Nursing Care Practices For Prevention of Ventilated

Nursing Care Practices for prevention of Ventilated associated infections in Intensive
Care Units
Literature review analysis of select studies
University
Name
Date

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Table of Contents
Table of Contents.......................................................................................................................2
Introduction................................................................................................................................3
Appraisal process.......................................................................................................................3
Authorship..............................................................................................................................3
Review of aims and objectives................................................................................................4
Research Design.....................................................................................................................5
Data Collection......................................................................................................................6
Data Analysis.........................................................................................................................6
Discussion..............................................................................................................................7
Credibility and Evaluation of the RCT studies..........................................................................8
Analysis on applicability of evidence......................................................................................10
Conclusion................................................................................................................................11
References................................................................................................................................13

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Nursing Care Practices for prevention of Ventilated associated infections in Intensive
Care Units
Literature review analysis of select studies
Introduction
Critical appraisal processes are critical avenues engaged in systematic assessments
of scientific evidence to enable judgment t based on its trustworthiness, value and relevance
aspects in the context of interests. In the nursing practice, it offers an avenue for applying
research and evidence reliably and efficiently to maximize high-quality outcomes. Infections
in intensive care units have often been an issue of concern in nursing care practice. Uses of
ventilators in intensive care units are a common standard of practice in improving the overall
state of patients. Despite this, the occurrence of ventilator-associated pneumonia and other
underlying infections posse threats on the quality of care and outcomes of patients receiving
critical care. Various factors have been demonstrated to impact on this occurrence, attributes
about oral care and management practices in dealing with ventilator usage are key issues.
Further, bacterial resistance-associated occurrence poses a major threat to the quality of care
patients receives in these units. Ventilator-associated infections are common among the
mechanical ventilation process of oxygen breathers. Due to the complicated aspects of care,
associated infections such as pneumonia pose a critical danger on the overall health state
linked to high mortality and morbidity. Diagnosis often varies in clinical settings; however,
the application of evidence-based practice in the nursing arena remains a vital care approach.
Hence in this view undertaking, critical appraisal and evaluation through evidence-based
practice are fundamental in applying evidence-based care practices. Thus critical appraisal is
geared towards enabling the skills of health care professionals in making critical decisions
applying to their patients based on the relevance of truth and free from biases. In this review,
an assessment of two evidenced-based studies; Atashi et al., (2018) and Heyllyer et al.,
(2019) on the management of ventilator-associated infections in the intensive care units are
being focused.
Appraisal process
Authorship
The study by Hellyer et al (2019), has collaborated with various authors across
many domains in the care practice. The authors have a range of skills and qualifications from

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Doctoral to Master of Sciences and practising professional in the health care sector. The lead
author Professor Thomas Hellyer has affiliation in a translational and clinical research
institute, New castle UK. The second lead Professor McAuley, a medical doctor by
profession works in the regional intensive care unit, The Royal Hospitals, Belfast, UK and
affiliations in The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University
Belfast, Belfast, UK. The other authors totalling to thirty in number made significant
contributions in this article majority of them being practising health care professionals in
hospital care settings.
The article by Atashi et al (2018) comprises of five authors with the lead author
Vajihe Atashi, working in faculty of nursing and midwifery at Isfahan University of Medical
Sciences, Isfahan, Iran. The second author Yousefi Hojatollah practices at School of Nursing
and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran. Hosein Mahjobipoor is
at Anaesthesiology and Critical Care Department, Medicine School, Critical Care Research
Center, Isfahan University of Medical Sciences, Isfahan, Ira. Ahmadreza Yazdannik works at
Critical Care Nursing Department, Nursing and Midwifery School, Nursing and Midwifery
Care Research Center, Isfahan University of Medical Sciences, Isfahan, Ira. From this
assessment both authors of the articles are in the medical settings and schools engaged in
medical practice thus validating the use and applicability of the underlying knowledge
towards these articles is key.
Review of aims and objectives
Hellyer et al (2019) study assessed the use of broad-spectrum antibiotic in managing
ventilator-associated infections. The study asserts that the usage of antibiotics in the control
of these infections has been highly exploited leading to increased risks of adverse effects and
increasing the overall cost of care. The application of diagnostics tests is being fronted in this
study as an avenue to assess ventilator-associated infections to reduce this usage. Thus given
this, the study aimed at determining the measurement of bronchoalveolar lavage fluid IL-1β
and IL-8 and to assess how it could improve the antibiotic stewardship without affecting the
safety of the patient.
In the study by Atashi et al (2018), focus on oral health among patients being
ventilated in intensive care unit was focussed. Occurrence and deterioration of oral hygiene
are attributed to factors such as malnutrition, tracheal tube presence and nasogastric tubes

