well as the description of fatigue. Also, as the patient has type 2 diabetes, it is crucial to investigate her diet during the past few days (DeWit & Kumagai, 2014). Regarding the objective data, it is necessary to assess all the overt indicators and signs. That is to say, the patient should be checked in terms of skin crackles and dullness to percussion. Furthermore, it is necessary to conduct a chest X-ray. Other mandatory examinations include the general and biochemical blood tests. These assessments should be carried out for accurate diagnosis and treatment purposes.
National Guideline
The national guideline for Respiratory Diseases discussed in Healthy People 2020 could be considered. In particular, the objectives discussed in RD-7 Increase the proportion of persons with current asthma who receive appropriate asthma care according to National Asthma Education and Prevention Program (NAEPP) guidelines are applicable (Gould & Dyer, 2014). They dwell upon the plan of care for patients with acute respiratory diseases and promote practices for clinicians to promote health and prevent diseases.
Tests and Consultation
Given the protracted nature of the common cold, fever with severe weakness, the presence of productive cough and chest pain, ordering chest X-rays as mentioned above is essential. Also, it is necessary to carry out a microscopic examination and sputum culture, urine, and blood tests to determine the presence of antibodies against various infectious agents that can cause the disease (Gould & Dyer, 2014). To be able to limit the number of preliminary nursing diagnoses it would be useful to consult a pulmonologist.
Diagnosis
Because people with diabetes have weakened immune systems and disrupted metabolism, any infection is especially dangerous for them. In the case of Mrs. C., the common cold or seasonal flu has resulted in severe inflammation (DeWit & Kumagai, 2014). Thus, the preliminary nursing diagnoses are insufficient airway clearance due to inflammation, aggravated gas exchange, and fluid volume deficit. The medical diagnosis is pneumonia.
Ethical Considerations
When designing the plan of care for patients of senior age, certain ethical dilemmas might occur. Firstly, patients of older age cannot fully or clearly describe their condition. Secondly, they cannot always effectively communicate their wishes; therefore, the decision-making process becomes more complicated. The health care specialist should weigh all the aspects in terms of antimicrobial resistance emergence in the course of infectious disease treatment (DeWit & Kumagai, 2014). It is significant to evaluate the particular benefits the therapy would bring to the patient compared to the outcomes for prospective patients.
Plan of Care
The treatment plan should be based on antibiotics. It is possible to prescribe cephalosporins or the combination of trimethoprim and sulfamethoxazole (DeWit & Kumagai, 2014). However, it is crucial to be particularly attentive to the process of caretaking into account the type of diabetes, diabetic medicine that patient takes, and concomitant diseases. During treatment, the specialist, as well as the patient, should monitor blood glucose levels because the need for insulin might vary. Complementary therapy might include vitamins A, C, E intake. The patient can be prescribed with acidophilus caps and advised on a raw juice diet. Moreover, turpentine oil would help relieve pain.
Circle of Caring
To reach optimal health outcomes using the Circle of Caring, the nurses input should be intensified. In particular, the nurse furnishing care to Mrs. C. should be empowered to execute autonomy within the expertise by the acute patients needs (Gould & Dyer, 2014). Also, the nurse should be authorized to provide educational services and support to the patients family so that Mrs. Cs husband could take better care of the wife utilizing complementary therapies.
References
DeWit, S., & Kumagai, C. (2014). Medical-surgical nursing. New York, NY: Elsevier.
Gould, B., & Dyer, R. (2014). Pathophysiology for the health professions. New York, NY: Elsevier.
Ventilator-Associated Pneumonia: Comparison Between Quantitative and Qualitative Cultures of Tracheal Aspirates
This work investigated the significance of quantitative results in regards to tracheal secretion. Quantitative cultures exhibited increased specificity over qualitative cultures but posted a decreased sensitivity compared to qualitative. VAP diagnosis prediction was not achievable through quantification It involved 106 ICU patients under ventilation support. Evaluation of both clinical and radiological values and a conclusive diagnosis emanated from an agreement of the two or all experts. There is no consistency in endotracheal aspirate hence; it cannot evaluate the quantification of microorganisms in tracheal aspirates. Quantitative cultures from aspirated tracheal samples had increased specificity and decreased sensitivity as opposed to those from qualitative cultures. Management of VAP by Nurses depends on qualitative findings instead of quantitative cultures; the latter have high costs and workload as opposed to qualitative.
