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The National Ribat University
Faculty of graduate studies
and scientific research
A Thesis submitted in fulfillment of the requirement for the
Award of the Degree of Doctor of Philosophy in
Medical-Surgical Nursing
By:
Faroq Abdulghani Alshameri
BSc. Nursing science- University of Khartoum
M.Sc. Cardio-thoracic Nursing-University of Medical Sciences and Technology
Supervisor:
Alaadin Hassan Ahmed Professor of medicine – University of Khartoum
2013
ACKNOWLEDGMENT
My heartfelt gratitude to my supervisor Prof. Alaadin
Hassan Ahmed for his encouragement, guidance and
support helped me greatly in the understanding and writing
of this research.
I am greatly appreciative of the Omdurman Military
hospital and the staff who took part in my study, yielding
high response rates.
It is a pleasure to thank the staff of the National Ribat
University, especially my colleagues in faculty of nursing
sciences, for their esteemed support at various stages in this
research.
My regards and blessings to all those who supported me in
any respect throughout the writing of this research
DEDICATION
This work is dedicated to all these
candles that glowed up to
lighten my way To my mother
To my father
To my love
Tom my son and daughter
To my sisters
To my brothers
To my friends
List of Tables Table. NO Title Page.NO
1 Distribution of study subjects (Intervention and control groups)
regarding their demographic background (n=120) 53
2 The difference in the pretest knowledge level among study subjects
(intervention and control group) (n=120) 54
3
Mean of pre-test knowledge scores of participants regarding their
knowledge about Ventilator associated pneumonia prevention
(n=120)
55
4
Overall mean of pre-test knowledge scores for study subjects
(intervention and control group) regarding prevention of VAP
(n=120)
56
5
The difference in the post-test knowledge level among study
subjects (intervention and control group) regarding prevention of
VAP (n=120)
57
6 Mean of post-test Knowledge scores for study subjects
(intervention and control) regarding prevention of VAP (n=120) 58
7
Overall mean of post-test knowledge scores for study subjects
(intervention and control group) regarding prevention of VAP
(n=120)
59
8
The difference in pre and post-test knowledge level for study
subjects (intervention group) to assess the ICU nurses knowledge
regarding VAP prevention (n=60)
60
9 Overall mean of pre and post-test knowledge scores for
(intervention group) subjects regarding prevention of VAP (n=60) 61
10 Mean of pre and post-test Knowledge scores for (intervention
group) subjects regarding Prevention of VAP (n=60) 62
11 The difference in the pre and post-test knowledge level among
(control group) subjects regarding prevention of VAP (n=60) 63
12 Overall mean of pre and post-test knowledge scores for (control
group) subjects regarding prevention of VAP (n=60) 64
13 Mean of pre and post-test Knowledge scores for (control group)
subjects regarding Prevention of VAP (n=60) 65
14
Distribution of subject‟s (intervention and control) performance
compliance with VAP prevention guidelines in initial assessment
(n=120)
66
15
Mean of initial assessment performance compliance scores of study
subjects (intervention and control group) with elements of VAP
prevention (n=120).
67
16 Overall mean of initial assessment performance score for subjects
(intervention and control) regarding VAP prevention (n=120) 68
17
Distribution of subject‟s (intervention and control) performance
compliance with VAP prevention guidelines in final assessment
(n=120)
69
18
Mean of final assessment performance compliance scores of study
subjects (intervention and control) with elements of VAP
prevention (n=120).
70
19 Overall mean of final assessment performance scores for subjects
(intervention and control) regarding VAP prevention (n=120) 71
20
The difference in initial and final assessment of practice
compliance for study subjects (intervention and control group)
when assess the ICU nurses regarding VAP prevention (n=120)
72
21
Mean of initial and final assessment performance compliance
scores for study subjects (intervention and control) with elements
of VAP prevention (n=120).
73
22
Overall mean of initial and final assessment performance scores for
study subjects (intervention and control group) regarding
prevention of VAP (n=120).
74
List of Figures
Page. No. figure title Figure.
No
75 VAP incidence rate comparing for intervention and control group
in Pre and post intervention assessment. 1
List of Abbreviations
AARC American Association for Respiratory Care
CDC Centers for Disease Control and Prevention
CSS Closed Suction System
DA-HAI Device Associated Hospital Acquired Infection
EBP Evidence Based Practice
HAI Hospital Associated Infection
HME Humid Moist Exchangers
ICU Intensive Care Unit
MRSA Methycillin Resistant Staphylococcus Aureus
NHSN National health care safety network
NNIS National Nosocomial Infection Surveillance
PICU Pediatric Intensive Care Unit
RCT Randomized Controlled Trial
SIM Self Instructional Module
STP Structured Teaching Program
VAP Ventilator Associated Pneumonia
Abstract
Background: Ventilator Associated Pneumonia (VAP) is one of the most common hospital
acquired infection and is associated with increased mortality rate. Prevention of VAP is very
important aspect while caring for mechanically ventilator patient. The nurse‟s role in prevention of
VAP is very significant as they provide care to the critically ill patient round the clock.
Objective: The study aims to evaluate the effectiveness of Structured Teaching Program (STP) on
ICU nurses‟ knowledge and practice compliance regarding prevention of VAP.
Methods: A quasi experimental study with comparison groups (intervention and control) with
purposive sampling technique. Information and skill were collected from 120 ICU nurse‟s using
structured knowledge questionnaire and direct observation check list. Structured teaching program
was applied and post-test with final assessment were conducted after 2 weeks using same
questionnaire and check list and analyzing by statistical package for social sciences (SPSS) program
version 20.
Results: the overall mean of pre-test knowledge scores on prevention of VAP was found to be
(17.95 out of 40) for intervention group and (18.5 out of 40) for control group with statically
insignificant difference (p=0.617>0.05), in post-test found to be (32.05 out of 40) for intervention
group and (20.83 out of 40) for control group with statically significant difference (p=0.000<0.05) .
The overall mean of initial assessment for practice compliance was found to be (9.27 out of 20) for
intervention group and (4.97 out of 20) for control group with statically significant difference
(p=0.000<0.05), in final assessment found to be (12.77 out of 20) for intervention group and (5.7
out of 20) for control group with statically significant difference (p=0.000<0.05). The VAP
incidence rate of pre-intervention phase found to be (54.4 cases/1000 ventilator days) for
intervention group and (40.35 cases/1000 ventilator days) for control group. In post-intervention
found to be (39.6 cases/1000 ventilator days) for intervention group and (64.9 cases/1000 ventilator
days) for control group.
Conclusions: Overall findings showed that in pre-intervention there are knowledge deficit and
inadequate practice compliance among ICU nurses‟ regarding prevention of ventilator associated
pneumonia and the structured teaching program was effective in improving their knowledge and
practice compliance which leads to reduce in VAP incidence rate.
Recommendations: Establishing protocols and guidelines for VAP prevention in ICU through plan
for mandatory in-service education and ICU diploma courses in hospital acquired infection,
Continuous professional education programs and training workshops. Further prospective research
in wide range with team of researcher from ICU specialist is needed.
Key words: knowledge, practice compliance, ICU nurses‟ knowledge, Ventilator Associate
Pneumonia (VAP), Structured Teaching Program (STP).
الملخص
انر ذكرطة اشاء رلىد ي اكصر انؼذوي شىػا وأحذ(، VAPاالنرهاب انرئى انصاحة نجهاز انرفص االصطاػ ) : الخلفية
تارذفاع يؼذل انىفاخ. انىلاح ي االنرهاب انرئى انصاحة نجهاز ذوشها كى يصحىبح(، و HAI) انرط ف انطرشف
جاة يهى جذا جة يراػاذه اشاء ذمذى انؼاح نرط انجهاز انرفص االصطاػ. انرفص االصطاػ
يذي وحذج انؼاح انركسج و يرظ( ػه يؼرفح STPفؼانح ترايج انرؼهى انظى ) يذي انذراضح ان ذمى هذفد الهدف:
جهاز انرفص االصطاػ. انرسايهى انؼه فا رؼهك تانىلاح ي االنرهاب انرئى انصاحة ن
ذكىد ػح انذراضح ي ) يجىػح ذذخم " ذجرثح" ، ويجىػح ذحكى( يكىه ي يجىػر: دراضح شثه ذذخهح الطريقة
ونرحمك . يرض ف يجىػح انرحكى( 60يرض ف يجىػح انرذخم و 60( يرض ذى اخرارهى تانطرمح انغرظح )120)
. ذى ذطثك انثرايج انرؼه اضرثاح نماش انجاة انؼرف ولائح رصذ نماش يذي االنرساو انؼهاهذاف انذراضح ذى ذطىر
تاضثىػ ذى ػم االيرحا انهائ نهجاة انؼرف وانرمى انهائ نالنرساو انؼه تاضرخذاو فص االرهاء ي ذطثمهانظى وتؼذ
ثحس ) االضرثا انظى نرمى انؼرفح ولائح انرصذ انثاشر نرمى االنرساو انؼه(. وذى ادواخ انرمى ف انرحهح االون ي ان
. 20( االصذار رلى SPSSذحهم انؼهىياخ انرحصم ػهها تىاضطح ترايج انحسو االحصائح نهؼهىو االجراػح )
ذطثك انثرايج انرؼه( نهىلاح ي االنرهاب انرئى : انرىضط انكه نذرجاخ االيرحا انؼرف االون ) يا لثم النتائج
يغ ػذو ( نجىػح انرحكى 40ي 18.5( نجىػح انرذخم و ) 40ي 17.95انصاحة نجهاز انرفص االصطاػ وجذ اه )
ايج انرؼه( وجذ ، وف االيرحا انهائ ) يا تؼذ ذطثك انثر (p=0.617>0.05)وجىد فارق دانح احصائا ت انجىػر
يغ وجىد فارق دانح احصائا ت انجىػر ( نجىػح انرحكى40ي 20.83( نجىػح انرذخم و ) 40ي 32.05اه )
(p=0.000<0.05)( وجذ اه ) ( نجىػح انرذخم و 20ي 9.27. انرىضط انكه نرمى االنرساو انؼه االون ) يا لثم انرذخم
، ف انرمى انهائ )يا تؼذ (p=0.000<0.05)يغ وجىد فارق دانح احصائا ت انجىػر نجىػح انرحكى ( 20ي 4.97)
يغ وجىد فارق دانح احصائا ت ( نجىػح انرحكى20ي 5.7( نجىػح انرذخم و )20ي 12.77انرذخم( وجذ اه )
انصاحة نجهاز انرفص االصطاػ ف يرحهح يا لثم انرذخم . يؼذل حذوز االنرهاب انرئى(p=0.000<0.05)انجىػر
ىو ذفط ( نجىػح 1000حانح / 40.53ىو ذفط ( نجىػح انرذخم و ) 1000حانح / 54.4) ذطثك انثرايج ( وجذ اه )
ىو 1000حانح / 64.9) ىو ذفط ( نجىػح انرذخم و 1000حانح / 39.6انرحكى. ف يرحهح يا تؼذ انرذخم وجذ اه )
ذفط( نجىػح انرحكى.
هان مص ف انؼرفح وػذو انرساو ػه كاف ي لثم ف يرحهح يا لثم ذطثك انثحس كا : انرائج انكهح اظهرخ اه الخالصة
ذطثك انثرايج اػ . انصاحة نجهاز انرفص االصطيرظ وحذج انؼاح انركسج فا رؼهك تانىلاح ي االنرهاب انرئى
انرؼه انظى كا فؼال ف ذحط يطرىي يؼرفرهى وانرسايهى انؼه يا ادي ف انهاح إن خفط يؼذل حذوز االنرهاب
انرئى ف وحذج انؼاح انركسج.
االصطاػ ف : وظغ تروذىكىالخ ويثادئ ذىجهح نهىلاح ي حذوز االنرهاب انرئى انصاحة نجهاز انرفصالتوصيات
وحذج انؼاح انركسج ي خالل وظغ خطح داخم انؤضطاخ انصحح نهرؼهى االجثار والايح كىرضاخ دتهىو وحذج انؼاح
انركسج ف انىلاح ي انؼذوي انكرطثح ي انطرشفاخ، يىاصهح ترايج انرؼهى انه انطرر يغ الايح ورظ انرذرة انه.
تحىز يطرمثهح اخري ف اطار اوضغ ي لثم يجىػح تحس ذشم كم انؼايه ف وحذج انؼاح انركسج ونص انحاجح ان ػم
انرظ فمط .
: انؼرفح، االنرساو انؼه، يرظ وحذج انؼاح انركسج، االنرهاب انرئى انصاحة نجهاز انرفص مفاتيح الكلمات
االصطاػ، انثرايج انرؼه انظى.
Introduction
Ventilator-associated pneumonia (VAP) is the most common infectious complication among
patients admitted to intensive care units (ICUs), it refers to pneumonia that has developed in
patients who are receiving mechanical ventilation and develop it within 48 to 72 hours after tracheal
intubation(1)
.
VAP represents a common nosocomial complication arising in the ICU, affecting 8 to 20%
of ICU patients and up to 27% of mechanically ventilated patients.(2)
VAP is the leading cause of
hospital-acquired infections in the ICUs.(3)
In 2002, an estimated 250,000 healthcare-associated
pneumonias developed in U.S.A. hospitals and 36,000 of these were associated with deaths. Patients
with mechanically-assisted ventilation have a high risk of developing healthcare-associated
pneumonia. For the year 2010, National Health care Safety Network (NHSN) facilities reported
more than 3,525 VAPs and the incidence for various types of hospital units ranged from 0.0-5.8 per
1,000 ventilator days.(4)
Mortality rate in patients with VAP range from 20 to 50% and may reach
more than 70% when the infection is caused by multi-resistant and invasive pathogens.(5-7)
The incidence of VAP is 37.2 per 1000 ventilation day in developing countries and the
mortality rate for VAP patients was 80%(8)
. VAP is also associated with considerable morbidity,
including prolonged ICU length of stay, prolonged mechanical ventilation, and increased costs of
hospitalization.(6, 9, 10)
A systematic review was conducted to determine the incidence of VAP and its attributable
mortality rate, length of stay and costs. Results indicated that 10% - 20% of patients receiving >48
hrs. of mechanical ventilation will develop VAP(11)
. Critically ill patients who develop VAP appear
to be twice as likely to die compared with similar patients without VAP. Patients with VAP have
significantly longer Intensive Care Unit stay of 6 days. Patients who develop VAP incur in
additional hospital costs(11)
.
The main contributing factor of VAP is microaspiration of oropharyngeal organisms from
around the endotracheal tube‟s cuff into the distal bronchi, which is followed by proliferation of
bacteria and its invasion of lung parenchyma.(12)
Pseudomonas aeruginosa, Klebsiella species, Enterobacter species, and nontypable
Haemophilus influenzae are the most common gram-negative isolates. Staphylococcus aureus,
including the more recently emerged methicillin- resistant strains, has been documented to be
the most common gram-positive isolate.(13)
The lack of gold standard for diagnosis VAP in both adults and children makes an
interpretation of the literature complex. The clinical criteria for the diagnosis of VAP have been
established by CDC. Patients who are mechanically ventilated for more than or equal to 48 hrs.
must have two or more abnormal chest radiographs with at least one of following symptoms: new
or progressive and persistent infiltrate, consolidation, cavitation, and/or pneumatocels to confirm
VAP.(11)
Given the above statistics, it would be safe to conclude that the high incidence, costs of
treatment and the high mortality rates associated with VAP are suggestive of either a gap in
knowledge of VAP or a failure to translate that knowledge into practice by those caring for this
patient population. Healthcare delivery has shifted toward evidence-based practice in recent years
and the goal of evidence-based practice is to improve and provide high quality health care, resulting
in positive patient outcomes.(14)
A number of evidence-based guidelines have been developed in recent years to direct
clinical practice in an attempt to improve patient care, and in particular care of the critically ill.
Specific guidelines have been developed to both prevent VAP and treat it appropriately as soon as
possible. Main preventive strategies include proper positioning, use of sterile equipment and
educational strategies for educating health care personnel regarding prevention of VAP.(15)
Numerous studies exist regarding evidence- based measures for preventing VAP, however,
only a few studies have been performed in recent years to assess the impact of an educational
program on knowledge and its impact on practice in preventing VAP(14, 16)
. Although there is
currently no literature to show a definitive correlation between the use of ventilator bundles and a
decrease in VAP rates, there is strong evidence to suggest a positive association between the
two(17)
. There also remains a deficiency in literature regarding nurses‟ knowledge of VAP and its
preventive measures.
Given the deficiency in current literature regarding direct studies to examine ICU nurses‟
knowledge of VAP, this study will provide an opportunity to examine groups of ICU nurses‟
knowledge before and after an educational program on VAP. The study will also assess the impact
of that educational intervention on nursing practice in preventing VAP.
Justification of study
Mechanical ventilation is one of the major supportive modalities in the intensive care unit.
However it carries risks for complications, ventilator associated pneumonia (VAP) being the most
common one. As lungs are usually amongst the major organs involved in multiple organ failure,
challenge of delivering appropriate ventilation with as little complications as possible intervention
is extremely important(18)
.
