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Effect of implementing training programme for nurses about care bundle on prevention of ventilator‐associated pneumonia among newborns
Nursing in Critical Care
Abstract
Background
Ventilator‐associated pneumonia (VAP) is a frequent and severe complication among newborns in neonatal intensive care units (NICUs). It is associated with elevated morbidity and mortality rates, more extended hospital stays and increased health care costs. Implementing preventive care bundles and structured sets of evidence‐based practices reduces VAP incidence. As primary caregivers, nurses are critical in consistently applying these preventive measures in NICU settings.
Aim
To evaluate the impact of a structured training programme on nurses' practices in the prevention of VAP among ventilated newborns in NICUs.
Study Design
This prospective, pre‐ and post‐intervention study was conducted with 27 nurses caring for mechanically ventilated newborns. All newborns admitted to the NICU who met inclusion criteria were included in the study (34 newborns pre‐intervention, 38 newborns post‐intervention and 41 newborns 3 months after the intervention).
Results
The results indicate significantly improved nurses' practices for VAP prevention across the core, equipment‐related general measures, with total mean scores increasing from 50.67% (95% CI: 44.30–56.92) pre‐programme to 89.26% (95% CI: 85.68–92.84) immediately post‐programme and 73.33% (95% CI: 67.79–78.88) after 3 months ( p < .001). Before the programme, 85.3% of newborns developed VAP. However, this dropped dramatically to just 10.5% immediately after the programme, with a relative risk of 0.123 (95% CI: 0.046–0.328, p < .001). Even 3 months later, the rates remained much lower at 19.5% than before the programme, with a relative risk of 0.228 (95% CI: 0.117–0.445, p < .001). Multivariate logistic regression showed that only overall nurses' practices remained statistically significant in reducing VAP risk (OR = 0.819, 95% CI: 0.728–0.920, p = .001) after adjusting for confounders. Prolonged ventilation and individual components of nursing practices were not significant in the multivariate model.
Conclusions
This study demonstrates that a structured educational programme can significantly enhance nurses' adherence to VAP preventive practices and reduce VAP incidence. Regular training initiatives are crucial for sustaining high care standards, thereby improving neonatal patient health care outcomes.
Relevance to Clinical Practice
Newborns in the neonatal intensive care unit (NICU) are at a higher risk of developing ventilator‐associated pneumonia (VAP) because of their fragile immune systems, the need for mechanical ventilation and prolonged hospital stays. VAP can lead to severe complications, including increased morbidity, mortality and long‐term health issues. Training NICU nurses on VAP prevention care bundles is crucial for improving neonatal care, reducing preventable infections and optimizing clinical outcomes in a highly vulnerable neonatal population. It supports evidence‐based practice, enhances nurse competence and contributes to the overall quality of care in neonatal intensive care settings. As a result, implementing such a training programme should be a top priority in NICU clinical practice.
... Nursing interns are a crucial target for focused educational interventions because they frequently lack experience in caring for these high-risk patients. Finally, teaching nursing interns about VAP prevention lays the groundwork for their career-long commitment to evidencebased practice and lifelong learning (Kamerikar et al. 2017;Elsaeed et al. 2025). ...
To assess the impact of a self‐instructional ventilator‐associated pneumonia care bundle prevention module on pediatric nursing internship students' knowledge and clinical performance. A two‐arm randomized control was carried out. One hundred nursing interns were assigned randomly into two equal groups: control and study. Nursing interns' knowledge test, ventilator‐associated pneumonia observational checklist bundle, and self‐instructional module feedback questionnaire were used. Before the intervention, both groups had 100% low knowledge. Post‐intervention, the study group achieved 100% high knowledge, compared to 16% in the control group (p < 0.001). After 3 months, 92% of the study group maintained high knowledge vs. 6% in the control group. Performance followed a similar trend, with the study group showing 96% high performance initially and 88% after 3 months. Implementing a self‐instructional module significantly enhanced nursing internship students' performance and knowledge of ventilator‐associated pneumonia care bundle prevention. Nursing interns' application of the self‐instruction module on bundle prevention guidelines enhances their professional growth, delivers safe, appropriate practice, and improves the quality of care to critically ill children.
Background
Kinesiophobia could act as a significant barrier against physical activity following cardiac procedures worsening cardiovascular health problems and potentially leading to conditions like hospital-acquired anxiety and depression among patients with cardiovascular disease (CVD). Nurses are the vanguard health care team who can aid patients in taking proactive steps to overcome fear of movement following cardiac procedures.
Aim
The overarching aim is to investigate the relationship between kinesiophobia, anxiety and depression, and patients’ perception of nursing care.
