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CRITICAL CARE NURSES KNOWLEDGE OF EVIDENCE
BASED GUIDELINESS FOR PREVENTING -
VENTILATOR ASSOCIATED PNEUMONIA
Project Report
Submitted in partial fulfillment of the requirements
for the Diploma in Neuro Nursing
Submitted by
SURYA. S.
Roll No : 5659
SREE CHITRA TIRUNAL INSTITUTE FOR
MEDICAL SCIENCES AND TECHNOLOGY
TRIVANDRUM
OCTOBER 2007
CERTIFICATE FROM SUPERVISORY GUIDE
This is to certify that Surya. S. has completed the project work on
"Critical care nurses knowledge of evidence based guideliness for preventing
ventilator associated pneumonia" under my direct supervision and guidence
for the partial fulfillment for the Diploma in "Neuro Nursing" in the University
of Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Trivandrum.
It is also certified that no part of this report has been included in any
other thesis for procuring any other degree by the candidate.
Trivandrum October 2007.
~s6 .. J'\CL'N\M'\J G ~ ~- ::;,._-~I It-To) Saramma. P. P.
Lecturer in Nursing Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Trivandrum - 696011.
CERTIFICATE FROM CANDIDATE
This is to certify that the project on "Critical care nurses knowledge of
evidence based guidelines for preventing ventilator associated pneumonia"
is a genuine work done by me at the Sree Chitra Tirunallnstitute for Medical
Sciences and Technology, Trivandrum, under the guidance of Saramma. P.
P. It is also certified that this work has not been presented previously to any
university for award of degree, diploma or other recognition.
Trivandrum
Surya. S. Roll No: 5659
Sree Chitra Tirunallnstitute for Medical Sciences and
Technology, Trivandrum- 696011
APPROVAL SHEET
This is to certify that Miss. Surya. S. bearing Roll No: 5659 has been
admitted to the Diploma in Neuro Nursing in January 2007 and she has
undertaken the project entitled "Critical care nurses knowledge of evidence
based guidelines for preventing ventilator associated pneumonia" which is
approved for the Diploma in Neuro Nursing awarded by the Sree Chitra
Tirunal Institute for Medical Sciences and Technology, Trivandrum, as it is
found satisfactory.
(Examiners)
Guide(s)
Date:
Place:
ACKNOWLEDGEMENT
First of all let me thank god all might for the unending love, care and
blessing especially during the tenure of this study. I take this
opportunity to express my sincere gratitude to Mrs. Saramma. P.P.
lecturer in nursing, Sree Chitra Tirunal Institute of Medical Science
and Technology, Trivandrum, for the guidance. She provided for
executing this study. Her advice regard the concept, basic guidelines
and analysis of data were very much encouraging. Her contribution
and suggestions have been extremely grateful With profound sentiments
and gratitude the investigator acknowledge the encouragement and
help received from the following persons for the successful
completion of this study.
The investigator also takes this opportunity to express the sincere
thanks to Mrs. Sudarsa S and Mrs. Girija Devi (ward sisters) in Neuro
Surgical and Neuro Medical ICU.
The investigator record special thanks to library staff of SCTIMST for
granting permission to utilize the library facility.
The investigator wishes to express heartful thanks to parents and near
ones for their prayer, encouragement and help throughout this
procedure.
All the staff nurses working in Neuro Medical and Neuro Surgical ICU
and colleagues in the department has helped for completion of study
at some time for which I am indebted to them. Surya.s
ABSTRACT
Critical Care Nurses knowledge of evidence Based Guidelines for preventing ventilator Associated pneumonia.
Ventilator Associated Pneumonia (VAP) is defined as pneumonia that
develops after initiation of mechanical ventilation. Ventilator Associated
Pneumonia is the most common hospital acquired infection among patients
who require ventilatory support. Objectives of the study were to assess the
critical care nurses knowledge of evidence based guidelines for preventing
Ventilator Associated Pneumonia and to find out the relationship between
Critical Care nurses knowledge of evidence based guidelines for preventing
ventilator associated pneumonia and selected variables. The study was
conducted in Neuro Medical and Neuro Surgical ICU of Sree Chitra Tirunal
Institute for Medical Science and Technology, Thiruvananthapuram. Ten
nursing related interventions were identified from a review of evidence based
guidelines for preventing VAP. Ten multiple choice questions (1 question per
1 intervention) were based on selected interventions based were distributed
to 30 critical care nurses in NMICU & NSICU of SCTIMST. The study
concluded that the mean knowledge of nurses working in NMICU & NSICU
with regard to the knowledge of preventing VAP is above average. There
was no significant difference between the mean knowledge of nurses about
VAP guidelines with regard to their experience, professional qualification or
area of work
TABLE OF CONTENTS Page No.
Chapter -1 Introduction 1
1.1 Background of study 3
1.2 Need and significance of the study 6
1.3 Statement of problem 10
1.4 Definitions of Terms 10
1.5 Objectives of study 10
1.6 Methodology 11
1 . 7 Limitations of the study 11
1.8 Summary 11
1.9 Organization of report 11
Chapter- II The Review of Literature 12
2.1 Evidence based guidelines for preventing VAP 12
2.2 Educational programme for preventing VAP 13
2.3 Oral health and Ventilator Associated Pneumonia 13
2.4 Summary 19
Chapter- Ill Methodology 20
3.1 Introduction 20
3.2 Research approach 20
3.3 Settings 20
3.4 Sample and Sampling Techniques 20
3.5 Criteria for sample collection 20
3.6 Development of Tool 21
3.7 Description of Tool 21
3.8 Pilot Study 22
3.9 Data Collection 22
3.1 0 Plan of analysis 22
3.11 Summary 23
Chapter IV Analysis and interpretation of data 24
4.1 Sample Characteristics 24
4.2 Critical care nurses knowledge of Ventilator Associated 24
Pneumonia guidelines
4.3 Summary 32
Chapter V Summary, Conclusion, Discussion,
Limitation and Recommendations 33
5.1 Introduction 33
5.2 Summary 33
5.3 Objectives of the study 34
5.4 Limitation 34
5.5 Major findings of the study 34
5.6 Recommendations forfuture study 35
5. 7 Discussion 35
5.8 Conclusion 37
Reference
Appendix
VIII List of Tables
Table 4.1 Distribution of sample by age
Table 4.2 Distribution of sample
Page No.
