Ventilator Associated Pneumonia
Analytic and Continental Philosophy of Ventilator Associated Pneumonia Hospital acquired infections (HAI) have become a major problem for patients’ outcomes and hospitals due to increase costs. The advancement made in medicine, technology, and general knowledge has increased the life expectancy. With this increase, patients are however sicker and have multiple comorbidities that make their care increasingly complex. Barrett, Smith, Elixhauser, Honigman, and Pines (2014) researched the utilization of intensive care units (ICU) and discovered that within nine years ICU stays increased three times within the time span (p. 1) or more specifically according to the Society of Critical Care Medicine (2016), there are about 5.7 million ICU admissions
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per year. One of the many reasons for ICU admission would be respiratory issues that require mechanical ventilation. The risk of pneumonia with mechanical ventilation can range from 9% to 27% and is often associated with increase hospital stays, mortality, and costs (Kalanuria, Zai, and Mirski, 2014). Due to the significant impact of ventilator associated pneumonia (VAP) on patients, their treatment, and cost; it is important to investigate the different methods of treatment, prevention and compare the delivery of care among healthcare professionals.
Phenomenon of Interest
Relevance
As a nurse in the cardiovascular intensive care unit (CVICU), many patients who are cared for come back from surgery on mechanical ventilation or are admitted to the unit due to respiratory distress and require intubation and mechanical ventilation. In healthy individuals the body’s defense mechanisms can usually protect the patient against pneumonia. The patients who require cardiovascular surgery usually have multiple comorbidities that prolong their need for the ventilator and hinder their ability to protect themselves effectively. Post-operative patients that are commonly seen in CVICU commonly have conditions where prolonged ventilation is required for hemodynamic support. Patients who are on the ventilator for more than a few days usually require nasogastric or oral gastric tube feedings. The feedings on its own can present a risk for aspiration in those with a decrease cough reflex and contribute to the risk. With all the risk factors for patients in the ICU it is important to know what are the common obstacles patients face and what can be done to prevent VAP.
Statistics
The Centers for Disease Control and Prevention (2016) estimates that more than 300,00 people need mechanical ventilation per year (p.1). Those on mechanical ventilation have a higher risk of tracheobronchitis and pneumonia. Multiple researchers including Craven and Hjalmarson (2010) have estimated the prevalence of acquiring pneumonia to be approximately 6%-20% with a fatality rate of 20%-40% (p.559). A diagnosis of VAP is made when a patient has the following symptoms: “fever, purulent tracheobronchial secretions, increased white blood cell count, increased respiratory rate, decreased tidal volume, and decreased oxygenation” (Koleff, 2016) within two to three days of intubation.
Cost
HAIs, specifically VAP can increase the length of stay in the ICU, prolong the time needed for mechanical ventilation, require additional drugs to treat the infection, increase the overall length of stay in the hospital, and create additional complications to the patient overall.
Currently, the Centers for Medicare and Medicaid (CMS) have stopped additional payment for certain HAIs. Central line associated blood stream infections (CLABSI) and catheter associated urinary tract infections (CAUTI) are among the two that CMS have stopped reimbursement for. While VAP is not on the list currently it is still an economic concern for hospitals. Restrepo et al. (2010) compared the costs of hospital stays between patients with VAP and patients without VAP. Their research showed that the average cost for patients with VAP estimated to be $76,730 compared to those without to be $41,250 (p. 509). The differences in cost can partly be attributed to length of stay, pharmacy, laboratory, and respiratory therapy costs related to treatment. At Cleveland Clinic (2016) the cost for one day in the coronary care or intensive care unit equals to be $5,136 in comparison to step down- $3,396, and medical/surgical- $1,699 (Room and Board- Per Day Charges, para. 1). This becomes relevant when considering patients who develop VAP prolong their time on the ventilator by an average of six days and their overall average of stay in the ICU increases to ten additional days compared to those without VAP (Restrepo et al, 2010, p. 513).
Analytic Philosophy After researching the relevance, statistics and cost associated with VAP, it is easy to see why hospitals place such a big emphasis on developing bundles to prevent VAP. The research shows that hospitals and patients both benefit from utilizing bundles. The statistics support the analytic theory when it comes to providing patient care and patient outcomes. Many quality improvement projects focus on what works better and what helps decrease the incidence of VAP on their unit. This theory strongly identifies with how hospitals can decrease the mortality rate, decrease costs, and length of stay associated with VAP. As a provider of care it is important to stay up to date with research and to know which intervention is more effective than the other.