Method
A descriptive correlational research design in two rural hospitals, conducted at cardiac intensive care units of Kafr Eldawar Hospital and Damanhur Medical National Institute. Data were collected from 265 nurses, using the following patient-reported outcome measures, the Tampa Scale for Kinesiophobia (TSK), the Hospital Anxiety and Depression Scale (HADS), the Person-Centered Critical Care Nursing Questionnaire (PCCNP) and the patients’ demographic and clinical profile.
Result
A significant negative correlation was found between HADS and PCCNP (r: -0.510, p < 0.001) however, Kinesiophobia was significantly and positively correlated (r: 0.271, p < 0.001). A direct effect of PCCNP in the presence of the mediator was found to be not statistically significant (-0.015, CR = 0.302, p = 0.763). Nonetheless, PCCNP indirectly affects kinesiophobia through HADS (p=-0.099).
Implication for nursing practice
Customizing individualized cardiac rehabilitation (CR) programs based on the emotional experience of cardiac patients will be conducive to rehabilitation and prognosis for patients, thereby lessening the physical burden and improving their quality of life.
The second most prevalent healthcare-associated infection in neonatal intensive care units (NICUs) is ventilator-associated pneumonia (VAP). This review aims to update the knowledge regarding the incidence of neonatal VAP and to summarize possible strategies for prevention. The VAP incidence ranges from 1.4 to 7 episodes per 1000 ventilator days in developed countries and from 16.1 to 89 episodes per 1000 ventilator days in developing countries. This nosocomial infection is linked to higher rates of illness, death, and longer hospital stays, which imposes a substantial financial burden on both the healthcare system and families. Due to the complex nature of the pathophysiology of VAP, various approaches for its prevention in the neonatal intensive care unit have been suggested. There are two main categories of preventative measures: those that attempt to reduce infections in general (such as decontamination and hand hygiene) and those that target VAP in particular (such as VAP care bundles, head of bed elevation, and early extubation). Some of the interventions, including practicing good hand hygiene and feeding regimens, are easy to implement and have a significant impact. One of the measures that seems very promising and encompasses a lot of the preventive measures for VAP are the bundles. Some preventive measures still need to be studied.
Background
Cardiopulmonary resuscitation (CPR) is considered one of the most stressful experiences in critical care nursing; it directly and indirectly leads to compassion fatigue and burnout.
Aim
Determine the levels of and relationship between postcode stress and compassion fatigue.
Design and methods
A descriptive-correlational study using 300 critical care nurses from five intensive care units in two hospitals was conducted.
Tools
Demographic and work-related data, the Postcode Stress Scale, and the Professional Quality of Life Scale: Compassion Fatigue subscale.
Results
Nurses had moderate to high postcode stress and compassion fatigue (67.98 ± 16.39 and 65.40±14.34, respectively). Moreover, there was a significant positive correlation between postcode stress, burnout (r=0.350, p=<0.001), secondary traumatic stress (r=0.518, p=<0.001), and subsequently, compassion fatigue (r=0.449, p=<0.001). In addition, higher levels of postcode stress were associated with higher levels of compassion fatigue with its subscales: burnout and secondary traumatic stress, with a coefficient of determination for compassion fatigue (0.199), burnout subscale (0.121), and secondary traumatic stress (0.266).
Conclusion
Critical care nurses involved in resuscitation experiences are susceptible to postcode stress, burnout, secondary traumatic stress, and compassion fatigue. There is a significant relationship between these factors, with higher levels of postcode stress contributing to higher levels of compassion fatigue and its subscales: burnout and secondary traumatic stress. These results highlight the importance of addressing and managing the psychological well-being of nurses in resuscitation settings to mitigate the adverse effects of stress and promote their overall resilience and well-being.
Introduction
Ventilator-associated pneumonia (VAP) is one of the dreaded events in sick children who are ventilated in the paediatric intensive care unit (PICU) and has a high mortality rate. So, there is a need to know the causative organisms, risk factors, and possible predictors in a particular PICU for prevention, early identification, and treatment to decrease morbidity and mortality. This study was planned with the objectives to determine the microbiological profile, associated risk factors, and outcome of VAP in children.
Methods
In this observational cross-sectional study conducted at Dr. B C Roy Post Graduate Institute of Paediatric Science, Kolkata, India, 37 VAP cases were diagnosed using clinical pulmonary infection score >6 and confirmed by tracheal culture and X-ray.