25
according to the area of work · 26
Table 4.3 Distribution of sample
according to the professional qualifications 27
Table 4.4 Mean standard deviation and p
value of nurse's knowledge by ICU experience 28
Table 4.5 Mean standard deviation and
p value of nurse's knowledge by qualification 29
Table 4.6 Mean standard deviation and
p value of nurse's knowledge by area of work 30
Table 4.7 Percentage of knowledge on
Ventilator Associated Pneumonia guidelines 31
IX List of Figures
Page No.
Figure 4.1 Distribution of samP,Ie by age 25
Figure 4.2 Distribution of sample according to the area of work 26
Figure 4.3 Distribution of sample according to the professional qualification 27
X LIST OF ABBREVATIONS
VAP Ventilator Associated Pneumonia
ICU Intensive Care Unit
HAP
NMICU
NSICU
NNIS
AACN
CDC
CPG
ACE
EBP
NNIS
NP
AHO
Hospital Acquired Pneumonia
Neuro Medical Intensive Care Unit
Neuro Surgical Intensive Care Unit
National Nosocomial Infection Surveillance System
American Association of Critical Care Nurses
Centers for Disease Control and prevention
Clinical Practice Guidelines
Academic Center for Evidence based practice.
Evidence Based Practice
National Nosocomial Infection Surveillance
Nosocomial Pneumonia
Accreditation of Health care Organization
f j
I CHAPTER I
INTRODUCTION
Ventilator Associated Pneumonia (VAP) is defined as pneumonia that
develops more than 48 to 72 hours after initiation of meclianical ventilation.
(Flanders 2006). With an incidence of 8% to 68% VAP is the most common
hospital acquired infection among patient who required ventilatory support
(Salahuddin 2004). Nosocomial pneumonia is a frequently occurring
complication of mechanical ventilation in ICU patients. In this specific patient
population the infection is also called Ventilator-Associated Pneumonia
(VAP). VAP usually develops when microorganisms reach the lung and
overcome the pulmonary host defense. Pulmonary infection results if the
bacterial inoculum is sufficiently large, if the microorganism is particularly
virulent,·or if the host defenses break down (Wunderink 1992)
Nosocomial pneumonia is a leading cause of death from hospital acquired
infections, with an associated crude mortality rate of approximately 30%
(Augustyn 2007). Ventilator Associated Pneumonia refers specifically to
nosocomial bacterial pneumonia that has d~veloped in patients who are
receiving mechanical ventilation. VAP that occurs within 48 to 72 hours after
tracheal intubations is usually termed early onset pneumonia it often results
from aspiration which complicates the intubations process. (Bubrani 2007).
VAP that occurs after this period is considered late onset pneumonia. Early
onset VAP is most often due to antibiotic sensitive bacteria (Eg. Oxacillin
1
1 I I
-1
I sensitive staphylococcus aureus, Haemophilus influenzae and streptococcus
pneumonia.
Development of fever increased white blood cells count and new or changing
lung infiltrate on the chest x ray are all signs of VAP. Diagnosis can be
challenging, because other lung disease can have similar signs. Culture of
tracheal aspirate show which bacteria or fungus are responsible for
Ventilator Associated Pneumonia. Some times bronchoscopy is necessary to
get better samples. Sometimes open lung biopsy to obtain lung tissue is
required. VAP can be accurately diagnosed by any one of several standard
criteria. Histopathologic examination of lung tissue obtained by open lung
biopsy, rapid cavitations of pulmonary infiltrate in the absence of cancer or
Tuberculosis, positive pleural fluid culture, same species with same
antibiogram isolated from blood and respiratory secretion without another
identifiable source of bacterimia and histopathologic examination of lung
tissue at autopsy (Fagon 1996)
Pathogens differ according to the onset of VAP. This distinction is important
microbiologically. VAP is typically categorized as either early-onset VAP or
late onset VAP. This distinction is important microbiologically. Early onset of
VAP usually caused by (Eg. Streptococcus pneumonia, Haemophilus Influenza,
and staphylococcus aurous). Late Onset VAP is commonly caused by
antibiotic resistant Nosocomial Organisms (E.g. Pseudomonas, aeruginosa,
Methicillin - resistant Streptococcus aureus, Acinetobactor species and
. Enetrobacter species) Most episodes of VAP are thought to develop from the
2
r t
1 aspiration of oropharyngeal secretion containing potentially pathogenic
organisms. Aspiration of gastric secretion may also contribute though to a
lesser degree. Tracheal intubations interrupt the body's anatomic and
I physiologic defenses against aspiration, making mechanical ventilation, a
major risk factor for VAP. (Harold 2004)
lntubations and mechanical ventilation greatly increase the risk for bacterial
pneumonia because the endotracheal tube allows direct entry of bacteria
into the tower respiratory tract and there by promote bacterial colonization.
Lung are colonized by nosocomial pathogens in many ways. Micro aspiration
of oropharyngeal secretions, aspiration of gastric contents direct inoculation
into the airways of intubated patients, inhalation of infected aerosols,
haematogenous spread if infection from a distant site and potentially
translocation of bacteria from Gt tract. Most VAP is associated with the
aspiration of bacteria from the oropharynx and Gl Tract (Tabtan 1994).
1.1 Background of study
VAP is the most common Nosocomial Infection diagnosed in intensive care
unit (ICU) (American Thoracic Society 2005). Based on the definition
employed the incidence of VAP ranges from 10% to 30% more importantly,
Crude mortality rates in VAP exceed 50% and the attributable cost of VAP
approaches $ 20,000 The last 5 years have seen a substantial increase in
our appreciation of an understanding of VAP. Additionally, nosocomial
infection generally and VAP specifically have become key areas of focus for
3
J I I
both the joint commission on Accreditation of Healthcare Organizations and
state legislatures across the country (Safdar 2005).
Ventilator Associated Pneumonia is a sub type of Hospital Acquired
Pneumonia (HAP) which occurs in people who are on mechanical ventilation
through an endotracheal or tracheotomy tube for at least 48 hours. VAP is a
medical condition that results from infection which floods the small, air filled
sacs (alveoli) in the lung responsible, for absorbing oxygen from the
atmosphere. VAP in distinguished from other kind of infectious pneumonia
because of the different type of microorganism's responsible antibiotics used
to treat, method of diagnosis, ultimate prognosis and effective preventive
measures. The pneumonia is most often caused by S. pneumonia,
H.lnfluenzae or S. aureus. However, in the hospital the organisms
associated with pneumonia is most often pseudomonas regardless of
whether or not the patient is ventilated.
