"1Evidence-Based Practice Project Student2Table of ContentsGenerating Evidence for Evidence-based PracticePart 1: IntroductionI. The problem statement………………………………….……………………....……….3II. The evidence-based question………………………………………..……….……….…4Part 2: Assemble relevant evidence & related literature III. Locating credibleevidence………………………………………………….…...………3IV. Appraise theevidence……………………………………………………….……...……4Part 3: Implementation of the interventionI. Planning ofchange………………………………………………………………..…....8-9II. Clinical protocol and pilot project………………………………………………9-14&23III. Integration and Maintenance…………………………………………………….…..14-15IV. Barriers andstrategies………………………………………………….……………15-18Part 4:Conclusion ………………………………………………..…………………………….18Part 5: References……………………………………………………………………………20-22Part 6: Appendices …………………………………………………………..…………….……23 3I. Management of Mechanically Ventilated Patients: Pilot Project……………………23-24II. Questions for Patient Ventilator Rounds………………………………………………..25III. Methodological matrix………………………………………………………………26-28IV. Prevention In- Service Flyer……………………………………………………………27Problem StatementThe development of pneumonia caused by mechanical ventilation is a significant problemin the intensive care units of hospital facilities.Ventilator-associated pneumonia (VAP) is the“most commonly reported healthcare-acquired infection” in patients requiring mechanicalventilation support (Garcia et al., 2009, p. 524).One of the most common reasons for an ICUadmission is related to respiratory distress or failure.VAP is described as a form of nosocomialinfection which occurs after the first 48 hours of receiving mechanical ventilation (Augustyn,2007).The length of stay (LOS) for patients developing VAP is higher than those neverrequiring mechanical ventilation by an increase of approximately six days (Garcia et al. 2009). In intensive care units (ICUs) across the United States (US), ventilator-acquired pneumonia alsoresults in prolonged periods of actual mechanical ventilation, the excess use of antimicrobialproducts, increased utilization of healthcare resources and costs, and significant increase in 4morbidity and mortality (Coffin et al., 2008).Garcia et al. (2009) found on average, estimatedcosts of an additional $11, 897 to $150,841 per individual case were spent.VAP has asignificant economic impact on our society, costing hospitals money which potentially couldhave been saved.Numerous risks factors contribute to the development of ventilator-acquired pneumoniaas mechanical ventilation presents a unique set of challenges for the patient requiring intubationand ventilator support.Rigorous clinical studies show oral secretions pose an increased risk fordeveloping VAP (Augustyn, 2007).Treatments, strategies and evidence-based interventionshave been developed to decrease the risks and reduce the prevalence of VAP. There is evidenceindicating the use of oral chlorhexidine and the removal of oral secretions before positionchanges may diminish the risks of developing ventilator-acquired pneumonia.By reducing thelevels of bacteria in the oropharynx there would theoretically be a decrease in the prevalence ofnosocomial pneumonia (Houston et al., 2002).Research demonstrates the use of 0.12%chlorhexidine gluconate oral rinse (CHX) pre and postoperatively reduces the incidence of VAPin patients who are intubated greater than 24 hours. Foreground QuestionIn adults supported with mechanical ventilation, what is the effect of oral chlorhexidineuse and removal of oral secretions prior to position changing on the development of ventilator- acquired pneumonia?Review of Evidence and Synthesis of LiteratureThis is a literature analysis of research reports and literature reviews which studied theeffects of removal of oral secretions prior to position change on the occurrence of VAP.Asummary of the articles can be found in Appendix C.The studies varied in design; fromrandomized to non-randomized, placebo, to longitudinal and a pilot study.Strength for each 5study is noted at Level II on the hierarchy as each one is a randomized or nonrandomized clinicalstudy.The research supports our clinical question and was utilized with the development ofadditions to be incorporated into the already existing ICU VAP protocol. The studies focused on in this review consisted of evidence evaluating oral secretionremoval and the use of chlorhexidine gluconate oral rinse to prevent VAP.The costeffectiveness of these interventions was found to be significant.Studies showed oral secretionsas being the medium to carry pathogens within the oropharyngeal site down into the respiratorytrack.The literature hypothesized removing oral secretions prior to the position change of apatient can prevent or minimize the movement of organisms into the respiratory tract which leadto VAP development.Some researchers also concluded the significance of chlorhexidine use forreducing nosocomial infections.The combination of both interventions creates a profound effecton reducing VAP occurrences its research importance, which this practice change aims tostrongly support.The review of literature consists of evidence dating from 1996 to 2008, indicating theneed for continued research and