Evidence based guidelines for prevention of Ventilator-associated Pneumonia among Intensive Care Unit Staff Nurses

 

Mrs. Indrawati Rao1, Dr. Prampal Kaur Cheema2

1PhD Research Scholar, Principal, Government College of Nursing, New Civil Hospital Campus,

Majura Gate, Surat, Gujarat-395001

2Principal, Swami Premanad College of Nursing, G.T. Road, Mukerian, Punjab-144211

*Corresponding Author E-mail: parampal_cheema@yahoo.co.in

 

ABSTRACT:

Ventilator associated pneumonia is a common hospital acquired pneumonia in ventilated patients. VAP occurs in 28% of patients who receive mechanical ventilation, where its rate of occurrence varies with the duration of mechanical ventilation. The aim of the study was to assess impact of educational intervention on knowledge and practice of intensive care staff   nurses regarding evidence based guidelines for prevention of ventilator-associated pneumonia (VAP) among patients admitted in intensive care units of New Civil Hospital, Surat. Evaluative (quantitative) research approach and pre experimental with one group pretest post test research design was adopted for this study. A sample of 30 staff nurses working in intensive care unit of New Civil Hospital, Surat were selected by non-probability purposive sampling technique. Knowledge level was assessed by self-structured knowledge questionnaire and practice level by observational checklist. The data was analyzed by using descriptive and inferential statistics. The results revealed that maximum subjects 46.66 % were between age group 20-30 years, majority 90 % were female, about 80% had done GNM, 53% were having between 5-10 years of working experience. The mean posttest knowledge score was 20.67 higher than the mean pretest knowledge score 15 and mean posttest practice score was 11.8 higher than the mean pretest practice score 6.4.The karl pearson’s correlation value computed between knowledge and practice scores of staff nurses r was 0.9, this indicates the existence of  moderately positive correlation between knowledge and practice score. The calculated chi- square value for knowledge and practice scores with selected socio demographic variables revealed that there was no statistical association. Furthermore the study revealed that educational intervention program on evidence based guidelines for prevention of ventilator associated pneumonia was effective in improving knowledge and positive practice regarding VAP.

 

KEYWORDS: Knowledge, practice, ventilator associated pneumonia, intensive care unit, evidence based guidelines

 

 

INTRODUCTION:

“Every human being is the author of his own health or disease.”

                                                               Gautham Budha

 

Ventilator associated pneumonia is a common hospital acquired pneumonia in ventilated patients. Ventilator Associated Pneumonia (VAP) is defined as pneumonia occurring in a patient within 48 hours or more after intubation with an endotracheal tube or tracheostomy tube, which is not present before. It is characterized by a new or a progressive pulmonary infiltrate, fever, leukocytosis and purulent tracheobronchial secretions. Approximately 10-20% of critical care patients develop VAP. It carries a high mortality rate ranging 6% - 68% and may be as high as 74% in high risk populations, indicating a serious health hazard among ventilated patients. VAP is associated with increased morbidity, mortality, duration of hospitalization and cost of treatment.1

 

Implantation of evidence-based guidelines (EBGs) in clinical practice is an effective measure for prevention of prevalent disease. Development and implementation of EBGs is an important and complex process and need to abundant time and cost. Although the countries and healthcare systems are spending billions of dollars annually for translation of EBGs into clinical practice, these costly efforts have not yielded a brilliant results.2 Prevention of ventilator associated pneumonia (VAP) by the way of implementation of EBGs, is one of the most common examples of these hard labors. The leading rationale of importance of controlling VAP is because of its high prevalence, increased morbidity and mortality, prolonged ICU and hospital stay, and excessive costs. Although the abundant time and energy which spend for prevention of VAP, this nosocomial infection is still remains a challenging problem in intensive care units (ICUs).3,4

 

Previous studies are shown that preventive strategies of VAP can decrease the rate of VAP and consequently can decrease the burden of costs on healthcare systems. Furthermore, prevention of VAP can improve patients’ outcomes and increase quality of care.5

 

Need of the study:

Critically ill patients in the intensive care unit are at high risk for infections associated with increased morbidity, mortality, and health care costs. The overall infection rate in critically ill patients approaches 40% and may be as high as 50% or 60% in patients who remain in the ICU for more than 5 days. Respiratory tract infections account for 30% to 60% of all such infections. The incidence of pneumonia acquired in the ICU ranges from 10% to 65%. Among patients at high risk for ventilator-associated pneumonia (VAP) are those who have chronic obstructive pulmonary disease, burns, neurosurgical conditions, the acute respiratory distress syndrome, and witnessed aspiration; those who are re intubated; and those who receive paralytic agents or enteral nutrition.6,7

·       Ibrahim et al.  (2011) examined 132 patients with ventilator associated pneumonia. Most of the patients had underlying illnesses such as congestive heart failure (55%), Chronic Obstructive disease (45%), Diabetes Mellitus (27%), Acute Renal failure (28%), Immuno compromise (14%) and Bacteremia (9.8%).