To ensure the highest standards of nursing care, nursing practice must be based on a strong
body of scientific knowledge and proper practice. This can be achieved through adherence to the
evidence based guidelines for prevention of ventilator associated pneumonia, ultimately improving
patient outcomes. Improved outcomes will shorten the length of patients‟ ICU stay, and overall
need for hospitalization, as well as benefit the patient financially due to decreased hospital costs.
Hospitals also gain benefits, as they are continually faced with the challenge of providing cost
effective services to patients and communities.
In Sudan, where shortage of nursing staff is evident, skilled and knowledgeable nurses are
extremely important and are needed to make appropriate decisions pertaining to patient care in
order to minimize risks to their patients‟ health and wellbeing. Evidence-based practices should
empower intensive care nurses to make appropriate decisions and prevent poor outcomes in the
recovery of mechanically ventilated patients.
Education plays the key role in the management of patients with VAP. Use of education
program with self-study education modules on nursing care for patients at risk of VAP can
significantly reduces the VAP rate(19, 20)
. Nurses are the key ICU personal, as they provide
continuous care to the patients. Thus, when nurses educated on VAP prevention, they can apply
evidence-based practice, leading to reduced VAP related morbidity and mortality.
The purpose of study
The purpose of this research to evaluate the improvement of the nurse‟s practice after the
application of the educational program provided for prevention of ventilator associated pneumonia
in intensive care unit.
Research Questions
The research questions that the study will address are:
1) What is the baseline knowledge of ICU nurses regarding the basic concepts and
interventions for VAP prevention?
2) What is the impact of nursing education program on ICU nurses‟ knowledge on VAP
prevention?
3) What is the impact of nursing education program on ICU nurses‟ practice compliance with
VAP prevention?
4) How far can the application of nursing education programme for VAP prevention decrease
VAP rate in ICU?
General Objective
To evaluate the effect of nursing educational program of ventilator associated pneumonia on
nursing knowledge and practice in ICU.
The specific objectives of this study are:
1) To assess the existing knowledge regarding prevention of Ventilator Associated Pneumonia
among Intensive Care Unit nurses.
2) To assess the existing practice compliance regarding prevention of Ventilator Associated
Pneumonia among Intensive Care Unit nurses.
3) To measure the existing VAP incidence rate in Intensive care units under study.
4) To evaluate the effectiveness of nursing education programme regarding VAP prevention
on ICU nurse‟s knowledge.
5) To evaluate the effectiveness of nursing education programme regarding VAP prevention
on ICU nurses practice compliance.
6) To measure the effectiveness of nursing education programme on VAP incidence rate in
ICUs under study.
Theoretical Underpinnings
Nursing theories often provide the basis of nursing practice by generating further knowledge
consistent with everyday observations. A useful theory makes logical assumptions about a
behaviour, health problem, or target population(21)
.
A well-defined theory is therefore of paramount significance in guiding nursing practice,
especially if its application results in better patient care, enhanced professional status and guidance
for research and evidence based practice.(21)
This study‟s theoretical framework is guided by Knowles, andragogy model for adult
learning. Learning is a dynamic, continuous process that involves behaviour alteration in order to
produce change. Adult learning principles provide a good foundation for effective nursing
education especially in the ICU setting where there are significant levels of stress and strict time
constraints. According to Knowles, in order for learning to be effective, the adult must be ready and
willing to learn. Adults have a strong sense of self-concept, are goal-oriented learners, and they like
to make their own decisions. Any educational technique used in adult learning should emphasize
the practical application of information whilst fully engaging the learner in the process. The manner
in which adults learn and the techniques employed in adult education are different from those used
with children.(22)
Knowles outlined six conditions for optimal learning within the adult population. He noted
that adults learn best when they (1) are motivated; (2) can apply or use what they have learned to
their current situation; (3) have a reason for learning; (4) are self-directed; assuming that with or
without the help of other people, a person is takes the initiative to identify their learning needs,
design some goals for learning, select and apply appropriate learning strategies, and finally evaluate
learning outcomes. (5) draw from past experiences; and (6) use a task, problem, or life-centred
approach.(22)
Nurses must have a good understanding of the adult learning theory in order to incorporate
its concepts into the development and implementation of a plan of care that reduces risks while
improving quality of care to the patients. This framework will be utilized in this study to design an
educational program that will be used to meet the learning needs of the participants.
Based on Knowles learning theory, the assumption is that the nurses in this study will be
motivated to apply knowledge from the education program to improve practice.
Operational Definitions
Andragogy
“The art and science of helping adults learn”(23)
Learning
A change in human disposition or capability over a period of time, often represented by a change in
behaviour(24)
.
Structured teaching programme
In this study, it refers to systematically organized teaching programme prepared by the investigator
for Intensive Care Unit nurses regarding prevention of Ventilator Associated Pneumonia.
Knowledge
In this study, it refers to the correct responses of nurses to the structured questionnaire regarding
prevention of Ventilator Associated Pneumonia.
Prevention
In this study, it refers to precautionary measures taken by nurses to avoid Ventilator Associated
Pneumonia.
Effectiveness
In this study, it refers to significant gain in knowledge and practice compliance of nurses regarding
prevention of ventilator associated pneumonia as determined by significant differences in pre-test
and post-test knowledge scores and practice compliance assessed by structured knowledge
questionnaire and direct observation check list.
Pneumonia
An acute inflammation of the lung parenchyma that is caused by an infectious agent leading to
alveolar consolidation(25)
.
Nosocomial Pneumonia
Pneumonia that is acquired while a patient is inside the hospital.(25)
Ventilator-Associated Pneumonia
A nosocomial pneumonia in a patient on mechanical ventilator support by endotracheal tube or
tracheostomy for more than 48 hours(26)
.
Bundle
“A group of interventions related to a disease process that, when executed together, result in better
outcomes than when implemented individually”(27)
.
Hypotheses
Research Hypothesis
H01- There will be no difference between pre and post-test mean knowledge scores
regarding prevention of Ventilator Associated Pneumonia among Intensive Care Unit nurses in
intervention group at selected hospitals.
H11- There will be a significant difference between pre and post-test mean knowledge scores
regarding prevention of Ventilator Associated Pneumonia among Intensive Care Unit nurses in
intervention group at selected hospitals.
H02- There will be no difference between pre and post-test mean compliance practice scores
regarding prevention of Ventilator Associated Pneumonia among Intensive Care Unit nurses in
intervention group at selected hospitals.
H12- There will be a significant difference between pre and post-test mean compliance
practice scores regarding prevention of Ventilator Associated Pneumonia among Intensive Care
Unit nurses in intervention group at selected hospitals.
H03- There will be no difference between pre intervention and post intervention VAP
incidence rate in intervention group at selected hospitals.
H13- There will be a significant difference between pre intervention and post intervention
VAP incidence rate in intervention group at selected hospitals.
LITERATURE REVIEW
VAP and other key words relating to the research have already been defined. Knowledge
relating to preventive measures for VAP is continuously developing and expanding. Nursing
knowledge in the clinical setting also needs to grow. The literature reviewed suggests that either a
gap in nursing knowledge of VAP or a failure to translate knowledge into practice may augment the
development of VAP among mechanically ventilated patients. An evaluation of nursing knowledge,
practice compliance and application of current research into clinical setting is an important
component for achieving excellence and quality care delivery to patients.
Reviewing the literature is of particular relevance and importance in the study of VAP. VAP
is associated with high costs, high morbidity and mortality rates. This chapter will review what is
currently known through research about VAP and existing bundles of care to prevent it. Although
the literature reviewed for this study yielded numerous studies assessing nurses‟ knowledge and
practice of VAP prevention, most if not all of these studies addressed single elements and not
specific VAP bundles.
A full understanding of VAP is important when considering the assessment and caring for
the ventilated patient.
2.1 Background:
2.1.1 PATHOGENESIS OF VAP
Mechanical ventilation has been a mainstay of both adult and pediatric critical care for
almost half a century(28)
. Along with other various treatment approaches in the ICU‟s, there are
many intricacies associated with mechanical ventilation as a treatment approach. These
complications include, but are not limited to, lung trauma from large pressure volumes, oxygen
toxicity, and increased risk of aspiration and lung colonization by bacteria, which often results in
pneumonia(29)
.
VAP can be attributed to a broad spectrum of bacterial pathogens. These pathogens range
from gram-negative bacilli, gram-positive cocci, to methicillin resistant staphylococcus aureus(30)
.
These bacterial pathogens migrate into the respiratory system primarily through colonization of the
oral cavity, trachea, sinuses or stomach. If left untreated, the bacteria can further migrate into the
lower airways through aspiration. The oropharyngeal flora changes from the usual gram-positive
streptococci to mostly gram-negative organisms that are more destructive within 48 hours of
intubation. When this happens, a diagnosis of early onset VAP is made. Late onset VAP is when the
infection occurs after 4 days of mechanical ventilation(31)
.
There are numerous risk factors associated with increasing the chances of developing of
VAP in the mechanically ventilated patient. Colonization of the oropharynx, with subsequent
aspiration of secretions into the lower respiratory system is the single most important cause for
VAP (32-34)
. In addition, the presence of an endotracheal tube provides a direct route for colonized
bacteria to enter the lower respiratory tract. Because oral and upper airway secretions can pool
above the endotracheal tube cuff and form a biofilm which may harbor large amounts of bacteria,
bacteria can be easily transmitted into the lower respiratory airways during periods of ventilator-
induced breaths (35)
.
Mechanically ventilated patients often require sedation in order to facilitate adequate
ventilation, decrease work of breathing, discomfort, and stress. Sedation however decreases the
patient‟s ability to clear oropharyngeal secretions by depressing both the gag and cough reflexes.
Again, this predisposes them to aspiration and colonization of the lungs by bacteria(30)
.
A commonly favored practice in the ICU is early enteral nutrition. Nutritional needs of the
mechanically ventilated patient are often met via gastric tube feedings. This practice certainly
contributes to improved patient outcomes, while providing significant prophylaxis against the
development of gastric stress ulcers(36)
. Although this route for providing nutrition to the ventilated
patient is preferred over the intravenous route, it often poses complications with aspiration
especially when the patient assumes a supine position while receiving feedings(37)
.
Recommendations are yet to be established by the CDC regarding the frequency for checking
residual volumes or modifications in feeding procedures to prevent VAP (14)
.
Intubated patients are often prescribed gastric ulcer prophylaxis, due to the high risk of
bleeding secondary to gastric ulceration in critically ill patients. Gastric alkalinization with the use
of H2 receptor blockers is a significant risk factor for VAP (38)
. Other factors increasing
susceptibility to VAP include poor oral and nasal hygiene, poor infection control measures during
endotracheal suctioning, extended periods of intubation, poor hand washing practices, and supine or
semi-recumbent position especially when the patient is receiving enteral feedings. ICU nurses who
work with mechanically ventilated patients need to adopt and implement strategies aimed at
preventing VAP (31, 34)
.
2.1.2 VAP Risk Factors
The single largest VAP risk factor is the endotracheal tube. Because mechanical ventilator
support cannot be performed without the endotracheal tube (or other artificial airway), it is a
necessary evil. The endotracheal tube provides a direct passageway into the lungs, bypassing many
“natural protection” mechanisms. The endotracheal tube increases the risk for VAP by:(39)
• preventing cough (the patients natural defense)
• preventing upper airway filtering
• preventing upper airway humidification
• inhibiting epiglottic and upper airway reflexes
• inhibiting cilliary transport by the epithelium
• acting as a direct conduit into the lungs for airborne pathogens
• potentially acting as a reservoir for pathogens by providing a place for biofilm to form
• having a cuff which provides a place for secretions to “pool” in the hypoglottic area
• initiating a foreign body reaction, interfering with the local immune response
Host or patient risk factors include:(40)
• age of 65 or more
• underlying chronic illness (e.g. Chronic Obstructive Pulmonary Disease (COPD),
emphysema, asthma)
• immunosuppression
• depressed consciousness
• thoracic or abdominal surgery
• previous antibiotic therapy
• previous pneumonia or remote infection
Other device treatment and personnel related risk factors include:(40-43)
• nasogastric tube placement
• bolus enteral feeding
• gastric over-distension
• stress ulcer treatment
• supine patient position
• nasal intubation route
• instillation of normal saline
• understaffing
• nonconformance to hand washing protocol
• indiscriminate use of antibiotics
• lack of training in VAP prevention
2.1.3 DIAGNOSIS
The accurate diagnosis of VAP is difficult and controversial. Some studies have advocated
for a diagnosis based on clinical and radiological findings(44)
, while others, have proposed for more
invasive testing such as quantitative bronchoscopy samples which account for a more accurate
diagnosis(45)
. In addition to new or worsening lung infiltrates on the chest x-ray, other clinical
findings such as fever, leukocytosis, and purulent secretions are often the mainstay for the diagnosis
of VAP(46)
. Because of VAP‟s high morbidity and mortality rates, to reaching a universal criterion
for diagnosis should not be the main focus; instead, emphasis should be placed on identifying and
implementing preventative strategies. Early intervention and treatment are critical to reducing
infection rates(47)
.
2.1.4 VAP prevention Strategies
Three Major VAP Prevention Principles
Ventilator associated pneumonia can be reduced with the implementation of a Best Practices
program with these three factors or principles: (39)
• Staff education
• Colonization reduction
• Aspiration avoidance
Staff Education
To change the VAP rate in any given ICU, a change in human behavior is needed. Like all
behavioral changes, education and reinforcement is required. Education is therefore the first step in
a VAP best practice program, followed by reduction of oropharyngeal colonization and reduction of
aspiration. Education of the staff about VAP is absolutely necessary for a successful program. The
implementation of all three strategies are required to maximally lower the VAP rate over the long
term.(48)
Colonization Reduction
Colonized secretions reside in both the gastrointestinal tract and oropharynx. Basic nursing
care principles are the first line of defense. Incorporating the following key points and practices can
reduce colonization. (40)
• Hand washing
The practice of hand washing and the wearing of gowns and gloves are basic and quite
possibly the most important actions taken for reducing colonization. Methicillin Resistant
Staphylococcus aureus (MRSA) is commonly spread by caregivers‟ hands.Gloves and gowns have
been shown to be effective in preventing the nosocomial spread of antibiotic resistant bacteria
including Vancomycin-resistant enterococci (VRE) as well as MRSA.(42)
• Oral Hygiene
The importance of patient oral and nasal hygiene is often overlooked, although it is one of
the most basic of nursing interventions. Sole found that less than half of the 27 surveyed sites (48%)
had written policies for oral care of intubated patients, and even fewer (37%) had oral suction
policies.(49)
The use of closed suction systems (CSS) may contribute to the inattention paid to oral
care in that oral suctioning is an integral part of traditional open suction procedures. Yet, it is
widely recognized that the mouth is a virtual garden of normal bacterial flora and pathogenic
organisms. Both Kollef and Kunis have advocated chlorhexidine oral rinse to reduce the oral
bacterial load; however, its regular use may lead to chlorhexidine resistant organisms. Several
studies have shown that oral decontamination is an effective method for reducing VAP.(50-52)
• Common Suction Protocol
Standardized, common endotracheal suction protocols, in which everyone suctions the same
way, are of central importance in the reduction of colonization. The use of a CSS should be part of a
VAP reduction program.(42, 53)
It has been shown that a focused education program using a common
protocol actually lowered the infection rate and substantially reduced the associated costs and
morbidity.(19)
• Closed Suction System (CSS)
The CSS provides a barrier to separate the contaminated (colonized) catheter from the
caregiver and other patients. One study has shown a significant reduction in the VAP rate with
closed suctioning.(54)
The recently revised clinical practice guideline published by the American
Association for Respiratory Care (AARC) recommends the use of the CSS as part of a VAP
prevention strategy. In addition to reducing the risk of microbial contamination as compared to the
open suctioning technique, closed suctioning permits continuous ventilation reducing respiratory
stress and vulnerability.(53)
Change out timing of CSS at 24 hours is presently being debated with at least two studies.(55,
56) Another study has shown increased colonization when extending the use of the CSS longer than
the recommendations stated on the label.(57)
The length of time a CSS can be safely used beyond
that which is indicated in the Directions for Use has not been determined.(53)
• Saline Lavage
Research does not support the use of saline lavage. Saline instillation in either the
endotracheal tube or the tracheostomy tube is controversial and may even be detrimental to the
patient.(58)
One study concludes that bacteria may be dislodged from the catheter and endotracheal
tube into the lung during the procedure while simultaneously causing oxygen desaturation.(59)
However, some textbooks still recommend the use of saline sparingly for thick secretions.(60)
• Closed Suction System Rinse Protocol
Saline instillation into the patient‟s artificial airway as discussed above is controversial and
not supported by the literature, but this is not to say that saline rinsing the CSS after the suction
episode should not be done. Thorough and complete rinsing of the CSS with sterile saline after the
suction is of utmost importance when attempting to minimize colonization. Interestingly, Sole
found that there is a difference in practice between nurses and respiratory therapists when rinsing
the CSS.(49)
The optimal method of cleansing the system is to follow the Directions for Use
provided by the manufacturer.(39)
• Maintain Closed Circuit
Obviously reducing the opportunity for contamination to occur from outside pathogens will
reduce the colonization within the circuit; therefore, maintaining a closed circuit is emphasized by
the AARC(43)
and others.(61)
• Use Closed Condensation Traps
Condensation traps permit drainage without requiring the circuit to be opened, thus
preventing external contamination. When using active humidification, the use of condensation traps
in the ventilator circuit which do not require opening to be emptied is recommended by Zack.(19)
This also reduces manipulation of the tubing thus reducing contaminated colonization dump into the
airways. Opening the circuit for other procedures should be avoided.(53)
• Stress Ulcer Prophylaxis
All patients receiving mechanical ventilator support are susceptible to gastrointestinal
hemorrhage (stress ulcer).(42)
Prophylactic agents such as antacids and histamine type-2 antagonists
are often used to protectively reduce peptic acidity. In this changed pH environment, the stomach
may become colonized with pathogenic bacteria. As gastric volume is increased, micro-aspiration
may also occur at any time. Both factors will increase the opportunity for VAP to occur.