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employed for feeding, treatment and reducing saliva due to fever and other care-related
effects. The study focused on the role of oral flora in initiating infections among patients. The
study attributes significance of various studies in understanding the mechanism of an oral
factor in infection emergence; however, its focus aims at evaluating the effect of the oral care
program on the overall incidence rate of ventilator-associated pneumonia infections in
intensive care units.
Research Design
Both studies in this focus employed randomized control approaches. Atashi et al
(2018) undertook a parallel randomised clinical trial having both intervention and control
groups. The study population comprised of intubated patients in ICU settings in hospitals
between November 2016 and August 2017 among affiliated hospitals to Isfahan University of
Medical Sciences, Iran. The study selected the participants through convenience sampling
approach, with inclusion criteria of age bracket between 18-65 years with an endotracheal
tube being placed through the mouth opening, being in the hospital not less than 24 hours,
patients lacking autoimmune disorders, sepsis, pneumonia absence, no pregnancy and lack of
oral and perioral lesions. The exclusion criteria entail the death of patients, transfer from ICU
settings and development of oral lesions and withdrawal from participation in the study.
Simple randomization and blinding were done on the subjects. The two groups
intervention entail activities of oral care, training of research associates to manage this group
was performed. The training covered aspects of cuff pressure of the endotracheal tube, head
elevation, deep mouth and throat suctioning, tooth brushing and overall oral cavity care.
The study by Hellyer et al (2019) employed subjects admitted at ICU with
suspicions of ventilator-associated pneumonia. The trial took place in24 ICUs across
hospitals in National Health Service across the UK. Patients were screened to pass the
eligibility tests and inclusion criteria were worsening chest radiography, changes in the
alveolar with at least, change in body temperature and white cell count and tracheal
secretions. Further, patients who were unlikely to have extrapulmonary infection treatment
were included. Exclusion of patients was undertaken based on the fulfilment of criteria with
the prediction of poor tolerance bronchoscopy and bronchoalveolar lavage.

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Data Collection
Among the intervention group, oral state of the patients was undertaken based on
Beck Oral Assessment Scale and this initiated frequency of care based on the periodic hourly
interval of every 12,8,6 and 4 hours among patients with no, mild, moderate and severe
disorder states. In the control group, data collection was undertaken based on a demographic
questionnaire and clinical Pulmonary Infection Score (CPIS). This questionnaire entailed age,
gender, drug usage, hospitalization reason, drugs and smoking history. The CPIS tool was
used to detect the ventilated associated pneumonia, with an overall scale of 0-10 scores
assessing six key components. The validity and reliability of the score have been improved
based on previous who had been undertaken. The scale was completed and recorded by ICU
staff periodically in the study group days in both groups.
Hellyer et al (2019), defined ventilator-associated pneumonia with the growth of
potential pathogen organism of at least 104 colony forming units per ml in the
bronchoalveolar lavage fluid. Microbial testing as undertaken with bacteria growth at 104
CFU/mL or more was being linked to ventilator-associated pneumonia.
Data Analysis
The data analysis in Atashi et al (2018) was performed using SPSS version 16. The
Fishers exact tests and Chi-Square and t-tests were employed to assess the demographic
variables. Chi-square tests were employed in testing group differences, t-tests were used to
examine the quantitative variables while the Mann-Whitney U tests were performed on CPIS
between the two groups. The statistical level was set at p<0.05.
In the study by Hellyer et al (2019), the primary analysis was based on intention to
treat population. The outcome was analysed based on the primary outcome of both the
groups. Sensitivity was analysed based on the discrete-time Cox proportional hazard model in
the centre while randomization group based on covariates. The secondary analysis was
undertaken based on the Cox proportional hazard model, logistic regression, and linear
regression as appropriate. Subgroup analysis was also undertaken. The analysis was done
using R version 3.3.2.