·       Zeinab M. Hassan (2016) conducted study on Knowledge level of nurses in Jordan on ventilator‐associated pneumonia and preventive measures. Pre and post intervention observational research design used. Data based on a self‐reported questionnaire from 428 nurses who worked in intensive care units were analyzed. More than three‐quarters of nurses had a low knowledge level regarding pathophysiology, risk factors and ventilator‐associated pneumonia preventative measures. Nurses showed significant improvements in mean scores on the knowledge level of ventilator‐associated pneumonia and prevention measures after an educational programme.8

 

Problem Statement:

A study to assess the effectiveness of educational intervention program on knowledge and practice regarding evidence based guidelines for prevention of ventilator-associated pneumonia (VAP) among intensive care staff nurses at New Civil Hospital, Surat, Gujarat.

 

Objectives:

·       To assess the pretest knowledge and practice regarding evidence based guidelines for prevention of ventilator associated pneumonia among staff nurses working in intensive care units at New Civil hospital, Surat.

·       To develop and implement the educational intervention program regarding evidence based guidelines for prevention of ventilator associated pneumonia among staff nurses working in intensive care unit at New Civil hospital, Surat.

·       To evaluate effectiveness of educational intervention program by compare pretest and post test knowledge and practice score.

·       To find out the correlation between knowledge and practice regarding evidence based guidelines for prevention of ventilator associated pneumonia among staff nurses working in intensive care unit at New Civil hospital, Surat.

·       To determine the association between pretest knowledge and practice score regarding evidence based guidelines for prevention of ventilator associated pneumonia among staff nurses with selected socio- demographic variables.

 

Hypothesis:

H01: There will be no significant difference between the mean pre-test and post-test knowledge score of staff nurses working in intensive care unit regarding evidence based guidelines for prevention of ventilator associated pneumonia.

H02: There will be no significant difference between the mean pre-test and post-test practice score of staff nurses working in intensive care unit regarding evidence based guidelines for prevention of ventilator associated pneumonia

H03: There will be no significance correlation between pretest knowledge score and practice score of staff nurses working in intensive care unit regarding evidence based guidelines for prevention of ventilator associated pneumonia.

H04: There will be no significant association of pre-test knowledge scores of staff nurses working in intensive care unit regarding evidence based guidelines for prevention of ventilator associated pneumonia with their selected demographic variables.

H05: There will be no significant association of pre-test practice score of staff nurses working in intensive care unit regarding evidence based guidelines for prevention of ventilator associated pneumonia with their selected demographic variables.

 

Assumption:

·       Staff Nurses may have some knowledge and do practice regarding evidence based guidelines for prevention of VAP.

·       Educational intervention program upgrade their knowledge and make competent to do correct practice for prevention of VAP.

 

Delimitation:

Study is delimited to the staff nurses working in intensive care units of New civil Hospital, Surat.

 

RESEARCH METHODOLOGY:

Research approach– Quantitative research approach

Research design- Pre experimental one group pretest – posttest design

Variables of the study:

·       Independent variable: Educational Intervention Programme

·       Dependent variable: Knowledge and practice of Staff Nurses regarding prevention of VAP.

Research setting– Intensive care Unit, New Civil Hospital , Surat

Population– Staff Nurses working in Intensive care Unit of New Civil Hospital, Suart

Sample size– 30

Sampling technique– Non-probability purposive sampling technique

 

Description of data:

·         Section-I: Demographic variables of subject

·         Section–II: Self structured knowledge questionnaire- total 30 questions related to guidelines for prevention of VAP.

·         Section-III: Observational practice Checklist on hand hygiene, oral care and suctioning from ETT/ tracheostomy

·         Section–IV: develop educational intervention on evidence based guidelines for prevention of VAP.

 

Validity of data:

validated by 10 experts in the field of nursing.

 

Reliability: The reliability of the tool was calculate by using Split half method and the value were 0.8, 0.75 respectively.

 

Ethics and consent: Informed consent taken to all subject. Before conducting this study took permission from Medical Superitendentant, New civil Hospital, Surat.

 

RESULTS:

Section I: Frequency and percentage distribution of the socio-demographic variables.

Sl. No

Variable

Frequency (f)

Percentage (%)

1.

Age in years

20-30

14

46.66%

31-40

10

33.3%

41-50

06

20%

Above 50

0

0%

2.

Sex

Male

3

10%

Female

27

90%

Others

0

0%

3

Experience

0-5

16

53%

5-10

2

6.67%

10-15

10

33.3%

>15 years

2

6.6%

4

Area of experience

Medical

8

26.66%

Surgical

5

16.67%

ICU/CCU

10

33.33%

Emergency

5

16.67%

Ortho.

2

6.67%

5.