Alternatively, sulcralfate has been advocated because it does not decrease the acidity or increase
gastric volume and can prevent bleeding. (48)
• Selective Decontamination of the Digestive Tract (SDD)
If microorganisms survive the peptic environment, regurgitation or reflux can place bacteria
into the esophagus and upper airway. A procedure more widely used in Europe,(43)
administration of
topical antibiotics (Tobramycin, Polymixin B and others) via a paste or solution into the mouth and
stomach with the goal of reducing the colonization and subsequent VAP, is controversial. However,
neither of two meta-analyses of the research literature showed significant difference in mortality
when the data was corrected for the systemic administration of antibiotics.(62)
Furthermore, the use
of SDD has been associated with emergence of antibiotic-resistant strains of bacteria -- a worldwide
problem which is on the increase. (62)
Aspiration Reduction or Prevention
The pathogenesis of VAP involves micro-aspiration of oropharyngeal and/or gastric
secretions.(63)
Any intervention which reduces the opportunity for aspiration will reduce the
opportunity for VAP. Many of these interventions are simple and cost efficient. Key points for
reducing or preventing aspiration include, but are not limited to, the following:(39)
• Regular Oral Suction and Hygiene
As mentioned in the oral hygiene section above, oral care which includes suctioning is
widely recognized as a major preventive strategy, yet actual practices vary widely and do not
always reflect current research.(49, 64)
The CDC guideline, “Guidelines for Preventing Health-Care
Associated Pneumonia, 2003”, recommends oral suction as a routine prior to extubation.(65)
In
addition, Zack included oral hygiene in the educational program which reduced VAP by 57.6% in a
hospital which has 5 intensive care units.(19)
• Subglottic Suction
The endotracheal tube prevents glottic closure. As a result, the patient is unable to cough
and remove secretions in a natural way. However, accumulation or pooling of oropharyngeal
secretions above the endotracheal tube cuff occurs and then these fluids can be aspirated. Removal
of these secretions by suction can reduce the risk of aspiration and may be the most cost effective
and safe intervention.(66)
Four studies have shown subglottic suction to be safe and effective,(66-69)
while only one study showed no difference in colonization.(70)
• Minimize Endotracheal Tube Manipulation and Maintain Cuff Pressure
Cuffed endotracheal tubes are essential in adults when positive pressure ventilation is used.
The correct pressure within the cuff is critical to prevent aspiration around the cuff yet maintain
ventilation and adequate capillary perfusion of the contacted mucosa.(71)
The ideal cuff pressure has
not been established; however, most authors agree that the cuff should be maintained at or below 20
mm/Hg as one study has shown that VAP is increased by 2.5 times if the cuff pressure is allowed to
go below 20 mm/Hg.(49)
Presumably, pathogenic laden secretions are able to migrate between the
cuff and tracheal wall through minute channels which may be created when the pressure drops and
the cuff is manipulated. Therefore, cuff pressure should be measured and recorded on a regular
basis.(40, 49, 71)
Also, when the tube is repositioned, oral care and subglottic suction should be
performed to reduce disruption and aspiration of colonized bacteria. Unnecessary manipulation of
the tube should be avoided.(40)
• Reverse Trendelenberg‟s (Head Up) Position
Supine body position is a risk factor for VAP. Elevation of the head of the bed to 30 degrees
is strongly supported as a preventive strategy that lowers the risk of aspiration.(72)
Semi-recumbent
(elevation of head above 30 degrees) position is low cost, and effective.(63)
Routine (standing)
orders to keep all mechanically ventilated patients in the semi-recumbent position can be cost
effective but will require an education program for both nurses and physicians to ensure
compliance.(73)
• Post-pyloric Feeding
When gastric feeding tubes are placed, the gastroesophageal (cardiac) sphincter is violated
which can cause or contribute to reflux. The feeding tube is yet another PVC tube transcending the
oropharynx, which can provide a route for microbial access and colonization. Alternatively,
delivering the feeding solution via percutaneous enteral gastric tube into the small bowel (post
pyloric) has several advantages: reduction in gastroesophageal regurgitation, increased nutrient
delivery, shorter feeding time, and a lower VAP rate.(74)
In addition, continuous rather than bolus
feeding is better tolerated by the patient to keep the stomach from
becoming over distended and preserve peptic acidity at levels lethal to most bacteria.(40)
The
optimal approach for providing nutrition to mechanically ventilated patients is yet undefined;
however, small bowel feeding is associated with an overall reduction of pneumonia.(48)
• Early Extubation
Because the occurrence of VAP increases with the length of mechanical ventilation,(41)
it is
important to wean the patient off the system as soon as clinically feasible.(40, 42)
Furthermore,
premature or accidental extubation prevention strategies are important as reintubation will increase
the risk of aspiration.(39)
2.1.4 CURRENT PROTOCOLS/BUNDLES TO PREVENT VAP
Bundled strategies for preventing VAP were developed in order to promote the delivery of
evidence-based care in a more standardized and deliberated fashion(75)
. A bundle of care is defined
as “individual interventions or best practices for a specific disease process that when grouped
together have an even greater positive impact on the patient outcome”. Bundled practices correlate
with a significant reduction in VAP(76)
.
Numerous bundles of care have been documented in literature. These bundles include
anywhere from sepsis bundles, cardiovascular disease risk reduction bundles, infection prevention
and VAP bundles(77-79)
. Ventilator bundles are among a list of those that have been effective in
improving compliance to changes in clinical nurses‟ practice and consequently a reduction in the
incidence of VAP. Lawrence and Fulbrook, noted that among all the known care bundles, the
ventilator care bundle is the most widely implemented(17)
.
Based on the risk factors contributing to the development of VAP outlined earlier in this
literature review, ventilator bundles have been put in place in hospitals around the world. In 2004,
the Canadian Critical Care Trials group developed guidelines to prevent VAP using bundles of care.
Other organizations have followed suit in issuing guidelines to prevent VAP. In 2004, the
American Association of Critical Care Nurses (AACN) issued the VAP practice alert. Their
guidelines included head of the bed elevation between 30 and 45 degrees, continuous aspiration of
sub glottis secretions and minimal changes of the ventilator circuit. The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) also developed a ventilator bundle composed
of head of the bed elevation, daily weaning trials from sedation, gastric ulcer and deep vein
thrombosis prophylaxis(80)
.
Significant reduction in the incidence of VAP with strict adherence to the bundles has been
documented (81)
. Although these ventilator bundles are different from one hospital to another, use of
these bundles has yielded substantial success in reducing the incidence of VAP (82)
. The most
commonly used ventilator bundles are comprised of interventions for peptic ulcer prevention, deep
vein thrombosis prophylaxis, head of the bed elevation and sedation vacation(83)
. In 2003 the US
Centers for Disease Control and Prevention provided recommendations for nursing actions to
prevent VAP. These recommendations include head of the bed elevation to at least thirty degrees if
not contraindicated, oral care, hand washing and changing the ventilator circuit when it is visibly
soiled(84)
.
The three elements of the ventilator bundle discussed in this literature review are: head of
bed elevation at least 30 degrees, if there are no contraindications, oral decontamination, and hand
washing with each patient contact. These guidelines are part of the recommended list put in place
by the CDC since 2003.
Head of the Bed Elevation
Head of the bed elevation is a simple and cost-free intervention, which has been proven to
reduce the risks of VAP. Benefits of elevating the head of the bed are well documented. Wip and
Napolitano (2009) noted that head of the bed elevation to at least 30 degrees is the single most
important element that is directly associated with a reduction in VAP(85)
. Vincent (2004) also noted
that the semi recumbent position facilitates easy diaphragmatic descent, better ventilation and a
decreased risk of aspiration(86)
.
This intervention is relatively easy to implement given the special electronic beds found in
virtually all ICU units. For the most part, it is a matter of pushing a button on a bed in order to
elevate the head of the bed. Previous literature indicated the significance of non-adherence with
rates up to 50% among ICU nurses(87, 88)
. Wolken, Woodruff, Smith, Albert, and Douglas (2012)
conducted a study in a 24-bed medical ICU at a 477-bed university teaching hospital in Denver to
evaluate head of bed elevation adherence over a 7-month period in 2007. In this study, three
hundred and thirteen patients were monitored for a total of 1,373 ventilator days. This study showed
a 24% non-adherence rate for head of the bed elevation in mechanically ventilated patients at this
hospital(89)
.
In an earlier study of 170 randomly selected ICU patients by Grap, Munro, Bryant, and
Ashtiani, (2003), results showed a mean backrest elevation of 19 degrees for patients. Almost 70%
of the patients in this study were found to be supine with mechanically ventilated patients having a
lower backrest elevation than non-ventilated patients. Findings from these studies strongly suggest a
gap in knowledge or failure to follow guidelines regarding the importance of head elevation in
preventing VAP(90)
.
Oral Decontamination
Pathogens responsible for VAP are often located in the oral mucosa. Oral hygiene plays a
significant role in preventing nosocomial infections. If performed in a timely and consistent
manner, good oral care practices can reduce the number of bacteria in the oral cavity thereby
reducing risks of lung colonization and ultimately the development of VAP(91)
. Munro and Grap
(2004) also noted “Reducing the number of microorganisms in the mouth reduces the pool of
organisms available for translocation to and colonization of the lung”(92)
. In a randomized controlled
trial study at a university hospital in Bangkok, Thailand, the use of 2% chlorhexidine solution for
oral decontamination had a VAP incidence of 4.9% compared to 11.9% in the control group(93)
.
Chan and Hui-Ling (2010) conducted a descriptive cross-sectional study in Singapore in
order to assess local nurses‟ knowledge of oral care of the critically ill patient. In that study, only
29.3% of the 244 nurse participants indicated that good oral care significantly impacts patients‟
outcomes. 33.7% indicated that they did not have adequate training regarding proper oral care
practices for the mechanically ventilated patient. Additionally 65.8% of the total participants also
indicated an essential need to attend a proper training session on oral care in addition to the need for
more information and education on “research proven oral care standards.” Results of Chan and Hui-
Ling‟s study showed that a majority of Singapore nurses working in the critical care setting lacked
or had outdated knowledge regarding good oral care practices for the ventilated patient hence they
were ill equipped to meet the oral hygiene demands of these patients(91)
.
In the United States, a multisite study of oral care practices by Cutler and Davis (2005)
showed that over 50% of the hospitals in the country have not established specific oral care
protocols for mechanically ventilated patients(94)
. In the United Kingdom, results from a survey by
Sedwick et al. (2012), also revealed that only 56% of hospitals in the United Kingdom had
established oral care protocol for their hospitalized patients(95)
.
Hand Washing
Improper hand washing techniques, which result in the cross-contamination of patients, have
been identified as the biggest nurse-related risk factor for VAP(44)
. Nurses do not always adhere to
proper hand washing guidelines, although their compliance rate is higher than physicians‟ 73.9% vs.
52.5% for physicians. Current studies also show that if at all they do, nurses wash their hands more
after the completion of a procedure than before touching a patient(96)
.
Hand decontamination before and after patient contact, is one of the important measures to
reduce the spread of germs. Hand hygiene includes one of the following: washing hands with soap
and water if there is visible dirt or soiling with body fluids or using an alcohol-based antiseptic for
in the absence of soiling.
In a recent study on hand washing practices among 1200 ICU nurses, Sedwick et al. (2012)
found that only 82% of nurses washed their hands between patient care. This translates to a
noncompliance rate of 18% with hand hygiene practices when caring for patients(95)
. Creedon
(2006) also noted similar results in an observational study to assess compliance with of 73
healthcare workers with hand washing after implementing a multifaceted hand hygiene program. A
32% increase in compliance was noted, again translating to about 83% conformity(97)
.
2.2.1. STUDIES RELATED TO INCIDENCE, PREVALENCE AND ETIOLOGY OF
VENTILATOR ASSOCIATED PNEUMONIA.
A quasi experimental study was conducted in an ICU of Brazil to examine the effect of a
series of interventions to reduce the incidence of Ventilator Associated Pneumonia. It consisted of 3
phase interventions. Phase 1 consisted of some evidence based practices, phase 2 consisted of same
interventions and in phase 3, same interventions were continued with oral decontamination with
chlorhexidine and aspiration of subglottic secretions. Study findings revealed that, incidence of
VAP were 16.4% in phase 1, 15% in phase 2 and 10.4% in phase 3. They concluded that, reducing
VAP to zero is a complex process that involves multiple interventions.(98)
A prospective study was conducted at Spain to ascertain the frequency, risk factors and
causes of early and late onset VAP in ICU. Study consisted of all patients on mechanical ventilator
for more than 48 hours. Results of the study revealed that, incidence of VAP were 20.31 per 1000
patient days. Pathogens most commonly isolated were, Staphylococcus aureus and Pseudomonas
aeruginosa in early onset and Pseudomonas species in late onset VAP. Study concluded that, risk of
developing late onset versus early onset VAP was twice as great in post operative patients.(99)
A randomized clinical trial was conducted in an intensive care unit of county hospital to
investigate the incidence of VAP associated with enteral feeding. The study included 44
endotrachealy intubated children followed up for a period of one year. Results of the study revealed
that the risk of developing VAP with enteral feeding was 15%.(100)
A descriptive study was conducted in a Pediatric hospital of south Africa, to obtain a
preliminary etiological factor associated with VAP. The study consisted of 230 children admitted in
PICU over a period of 18 months. Broncho alveolar lavage was conducted to diagnose VAP. The
study concluded that, Acinetobacter was the most common VAP pathogen, followed by Klebsiella
and Staphylococcus aureus.(101)
A cross sectional study was conducted in MICU of Children‟s hospital of Lahore to
determine the frequency of VAP and identify associated factors of VAP. Of the 93 mechanically
ventilated children in the study, 16 developed VAP and 46% were less than 1 year age. The results
of the study revealed that frequency of VAP was 17%. Factors associated with VAP were: age less
than 1 year, unplanned intubation and continuous sedation.(102)
A study was conducted in the ICU of a hospital at Turkey to assess the incidence and
etiology of VAP and resistance pattern of gram negative organisms. VAP was diagnosed with the
help of CDC criteria for a period of 2 years. Results of the study revealed that, VAP incidence rate
was 22.6 per 1000 ventilator days. Most frequently isolated pathogens were, Acinetobacter,
pseudomonas, and MRSA. 90% of Acinetobacter isolates were resistant to ceftazidime, 32% to
imipenem and 80% to ciprofloxacin.(103)
An epidemiologic surveillance program was established in Saudi Arabia as a joint project
between ICU and Infection Prevention and Control Department to regularly report VAP rates to
guide evidence-based VAP preventive strategies. VAP cases were diagnosed according to
predefined criteria. Of 2,812 ventilated patients, 433 (15.4%) developed VAP corresponding to 15.9
episodes per 1,000 ventilator-days. The rate decreased from 19.1 in 2003 to 6.3 per 1,000 ventilator-
days in 2009. On multivariate analysis, VAP was associated with accidental extubation trauma
versus medical diagnosis, chronic obstructive pulmonary disease and neuromuscular blockade.(104)
2.2.2 STUDIES RELATED TO KNOWLEDGE and PRACTICE COMPLIANCE OF
NURSES REGARDING PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA.