Diagnosis of Ventilator-Associated Pneumonia: A Systematic Review of the Literature
The study involved a qualitative review of published materials to compare criteria of diagnosing VAP especially on its importance in diagnosing, culturing methods, and effects to the host. The study involved a Medline search of published literature on VAP and diagnostic availability. There was analysis of 64 articles and 25 adult patients who contributed to the study.
Quantitative cultures obtained by criteria including BAL, pBAL, and TBA seem to be equal in diagnosing VAP. Before nurses can decide on antibiotic therapy, they ought to evaluate their patients by imaging process, culturing bacteria, and utilizing biomarkers to make a sound decision. This would not only reduce mortality rate but also cut on medical cost to the patients.
Impact of Invasive and Noninvasive Quantitative Culture Sampling on Outcome of Ventilator-Associated Pneumonia
The study evaluated the impact of using both invasive (PSB and BAL) fiber optic bronchoscopy and noninvasive quantitative endotracheal aspirates QEA diagnostic methods for VAP. Diagnosis on first group was based on QEA and fiber optic bronchoscopy in association with PSB and BAL, while the second group were sampled using QEA only. The study was limited to a smaller sample size, hence unreliable. Though it offers good diagnostic tidbits, a fiber optic bronchoscopy using PSB or BAL is expensive and time consuming. Both invasive and noninvasive diagnostic criteria had no differences in mortality or morbidity rate. The significance to nurse occurs when choosing the type of antibiotic to administer since the prognostic factor for poor recovery from pneumonia is treatment with inappropriate antibiotics. There is a reduction in mortality and costs when the right regimen is given.
Quantitative Culture of Endotracheal Aspirates in the Diagnosis of Ventilator-Associated Pneumonia in Patients with Treatment Failure
The study investigated the correlation between noninvasive quantitative endotracheal aspirate cultures with both protected specimen brush (PSB) and BAL to VAP patients with medical complications. The correlations between QEA /PSB and QEA/ BAL were very significant. They are all within an acceptable specificity and sensitivity. There was the recruitment of Forty-eight patients under mechanical ventilation and suspicious of VAP. QEA cultures choice as diagnostic tool leads to overtreatment while the combination of PSB and BAL as reference increase the specificity of QEA in VAP diagnosis. The limitation of the study was the small sample size. The combination of both PSB and BAL increased the agreement between invasive and non-invasive methods to 92%. Prior use of QEA could be more significant to nurses in arranging for appropriate antibiotic use. It saves costs and reduces the risks of antibiotic misuse.
The Role of Quantitative Cultures of Non-Bronchoscopic Samples in Ventilator-Associated Pneumonia
The study determined the importance of quantitative cultures of non-Bronchoscopic samples and Endotracheal aspirates for the management of VAP. The study involved fifteen patients in ICU undergoing mechanical ventilation for a period not less than 48 hours. There were two groups of patients. Comparison of results to gold-standard methods like lung tissue histology is a requirement. The sample size used also raises an eyebrow; a similar study on a larger group could validate it.
BBS and ETA methods were in harmony. The importance of the findings in nursing is that the quantitative culture obtained from lower respiratory tract samples through non-Bronchoscopic method facilitates management and early diagnosis of VAP. This method is safe to their patients as well as being cost effective.
Accuracy of BAL Methods Using Fiber Optic Bronchoscopy to Diagnose VAP
The study focused on getting already published materials that evaluated the accuracy of BAL methods using fiber optic bronchoscopy to diagnose VAP. A prospective study on 23 articles had a review and enrollment of 957 patients suspected of VAP. There was no standardized method for calculating both specificity and sensitivity; some studies did not report either. BAL has two major risks, those associated with the use of fiber optic bronchoscope, and those gotten when instilling fluid during bronchoscopy. With a variety of literature at their disposal prior done on management of VAP, clinician or nurse could settle to a particular study diagnostic criterion that is less expensive to the patient as far as the cost of the procedure and antibiotic therapy is concerned.
Efficacy of Bilateral Bronchoalveolar Lavage for Diagnosis of Ventilator-Associated Pneumonia
The study investigated the effectiveness of BAL in detecting the bacterial cause of VAP that existed for a period over 5 years to a total of 27 mechanically ventilated patients who provided 399 BAL samples for quantitative bacterial cultures there was a comparison of cultures and radiographic findings
The right lung sample offered better predictor of VAP presence than bilateral. The major strength of this work was the large number of patients sampled, most of whom were trauma males patients the study did not compare their results with a gold standard analysis like histological processing to help in confirming infection. Nurses can consider carrying out unilateral right lung samples instead of bilateral sampling when detecting causative agents for VAP make their work faster and safer for the patients.
