3034Phm Evidence Based Practice : Assessment Answers
Answer
Introduction
Ventilator associated pneumonia (VAP) is a common nosocomial infection in the ICU that is associated with increased morbidity, mortality and medical cost. It is type pneumonia where symptoms of fever, altered white blood count and sputum changes are seen following 48-72 hours of endotracheal intubation (Kalanuria, Zai & Mirski, 2014). Hence, the condition is most likely to be found in mechanically ventilated patients and it increases burden for critical care nurses. In response to this issue, the main purpose of the paper is to discuss how ventilator pneumonia as an issue in the ICU and identify the research article that provides the strongest evidence to prevent the issues. The description of best evidence is provided following the steps of the EBP process.
Rational for EBP as an issue in ICU practice
VAP is regarded as an undesirable condition in ICU patient because it increases length of stay in the intensive care unit and prolongs duration of ventilator support. The rate of VAP in hospital varies due to diagnostic criteria and knowledge of nurses in preventing the condition. Barriers and facilitator to managing VAP in the ICUs may also vary because of factors like communication between staffs, education and knowledge related to VAP, guideline awareness, management process for VAP and appropriate use of technology (Safdar et al., 2016). Another issue for nurse is that variety of preventive measures has been recommended for preventing VAP Eom et al. (2014), however the effectiveness of these intervention needs to be confirmed by means of evidence based practice process.
Preventing VAP through the EBP process:
Evidence based practice (EBP) is regarded as a process that can support nurses to address gap in patient care and achieve better health outcome for patient. By engaging in the process of the judicious use of current best evidence related to practice issue and integration of the evidence with patient values and clinical expertise, optimal care can be provided to patients (Hall & Roussel, 2016). This paper is concerned with the practice issue of prevention of VAP in ICU. The six steps of the EBP process that can help to identify the best evidence that supports prevention of VAP in the ICU are as follows:
Asking a clinical guiding question:
The best research articles for prevention of VAP in ICU can be retrieved by ICU nurse by first developing a clinical guiding question. The PICO question for the use of VAP can be as follows:
Which preventive measures (intervention) are most useful in the prevention of VAP (outcome) in ICU patients (population)?
Searching for the best evidence
Keywords from the clinical question can be used to search for relevant articles related to the practice issue. Terms like preventive measures and VAP, VAP prevention and ICU patients and prevention for VAP can be used to retrieve relevant articles. The articles can be searched from different databases and search engines like Google Scholar. The search for articles related to the prevention of VAP revealed implementation of VAP bundle approach as the most effective approach to prevent VAP as it includes variety of interventions to reduce the incidence of VAP. The Institute for Healthcare Improvement (IHI) developed the bundle and it includes all interventions necessary for VAP prevention such as elevation of head of bed (30°- 45°), daily sedation, stress ulcer prophylaxis and breathing trials (Hellyer et al., 2016). Kalanuria, Zai and Mirski (2014) revealed that high compliance rate of about 95% is necessary to achieve best results for patients. Hence, in accordance with these results, articles reporting about adherence to VAP bundle and its outcomes were analysed. The research study by Mohamed (2014) and Eom et al. (2014) were found to provide the best evidence regarding the effectiveness of VAP bundle in prevention of VAP. This was because Mohamed (2014) evaluated both compliance rate as well as effectiveness related outcomes and Eom et al. (2014) conducted a multi-centre study.
Critically appraising the evidence
To determine whether the research evidence selected is the best one to be applied in clinical practice, it is necessary to evaluate the strength, weakness, reliability, validity and applicability of the research evidence. This can be done by analysing the research aim, methodology and rigor in research design. Any kinds of bias that affects study results should also be analysed. Mohamed (2014) is found as a reliable evidence because it gave both after and before intervention results and the most vital factor of compliance to the bundle was also analysed. Furthermore, validated criteria and was used to measure outcomes. Eom et al. (2014) revealed the applicability of the intervention because of multi-centre evaluation.
Integrating the evidence with clinical expertise
To integrate the chosen evidence into practice, it will be necessary for nurse to determine the changes needed to implement the EBP decision. ICU nurse can consult with care providers regarding the intervention and they can take special skill trainings to effectively implement the intervention.
Evaluating the outcome of the EBP practice decision
After implementation of the identified intervention, it will be necessary for nurse to analyse the outcome of the intervention and determine whether expected outcomes were achieved or not. If expected outcome is not achieved, then it is necessary to identify the cause behind and make changes in care planning accordingly.
Disseminating the findings
Based on the experience of implementing best practice evidence using the EBP process, a nurse can disseminate the evidence to colleagues within the organization so that events like VAP can be prevented in the future.
Conclusion:
The paper summarized the process of identifying the best intervention to prevent VAP in ICU using the EBP process. In response to the issue of prolonged hospital stay and increased health care cost, the VAP bundle was identified as the best preventive step to reduce incidence of VAP. The critical appraise process and the steps needed to properly integrate the evidence with clinical expertise revealed VAP bundle as a solution to reduce VAP in ICU patients.
References:
Eom, J.S., Lee, M.S., Chun, H.K., Choi, H.J., Jung, S.Y., Kim, Y.S., Yoon, S.J., Kwak, Y.G., Oh, G.B., Jeon, M.H. and Park, S.Y., 2014. The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. American journal of infection control, 42(1), pp.34-37.
Hall, H. R., & Roussel, L. A. (2016). Evidence-based practice. Jones & Bartlett Publishers.
Hellyer, T. P., Ewan, V., Wilson, P., & Simpson, A. J. (2016). The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. Journal of the Intensive Care Society, 17(3), 238–243. https://doi.org/10.1177/1751143716644461
Kalanuria, A. A., Zai, W., & Mirski, M. (2014). Ventilator-associated pneumonia in the ICU. Critical care, 18(2), 208.
Mohamed, K.A.E., 2014. Compliance with VAP bundle implementation and its effectiveness on surgical and medical sub-population in adult ICU. Egyptian Journal of Chest Diseases and Tuberculosis, 63(1), pp.9-14.
Safdar, N., Musuuza, J. S., Xie, A., Hundt, A. S., Hall, M., Wood, K., & Carayon, P. (2016). Management of ventilator-associated pneumonia in intensive care units: a mixed methods study assessing barriers and facilitators to guideline adherence. BMC Infectious Diseases, 16, 349. https://doi.org/10.1186/s12879-016-1665-1
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