Results
The number of paediatric patients suffering from VAP was 37 (36.2%). The commonest age group involvement was one to five years. The microbiological profile included Pseudomonas aeruginosa (29.8%) and Klebsiella pneumoniae (21.6%) as the commonest organisms followed by Staphylococcus aureus (18.9%) and Acinetobacter (13.5%). The factors significantly associated with the increased frequency of VAP were the use of steroids, sedation, and reintubation. The mean duration of mechanical ventilation (MV) in VAP was 15 days compared to non-VAP (seven days), and the longer duration of ventilation was significantly associated with VAP (p=0.00001). Mortality in VAP was 48.54% compared to non-VAP (55.84%) with no significant association (p=0.0843) of VAP with death occurrence.
Conclusion
The present study showed that VAP occurrence is associated with prolonged duration of MV, PICU stay, and hospital stay but is not significantly associated with mortality. It also indicated that gram-negative bacteria were the most common VAP causative organisms in this cohort.
Mechanical ventilation is a common procedure performed in pediatric intensive care units, with over 20% of patients requiring invasive ventilator support. The most common indication for endotracheal intubation and ventilation in the pediatric population is respiratory failure either due to respiratory embarrassment or neurologic pathology. Despite the use of ventilation modes that are lung protective in the pediatric population, complications of mechanical ventilation occur frequently. These include atelectasis, post-extubation stridor, perioral tissue damage, ventilator associated pneumonia, mucus plugging, pneumothorax, pneumomediastinum, and ICU neuromyopathy. The purpose of this review is to discuss the risk factors, presentation and management of complications associated with mechanical ventilation in the pediatric population.
The concept of improving the quality and safety of healthcare is well known. However, a follow-up question is often asked about whether these improvements are cost-effective. The prevalence of nosocomial infections (NIs) in the neonatal intensive care unit (NICU) is approximately 30% in developing countries. Ventilator-associated pneumonia (VAP) is the second most common NI in the NICU. Reducing the incidence of NIs can offer patients better and safer treatment and at the same time can provide cost savings for hospitals and payers. The aim of the study is to assess the direct costs of VAP in the NICU. This is a prospective study, conducted between January 2017 and June 2018 in the NICU of University Hospital “St. George” Plovdiv, Bulgaria. During this period, 107 neonates were ventilated for more than 48 h and included in the study. The costs for the hospital stay are based on the records from the Accounting Database of the setting. The differences directly attributable to VAP are presented both as an absolute value and percentage, based on the difference between the values of the analyzed variables. There are no statistically significant differences between patients with and without VAP in terms of age, sex, APGAR score, time of admission after birth and survival. We confirmed differences between the median birth weight (U = 924, p = 0.045) and average gestational age (t = 2.14, p = 0.035) of the patients in the two study groups. The median length of stay (patient-days) for patients with VAP is 32 days, compared to 18 days for non-VAP patients (U = 1752, p < 0.001). The attributive hospital stay due to VAP is 14 days. The median hospital costs for patients with VAP are estimated at €3675.77, compared to the lower expenses of €2327.78 for non-VAP patients (U = 1791.5, p < 0.001). The median cost for antibiotic therapy for patients with VAP is €432.79, compared to €351.61 for patients without VAP (U = 1556, p = 0.024). Our analysis confirms the results of other studies that the increased length of hospital stays due to VAP results in an increase in hospital costs. VAP is particularly associated with prematurity, low birth weight and prolonged mechanical ventilation.
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Objectives
To evaluate Infection prevention and control (IPC) training workshops using Kirkpatrick model level 1 and 2 regarding satisfaction of trainees and improvement of their knowledge and skills.
Methods
A cross-sectional study was conducted on 353 healthcare workers from January 2020 to March 2020, at four hospitals in Islamabad, Pakistan. Training feedback questionnaires and pre and post tests were employed for data collection. The authors analyzed data using SPSS version 25.
Results
The majority (52%) of participants rated the trainings as “Excellent”, 44% rated “Good” while 2% graded “Average”. Pre and post-tests mean scores demonstrated statistically significant improvement in knowledge and skills (p< 0.001).
Conclusion
The training workshops significantly improved healthcare workers knowledge and skills regarding Infection Prevention and Control and earned high satisfaction scores from the trainees.
Objective
We hypothesized that the implementation of evidence-based interventions shaping a bundle approach could significantly reduce the incidence of ventilator-associated pneumonia (VAP) in the neonatal intensive care unit.
Study design
We conducted a prospective observational cohort study including neonates undergoing mechanical ventilation >48 h. VAP rate and endotracheal intubation ratio were compared before (pre-period) and after (post-period) applying VAP prevention bundle strategies.