The Appropriate Diagnostic Threshold for Ventilator Associated Pneumonia Using Quantitative Cultures
The study reflected on analysis of a larger patient population for purpose of deciding the maximum effects of VAP, as well as identifying the potential patient size who may benefit from a lower threshold. The work came up an idea that the occurrence frequency of organisms in false negative results was similar to those seen in VAP but did not give false negative BAL.
526 patients underwent fiber optic bronchoscopy procedures with BAL and culturing happened later for microbiological assay. Data included cultured organisms, quantitative colony counts, duration of culturing, and the sensitivities of the methods. This study is important to nurses in early identifying a patient likely to develop false-negative test results. The early false negative BALs result is vital for appropriate therapy institutions and hence reduces mortality that is usually associated with delay in diagnosis.
Direct E-Test (Ab Biodisk) of Respiratory Samples Improves Antimicrobial Use in Ventilator-Associated Pneumonia
A European Task Force composed of experts in the field of ventilator-associated pneumonia steered by Torres and J. Carlet answered some questions regarding VAP management. It came up with the idea that the only alternative to diagnosing VAP is through the Clinical Pulmonary Infection Score (CPIS).
Mortality and the Diagnosis of Ventilator-Associated Pneumonia: A New Direction
This article reviewed studies done by other researcher. It reviewed publications dealing with description, contrast, and debates on the merits of some techniques and strategies for diagnosis of VAP. However, most of previous studies did not address the inaccuracies of clinical criteria for diagnosing VAP as this paper did.
The methodology used in this article was mainly literature review of secondary data. The limitation in this work was the absence of raw data to support the facts discussed by the researcher. However, much information criticized the deficits in other researcher.
Nurses and physicians are likely to benefit from the truth revealed in this article in deciding whether to use quantitative or no quantitative cultures for better outcomes.
Bronchoscopic BAL in the Diagnosis of Ventilator Associated Pneumonia
This article covered utilization of fiber optic bronchoscopy in BAL methods. This happened by reviewing 23 studies and evaluating the efficiency of BAL methods utilizing fiber optics bronchoscopy in VAP diagnosis happened to 957 patients. The study compared BAL in either Bronchoscopic procedures or non-Bronchoscopic methods. Unfortunately, Proper standardization of BAL is yet accomplished. This method has many shortcomings in many ways such as lack of clarity on sensitivity and specifity, undefined population of study among others. The outcomes of the study revealed that the sensitivity percentage in quantitative BAL fluid was lower than specificity was higher and the results were unreliable. Nurses become aware of BALs major side effects since through oxygenation of VAP patients do not guarantee full recovery.
Adherence to Ventilator-Associated Pneumonia Bundle and Incidence of Ventilator-Associated Pneumonia in the Surgical Intensive Care Unit
The study examined the benefits of a ventilator-associated pneumonia bundle in VAP incidences occurring in Surgical Intensive Care Units. The rising priorities of VAP in all United SStatesICUs must have triggered this study. In addition, it reflects the increasing cases of infections of VAP in ICUs that have raised costs of medication. Due to the urgency and impacts of this situation, most hospitals and Healthcares have tried to comply with VAP prevention measures in order to curb nosocomial infection.
The researcher retrieved data from Infection Control Committee Surveillance database of SICU patients for 38 months. The availability of public database eased study. The longevity of the study ensured the efficiency of the results and conclusions. The two SICUs registered an increase of VAP bundles compliance. In addition, both nurses and patients are likely to benefit from the compliance of VAP bundles through efficiency and cost saving.
Ventilator Associated Pneumonia and Infection Control
This study reflected on causal agents of VAP as well as possible control measures of VAP. They emphasized on the risks of environment provided by pharynx and gastrointestinal tract for microorganism that that cause VAP during mechanical ventilation. They also advocate for proper control policies since diagnosis of these cases is difficult. Through literature review of previous studies, Alp and Voss defined measures that were applicable in mitigating VAP at early stages in order to save on costs of treatment. The strength of this study is the fact that related studies confirmed that cases of VAP were increasing in ICUs hence, control measures were vital. The outcomes of the study will reduce cases of infection through risks reduction, improved hospitalization environments, good hygiene among others.