A survey was conducted to determine ICU nurses knowledge of EBP for the prevention of
VAP. Questionnaires were distributed to nurses. Results of the study revealed that only 20% of
nurses knew that ventilator circuits should be changed once weekly and only 60% nurses knew that
subglottic drainage of secretions would reduce VAP. At the end of the study they concluded that,
nurses lack knowledge regarding recommendations for VAP prevention and continuing education
would help to improve EBP.(105)
A descriptive study was conducted in Italy to evaluate nurses knowledge regarding
prevention of VAP. The sample included 106 nurses. They were given a questionnaire, listing 21
non pharmacological strategies for the prevention of VAP. Results of the study revealed that 22.6%
nurses had satisfactory knowledge, 54.8% had poor knowledge, 80.9% said that they applied one or
more strategy and 17.9% had applied none. They concluded that, VAP preventive strategies are
widely applied by nurses but not in a responsible and informed manner.(106)
A study was conducted among ICU nurses of Europe to assess their knowledge regarding
prevention of VAP. A validated multiple-choice questionnaire was distributed. The average score
was 45.1%. 55% of respondents knew that the oral route is recommended for intubation; 35% knew
that ventilator circuits should be changed for each new patient; 38% knew that HME were the
recommended humidifier type, but only 21% knew that these should be changed once weekly;
closed suctioning systems were recommended by 46%, and 18% knew that these must be changed
for each new patient only; 51% and 57%, respectively, recognized that subglottic drainage and
kinetic beds reduce VAP incidence. Most (85%) knew that semi-recumbent positioning prevents
VAP.(107)
A study was conducted to assess the knowledge of and compliance with guidelines for
prevention of VAP among physicians, nurses, and students in ICU. All ICU HCW were invited to
complete a 20-point questionnaire. Personal knowledge and daily practice were scored from 0 to 10
points. 54 physicians, 108 nurses, and 27 students participated in the study. The median scores for
daily clinical practice for physicians and nurses were 5 (4-6) and 4 (3-5), respectively. HCWs with
more than 1 year of ICU experience scored significantly better in personal knowledge than those
with less experience.(108)
A descriptive study conducted by Ali N, in Cairo University Hospital, Egypt (2013) the aim
of study was to assess the critical care nurses knowledge and compliance with VAP prevention
bundle. A convenience sample of 45 critical care nurses was recruited from different critical care
units, the data collected by validated 20 items questionnaire and direct observational check list. The
results of 20 items question revealed unsatisfactory knowledge scores (mean = 7.46 ± 2.37) and
most of the nurses were not compliance with VAP prevention bundle practice ( average mean= 8.62
± 7.9 out of 29) and there‟s no specific protocol follow for VAP prevention.(109)
A descriptive study conducted by Gomes V, in South Africa, Johannesburg, (2010), to
determine the knowledge of nurses working in ICU with aspect of evidence based guidelines for
prevention of VAP. Included 83 nurses, found that; the knowledge of ICU nurses lacking in the
evidence based guidelines for VAP prevention. Of the 83 participants, 18 of them (21.6%) achieved
a pass mark consider to have adequate knowledge, and 65 (78.4%) didn‟t achieved a pass mark
consider to have inadequate knowledge and the mean scores of participants was (4.25 ± 1.5).(110)
A descriptive study conducted by Al-Khadir M, in Al-Shaab teaching Hospital, Sudan
(2012), to assess the level of ICU nurses knowledge and practice regarding VAP guidelines,
included 40 ICU nurses, found that; 25% of participants had poor knowledge level, 57.5% of them
had fair knowledge level and 17.5% of them had good knowledge level. Regarding practice level
found that; 42.5% of participants had fair practice level, 32.5% poor practice level and 2.5% of
them had good practice.(111)
A descriptive study conducted in major governmental hospitals in Sudan by Osman M,
(2014) to assess the nurses‟ knowledge and practice regarding application of international
guidelines for VAP prevention, included 140 ICU nurses found that; the mean percentage for total
knowledge (42.8%) and regarding practice compliance found poor practice compliance (42%).(112)
A descriptive study conducted by AlKhatib M, in Lebanon (2010) to evaluate knowledge of
critical care provider (physician, nurses and respiratory therapist) in the ICU. About evidence based
guidelines for VAP prevention. Found that; the mean total scores of physician, nurses and
respiratory physiotherapists were 80.2%.78.1% and 80.5% respectively with no significant between
them.(113)
2.2.3. STUDIES RELATED TO STRATEGIES FOR THE PREVENTION OF
VENTILATOR ASSOCIATED PNEUMONIA.
A randomized controlled trial was conducted at Netherlands to identify the effectiveness of
probiotics and antibiotics in the prevention of VAP. The study consisted of 2 groups. Results of the
study revealed that selective decontamination of digestive tract (SDD) and selective oral
decontamination (SOD) using antibiotics were effective in reducing the incidence of VAP.(114)
A literature search was conducted in UK to determine the role of chlorhexidine and tooth
brushing in the prevention of VAP. It consisted of 6 databases and 8 studies that met the criteria.
Findings of the study revealed that chlorhexidine was successful in reducing VAP. At the end of the
study they concluded that, using a combination of chlorhexidine and colistin was more efficient but
use of tooth brush in reducing VAP was inconsistent.(115)
An experimental study was conducted at KLE institute, Belgaum to study the effect of
multimodality chest physiotherapy in mechanically ventilated patients for the prevention of VAP.
Study consisted of 101 patients with 51 in controlled group and 50 in study group. Manual
hyperinflation and suctioning were administered to patients in controlled group while the study
group received positioning and chest wall vibration in addition to hyperventilation and suctioning.
Results of the study showed that there was significant decrease in mortality rate among study group
(24%) as compared to controlled group (49%).(116)
A double blind, placebo controlled study was conducted at Netherlands to determine the
effect of oral decontamination with chlorhexidine on VAP incidence. The study included 385
patients (130 on placebo, 127 on chlorhexidine and 128 on chlorhexidine/ colistin). The results
revealed that, risk of VAP was reduced in both treatment group compared to placebo. (65% for
chlorhexidine and 55% for chlorhexidine/ colistin). The study concluded that topical oral
decontamination with chlorhexidine reduces the incidence of VAP.(117)
A randomized control trial was conducted in China to assess the effectiveness of probiotics
in reducing VAP. The control group received routine treatment while the experimental group
received probiotics. The number of pathogenic bacteria colonized in oropharynx and lower
respiratory tract in the 2 groups were examined. The probiotic group had lower bacterial
colonization. The study concluded that probiotic administration decreases the colonization of
bacteria and thus reduces the occurrence of VAP in neonates undergoing mechanical ventilation.(118)
A study was conducted in MICU of China to study the effects of bifidobacterium on
respiratory and gastrointestinal tracts in neonates receiving mechanical ventilation. The neonates
were randomly assigned to experimental and control groups. Experimental group was given
bifidobacterium from 2nd day of mechanical ventilation. Results of the study revealed that,
bifidobacterium can decrease gastric PH, gastric bacteria colonization and thus blocks the infection
route -„ stomach-oropharynx-respiratory tract‟‟ and decreases the incidence of VAP in neonates.(119)
A nurse led VAP surveillance program was conducted in PICU and NICU of UK hospital to
assess the effectiveness of VAP care bundle in reducing VAP. All nursing staff had multiple
training opportunities. VAP project education became a routine part of staff induction. The major
features of the bundle of care were (1) elevation of bed to maximum, (2) mouth care using
chlorhexidine, (3) clean suctioning practice, (4) all patients not on full feeds commenced on
ranitidine and (5) 4-hourly documentation. After the institution of the bundle, no pediatric case of
VAP was recorded over a 12-month period. The study concluded that, pediatric VAP bundle was
associated with reduced VAP.(120)
Ventilator-associated pneumonia due to multidrug-resistant (MDR) pathogens is a leading
healthcare-associated infection in mechanically ventilated patients. Methicillin-resistant
Staphlococcus aureus and several different species of Gram-negative bacteria can cause MDR
VAP. Especially difficult Gram-negative bacteria include Pseudomonas aeruginosa, Acinetobacter
baumannii, carbapenemase-producing Enterobacteriae and extended-spectrum β-lactamase
producing bacteria. Evidence-based strategies to prevent VAP that incorporate multidisciplinary
staff education and collaboration are essential to reduce the burden of this disease and associated
healthcare costs.(121)
A thorough evidence-based literature review was conducted in USA to investigate whether
the use of silver-coated endotracheal tubes reduces the incidence of VAP. The following databases
were consulted: CINAHL; Medline; Health Source: Nursing and Academic edition; ProQuest
Nursing and Allied Health Source; Cochrane Database of Systematic Reviews; TRIP Database; and
National Guideline Clearing house. Results of the study revealed that use of silver-coated
endotracheal tubes reduces the prevalence of VAP.(122)
A quasi-experimental study was conducted in a MICU of Brazil. Multiple interventions to
optimize VAP prevention were performed from October 2008 to December 2010. All of these
processes, including the Institute for Healthcare Improvement's (IHI) ventilator bundle. They found
VAP rates of 1.3 and 2.0 per 1,000 ventilator days respectively in 2009 and 2010, achieving zero
incidence of VAP several times during 12 months, whenever VAP bundle compliance was over
90%. Results suggest that, it is possible to reduce VAP rates to near zero and sustain these rates, but
it requires a complex process involving multiple performance measures and interventions.(123)
A quantitative study used a pre-post program design of 90 staff nurses in the an ICU of USA
to examine the impact of the first nurse-implemented Tele-ICU staffing model, with the intent that
shared nursing vigilance and collaboration can decrease patient complications potentially impacting
patient outcomes. Data demonstrated post-tele-ICU implementation improvements as follows:
severity-adjusted LOS decrease, 15% ; severity-adjusted ICU mortality decrease, 14%; compliance
improvement of "at-risk" patients, restraint documentation 26% improvement; ventilator bundle
compliance, 6% increase; and VAP, 13% decrease in patient-days. Effective nursing collaboration
and communication and improved patient outcomes can be attained through Tele-ICU program.(124)
A randomized, double-blind, multicenter trial was conducted in Switzerland hospital to
assess whether azithromycin could prevent VAP in patients colonized by rhamnolipids producing
isolates. Ninety-two patients were enrolled; 43 azithromycin-treated and 42 placebo patients were
eligible for the per-protocol analysis. In the per-protocol population, the occurrence of
Pseudomonas aeruginosa VAP was reduced to 5 fold in the azithromycin group as compared to
placebo group.(125)
A systematic literature search of Pubmed, Embase, and Cochrane Central Register of
Controlled Trials was conducted to compare SSD (Subglottic Secretion Drainage) with standard
endotracheal tube care in mechanically ventilated chidren. Ten RCTs (Randomized Controlled
Trials) with 2,213 patients were identified. SSD significantly reduced incidence of VAP and
shortened ventilation duration by 1.55 days.(126)
A cross-sectional survey was conducted at Malaysia to determine methods used, frequency,
and attitude of nurses toward oral care provided to mechanically ventilated patients in Malaysian
ICUs. Cotton with forceps was used by 73.4% nurses, forceps and gauze by 65% nurses or spatulas
and gauze by36% nurses. Toothbrushes were used by 50.8% of the nurses. Nurses in this hospital
reported to have positive attitude toward providing oral care. The survey concluded the need to have
standardized oral care protocols in ICUs.(127)
A Retrospective cohort study was conducted in the ICU of Scott and White Memorial
Hospital, to study the effectiveness of multidisciplinary approach in reducing the incidence of VAP.
The VAP rate during 2008 was 4.3/1,000 ventilator days, and the 2009 rate was 1.2/1,000 ventilator
days. The 2008 to 2009 VAP rate ratio was significantly greater than 1. Reduction of the incidence
of VAP occurred with an intervention that included respiratory therapists doing oral care in patients
receiving invasive mechanical ventilation.(128)
A study was conducted in an ICU of Spain to review the current knowledge on VAP
pathogenesis and the latest preventive measures. Findings of the study were: Pathogen-laden
oropharyngeal secretions leak across the endotracheal tube (ETT) cuff; thus, a continuous control of
the internal cuff pressure and cuffs made of polyurethane improve sealing effectiveness and
associated risks of infections, antimicrobial-coated ETTs have shown beneficial effects in VAP
incidence. The use of oropharyngeal decontamination with antiseptics and the use of probiotics are
potential alternatives to selective digestive decontamination in preventing VAP.(129)
An interventional study was conducted by Al-Tawfiq J, and Abed M, in Dhahran, Saudi
Arabia (2010), to evaluate the impact of Institute for Health care Improvement (IHI) bundle to
decrease the rate of VAP infection. Founded that; the implementation of the VAP prevention bundle
resulted in the reduction of VAP rates from a mean of 9.3 cases per 1000 ventilator days to 2.3
cases per 1000 ventilator days.(130)
2.2.4. STUDIES RELATED TO EDUCATION PROGRAM FOR BETTER PATIENT
OUTCOME.
A pre intervention and post intervention observational study was conducted at Washington
to determine whether educational initiative could decrease rates of VAP. Setting consisted of two
teaching and two community hospitals. A self study module was introduced for ICU nurses and
respiratory care practitioners. Results of the study revealed that, VAP rates for all four hospitals
dropped by 46% from 8.75 per 1000 to 4.74 per 1000 ventilator days after the educational
intervention. They concluded that, educational interventions can be associated with decreased rate
of VAP.(20)
A study was conducted to determine if an EBP educational program would improve the
quality of care delivered to patients on mechanical ventilator, thereby reducing VAP rates. The
results of the study revealed that, there was an improvement in oral health after the intervention.
The frequency of oral care determination also improved and VAP rates decreased by 50% following
EBP educational program.(131)
A pre experimental study was conducted in a hospital of Pakistan by Metherali S, (2011) to
assess the nurses knowledge of evidence-based guidelines for prevention of ventilator-associated
pneumonia in critical care areas. This study investigated the impact of a 5-hour teaching module on
nurses' knowledge to practice evidence based guidelines for the prevention of VAP. Forty nurses
were included in the study. The knowledge of nurses was assessed before, immediately after and 4
weeks after the intervention. Knowledge was assessed through a self-developed validated tool,
consisting of multiple choice questions. Knowledge scores of participants increased significantly
after the educational intervention in the first post-test; however, there was a decline in the score in
post-test2.(132)
A quasi experimental study was conducted in Spain by Rose G, and et al. (2012) to assess
the effectiveness of training program on nurses knowledge of VAP prevention, compliance with
VAP preventive measures, VAP incidence and determining whether nursing workload affects
compliance. A questionnaire to assess nurses' knowledge of VAP prevention measures was
administered followed by 8 training sessions regarding prevention of VAP followed by a post test.
Nurses answered more questions correctly on the post-intervention questionnaire than on the pre-
intervention. The study concluded that, the programme improved both knowledge of and
compliance with VAP preventive measures.(133)
A quasi-experimental study was conducted by Musvosvi E, (2013) in USA, California State
University, nonequivalent groups design was selected to examine nurses‟ knowledge and
compliance with ventilator bundle elements before and after in-service education. One sample
nonparametric testing was used to analyze pretest and posttest scores. Twenty-five nurses from the
interventional group scored 100% on the pretest (no room for improvement), resulting in a
statistically significant score increase (p=.009). However, nurses who had room for improvement,
had a mean score increase of 1.33 (P<.0.0 =0.0156. The overall compliance with ventilator bundle
elements had a mean increase of 4.3% among the intervention group. Results of this study showed
evidence to support the claim that an educational in-service is effective in improving knowledge
and compliance with elements of the ventilator bundle.(134)
A quasi experimental study was conducted by Rao SH, in Bengaluru, India (2013). Aimed
to evaluate the effectiveness of structured teaching program on Knowledge among PICU Nurses
regarding prevention of Ventilator Associated Pneumonia at selected Hospitals. One group pre-test
and post-test without a control group using pre-experimental design was used, with purposive
sampling technique. Information was collected from 30 Registered PICU Nurses using structured
knowledge questionnaire. STP was implemented and post-test was conducted after 7 days using
same questionnaire. The results showed; the overall pre test knowledge scores of PICU Nurses on
prevention of Ventilator Associated Pneumonia was found to be 36% and 84.4% in the post test
with 48.4% enhancement in the mean percentage knowledge. There was significant association
between post test knowledge scores and selected demographic variables with gender (χ2 3.91) ,
professional educational qualification (χ2
3.91), total clinical experience (χ2 6.23), religion (χ
2 9.18)
and witnessing a case of VAP(χ25.49). the study Concluded that: Overall findings showed that there
is knowledge deficit among staff nurses regarding prevention of Ventilator Associated Pneumonia
and STP was effective in improving their knowledge.(135)
An intervention study conducted in Thailand (2007) to evaluate the effectiveness of an
educational program to reduce VAP in tertiary care center in Thailand; A 4- Year study, revealed
that; before the intervention there were 45 episodes of VAP (20.6 cases per 1000 ventilator days),
after the intervention the rate of VAP decreased to (8.6 cases per 1000 ventilator days).(136)
A pre and post intervention study design was conducted in Karachi, Pakistan (2011) to
investigate the impact of 5 hours teaching module on nurses‟ knowledge to practice evidence based
guidelines for the prevention of VAP. Concluded that; the 5 hours teaching module significantly
enhanced nurses‟ knowledge towards evidence based guidelines for the prevention of VAP.(137)
Research Methodology
1. Study Design
This is a quasi-experimental study design. This study employed the equivalent groups
design (EGD), which comprised of a pretest and a posttest for intervention and control group. The
study was carried out in three ICU environments in three phases. Two ICU were used as the control
and the other one as the experimental unit.
2. Study Population
The target population of the study was:
1) Registered Staff Nurses working at Khartoum Teaching Hospital, The National Ribat
University Hospital and Omdurman Military Hospital. A total number of 120 subjects were
chosen for the study.
2) Adult patients on mechanical ventilation admitted to ICU at Khartoum Teaching Hospital,
Omdurman Military Hospital and The National Ribat University Hospital during the study
period.
Criteria for Selection of the Sample
2.1. For Nurses:
Inclusion criteria:
1) Registered nurses with an intensive care (ICU) qualification, including permanent and
temporary staff.
2) Registered nurses with no formal training in ICU. These nurses were included as they are in
close contact with mechanically ventilated patients and need to be familiar with ventilator
associated pneumonia and the current evidence based guidelines for prevention of VAP.
