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

Results

Demographic data for the nurses showed a range of ages, educational levels, years of experience in critical care, and total hospital experience (Table 2). Most nurses in the CCU (79%) and the SICU (86%) were female. Most (57%) were between 31 and 50 years of age; 13 CCU nurses (39%) were 41 to 50 years old, and 11 SICU nurses (39%) were 31 to 40 years old. Most nurses in both the CCU (61%) and the SICU (79%) had a bachelor of science degree in nursing. Hospital experience for most CCU (64%) and SICU (64%) nurses was 5 years or more. Similarly, most CCU (64%) and SICU (68%) nurses had 5 years or more of critical care experience.

Nurses' scores on the pretests and posttests are compared in Table 3. The changes in test scores indicate that the 30-minute education session increased the knowledge gained by the nurses about VAP and the ventilator bundle (independent t test, P < .001). Scores changed significantly ([chi square] tests, P < .05) from pretests to posttests for 8 of the 10 questions. The 2 questions that did not show improvements in scores were 2 true-false choice items regarding best-practice guidelines and hand washing (98%-100% correct on both the pretest and the posttest).

As for changes in practice patterns, nurses elevated the HOB to 30[degrees] or higher for 74% of the patients after the education sessions as compared with only 44% before the sessions (P < .001, Table 4). After the education sessions, significantly more nurses washed their hands before contact with a patient and significantly fewer nurses wore nail polish and tings (P < .05). However, even before the education sessions, most nurses washed their hands after contact with a patient (96%) and very few nurses wore artificial nails (1%). Additionally, although compliance with hand washing before contact with a patient increased significantly after the education sessions, compliance was still low (11% before education vs 45% after education). Possible contraindications to HOB elevation at 30[degrees] to 45[degrees] included decubitus ulcers, hemodialysis, continuous renal replacement therapy, intra-aortic balloon pump, emergency invasive procedures, hypotensive episodes, hemodynamic monitoring, and postoperative procedure(s) that may require the patient to be positioned supine or the HOB to be set at a lower elevation. Presence of possible contraindications to HOB elevation did not change from before to after the education sessions (P > .05).

Examination of patients' charts for practices related to the ventilator bundle showed significant improvement in HOB elevation, from 51% before the education sessions to 69% after the education sessions (P = .009, Table 5). The frequency of oral care increased significantly (P = .009). After the education sessions, 35% of the audited records showed documented oral care 3 times per shift, whereas only 16% showed the same frequency of care before the sessions. Residual volume in the nasogastric tube was also checked more frequently after the education sessions; 18% of patients were checked 3 times per shift, whereas only 3% of patients were checked that often before the sessions.

Discussion

Education sessions were presented to most nurses in the CCU and SICU. After the nurses completed the sessions, their knowledge increased and their use of evidence-based practice improved. Thus the goals of the project were successfully met, as shown by the significant improvement in the nurses' test scores and in the number of patients who received the level of care recommended in the ventilator bundle. These results show that targeted intervention with a 30-minute education session can influence nurses' knowledge and clinical practice.

Significant changes were noted in the nurses' hand-washing practices before contact with a patient and in their use of nail polish and wearing of rings. The actual HOB elevation used, notation of HOB elevation in patients' charts, oral care, and checking of residual volume in the nasogastric tube also improved significantly. The observed practices also indicated some level of professionalism and awareness among the nurses regarding proper hand washing after contact with patients as well as the problems associated with wearing artificial nails. Such practices should be positively reinforced.