Annotated Patient Case Study

The prevention of VAP through standardized care can reduce mortality rates, reduce mechanical ventilation days, and decrease costs and improve patient outcome.

Ventilator - associated pneumonia (VAP) is the second most common hospital acquired infection (HAI) and is associated with high morbidity and mortality rates for ventilated patients in intensive care units (Bingham, Ashley, Jong, & Swift, 2010). The VAP increases patients’ mortality rates, length of stay and hospital costs (Hiner, Kasuya, Cottingham, & Whitney, 2010). The VAP is the leading causes of death due to nosocomial infections and the

Among critically-ill patients in acute care facilities, pneumonia is one of the most frequently acquired hospital infections (Curtin, 2011). Ventilator-associated pneumonia (VAP) is the second most common healthcare-associated infection (HAI) in the United States and it is responsible for approximately 25% of infections that occur in intensive care units (Sedwick et al., 2012). VAP is defined as a hospital-acquired lung infection that develops in patients who are intubated and receiving mechanical ventilation at the time of or within 48 hours prior to the onset of infection (Sedwick et al., 2012; Gianakis et al., 2015). The definition of VAP, provided by the Centers for Disease Control and Prevention (CDC), encompasses a combination of radiological,

During the surveillance, data from nursing documentation, physician progress notes, laboratory results, and direct observations. Data was collected from the time of admission until the diagnosis of VAP was made. The patients who were discharged from the ICU and sent to a regular medical surgical floor were followed for an additional 48 to ensure that VAP would be detected that manifested after the discharge.

Combinations of various criteria to establish a diagnosis in patients with VAP have been suggested and validated (Table 1). The National Nosocomial Infection Surveillance (NNIS) system was developed in the 1970s by the Centers for Disease Control as a tool to describe the epidemiology of hospital-acquired infections and to produce aggregated rates of infection suitable for inter-hospital comparison, but was never compared to pathological results. The NNIS system was compared to bronchoalveolar lavage (BAL) fluid cultures in 292 trauma patients and had a sensitivity of 84% and a specificity of 69% [15]. More recently, the Clinical Pulmonary Infection Score (CPIS) was proposed by Pugin et al. [16], based on six variables (fever, leukocytosis, tracheal aspirates, oxygenation, radiographic infiltrates, and semi-quantitative cultures of tracheal aspirates with Gram stain) [16]. The original description showed a sensitivity of 93% and specificity of 100%, but this study included only 28 patients and the CPIS was compared to quantitative culture of BAL fluid using a 'bacterial index ' defined as the sum of the logarithm of all bacterial species recovered, which is not considered an acceptable gold standard for the diagnosis of VAP. Compared to pathological diagnosis, CPIS had a moderate performance with a sensitivity between 72 and 77% and specificity between 42 and 85% [11,17]. Likewise, CPIS was not sufficiently accurate compared to a BAL fluid-established

According to the Surviving Sepsis Campaign, careful infection control practices should be reviewed in nursing considerations, should be established during care delivery of septic patients. Infection control measures include: hand washing, urinary and venous catheter care, protective skin barrier, airway management, head of the bed elevated greater than 30°, and subglottic suctioning (Dellinger, et al., 2013, p. 595). [continue with preventative measures, i.e. handwashing

In a research study, ICU healthcare workers were asked to complete an anonymous questionnaire related to personal knowledge of ventilator- associated pneumonia prevention. The most recognized prevention guidelines of ventilation associated pneumonia were the use of a semi-recumbent position and the need to have written guidelines in the unit, more than 90% of the health

According to Safer healthcare now (2012), “Ventilator-associated pneumonia (VAP) is defined as a pneumonia occurring in patients requiring a device intermittently or continuously to assist respiration through a tracheostomy or endotracheal tube” p11.The development of VAP has many potential causes some of which included aspiration, intubation procedure, biofilm formation,

There are numerous other techniques used to prevent VAP. Like many respiratory problems the head of the bed should always be elevated to between 30 and 45 degrees to prevent aspiration of fluids and sputum. The tubing for the ventilator should only be changed on a as needed basis. The continuous changing of tubes moves the bacteria and can introduce new bacteria into the respiratory system. Patients should also receive “sedation vacations” and prophylaxis medications to prevent peptic ulcers. Weaning of the mechanical ventilator should also be done as soon as possible

