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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16. Jarvis, (1991). Nosocomial pneumonia 9 (15): 756-9

17. Cross et al., ( 1981). Role of respiratory assistance device in endemic

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18. Cross et al, 1988. Nosocomial pneumonia is mechanically ventilated

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based guideline for preventing VAP 10(72): 1-10

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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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