Ventilator Bundle Many institutions have adopted the ventilator bundle as a way to decrease the incidences of VAP in their ICUs as a suggestion from the Institute for Healthcare Improvement (IHI). Lawrence and Fulbrook (2011) reviewed ten different studies that implemented the ventilator care bundle and evaluated its’ effectiveness. The bundles that were included in the review consisted of elevation of the head of bed, sedation vacations and readiness to wean, gastric ulcer prevention, and DVT prophylaxis. All studies that were reviewed used those four interventions as a part of their bundle in addition to other policies related to the institution. Of the ten studies the rates of VAP decreased between 34% and 85%, the required time on mechanical ventilation was reduced by an average of four to eight days, and ICU length of stay was decreased by 18% to 39%. The combined research and review shows how important of a difference certain interventions make in caring for patients who require mechanical ventilation. While there are some inconsistencies that skews the data, like compliance, the correlation still remains strong enough to favor the analytic philosophy (pp. 222-227).
Continental Philosophy The analytic philosophy shows how effective ventilator bundles are in VAP, but the continental philosophy helps define VAP more fully. The research that was done all showed that ventilator bundles are useful in preventing VAP, however each study did not produce a consistent rate of decrease in prevention, time on the ventilator, or time in the ICU. This philosophy helps healthcare providers figure out why and if certain interventions are possible in their area of work. While providers need to know which intervention has the best results for their patients, they also need to be aware of the resources or staff that perform these interventions. Being aware of the full picture can change the plan of care.
Delivery of Care and Compliance
Nurses play a major role in implanting the ventilator bundle and patient outcomes. Compliance is a major contributor to the differences in results with the ventilator bundle. Nurses’ perception, time, compliance, education, and attitude all assist in the success of the bundle. Branch-Elliman, Wright, Gillis, and Howell (2013) sent out a survey to 291 nurses in the critical care area to determine their perception of the ventilator bundle, specifically the time required, the impact of the bundle, and their attitude toward preventing VAP. Of the 291 surveys that were emailed, 119 critical care nurses responded. The survey found that the nurses did not feel that the ventilator bundle delayed other patient care nor did patients miss out on other aspects of care due to the bundle. The nurses reported that the bundle did increase their overall workload and increase need for intervention, such as suctioning with mouth care (pp. 357-360).
As part of the ventilator bundle, elevating the head of the bed decreases the chances of VAP. Hiner, Kasuya, Cottingham, and Whitney (2010) wanted to determine clinicians’ knowledge and perception when it came to elevating head of the bed. One hundred and seventy-five participants were asked the following questions: “What is the level of the head of the bed? What head-of-bed elevation is associated with decreased incidence of ventilator-associated pneumonia? When providing care, how do you routinely determine the head-of-bed elevation?” (p. 164). From this study, the researchers learned that the majority of nurses knew what the recommendation was and had the highest percentage, along with respiratory therapist, in accurately determining head of bed elevation. However, 30% of clinicians guessed and 12% either asked the nurse or guessed (pp. 164-166). The two studies help fully define and support the analytic philosophy by further explaining the differences in results among all the studies.
Ways of Knowing Carper’s four ways of knowing for nursing are divided into categories that include: empirics, esthetics, ethics, and personal.
Empirical knowing can be viewed as concrete, cause and effect, or facts from studies. Esthetic knowing helps nurses perceive and want to understand the why. Ethical knowing helps the nurse in determining what is right or wrong, what is should and should not be done, and is based on respect of patients. Lastly, personal knowing can simply be defined as our own experiences, how nurses feel, and it effects the quality of care nurse provide (Brugger and Madison, 2015). The four patterns of knowing can influence a practitioner by examining self to eliminate bias, treat patients equally, remain current on evidence based practices, and seek to understand patients as a whole. Carper’s four ways of knowing can help practitioners identify what their weaknesses are and strive to improve the care provided to patients. McGovern, Lapum, Clune, and Martin (2013) integrated Carper’s four ways of knowing into the simulations for undergraduate nursing students. Their simulations aimed at educating students on experiencing patient care in a clinical sense and experience the art of nursing. Without Carper’s ways of knowing being the fundamental basis of design and delivery, students focused primarily on the physical aspect of care. The design helped developing a relationship and realizing self-bias that could shape interaction (pp. …show more content…
46-49).
Conclusion
Preventing and decreasing the chances of patients acquiring VAP is possible through the ventilator bundle.