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Discussion
Hellyer et al (2019) investigated the clinical outcomes of the ventilation associated
pneumonia rapid trial, applying a validated tool; there was no improvement or reduction of
antibiotic use. This as study as discussed by the author's details the first trial to use
biomarkers in the exclusion of ventilator-associated pneumonia to increase empirical
antibiotics mechanisms. The study discusses the relevance of biomarkers in showing
ventilator-associated pneumonia cases. The rate of confirmation was low in this study,
leading to influence in the duration of antibiotic duration among patients raising questions
and concerns over bacterial resistance infections.
The application of IL-1β and IL-8 biomarkers was an essential element for the
exclusion of the test due to the negative likelihood ratio of less than 0.1, the results of this
study yielded positive attributes in discontinuing of antibiotics. The trial embedded process
evaluation in a bid to understand the behaviours through expert guidance. The findings
revealed that effect absence was linked to health care professionals’ behaviour compared to
the poor performance of tests. The study further elaborates on the prescribing characteristics
among health care professionals which were likely linked to lack of effect. The concern
raised in this study entails the failure to treat the process of ventilator-associated infections
which affects the prescription of fewer antibiotic-free days. There is an underlying
assumption of efficacy and safety of antibiotics in care units to avoid harm was enhanced by
suspicion of ventilator-associated pneumonia.
The study further attributes limitation aspect on confinement of time point
assessment; this was motivated by the desire to provide health care professionals with
bronchioalveolar lavage fluid culture results to consider medication. The study makes a
conclusion based on the information obtained and indicates that the exclusion of biomarker
approaches on ventilator-associated pneumonia was not able to reduce the use of antibiotics.
Further, the study suggests that as part of the process evaluation, application of technology
and clinician behaviour had an elevated influence on the aspects of the outcome. The
behavioural mechanism of antibiotic prescription is prevalent in care settings. The study
concluded by recommending future trials on the incorporation of implementation strategies
which are informed by factor characterization influenced by the levels of prescribing and
diagnostic approaches in the decision process of health care professionals.

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Atashi et al (2018) focus on the underlying aim of the study in its initial opening
statement of the discussion. The linkage of oral care program and the occurrence of
ventilator-associated pneumonia showed no effect. There was no observed significant
difference in the two groups regarding the occurrence of ventilator-associated pneumonia,
despite a lower incidence of pneumonia infections. The discussion of this study revolves
around comparing other studies findings concerning oral care in reducing the incidence of
ventilator-associated pneumonia infections.
The study further highlighted various limitations such as the setting of the study; this
was carried out in an intensive care unit which the authors recommend that other settings
being employed also. Further lack of sufficient supervisor managing nurses in their oral
performance was observed as a hindrance in oral care hygiene, thus limiting the accuracy of
care practices performed by the patients. This is different from the study by Hellyer et al
(2019) who entrenched process evaluation as an avenue to guide the overall process of
biomarker administration and collection process in antibiotic use on ventilator-associated
pneumonia infections.
Credibility and Evaluation of the RCT studies
In assessing therapeutic intervention employing randomised control trails often three
fundamental questions are at play. First is as to whether the results are valid, this
encompasses if the results provided represent the truth, provision of unbiased estimates on
treatment effect or is surrounded by biasness of any nature. In this assessment, it is
fundamental to note that the study by Hellyer et al (2019), focused on reliable and valid tools
in its assessment and evaluation process, and established criteria for the assessment of poor
tolerance on bronchoscopy and bronchoalveolar lavage was employed. This was a standard
performance assessment for all the subjects. The criteria were based on standard assessments
of heart rates, PaO2, mean arterial pressure, bleeding diathesis and intracranial pressure. These
have undergone validation and are employed in clinical settings as standard measures of
assessments. The sample largely represented the entire population category of the subjects
with an elaborate treatment of effect assessment protocols being undertaken.
Atashi et al (2018), further employed data tools which have been validated for use in
the clinical practice. The Beck Oral Assessment Scale was employed which assess oral cavity
and the Clinical Pulmonary Infection Score (CPIS) both validated tools enhancing the
validity of the data obtained. Despite these essential tools being applied, lack of standardized