Result
One hundred seventy-four neonates were included in pre-period (30 months) and 106 in post-period (17 months). Demographic characteristics were comparable and device use ratios were similar. Twenty-eight VAP episodes were diagnosed, 25 in the first period and 3 after the implementation of prevention bundle. This represents a reduction in the incidence rate from 11.79 to 1.93 episodes/1000 ventilator days (p < 0.01).
Conclusion
The implementation of an educational evidence-based program using a bundle approach to prevent VAP has shown a statistically significant reduction in its incidence density.
Background
Endotracheal suction (ETS) is essential in intubated patients to prevent tube occlusion and is one of the most common nursing interventions performed in intensive care.
Aims and objectives
To explore how paediatric ETS practices reflect evidence‐based practice (EBP) recommendations in paediatric intensive care units (PICU) worldwide.
Study design and methods
A cross‐sectional electronic survey linked to a real patient suction episode. Nurses completed the survey following a recent ETS episode. Evidence‐based practice (EBP) was defined based on four of the American Association for Respiratory Care (AARC) best evidence recommendations: pre‐oxygenation before suction, use of a suction catheter no more than half the diameter of the tracheal tube, shallow depth of suction, and the continuous suction applied upon withdrawal of the catheter. Participants included PICU nurses who performed ETS in children (0‐17 years) excluding preterm neonates.
Results
Four hundred forty‐six complete surveys were received from 20 countries. Most nurses (80%, 367/446) reported that their units had local guidelines for ETS. The most common reason for suctioning (44%) was audible/visible secretions. Over half of ETS episodes (57%) used closed suction. When exploring the individual components of suction, 63% (282/446) of nurses pre‐oxygenated their patient prior to suction, 71% (319/446) suctioned no further than 0.5 cm past end of the endotracheal tube (ETT), 59% (261/446) used a catheter no more than half the diameter of the ETT, and 78% (348/446) used continuous negative pressure. 24% of nurses gave patients an additional bolus of sedative, analgesic, and/or muscle‐relaxant medication prior to suction; this decision was not related to the child's history of instability with suction, as there was no significant difference in those who reported patients had a history of being unstable with suction (P = .80). 26% (117/446) of nurses complied with all four EBP components in the reported suctioning episode.
Conclusions
Considerable variation in paediatric endotracheal suctioning practices exists internationally. Although most nurses applied single components of evidence‐based recommendations during ETT suctioning, just a quarter applied all four elements.
Relevance to clinical practice
Nurses’ need to consider and strive to apply EBP principles to common nursing interventions such as ETS.
A training program for home-based acute pediatric nursing care was evaluated to determine if nurses had been adequately prepared. Many nursing training programs are evaluated but they are often limited to capturing perceptions about the training itself. Comprehensive evaluation of the training and its impact on acute care practice in the community was sought. The Kirkpatrick model for training evaluation provided the framework for this comprehensive, multilevel evaluation and, consequently, for the research approach. A set of mixed-methods research tools was developed. The sample size was limited to a specific group of nurses, heightening the need for high participation rates in the first three levels of the evaluation. A mixed-methods approach facilitated qualitative or quantitative data to be collected for each of the Kirkpatrick’s levels of evaluation, but required the researcher to have skills in data collection for both the methods. The approach enabled a comprehensive, multifaceted evaluation of the training and its impact on the clinical practice to be undertaken. The Kirkpatrick model proved valuable and most appropriate for evaluating this training program for nurses.
Introduction:
Ventilator-associated pneumonia (VAP) is a nosocomial infection that develops 48 h after the initiation of mechanical ventilatory support. Current evidence-based guidelines demonstrate that VAP prevention is feasible through the implementation of certain VAP prevention bundle of interventions simultaneously. We aimed in this study to investigate the effect of VAP prevention pre- and post- implementation.
Methods:
This is a single-center, cohort study that took place at the Pediatric Intensive Care Unit (PICU) of King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia from January 2015 to March 2018 and assessed the rate of VAP before and after implementation of the bundle.
Results:
The study included 141 children, 95 were included from the pre-bundle group and 36 from the bundle group. VAP developed in 35% of the pre-bundle group compared to 31% of the bundle group (p = 0.651) with incidence rates equaled to 18 and 12 per 1000 ventilator days, respectively.
Conclusion:
This study found that VAP bundle did not significantly reduce VAP rate in the PICU. Further large prospective multi-center studies with longer intervention duration are indicated to investigate the benefits of using VAP prevention bundle.