There have been many studies done to support the analytical philosophy of this phenomenon of interest (POI) through the ventilator bundle. The continental philosophy does help define the POI more in depth. Through Carper’s ways of knowing, nursing staff who are in direct contact with patients can use the qualitative and quantitative data provided to influence their
care.
per year. One of the many reasons for ICU admission would be respiratory issues that require mechanical ventilation. The risk of pneumonia with mechanical ventilation can range from 9% to 27% and is often associated with increase hospital stays, mortality, and costs (Kalanuria, Zai, and Mirski, 2014). Due to the significant impact of ventilator associated pneumonia (VAP) on patients, their treatment, and cost; it is important to investigate the different methods of treatment, prevention and compare the delivery of care among healthcare professionals.
Phenomenon of Interest
Relevance
As a nurse in the cardiovascular intensive care unit (CVICU), many patients who are cared for come back from surgery on mechanical ventilation or are admitted to the unit due to respiratory distress and require intubation and mechanical ventilation. In healthy individuals the body’s defense mechanisms can usually protect the patient against pneumonia. The patients who require cardiovascular surgery usually have multiple comorbidities that prolong their need for the ventilator and hinder their ability to protect themselves effectively. Post-operative patients that are commonly seen in CVICU commonly have conditions where prolonged ventilation is required for hemodynamic support. Patients who are on the ventilator for more than a few days usually require nasogastric or oral gastric tube feedings. The feedings on its own can present a risk for aspiration in those with a decrease cough reflex and contribute to the risk. With all the risk factors for patients in the ICU it is important to know what are the common obstacles patients face and what can be done to prevent VAP.
Statistics
The Centers for Disease Control and Prevention (2016) estimates that more than 300,00 people need mechanical ventilation per year (p.1). Those on mechanical ventilation have a higher risk of tracheobronchitis and pneumonia. Multiple researchers including Craven and Hjalmarson (2010) have estimated the prevalence of acquiring pneumonia to be approximately 6%-20% with a fatality rate of 20%-40% (p.559). A diagnosis of VAP is made when a patient has the following symptoms: “fever, purulent tracheobronchial secretions, increased white blood cell count, increased respiratory rate, decreased tidal volume, and decreased oxygenation” (Koleff, 2016) within two to three days of intubation.
Cost
HAIs, specifically VAP can increase the length of stay in the ICU, prolong the time needed for mechanical ventilation, require additional drugs to treat the infection, increase the overall length of stay in the hospital, and create additional complications to the patient overall.
Currently, the Centers for Medicare and Medicaid (CMS) have stopped additional payment for certain HAIs. Central line associated blood stream infections (CLABSI) and catheter associated urinary tract infections (CAUTI) are among the two that CMS have stopped reimbursement for. While VAP is not on the list currently it is still an economic concern for hospitals. Restrepo et al. (2010) compared the costs of hospital stays between patients with VAP and patients without VAP. Their research showed that the average cost for patients with VAP estimated to be $76,730 compared to those without to be $41,250 (p. 509). The differences in cost can partly be attributed to length of stay, pharmacy, laboratory, and respiratory therapy costs related to treatment. At Cleveland Clinic (2016) the cost for one day in the coronary care or intensive care unit equals to be $5,136 in comparison to step down- $3,396, and medical/surgical- $1,699 (Room and Board- Per Day Charges, para. 1). This becomes relevant when considering patients who develop VAP prolong their time on the ventilator by an average of six days and their overall average of stay in the ICU increases to ten additional days compared to those without VAP (Restrepo et al, 2010, p. 513).
Analytic Philosophy After researching the relevance, statistics and cost associated with VAP, it is easy to see why hospitals place such a big emphasis on developing bundles to prevent VAP. The research shows that hospitals and patients both benefit from utilizing bundles. The statistics support the analytic theory when it comes to providing patient care and patient outcomes. Many quality improvement projects focus on what works better and what helps decrease the incidence of VAP on their unit. This theory strongly identifies with how hospitals can decrease the mortality rate, decrease costs, and length of stay associated with VAP. As a provider of care it is important to stay up to date with research and to know which intervention is more effective than the other.
