Enhancing Nurses ` Competency on Adherence to Bundle Prevention Protocol for Ventilator Associated Pneumonia

Introduction:  

Today ventilator-associated pneumonia (VAP) is a potentially preventable iatrogenic illness that may develop following mechanical ventilation and a major health concern in hospitals. It represent  a type of  lung  infection that  affects  critically ill patients  and developed 48 hours or longer post  mechanical ventilation . Moreover, the leading cause of nosocomial infection, increased morbidity, longer hospital stay, increased health care costs, and higher mortality rates    (Marini    et al., 2016   & Kollef et al., 2014). It occurs because the obtunded endotracheally intubated patient is at risk of inoculation of lower respiratory tract with microorganisms. Staphylococcus   aurous is the most common pathogen associated with VAP and the leading cause of death. VAP can be of two types: Early onset which develops within 5 days of mechanical ventilation and late onset which develops 5 days or more after mechanical ventilation.  The diagnosis  usually requires a new infiltrate on chest x-ray plus  temperature >38 °C or <36 °C , white blood cell count  >12 × 109/ml, purulent secretions from the airways and reduction in gas exchange   (Russell  et al., 2016  &  Michetti  et al.  , 2014).

The incidence of VAP increases with duration of mechanical ventilation.   Estimated rates are 3% per day for the first 5 days, 2% per day for days 6-10 and 1% per day after day 10.  In  New York ,  the  rates of  adults  VAP  might count 27% of all  infections in  CCU .    The National Healthcare Safety Net-   work reported   2.1 to 10 incidents per 1,000 ventilator days. Research evidence shows that VAP incidence reaches around 32% in Athens.   In Egypt,  it   is  a  tremendous  problem with  continuous elevation in its incidence  . This observation was supported through studies concerned with incidence of VAP in two universities; Alexandria (four studies) and Mansoura (one study). Incidence of VAP ranged from 16% to 75%  with the lowest ratio in Alexandria  ( Burja   et  al., 2017  ,  Ismail  &  Zahran  , 2015    &  Fathy  et al.  , 2013).             

Risk factors of VAP were classified as patient related risk factors: chronic diseases, immunosuppressed   drugs, low consciousness, thoracic / abdominal surgery, previous antibiotic    and    infection. Access  , treatment  and  personnel related risk factors  :    placement of  ryle , enteral  feeding, gastric over distension , stress ulcer treatment , supine position, nasal intubation, instillation of normal saline,  shortage of  staff , poor  hand washing protocol , and lack of  training  in  VAP  prevention  ( Wong  et al., 2016 &  Safdar   et al.  , 2015).

Prevention of VAP include:  minimizing occurrence of micro-aspiration, colonization of upper airway and GI tract with potentially pathogenic organisms or contamination of ventilator/ respiratory equipment. Bundle  care  of  VAP  is  defined  as  a   series  of  steps  related to ventilator care that should be  implemented together  to improve clinical outcomes and  prevention of VAP. Recent evidence has challenged current widespread practice so; most recent   advances in interventions for VAP prevention are needed (Marini & Khan, 2016   and   Kalanuria   et al.  , 2014).  

According to the Institute for Healthcare Improvement (IHI) five components of ventilator associated pneumonia bundle are: Hand washing and use of gloves. Elevation of head of bed to 30- 45 degrees. Suctioning of sub-glottic secretions. Daily sedation vacation, assessment of readiness to extubation and implementation of comprehensive oral hygiene program.  Peptic ulcer and deep vein thrombosis prophylaxis   (Larrow, 2016 & Zack   et al., 2012).

Nurses play an important role in identification of risk factors and pathophysiology of ventilator associated pneumonia, mechanical ventilation, duration of ventilation, prevention of VAP by using a bundle care. Prevention of VAP becomes the focus for both nurses and respiratory therapists working with ventilated patients (Dewit et al., 2016 and Hinkle & Cheever, 2014).