Background: Ventilator Associated Pneumonia (VAP) is a common syndrome in pediatrics primarily in infants and early childhood. Mechanical ventilation is one of the leading supportive modalities of management in the intensive care unit, but it conveys a lot of threats and complications. This study aimed to assess the impact of nursing guidelines on nurses’ knowledge and performance regarding to prevention of ventilator associated pneumonia in neonates through the following: 1) Assessment of nurses’ knowledge and performance regarding to prevention of ventilator associated pneumonia in neonates. 2) Designing, implementing and evaluating the impact of nursing guidelines on nurses’ knowledge and performance regarding to prevention of ventilator associated pneumonia in neonates.Methods: Research design: A quasi-experimental design was utilized to conduct this study. Settings: The study was convoyed at Maternity & Gynecological and Children’s Hospitals affiliated to Ain shams University Hospitals from neonatal intensive care units. Sample: A convenient sample method of forty three (43) nurses, and fifty (50) neonates’ infants on mechanical ventilation was included in the study as a single study group. Tools: The questionnaire format, the observation checklist and implementation of nursing guidelines was assessed the nurses’ knowledge and performance regarding to prevention of ventilator associated pneumonia in neonates. The implementation of nursing guidelines was premeditated as reference guidelines for nurses.Results: There were statistically significant differences between mean scores of the pre and post test as regards nurses’ knowledge and performance regarding to prevention of ventilator associated pneumonia in neonates.Conclusions: Application of the nursing guidelines has a positive outcome on improving nurses’ knowledge and performance regarding to prevention of ventilator associated pneumonia in neonates. Recommendations: The current study recommended that directing a written protocol for prevention of ventilator associated pneumonia in neonates to support satisfactory knowledge, and competent practices are actually required at neonatal intensive care units.
Background:
Ventilator-associated pneumonia (VAP) is a severe intensive complication and remains under estimated in neonatal intensive care unit (NICU). Center for Disease Control defined criteria for adults and pediatrics without neonatal criteria. The objective of this article was to evaluate the rate, the risks factors and the outcome of neonates suffering from ventilator-associated pneumonia in a French NICU.
Methods:
We conducted a prospective observational study within a one-year period in our NICU. Three hundred and eighty-one neonates under 28 days of age were included. Data analyses were performed using Fischer exact-test, Kolgomorov analysis, Mann-Whitney test and logistic regression. We used stata version 13.0 for the statistics.
Results:
Seventeen patients were diagnosed with ventilator-associated pneumonia. Incidence rate of VAP was 8.8 per 1 000 invasive mechanical ventilator days. The median age at diagnosis was 20 days [range: 4 - 45]. Extremely low birth weight (under than 1000 grams) were significantly associated with VAP (Odds Ratio 4.31 [95% confidence interval 1.38- 13.39]). Newborns suffering from VAP had a significantly longer duration of invasive ventilation (median: 16 days [range 4-75] versus 3 days [range 1-28], p< 0.001) and hospital length of stay (median: 34 days [range 7-91] versus 7 days [range 1-56], p < 0.001). Mortality rate was significantly higher in patient with VAP (p: 0.028).
Conclusions:
We describe the first French study on VAP in a neonatal population. Amongst nosocomial infections, VAP is a complication with severe consequences for NICU patients. Larger studies are needed to better define a diagnosis strategy and prevention bundle.
Ventilator-associated pneumonia (VAP) is defined as nosocomial pneumonia developing 48 hour or more after initiation of mechanical ventilation. It is the second most common nosocomial infection in pediatric intensive care units (PICUs), accounting for 20% of all nosocomial infections in the pediatric population. The prevention of VAP is a major focus of many recent safety initiatives and focuses on modification of risk factors. The main aim of the study was to evaluate the effect of implementing training program for nurses on prevention of pediatric ventilator-associated pneumonia. A quasi-experimental research design was used in the study. The study was carried on Medical Intensive Care Unit at Mansoura University Children's Hospital. The study involved a convenient sample of 40 critical care nurses regardless of their age, education and years of experience. The study was conducted in Pediatric Intensive Care Unit at Mansoura University Children hospital. Two tools were used for data collection including questionnaire to assess the nurses' knowledge about Pediatric ventilator-associated pneumonia and its prevention and pediatric ventilator-associated pneumonia prevention observation checklist. The results of the present study indicated that, the nurses' knowledge and practices of ventilator-associated pneumonia and its prevention in PICU was improved after the implementation of the training program either immediately or 3 months later than before its implementation. There is also a need for periodic refreshing in-service training program should be provided to nurses' in PICU in order to improve their knowledge and practices regarding VAP prevention.
Ventilator-associated pneumonia (VAP) is a serious health care- associated infection, resulting in high morbidity and mortality. It also prolongs hospital stay and drives up hospital costs. Measures employed in preventing ventilator- associated pneumonia in developing countries are rarely reported. In this study we tried to assess the efficacy of our designed “VAP prevention bundle” in reducing VAP rate in our neonatal intensive care unit (NICU).