VAPprimarily occurs because the endotracheal or tracheotomy tube allows
free passage of bacteria into the lower segment of lung; in a person who
often has underlying lung or immune problems. Bacteria travel in small
droplets both through the endotracheal tube and around the cuff. Often,
bacteria colonize the end tracheal or tracheostomy tube and are emboli zed
into the lungs with each breath. Bacteria may also be brought down into the
lungs with each breath. Bacteria may also be brought down into the lungs
with procedures such as deep suctioning or bronchoscopy.
4
Prevention of VAP involves limiting exposure to resistant bacteria,
discontinuing mechanical ventilation as soon as possible, and a variety of
strategies to limit infection while intubated. Resistant bacteria are spread in
much the same ways as any communicable diseases. Proper hand washing,
sterile technique for invasive procedure, and isolation of individuals with
unknown resistant organisms, are all mandatory for effective infection
control.
Other recommendations for preventing VAP include raising the head of the
bed at least 30-45degrees and placement of feeding tubes beyond the
pylorus of the stomach. Antiseptic mouth washes may also reduce the
incidence of VAP.
Prevention of VAP is a multidisciplinary team effort in which nurses,
respiratory therapists and physicians each plays a vital role. (Causeywa
1981)
Endotracheal intubations and mechanical ventilation predispose a patient to
VAP by interfering with normal defense mechanisms that keep
microorganisms out of the lungs. Endotracheal airway secretions, that
accumulates below and above the ET Tube cuff is an ideal growth medium
for pathogens. The ET tube is also prevents normal closure of the epiglottis,
resulting in an incomplete seal of the laryngeal structure that normally
protect the lungs. This can contribute to aspiration which often leads to VAP.
5
VAP is characterized by pulmonary infiltrates and fever. Other assessment
findings include leucocytosis purulent tracheal secretions, decreased
oxygenation and pathogenic microorganisms cultured from tracheal aspirate.
Risk factors are related to poor infection control technique by health care
providers including inadequate hand hygiene and failure to wear gloves
when handling respiratory secretion or equipment contaminated with
respiratory secretions (Torres 1990)
Nurse's lack of knowledge may be a barrier to adherence to evidence based
guidelines for preventing Ventilator Associated Pneumonia. (Labeau et al
2007). In the Neuro Medical Intensive Care Unit (NMICU) of SCTIMST many
patients are receiving mechanical ventilation. Therefore there is more
possibility for VAP pneumonia. In NMICU from January 2005 to Sept. 2007,
161 patients were put on mechanical ventilatory support; same of these
patients were on artificial ventilation for many months. At the same time in
neuro surgical ICU's very rarely patients need continuous mechanical
ventilation. Adherence to the best nursing practice guidelines is
recommended for prevention ofVAP.
1.2 Need and Significance of study
Ventilator Associated Pneumonia represents a major health problem
because of the excess mortality and morbidity rate in hospital and also this
infection will aggravate the underlying disease process worsening the
condition of the patient. Prevention of Ventilator-Associated Pneumonia
6
focuses on avoiding micro aspiration of sub glottis secretion preventing
oropharyngeal colonization with exogenous pathogens and preventing
contamination of ventilator equipment. Labeau et al developed a reliable and
valid questionnaire to determine critical care nurses knowledge of evidence
based guideline preventing VAP (Labeau et al 2007). Pneumonia has
accounted for approximately 15% of all hospital-associated infections and
24% - 27% of all infections acquired in the medical intensive care unit, and
coronary care unit, respectively (Horan 1986). It has been the second most
common hospital associated infection after that of urinary tract. (Emori et al
1993). The primary risk factor for the development of hospital associated
bacterial pneumonia is mechanical ventilation (with its requisite endotracheal
intubation) (Jarvis 1991 ).
The National Nosocomial Infection Surveillance System (NNIS) reported that
in 2002, the median rate of VAP per thousand ventilator days in NNIS
hospital ranged from 2.2 in pediatric ICU to 14.7 in trauma ICU. In other
reports, patient receiving continuous mechanical ventilation had 6-21 times
the risk of developing Hospital Associated Pneumonia compared with
patients who were not receiving mechanical ventilation. Because of the
tremendous risk in the last two decades most of the research on Hospital
Associated Pneumonia has been focused on VAP. Other major risk factors
for Pneumonia have been identified in various studies. Most of these
conditions usually coexist with mechanical ventilation, in the same critically ill
patient. These include primary admitting diagnosis of burns, trauma or
7
disease of central nervous system, depressed level of consciousness, prior
episode of large volume aspiration, underlying chronic lung disease, > 70
years of age, 24 hours ventilator circuit change, stress bleeding prophylaxis
with ametidine with or without antacid, administration of antimicrobial agent,
presence of naso gastric tube, severe truma and recent bronchoscopy
(Cross 1981 ). The fatality rate for Hospital Associated Pneumonia in general,
and VAP in particular, are high for Hospital -Associated Pneumonia, an
attributable mortality rate of 20%- 33% have been reported; VAP accounted
for 60 % of all deaths due to hospital associated infection (Cross 1988). In
studies in which invasive techniques were used to diagnose VAP, the crude
mortality rates ranged from 4% in-patient with VAP, but without antecedent
antimicrobial therapy to 73% in patients with VAP caused by pseudomonas
or Acinetobactor Spp. and attributable mortality rate ranged from 5-8% to
13.5% (Leu 1989). These wide ranges in crude and attributable mortality rate
strongly suggest that a patient underlying disease and organ failure,
antecedent receipt of antimicrobial agent and the infecting organisms (Fagon
1996)
VAP is an important safety issue in critically ill patients receiving mechanical
ventilation. The American Association of Critical Care Nurses (AACN)
recommended steps for reducing the incidence of VAP. These steps are
based on the best practice guidelines for patient receiving mechanical
ventilation called "The ventilator bundle". These step incorporate the
following guide lines from the Centers for Disease Control and prevention
(CDC) for preventing Nosocomial Pneumonia.
8
Elevation of head of bed 30 to 45 degree, unless medically contra
indicated
Continuous removal of subglottic secretion
Change of ventilator circuit no more often than every 48 hours.
Washing of hands before and after contact with each patient.
(Biancofiors 2006)
Dodek et al 2004 looked for physical, body positioning and pharmacological
interventions that might influence the development of VAP, independently
and in duplicate, these authors scored the validity of trials. The effect size
and confidence intervals; the homogeneity of results; and safety, feasibility
and interventions or strategies with relevance for nursing practice were
selected.