3) Nurses who were available at the time of data collection.
4) Nurses who were willing to participate in the study.
Exclusion criteria:
1) Enrolled and auxiliary nurses as their category of nursing are not expected to have skills and
in depth knowledge of mechanical ventilation and evidence based guidelines on prevention
of VAP.
2) Nurses who were working in areas other than Adult Intensive Care Unit.
2.2.For Patients:
Inclusion criteria:
1) Adult patients on mechanical ventilation during the Period of the study.
Exclusion criteria:
1) Patients develop pneumonia in less than 48 hrs. from initiation of mechanical ventilation.
2) Transferred patients from other hospital on mechanical ventilation.
3) Patient with Pneumonia before the initiation of mechanical ventilation.
3. Study Phases
Phase 1 (from October to December 2014)
The researcher observed the participants practice compliance regarding twenty elements of
the ventilator associated pneumonia prevention international guidelines from CDC 2003 that related
to nursing practice (infection control measures, ventilator care measures, endotracheal care
measures and aspiration and colonization prevention strategies) and measured the VAP incidence
rate in both the intervention and control groups prior to the educational session on at least 90
ventilator days.
Phase 2 (From January to February 2015)
In phase 2, participants in the interventional group and control group completed the multiple
choice question (MCQ) assessment test before an educational program on VAP.
The intervention consisted of small group sessions of a 60-minute on VAP and its prevention
strategies in order to afford all nurses an equal opportunity to participate. The Structured education
program was prepared and delivered by the researcher. The researcher collaborated with the clinical
nurse educators to design and put together handouts (self-study education modules)(annex I) , a
power point presentation and wall poster about VAP prevention keys (annex II).
The pretest was administered to all participants during their work hours. Small group
educational sessions were given immediately following the pretest. Participants were afforded time
to ask questions regarding subject material covered during the educational program. To ensure that
all nurses in intervention group will attend the education program. The researcher administered the
sessions in the morning and evening nurses working time for un busy nurses by head nurses team
coordinate, and to encourage them more to participate in the study the researcher coordinates with
ICU matron to afford the nurses attendance certificate from the hospital administration in
educational program for VAP prevention after they completed the post-test questionnaire.
A posttest was then administered after 2 weeks from end of the educational program and the
attendance certificate in the program was awarded to the participants (Annex III). The VAP
prevention key poster also putted in ICU wall to remind the staff all the time. In the same time the
post-test also administered to control group.
Phase 3 (From March to April 2015)
An observation of VAP practice in the intervention and control ICU was conducted during this
phase. The researcher performed the observation over a two-week period and results were collected
and tallied, and VAP incidence rate was measured for at least 60 ventilator days.
4. Study setting
The study was conducted in the Khartoum Teaching Hospital, Omdurman Military Hospital
and Al-Ribat University Hospital. The criteria for selecting these setting were geographical
proximity, feasibility for conducting the study, availability of the required sample because nurses
working in these units are responsible for a larger population of mechanically ventilated patients
than other nurses in an acute care hospitals, and familiarity of the investigator with these settings.
The military hospital is located in Omdurman district beside the Nile in the
Mogran area (annex IVa). It provides all health services for army forces and their
families (during service and retirement). It consist of many clinics and many wards
such as; medical wards, obstetrics and gynecology, pediatrics wards, nursery, ICU
and CCU and surgical wards. The ICU department receives the medical and surgical
cases, in addition to emergency admissions provide a comprehensive intensive care.
There are 22 beds in the ICU and covered by 109 nurses, working in two shift; 8
hours morning shift and 16 hours afternoon and night shift with 1: 1 nurse to patient
ratio.
Al-Khartoum teaching hospital is the largest hospital in Sudan, a public
hospital, located in the center of Khartoum, near to Khartoum University, faculty of
medicine (annex IVb). It consist of many clinics and many wards such as; medical
wards, obstetrics and gynecology, pediatrics words, nursery, ICU and CCU and
surgical wards. The ICU department receive the medical and surgical cases, in
addition to emergency admissions, it provides intensive care by limited resources.
There are 16 bed in the ICU, and covered by 58 nurses working in two shifts; 8 hours
in morning and 16 hours in afternoon and night shift.
The Ribat University Hospital is well equipped building to present the ideal
health services for the surrounding population. It locates at Burry area of Khartoum
(annex IVc). The Ribat University Hospital is the central hospital which was
established to offer medical care to police forces and their families (during service
and retirement) and for chronic cases referred from different state police hospitals.
It consist of many clinics and many wards such as; medical wards, obstetrics and
gynecology, pediatrics wards, nursery, ICU and CCU and surgical wards. The ICU
department receives the medical and surgical cases, in addition to emergency
admission, provide intensive care by limited resources. There are 10 beds in the ICU,
and covered by 24 nurses, working in two shifts; 8 hours in morning and 16 hours in
afternoon and night shift.
5. Sampling
5.1. Sample size:
The sample size for the present study was 120 nurses and 113 Patients.
5.2.Sampling Technique:
1) For Nurses:
This study utilized a nonprobability sampling of 120 ICU nurses from Khartoum Teaching
Hospital, Omdurman Military Hospital and the National Ribat University hospital. Sixty nurses
(from Omdurman military hospital) were in the interventional group as total coverage sample and
60 nurses (from Khartoum Teaching Hospital and the National Ribat University Hospital) were in
the control group as convenience sample.
2) For Patients:
This Study utilized Total covering Sample for adult patients on mechanical ventilation that
admitted during the period of the study who met the study inclusion criteria (annex V).
6. Data collection
5.1.1. Selection and Development of Tools
A structured knowledge questionnaire, Observation check list were selected for the study to
assess nurses‟ knowledge and practice compliance and patient ICU sheet to measure the incidence
of VAP among patients under study. It was considered to be the most appropriate instrument to
elicit the response from subjects.
A. Development of the Tools
A structured knowledge questionnaire was prepared to assess the knowledge of staff nurses
regarding prevention of VAP and observation check list to assess the compliance to practice. The
steps carried out in preparing the tools is:
Literature review.
Preparation of blue print.
Establishment of validity and reliability.
a. Review of Literature
Review of literature from books, journals, published and unpublished research studies were
reviewed and used to develop the tools.
b. Description of the Tools
In the present study the following tools were used.
Tool I (annex VI): Structured knowledge questionnaire was developed by the researcher based on
CDC guideline (Center for Diseases Control and prevention 2003 and 2008, in addition to some
items were adopted from a reliable questionnaire developed by Blot, Labeau, Vandijick, Clas, and
Van Aken,2007).
Part-I: consisted of 6 items related to socio-demographic data of the subjects such as Age, Gender,
Professional Educational qualification, Total clinical experience in years, education training
program on VAP.
Part-II: Structured knowledge questionnaire consisted of 40 items (questions) on knowledge about
prevention of VAP. Each item of the questionnaire had one correct answer, every correct answer
would fetch one mark, and the total score of the knowledge questionnaire was 40 scores.
Section-A: Consisted of 6 (15%) items regarding general information about VAP.
(6 questions = 6 scores).
Section-B: Consists of 3 (7.5%) items on anatomy of lungs.
(3 questions = 3scroes).
Section-C: Consists of 5 (12.5%) items regarding Mechanical Ventilation.
(5 questions = 5 scores)
Section-D: Consists of 6 (15%) items regarding Diagnosis and treatment of VAP.
(6 questions = 6 scores)
Section-E: Consists of 20 (50%) items regarding VAP prevention international guidelines.
(20 questions = 20 scores)
Scoring of the Items:
Each correct answer was given a score of „one‟ mark and wrong answers „zero‟ score.
Obtained score
Percentage = ------------------- x 100
Total score
To find out the association with the selected variables, the knowledge aspect was categorized into
three groups.
Below 50% = Inadequate knowledge.
51–75% = Moderate knowledge.
Above 75% = Adequate knowledge.
Tool II (annex II): Direct observation check list was adopted based on CDC evidence based
guidelines, 2003 and 2010.
Consisted of 20 items on practice about prevention of VAP. Each item of the check list had
one mark, and the total score of the practice compliance check list was 20 scores.
Section-A: consist of 3 (15%) items regarding infection control measures.
(3 items = 3 scores).
Section-B: consist of 5 (25%) items regarding mechanical ventilator care.
(5 items = 5 scores).
Section-C: consist of 6 (30%) items regarding endotracheal suction care.
(6 items = 6 scores).
Section-D: consist of 6 (30%) items regarding aspiration and colonization prevention
strategies. ( 6 items = 6 scores).
Tool III (annex III): VAP incidence calculation sheet
The VAP incidence rate collected from patient ICU sheet and calculating by dividing the
numbers of VAPs by the number of Ventilator days and multiplying the results by 1000.(138)
c. Content Validity of the Tools
The prepared blue print of the tools along with objectives of the study were submitted to 5
experts for content validity who included 4 educators in the field of Adult Health Nursing and 1
statistician. The suggestions given by them were incorporated and the tools were modified. The
final tool got its shape after modification based on the opinion of guide.
d. Reliability assessment:
The developed and validated tools for the knowledge questionnaire and performance check
list were tested for reliability on a sample of 10 subjects. Test retest using Alpha Cronbach revealed
that all items are significantly differed and has a correlation coefficient above the threshold of
significance (r=0.87) for knowledge questionnaire. On the other hand, the Alpha Cronbach value for
performance check list in the sample was (r=0.85). Which indicating strong reliability of both tools.
B. Development of Structured Teaching Program (STP)
The structured teaching program was developed based on the review of the related research / non-
research literature and the objectives stated in the blue print.
The following steps were adopted to develop the STP.
• Development of content blue print.
• Development of STP.
• Establishment of content validity of STP.
• Pre-testing of STP.
Content Blue Print
A blue print of objectives and content items pertaining to knowledge regarding Ventilator
Associated Pneumonia and its prevention was prepared for the construction of structured knowledge
questionnaire. Objectives were distributed under the following learning areas.
• General information regarding Ventilator Associated Pneumonia.
• Anatomy of lungs.
• Mechanical ventilation.
• Diagnosis and treatment of Ventilator Associated Pneumonia
• Prevention of Ventilator Associated Pneumonia
Preparation of Structured Teaching Program (STP)
(i) Preparation of first draft of STP
First draft of STP was developed, keeping in mind the objectives, criteria checklist,
literature reviewed and the opinion of experts. The main factors that were kept in mind while
preparing STP were: professional qualification of the subjects, method of teaching to be adopted,
simplicity of language, and relevance of teaching aids.
(ii) Content Validity of the Teaching Plan
The initial draft of structured teaching program was given to experts in the field along with
the tools. The suggestions were incorporated in the structured teaching program and tools.
(iii) Preparation of Final Draft of STP
The final draft of STP was prepared after incorporating expert‟s suggestion; the final
teaching plan got its shape after the modifications based on the opinion of guide.
(iv) Selecting the Method of Teaching
Lecture cum discussion method was selected as an appropriate method of teaching staff nurses. It
was planned to teach in small groups.
(v) Selection and Preparation of Appropriate Audio-Visual Aids
LCD, Flash cards, chalk board and charts were considered appropriate to increase the impact
of teaching.
(vi) Planning to Implement the Structured Teaching Program
The time and date to implement the structured teaching program was planned and decided in
co-ordination with the Medical Superintendent/Director and the Nursing superintendent of the
concerned hospitals.
(vii) Determining the Method of Evaluating the Structured Teaching Program
The evaluation of structured teaching program was planned through conducting post-test
after 2 weeks of implementation of structured teaching program.
(viii) Description of Structured Teaching Program
The STP was titled “ Prevention of Ventilator Associated Pneumonia ”. The STP was
structured for one session, which was prepared to enhance knowledge of ICU staff nurses regarding
Ventilator Associated Pneumonia and its prevention. It consisted of the following content area:
• Introduction
• Definition of VAP
• Anatomy of lungs
• Mechanical ventilation
• Incidence of VAP
• Etiology of VAP
• Risk factors of VAP
• Pathophysiology of VAP
• Clinical presentation of VAP
• Diagnosis of VAP
• Management of VAP
• Preventive strategies of VAP
5.1.2. Pilot Study
A pilot study was conducted from 30-8-2014 to 5-09-2014 at Omdurman Military Hospital,
Khartoum, Sudan. Administrative approval was obtained from the Hospital administration to
conduct the pilot study. The purpose of the pilot study was to:
• Evaluate the effectiveness of structured teaching program and reliability of tools
• Find out the feasibility of conducting the final study and
• Determine the method of statistical analysis
After selecting 10 staff nurses by purposive sampling technique, pre-test was administered
by using the structured knowledge questionnaire and initial assessment of performance by direct
observational check list. On the same day, STP was administered for 60min.
After 7days, the post-test was administered by using the same structured knowledge
questionnaire and observation check list to evaluate the effectiveness of STP on the knowledge and
practice compliance regarding Prevention of VAP and reliability of tools. The findings of the Pilot
Study revealed that the Study is feasible.
5.1.3. Period of Data Collection:
Formal permission was obtained from the Director and Medical Superintendent of
Khartoum Teaching Hospital, the National Ribat University Hospital and Omdurman Military
Hospital (annex X).
The data were collected from October 2014 to April 2015
5.2. Variables under Study
Independent variable (IV): Structured Teaching Program (STP)
Dependent variable (DV): Knowledge of ICU Staff Nurses on prevention of VAP,
incidence of VAP and Practice of ICU Staff Nurses on prevention of
VAP.
Attribute variables (AV): Personal characteristics which include Age, Professional
Educational qualification, total clinical experience in years, and
previous education training program on VAP.
5.3. Plan of Data Analysis
The data obtained were analyzed in terms of achieving the objectives of the study using
descriptive and inferential statistics.
Descriptive statistics:
• Frequencies and percentage distribution were used for analyzing of socio demographic
characteristics and the level of knowledge.
• Mean, Mean percentage and standard deviation were used for analyzing pre-test and post-
test scores.
Inferential statistics:
• Application of paired „t‟ test to ascertain whether there is a significant difference in the
mean knowledge score and practice compliance scores of pre-test and post-test values for
intervention and control groups.
• Application of independent „t‟ test to ascertain whether there is a significant difference in
the mean knowledge score and practice compliance scores of intervention and control
groups pre-test and post-test values .
7. Ethical consideration
The following ethical requirements were taken into consideration during this study:
The research proposal was submitted to the University Postgraduate Committee for a
permission to conduct the study moreover permission was obtained to ensure compliance with
ethical standards.
Ethical clearance and permission were taken from ministry of health to conduct the study.
Application for permission to conduct the study was be made to the management of all three
hospitals included in the study.
To ensure confidentiality and anonymity of the participants no names were recorded during
data collection and reporting. Consent forms and questionnaires were separated at the time of
data collection to maintain anonymity of participants.
Results
In this study, experimental approach was adopted to assess the effectiveness of Structured
Teaching Program on knowledge and practice compliance regarding prevention of VAP among
adult ICU nurses at selected hospitals, Khartoum state. The samples were 120 nurses (60 from
intervention group and 60 from control group) the data collected were tabulated, analyzed and
interpreted by using descriptive and inferential statistics based on the objective of the study.
Analysis was done based on the objective and hypothesis of the study. A two-tailed p value at 0.05
was taken as the level of significance.
The majority of the participants in the intervention group age between (21-27 years), while
in the control group the age between (25-33 years). Most of the participants in the intervention and
control group were females. The experience of the intervention group and the control group varies.
Also the education levels varies for both groups. (table 4-1).
The majority pre-test knowledge level of the participants in both groups (intervention and
control group) was inadequate ( < 50% scores). (table 4-2).
The means of the pretest knowledge aspects scores for both groups (intervention and control
group) were less than half of the maximum score. Also there were no differences in pretest means
knowledge aspects between the two groups (p >0.05), except regarding lung anatomy aspect and
VAP diagnosis and treatment aspect (p <0.05). (table 4-3).
The study groups (intervention and control) were comparable in knowledge before the
intervention (p = 0.617>0.05) and the overall mean of both groups less than half of maximum score
(40 scores). (table 4-4).
The post-test knowledge levels of the intervention and control group differed
(p=0.000<0.05). Where the majority of participants in the intervention group had an adequate
knowledge level, while in the control group had an inadequate knowledge level. (table 4-5).
The means of post-test knowledge aspects scores for the intervention and control group were
different significantly (p=0.00<0.05). Where the most means post-test knowledge aspects score in
the intervention group were near the maximum score, while in the control group were near the half
maximum score. (table 4-6).
The overall mean of post-test knowledge scores for the intervention and control group were
significantly different. (p=0.000<0.05). (table 4-7).
The knowledge levels for the intervention group of pre and post- test were significant
different (p=0.000<0.05). Where the majority of the participants in pre- test had inadequate
knowledge level, while in the post-test had adequate level of knowledge. (table 4-8).
The education program improved the nurses‟ knowledge scores. Where the overall mean of
pre-test knowledge scores for the intervention group was (17.95 out of 40) and become (32.05 out
of 40) in post-test.(table 4-9).
The means of pre and post-test knowledge aspects scores for the intervention group were
significantly different (p=0.000<0.05) which indicated the education program enhanced and
improved all knowledge aspects of VAP prevention for nurses‟.(table 4-10).
