Efficacy of VAP Care Bundle in Adult ICU Patients: A Literature Review
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This literature review evaluates the feasibility and effectiveness of VAP care bundles in preventing risk of VAP in adult ICU patients. The review summarizes the outcome of various research studies and groups them under common themes.
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Running head: LITERATURE REVIEW Literature review Name of the student: Name of the University: Author’s note
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1LITERATURE REVIEW Introduction: Patients in the intensive care units (ICU) are at risk of mortality not only due to critical illness, but also because of secondary complication caused due to occurrence of ventilator associated pneumonia (VAP) in ICU. VAP is a type of pneumonia that is diagnosed after 48 hours of endotracheal intubation and patients receiving VAP has high likelihood of developing mechanical ventilation. It is a common cause of hospital morbidity and mortality despite development of advanced diagnostic techniques (Othman and Abdelazim 2017).The common symptoms of VAP include signs related to pulmonary infection such as fever, purulent secretions and bacteriological evidence of pulmonary infection. The main burden for ICU staffs is that diagnosis of VAP prolongs length of stay in the ICU and has huge implications on medical care and cost (Ranjan et al. 2014).Hence, in response to this issue, finding the best intervention to prevent and control VAP events in ICU setting is critical. InresponsetothehighincidenceofVAPinICU,theInstituteforHealthcare Improvement (IHI) recommended the use of bundle of care such as oral care with chlorhexidine, head of bed elevation, stress ulcer prophylaxis, daily sedation assessment and breathing trials to reduce the incidence of VAP (Kalanuria, Zai and Mirski 2014). Currently in my practice setting, individual interventions like head of bed elevation and stress ulcer prophylaxis is being used to manage VAP. However, the VAP care bundle is a new component and it is not sure whether it can provide desired outcomes or not. Hence, a literature review has been undertaken to evaluate the feasibility and effectiveness of VAP care bundles in preventing risk of VAP in adult ICU patients.
2LITERATURE REVIEW Methods: The search for relevant research literatures related to the research topic was done using the databases like CINAHL, PubMed and Medline. The search terms that were used to retrieve articles from the above mentioned databases included Ventilator associated pneumonia (VAP)/ VAP care bundle/ventilator care bundles, VAP prevention bundle; efficacy/effectiveness/impact; intensive care units (ICU)/ICU patients/surgical ICU. After entering the search terms, the suitability of the articles for the research topic was evaluated first by reading abstract and title of the research articles. Additional articles related to VAP bundle in ICU were also obtained after reviewing reference list of many articles.Apart from search terms, the search process was guided by certain inclusion and exclusion criteria. The main inclusion criteria were that all research articles must be full-text articles published within 2009 and it must have VAP care bundle as the main intervention for the research. Articles that reported about the use of VAP bundle in care settings other than ICU were excluded. The age of research participants was also a primary inclusion criteria as the main purpose of the literature review was to evaluate outcomes in ICU patients. Thematic approach has been taken to summarize outcome of various research studies and group them under common themes. Literature review (Establishing the efficacy of VAP care bundle in ICU patients): With the IHI ‘s recommendation of using VAP prevention bundle rather than single intervention to prevent VAP in ICU setting, there is a need to conduct rigorous analysis of researchliteraturestoassesstheefficacyofthenewinterventionanditssuitabilityfor implementation in the clinical setting.