Use of Oral endotrachel tubes
Frequentcy of ventilator circuit changes
Use of a heat and moisture exchanger
Frequency of humidifier changes
Use of a closed suction system
Frequency of change in suction system,
Drainage of subglottic secretions
Use of kinetic beds
Use of semirecumbent positioning
Chest physiotherapy
9
These interventions were designed to assess knowledge about the impact of
the intervention on the risk for VAP. These were based on the economic
consideration.
1.3 Statement of the Problem
Critical Care Nurses knowledge of evidence based guidelines for preventing
Ventilator-Associated Pneumonia.
1.4 Definition of Terms
Ventilator associated pneumonia. : Ventilator. Associated Pneumonia (VAP) is
defined as pneumonia that develops after initiation of mechanical ventilation.
Critical Care Nurse: A critical care nurse is a licensed professional nurse
who is responsible for ensuring that all critically ill patients and their families
receive optimal care. In this study critical care nurse means Registered
nurses working as permanent and I or Temporary Staff nurses in Neuro
Medical and Neuro SurgicaiiCUs of SCTIMST, TVM.
Knowledge: Knowledge is defined as the facts information and skills
acquired by a person through experience and education. In this study
knowledge of evidence based guidelines means, measured as the scores
obtained in the knowledge test, administered by the investigator.
1.5 Objectives of the study
1. To assess the critical care nurses knowledge of evidence based
guidelines for preventing Ventilator-Associated Pneumonia.
2. Tofind out the relationship between critical care nurses knowledge of
evidence based guidelines for preventing Ventilator Associated Pneumonia
and selected variables.
10
r 1.6 Methodology
The survey approach is used in this study. The data will be collected from 30
staff nurses who are working in NMICU and NSICU of SCTIMST. After
obtaining informed consent from each nursing staff; a multiple choice
questionnaire is given. The questionnaire is related to prevention of
Ventilator Associated Pneumonia .. The validity of the tools are checked by·
the experts of SCTIMST. The duration of the study is August to October
2007.
1.7 Limitations of the study
The study is limited to Staff Nurses working in two intensive care units of
SCTIMST.
1.8 Summary
This chapter deals with introd.uction, background of the study need and
significance of the study, statement of the problem, definition of terms,
objectives of the study, methodology and limitations.
1.9 Organization of report
The chapter II deals with summary of related reviewed. Chapter Ill deals with
methodology of study. Chapter IV contains analyses and interpretation of the
findings. Chapter V consists of summary, conclusion, implication and
limitation the study and recommendations. This report also includes a
selected bibliography and appendix.
11
···----·----~--------
CHAPTER II
THE REVIEW OF LITERATURE
The review of literature is an important aspect of any research project from
beginning to end. It gives greater insight into the problems and helps in
selecting methodology, developing tools and also analyzing data. With these
in view an intensive review of literature has been done.
The review of literature relevant to this study is presented in the following
sections
2.1 Evidence based guidelines for preventing VAP
The centers of Disease Control and Prevention (CDC) guidelines
recommended staff education about epidemiology and infection control
practice related to prevention of VAP. One recommended strategy is for staff
to participate in interventions to prevent VAP. Knowing the VAP organisms
prevalent in the unit is one component of the recommended staff education.
(Tablan et al2003)
The Academic Center for Evidence based practice (ACE} star model was
used to implement evidence - based Clinical Practice Guidelines (CPG) in
order to decrease Ventilator - Associated Pneumonia incidence rates
ventilator days. The goal was to interrupt person-to-person transmission of
bacteria and bacterial colonization using low-cost, evidence based -
strategies to prevent VAP. A clinical practice guidelines was developed for
the prevention of VAP and included five nursing activities, head of bed-
12
elevation, Oral care, ventilator tubing condensate removal, hand hygiene
and glove use (Abbott et al 2006)
2.2 Educational programme for preventing VAP
Education is the key to prevent VAP. Study found that VAP rate at two
teaching hospitals were reduced by an average of 46% of after the
respiratory therapist and intensive care nurses completed a staff
development programme about risk factors and strategies to prevent VAP.
The strategies to prevent VAP are effective only if staff is educated about
VAP and encouraged to follow best practice guideline. (Kollef MH 1999). The
research is selected nursing intervention or strategies with relevant of
nursing practice. The questionnaire also included the question on general
characteristics response, sex, years of ICU experience where respondent
worked and whether the respondent had a special degree in emergency and
intensive care (Labeau et al 2007)
2.3 Oral health and Ventilator Associated Pneumonia
VAP is the leading cause of death from nosocomial infections and is the
second most common nosocomial infection in the United States.
Mechanically ventilated patients have a six fold to 21 fold increased risk of
developing pneumonia in to 10 to 25 percent of ventilated patients
developing the disease. Mechanical ventilation involves the placement of an
endotracheal tube in to the lower airway. The bacteria that cause disease
colonize the tube surface, which facilitates the· transits of bacteria to the lung.
(Sufdar 2005)
13
Colonization of the intestinal tract has been assumed to be Important in the
pathogenesis of Ventilator Associated Pneumonia (VAP) but related impact
of oropharyngeal, gastric or intestinal colonization have not been elucidated,
our aim was to prevent VAP by modulation of oropharyngeal colonization,
without influencing gastric and intestinal colonization and without systemic
prophylaxis. (Dennis 2001)
Evidence based guideline for preventing VAP
Cason et al (2007) prepared guideline for the prevention of Ventilator
Associated Pneumonia in intensive care units. The researches found that
such guidelines protocol helped to significant reduction in rate of Ventilator
Associated Pneumonia.
Abbott et al (2006) conducted a study about "Adoption of a Ventilator -
Associated Pneumonia clinical practice guideline. The researchers -
associated pneumonia clinical practice guidelines. The researchers found
that the academic center for evidence based Clinical Practice Guideline
(CPG) in order to decrease Ventilator Associated Pneumonia. The main goal
was to interrupt person to - person transmission of bacteria and bacterial
colonization using low cost, evidence based strategies to prevent VAP. The
observation data were collected to· evaluate the adoption of the Clinical
Practice Guideline (CPG) in order to decrease Ventilator-Associated
Pneumonia. The main goal was to interrupt person low cost evidence based
strategies to prevent VAP. The observation data were collected to evaluated
the adoption of the CPG while caring for 106 ventilated patients. The results
of this research study support the idea that adoption of evidence based
14
practice based practice contributed to decreased VAP rates. Therefore the
ICU headers should emphasize strategies that routines adoption of evidence
based clinical practice guidelines.