The knowledge level of the control group was not different in pre and post- test
(p=0.111>0.05). Where the majority of the participants had an inadequate knowledge level in pre
and post-test. (table 4-11).
The overall mean of knowledge scores for the control group was not different in pre and
post-test (p=0.08>0.05). (table 4-12).
The means of pre and post-test knowledge aspects scores for the control group were not
different (p>0.05), except regarding general information about VAP where there was a significant
difference (p=0.001<0.05), also regarding mechanical ventilation care (p=0.008<0.05). (table 4-13).
The distribution of the study subjects (intervention and control group) performance
compliance in initial assessment did not varies in most of the practical items (p >0.05), except
regarding humidity respiratory circuits using humidifier (p=0.00<0.05), regarding changing
ventilator circuits when become soiled or malfunctioned (p=0.00<0.05) and using sterile water to
fill bubbling humidifier (p=0.003<0.05), that difference was more in intervention group because
these supplies were not available for the control in ICUs and according to hospital policy. Also
regarding maintenance of adequate pressure in endotracheal tube cuff (p=0.000<0.05) which not
done in control group because the device that measure the pressure (manometer) was not available
for the control in ICUs supply. (table 4-14).
The means of initial assessment performance compliance elements scores for the
intervention and control group varied in value (p>0.05). (table 4-15).
The overall mean of initial assessment performance compliance scores was low in both
groups and there was difference in mean value for the intervention and control group
(p=0.000<0.05) but both groups had a mean of <50% of the max score. (table 4-16).
The majority of the study subjects in the intervention group were compliant to the
international VAP prevention guidelines in the final assessment of practice, while the control group
were not compliant with significant different between them in all items of practice (p<0.05). (table
4-17).
The means of final assessment performance elements compliance scores of the study
subjects were different significantly between the intervention and the control group in all elements
of practice (p<0.05). (table 4-18).
The overall mean of final assessment performance compliance scores of the study subjects
were different significantly between the intervention and the control group (p<0.05).
(table 4-19).
The majority of the study subjects in the intervention group improved in practicing
compliance in final assessment from initial assessment in the most items (p<0.05), while no
significant difference found in the control group (p>0.05). (table 4-20).
The means of initial and final assessment performance elements compliance had a
significant difference in intervention group for all elements (p<0.05), while there were no difference
in the control group (p>0.05). (table 4-21).
The applied education program provided positive impact in nurses performance compliance
in intervention group, where there was significant difference between the initial assessment mean
and final assessment mean (p=0.000<0.05). While in the control group no significant difference
(p=0.07>0.05). (table 4-22).
The VAP incidence rate for intervention group was (54.4/1000 ventilator days) in pre
intervention assessment and the rate decreased to (40.53/1000 ventilator days) in post intervention
assessment, which reflects the positive impact of education program in decreasing the VAP
incidence rate. But for the control group, the VAP incidence rate was (39.6/1000 ventilator days) in
initial assessment and became (64.9/1000 ventilator days) in final assessment.(fig. 4-1)
Section I: Demographic Date
Table (4-1): Distribution of study subjects (Intervention and control groups) regarding their
demographic background (n=120):
Variables Intervention (n=60) Control (n=60) Significant
Freq. Percent Freq. Percent Chi x2 p value
Gender:
- Male 13 21.67 21 35.00 3.065 0.08
- Female 47 78.33 39 65.00
Age:
- Mean 23.98 29.45 0.000*
- Std. deviation 2.81 4.02
Level of qualifications:
- Diploma 0 0.00 9 15.00
4.095 0.06 - Bachelor 57 95.00 47 78.33
- Master 3 05.00 4 06.67
Experience years:
- Less than 1 year 40 66.67 17 28.33
29.42 0.000* - (1-5) years 14 23.33 33 55.00
- (6-10) years 3 05.00 8 13.33
- More than 10 years 3 05.00 2 13.33
Possession Diploma in I.C.U:
- Yes 5 08.33 19 31.67 17.17 0.000*
- No 55 91.67 41 68.33
Attendance an education program in infection control:
- Yes 31 51.67 33 55.00 2.055 0.10
- No 29 48.33 27 45.00
*significant at 5% level.
Section II: Nurses knowledge regarding VAP prevention
A) Pre-test:
Table (4-2): The difference in the pretest knowledge level among study subjects (intervention
and control group) (n=120)
Knowledge level Category
Respondents of knowledge (x2)
p value Intervention group (n)
Control group (n)
Inadequate < 50% Score 36 41
0.172*
Moderate 50-75 % Score 24 17
Adequate > 75% score 0 2
Total 60 60
* Not Significant at 5% level
Table (4-3); Means of pre-test knowledge aspects scores of participants regarding their
knowledge about Ventilator associated pneumonia prevention (n=120)
No
Knowledge aspects Max. score
Respondents knowledge
Independent “t” test p value
Intervention group Control group
Mean SD Mean SD
I General information of VAP 6 2.58 1.36 2.35 1.54 0.483
II Anatomy of Lungs 3 0.88 0.84 1.47 1.01 0.000*
III Mechanical ventilation 5 3.02 1.58 2.30 1.03 0.137
IV Diagnosis and treatment 6 1.88 1.30 2.53 1.70 0.001*
V International guidelines for
VAP Prevention 20 9.58 2.67 9.85 3.74 0.080
*significant at 5% level.
Table (4-4): Overall mean of pre-test knowledge scores for study subjects (intervention and
control group) regarding prevention of VAP (n=120)
Group Max score
Respondents Knowledge Independent “t” test
P value Mean SD
Intervention 40 17.95 5.58
0.617*
Control 40 18.50 6.39
*Not significant at 5% level. t(118)= _ 0.502
B) Post-test:
Table (4-5): The difference in the post-test knowledge level among study subjects
(intervention and control group) regarding prevention of VAP (n=120)
Knowledge level Category
Respondents of knowledge (x2)
p value Intervention group (n)
Control group (n)
Inadequate < 50% Score 0 30
0.000*
Moderate 50-75 % Score 17 28
Adequate > 75% score 43 2
Total 60 60
* Significant at 5% level
Table (4-6): Means of post-test Knowledge aspects scores for study subjects (intervention and
control) regarding prevention of VAP (n=120)
No
Knowledge aspect Max. score
Respondents knowledge
Independent “t” test p value
Intervention group Control group
Mean SD Mean SD
I General information of VAP 6 5.10 0.85 3.30 1.16 0.000*
II Anatomy of Lungs 3 2.17 0.80 1.67 0.95 0.001*
III Mechanical ventilation 5 4.38 0.73 2.83 1.04 0.000*
IV Diagnosis and treatment 6 4.15 1.19 2.80 1.61 0.000*
V International guidelines for
VAP Prevention 20 16.2 1.91 10.2 3.32 0.000*
*significant at 5% level.
Table (4-7): Overall mean of post-test knowledge scores for study subjects (intervention and
control group) regarding prevention of VAP (n=120)
Group Max score
Respondents Knowledge Independent “t” test
P value Mean SD
Intervention 40 32.05 3.77
0.000*
Control 40 20.83 5.74
*significant at 5% level. t(118)=12.63
C) Effect of educational program on nurses knowledge
Table (4-8): The difference in pre and post-test knowledge level for study subjects
(intervention group) to assess the ICU nurses knowledge regarding VAP
prevention (n=60)
Knowledge level Category
Respondents of knowledge (Intervention group ) (x2)
p value Pre-test (n) Post- test (n)
Inadequate < 50% Score 36 0
0.000*
Moderate 50-75 % Score 24 17
Adequate > 75% score 0 43
Total 60 60
* Significant at 5% level X2(2df)=80.95
Table (4-9): Overall mean of pre and post-test knowledge scores for (intervention group)
subjects regarding prevention of VAP (n=60)
Test time Max score
Respondents Knowledge (intervention group) Paired “t” test
p value Mean SD
Pre-test 40 17.95 5.58
0.000* Post-test 40 32.05 3.77
Enhancement 14.1 4.75
*significant at 5% level. t(59)=-16.31
Table (4-10): Means of pre and post-test Knowledge aspects scores for (intervention group)
subjects regarding Prevention of VAP (n=60)
No Knowledge aspects
Respondents knowledge (intervention group)
Paired “t” test
p value Pre test Post test Enhancement
Mean SD Mean SD Mean
I General information of VAP 2.85 1.36 5.10 0.85 2.25 0.000*
II Anatomy of Lungs 0.88 0.84 2.17 0.80 1.29 0.000*
III Mechanical ventilation 3.02 1.58 4.38 0.73 1.36 0.000*
IV Diagnosis and treatment 1.88 1.30 4.15 1.19 2.27 0.000*
V International guidelines for VAP
Prevention 9.58 2.67 16.2 1.91 6.62 0.000*
*significant at 5% level
Table (4-11): The difference in the pre and post-test knowledge level among (control group)
subjects regarding prevention of VAP (n=60)
Knowledge level Category
Respondents of knowledge (Control group) (x2)
p value Pre test Post test
Inadequate < 50% Score 41 30
0.111
Moderate 50-75 % Score 17 28
Adequate > 75% score 2 2
Total 60 60
* Not Significant at 5% level X2(2df)=4.39
Table (4-12): Overall mean of pre and post-test knowledge scores for (control group) subjects
regarding prevention of VAP (n=60)
Time of test Max score
Respondents Knowledge (control group) Paired “t” test
p value Mean SD
Pre-test 40 18.50 6.39
0.08 Post-test 40 20.83 5.74
Enhancement 2.33 9.8
*Not significant at 5% level. t(59)=-1.733
Table (4-13): Means of pre and post-test Knowledge aspects scores for (control group)
subjects regarding Prevention of VAP (n=60)
No Knowledge aspects
Respondents knowledge (control group)
Paired “t” test
p value Pre test Post test Enhancement
Mean SD Mean SD Mean
I General information of VAP 2.35 1.54 3.30 1.16 0.95 0.001*
II Anatomy of Lungs 1.47 1.01 1.67 0.95 0.20 0.344
III Mechanical ventilation 2.30 1.03 2.83 1.04 0.53 0.008*
IV Diagnosis and treatment 2.53 1.70 2.80 1.61 0.27 0.406
V International guidelines for VAP
Prevention 9.85 3.74 10.2 3.32 0.35 0.593
*significant at 5% level
Section III: Nurses Practice regarding VAP prevention
A) Initial Assessment Table (4-14): Distribution of subject’s (intervention and control) performance compliance
with VAP prevention guidelines in initial assessment (n=120)
No. Practice items
Type of group Independent t
Intervention (n=60)
Control (n=60)
t value
p value
Infection control measures:
1 Wash hand before and after patient contact. 24 16 1.08 0.28
2 Wash hand between patients. 28 22 0.77 0.44
3 Change gloves between patients. 28 18 1.32 0.19
Ventilator care measures:
4 Drain and discovered periodically any condensate that collects in the tubing of M.V.
32 18 1.85 0.06
5 Humidity respiratory circuit using humidifier. 56 18 6.53 0.00*
6 Using new ventilator circuits for each patient. 60 56 1.43 0.15
7 Changing ventilator circuits when become soiled or malfunctioned.
28 12 3.72 0.00*
8 Using sterile water to full bubbling humidifier. 36 14 3.05 0.003*
Endotracheal suction care:
9 Maintain adequate pressure in endotracheal tube cuff.
44 0 8.93 000*
10 Wear clean gloves with closed suction system. NA NA - -
11 Wear sterile gloves with an open suction system. 40 28 1.56 0.12
12 Using sterile technique when applying tracheal suctioning.
14 12 0.30 0.75
13 Sterilization or disinfection of suction equipment. 30 12 2.52 0.01*
14 Avoid Saline lavage with suctioning. 24 18 0.80 0.42
Prevent Aspiration and colonization:
15 Monitor continuous patient positions (300-450) if not contraindicated.
32 20 1.56 0.12
16 Perform regular oral hygiene with antiseptic mouth wash.
26 16 1.35 0.18
17 Use topical antimicrobial agents for oral decontamination.
16 0 3.24 0.002*
18 Perform regular oral suction. 28 18 1.32 0.19
19 Continuous aspiration of subglottic secretion if ventilator more than 48 hours.
ND ND - -
20 Check the gastric residual volume (GRV) every 4 to 6 hours.
NA NA - -
*Significant at 5% level.
NA= Not available
ND= Not done.
Table (4-15): Means of initial assessment performance compliance scores of study subjects
(intervention and control group) with elements of VAP prevention (n=120).
No Elements Max. score
Groups
Independent t test
Intervention Control
mean SD mean SD t value p value
I Infection control measures. 3 1.33 0.99 0.93 0.90 1.62 0.100
II Ventilator care measures. 5 3.70 1.02 1.97 1.35 5.60 0.000*
III Endotracheal suction care. 6 2.53 1.10 1.17 0.79 5.50 0.000*
IV Prevent aspiration and colonization 6 1.70 1.02 0.90 0.66 3.59 0.001*
*Significant at 5% level.
Table (4-16): Overall mean of initial assessment performance score for subjects (intervention
and control) regarding VAP prevention (n=120)
Group Max score
Respondents skills Independent “t” test
p value Mean SD
Intervention 20 9.27 2.80
0.000*
Control 20 4.97 2.15
*significant at 5% level. t(118)=6.65
B) Final Assessment Table (4-17): Distribution of subject’s (intervention and control) performance compliance
with VAP prevention guidelines in final assessment (n=120)
No. Practice items
Type of group Independent t
Intervention control t value
p value n(60) % n(60) %
Infection control measures:
1 Wash hand before and after patient contact. 38 63.3 20 33.3 2.39 0.02*
2 Wash hand between patients. 40 66.7 22 36.7 2.39 0.02*
3 Change gloves between patients. 44 73.3 24 40.0 2.72 0.009*
Ventilator care measures:
4 Drain and discovered periodically any condensate that collects in the tubing of M.V.
46 76.7 26 43.3 2.75 0.008*
5 Humidity respiratory circuit using humidifier. 58 96.7 30 50.0 4.73 0.000*
6 Using new ventilator circuits for each patient. 60 100 44 73.3 3.24 0.002*
7 Changing ventilator circuits when become soiled or malfunctioned.
40 66.7 18 30.0 3.00 0.004*
8 Using sterile water to full bubbling humidifier. 44 73.3 22 36.7 2.66 0.009*
Endotracheal suction care:
9 Maintain adequate pressure in endotracheal tube cuff.
54 90 0 00 16.1 0.000*
10 Wear clean gloves with closed suction system. NA NA NA NA - -
11 Wear sterile gloves with an open suction system. 50 83.3 32 53.3 2.59 0.01*
12 Using sterile technique when applying tracheal suctioning.
32 53.3 16 26.7 1.88 0.06
13 Sterilization or disinfection of suction equipment. 38 63.3 10 16.7 4.12 0.000*
14 Avoid Saline lavage with suctioning. 40 66.7 22 36.7 2.39 0.02*
Prevent Aspiration and colonization:
15 Monitor continuous patient positions (300-450) if not contraindicated.
56 93.3 28 46.7 4.50 0.000*
16 Perform regular oral hygiene with antiseptic mouth wash.
38 63.3 14 23.3 3.36 0.001*
17 Use topical antimicrobial agents for oral decontamination.
22 36.7 0 00 4.09 0.000*
18 Perform regular oral suction. 38 63.3 16 26.7 3.01 0.004*
19 Continuous aspiration of subglottic secretion if ventilator more than 48 hours.
ND ND ND ND - -
20 Check the gastric residual volume (GRV) every 4 to 6 hours.
32 53.3 0 00 5.75 0.000*
*significant at 5% level. NA= Not available. ND= Not done.
Table (4-18): Means of final assessment performance compliance scores of study subjects
(intervention and control) with elements of VAP prevention (n=120).
No Elements Max. score
Groups
Independent t
Intervention Control
mean SD mean SD t value p value
I Infection control measures. 3 2.03 0.85 1.10 0.84 4.26 0.000*
II Ventilator care measures. 5 4.10 0.80 2.33 1.02 7.41 0.000*
III Endotracheal suction care. 6 3.53 0.93 1.33 0.92 9.16 0.000*
IV Prevent aspiration and colonization 6 3.10 1.12 0.97 0.85 8.28 0.000*
*Significant at 5% level.