This prospective before-and-after study was conducted at university hospital NICU, all neonates who had mechanical ventilation for ≥ 48 h were eligible. VAP rates were evaluated before (phase-I) and after (phase-II) full implementation of comprehensive preventive measures specifically designed by our infection control team.
Of 143 mechanically ventilated neonates, 73 patients developed VAP (51 %) throughout the study period (2500 mechanical ventilation days). The rate of VAP was significantly reduced from 67.8 % (42/62) corresponding to 36.4 VAP episodes/1000 mechanical ventilation days (MV days) in phase-I to 38.2 % (31/81) corresponding to 23 VAP/1000 MV days (RR 0.565, 95 % confidence interval 0.408-0.782, p = 0.0006) after VAP prevention bundle implementation (phase-II). Parallel significant reduction in MV days/case were documented in post-intervention period (21.50 ± 7.6 days in phase-I versus 10.36 ± 5.2 days in phase-II, p = 0.000). There were a trend toward reduction in NICU length of stay (23.9 ± 10.3 versus 22.8 ± 9.6 days, p = 0.56) and overall mortality (25 % versus 17.3 %, p = 0.215) between the two phases but didn’t reach statistical significance. The commonest micro-organisms isolated throughout the study were gram-negative bacteria (63/66, 95.5 %) particularly Klebsilla pneumonia (55/66, 83.4 %).
Implementation of multifaceted infection control bundle resulted in reduction of VAP rate, length of stay in our NICU.
Objective:
To assess adherence to a ventilator care bundle in an intensive care unit and to determine the impact of adherence on the rates of ventilator-associated pneumonia.
Methods:
A total of 198 beds were assessed for 60 days using a checklist that consisted of the following items: bed head elevation to 30 to 45º; position of the humidifier filter; lack of fluid in the ventilator circuit; oral hygiene; cuff pressure; and physical therapy. Next, an educational lecture was delivered, and 235 beds were assessed for the following 60 days. Data were also collected on the incidence of ventilator-acquired pneumonia.
Results:
Adherence to the following ventilator care bundle items increased: bed head elevation from 18.7% to 34.5%; lack of fluid in the ventilator circuit from 55.6% to 72.8%; oral hygiene from 48.5% to 77.8%; and cuff pressure from 29.8% to 51.5%. The incidence of ventilator-associated pneumonia was statistically similar before and after intervention (p=0.389).
Conclusion:
The educational intervention performed in this study increased the adherence to the ventilator care bundle, but the incidence of ventilator-associated pneumonia did not decrease in the small sample that was assessed.
Services employing staff to support people with disability usually provide training in a range of areas including communication and managing challenging behaviour. Given that such training can be costly and time-consuming, it is important to evaluate the evidence presented in support of such programs. Efficacy in clinical practice is measured using evidence-based practice. However, there is currently no model that is widely used to compare and evaluate training programs despite the large number of training programs reported each year.
Six studies published in the last decade that reported the outcomes of communication-based training and six that reported on the outcomes of challenging behaviour training were evaluated using the 4-level Kirkpatrick model.
Comparison of the levels of evidence is made for these 12 studies.
The Kirkpatrick model provides one technique for appraisal of the evidence for any reported training program and could be used to evaluate whether a training program is likely to meet the needs and requirements of both the organisation implementing the training and the staff who will participate.
Objective
To assess the effect of different frequencies of ventilator circuit changes in neonates and children through a systematic review and meta‐analysis.
Interventions
(1) “No routine change of ventilator circuit (unless visibly soiled)” versus “routine change at any fixed interval”; (2) routine change of circuit at “less frequent” versus “more frequent” intervals.
Outcomes
Primary outcomes were VAP rate (number of VAP episodes per 1000 ventilator‐days) and all‐cause mortality before discharge.
Methods
MEDLINE, CENTRAL, EMBASE, and CINAHL were systematically searched from inception till November 3, 2020. Two authors assessed trial eligibility and risk of bias, and independently extracted data. Data were synthesized using fixed effects model. GRADE was used to assess certainty of evidence (CoE).
Results
We identified six studies enrolling 768 participants evaluating circuit changes at two fixed intervals. Meta‐analysis of studies on circuit changes “once in less than 7 days” versus “once weekly” showed no difference in VAP rate (risk ratio: 0.83 [0.38–1.81]; one randomized controlled trial (RCT) and 0.94 [0.49–1.81]; two before‐after studies) or mortality before discharge (0.67 [0.34–1.3]; one RCT and 1.01 [0.63–1.64]; two before‐after studies). CoE was very low. Less frequent circuit changes reduced health‐care costs. No study evaluating “circuit changes only when visibly soiled” versus “circuit changes at a fixed interval” was identified.