Minerva (2007) conducted a study to evaluate the nurses' knowledge and
application of evidence based guidelines for preventing Ventilator
Associated Pneumonia. The study was conducted in 106 nurses working in
the ICU of a major Italian hospital. 84 nurses responded to the
questionnaire, only 20 declared that their knowledge of VAP and the
strategies used to prevent VAP. It were satisfactory, where 36 declared that
they were poorly informed, 14 nurses said that they applied on more
strategies and 14 that they applied none. The result of these survey VAP
prevent strategies are wildly applied by nurses, but not a responsible and
informed manner. It is important to ensure that nurses receive continuous
training and are involved in drawing up and updating departmental protocol
and guidelines for care and behavior.
Hyeland (2002) evaluated the current use of strategies to prevent VAP and
to identify interventions to target for quality improvement initiatives. These
research studies suggest that significant opportunities. These research
studies suggest that significant opportunities exit to Improve VAP preventing
practice in Canada.
Educational programme for preventing VAP
Carolyn (2007) prepared a questionnaire for evaluating the extent to which
'nurses working in the intensive care units for managing the adult patient
receiving mechanical ventilation'. The study conducted nurses attending
15
education seminars in united state. 29 item questionnaire about the type and
frequency of care provided. Result of this survey total twelve hundred (1200)
nurses completed the questionnaire, most 50% reported with hand washing
guideline, 25% reported wearing gloves, 25% reported having an oral care
protocol in their hospital. The questionnaire had faced and content validity.
The researchers found that oral care protocol are more often congruent with
guidelines than are practice of nurses employed hospital without such
protocol. Significant reduction in rate of Ventilator-Associated Pneumonia
may be achieved by broader implementation of oral care protocol.
Stijn(2007) a Survey using a validated multiple choice questionnaire
developed to evaluate nurses knowledge to VAP prevention. The
questionnaire was distributed and collected during the annual Congress of
the Flemish society for critical care nurses (November 2005). The
demographic data included were gender, years of intensive care experience,
number of critical beds and whether the respondents hold a special degree
in emergency and intensive care.
The researcher's collected 635-questionnaire20% of the respondents the
oral route as recommended, way for intubations. It was known by 49%
respondents that ventilator circuits should be changed for each new patient.
Heat and moisture exchanges were checked as recommended type of
humidifiers by 55% of respondents, but only 13% knew that it is
recommended to change then once weekly. Semi recumbent positioning is
well known two prevent VAP (90%) the average knowledge level was higher
among those holding a special degree in emergency and intensive care.
16
Result of this survey with the questionnaire could be used to focus
educational program on preventing VAP.
Sierra et al (2005) conducted a study "for prevention of ventilator associated
pneumonia and its diagnosis in ICU through a returned completed
questionnaire. This survey conducted in 32 hospitals of the public health
care system of southern Spain. The study suggested that clinical practice for
preventing and diagnosis Ventilator Associated Pneumonia is variable.
Labeau et al (2007) developed a reliable and validated a questionnaire for
evaluating critical care nurses knowledge for preventing Ventilator
Associated Pneumonia. Researchers selected a total 10 interventions or
strategies with relevance of nursing practice. The questionnaire also
included questions on general characteristics of the respondents; sex, years
of 1cu experience, number of ICU beds in the hospital where the respondent
worked and any other special degree. In emergency and intensive care the
most 368 respondents were women. A total of 274 respondents had more
than 10 years of ICU experience and 274 worked in the units with more than
15 beds hospital. The result of this survey with this questionnaire can be
used to focus educational program on Ventilator Associated Pneumonia.
Oral health and Ventilator Associated Pneumonia
Ross (2007) conducted a study in a single critical care center in (USA). The
impact of an evidence based practice education program on the role of oral
care in the prevention of Ventilator Associated Pneumonia. The researchers
conducted the education program would improve the quality of oral care
delivered to mechanically ventilated patients, there by reducing the VAP.
17
The researchers found that VAP rate have decreased by 50% following
Evidence Based Practice (EBP) educational program focused on patient
outcome rather than a task to be performed improved the quality of oral care
delivered by the nursing staff.
Genu it et al (2001) a retrospective study was conducted over a period of 10
months (October-1998 July 1999) in surgical ICU patients requiring
mechanical ventilation (No.95) during the first 5 months, a WP was applied
to all patients requiring mechanical ventilation. During the following 5
months, a Chlorhexidine (CH) 0.12% oral rinse administered twice daily was
added to the protocol, initiated on ICU admission in all incubated patients.
The data collection included age, gender, race, risk factor, Co morbid
conditions, severity of a the acute illness at admission, duration of ventilation
ICU and total hospital length to stay, and incidence of VAP and in hospital
morality rates. Both WP and WP+CH groups were compared using the
National Nosocomial Inflection Surveillance (NNIS) and hospital databases
as historic controls.
The result of these study the institution of WP alone led only to a slight
decrease in the incidence of VAP but a significant reduction in the median
duration of mechanical ventilation by 40% (4.5 days, P<0.008). The addition
of CH to the WP led to a significant reduction and delay in occurrence of
VAP (37% overall 75% for late VAP, P<0.05)
Deriso and Colleagues (1996) conducted a prospective study was on
example of a well-designed intervention that demonstrates the potential for
improved oral hygiene to prevent pneumonia. The authors examined two
18
\
groups of subjects who were admitted to a surgical ICU a test group of 173
people who received a 0.12 percent chlorhexidine and oral rinse twice a day
and control group of 180 subjects who received a placebo rinse. This study
found that the incidence of pneumonia in the chlorhexidine group was 60
percent lower than that in the control group.
2.4 Summary
The review of literature on the above areas helped the investigator to gain
knowledge about the prevention of Ventilator-Associated Pneumonia. The
literature review also helps in the design of the study, development of tool,
information about sample, data collection and plan of analysis.
19
3.1 Introduction
CHAPTER Ill
METHODOLOGY
This chapter provides a brief description of different steps taken to conduct
this study. It deals with the research approach, research design, setting, the
sample and sampling technique, development of tool, description of tool,
pilot study, data collection procedure and plan of analysis.
3.2 Research approach
The survey approach was selected as the objectives of the study were to
based on guideline for preventing VAP, in SCTIMST, TVM.
3.3 Settings
The study was conducted in the Sree Chitra Tirunal Institute for Medical
Science and Technology, Trivandrum.