Table (4-19): Overall mean of final assessment performance scores for subjects (intervention
and control) regarding VAP prevention (n=120)
Group Max score
Respondents skills Independent “t” test
p value Mean SD
Intervention 20 12.77 2.31
0.000*
Control 20 5.73 2.13
*significant at 5% level. t(118)=12.24
C) Effects of educational program in nurses practice Table (4-20): The difference in initial and final assessment of practice compliance for study
subjects (intervention and control group) when assess the ICU nurses regarding
VAP prevention (n=120)
No. Practice items
intervention paired p
value
Control paired p
value Initial Final Initial Final
% % % %
Infection control measures:
1 Wash hand before and after patient contact. 40 63.3 0.03* 26.7 33.3 0.48
2 Wash hand between patients. 46.7 66.7 0.05 36.7 36.7 1.00
3 Change gloves between patients. 46.7 73.3 0.003* 30.0 40.0 0.32
Ventilator care measures:
4 Drain and discovered periodically any condensate that collects in the tubing of M.V.
53.3 76.7 0.006* 30.0 43.3 0.25
5 Humidity respiratory circuit using humidifier. 93.3 96.7 0.57 30.0 50.0 0.08
6 Using new ventilator circuits for each patient. 100 100 - 73.3 93.3 0.03*
7 Changing ventilator circuits when become soiled or malfunctioned.
63.3 66.7 0.78 20.0 30.0 0.32
8 Using sterile water to full bubbling humidifier. 60.0 73.3 0.37 23.3 36.7 0.25
Endotracheal care measures:
9 Maintain adequate pressure in endotracheal tube cuff.
73.3 90 0.02* 00 00 -
10 Wear clean gloves with closed suction system. NA NA NA NA NA NA
11 Wear sterile gloves with an open suction system.
66.7 83.3 0.09 46.7 53.3 0.60
12 Using sterile technique when applying tracheal suctioning.
23.3 53.3 0.009* 20.0 26.7 0.42
13 Sterilization or disinfection of suction equipment.
50.0 63.3 0.04* 20.0 16.7 0.76
14 Avoid Saline lavage with suctioning. 40.0 66.7 0.009* 30.0 36.7 0.57
Aspiration and colonization prevention measures:
15 Monitor continuous patient positions (300-450) if not contraindicated.
53.3 93.3 0.000* 33.3 46.7 0.40
16 Perform regular oral hygiene with antiseptic mouth wash.
43.3 63.3 0.01* 26.7 23.3 0.74
17 Use topical antimicrobial agents for oral decontamination.
26.7 36.7 0.08 00 00 -
18 Perform regular oral suction. 46.7 63.3 0.05 30.0 26.7 0.769
19 Continuous aspiration of subglottic secretion if ventilator more than 48 hours.
NA NA NA NA NA NA
20 Check the gastric residual volume (GRV) every 4 to 6 hours.
NA 53.3 0.000* ND ND ND
*Significant at 5% level. NA= Not Available. ND= Not Done.
Table (4-21): Means of initial and final assessment performance compliance scores for study
subjects (intervention and control) with elements of VAP prevention (n=120).
No Elements Max. score
Intervention Paired p
value
Control Paired p
value Initial Final Initial Final
mean mean mean mean
I Infection control measures. 3 1.33 2.03 0.002* 0.93 1.10 0.37
II Ventilator care measures. 5 3.70 4.10 0.05 1.97 2.33 0.14
III Endotracheal suction care. 6 2.53 3.53 0.000* 1.17 1.33 0.47
IV Prevent aspiration and
colonization 6 1.70 3.10 0.000* 0.90 0.97 0.75
*Significant at 5% level.
Table (4-22): Overall mean of initial and final assessment performance scores for study
subjects (intervention and control group) regarding prevention of VAP (n=120).
Max Score
Intervention group
Paired “t” test
p value
Control group
Paired “t” test
p value
Initial assessment
Final assessment
Initial assessment
Final assessment
Mean SD Mean SD Mean SD Mean SD
20 9.27 2.80 12.77 2.31
0.000*
4.97 2.15 5.73 2.13
0.07 Enhancement
In Mean 3.5 0.76
*significant at 5% level.
Section IV: Effects of educational program in VAP incidence
Fig.(4-1): VAP incidence rate comparing for intervention and control group in Pre and post
intervention assessment.
Discussion
VAP is a serious complication of mechanical ventilation with high morbidity and mortality
rate.(7, 44)
ICU nurses‟ knowledge and role in preventing VAP is paramount in reducing its
occurrence. According to Vandijck, Lobeau, Volgelares and Blot, knowledge is a primary
precondition for compliance with protocol for preventing VAP.(107)
This study aimed to evaluate the impact of a structured teaching program on ICU nurses
knowledge and practice compliance regarding VAP prevention.
Even though there is an extensive body of literature on VAP prevention and protocols, there
is paucity of studies focusing on the impact of structured teaching program on increasing
knowledge and improving clinical practice for VAP prevention. Moreover, this is the first study
addressing this problem in Sudan.
A quasi-experimental study with comparison groups (intervention and control) design, the
pre and post-test structured questionnaire was designed to evaluate the knowledge, observation
check list to evaluate practice compliance of 120 nurses‟ staff regarding prevention of VAP and
Patient ICU sheet to calculate the VAP incidence rate.
The pre-test and initial assessment followed by implementation of structured teaching
program (STP) and post-test and final assessment was conducted after 2 weeks from end STP to
evaluate the effectiveness of structured teaching program.
The findings of the study are discussed under the following headings:-
1- Demographic characteristics
2- Baseline assessment of nurses‟ knowledge and practice compliance regarding prevention of
VAP.
3- Evaluation of the effectiveness of Structured Teaching Program.
4- Hypothesis testing
1- Demographic data :
The findings of this study revealed that; majority of staff nurses (78.3%) and (65.0%)
were females in intervention and control group respectively and there was statically
insignificant difference between the two groups (p=0.08>0.05) (table 4-1). For intervention
group the mean age of participants was (24±3) and most of them (66.7%) had experience less
than 1 years, low age and experience years of participants were due to the majority of them are
new graduates and their spend the national service, also the hospital law not premises to do
permanent job contract unless for militaries. On the other side the control group participants
had mean age (29±4) and more than half (55 %) of them had between 1-5 experience years.
There was statically significant difference between the two groups regarding age of participants
(p=0.000<0.05) and years of experiences (p=0.000<0.05) (table 4-1).
Distribution based on level of qualification; the majority of participants (95% and 78.3%)
had Bachelor degree and only (5.0% and 6.6%) of them had master degree for the intervention
and the control groups respectively and there was statically insignificant difference between the
two groups (p=0.06>0.05) (table 4-1).
With respect to attended an education program in infection control, more than half of the
participants (51.6% and 55.0%) attended education program and there was statically
insignificant difference between the two groups (p=0.10>0.05) (table 4-1).
2- Baseline assessment of nurses’ knowledge and practice compliance regarding prevention
of VAP.
a) Baseline knowledge assessment
The present study confirmed that; the overall mean of pre-test knowledge for the
intervention group is (17.95 out of 40) and (18.50 out of 40) for the control group, which is less
than 50% of max. score for both groups and revealed that the two groups were comparable in
knowledge before intervention (p=0.617>0.05) (table 4-4). The majority of participants(60.0%
and 68.3) had inadequate knowledge level (< 20 correct answers), (40.0% and 31.7%) had
moderate knowledge level (20-30 correct answers) for the intervention and the control group
respectively, and no one of them had adequate knowledge (>30 correct answers) (table 4-2).
These findings are in line with those reported by Modather Osman (2014), who
conducted a descriptive study in Sudan in order to assess the nurses‟ knowledge and practice
regarding application of international guidelines for VAP prevention in majority governmental
hospital in Khartoum state. According to the author; the mean of total knowledge for
participants was (8.5 out of 20).(112)
This findings also are agreeable with the results of a descriptive study conducted by
Vivana Gomes in South Africa (2010) in order to determine the knowledge of nurses‟ working
in ICU with respect of evidence guidelines for VAP prevention. Her study revealed that; the
knowledge of ICU nurses lacking in the evidence guidelines for VAP prevention; where only
(21.6%) of participants achieved a pass mark considered to have adequate knowledge level and
(78.4%) of them didn‟t achieved a pass mark and are considered to have inadequate knowledge
level and the mean scores of participants knowledge was (4.25±2.37 ).(110)
Another descriptive study conducted by Nahla Ali in Egypt (2013) to assess the critical
care nurses‟ knowledge and compliance with VAP prevention bundles, revealed that; the
participants had unsatisfactory knowledge score (mean=7.46±2.37 out of 20 scores).(109)
b) Base line practice compliance:
The present study confirmed that; the overall mean of initial practice compliance
assessment for intervention group was (9.27±2.80 out of 20) and (4.97±2.15 out of 20) for
control group with statically significant difference between the two groups (p=0.000<0.05) but
this difference not great in the value where the both groups had mean of <50% of the max.
score and didn‟t mean much in practical terms (table 4-16), which indicates that there was poor
practice compliance of nurses regarding VAP prevention.
These findings are confirmed with Nahla Ali found in her study in Egypt (2013) which
revealed that; most of nurses were not compliant with VAP prevention bundle practice (average
mean=8.62±7.9 out of 29).(109)
Also it similar with Modather Osman study which conducted in majority of
governmental hospitals in Khartoum state, Sudan (2014) and the study found that; (42%) of
subjects had poor practice compliance(112)
.
On the other hand the results of the study conducted by Mujahed Alkhadir in Sudan
(2012) differ from the finding of this study, which revealed that; (42.5%) of participants had
fair practice level, (32.5%) poor practice and (2.5%) of them had good practice.(111)
3- Evaluation of the effectiveness of Structured Teaching Program
a) In knowledge:
The present study confirmed that; there was a considerable improvement of knowledge
after the application of the Structured Teaching Program and it‟s statistically established
significant.
The overall mean knowledge scores in the pre-test for intervention group was (17.95 out
of 40) and (32.05 out of 40) in post-test with 14.1 mean knowledge enhancement (table 4-9).
This indicate that, education program leads to increase in knowledge which impacted on
prevention of VAP.
These findings are in line with those reported by Shilpa Rao in India (2013) in order to
evaluate the effectiveness of structured education program on knowledge among PICU nurses
regarding prevention of VAP. Results of this study revealed that; the overall pre-test mean
knowledge scores of PICU was found to be (14.4 out of 40) and (33.76 out of 40) in post-test
with 19.36 enhancement in mean knowledge scores.(135)
These findings also in agreement with the results of study conducted by Ennis Musvosvi
in U.S.A. (2013) in order to examine nurses‟ knowledge and compliance with ventilator bundle
elements before and after in-service education. Found that; the nurses who had room for
improvement, had a mean score increase of 1.33 in knowledge post-test from pre-test.(134)
Another study conducted in Pakistan (2011) by Metherali, to investigate the impact of
5-hours teaching module on nurses‟ knowledge to practice evidence based guidelines for the
prevention of VAP. The study revealed that knowledge scores of participants increased
significantly after the education intervention in the first post-test.(132)
b) In Practice Compliance
The present study confirmed that; there was a considerable improvement of practice
compliance after the application of the Structured Teaching Program and it established as a
significant statistically.
The overall mean practice scores in initial assessment was (9.27±2.8) and (12.77±2.3) in
final assessment with (3.5) mean practice enhancement (table 4-22). This indicates that
educational program leads to increased practice compliance which have an impact on
prevention of VAP.
That resembles the results of Ennis Musvasi study (2013) in U.S.A., which found that;
nurses who had room for improvement, had a mean score increase of 4.3% on practice
compliance with ventilator bundles elements among the intervention group after education
program.(134)
Another study conducted in Spain by Gatell Rose and colleagues (2012), in order to
assess the effectiveness of training program on nurses knowledge of VAP, compliance with
VAP preventive measures, VAP incidence and determining wither nursing workload affect
compliance concluded that; the program improved both knowledge and compliance with VAP
preventive measures.(133)
Furthermore the present study revealed that; all participants in both study groups
(intervention and control) didn‟t perform the following (wear clean gloves with closed suction
system, continuous aspiration of subglottic secretion) (table4-21) because the closed suction
system and subglottic endotracheal tube wasn‟t available in the Sudan at all governmental and
private hospital, also checking the gastric residual volume every 4-6hrs wasn‟t performed by all
the participants, because they believe the presence of ET tube in patient with mechanical
ventilation is enough to prevent the aspiration (table4-15).
These findings confirmed by Nahla Ali study in Egypt (2013) that explored the closed
suction, subglottic suction extitubation and weaning trials and peptic ulcer prophylaxes practice
were not done by nurses.(109)
c) In VAP incidence rate
The VAP incidence rate is collected from patient ICU sheet (Appendix VIII) and
calculated by dividing the numbers of VAPs by the number of Ventilator days and multiplying
the results by 1000.(138)
In the three months period before the intervention (teaching program), 43 episodes of
VAP (21 in intervention and 22 in control) , were recorded in the total of 941 ventilator days
(386 in intervention and 555 for control) among 66 patient on mechanical ventilation that meet
the study inclusion criteria.
This corresponded to the infection rate of 54.4 and 39.6 cases per 1000 ventilator days
for the intervention and the control group respectively (fig 4-1).
This finding is similar with those reported by study conducted in Turkey (2011), in order
to assess economic burden of VAP in a developing country, which revealed that; VAP
developed in 96 (60%) patient with 47.9/1000 ventilator days.(8)
This findings also in agreement with the result of a systemic review study about; VAP in
adults in developing countries, conducted by Arabi Alshirwi and colleagues (2008), revealed
that; in developing countries the rates of VAP vary from 10 to 41.7 cases per 1000 ventilator
days.(139)
In the two-month period Following the intervention (Teaching Program), 32 episodes of
VAP (14 intervention and 18 control),were recorded in the total of 624 ventilator days (347 in
intervention and 277 in control) among 47 patients on mechanical ventilation that meet the
study inclusion criteria .
This corresponded to the infection rate of 40.3 and 64.9 cases per 1000 ventilator days
for the intervention group and the control group respectively (fig4-1).
These findings are in line with those reported by Reem AlSadat and colleagues (2012),
who conducted a similar study in Syria in order to assess use of VAP bundle and statistical
process control chart to decrease VAP rate. According to authors; the pre-intervention VAP
incidence rate was 39 cases per 1000 ventilator days and reduced to 6.4 cases per 1000
ventilator days post-intervention. (140)
The findings of the present study confirm a considerable improvement on VAP
incidence rate can be achieved by introducing evidence-based protocols. More specifically, in
the intervention group the VAP incidence rate of 54.4 in the pre-intervention period decreased
to 40.3 cases per 1000 ventilator days in the post-intervention phase. Thus, the teaching
program was effective in reducing the VAP incidence rate.
This finding is also in agreement with the results of four years study conducted in
Thailand by Anusha Apisarnthanarak and colleagues in (2007) to evaluate the effectiveness of
an education program in reducing VAP in tertiary care center. The authors reported that; 45
episodes of VAP (20.6 cases per 1000 ventilator days) recorded before intervention decreased
to (8.5 cases per 1000 ventilator days) following the intervention.(136)
4- Hypothesis Testing
One of the goals of research is to develop a body of knowledge that will advance
nursing practice by delivering clinically effective care. Reed and Lawernce defined nursing
knowledge as an awareness that is regarded as useful and significant to nurses and patients in
understanding and facilitating human health process.(141)
If education has the potential to
improve knowledge, the nurses should afford the opportunity to advance their knowledge in the
clinical setting through ongoing educational program post interventional observations
suggesting a strong coalition between knowledge and improved clinical practices. While
compliance in the interventional group increased after education, compliance in the control
group actually declined.
H01 = There will be no difference between pre-test and post-test mean knowledge
scores regarding prevention of VAP among ICU nurses in intervention group at selected
hospitals.
The above null hypothesis is rejected, So the alternative hypothesis is accepted, since
there was a significant change between the pre- and post-test mean knowledge scores regarding
prevention of VAP among staff nurses in the intervention group at p<0.05 significance level
(5%). The pre-test mean knowledge of 17.95 increased to 32.05 at the post-test (p=0.000), as
shown in (Table 4-9). On other hand, the pre-test mean knowledge scores in the control group
was 18.50 and increased only slightly to 20.83 at the post-test. This, increase was not
statistically significant, as p=0.08 was above the threshold of 0.05 (Table 4-12).This finding
confirms that the improvement in mean knowledge scores of the nurses that comprised the
intervention group was due to the teaching program, rather than mere chance.
Hence, the stated hypothesis H11 is accepted as there was a significant improvement in
knowledge scores of staff nurses after administration of the structured teaching program.
H02 = There will be no difference between pre- and post-intervention assessment mean
compliance practice scores regarding prevention of VAP among ICU nurses in intervention
group at selected hospitals.
The above null hypothesis is rejected, so the alternative hypothesis is accepted, since
there was significant change between the pre- and post-intervention assessment mean practice
compliance scores regarding prevention of VAP among staff nurses in the intervention group at
p<0.05 significant level (5%). The pre-intervention assessment mean practice of 9.27 increased
to 12.77 at the post-intervention assessment (p=0.000) as shown in (Table4-22). On other hand,
the pre-intervention mean practice compliance scores in the control group was 4.97 and
increased only slightly to 5.73 at the post-intervention assessment. This, increase was not
statistically significant (Table4-22). This finding confirms that the improvement in mean
practice compliance scores of the nurses that comprised the intervention group was due to the
teaching program, rather than mere chance.
Hence, the stated hypothesis H12 is accepted as there was significant improvement in
practice compliance scores of staff nurses after administration of the structured teaching
program.
H03= There will be no difference between pre-intervention and post-intervention VAP
incidence rate in intervention group at selected hospitals.
The above null hypothesis is rejected, so the alternative hypothesis is accepted, since
there was significant change between the pre- and post-intervention VAP incidence rate in the
intervention group. The pre-intervention VAP incidence rate of 54.4 reduced to 40.3 cases per
1000 ventilator days at the post-intervention. On other hand, the pre-intervention incidence rate
in the control group was 39.6 and increased to 64.9 cases per 1000 ventilator days at the post-
intervention (fig. 4-1). Hence, the stated hypothesis H13 is accepted.