close monitoring of clinical practice changes based on the bestevidence at the moment. This problem was identified long ago and yet still needs furtherevidence for best practice. Three articles discuss removing oral secretions prior to positionchanges of patients which are one of the two independent variables of interest for this review.In one of those studies, VAP was diagnosed in 24 of 159 patients in the control group, but onlyin five of 102 patients in the study group within the study group receiving oral suctioning prior toall position changes (Chao, Chen, Wang, Lee, & Tsai, 2008).A similar study showed VAPoccurrence at 2.6% in the study group and 11% in the control group with probability of < 0.001(Tsai, Lin, Chang, 2008).6Studies by DeRiso et al. (1996) and Houston et al. (2002) each sought to evaluate theefficacy of oropharyngeal decontamination on nosocomial infections in patients undergoing heartsurgery using CHX before and after surgery.Both DeRiso et al. and Houston et al. discoveredan overall reduced rate of VAP (52% and 69% respectively for each study).The significancelevel for both studies was less than .01 (use the higher of the two) with the use of CHX with oralsuctioning of subjects for these studies.Another related intervention assessed in a similar randomized clinical study was the useof subglottal suctioning by Smulders et al. (2002) and its effect on VAP incidence.Thisintervention was appropriate for this review of literature; four percent of patients who underwentcontinuous suctioning developed VAP as compared to 16% in the control group. A commonfinding in the studies reviewed was the savings in spite of the costs of using CHX and equipmentfor oral and subglottal secretion removal.The majority of these studies revealed a significantlyreduced duration of mechanical ventilation and LOS in the ICU. All research studies in this literature review, with the exception of Tsai et al.’s study,consisted of study groups homogenous in patient samples, which suggest effectiverandomization.Tsai et al.’s study has patient heterogeneity (of both medical and surgical ICUpatients) which may have confounded the results. Also, the results of Chao et al.’s study didyield a significant difference with the distribution of patients having a history of COPD, DM, useof antacids, and surgery.These variables were then evaluated with logistic regression for theirrelationship in VAP development, and the results of the logistic regression showed no significantimpact on the direct development. Overall the reviews are well organized, use appropriatelanguage, and use mostly all paraphrasing.This review summarizes key finding of evidence forclinical practice, and provides similar conclusions like our study regarding interventions toimplement in practice.7This literature review consisted of all but one study which were experimental in natureand hold “a high degree of internal validity because of the use of manipulation andrandomization” (Polit & Beck, 2008, p. 295).Tsai et al.’s study was a time-sequenced, non- randomized quasi-experimental study most vulnerable to threats to internal validity out of all theliterature reviewed.But the remaining study participants in the rest of these experimentaldesigns were all randomized after meeting inclusion criteria.Only two studies (by Houston et al.and Tsai et al.) may have had questionable internal validity.Houston et al.’s study group waslarge but possibly too broad with subjects intubated for too short of a period to have theintervention be significant.This provides evidence for the need to implement such anintervention and continue research.This may have led to potential Type I and II errors.Tsai etal.’s weakness was the limitation of a non-randomized control study and patient heterogeneity aspreviously mentioned.In addition, Chao et al. used a staff nurse of the ICU to conduct datacollection; because it is her ICU she may want “her unit” to do well with compliance with thestudy, creating bias.Also, in both this and Smulders et al.’s studies suctioning pressure wasdiscussed.Internal consistency was not documented and this lack of information affects thereliability of the measurement tools.Selection bias does not appear to be a concern in thesestudies, and there appears to be no threat of history and the groups were mainly homogenous. Overall the internal validity of the research in this literature review is rather strong taking intoconsideration these few discussed weaknesses.8 Regarding external validity, the research findings in these studies can easily be generalizedto similar mechanically-ventilated ICU adult populations.The patient populations wererepresentative of the typical ICU population and because of this, external validity is strong. Steps were taken to control characteristics which could impact the groups being compared, andany requirements for participants were taken into consideration when developing the sample.The study by DeRiso et al. was double-blinded and placebo-controlled in designtechniques, and Smulders et al.’s study reported blinding with the radiologists in regards toreading all X-ray reports. These techniques enhanced the internal validity. The studies