Conclusion
There is no evidence to suggest that ventilator circuits can be safely left unchanged until visibly soiled in neonates and children. Extending circuit changes interval to “once weekly” may not increase VAP rate (CoE—very low) and reduces healthcare costs.
Objective
The objective of this study was to review and critically appraise the evidence for paediatric endotracheal suction interventions.
Data sources
A systematic search for studies was undertaken in the electronic databases CENTRAL, Medline, EMBASE, and EBSCO CINAHL from 2003.
Study selection
Included studies assessed suction interventions in children (≤18 ys old) receiving mechanical ventilation. The primary outcome was defined a priori as duration of mechanical ventilation. Secondary outcomes included adverse events and measures of gas exchange and lung mechanics.
Data extraction
Data extraction were performed independently by two reviewers. Study methodological quality was assessed using Cochrane's risk of bias tool for randomised trials or the Newcastle–Ottawa Scale for observational studies. Overall assessment of the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations criteria.
Results
Overall 17 studies involving 1618 children and more than 21,834 suction episodes were included in the review. The most common intervention theme was suction system (five studies; 29%). All included trials were at unclear or high risk of performance bias due to the inability to blind interventionists. Current evidence suggests that closed suction may maintain arterial saturations, normal saline leads to significant transient desaturation, and lung recruitment applied after suction offers short-term oxygenation benefit.
Limitations
Lack of randomised controlled trials, inconsistencies in populations and interventions across studies, and imprecision and risk of bias in included studies precluded data pooling to provide an estimate of interventions effect.
Conclusions
Based on the results of this integrative review, there is insufficient high-quality evidence to guide practice around suction interventions in mechanically ventilated children.
Purpose:
The purpose of this review was to ascertain the impact of ventilator bundles on the incidence of ventilator-associated pneumonia in mechanically ventilated neonates and children in intensive care units.
Methods:
A systematic review was conducted. Key computerised databases (CINAHL, Medline, Embase and Cochrane) as well as additional sources, with no publication date limitations, were extensively searched in January 2018. Inclusion criteria focused on ventilator bundles used in mechanically ventilated neonates and children aged from 0 to 18 years. After identification and inclusion, all studies were critically appraised for quality. Data were analysed and narratively synthesised.
Results:
Eight studies of observational and nonrandomised interventional methods design were included in the review. However, the validity of five of the eight studies which were reviewed was considered substandard. In addition, there were variations in the care bundles elements studied. Nevertheless, all these studies demonstrated that the incidences of VAP in mechanically ventilated neonates and children were found to be significantly reduced by the use of ventilator bundles.
Practice implications:
This systematic review determines that ventilator bundles impact positively on the incidence of VAP in critically ill neonates and children in the neonatal intensive care unit and paediatric intensive care unit. However, the variations in the bundle elements and insufficient valid evidence necessitates further research in the area to validate the findings and to ensure standardisation of clinical practice. Prevention of VAP is aimed at avoiding the risk of aspiration in the lungs, colonisation of respiratory tract with pathogenic microorganisms and contamination of respiratory equipment. Moreover, the implementation of evidence-based interventions grouped together is fundamental to improve patient outcomes. It is recommended that a further bona fide research is required to standardise the components of paediatric ventilator bundles.
Background:
We aimed to investigate the effectiveness of evidence-based bundle that we developed to reduce ventilator-associated pneumonia (VAP) rates and to assess the degree of compliance rates to this strategy in a tertiary neonatal intensive care unit.
Methods:
This before-after prospective cohort trial divided into two periods was conducted. All neonates requiring ventilation were enrolled in the study. VAP incidence, compliance rates to bundle components and the contribution of each bundle component to VAP rates were compared between the periods.
Results:
Throughout the study period, 13 VAP episodes were observed. Full adherence to all six components of the bundle doubled in the active-bundle period (12.8 vs. 24.3%, p < 0.01). The mean VAP rate decreased from 7.33/1000 to 2.71/1000 ventilator days following intervention ( p = 0.083).
Conclusion:
This study showed that reliable implementation of a neonate-specific VAP prevention bundle can produce sustained reductions in VAP rates.
This study evaluated the effectiveness of an educational course that aimed to expand student nurses' knowledge about the guidelines for ventilator-associated pneumonia (VAP) prevention. In the pretest, the students revealed poor knowledge (mean score ± SD, 6.3 ± 2.8 out of 20). After completion of the educational program, participants in the experimental group showed a significant improvement (t105 = 14.9, P < .001). The control group showed no significant improvement. More focus on VAP prevention guidelines is essential in nursing curricula.