Conclusions
A quasi-experimental case-control study design, to evaluate the effectiveness of structured
teaching program on knowledge and practice compliance regarding prevention of ventilator
associated pneumonia among adult ICU nurses at selected hospitals, Khartoum.
The data was collected from 120 subjects through purposive sampling technique.
Further the conclusion was drawn on the basis of the findings of the study which includes:
- The overall mean of pre-test knowledge scores on prevention of VAP was found to be
(17.95 out of 40) for intervention group and (18.50 out of 40) for control group.
- The overall mean of post-test knowledge scores on prevention of VAP was found to be
(32.05 out of 40) for intervention group and (20.83 out of 40) for control group. which
indicates that; nurses in intervention group gained knowledge after teaching program was
applied.
- The overall mean of initial assessment practice compliance scores on prevention of VAP
was found to be (9.27 out of 20) for intervention group and (4.97 out of 20) for control
group.
- The overall mean of final assessment practice compliance scores on prevention of VAP was
found to be (12.77 out of 20) for intervention group and (5.7 out of 20) for control group.
Which indicate that nurses in intervention group improve their practice compliance after
administration of teaching program.
- The VAP incidence rate of pre intervention phase was found to be (54.4
cases/1000ventilator days) for intervention group and (40.35 cases/ 1000 ventilator days) for
control group.
- The VAP incidence rate of post intervention phase was found to be (39.6 cases/
1000ventilator days) for intervention group and (64.9 cases/1000 ventilator days) for control
group. Which indicate that; the VAP incidence rate for intervention group reduced after
teaching program was implanted.
Limitation of the study
- The study is limited to nurses‟ staff of Omdurman military, Khartoum teaching, the National
Ribat hospitals, Khartoum state.
- Small number of subjects limits generalization of the study.
- The sample for the study was limited to 120 ICU nurses only.
- Some of the nurses refused to participate especially in control group, saying that they “don‟t
know” anything about this topic.
- It was difficult to gather all nurses for structured teaching program.
- The VAP as formal diagnosis not documented in doctor or nursing sheets even patient
develop it, so there is no form of VAP incidence tracking in the hospitals, although there is
no a ventilator bundle in place.
- The observational phase in this study might have had inherent limitation. One obvious
limitation is the effect of the “observer” on the “observed”.
Recommendations
Based on the results of the study, the following recommendations are proposed:
- Manual information booklets and self-instruction modules should be developed by
specialists in area of prevention of VAP.
- The hospital administers should put plan for mandatory in-services education and ICU
diploma courses in hospital acquired infection, especially VAP.
- The nursing administers should appoint nursing professionals in ICU based on the in-service
education obtained on VAP.
- Nursing curriculum should emphasis on strengthening students‟ clinical knowledge
regarding various hospital acquired infections (HAI).
- The health service provider should encouraged to disseminate knowledge by publications
and organizing journal clubs, workshops, seminars, conferences.
- The hospital administers should developed protocols, diagnosis, reporting VAP cases and
appropriate treatment of VAP.
- The hospital administer should reinforce the ICU staff to written VAP as formal diagnosis in
their follow up sheet and develop form for VAP incidence tracking in the hospitals.
- Conduct a similar study with large sample to generalize the findings.
- An experimental study can be undertaken with research team contain another ICU specialist
like physiotherapist, anesthetist and respiratory therapist for more effective outcome.
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The National Ribat University
Faculty of Graduate Studies & Scientific Research
Impact of Structured Teaching
Program
on ICU Nurses’ Knowledge and
Practice
Compliance for Ventilator- Associated
Pneumonia (VAP) Prevention
in Selected Hospitals, Khartoum State.
October 2014- April 2015
Research presented to a Ph.D in Medical-Surgical
Nursing
Prepared By: Faroq Abdulghani Albdulrazzaq
Alshameri
Supervisor : Prof. Alaadin Hassan Ahmed
September 2015
TABLE OF CONTENTS
No Particular Page No.
1 Acknowledgement III
2 List of tables IV- V
3 List of figures V
4 List of abbreviation VI
5 Abstract VII-VIII
6 Introduction 1-3
7 Justification 4
8 Research questions 5
9 Research objectives 6
10 Operational definition 8-9
11 Research hypothesis 10
12 Literature review 11-38
- Background
- Studies related to incidence, prevalence and etiology of
ventilator associated pneumonia.
- Studies related to knowledge and practice compliance of
nurses regarding prevention of ventilator associated
pneumonia.
- Studies related to strategies for the prevention of ventilator
associated pneumonia.
- Studies related to education program for better patient
outcome.
12-26
27-28
29-31
31-36
36-38
13 Research methodology 39-51
14 Results 52-77
15 Discussion 78-85
16 Conclusion 86
17 Limitation 87
18 Recommendation 88
19 References 89-100
20 Annexes 101
CHAPTER ONE
Introduction
Justification
Objectives
Hypothesis
CHAPTER TWO
Literature
Review
CHAPTER
THREE
Research
Methodolog
y
CHAPTER
FOUR
Results
CHAPTER
FIVE
Discussion
CHAPTER
SIX
Conclusion
Recommendations
References
Annexes
National Ribat University
Faculty of Graduate Studies & Scientific Research
Nursing Sciences collage
concerning intensive care nurses’ knowledge Evaluation questionnaireregarding prevention of Ventilator-Associated Pneumonia (VAP)
DEMOGRAPHIC DATA --SECTION I
This questionnaire is anonymous. Please do not write your name.
Please indicate the following:
1. Age in years:
2. Sex:
a) Male
b) Female
3. Total clinical experience in years
a) ˂ 1 years
b) 1-5 years
c) 6-10 years
d) ˃ 10 years
4. Professional educational qualification in nursing
a) Diploma
b) Bachelor
c) Master
d) PHD
5. Do you have a Degree or Diploma in Intensive Care Nursing?
a) Yes
b) No
6. Do you have education attending infection control workshops or conference?
a) Yes
b) No
7. Do you have attending training programs on prevention of VAP?
a) Yes
b) No
Annex (VI)
Adopted from literature review
1
Structured knowledge questionnaire -II -SECTION Instructions:-
a) Answer all questions
among the Select the best answerb) Every question has 4 alternative responses.
options provided by placing correct option in the BOX provided.
c) Each question carries 1 mark
PART A: General 1. VAP stands for
a) Ventilator acquired pneumonia
b) Ventilator associated pneumonia
c) Ventilator assisted pneumonia
d) Ventilator affected pneumonia
2. Among the nosocomial infections, VAP is
a) First common nosocomial infection
b) Second common nosocomial infection
c) Third common nosocomial infection
d) Fourth common nosocomial infection
3. VAP occurs after the following hours of intubation
a) 12 hours
b) 24 hours
c) 48 hours
d) 72 hours
4. VAP is characterized by
a) Hypothermia
b) Thrombocytopenia
c) Purulent tracheobronchial secretion
d) Convulsions
5. Mechanism of developing VAP are, the following EXCEPT,
a) Aspiration of secretions
b) Colonization of aero digestive tract
c) Use of contaminated equipment
d) Use of sterile equipment
6. Which of the following patient findings increases the risk of microorganisms
entering the lower respiratory tract?
a) An increased gag reflex
b) Increased pooling of secretions in the oropharynx
c) Increased mucocillary clearance of secretions
d) Increased cough
PART B: Anatomy of lungs 7. The number of lobes in Right lung and left lung are
a) 2 and 4 respectively
b) 2 and 3 respectively
c) 3 and 2 respectively
d) 4 and 2 respectively
8. The conducting zone of respiratory system include, EXCEPT;
a) Trachea.
b) Bronchi.
c) Nasal cavity.
d) Alveolar ducts.
9. The sympathetic nervous system via noradrenaline acts on the following
receptor to cause bronchodilation
a) Alpha Receptors
b) Beta Receptors
c) Muscarnic Receptors
d) Nicotinic Receptors
PART C: Mechanical ventilation
10. Mechanical ventilation can be provided through following route
a) Oral intubation
b) Nasal intubation
c) Tracheostomy
d) All the above
11. The main indication for mechanical ventilator support is
a) Congestive heart failure.
b) Hepatic failure.
c) Respiratory failure.
d) Renal failure.
12. Mechanical ventilation is:
a) Life support system.
b) Life measuring system.
c) Life threatening system.
d) Life prolonging system.
13. CPAP stands for
a) Continuous peak airway pressure
b) Combined peak airway pressure
c) Continuous positive airway pressure
d) Combined positive airway pressure
14. SIMV stands for
a) Synchronized Intermittent Mandatory Ventilation
b) Standardized Intermittent Mandatory Ventilation
c) Systematic Intermittent Mandatory Ventilation
d) Spontaneous Intermittent Mandatory Ventilation
PART D: Diagnosis and Treatment
15. The most common pathogen responsible to develop VAP:
a) Gram positive bacilli
b) Gram negative bacilli
c) Viral agents
d) Fungal agents
16. CPIS stands for
a) Critical pulmonary inflammation score
b) Clinical pulmonary inflammation score
c) Clinical pulmonary infection score
d) Clinical pulmonary infiltration score
17. CPIS consists of
a) Clinical criteria
b) Radiologic criteria
c) Microbiologic criteria
d) All the above
18. Following score on CPIS is an indication of VAP
a) 2
b) 4
c) 6
d) 8
19. Emperic therapy is started
a) Before getting culture report
b) After getting culture report
c) Any time as per physicians order
d) Before discharging the client from hospital
20. Drug of choice for VAP is the following drug EXCEPT
a) Cefepime and gentamicin/amikacin/tobramycin
b) Vancomycin/linezolid and ceftazidime
c) A carbapenem
d) Fluoroquinones
PART E: Prevention of VAP 21. The following route is recommended to prevent VAP
a) Oral
b) Nasal
c) Tracheostomy
d) Any of the above
22. Frequency of ventilator circuits changes recommended
a) change the circuits every 48 hrs.
b) change the circuits every week.
c) change the circuits for every new patient.
d) change the circuits as per physicians order.
23. Suction systems recommended to prevent VAP is
a) Open suction systems
b) Closed suction systems
c) As per doctors order
d) As per hospital policy
24. Endotracheal tubes with extra lumen for drainage of subglottic secretions
will help to prevent VAP
a) Agree
b) Disagree
c) Does not influence the risk of VAP
d ) Depends on the duration of ventilation
25. Rotate Kinetic beds will
a) Increase the risk of VAP
b) Reduce the risk of VAP
c) Does not influence the risk of VAP
d) Depends on patient‟s weight
26. Preferred Position for patients on ventilator to prevent VAP
a) Supine
b) Prone
c) Semi fowlers
d) Lateral
27. Oral suction catheter should be stored between uses
a) On the Ventilator
b) In a clean plastic bag
c) On the suction apparatus
d) At the patient‟s bed side
28. Use of multiple antibiotics will increase the risk of patient to develop VAP
a) True
b) False
c) Sometimes
d) Depends on patient‟s age
29. Fluid that should be used in humidifier
a) Sterile water
b) Dextrose water
c) Tap water
d) Normal saline
30. Frequency of suctioning recommended is
a) Every 2 hours
b) As per hospital protocol
c) Whenever necessary
d) After feeds
31. The procedure that should be done before suctioning is
a) NG aspiration
b) Chest physiotherapy
c) Back care
d) NG feeding
32. Sedation protocol is necessary to
a) Prevent infection
b) Increase the sedation
c) Plan early weaning
d) Plan late weaning
33. Which of the following are the best two prevention strategies for VAP
a) Prevent colonization and aggressive antibiotic use
b) Prevent aspiration and use non-invasive ventilation
c) Hand washing and glove usage
d) Prevent or reduce colonization and prevent or reduce aspiration.
34. What are ways the critical care nurse can decrease the chance of VAP
frequencies with oral care?
a) Daily oral assessment, oral care with antiseptic solution and continuous oral
suctioning.
b) Use of oral swabs, suctioning of oral mucosa every 6 hours and weekly oral
assessment.
c) Brushing patient‟s teeth with antimicrobial toothpaste and frequent rinsing
d) Allowing patient‟s family to suction when needed and to report the number of
times the patient was suctioned
35. Endotracheal and gastric tubes should be placed orally to prevent
a) Sinusitis
b) Meningitis
c) Pharyngitis
d) Laryngitis
36. Which of the following is true according to the hand hygiene;
a) Use of alcohol rub was associated with higher hand contamination.
b) Hand washing is not necessary if gloves are changed frequently.
c) Hand washing should be done before and after any contact with patients.
d) Hand washing need just before the wearing gloves.
37. Selective decontamination of tracheostomy site can be done using
a) Topical antibiotic
b) Intravenous antibiotic
c) Intramuscular antibiotic
d) Intrathecal antibiotic
38. Which of the following is NOT a recommendation from the CDC for
decreasing
VAP rates in hospitals?
a) Continue current practices in VAP prevent.
b) Institute educational training programs for staff to heighten awareness of
VAP prevention.
c) Implement protocols for preventing VAP that include practices recommended
by the CDC.
d) Develop and implement comprehensive oral hygiene programs to provide
oropharyngeal cleansing and decontamination with or without antiseptic
agents.
39. Following Vaccination helps to prevent VAP EXCEPT;
a) Influenza
b) Pneumococci
c) Haemophilus B
d) Rubella
40. Gastric over distension can be prevented by the use of
a) Anticholinergic agents
b) Narcotics
c) Metoclopramide
d) Proton pump inhibitors
National Ribat University
Faculty of Graduate Studies & Scientific Research
Nursing Sciences collage
concerning intensive care nurses’ knowledge ck list Observation Cheregarding prevention of Ventilator-Associated Pneumonia (VAP)
Not
done Done Items No.
Wash hand before and after patient contact. 1
Wash hand between patients. 2
Change gloves between patients. 3
Drain & discovered periodically any condensate that collects in the tubing
of M.V. 4
Humidity respiratory circuit using humidifier. 5
Using new ventilator circuits for each patient. 6
Changing ventilator circuits when become soiled or malfunctioned. 7
Using sterile water to full bubbling humidifier. 8
Maintain adequate pressure in endotracheal tube cuff. 9
Wear clean gloves with closed suction system. 10
Wear sterile gloves with an open suction system. 11
Using sterile technique when applying tracheal suctioning. 12
Sterilization or disinfection of suction equipment. 13
Avoid Saline lavage with suctioning. 14
Monitor continuous patient positions (30
0-45
0) if not contraindicated. 15
Perform regular oral hygiene with antiseptic mouth wash. 16
Use topical antimicrobial agents for oral decontamination. 17
Perform regular oral suction. 18
Continuous aspiration of subglottic secretion if ventilator more than 48
hours. 19
Check the gastric residual volume (GRV) every 4 to 6 hours. 20
National Ribat University
Faculty of Graduate Studies & Scientific Research
Ventilator associated Pneumonia (VAP) Incidence sheet
Hospital Name: ……………………………………………………… Unit:
…..…………………..
Bed No: ………………………… Age: ……………………….. Sex:
…………….…………………
Date of admission: ………………………………………………….
Source of patient admission:
- Home
- Other unit in the hospital
- Refer from other hospital
Underlying condition: Diagnosis:………………………..
- Cardio vascular diseases.
- Gastro intestinal Diseases.
- Diabetes Mellitus.
- Cerebrovascular or other neurological disorder.
- Pulmonary disease.
- Immunocomprimised state.
- Malignancy.
- RTA (Trauma).
Date of intubation & connection to mechanical ventilation :………………………..
VAP occurrence : Yes No
Date of VAP (Ventilator associated Pneumonia) occurrence :……………….........
Date of extubation : ………………………………….
Date of discharge from unit : …………………………………..
Date of death in unit : ……………………………………………….
National Ribat University
Faculty of Graduate Studies & Scientific Research
Nursing Sciences collage
Study title:
“Effectiveness of Nursing Educational Program in Reducing
Ventilator-Associated Pneumonia in Khartoum state
Hospitals.”
Objective: Measure the incidence of VAP.
Ventilator Associated Pneumonia:
Defined as Parenchymal lung infection occurring more than 48 hours after initiation
of mechanical ventilation.
for Ventilator associated Pneumonia used in this study is derived Diagnosis Criteria
from U.S. Centers for Diseases Control and Prevention.
1. Patient has chest radiograph findings showing new or progressive infiltrates,
consolidation, cavitation, or pleural effusion that persists for <48h and new
onset of purulent sputum or change in character of sputum.
or
2. Patient has chest radiograph findings showing new or progressive infiltrates,
consolidation, cavitation, or pleural effusion that persists for <48 h and the
following 2 criteria: (1) temperature, <38_C; and (2) WBC count <10,000
cells/mL.
Patient Criteria in this study:
Inclusion Criteria:
- Adult patients on mechanical ventilation.
Exclusion Criteria:
1) Patients develop VAP in less than 48 hrs. from initiation of mechanical
ventilation.
2) Transferred patients from other hospital on mechanical ventilation.
3) Patient with Pneumonia before the initiation of mechanical ventilation.