This article reflects on various types of nosocomial pneumonias. The different types described include ventilator-associated and hospital acquired pneumonia. The comparison between VAP and HAP is the means of infection and time taken to contact the disease. VAP emanates from microorganisms inhibition in lower respiratory tract and lung parenchyma. HAP expresses some signs and symptoms 48 hours after the patients admission in hospital. The danger associated with HAP is the possibility of a patient being retained an extra of 7-9 day hence increasing hospital bills. The article also suggests some means of taking care of a HAP and VAP patients. In terms of methods and design, the paper had deficit in ideas. However, the article gives some advice to nurses on attending affected patients.
Clinical Diagnosis of Ventilator-Associated Pneumonia Revisited: Comparative Validation Using Immediate Post-mortem Lung Biopsies
The article had much focus on assessment of diagnostic value using various clinical criteria as well as evaluating the contributions of microbial testing ineffective clinical diagnosis of suspicious VAP. The studied sample had twenty-five patients under mechanical ventilation. There was acquisition of several bilateral lungs Specimen immediately after death. Reference testing utilized the result of presence of histological pneumonia and cases of lung cultures. As a result, there was a sensitivity of 69% and specifity of 75% due to the presence of infiltrates. The non-invasive cases also registered a certain percentage of sensitivity and specifity. The significance of this article to nurses is the revelation combination of antibiotics to the patient does not improve the effectiveness.
References
Alp, E., & Voss, A. (2006). Ventilator associated pneumonia and infection control. Annals of Clinical Microbiology and Antimicrobials, 5(7), 1-11.
Amanullah, S. et al. (2011). Ventilator-Associated Pneumonia medscape reference. Web.
Bird, D. 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.
Bouza, E. et al. (2007). Direct E-test (AB Biodisk) of respiratory samples improves antimicrobial use in ventilator-associated pneumonia. Clin Infect Dis, 43,382-7.
Camargo, L.F.A. et al. (2004). Ventilator associated pneumonia: comparison between quantitative and qualitative cultures of tracheal aspirates. Critical Care, 8, R422- R430.
Croce, M.A. et al. (2004). The Appropriate Diagnostic Threshold for Ventilator- Associated Pneumonia Using Quantitative Cultures. J Trauma, 56, 931936.
El-Ebiary, M., & Torres, A. (2000). Bronchoscopic BAL in the Diagnosis of Ventilator- Associated Pneumonia. Chest, 117, 198S-202S.
Fàbregas, N., et al. (1999). Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax, 54(10), 867-73.
Liang, W.C. et al. (2002). Quantitative Culture of Endotracheal Aspirates in the Diagnosis of Ventilator-Associated Pneumonia in Patients with Treatment Failure. Chest, 122(2), 662-9.
Rajasekhar, et al. (2006). The Role of Quantitative Cultures of Non-Bronchoscopic Samples in Ventilator Associated Pneumonia Ind. J. of Med. Microb.,24, 07-113.
Rea-Neto, A. et al. (2008). Diagnosis of ventilator-associated pneumonia: a systematic Review of the literature. Critical Care, 12, 56.
Sanchez, J.M.N. et al. (1998). Impact of Invasive and Noninvasive Quantitative Culture Sampling on Outcome of Ventilator-Associated Pneumonia. Am J Respir Crit Care Med, 157, 371376.
Wunderink, R.G. (1998). Mortality and the Diagnosis of Ventilator-associated Pneumonia: A New Direction. Am. J. Respir. Crit. Care Med., 157(2), 349-350.
Zaccard, et al. (2000). Efficacy of Bilateral Bronchoalveolar Lavage for Diagnosis of Ventilator-Associated Pneumonia. J. Clin. Microbiol., 47(9), 2918-24.
Zaccard, C.R. et al. (2009). Efficacy of Bilateral Bronchoalveolar Lavage for Diagnosis of Ventilator-Associated Pneumonia. J Clin Micr , 47(9), 2918-24.
Ventilator-associated pneumonia (VAP) is a nosocomial infection that starts after 72 hours of endotracheal intubation of patients in intensive care units. This type of pneumonia is linked with a high mortality rate, increased cost of care, and length of hospitalization. The disease incidence in a critical care setting is about 65 %, it also increases the clients stay in the hospital for about 4.3 days and accounts for an increase in mortality rates to about 70% from 20% (Álvarez-Lerma et al., 2018). Currently, this hospital-acquired disease is the leading cause of death for people discharged from intensive care units.