3LITERATURE REVIEW Based on search criteria, several studies were found to report about the impact of VAP care bundles on preventing VAP in ICU setting.Lim et al. (2015)used a modified six item care bundle compared to IHI’s five item bundle to analyse ventilator utilization and VAP incidence in five surgical ICUs in a hospital. The study revealed the reduction in ventilator utilization post the VAP bundle intervention and remarkable reduction in VAP cases.The VAP bundle design can be regarded as the main factor that influenced patient’s outcome. The strength of the study was that it included detailed interventions like hand hygiene before and after intubation procedure, adequate cuff pressure, oral cavity secretion, defined intubation indication and device rinsed with water to prevent the risk of infection. Inclusion of these additional interventions like hand hygiene is considered to be effective an interventional study revealed the effectiveness of hand hygiene in reducing VAP incidence (Saramma et al. 2011). However, one factor that limits applicability of the findings byLim et al. (2015)in all ICU setting is that the modified bundle had several components and all of these interventions may not work for patients with multiple co-morbidities before intubation. This point is also important because research evidence shows the efficacy of simplified VAP bundles too. For example,Su et al. (2017)revealed decrease in VAP rate by including a simplified three component bundle and the advantage of these bundles were that it had minimum compliance related issues in implementing it in ICU setting. Despite the challenges in using multiple components in VAP bundles, the research literatures confirms that strategies like multi-disciplinary team work and continuous education and bundle promotion can promote use of VAP bundle for the safety of adult ICU patients. Educational programs on infection control and other bundle preventive measures can enhance outcome of ICU patients (Meadows 2018).
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4LITERATURE REVIEW Apart from single centre studies, many multiple centre studies were also done to determine the efficacy of VAP bundles in different hospital ICU units. The analysis of multi- center study was necessary to confirm whether VAP prevention bundle is suitable to be implemented in different health care centers or not. In contrast to the single centre study done by Lim et al. (2015), Eom et al. (2014) evaluated the impact of the care bundles by conducting a quasi-experimental study in ICUs of six university hospitals. The VAP bundle in the study included components like head of bed elevation, peptic ulcer prophylaxis and venous thrombous prophylaxis and oral decontamination with oral chlorhexidine. Statistically significant reduction in VAP rate was found after the introduction of the VAP bundle. One of the major arguments regarding the use of VAP bundle is that it has various components and there are discordances regarding the benefits of these components. The advantage of the research by Eom et al. (2014) is that it evaluated the compliance rate for all of the components. Greatest impact on VAP reduction was found because of high compliance with oral decontamination with chlorhexidine. Other components also achieved good compliance rate.This finding is consistent with other research evidence as Enwere et al. (2016) clearly revealed the effectiveness of oral chlorhexidine by comparing the use of VAP bundle and chlorhexidine in ICU patients compared to those patients who did not received the prophlaxis. Hence, these evidences can be utilized to reduce health care cost and patient morbidity caused due to incidence of VAP. Another question that may arise while implementing VAP bundle in ICU setting is that whether all the elements of the VAP bundle can be easily adopted by health care staffs or not. Pogorzelska et al. (2011) looked to explore the question by examining the adoption of the ventilator bundle element and evaluating the effectiveness of individual elements. The validity of the research has been enhanced by the use of multi-centre analysis and conducting research in
5LITERATURE REVIEW 250 US hospitals. Four elements of the bundle were analysed in the study including head of the bed, sedation vacation, peptic ulcer and DVT prophylaxis.The research collected data from participants mainly related to the adoption elements of the bundle such as presence of written policy for each bundle element, presence of compliance assessment and correct implementation of the policy. As desired, there were 21 hospitals that achieved 95% compliance rate. The association between compliance rate and policy revealed the importance of organizational climate too to promote the success of VAP bundle elements. There is lack of studies which have evaluated the relationship between safety culture and VAP bundle outcomes. There is a need to conduct more studies in future to evaluate association between safety culture and VAP bundle to maximize the quality of care delivered in ICU settings. As Sachetti et al. (2014) suggested the success of VAP bundle after providing proper knowledge regarding the use of the bundle to ICU, the validity of the recommended intervention was further assessed by Narang (2008) by finding out whether knowledge and awareness of ventilator bundle can influence outcome variable of ICU patients or not. The retrospective observational study implemented the bundle after educating nursing staffs and other medical personnel through presentations and group discussions. Positive outcomes related to reduction in percentage of VAP incidence was found after the implementation of the intervention. Mogyoródi et al. (2016) supports the fact that education plays a vital role in the prevention of VAP and education can significant improve nurse’s ability to effectively use the VAP bundle. However, one significant limitations or gaps found in the work is that the study did not considered individual risk factors that can predispose patients to risk of developing VAP. Hence, there is a need for future research to determine the factors that limit the effectiveness of VAP bundle in different patient population. This may help to further enhance the efficacy of the VAP bundle or
6LITERATURE REVIEW identify other alternative to first reduce the latent cause before implementing the ventilator bundle. As mentioned by Kalanuria, Zai, and Mirski (2014), adherence to the bundle is crucial for success rate of VAP and Narang (2008) did not considered individual challenges faced by staffs in implementing the bundle. According to Kalanuria, Zai, and Mirski (2014), one the major factor that determines the success of VAP bundle is achieving high compliance rate. Therefore, interventions reporting about adherence to the bundle are critical to understand how adherence influences the rate of VAP. Sachetti et al. (2014) and Mohamed (2014) reported about the adherence aspect of the VAP.The advantage of the study by Sachetti et al. (2014) is that by implementing an educationalintervention,thestudyrevealedtheimportanceofeducationtoincreasethe adherence to the ventilator care bundle. However, the validity of the research findings is limited by short duration of the educational intervention. Hence, long-term beneficial effect could not be established. Mohamed (2014) investigated about the compliance rate of the VAP bundle over 1 year period and its effectiveness of adult ICU patient’s outcome. The compliance rate with the intervention gradually increased and the surgical sub-population got better benefits than other population group. The research overlooked certain vital factors that are needed to improve compliance rate. Luna (2015) also conducted an assessment of VAP compliance rate among nurses and it revealed different rates of compliance for different bundle elements. The highest adherence rate was found for chlorhexidine followed by sedation vacation and breathing trials. High adherence rate was also found for DVT prophylaxis and peptic ulcer prophylaxis. However, since the study was done in a single hospital, the findings cannot be applied in other settings because nursing
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7LITERATURE REVIEW education and other factors might also influence nurse’s perception regarding use of each elements of the VAP bundle. The point is also validated by the findings from the study by Alja’afreh, Mosleh and Habashneh (2018) which revealed a contrasting finding that ICU nurse have poor perception and attitude towards oral care for mechanically ventilated patients. The study was done in three Jordanian hospitals and it was found that nurses did not adhere to minimal standards of oral care. However, nurses had positive attitude towards oral care. This outcome might be influenced by the in-hospital training protocol and knowledge and experience of nurse too. Hence, reviewing findings from multi-centre analysis can confirm whether nurse’s attitudes towards oral care are influenced by training or other factors. Adherence to VAP bundle is critical to the success of the intervention. However, the gap in the research presented above is that most studies were quantitative studies and it gave limited ideas regarding the challenges a nurse can face in implementing different elements of the bundle. Analysis of qualitative studies was needed to get in-depth information related to challenges in using the protocol. Various studies investigated about the adherence or compliance to Institution- specific VAP guidelines. Kiyoshi-Teo et al. (2014) argues that availability of guidelines alone do not predict adherence to the recommended strategies. The author came to this conclusion after conducting a cross sectional descriptive study where to identify facilitators and barriers to adherence to the guideline for VAP prevention. Attitude towards the guideline was measured by agreement with the guideline content, intention and self-efficacy of users. Nurse’s professional characteristics did not influence the guideline and time availability was a factor that influence adherence to oral care. However, certain factors like lack of causal conclusion and self-reported data limits the reliability of the research findings. Despite this limitation, Kiyoshi-Teo and Blegen (2015) suggest that perception of users towards VAP bundle must be examined to