3.4 Sample and Sampling Techniques.
The sample was selected from the nursing staff working in NSICU and
NMICU of SCTIMST, Trivandrum. The size of the sample was 30. All the
staff nurses including in this study. The duration of study period was from
August 2007 to October 2007.
3.5 Criteria for sample collection
Inclusion Criteria
Nursing staff working in NMICU and NSICU of SCTIMST, TVM.
Exclusion Criteria
Nursing staff working in other department.
20
3.6 Development of Tool
Data collection tool refers to instruments, which was constructed to obtain
relevant data. An extensive review and study of literature helped in preparing
items for the tool. Labeau et al 2007 has prepared a reliable and valid
questionnaire to determine Critical Care Nurse's knowledge of evidence
based guidelines for preventing VAP. The investigator used this
questionnaire as tool for the study the tool was approved by experts of
SCTIMST, Trivandrum
3.7 Description of Tool
The tool used in the present study consisted of two parts
Part I
Part one consists of personal data such as Age, Area of working, prof.
qualification and ICU experience in years.
Part II
Knowledge were assessed by using a standardized questionnaire the
selection of multiple choice questions with 4 response alternatives or options
(The correct answer I response and 3 destructors or alternatives that are not
the answer). The selection of interventions or strategies to prevent VAP was
based on a recently published review of evidence-based guidelines for
preventing VAP. (Labeau et al 2007) On the basis. of the review a total of 1 0
interventions or strategies relevant for nursing practice were selected.
Use of endotracheal tubes, Frequency of ventilator circuit changes. Use of a
heat and moisture exchanger, Frequency of humidifier changes, use of a
closed suction system, Frequency of change in suctions system. Drainage of
21
subglottic secretion, use of kinetic beds, use of semi recumbent positioning
and Chest Physiotherapy. Actual duration of the knowledge assessment of
nursing staff was about 5-10 minutes.
3.8 Pilot Study
After obtaining permission from the authorities the pilot study was conducted
among 5 critical care nurses in cardiac ICU of SCTIMST between the age
group of 23-26. The purpose of the study was to test the feasibility. The pilot
study gave more information about the research study. The total time period
required was 5 to 10 minutes. The pilot study samples were excluded from
the main study. After making necessary correction in the tool, the main study
was conducted.
3.9 Data Collection
For data collection formal permission was obtained from the authorities. The
total period of data collection was from August to October 2007. The
investigator first introduced and explained the need and purpose of study.
Confidentiality of their responses was assured and consent was obtained
from each nursing staff. The nursing staffs were interviewed with the
structured tool. The time takes for the assessment was about 5 - 10 minutes.
3.10 Plan of analysis
The investigator developed a plan for data analysis after the pilot study. The
data obtained from the nursing staff would be analyzed by descriptive
. statistics and present in the form of bar diagram.
22
3.11 Summary
The chapter presented the research approach used for the study research
design of the study, setting of the study, sample and sampling techniques
development of description of tool, pilot study, data collection procedure and
plan of analysis.
23
CHAPTER IV
ANALYSIS AND INTERPRETATION OF DATA
This chapter analyses and interprets data collected from 30 staff nurses who
areworking in NMICU, NSICU of SCTIMST, TVM.
Analyses are a process of organizing and synthesizing data in such a way
research questions can be answered. The questionnaire was based on
evidence-based guidelines for preventing Ventilator Associated Pneumonia.
Interpretation refers to a process of making sense of the results and
examining the implications of the findings in a boarder context.
The aim of this research study was to assess the Critical Care Nurses
knowledge of evidence based guide lines for preventing Ventilator
Associated Pneumonia and to find out the relationship between critical care
nurses knowledge of evidence based guidelines for preventing VAP and
selected variables.
The data were coded and entered in Microsoft Excel sheet and were
analyzed using Epi Info version3.2.
The findings of the study were arranged and analyzed under the following
section.
4.1 Sample characteristics
4.2 Critical Care nurses knowledge of Ventilator Associated Pneumonia
guidelines.
24
4.1. Sample Characteristics
The age of the nurses ranged from 24 to 52 years with a mean of 35.3±8.75,
median 37.5 and mode 38. The age distribution is given in Table 4.1.
Table 4.1 Distribution of sample by age
Age Group Frequency Percentage
24-31 years 13 43.3%
32-39 years 9 30%
40-46 years 5 16.6%
47-52 years 3 10%
Total 30 99.9%
The data given Table 4.1 show that majority of nurses (73.3 %) were below 40
years. The same data is shown as bar diagram in the figure 4.1.
Table 4.1 Distribution of sample by age
24-31 32-39 42-46 47-52
Age Group
25
Distribution of sample according to the area of work is given in Table 4.2 and
figure 4.2
Table 4.2 Distribution of sample according to the area of work
Area of Work No. of Staff Percentage of mark
NMICU 16 53.3%
NSICU 14 46.6%
The data given Table 4.2 show that Critical Care Nurses those who are
working in NMICU and NSICU. The percentage is almost same in both ICU
staffs.
• NMICU
• NSICU
Figure 4.2 Pie Diagram showing distribution of sample according to the area
of work.
26
Distribution of samples according to the professional qualification is given in
table 4.3 and Figure 4.3
Table 4.3 Distribution of samples according to the professional qualification
Professional qualification Frequency Percentage
GNM 14 46.7%
B.Sc (N) 8 26.7%
Specialty nursing 8 27.7%
Total 30 100.0%
The data given in table 4.3 show that nurses professional qualification (GNM,
BSC (N) and specialty nursing) from total 30 sample.
• GNM • B.Sc (N) • Speciality nursing
Fig.4.3 Pie diagram showing the distribution of samples according to the
professional qualification.
27
l • 4.2 Critical Care Nurses Knowledge of ventilator associated pneumonia
guidelines.
Knowledge of 30 critical care nurses ranged from 3 to 1 0 (maximum score
10) with a mean of 8.1±2, median 9 and mode 10. This shows that mean
knowledge of nurses working in ICU with regard to VAP is above average.
The relationship of ICU nurses knowledge and selected variables are shown
in Table 4.4, 4.5 and 4.6.
Table 4.4 Mean, standard deviation and 'p' value of nurses knowledge by
ICU experience.