Ventilator Bundle Many institutions have adopted the ventilator bundle as a way to decrease the incidences of VAP in their ICUs as a suggestion from the Institute for Healthcare Improvement (IHI). Lawrence and Fulbrook (2011) reviewed ten different studies that implemented the ventilator care bundle and evaluated its’ effectiveness. The bundles that were included in the review consisted of elevation of the head of bed, sedation vacations and readiness to wean, gastric ulcer prevention, and DVT prophylaxis. All studies that were reviewed used those four interventions as a part of their bundle in addition to other policies related to the institution. Of the ten studies the rates of VAP decreased between 34% and 85%, the required time on mechanical ventilation was reduced by an average of four to eight days, and ICU length of stay was decreased by 18% to 39%. The combined research and review shows how important of a difference certain interventions make in caring for patients who require mechanical ventilation. While there are some inconsistencies that skews the data, like compliance, the correlation still remains strong enough to favor the analytic philosophy (pp. 222-227).
Continental Philosophy The analytic philosophy shows how effective ventilator bundles are in VAP, but the continental philosophy helps define VAP more fully. The research that was done all showed that ventilator bundles are useful in preventing VAP, however each study did not produce a consistent rate of decrease in prevention, time on the ventilator, or time in the ICU. This philosophy helps healthcare providers figure out why and if certain interventions are possible in their area of work. While providers need to know which intervention has the best results for their patients, they also need to be aware of the resources or staff that perform these interventions. Being aware of the full picture can change the plan of care.
Delivery of Care and Compliance
Nurses play a major role in implanting the ventilator bundle and patient outcomes. Compliance is a major contributor to the differences in results with the ventilator bundle. Nurses’ perception, time, compliance, education, and attitude all assist in the success of the bundle. Branch-Elliman, Wright, Gillis, and Howell (2013) sent out a survey to 291 nurses in the critical care area to determine their perception of the ventilator bundle, specifically the time required, the impact of the bundle, and their attitude toward preventing VAP. Of the 291 surveys that were emailed, 119 critical care nurses responded. The survey found that the nurses did not feel that the ventilator bundle delayed other patient care nor did patients miss out on other aspects of care due to the bundle. The nurses reported that the bundle did increase their overall workload and increase need for intervention, such as suctioning with mouth care (pp. 357-360).
As part of the ventilator bundle, elevating the head of the bed decreases the chances of VAP. Hiner, Kasuya, Cottingham, and Whitney (2010) wanted to determine clinicians’ knowledge and perception when it came to elevating head of the bed. One hundred and seventy-five participants were asked the following questions: “What is the level of the head of the bed? What head-of-bed elevation is associated with decreased incidence of ventilator-associated pneumonia? When providing care, how do you routinely determine the head-of-bed elevation?” (p. 164). From this study, the researchers learned that the majority of nurses knew what the recommendation was and had the highest percentage, along with respiratory therapist, in accurately determining head of bed elevation. However, 30% of clinicians guessed and 12% either asked the nurse or guessed (pp. 164-166). The two studies help fully define and support the analytic philosophy by further explaining the differences in results among all the studies.
Ways of Knowing Carper’s four ways of knowing for nursing are divided into categories that include: empirics, esthetics, ethics, and personal.
Empirical knowing can be viewed as concrete, cause and effect, or facts from studies. Esthetic knowing helps nurses perceive and want to understand the why. Ethical knowing helps the nurse in determining what is right or wrong, what is should and should not be done, and is based on respect of patients. Lastly, personal knowing can simply be defined as our own experiences, how nurses feel, and it effects the quality of care nurse provide (Brugger and Madison, 2015). The four patterns of knowing can influence a practitioner by examining self to eliminate bias, treat patients equally, remain current on evidence based practices, and seek to understand patients as a whole. Carper’s four ways of knowing can help practitioners identify what their weaknesses are and strive to improve the care provided to patients. McGovern, Lapum, Clune, and Martin (2013) integrated Carper’s four ways of knowing into the simulations for undergraduate nursing students. Their simulations aimed at educating students on experiencing patient care in a clinical sense and experience the art of nursing. Without Carper’s ways of knowing being the fundamental basis of design and delivery, students focused primarily on the physical aspect of care. The design helped developing a relationship and realizing self-bias that could shape interaction (pp. …show more content…
46-49).
Conclusion
Preventing and decreasing the chances of patients acquiring VAP is possible through the ventilator bundle.
There have been many studies done to support the analytical philosophy of this phenomenon of interest (POI) through the ventilator bundle. The continental philosophy does help define the POI more in depth. Through Carper’s ways of knowing, nursing staff who are in direct contact with patients can use the qualitative and quantitative data provided to influence their
care.