Research is consistent that nurses must have the capacity to use relevant data sources to integrate research evidence with clinical expertise in what is commonly known as evidence-based practice (Fachiano & Snyder, 2012). This section reviews and summarizes the data sources that will be used to guide the proposed EBP intervention.
The article by Grap (2009) reviewed the findings of other primary research studies to demonstrate several evidence-based practices that could be used to reduce the risks associated with mechanical ventilation. Evidence from the article suggests that ventilator-associated pneumonia can be significantly reduced through the use of higher backrest elevations (30° to 45°), ensuring proper oral health practices to minimize the colonization of the oropharynx by pathogens (e.g., by using oral applications of chlorhexidine at the time of intubation), and following recommended practices in sedating critically ill patients.
The main strength of the article lies in its use of primary research sources and data to outline effective EBP interventions that could be used to reduce the risks associated with mechanical ventilation. However, the article’s findings are limited due to the use of a broad scope of the study (mechanical ventilation), leading to issues of generalizability in VAP contexts
The article by Gupta et al. (2016) detailed some of the best practices to prevent aspiration of oral colonization, which is a common cause of ventilator-associated pneumonia in intensive care settings. The recommended oral care interventions include (1) conducting an initial admission and daily assessment of the patient’s oral cavity to allow for early identification of oral hygiene problems, (2) using unit-specific protocols to not only minimize the development of mucositis, but also to help the patient in maintaining normal saliva production and oral tissue health, (3) keeping the head of the bed elevated to at least 30° to assist in preventing reflux and aspiration of gastric contents, and (4) routinely suctioning the patient’s oral and subglottic discharges to reduce aspiration of infected secretion into the lungs.
In strengths, the article relied on credible data sources and guidelines to discuss the relationship between the aspiration of oral colonization and VAP. Additionally, the article focused on ICU, hence reducing the challenges associated with data applicability. However, the recommended oral health care interventions are not supported by relevant literature as would be expected in EBP contexts.
The study by Kubbara et al. (2015) investigated the application and interpretation of CDC guidelines (VAC, IVAC, VAP) by diverse groups of healthcare providers in the assessment of ventilator-associated pneumonia. Evidence from the study suggests that the application of the CDC guidelines varies between different healthcare providers, hence the need to allow for the modification of the guidelines across settings based on clinical or professional judgment. In strengths, the study not only used validated CDC guidelines and appropriate methodological strategies but also recruited a diverse sample to identify attitudinal shifts in the application of the guidelines. A major limitation, though, lies in the fact that the authors failed to elaborate on how the application and interpretation of CDC guidelines influence VAP incidents in the ICU.
The study by Klompas et al. (2015) investigated the effectiveness of two clinical interventions (coordinated awakening and spontaneous breathing) in preventing the incidence of ventilator-associated events in intensive care settings. Evidence from the study suggests that coordinated awakening (e.g., by use of bedside alarms) and assisting patients to breathe impulsively without the use of sedation are positively associated with a reduction in duration of mechanical ventilation in the ICU and hospital length-of-stay. In strengths, this study used an appropriate research design to investigate the two interventions and is specific in its scope and applicability in the ICU. However, it is felt that the sample size used is not adequate to generalize the findings to larger contexts.
The study by Sedwick et al. (2012) aimed at investigating how the implementation of bundled practices in a hospital’s intensive care units affected the incidence of ventilator-associated pneumonia within the units. The bundled practices that were implemented in the units included elevation of head-of-bed (30° to 45°), prophylaxis for peptic ulcer disease, prophylaxis for deep-vein thrombosis, routine intermission of sedation, routine evaluation of readiness for extubation, daily oral care with chlorhexidine, protocols for mouth care and hand washing, head-of-bed alarms, and subglottic suctioning. Evidence from the study demonstrates that strict adherence to the bundled practices not only reduces pneumonia-associated mortality and morbidity of patients receiving mechanical ventilation but also shortens hospital stays and ensures that healthcare costs are kept at a minimum.
In strengths, the study’s scope is specific to VAP in intensive care contexts and the researchers used CDC guidelines on VAP to guide the research process. However, it is felt that the VAP bundle used in the study contains very many interventions that may be difficult to monitor in clinical contexts. Additionally, the study was carried out in one hospital, meaning that it may be difficult to generalize the findings to other contexts.
Lastly, the study by Azab et al. (2015) used the context of developing countries to evaluate the effectiveness of predesigned VAP bundled practices in reducing the incidence of ventilator-associated pneumonia in neonatal intensive care settings. The VAP prevention bundle used in the study consisted of head-of-bed elevation (30° to 45°), fortification of hand hygiene practices, sterile suction and handling of respiratory apparatus, intubation, re-intubation, and endotracheal tube (ETT) suction as stringently specified in the unit standards, changing ventilator circuit if noticeably dirty or mechanically faulty, implementing routine mouth care with normal saline and suctioning of oro-pharyngeal secretion, performing daily evaluations for readiness for extubation to nasal continuous air pressure (NCPAP) at morning round, as well as sedation vacation for sedated patients (Azab et al., 2015). Evidence from the study demonstrates that the implementation of a comprehensive infection control bundle consisting of the described clinical interventions leads to a significant reduction of VAP incidence and duration of stay in the intensive care unit.
This article is specific in scope as it studied VAP in neonatal intensive care settings. Additionally, the study used an appropriate research approach, design, and data collection techniques to gather data from the field. However, the main findings are limited to one hospital and the sample size used is not adequate in ensuring that findings can be generalized to other contexts.
References
Azab, S.F.A., Sherbiny, H.S., Saleh, S.H., Elsaeed, W.F., Elshafiery, M.M., Siam, A.G.,…Ghaith, T. (2015). Reducing ventilator-associated pneumonia in neonatal intensive care unit using “VAP preventive bundle”: A cohort study.BMC Infectious Diseases, 15(1), 1-7. Web.
Fachiano, L., & Snyder, C.H. (2012). Evidence-based practice for the busy nurse practitioner: Part three: Critical appraisal process. Journal of the American Academy of Nurse Practitioners, 24, 704-715. Web.
Grap, M.J. (2009). Not-so-trivial pursuit: Mechanical ventilation risk reduction.American Journal of Critical Care, 18, 299-309. Web.
Gupta, A., Gupta, A., Singh, T.K., & Saxsena, A. (2016). Role of oral care to prevent VAP in mechanically ventilated intensive care unit patients. Saudi Journal of Anesthesia, 10(1), 95-97. Web.
Klompas, M., Anderson, D., Trick, W., Babcock, H., Kerlin, M.P., Sincowitz-Cochran, R.,…Pratt, R. (2015). The preventability of ventilator-associated events. The CDC prevention epicenters wake up and breathe collaborative.American Journal of Respiratory and Critical Care Medicine, 191, 292-301. Web.
Kubbara, A., Khan, A.R., Alreefi, F., Abdelkarim, A., Rehman, S., Hariri, A.,…Assaly, R. (2015). Applications of CDC ventilator associated pneumonia surveillance guideline to the real world. In C49: Refining quality and communication in the ICU (pp. A4545-A4545).New York, NY: American Thoracic Society.
Sedwick, M.B., Lance-Smith, M., Reeder, S.J., & Naardi, J. (2012). Using evidence-based practices to prevent ventilator-associated pneumonia. Critical Care Nurse, 34, 41-50. Web.