Qualification

A.N.M

0

0%

G.N.M

24

80%

B.Sc. N

6

20%

Any Other

0

0%

 

Table: 2 Significance difference between pretest and posttest knowledge score

Knowledge Score

Pre-test

Post-test

 

F

%

Mean

SD

f

%

Mean

SD

Mean difference

t value

Inference

Poor Knowledge 0-40%

6

20%

 

 

15

 

 

3.8

0

0

 

 

20.67

 

 

2.25

 

 

5.67

 

 

7.08

 

Significance

P<0.05

 Average Knowledge 40-60%

18

60%

5

16.60%

Good Knowledge 60-80%

6

20%

23

76.70%

Very Good Knowledge 80-100%

0

0

2

6.70%

 

Table: 3 Significance difference between pretest and posttest practice score

Practice Score

Pre-test

Post-test

 

f

%

Mean

SD

f

%

Mean

SD

Mean difference

t value

inference

0-40%

Very Poor Practice

12

40%

 

 

6.4

 

 

1.8

0

0

 

 

11.8

 

 

1.1

 

 

5.4

 

 

13.84

 

 

Significance<0.05

40-60%

Poor Practice

16

53.4%

0

0

60-80%

Average Practice

2

6.6%

22

73.4%

80-100%

Regular Practice

0

0

8

26.6%

 

·       Table: 2 revealed that the calculated value of paired t value (tcal = 7.08) is higher than the table value (t29 = 2.05). It indicates that the gain in knowledge score was statistically significant at p <0.05 level. So null hypothesis rejected and research hypothesis accepted.

·       Table: 3 revealed that the calculated value of paired t value (tcal = 13.84) is higher than the table value (t29 = 2.05). It indicates that the gain in practice score was statistically significant at p <0.05 levels. So null hypothesis rejected and research hypothesis accepted.

·       The karl Pearson's correlation value computed between knowledge and practice scores of staff nurses r was 0.9. This indicates the existence of moderately positive correlation between knowledge and practice score.

·       The calculated chi-square value revealed that there was no association between knowledge and practice of staff nurses regarding evidence based guidelines for prevention of ventilator associated pneumonia with selected socio demographic variables at 0.05 level of significance.

 

RECOMMENDATIONS:

Based on the findings of the study, the following recommendations have been made for study:

·       A similar study can be conducted by using true experimental approach and comparison between two different settings.

·       The study can be replicated on larger samples for better generalization.

 

CONCLUSION:

The study revealed that educational intervention program on evidence based guidelines for prevention of ventilator associated pneumonia was effective in improving and acquainting current knowledge of staff nurses as evidence by increased posttest knowledge and practice score of staff nurses regarding VAP.

 

REFERENCES:

1.      Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society, Clinical Infectious Diseases, Volume 63, Issue 5, 1 September 2016, Pages e61,e111, https://doi.org/10.1093/cid/ciw353, 14 July 2016

2.      Chaudoir SR, Dugan AG, Barr CH. Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures. Implementation science: IS. 2013; 8:22. PubMed PMID: 23414420. Pubmed Central PMCID: 3598720.

3.      Blot S, Rello J, Vogelaers D. What is new in the prevention of ventilator-associated pneumonia? Current opinion in pulmonary medicine. 2011 May;17(3):155-9. PubMed PMID: 21326100.

4.      Turton P. Ventilator-associated pneumonia in paediatric intensive care: a literature review. Nursing in critical care. 2008 Sep-Oct;13(5):241-8. PubMed PMID: 18816310.

5.      Jansson M, Ala-Kokko T, Ylipalosaari P, Syrjala H, Kyngas H. Critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia--a survey study. Intensive & critical care nursing: the official journal of the British Association of Critical Care Nurses. 2013 Aug;29(4):216-27. PubMed PMID: 23566622.

6.      Yeganeh M,Yekta H Farmanbar  R et al Knowledge of evidence-based guidelines in ventilator-associated pneumonia prevention, J Evid Based Med. 2019 Feb;12(1):16-21. doi: 10.1111/jebm.12188. Epub 2019 Feb 12.

7.      Dodek P, Keenan S, Cook D, Heyland D,Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia, Ann Intern Med. 2004 Aug 17;141(4):305-13

8.      Zeinab M Hassan RN, PhD Knowledge level of nurses in Jordan on ventilator‐associated pneumonia and preventive measures, https://doi.org/10.1111/nicc.12273

9.      Akin korhan Hakverdioğlu Yönt G et al, Knowledge levels of intensive care nurses on prevention of ventilator-associated pneumonia. Nurs Crit Care. 2014 Jan;19(1):26-33. doi: 10.1111/nicc.12038. Epub 2013 Jul 10

 

 

 

 

 

 

Received on 17.05.2019         Modified on 18.06.2019

Accepted on 21.07.2019       ©A&V Publications All right reserved

Int.  J. of Advances in Nur. Management. 2019; 7(4):301-304.

DOI: 10.5958/2454-2652.2019.00070.2