wereeach performed in only one setting, but could very easily be replicated in another ICUenvironment.Tsai et al. and Chao et al.’s studies had a period during their research which wasdedicated to educating staff on the protocol to be implemented to the experimental group.Thisenhanced intervention fidelity in both studies.Also, the individual collecting the data from Chaoet al.’s study group was a trained staff member of the ICU floor, and such actions facilitated astrong reaction with the intervention and validated construct.No incentives were provided tostaff members for compliance with Chao et al.’s study, but staff was aware of the fact that theclinical setting was being monitored and data collected based upon their performance.However,normally nurses are not monitored closely and corrected for actions.Education for new changesto protocols is usually brief, and like any change, will take some time for the staff to acclimateto. There appears to be no apparent threat to construct validity with the discussed literature. However one could argue the researcher’s expectancies for desired outcomes playing an effect. For example, Tsai et al. and Chao et al.’s studies involved the staff received a thorougheducation and period of time to learn the protocol for the study’s intervention.Knowing theresearcher’s expectations, this could “become part of the treatment construct that is being tested” 9(Polit and Beck, 2008, p. 301).Researchers appropriately balanced all concerns for validity intheir study.Planning a Change After critically analyzing the evidence, the nurse develops a plan to apply the findings to aclinical practice.Developing a plan for change includes identifying strategies to gaincooperation and evaluating outcomes. Once it is decided that evidence supports a practicechange, the change agent or facilitators must develop and test the improvement.This steprequires some preliminary planning and research.Is the innovation practical, the evidencetransferable, is the organization ready for change, are outcomes measurable and will is it possibleto implement the EBP within the organization (Newhouse, Dearholt, Poe, Pugh & White, 2007)? If the answers are agreeable, the innovation must be authorized through the appropriateorganizational channels.The implementation of an evidence-based practice is considered aquality improvement initiative and does not require the hospital Institutional Review Boardapproval.The Quality Care Committee, which oversees process improvement, protocol, andpolicy changes, will review and approve this proposed implementation of evidence-basedpractice, as part of the initial planning.The planning phase includes assessing the feasibility ofchange, defining the change, identifying resources, and defining the desired outcomes (Reavy &Tavernier, 2008). The proposed EBP innovation is to complement the policy for oral care and suctioning ofmechanically ventilated patients with a 10% chlorhexidine gluconate oral rinse and increasesuctioning to every two hours prior to repositioning.These interventions can also be increasedaccording to the patients’ needs.The expected outcomes of the change are improved patientcare, reduced costs related to VAP infection and increased lengths of stay, and the reduction ofthe incidence of VAP in patients mechanically ventilated for more than 24 hours.The project 10feasibility is very good, due to the small scale of the intervention, the ease of implementationinto protocol already in place, it’s compatibility with the practice environment, and it is simple totest in a small sample (Newhouse, Dearholt, Poe, Pugh & White, 2007).Other aspectscontributing to the project’s potential for success is the availability of ample resources includingthe Quality Care Committee, Clinical Nurse Specialist, ICU Nurse Educator, Unit Preceptors,Clinical Managers, and Infection Control Nurse.Implementation and Evaluation of Change Proposed Project The authors plan to implement changes in current policy of management of ventilatedpatients as a pilot project at Scottsdale Healthcare Shea ICU.The change will be to addchlorhexidine rinse for oral care every two hours and suctioning of oral secretions prior torepositioning the patient.The data will be collected on all ventilated patients during dailymultidisciplinary team vent rounds by the infection control nurse. See Appendix A for pilotproject with current changes in policy.We plan to implement the change at ScottsdaleHealthcare Shea medical surgical ICU from June 1, 2010 to April 1, 2011.Implementation PlanTo enhance the patient outcome during hospitalization, an evidence-based pilot projectwill be implemented.As mentioned earlier, the problem of VAP pertains to all ventilatedpatients in different ICUs, but it is easier to start the pilot project in one unit and expand it to theother ICUs of the Scottsdale Healthcare hospitals after assessing the effectiveness of the plan andmaking any necessary changes after the evaluation process.The authors propose to implementthe pilot project initially in the ICU of Scottsdale Healthcare at Shea campus.The plan will bepresented to the ICU nurse manager, supervisors, infection control nurse, and the clinical "