Evidence-based practice: use of the ventilator bundle to prevent ventilator-associated pneumonia

American Journal of Critical Care, Jan, 2007 by Arlene F. Tolentino-DelosReyes, Susan D Ruppert, Shyang-Yun Pamela K. Shiao

Methods

We conducted a clinical education project to assess nurses' knowledge about use of the ventilator bundle to prevent VAP and the related practice patterns in a coronary care unit (CCU) and surgical ICU (SICU) at a large hospital based in a medical center in a major metropolitan city. Changes in knowledge and nursing practices related to the ventilator bundle and VAP prevention were examined before and after education sessions about current evidence-based interventions. A total of 8 sessions were conducted to include most of the nurses working in the 2 units. These sessions included a 30-minute presentation, a pretest, and a posttest. An educational poster containing a copy of the presentation was placed in each unit after the education sessions for those nurses who were unable to attend. The 30-minute PowerPoint and poster presentation included materials from AACN's VAP practice alert, information from the literature obtained through Internet research, and the guidelines from the CDC.

A 10-item test was constructed to examine nurses' knowledge about VAP and its prevention by using interventions that are based on the ventilator bundle. The questions on the 10-item test contained information from the PowerPoint presentation. The project director conducted all the education sessions in the CCU and the SICU. Additionally, the project director created the PowerPoint and poster presentations as well as the 10-item test, all of which were reviewed by 2 critical care nursing experts and educators to establish content validity. The test included 10 questions on such topics as best-practice guidelines, microorganisms that cause VAR hand washing, supine positioning, enteral feeding, factors related to VAR definition of VAP, and diagnosis of pneumonia.

Participants included 14 night-shift nurses and 14 day-shift nurses from the SICU and 15 day-shift nurses and 18 night-shift nurses from the CCU. These participants comprised approximately 65% to 70% of all the nurses in each unit. Pretests and posttests were administered immediately before and after the in-service education sessions. In addition, the practice patterns of nurses were observed during the 1 month preceding and the 1 month following the education sessions. Practice patterns were assessed both before and after the education sessions by observing the care rendered to 30 patients in the SICU and 69 patients in the CCU, all of whom were receiving mechanical ventilation. HOB elevation was measured by checking the beds that were equipped with angle measurement to specify the degrees of elevation.

Practice was observed during shift reports at 7 AM and 7 PM. Factors assessed included whether HOB elevation was addressed during shift reports; the hand-washing practices of nurses; and whether nurses had artificial nails, wore nail polish, or wore rings (with the number of rings noted) during contacts with patients. Records in the computer information system were used to audit patients' charts for HOB elevation, frequency of oral care, and frequency of nasogastric tube checking in the preceding 12 hours. All data were collected and analyzed by the project director and reviewed by 2 critical care nursing experts who were project team members. Project implementation and evaluation took 6 months.