Significance of the study:

VAP is the most commonly reported health care acquired infection  in  CCU  and the hospital mortality rate of ventilator patients who develop VAP is 46%, compared to 32%  do not develop  . Moreover, it   increases   severity of illness as it elevates oxygen demands, sputum production, and produces alveolar collapse leading to impaired gas exchange.  Patient might experience discomfort, agitation, delirium, immobility, and/or risk for impaired skin integrity, hemodynamic instability, as well as an increased   stress response and malnutrition (Larrow, 2016 & Mori et al.  , 2016). 

Critical care nurse has an important and crucial role in developing the best practice standards in an attempt to prevent VAP. Nurses' education and reinforcement is considered as the cornerstone and the first step in preventing VAP. Therefore, the present study was designed to   enhance    nurses `   competency on   bundle prevention protocol for ventilator associated pneumonia (VAP)   .        

Aim of the Study:

This  study  aimed  to  evaluate the effect of  enhancing   nurses `   competency  on   bundle  prevention  protocol  for  ventilator associated pneumonia (VAP )     . This aim was achieved as follows    :

• Assess studied nurses' knowledge, practices and anxiety    level   as regards bundle prevention protocol for   VAP   .      
• Identify the obstacles affecting on studied nurses' competency (physical, psychological, social and administrative) added to   the suggested solutions. 
• Develop and implement the educational    guidelines   for the studied nurses about    bundle prevention protocol for   VAP    .

Evaluate   its effect on :  

• Nurses` knowledge, practices and anxiety    level. 
• Incidence    of     VAP  among studied patients post guidelines     

Hypothesis:

It  was  hypothesized   that  , the   educational  guidelines   had   a  positive effect on   nurses`  competency (knowledge and practices) as regards implementation of  bundle  prevention  protocol  for  VAP  among mechanical ventilated patients  .       

2. Subjects and Method:

Operational definitions: 

Competency:   means nurses` knowledge and practices

Educational guidelines:   means theoretical and practical sessions   . 

Adherence:  means implementing bundle prevention protocol of   VAP for full initially intended duration.

Research design:

A quasi-experimental design was utilized to conduct this study

Setting:

This study was conducted in:  Medical    Hospital   affiliated   to  Ain Shams University hospitals   and   El Sayed Galal Hospital    in the following Critical   Care Units (Neuro- Medicine, ICU, CCU   and   Emergency)    .

Subjects: 

A purposive sample was   composed of 70 nurses with different ages, education and experiences.  In addition,   40 critically ill patients with different diagnosis they   were taken as follows:

Ain Shams University Hospitals  

Medical Hospital (  40  nurses  ,  20   patients    )  :   

10 nurses and 5   patients from each unit (Neuro- Medicine, ICU, CCU   and   Emergency).

El Sayed - Galal Hospital   : 

Medical Hospital (30 nurses, 20   patients    ):   

7  nurses  and  5   patients  from  each  unit  (  Neuro- Medicine  (7) , ICU (7) , CCU (7)  and   Emergency  ( 9))     

Inclusion   criteria   for    :

• Nurses   
  • Nurses willing to participate in the study.
  • Nurses working in critical care units.
  • Nurses` experience not less than one year.
• Patients 
  • Patients   on mechanical ventilator
  • Patients  without  VAP

Tools of data collection:

Self-administered questionnaire (pre/post tests) . It was designed by the researchers in light of the relevant and related literatures      and written in simple Arabic language .  Data obtained were related to:

Demographic characteristics of the studied nurses  which included (age, sex, qualifications, years of experience and previous training )

Nurses` knowledge assessment  sheet  about  :  

Ventilator associated  pneumonia  (VAP) prevention  bundle  : Definition of  VAP , diagnostic  measures , management  , characteristics   and  complications  . Moreover, definition of VAP prevention bundle and   its    components. 

Risk   factors of   VAP: (Patients     : Disturbed level of consciousness, malnutrition and aspiration of contaminated secretion. Nurses    : Suctioning, frequently, utilizing clean gloves for tracheal suction, performing ineffective hand hygiene, rubbing with Alcohol when visible secretions and washing hands when there is no visible secretions   . Doctors: Giving multiple antibiotics, broad spectrum and intubating patients nasally).  