The results showed significant re-ductions in preventable pulmonary complications (PPCs) in those patients. 2 other studies found that patients who had automated turning, spent less time in the intensive care unit (ICU), and “researchers in another study also reported decreased duration of mechanical ventilation” (Hannenman et al. 2015, p. 25). However, none of the prior studies that were done made a com-parison between patients with automated turning, versus patients who were turned manually eve-ry two hours. Research has shown that, “intensive care patients are not turned every 2 hours for a variety of reasons” (Hannenman et al. 2015, p. 25). When a patient is bedridden, it is the nurse’s responsibility to turn the patient every 2 hours. Turning a patient and changing their posi-tion helps keep the patient’s blood flowing, as well as prevents bedsores (Pellico, 2012). A study was done on a specific group of individuals who all fell within the same

In high acute settings, such as intensive care units essential nursing care such as oral care is very vital to prevent life-threatening complications such as nosocomial – acquired, Ventilator-Associated Pneumonia (VAP), and also most patients in intensive care are on oral intubation, and medications such as anticholinergics, antihypertensives, which may lead to xerostomia (dry mouth). One of the challenging nosocomial infections is VAP, and a leading cause of mortality in hospital patients in high acuity settings (Jones, 2007). The development of VAP is occurred due to mechanical ventilation, longer ICU stays and longer intubation periods, increasing the mortality of ICU patients to as high as 70 per cent (Jones, 2007). Good

National Taiwan University did a retrospective review of data to decrease VAP density by fifty percent at a SICU medical center. The sample population consisted of adult surgical intensive care unit invasively ventilated patients, “The primary aim of this study was to check the efficacy of the VAP bundle by comparing the before and the after density at SICUs. A multidisciplinary teamwork was set up including administrator (vice superintendent), quality improvement and infection control professionals, SICU doctors, and nurses, respiratory therapists, pharmacists, and general affairs and information technology specialists.”(Lim, et al., 2015)

“Ventilator -associated pneumonias are the leading cause of death for patients diagnosed with hospital acquired infections” (Sadeghi, Barzi, Mikhail, & Shabot, 2013, p. 223). Pneumonia rates are higher in mechanically ventilated patients because the artificial airway increases the opportunity for aspiration and colonization. The rate of VAP increases for patients ventilated more than three days resulting in length of stay in ICU and LOS after discharge from ICU (Sedwick, Lance-0Smith, Reeder, & Nardi, 2012).

In Egypt the incidence rate of VAP was 15.3% that increased the risk of mortality rate by 33% in contrast to the patient without VAP which was just 24.3% (Timsit, Zahar and Chevret, 2011, p.469). However, VAP independently cannot predict the death of the patient, there are other reasons associated with the VAP such as severity of disease, and duration of ICU stay (Myny et al., 2014, p.120). A study of Faisy et al.,(2011, p.1257) reveals that the risk factor associated with the VAP are: history of lungs diseases, immune compromised state, nutritional deficiency. In order to reduce the incidence rate of VAP in ICU settings, it is very necessary to follow the evidence based process indicator as a quality indicator because it tries to find out the obstacle that had been faced in the past and provides a proper guideline and feedback to improve the quality of service, in addition close surveillance, monitoring the previous outbreak and feedback from results could help to reduce the incidence rate (Wong, Mathieu and Williams, 2012, p.80). While working in ICU, the most patient experiences the problem of weaning. A study of Prasad, Chaudhry and Khanna,(2009, p. 221) reveals that patient experience the weaning failure at the time of extubate because of prolonged and dependency on mechanical ventilation. Other reason behind the weaning failure are: old age, increased minute ventilation, severe

While in three Arabian Gulf countries according to a study that estimated the risk of VAP in adult and neonatal ICU patients in GCC countries is prob-ably higher than the US but lower than many developing countries (3). Thus education for health care providers on the prevention of VAP is essential, because the occur-rence of infections is directly related to the adequacy of staff. In 2015 a study was done in Taif University concluded that the educational level and the length of ICU experi-ence of nurses impact the use of VAP guidelines (4). Protocols are set to follow in or-der to limit the infection. Every hospital must have a protection criteria, strict rolls and protocols that each and every employee is obliged to follow in the sake of patients health and their safety. National Guard Health Affairs (NGHA) clinical practice guide-line care is set as follow, the head of bed must be elevated 30 - 45 degrees, sedation vacation, Peptic Ulcer disease prophylaxis, deep vein thrombosis prophylaxis, Chlor-hexidine use including brushing of teeth, ETT with CASS, ETT cuff pressure main-tained 20-30cm