Star memorial hospital needs to adopt a ventricular bundle, the hospital has a capacity of 1000 patients and it has 18 beds in the intensive care unit. Approximately 80 % of patients in ICU are usually mechanically ventilated. Ventilator-associated pneumonia continues to be an important infection affecting critically ill patients in this hospital. This disease has increased morbidity, and mortality, thus, there is a need to implement evidence-based guidelines in critical care to reduce VAP incidence in the clinical setting.
Significance of Quality Improvement in the Organization
VAP has negative impacts on critically ill patients and is linked to the high cost of care. For this reason, its incidence should be reduced by creating a patient safety intervention to be deployed by health care professionals, patient care, and hospital leaders. A standardized care delivery model called the ventilator bundle, which combines several care delivery strategies for patient care optimization needs to be adopted. The bundle consists of five activities, which are daily goals, education, day to day management, team meetings, and structured oral care.
The inclusion of several interventions during implementation produces better outcomes as compared to one intervention. The ventilator bundle lays emphasis on a specific aspect of treatment required by the patient before initiating groundwork for the care team. It also improves guidelines and protocols to bring out ideal patient outcomes. The package activities are deep vein thrombosis prophylaxis, target head-of-the-bed (HOB) elevation, daily sedation vacations, structured oral care, peptic ulcer disease prophylaxis, and daily assessments for extubate. Expected outcomes include a reduction in mortality, morbidity, sedation days, length of hospital days, and reduction of patients in need of subsequent mechanical ventilation.
Evidence-based Healthcare
Evidence-based care is the explicit, judicious conscientious utilization of the most recent suggestion with a better outcome in making decisions for individual-based care. This practice has gained momentum in the healthcare system and it has forced nurses to update their skills and knowledge to augment a provider-client decision making process. There are six steps involved in the evidence-based practice which are; asking clinical guiding question, searching for evidence, critically appraising the evidence, integrating evidence with clinical expertise, evaluating the outcome, and disseminating the outcome.
The clinical guiding question for this initiative follows the PICOT format, which stands for the patient, problem of interest, intervention, comparison outcome, and finally time period. Thus, the focus question is: In critically ill patients admitted in ICU, is using a ventilator bundle efficient in reducing VAP complications such as increased morbidity, mortality, and length of stay in hospital as compared to one type of intervention over seven months period.
In the second step, the best evidence is tracked down, nurses and doctors assess the outcomes of a practice based on the ability to undertake routine activities and life quality. Evidence is obtained from the Cochrane Collaboration database and papers with systemic randomized control trials are reviewed. Prior to using the evidence, an appraisal is conducted to determine whether the evidences are valid followed by a meta-analysis of the results in the third phase.
The fourth step involves changing practice to align with the evidence and convincing staff to adopt the initiative. Patients admitted in ICU and interventions used on them are audited in the fifth stage to determine the success of the project. Outcome dissemination is the last step, it is done by making evidence-based protocols to be used as a reference in and out of the hospital. In addition, the findings are disseminated through lectures, conferences, manuscripts, and online media.
Previous Research Supporting the quality improvement initiative
Evidence of ventilator bundles effectiveness in controlling VAP has been demonstrated by Parisi et al., (2016). These authors examined the effects of staff education and VAP implementation on disease incidence, mechanical ventilation duration, length of stay in the hospital, and the period between incidences in the multidisciplinary intensive care unit. They discovered that VAP incidence and duration of hospitalization decreased in units using the ventilator bundle intervention.
A Meta-Analysis of published randomized controlled trials article conducted by Su et al., (2020) showed that probiotics are effective and safe in controlling VAP in patients who received mechanical ventilation. This is because the disease incidence reduced in the studies pooled, however, there was no significant difference in ICU mortality and the length of stay in hospitals between the patients using probiotics and those not. The results obtained from this research implies that one intervention is not effective in the management of VAP.
Oral cavity contamination increases the colonization of pathogens responsible for the dissemination of pulmonary infection such as pneumonia. In ICU, prophylaxis with topical antibiotics is used to induce bacteria resistance. Rabello, Araújo, & Magalhães, (2018) conducted seven systemic reviews on the prevention of ventilator-associated pneumonia using chlorhexidine. The drug is effective in controlling VAP in the cardiothoracic intensive care unit only. Thus, there is a need to include other interventions in intensive care units as a bundle.