N=30
Experience Category Mean Standard p deviation
s3 years 8.36 1.98 N =14 0.52
>3 years 7.88 2.06 N=16
The given Table 4.4 show that the knowledge of critical care nurses with less
than 3 years experience ranged from 3 to 10. The knowledge of critical care
nurses with more than 3 years experience ranged from 4 to 10. The data given
in Table 4.4 show that there was no significant difference between the mean
knowledge of nurses about VAP with regard to their experience. The mean
knowledge score of nurses and that of nurses with s 3 years experience
were 8.36± 1.98, and that of nurses with > 3 years experience was
7.88±2.06. A student 't' test did not show in significant difference in the mean
knowledge (p=0.52).
28
4.1. Sample Characteristics
The age of the nurses ranged from 24 to 52 years with a mean of 35.3±8.75,
median 37.5 and mode 38. The age distribution is given in Table 4.1.
Table 4.1 Distribution of sample by age
Age Group Frequency Percentage
24-31 years 13 43.3%
32-39 years 9 30%
40-46 years 5 16.6%
47-52 years 3 10%
Total 30 99.9%
The data given Table 4.1 show that majority of nurses (73.3 %) were below 40
years. The same data is shown as bar diagram in the figure 4.1.
Table 4.1 Distribution of sample by age
24-31 32-39 42-46 47-52
Age Group
25
Distribution of sample according to the area of work is given in Table 4.2 and
figure 4.2
Table 4.2 Distribution of sample according to the area of work
Area of Work No. of Staff Percentage of mark
NMICU 16 53.3%
NSICU 14 46.6%
The data given Table 4.2 show that Critical Care Nurses those who are
working in NMICU and NSICU. The percentage is almost same in both ICU
staffs.
• NMICU
• NSICU
Figure 4.2 Pie Diagram showing distribution of sample according to the area
of work.
26
Distribution of samples according to the professional qualification is given in
table 4.3 and Figure 4.3
Table 4.3 Distribution of samples according to the professional qualification
Professional qualification Frequency Percentage
GNM 14 46.7%
B.Sc (N) 8 26.7%
Specialty nursing 8 27.7%
Total 30 100.0%
The data given in table 4.3 show that nurses professional qualification (GNM,
BSC (N) and specialty nursing) from total 30 sample.
• GNM • B.Sc (N) • Speciality nursing
Fig.4.3 Pie diagram showing the distribution of samples according to the
professional qualification.
27
Table 4.5 Mean, standard deviation and 'p' value of nurse's knowledge by
qualification.
Professional I
Mean Standard p
Qualification deviation
GNM 7.43 2.47
N=14
BSc (N) 0.21 8.50 1.31
N=8
Specialty nursing 8.88 1.36
N=8
Table 4.5 show that the critical care nurses knowledge ranged 3 to 10
(GNM), 6 to 10 Bsc (N), 6 to 10. Specialty nursing. The Table 4.5 shows that
the mean knowledge of nurses with GNM qualification was 7.43±2.47 with
Bsc nursing qualification it was 8.50±1.31 and for nurses with specialty
qualification it was 8.88±1.36. A students 't' test did not show a significant
difference in this mean knowledge. (p=0.21)
29
Table 4.6 Mean Standard deviation and 'p' value of nurses knowledge by
area of work.
Type of ICU Mean Standard P value
deviation
NMICU 8.69 1.74
N=16
0.08
NSICU 7.43 2.14
N=14
Table 4.6 the knowledge of nurses working in NMICU ranged from 4 to 10
and in NSICU ranged from 3 to 10. The data given in Table 4.6 shows that
the mean knowledge of NMICU nurses was 8.69±1.74, and that of NSICU
nurse was 7.43±2.14. Though the mean knowledge of NMICU nurses was
more than NSICU. A student t' test did not show a significant difference in
this mean knowledge (p=0.8).
30
Table 4.7 Percentage of knowledge on Ventilator Associated Pneumonia
guidelines
I Sl. I Question Frequency Percentag No e
1. Use of oral endotracheal tubes 21 70%
2. Frequency of ventilator circute 22 73.3% changes
3. Use of a heat and moisture 29 96.7% exchanger
4. Frequency of humidifier 22 76.3% chang_es
5. Use of a closed section system 23 76.7%
6. Frequency of changes in 19 63.3% suction system
7. Drainage of subglottic 24 80% secretion
8. Use of kinetic beds 27 90%
9. Use of semirecumbent position 28 93%
10 Chest physiotherapy 28 93.5%
The data given in Table 4.7 show the critical care nurses knowledge in
specific content area related to VAP guidelines. There were 10 questions
with relevant nursing practices. The percentage of nurses who had oral
endotracheal tubes, frequency of Ventilator circuit changes, the use of heat
and moisture exchange, frequency of humidifier changes, use of a closed
suction system, frequency of changes suction system, drainage of subglottic
secretions, use of kinetic bed semi recumbent position and chest
physiotherapy. The percentage of nurses who had correct knowledge with
regard to the different guidelines ranged from 63.3% to 96.7%.
31
l 1 4.3 Summary
This chapter deals with analyses and interpretation of data collected from 30
critical care nurse of SCTIMST, TVM. Descriptive inferential statistics were
use for the analyses. Bar and Pie diagram were used to illustrate the findings
of the study.
32
CHAPTER V
SUMMARY, CONCLUSION, DISCUSSION,
LIMITATIONS AND RECOMMENDATIONS
5.1 Introduction
A brief account of the study is given in this chapter, which cover objectives,
findings of the study and possible application of the result. Recommendation
for future research and suggestions for improving the present's study are
also presented.
5.2 Summary
This study was conducted with the objectives to assess the critical care
nurses knowledge of evidence based guidelines for preventing Ventilator
Associated Pneumonia and to find out the relationship between critical care
nurses knowledge of evidence based guidelines for preventing Ventilator
associated Pneumonia and selected variables.
A review of related research literature helped the investigator to get a clear
concept about the topic under taken, as well as to develop tools,
methodology of study and decide plan of data analyses.
The study was conducted in NMICU and NSICU of SCTIMST; the size of the
sample was 30. All staff nurses working in their two units were including in
this study. The duration of the study was from August 2007 to October 2007.
The selection of intervention or strategies to prevent the VAP was based on
a recently published review of evidence-based guidelines for preventing
VAP. (Labeau et al 2007). On the basis of this review of literature a total 10
33
intervention or strategies relevant for nursing practice in this setting were
selected.
5.3 Objectives of the study
1. To assess the critical care nurses knowledge of evidence based
guidelines for preventing Ventilator Associated Pneumonia.
2. To find out the relationship between critical care nurse's knowledge of
evidence based a guidelines for preventing Ventilator associated Pneumonia
and selected variables.