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oral cavity practices by the nurses could be a confounding factor affecting the results
obtained. Lack of process evaluation to standardize the oral care for patients was an
underlying aspect in the results obtained. The subjects largely represented the general
population settings especially patients receiving care at intensive care units, making the
results to apply to other settings, however with caution on the underlying limitations.
Further, both studies undertook randomization effects. The study by Atashi et al
(2018) performed simple randomization based on the random number table through the usage
of an independent person unaware of the study. The randomization process was enabled
through concealment of numbers in separate envelopes with serial numbers being used;
however, the blinding effect was not used due to the nature of the intervention being carried
out. Hellyer et al (2019), performed random assignments based on 1:1 ratio through web-
based randomization service. The randomization sequence generated was placed in sealed
envelopes. The randomization process entailed randomly permuted block size. An initial
double-blind effect was performed before results being communicated to the clinicians in the
study.
The participants were properly accounted for in the studies. The study by Hellyer et
al (2019), developed a conceptual subjects map outlining all the stages of recruitment and
exclusion process. This was essential in accounting for all the subjects employed in the study.
Out of the 360 patients recruited, 210 were finally randomised, the results led to 81 subjects
being included in the per-protocol analysis in the intervention group while 105 subjects in the
control group. In Atashi et al (2018), a study among the 80 patients recruited, two exclusions
were performed among the intervention group and two from the control group.
The analysis was undertaken in both studies aimed at addressing the aims and
objectives of the study. The analysis methods were effective in analysing the randomized
control design employed. The study Atashi et al (2018), considered aspects of attrition in
formulated the subjects to be recruited in the study. The analysis offered justifications as to
how various tools of statistical measures such as the chi-square, t-tests and Mann-Whitney U
tests were employed and the variables applicable to tests. In the study by Hellyer et al (2019),
the analysis of various outcomes was employed with justification on the analysis being made.
The analysis was made using poison regression, Cox proportional model, linear regression
and logistic regression analyses which were justified based on the results and data collected.

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Presentation of key findings in any study is a fundamental step in RCT studies.
Outcomes need to be analysed and the results presented in comparison of the groups. The
findings significance is key in evaluating the tested parameters. The data obtained was based
on intention to treat principles. The study by Hellyer et al (2019), showed no significant
difference among the antibiotic use in the duration period employed in the intention to treat
analysis (p=058). Lavage of bronchoalveolar was linked to a small and transient rise in the
use of oxygen. Prescription factors, the slow pace of bronchoalveolar lavage and depending
on trail chain of procedures were emerging aspects of impairing the trial processes. In the
study by Atashi et al (2018) showed that chi-square tests did not offer any significant
difference (p=0.0059), however, the occurrence of pneumonia-related infection was lower in
the intervention group compared to the control group.
Analysis on applicability of evidence
The results obtained from these two studies demonstrate application aspect in the
care practice. In the study by Atashi et al (2018), there was no statistical difference among the
two groups. Key aspects of ventilator-associated pneumonia infections entailing head bed
elevation on 30°–45°, reducing the level of sedation, assessing the readiness of patients for
extubation, oral care, hand hygiene and sub glotting suctioning are effective measures in
preventing ventilator acquired infections. Recommendations on the care provider's impact on
oral care and a combination of these avenues are essential in preventing ventilator acquired
infections.
These findings are in line with other studies, a study by Kalanuria, Ziai & Mirski,
(2014) on ventilator-associated pneumonia in ICU showed an adverse effect among intubated
adults leading to increase adverse outcomes in the care settings, hence demonstrates that
undertaking patients readiness process as outlined by Atashi et al (2018) is crucial in
minimizing these effects. Further Wu et al (2019) in assessing risks factors for the
development of this infection showed that employing preventive strategies is key in reducing
the overall incidence of ventilator acquired infections. In classifying the risks factors linked
to increased infection rates, increases exposure of bacteria and invasive procedures such as
the application of sedation tend to increase the risks of pneumonia infections.
The study by Hellyer et al (2019), demonstrated that the usage of antibiotics is still
high among suspected cases of ventilator-associated pneumonia infections, while the
antibiotic stewardship was not increased by rapid sensitive rule-out test, the prescribing