Scoring system:

Responses of the studied nurses were scored as (1) for correct answer and (zero) for incorrect answer. The total score was categorized into either satisfactory level (from 70% and more) or unsatisfactory level (less than 70%). 

An   observation   checklist   (pre / posttests): 

It was  adopted from (  Lewis  et al. ,  2014  , Hinkle  & Cheever ,  2014    and  Dewit   et al. ,2016  )  , developed and filled by the researchers to evaluate studied   nurses ' practices regarding :

Care  of  patients  with   ventilator associated  pneumonia (VAP )   : Infection control measures , sterilized ambo bag / neubelizer  device ,    postural  drainage , percussion  and  vibration   technique , patient's position changed  frequently , endotracheal   tube   care  ,   nasogastric   tube    feeding / care  and   ventilator    care  . 

Nurses’ practices   regarding   bundle prevention protocol   of   VAP:  Patients` position (Keep head   position in 30 - 45 degree). Infection control measures (Hands  washing  pre/post  patient  contact and in  between  - Change  gloves  between patients  - Sterile ambu bag    and  disinfect it before use) . Ventilator care  (Drain  and  discard  periodically  any condensate  collected  in      mechanical  ventilator  tube   -  Humidify  respiratory circuit using humidity and heat exchange filter  -  Replace humidifiers  and  ventilator circuit regularly  -  Change  heat moisture exchanger  when  becomes  visibly).   Endo  tracheal suction care (Adequate pressure in endotracheal tube cuff  - Wear clean gloves with closed / open suction      -  Use   sterile  equipment / technique  with  tracheal  suction -  Replacement of suction  solution   and     tubes  -  Use  saline/ distilled  water   prior   to  suction   -  Continuous   aspiration   of   sub  glottis   secretions   if  ventilator   more   than  48   hours) . Oral care   (Oral hygiene with antiseptic solution   -   Topical antimicrobial agents for oral decontamination   regularly).  Peptic ulcer prophylaxis   (Checking   gastric  residual  volume  every  4 - 6  hours  -  Administer   enteral      feeding   -     Routine  acidification  of  gastric   feeding). Extubation  and  weaning  trials  (Sedation  interruption -  Daily  readiness  assessments  to wean  and  extubate) . DVT prophylaxis (Using   anti-embolic   stockings or sequential compression).

Scoring system:

A correct practice was scored as (1), while the incorrect (zero). It was scored into either inadequately done (less than 70%) or adequately done (70% and more).The total score was categorized as satisfactory = 70 – 100, or unsatisfactory = less than 70.

Hamilton Anxiety Rating Scale (pre / posttests):

It was developed by Hamilton (1959) and modified by the researchers. This scale formed of thirteen variables: anxious mood, tension, insomnia, cognitive changes, depression, somatic (sensory), cardiovascular, respiration, gastrointestinal, genitourinary, autonomic symptoms, somatic (muscular) and the behavior at the interview. Testing reliability of the scale items using alpha cronbach test = 0.83.

Scoring system:

Answers were (0-3) scores and total score ranged from 0-39, the following categorization were adapted:  no anxiety (zero), mild anxiety (0 - less than 23), moderate anxiety (23 - less than 29) and severe anxiety (29 - 39).

Nurses` opinnionair sheet   (pretest): It was designed by the researchers to identify their opinions regarding the     competency   obstacles (physical, psychological, administrative and social obstacles) in   care of studied   patients, added to the suggested   solutions   .  

Patients` condition assessment sheet (posttests). It was composed of the following: 

• Characteristics of the studied patients as regards age , length of intubation / ventilation (days)  and  length of stay in ICU (days)  .
• Patients`   assessment as regards the incidence    of     ventilator associated pneumonia among studied patients     .

Content validity:

It was assured by a group of experts from CCU   and Medical– Surgical Nursing.  . Their opinions were collected as regards to tools format layout, consistency and scoring system. Tools` contents were tested regarding to the knowledge accuracy, relevance and competence.

Ethical considerations:

In the planning stage approval was obtained from directors of the above mentioned settings. All nurses were informed about the study and their rights according to medical research ethics that they were free to decide whether or not they would participate in the study. Then a written informed consent was obtained from each nurse who agreed to participate in the study. 