Steps Necessary to Implement the Quality Improvement Initiative
The implementation process begins with planning for staff education, results tracking, data collection, outcome reporting, and creation of a team that will spearhead the initiative. The critical care nursing manager, medical director, chief quality officer, and nurse director are the key administrative champions that will supervise the project.
A goal sheet containing prioritized ventilator bundle interventions will be utilized each day in the intensive clinical care unit. In the daily rounds, the nursing care coordinator, nursing staff, and the attending physician will record the interventions used. The goal sheet aids in facilitating and tracking progress, encouraging fast response to arising patients problems and it also ensures that key issues are addressed. The sedation vacation will be effected by giving continuous sedation infusion when a patient is fully awake. However, in patients requiring continuous sedation after a vacation, the nurses will have to administer bolus sedation prior to restarting the infusion of sedatives.
Before executing the standardized care delivery process, staff will be familiarized with evidence-based information concerning VAP through training. Additionally, they will be introduced to the ventilator bundle and daily goal sheet in the staff meetings through on one sessions and poster presentations. Staff will be given a chance to voice their concerns and air their feedback on the initiatives during the meetings, which will take place weekly.
The ventilator bundle and daily goal sheet will be applied first on a few patients, it will then be refined based on the outcome through a plan do study act cycle. Thereafter, the goal sheet will be utilized during the daily nursing care routines. The program will be audited weekly by the quality data coordinator to track staff progress on bundle compliance and to address issues that may arise. Furthermore, an appraisal step will provide an opportunity for reinforcement, staff reeducation, and overall support.
Evidence and Rationale
Evidence suggests that oral care is critical in deterring pneumonia in an intensive care setting. Therefore, oral secretion decontamination and reduction of risk factors associated with VAP will be implemented. Good oral hygiene intervention using a structured oral care method done every 3 hours will be introduced to the bundle. In Intensive care unit, failure to utilize standardized processes in sedation, ventilator-associated pneumonia (VAP) prevention, blood transfusion, and venous thromboembolism (VTE) prophylaxis may result in poorer outcomes such as increased mortality and length of hospitalization. Thus, it is critical to implement all interventions that have been effective in controlling the nosocomial infection.
Evidence of effective interventions will be generated using the critical appraisal program. Additionally, credibility, and reliability of the indicators and articles used should be ascertained to ensure that the results used is valid enough for the new practice. It wise to adopt the ventilator bundle because it is cost-effective and simple to implement, in addition, this intervention has the potential of positively influencing the staff, patients, and hospital resources utilization. According to Parisi et al., (2020) study, the application of the package in a medical intensive care unit, resulted in the culture change that led to remarkable patients outcomes. Furthermore, the process of implementing a new protocol gave the healthcare team a sense of ownership and pride, which contributed to the success and quality improvement.
Process and Outcomes Measurement
The compliance rate will be utilized to indicate a ventilator bundle implementation degree, it will be calculated by dividing the number of all patients mechanically ventilated in the intensive care unit by patients under the ventilator bundle. The outcome measured in the intervention will include the rate of VAP incidence and the days between outbreaks. Reduction of VAP rate and increase in days between episodes after ventilator bundle implementation will signify the success of the initiative.
The quality improvement project targets ventilator-associated pneumonia, sedation, and length of stay in the hospital. The process will measure different variables such as the head of bed elevation, mouth care, early appropriate diagnostic measure and antibiotic therapy, compliance with individual processes, and daily interruption of sedative infusions. Descriptive statistics like standard deviation, means, and frequencies will be used to describe the population. Bivariate analyses such as chi-square statistics and Mann-Whitney U analyses will be utilized to compare the outcomes of the control group and that of patients undertaking ventilator bundle treatment. This quality improvement project hypothesis is: using a ventilator bundle is not efficient in reducing VAP incidence and other complications such as increased morbidity, mortality, and length of stay in the hospital.
References
Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., Álvarez-Rodríguez, J., Lorente, L., & Jam-Gatell, R. (2018). Prevention of ventilator-associated pneumonia: the multimodal approach of the Spanish ICU Pneumonia Zero program. Critical Care Medicine, 46(2), 181.