5.4 Limitation
The study is limited to staff nurses working in two intensive care units of
SCTIMST.
5.5 Major findings of the study
Knowledge of 30 critical care nurses ranged from 3 to 10 (maximum score
10) with a mean of 8.1±2, Median 9 and Mode 10, this shows that mean
knowledge of nurses working in ICU with regard to VAP is above average
.There was no significant difference between the mean knowledge of nurses
about VAP with regard to their experience
Critical care nurses knowledge ranged 3 to 10 (GNM),6 to 1 O(BSC nursing)
and 6 to 10 speciality nursing .The mean knowledge of nurses with GNM
qualification was 7.43±2.47 with BSC nursing qualification it was 8.50±1.31
and nurses with speciality nursing qualification was 8.88 ± 1.36.There was
no a significant difference in this mean knowledge regard to their
professional qualification
34
Knowledge of nurses working in NMICU ranged from 4 to 10 and NSICU
ranged from 3 to 10. the mean knowledge of NMICU nurses was 8.69± 1.74
and that of NSICU nurses was 7.43 ±2.14 ,though the mean knowledge of
NMICU nurses was more.There was no a significant difference in this mean
knowledge
Critical care nurses knowledge in specific content areas related to VAP
guidelines. There were the percentage of nurses who had correct knowledge
with regard to the different guidelines ranged from 63.3%to 96.7%.
5.6 Recommendations for future study
Keeping in mind the findings and limitations of the study, the following
recommendation were made for future research.
Similar study would be repeated in other intensive care unit of this institute.
5.7 Discussion
Labeau et al (2007) developed a reliable and valid questionnaire to
determine critical care nurses knowledge of evidence-based guidelines for
preventing VAP.
The selected interventions and multiple-choice questions (one question per
intervention) were subjected to face and content validation. The
questionnaire was distributed and collected during the annual congress of
the Flemish Society of critical care nurses (Belgium November 25, 2005).
The researchers collected 368 questionnaire (respondence rate 74.6%).
19% of the respondence recognized the oral route as recommended the way
of intubation. It was known by 49% of respondents that Ventilator Circuit
should be changed for each new patients. Heat and moisture exchangers
35
were checked as recommended type humidifier by 55% of respondents , but
only 13% knew that it is recommended to change them oncy weekly. Closed
suction were identified as recommended by 17% of respondents and 20%
knew that these must be changed for each new patients only. 60% and 49%
respectively recognized subglottic drainage and kinetic beds to reduce the
incidence of VAP. Semi recumbent position is well known to prevent VAP
(90%) the average knowledge level was higher among those holding a special
degree in emergency and intensive care.
Result of these surveys with the questionnaire could be used to focus
educational programme on preventing VAP.
The investigater selected the sample from the nursing staff working in
NSICU and NMICU of SCTIMST,TVM. The size of the sample was 30. The
duration of study period was from August 2007 to October2007.The
investigator collected 30 questionnaire , 70% of the respondence recognized
the oral route as recommended the way of intubation. It was known by
73.3% of respondents that ventilator circuit should be changed for each new
patient. Heat and moisture exchange were checked as recommended as the
type of humidifier by 96.7% respondents, but 76.3% knew that it is
recommended to change them once weekly. Closed suction system were
identified as recommended by 76.7% of respondents and about frequency
of change in suction system 63.3% of respondents, 80% and 90% of critical
care nurses respectively recognized subglottic drainage and kinetic beds
reduce incidence of Ventilator Associated Pneumonia.Semirecumbent
position is well known to prevent VAP 93% and chest physiotherapy reduce
36
the risk of VAP 93.5% respondents. The percentage of nurses who had
correct knowledge with regard to the different guidelines ranged from 63.3%
to 96.7%.
5.8 Conclusion
Based on the findings of the study, the following conclusions were drawn.
The mean knowledge of nurses working in ICU with regard to the knowledge
of preventing VAP is above average.
The study show that there was no significant difference between mean
knowledge of nurses about VAP with regard to the knowledge of preventing
their experience, Professional qualification or area of work.
37
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18. Cross et al, 1988. Nosocomial pneumonia is mechanically ventilated
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40
Age
Department
ICU Experience in years
Prof. Qualification
APPENDIX A
NMICU/NSICU
GNM/BSC (N) I Specialization
APPENDIX B
CRITICIAL CARE NURSE KNOWLEDGE OF EVIDENCE BASED
GUIDELINES FOR PREVENTING VENTILATOR ASSOCIATED
PNEUMONIA (VAP)
Encircle the best choice
1. Oral vs nasal route for endotracheal intubation
a. Oral intubation is recommended
b. Nasal intubation is recommended
c. Both routes of intubation can be recommended
d. I do not know
2. Frequency of ventilatory circuit changes
a. It is recommended to change circuits every 48 hours
b. It is recommended to change circuits every week
c. It is recommended to change circuits for every new patient
d. I do not know
3. Type of airway humidifier
a. heated humidifiers are recommended
b. heat and moisture exchangers are recommended
c. both type of humidifiers can be recommended
d. I do not know
4. Frequency of humidifier changes
a. It is recommended to change humidifiers every 48 hours
b. It is recommended to change humidifiers every 72 hours
c. It is recommended to change humidifiers every week.
d. I do not know
5. Open and closed suction system
a. Open suction system are recommended
b. Closed suction system are recommended
c. Both system can be recommended
d. I do not know
6. Frequency of changing the tubes in the wall suction systems
a. Daily changes are recommended
b. Weekly changes are recommended
c. It is recommended to change system for every new patient
d. I do not know
1 1 7. Endotracheal tubes with extra lumen for drainage of subglottic
secretions
a. These endotracheal tube reduce the risk of VAP
b. These endotracheal tube increase the risk of VAP
c. These endotracheal tubes do not influence the risk for VAP
8. Kinetic vs Standard beds
a. Kinetic beds increase the risk for VAP
b. Kinetic beds reduce the risk for VAP
c. The use of kinetic beds does not influence the risk for VAP
d. I do not know
9. Patient positioning
a. Supine positioning is recommended
b. Semirecumbent positioning is recommended
c. The position of the patient does not influence the risk for VAP
d. I do not know
10. Chest physiotherapy
a. Chest physiotherapy reduces the risk for VAP
b. Chest physiotherapy does not reduce the risk for VAP
c. The influence of chest physiotherapy on the risk for VAP is unknown.
d. I do not know
Comments
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