Pilot study:

A pilot trial was carried out on 10% of the total study sample to test the clarity and practicability of the tools, in addition to subjects and settings. Pilot subjects were later included in the study as there were no radical modifications in the study tools    . 

Procedure:  

• Study purpose was simply explained to the nurses who agreed to participate in the study prior to any data collection   . 
• The current study was started and completed within 6 months.
• Researchers started to collect data from the studied nurses in the critical care units of the above mentioned setting    using the pre   constructed tools    .
• Data were collected by the researchers 2 days/week, at morning / afternoon   shift,   added   to     through follow – up visit.
• The guidelines were designed based on analysis of the actual educational   nurses’ needs   in pretest   .
• Guidelines` content was written in simple Arabic language and consistent with the related literature, as well as met nurses’ needs and their level of understanding.
• Educational guidelines were presented in theoretical and practical sessions. Nurses were divided into small groups including 5 – 6 and repeated sessions included all nurses, each group obtained 4 sessions (2 theories and 2 practices). Moreover, each nurse was guided by simple written instructions and then orientation   about objectives and outline was   done.
• Theoretical part was implemented through lectures and group discussions, using data show and poster as a media. It was taken in  4  hours  for  2 sessions  (one session weakly for 2 hours) which were covered on 2 weeks ) and   cover  the  following   items  regarding  VAP  prevention  bundle  : Definition of  VAP , diagnostic  measures , management  , characteristics   ,  complications  ,  definition of  VAP  prevention  bundle  and   its    components   . In addition, risk   factors of   VAP (Patients     , nurses    and doctors). 
• Practical part was   implemented through demonstration, re- demonstration and video. It was taken  in   9  hours  for   3  sessions (one  session  weakly  for 3  hours ) and covers the following  items  . First  and  second sessions  regarding    care  of  patients  with   VAP: Infection control measures , sterilized equipment's and devices, postural  drainage  and  percussion technique , ventilator    care ,  patients` position , endotracheal   and    nasogastric   tube  care  /   feeding)   . Third session  regarding bundle  prevention  protocol   of   VAP was included  patients`  position  , infection control measures , ventilator care measures, endo  tracheal  suction care , oral care   , peptic  ulcer  prophylaxis,  extubation / weaning  trials   and  DVT prophylaxis
• Nurses were informed to be in contact with the researchers by telephone for any guidance.
• Nurses were assessed in groups that entail 5-6 according to their readiness.
• Ealuation  of  the  guidelines`  effect  on  studied   nurses and patients  as  regards  :
• Nurses` knowledge , practices  and anxiety level  by using  pretest  (Before guidelines sessions) ,  post – test (immediately after guidelines) and follow- up   test  (After  3  months later) by using the same  tools.
•  Nurses 'opinions regarding the   competency   obstacles in care of studied patients by using the   pretest.
•  Patients` incidence of VAP were assessed pre guidelines, one month post guidelines and after two months later using   the same tools.

Statistical Design:

The data collected were organized, sorted, tabulated and analyzed using Statistical Package for Social Sciences (SPSS). They were presented in tables and charts using numbers, percentages, means, standard deviations   and t – test . Level of significance was threshold at 0.05    .

Results: 

Table (1) : Characteristics  of  the  studied  nurses (n= 70)

Table (1):  Reveals   studied  nurses ’ characteristics. Results  clarified   that mean age  of nurses  at  Ain Shams   and El Sayed Galal Hospitals  were ( 33.3±25.2 & 33.3±27.3 respectively) . As regards  their gender ,   majority    of   them  were   female  (82.5  & 83.3 respectively ) .  Concerning  qualifications  , more than half of them  had diploma nursing  (52.5 & 53.3 respectively ) .  Regarding years of experience , nearly two thirds of them  were with less than five years of experience (67.5  & 66.7 respectively  ). In relation to previous training  ,  more than one third of them  had training  ( 37.5 & 36.7  respectively  )  .