Background:
Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices.
Purpose:
The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients.
Method:
In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance.
Findings/results:
In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014.
Implications for practice:
This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU.
Implications for research:
Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.
Ventilator-associated pneumonia (VAP) is the leading cause of death with hospital-acquired infections, and preventing it is one of the Saving Lives initiatives (Department of Health 2007). This article discusses the implementation of a purpose-designed VAP care bundle in a children’s intensive care unit and examines the unique role of nurses in the management of the change process. A nurse-led VAP education, implementation and surveillance programme was set up. Nurse education was paramount, as nursing staff acceptance and involvement was a key feature. A multi-method training strategy was implemented, providing staff with multiple training opportunities and introducing VAP project education as a routine part of staff induction. Bundle compliance was monitored regularly and graphs of the results produced quarterly; feedback proved to be useful in keeping staff informed and engaged in VAP reduction. Comparison of VAP incidence before and after introduction of the care bundle showed a reduction after its implementation. With a co-ordinated, multidisciplinary approach, VAP care bundles can result in significant and sustained reductions in VAP rates in the paediatric intensive care unit. Effective co-ordination and leadership is crucial to successful implementation of the VAP bundle, and nurses are well placed to undertake this role.
Objective:
Ventilator-associated pneumonia is considered the second most frequent infection in pediatric intensive care, and there is agreement on its association with higher morbidity and increased healthcare costs. The goal of this study was to apply a bundle for ventilator-associated pneumonia prevention as a process for quality improvement in the PICU of Hospital Italiano de Buenos Aires, Argentina, aiming to decrease baseline ventilator-associated pneumonia rate by 25% every 6 months over a period of 2 years.
Design:
Quasi-experimental uninterrupted time series.
Setting:
PICU of Hospital Italiano de Buenos Aires, Argentina.
Patients:
All mechanical ventilated patients admitted to the unit.
Intervention:
It consisted of the implementation of an evidence-based ventilator-associated pneumonia prevention bundle adapted to our unit and using the plan-do-study-act cycle as a strategy for quality improvement. The bundle consisted of four main components: head of the bed raised more than 30°, oral hygiene with chlorhexidine, a clean and dry ventilator circuit, and daily interruption of sedation.
Measurements and main results:
Ventilator-associated pneumonia prevention team meetings started in March 2012, and the ventilator-associated pneumonia bundle was implemented in November 2012 after it had been developed and made operational. Baseline ventilator-associated pneumonia rate for the 2 years before intervention was 6.3 episodes every 1,000 mechanical ventilation days. ventilator-associated pneumonia rate evolution by semester and during the 2 years was, respectively, 5.7, 3.2, 1.8, and 0.0 episodes every 1,000 mechanical ventilation days. Monthly ventilator-associated pneumonia rate time series summarized in a 51-point control chart showed the presence of special cause variability after intervention was implemented.
Conclusions:
The implementation over 2 years of a ventilator-associated pneumonia prevention bundle specifically adapted to our unit using quality improvement tools was associated with a reduction in ventilator-associated pneumonia rate of 25% every 6 months and a nil rate in the last semester.
Ventilator-associated pneumonia (VAP) is associated with significant morbidity and mortality in pediatric intensive care unit (PICU). Our purpose was to evaluate the effects of ventilator circuit change on the rate of VAP in the PICU.
A prospective randomized controlled trial was conducted at a university hospital PICU. Children (younger than 18 years) who received mechanical ventilation from December 2006 to November 2007 were randomly assigned to receive ventilator circuit changes every 3 or 7 days.
Of 176 patients, 88 were assigned to receive ventilator circuit every 3 days and 88 patients had a change weekly. The rate of VAP was 13.9/1000 ventilator days for the 3-day circuit change (n = 12) vs 11.5/1000 ventilator days (n = 10) for the 7-day circuit change (odds ratio, 0.8; confidence interval, 0.3-1.9; P = .6). There was a trend toward decreased PICU stay and mortality rate in 7-day change group compared to 3-day change group but did not reach statistical significance. Furthermore, switching from a 3-day to a 7-day change policy could save costs up to US $22,000/y.
The 7-day ventilator circuit change did not contribute to increased rates of VAP in our PICU. Thus, it may be used as a guide to save workload and supply costs.
Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.
Training evaluation: it doesn't have to be as formal as you think
- Kirkpatrick J
Effectiveness of an educational intervention on knowledge and practice of staff nurses on prevention of ventilator associated pneumonia among neonates in neonatal intensive care unit
- Dipanjali R