Parisi, M., Gerovasili, V., Dimopoulos, S., Kampisiouli, E., Goga, C., Perivolioti, E., & Nanas, S. (2016). Use of ventilator bundle and staff education to decrease ventilator-associated pneumonia in intensive care patients. Critical Care Nurse, 36(5), e1-e7.
Rabello, F., Araújo, V. E., & Magalhães, S. M. S. (2018). Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilatorassociated pneumonia in intensive care units: Overview of systematic reviews. International Journal of Dental Hygiene, 16(4), 441-449.
Su, M., Jia, Y., Li, Y., Zhou, D., & Jia, J. (2020). Probiotics for the prevention of ventilator-associated pneumonia: A meta-analysis of randomized controlled trials. Respiratory Care, 65(5), 673-685.
Vaccination is the Injection of a killed microbe to stimulate the immune system against the microbe, thereby preventing disease. Vaccinations, or immunizations, work by stimulating the immune system, the natural disease-fighting system of the body. The healthy immune system can recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off disease. To immunize against disease-causing microorganisms, the microorganism used in the vaccine has been weakened or killed to stimulate the formation of antibodies against the whole microorganism.
Vaccinations remain the best way to stop the spread of infectious diseases in epidemics, according to scientists in Italy. Epidemic outbreaks of an infectious disease are complex functions of both the characteristics of the pathogen and the movement and interaction patterns of the people (Lee, S., Rocha, L. E., Liljeros, F. & Holme, P. 2012). Widespread immunization programs in several parts of the world, including the United States and Europe, have virtually wiped out smallpox, polio and other fatal diseases. These shots are given to children on a regular schedule, but some vaccines also are given more than once, such as annual flu shots, while others are given less often or as needed, such as for pneumonia and shingles.
Researchers suggest in the new study that using vaccines as a weapon against epidemic outbreaks should be an obvious option to prevent the further spread of disease. Vaccination has made an enormous contribution to global health. Two major infections, smallpox and, rinderpest, have been eradicated. Global coverage of vaccination against many important infectious diseases of childhood has been enhanced dramatically since the creation of WHO’s Expanded Programme of Immunization in 1974 and of the Global Alliance for Vaccination and Immunization in 2000. Polio has almost been eradicated and success in controlling measles makes this infection another potential target for eradication. The measles virus is one of the most highly transmissible human infectious disease agents known, with a basic reproduction number (R0) of 12–18. This number means that a single primary case in a susceptible population would generate on average 12–18 new cases (Hotez, P. J, 2016)Despite these successes, approximately 6.6 million children still die each year and about a half of these deaths are caused by infections, including pneumonia and diarrhea, which could be prevented by vaccination.
Enhanced deployment of recently developed pneumococcal conjugate and rotavirus vaccines should, therefore, result in a further decline in childhood mortality. The development of vaccines against more complex infections, such as malaria, tuberculosis and, HIV, has been challenging and achievements so far have been modest. Final success against these infections may require combination vaccinations, each component stimulating a different arm of the immune system. In the longer term, vaccines are likely to be used to prevent or modulate the course of some non-infectious diseases. Progress has already been made with therapeutic cancer vaccines. Vaccines based on tumor antigens that are expressed differentially between tumors and normal cells and can stimulate immunity, and for which safety and efficacy have been proved in animal models and to the extent possible in therapeutic clinical trials, should be considered prime candidates for prophylactic cancer vaccines (Finn, O. J, 2014) .future potential targets include addiction, diabetes, hypertension and, Alzheimer’s disease.
All things considered, it is important to note that vaccines are among the most effective prevention tools available to clinicians as they prevent morbidity and mortality caused by epidemics and pandemics. In the last century, vaccination has been the most effective medical intervention to reduce death and morbidity caused by infectious diseases. It is believed that vaccines save at least 2–3 million lives per year worldwide. Smallpox has been eradicated and polio has almost disappeared worldwide through global vaccine campaigns. Most of the viral and bacterial infections that traditionally affected children have been drastically reduced thanks to national immunization programs in developed countries.
REFERENCES
Lee, S., Rocha, L. E., Liljeros, F., & Holme, P. (2012). Exploiting temporal network structures of human interaction to effectively immunize populations. PloS one, 7(5).
Finn, O. J. (2014). Vaccines for cancer prevention: a practical and feasible approach to the cancer epidemic. Cancer immunology research, 2(8), 708-713.
Hotez, P. J. (2016). Texas and its measles epidemics. PLoS medicine, 13(10).