8LITERATURE REVIEW promote success of the intervention. This is also theoretically valid conclusion as according to the Health Belief Model, individual health behaviour is dependent on attitudes and beliefs and examination of attitudes can help health care personnel to identify benefits and barriers to the use of ventilator bundle (Meadows 2018). The literature review suggest that various bundle element, institutional factors and nursing’s staffs perception influence adherence to the VAP bundle while caring for ICU patients. In response to these issues presented in the research articles, there is a need to identify best strategiesthatcanpromotesuccessofthebundleintervention.Borgert,Goossensand Dongelmans (2015)used systematic review method to identify the effective strategies for the implementation of care bundles for ICU patients. The significance of the study is that many strategies has been implemented in the past, however there is lack of understanding regarding the mosteffectivestepstoimplementcarebundles.Thefindingsfromtheresearchreveals education, reminders and audit feedback as the most frequently used strategies implemented in various hospital setting. However, the compliance to the care bundle is influenced by type and number of element and. Lawrence and Fulbrook (2011) states that compliance with four bundle element is possible as evidenced by the review of various ventilator care bundle with four elements. The gap found in the study byBorgert, Goossens and Dongelmans (2015)is that highlights about the frequency and types of strategies used to implement VAP bundles, however the study lacked conclusion regarding the strategy that can yield highest compliance to the care bundle. This was because of the heterogeneity of the data. To clarify regarding the effective steps to implement the VAP bundle, review of single strategies used in research were done. There was no study which individually reported about
9LITERATURE REVIEW adherence rate in relation to the strategy of reminding health care staffs regarding use of VAP bundles. In relation to feedback and audit related strategies, Lawrence and Fulbrook (2012) indicated variable outcomes after implementing the one month feedback strategy to improve compliance with VAP bundle elements. Compliance rate for individual elements increased however the compliance rate for overall bundle varied significantly. In contrast, Borgert et al. (2016) revealed that timely audit and feedback can significantly improve the success of the implementing process. However, the researcher could show the benefits for short period only as the compliance rate dropped once the audit and feedback intervention was dropped. Certain barriers affected the likelihood of reaching optimal effect. The first reason was that on many occasion, it was not possible to provide face-to-face feedback. Hence, it can be concluded that providing timely individual feedback is a labour intensive process particularly in ICU settings where large team exists. There is need for more research in the future that can evaluate the effect of audit and feedback for a long period. Conclusion: From the systematic review of research evidence, it can be concluded that VAP bundle is an effective intervention to control VAP incidence in adults ICU patients. The analysis of the intervention in various setting revealed that compliance to the bundle is an essential factor that can enhance the success of the intervention. Hence, while implementing these interventions in the ICUs, focusing on education and training aspect would be critical to get the desired outcomes. Multi-center analysis of research evidence also gives the insight that despite inclusion of many components in the VAP bundle, it can be easily implemented if proper training and education to staff is provided regarding its use. Education and training can significantly influence
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10LITERATURE REVIEW ICU nurse’s attitude towards VAP bundle elements and promote adherence to the VAP protocol too. Hence, when implementing VAP bundle intervention for the first time, it would essential to arrange for effective education program and also have a system in place to track adherence to the intervention.
11LITERATURE REVIEW References: Alja’afreh, M.A., Mosleh, S.M. and Habashneh, S.S., 2018. Nurses’ perception and attitudes towards oral care practices for mechanically ventilated patients.Saudi medical journal,39(4), p.379. Borgert, M. J., Goossens, A., and Dongelmans, D. A. 2015. What are effective strategies for the implementation of care bundles on ICUs: a systematic review.Implementation Science,10(1), 119. Borgert, M., Binnekade, J., Paulus, F., Goossens, A., Vroom, M., and Dongelmans, D. 2016. Timely individual audit and feedback significantly improves transfusion bundle compliance—a comparative study.International Journal for Quality in Health Care,28(5), 601-607. Enwere, E.N., Elofson, K.A., Forbes, R.C. and Gerlach, A.T., 2016. Impact of chlorhexidine mouthwash prophylaxis on probable ventilator-associated pneumonia in a surgical intensive care unit.International journal of critical illness and injury science,6(1), p.3. 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-associatedpneumonia:amulticenterstudy.Americanjournalofinfection control,42(1), pp.34-37. Kalanuria, A. A., Zai, W., and Mirski, M. 2014. Ventilator-associated pneumonia in the ICU.Critical care,18(2), 208.
