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...should reduce the risk of ventilator-associated pneumonia.
* OBJECTIVE To evaluate the extent to which nurses working in intensive care units implement best practices when managing adult patients receiving mechanical ventilation.
* METHODS Nurses attending education seminars in the United States completed a 29-item questionnaire about the type and frequency of care provided.
* RESULTS Twelve hundred nurses completed the questionnaire. Most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. Nurses in hospitals with an oral care protocol reported better compliance with hand washing and maintaining head-of-bed elevation, were more likely to regularly provide oral care, and were more familiar with rates of ventilator-associated pneumonia and the organisms involved than were nurses working in hospitals without such protocols.
* CONCLUSIONS The guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention are not consistently or uniformly implemented. Practices of nurses employed in hospitals with oral care protocols are more often congruent with the guidelines than are practices of nurses employed in hospitals without such protocols. Significant reductions in rates of ventilator-associated pneumonia may be achieved by broader implementation of oral care protocols.
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Ventilator-associated pneumonia (VAP) is the most common infectious complication among patients admitted to intensive care units (ICUs) and accounts for up to 47% of all infections among ICU patients. (1) When it occurs, VAP prolongs ICU length of stay and increases the risk of death in critically ill patients. (1) The data summary for 1992 to 2004 from the National Nosocomial Infections Surveillance System Report reveals a median VAP rate of 2.2 to 14.7 cases per 1000 patient days of mechanical ventilation in adult ICUs. (2) VAP continues to complicate the course of 8% to 28% of patients receiving mechanical ventilation. (3) For patients receiving mechanical ventilation in whom VAP develops, the estimated mortality rate is between 20% and 70%. (4-6)
An important precursor for the development of VAP is colonization of the oral cavity. The 2003 guidelines (7) from the Centers for Disease Control and Prevention (CDC) reported that 63% of patients admitted to an ICU have oral colonization with a pathogen associated with VAP. (7) Once in the ICU, 63% of patients admitted with an oral pathogen associated with VAP acquire an additional, second bacterial pathogen in the oral cavity. In 76% of VAP cases, the bacteria colonizing the mouth and lung are the same. (7) The most prevalent bacteria are gram-negative Pseudomonas aeruginosa and enterobacteria and gram-positive Staphylococcus aureus. (7)
The 2003 CDC guidelines for the prevention of VAP include recommendations for nursing care. These recommendations, summarized in Table 1, provide the best current directives for practice. The research evidence for the first 5 recommendations is strong and justifies broad-based implementation of the recommendations in healthcare. Recommendations 6 and 7 are based on strong theoretical rationale and clinical or epidemiological studies that provide supporting evidence.
To evaluate the extent to which ICU nurses implement these recommendations, we queried critical care nurses about the practices they use when caring for adult patients receiving mechanical ventilation. A national survey has not been completed since the CDC changed its guidelines in 2003.
Background
For each recommendation presented in Table 1, a brief summary of the evidence is provided. More recently published evidence also is included because it augments and expands the foundation for the CDC guidelines and highlights areas in which evidence continues to be gathered.
CDC Guidelines
Decontamination of hands before and after contact with a patient, along with wearing gloves, is an important action in the prevention of VAP. (7) The CDC guidelines recommend using either antimicrobial soap or nonantimicrobial soap and water if hands are visibly soiled with body fluids. Alcohol-based waterless antiseptic agents, such as hand rubs, are also good alternatives for soaps. Hand rubs can and should be used before and after contact with a patient if hands are not visibly soiled. Gloves should be changed and hands washed between contacts with different patients.
The 2003 CDC guidelines recommend staff education about epidemiology and infection control practices related to the 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.
Critically ill patients often have a depressed level of consciousness and an impaired gag reflex, leading to pooling of contaminated secretions in the posterior part of the oropharynx. Between 100 and 150 mL of secretions can accumulate within a 24-hour period. Microaspiration of these oropharyngeal secretions is a major risk factor for nosocomial pneumonia. (7) Placement of an endotracheal tube provides a direct pathway for these organisms to enter the lungs. In 85% of cases, the microorganism that causes the nosocomial pneumonia previously has been detected in cultures of microorganisms from subglottic secretions. (7) For these reasons, the CDC recommends that before an endotracheal tube cuff is deflated or an endotracheal tube is repositioned, the area above the cuff should be suctioned.
To reduce the risk of aspiration, the CDC recommends that patients receiving mechanical ventilation have the head of the bed elevated at an angle of 30[degrees] to 45[degrees] from horizontal unless contraindicated. Elevation of the head of the bed decreases the volume of gastric secretions, a change that reduces the risk for aspiration and VAP. (8)...
NOTE: All illustrations and photos
have been removed from this article.
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