University of Texas at Arlington College of Nursing
In partial fulfillment of the requirements of
N3645 Professional Nursing
Jeanean Boyd, MSN, RN
November 13, 2012
VAP Bundles, what to leave in, what to leave out?
Ventilator associated pneumonia (VAP) is a chronic and costly problem in the intensive care setting. VAP increases patient morbidity, mortality, and length of stay. These negative effects add significantly to the financial and emotional burden to the patient and family. VAP is being considered for addition to the Medicare non-reimbursable infection list, therefore healthcare providers need to proactively evaluate and implement procedures to minimize VAP rates. Article Summaries
The focus of this article was identifying the lack of universal diagnostic criteria for VAP and the impact of the lack of diagnostic standardization on interpretation of hospital reported VAP rates. The author’s contention is, despite an abundance of studies on VAP prevention the inconsistencies between institutions in diagnostic criteria can provide false zero and/or falsely elevated reported rates of infection. Additionally, the study that was primarily cited by the author did not include several interventions which he felt represented a major design flaw. In summary, the disparity in diagnostic criteria and variety of VAP prevention bundles make it difficult to clearly interpret currently available data regarding efficacy of specific interventions. I included this article based upon the three criteria I chose for inclusion: publication date within five years, clinical relevance, and statistically significant data produced by the study. This article specifically addresses the quandary surrounding diagnosis and prevention of VAP.
The authors of this study chose to compare the effects of mechanical treatment, pharmacological treatment, and a combination of both on VAP reduction. In preparation for the study the authors reviewed previously identified causes of VAP and chose to focus their study on the effect of reducing oropharyngeal colonization by potential respiratory pathogens. The conclusion of the study indicated that their analysis was confounded, in part by the defining criteria they chose to identify VAP. There was no significant reduction in VAP from toothbrushing(mechanical), and no sustained reduction beyond day three for the chlorhexedine(pharmacological) group. As has been noted in many studies there were additional, and perhaps more efficacious interventions concurrently in use, particularly elevation of the head of bed to thirty degrees. I included this article based upon the three criteria I chose for inclusion: publication date within five years, clinical relevance, and statistically significant data produced by the study. This article addresses the outcomes of specific nursing interventions targeting the reduction and/or elimination of VAP. Article Critiques
The researchers who designed this study attempted to minimize some of the confounding factors by applying certain aspects of the institution’s ventilator bundle to all of the study participants. This clearly defined standard of care improved the ability to directly attribute the effects of the research interventions. Prior to beginning the study the researchers observed the standard care of intubated patients in the facility and identified practices that were viewed as potentially contributing to oropharyngeal colonization. Based upon their observations, during the study period advanced oral care kits were exclusively used to provide oral care for the study group along with a clearly delineated schedule for performing different components of the oral care protocol. The result for the study group was a significant reduction in VAP with increased time to VAP. There was also a decrease in ventilator days and length of intensive care unit stay. The study confirmed...