Table (2) :  Characteristics   of   the  studied  patients  in    CCU   (n=40)

Table (2): Shows characteristics of the studied patients. Regarding the age , more than two fifths  (46 .0  & 40.0  )of  patients at Ain Shams   and El Sayed Galal Hospitals    had the age of  (20 - < 35 yrs  ) . Considering   the   length  of  intubation  and  ventilation /days  were  (  4-14  & 3-15  respectively  ) . As regards length of  stay  in   CCU  were  (6-15  &    5-14  respectively  ) . 

Table (3):Presentation  of studied  nurses’  knowledge   about    ventilator associated  pneumonia  (VAP) prevention  bundle  in  pre/post   tests 

Table (3): Shows studied nurses` satisfactory knowledge about VAP prevention bundle in pre/posttests.  Results indicated significant improvement in nurses’ knowledge regarding post and follow - up assessment (mean = 57.8 ± 1.7& 63.1 ± 1.3 respectively) compared to pre – assessment (37.5 ± 5.6), with t1 – test (between pre & post)  = 29.4   and  t2  test  (between  post & follow- up )  21.2     ), p < 0.05.

Table (4):  Presentation of studied nurses’ knowledge  about   Risk   factors  of   ventilator  associated    pneumonia (VAP)  in  pre/post   tests  

Table (4): Shows studied nurses` satisfactory knowledge about risk factors of VAP in pre/post tests . Results indicated significant improvement in nurses’ knowledge regarding post and follow - up assessment (mean = 55.8± 2.08 & 61.0±2.9 respectively) compared to pre – assessment (27.1± 13.02 ), with t – test = 18.3   and  12.4    respectively), p < 0.05.

Table (5): Presentation  of studied  nurses’  practices   regarding  care of  patients  with   ventilator associated  pneumonia (VAP )  in  pre/post   tests

*Significant at p < 0.05

Table (5): Reveals patients` satisfactory practices regarding   care of patients with VAP in pre/post tests .  Results showed significant improvement in patients’ practices regarding post and follow - up assessment (mean = 56 .7 ± 1.5& 62.5 ± 1.4 respectively) compared to pre – assessment (34.8 ± 3.7), with t – test = 46.6   and 0.42     respectively), p < 0.05.

Table (6): Presentation  of studied  nurses’  practices   regarding   bundle  prevention  protocol   of   VAP in  pre/post   tests

Table (6): Reveals  patients` satisfactory practices regarding   bundle  prevention strategy of  VAP  in  pre/post tests  .  Results   showed  significant improvement in patients’ practices regarding post and follow - up assessment (mean = 57 .0 ± 1.5 & 62.1 ± 1.3 respectively) compared to pre – assessment (36.1 ± 2.1), with t – test = 69.7  and  22.1   respectively), p < 0.05.

Table (7): Presentation of anxiety level   among the studied nurses in  pre/post   tests

Table (7): Reveals studied nurses’ anxiety level  in  pre/post tests . Concerning  anxiety level  ,  significant improvement was indicated in post test   then  follow – up  test as regards anxiety severity  (  14.0  & 8 .0  respectively  ) compared by pre test  23.0  .

Table (8): Nurses `   opinions   regarding     competency   obstacles  in  caring   of  studied  patients and suggested solutions   (  pre test )

Table (8): Presents nurses opinions  about   competency   obstacles  in  care  of  studied  patients and suggested  solutions . Insignificant   difference was found between Medical  and  Children Hospitals  regarding the obstacles: physical, psychological, administrative and social . In relation to the suggested solutions, insignificant difference  was observed regarding the suggested    solution: orientation program, adequate supplies, relation among health care team, in service training, job description and nurses' support

.

Table (9): Incidence    of     ventilator associated  pneumonia  among studied patients    in    post   tests 

Table (9): Shows   incidence   of  VAP  among  studied patients at  (Ain Shams University   and  El Sayed Galal   Hospitals  ) in  post and  follow up  tests  .  Results   showed  significant   reduction  in  follow - up assessment  compared  to  post    at   Ain Shams University   = 15.0 & 35.0  respectively  and  at  El Sayed Galal   =  20.0 &  30.0  respectively 

Figure  (1): VAP  among studied patients