12LITERATURE REVIEW Kiyoshi-Teo, H. and Blegen, M., 2015. Influence of institutional guidelines on oral hygiene practices in intensive care units.American Journal of Critical Care,24(4), pp.309-318. Kiyoshi-Teo, H., Cabana, M. D., Froelicher, E. S., and Blegen, M. A. 2014. Adherence to institution-specific ventilator-associated pneumonia prevention guidelines.American Journal of Critical Care,23(3), 201-215. Lawrence, P. and Fulbrook, P.,2011. The ventilator care bundle and its impact on ventilator‐ associated pneumonia: a review of the evidence.Nursing in critical care,16(5), pp.222-234. Lawrence, P. and Fulbrook, P., 2012. Effect of feedback on ventilator care bundle compliance: before and after study.Nursing in critical care,17(6), pp.293-301. Lim, K.P., Kuo, S.W., Ko, W.J., Sheng, W.H., Chang, Y.Y., Hong, M.C., Sun, C.C., Chen, Y.C. and Chang, S.C., 2015. Efficacy of ventilator-associated pneumonia care bundle for prevention ofventilator-associatedpneumoniainthesurgicalintensivecareunitsofamedical center.Journal of Microbiology, Immunology and Infection,48(3), pp.316-321. Luna, A., 2015. An Exploration of Nurse Adherence to Ventilator-Associated Pneumonia Bundle Interventions:AQuantitativeStudy.Retrievedfrom:https://scholar.dominican.edu/senior- theses/43/ Meadows,T.2018.NursingCompliancewithVAPBundle.Retrievedfrom: http://digitalcommons.murraystate.edu/cgi/viewcontent.cgi?article=1788&context=scholarsweek
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13LITERATURE REVIEW Mogyoródi, B., Dunai, E., Gál, J., and Iványi, Z. 2016. Ventilator-associated pneumonia and the importance of education of ICU nurses on prevention – Preliminary results.Interventional Medicine & Applied Science,8(4), 147–151. http://doi.org/10.1556/1646.8.2016.4.9 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. Narang, S., 2008. Use of ventilator bundle to prevent ventilator associated pneumonia.Oman medical journal,23(2), p.96. Othman, A.A. and Abdelazim, M.S., 2017. Ventilator-associated pneumonia in adult intensive care unit prevalence and complications.The Egyptian Journal of Critical Care Medicine,5(2), pp.61-63. Pogorzelska, M., Stone, P. W., Furuya, E. Y., Perencevich, E. N., Larson, E. L., Goldmann, D., and Dick, A. 2011. Impact of the ventilator bundle on ventilator-associated pneumonia in intensive care unit.International Journal for Quality in Health Care,23(5), 538–544. Ranjan,N.,Chaudhary,U.,Chaudhry,D.andRanjan,K.P.,2014.Ventilator-associated pneumonia in a tertiary care intensive care unit: Analysis of incidence, risk factors and mortality.Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine,18(4), p.200. Sachetti, A., Rech, V., Dias, A.S., Fontana, C., Barbosa, G.D.L. and Schlichting, D., 2014. Adherencetotheitemsinabundleforthepreventionofventilator-associated pneumonia.Revista Brasileira de terapia intensiva,26(4), pp.355-359.
14LITERATURE REVIEW Saramma, P.P., Krishnakumar, K., Dash, P.K. and Sarma, P.S., 2011. Alcohol-based hand rub and ventilator-associated pneumonia after elective neurosurgery: An interventional study.Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine,15(4), p.203. Su, K.C., Kou, Y.R., Lin, F.C., Wu, C.H., Feng, J.Y., Huang, S.F., Shiung, T.F., Chung, K.C., Tung, Y.H., Yang, K.Y. and Chang, S.C., 2017. A simplified prevention bundle with dual hand hygiene audit reduces early-onset ventilator-associated pneumonia in cardiovascular surgery units: An interrupted time-series analysis.PloS one,12(8), p.e0182252.