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culture among health care practitioners could affect. This is in line with one of the findings
established by Wu et al (2019) on increased exposure of antibiotic being associated with
increased ventilated pneumonia infections. Despite this, appropriate administration of
antimicrobial agents are key in improving the outcome of infections, lack of accurate
selection still hampers this process, thus lacking is appropriate diagnostic, therapeutic and
preventive strategies, (Chastre & Edouard, 2016). Employing this strategy as outline by
Atashi et al (2018) in this review is crucial in managing the level of infections.
Other underlying aspects of ventilator acquired infections entail prolong ventilation
process and length of stay in hospital (Abdelrazik & Salah Abdelazim, 2017). Further, the
duration of mechanical ventilation (Blot et al., 2014; Ding et al., 2017; Liu et al., 2017) and
the endotracheal intubation (Llitjos et al., 2019) play critical roles as risks factors similar to
our findings in this review.
In assessing the application of oral hygiene practices a meta-analysis study by Hua
et al (2016), showed that mouth wash practices are essential in reducing the development of
ventilator-associated pneumonia among critically ill patients from 24% to 18%, thus
signifying oral care is an essential aspect in hygiene practices at intensive care unit, similar to
our review findings. Further, hand hygiene education strategies among the health care
professionals are a key issue in reducing the development of infection and an overall
reduction of ventilator acquired pneumonia infections among patients (Romero et al., 2019).
Conclusion
Critical appraisal of evidence in clinical practice is fundamental in informing care
practice through an evidence-based approach. Systematic assessment of outcomes is crucial
in improving patient care quality in hospital settings. Adoption of the randomised control
studies offers a higher degree and confidence in terms of outcomes obtained. A proper
conducted RCT with an effective reporting approach taking into considerations the validity of
results, precision and applicability are essential elements. RCT falls in the second top
hierarchy in the evidence-based pyramid making it a critical approach in evaluating
outcomes. In this review, an assessment of ventilated associated pneumonia infection is an
essential aspect of care in intensive care units. Analysis of the two RCT studies is
instrumental in guiding and managing ventilator-associated pneumonia infections. The
findings demonstrate that us of antibiotic remains high in care settings, with antibiotic
stewardship having not effective in this aspect. The underlying prescribing culture among

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health care professionals plays a fundamental role in this process. Nursing practice
engagements of various prevention strategies are crucial in reducing the occurrence of
ventilator-associated infections in intensive care units. Employing empirical evidence-based
approaches is essential in reducing these infections in the intensive units, thus improving the
quality of care.

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References
Abdelrazik, O. A., and Salah Abdelazim, M. (2017). Ventilator-associated pneumonia in
adult intensive care unit prevalence and complications. Egypt. J. Crit. Care Med. 5,
61–63. doi: 10.1016/j.ejccm.2017.06.001
Atashi, V., Yousefi, H., Mahjobipoor, H., Bekhradi, R., & Yazdannik, A. (2018). Effect of
oral care program on prevention of ventilator-associated pneumonia in intensive care
unit patients: A randomized controlled trial. Iranian journal of nursing and
midwifery research, 23(6), 486.
Blot, S., Koulenti, D., Dimopoulos, G., Martin, C., Komnos, A., Krueger, W. A., et al.
(2014). Prevalence, risk factors, and mortality for ventilator-associated pneumonia in
middle-aged, old, and very old critically ill patients. Crit. Care Med. 42, 601–609.
doi:10.1097/01.ccm.0000435665.07446.50
Chastre, J., & Fagon, J. Y. (2019). Ventilator-associated pneumonia. American journal of
respiratory and critical care medicine, 165(7), 867-903.
https://doi.org/10.3389/fphar.2019.00482
Ding, C., Zhang, Y., Yang, Z., Wang, J., Jin, A., Wang, W., et al. (2017). Incidence, temporal
trend and factors associated with ventilator-associated pneumonia in mainland
China: a systematic review and meta-analysis. BMC Infect. Dis. 17:468. doi:
10.1186/s12879-017-2566-2567
Hellyer, T. P., McAuley, D. F., Walsh, T. S., Anderson, N., Morris, A. C., Singh, S., ... &
Emerson, L. M. (2020). Biomarker-guided antibiotic stewardship in suspected
ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and
process evaluation. The Lancet Respiratory Medicine, 8(2), 182-191.
Kalanuria, A. A., Ziai, W., & Mirski, M. (2014). Ventilator-associated pneumonia in the ICU.
Critical care (London, England), 18(2), 208. https://doi.org/10.1186/cc13775
Liu, Y., Di, Y., and Fu, S. (2017). Risk factors for ventilator-associated pneumonia among
patients undergoing major oncological surgery for head and neck cancer. Front.
Med. 11, 239–246. doi: 10.1007/s11684-017-0509-8

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Llitjos, J. F., Gassama, A., Charpentier, J., Lambert, J., de Roquetaillade, C., Cariou, A., ... &
Pène, F. (2019). Pulmonary infections prime the development of subsequent ICU-
acquired pneumonia in septic shock. Annals of intensive care, 9(1),
39.https://doi.org/10.1186/s13613-019-0515-x
Wu, D., Wu, C., Zhang, S., & Zhong, Y. (2019). Risk Factors of Ventilator-Associated
Pneumonia in Critically III Patients. Frontiers in pharmacology, 10.