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

Findings of this project further support results of earlier studies about educating hospital staff about VAP and the ventilator bundle. (9,11,12) Evidence-based practices, including those addressed in the ventilator bundle, should be a driving force in shaping nursing practice. The ultimate goal of evidence-based practice is high-quality healthcare with beneficial outcomes. Reinforcement of education can help ensure that the education improves nursing practices in a sustained manner. Consistent and accurate documentation of HOB elevation at 30[degrees] or higher, oral care, and checking of residual volume in the nasogastric tube, along with surveillance of proper hand-washing practice among nurses, should be recommended.

Use of the ventilator bundle includes elevating the HOB to 30[degrees] to 45[degrees] to prevent VAP among ICU patients who are receiving mechanical ventilation. Patients in the ICU, who are frequently positioned supine because of the presence of decubitus ulcers, for hemodynamic monitoring, or for particular bedside procedures, should be consistently returned to a semi-recumbent position. If HOB elevation at 30[degrees] to 45[degrees] is a factor in the formation of decubitus ulcers, then the patient could still be placed in the semi-Fowler's position but turned from side to side at least every 2 hours.

The limitations of this project included the fact that not all the nurses in the CCU and SICU were able to participate in the live education sessions; for those who could not attend, the information was provided through an educational poster that was posted in the unit. In some cases, nurses who attended the sessions shared the information with those who did not attend. Because of the nature of the project and the scheduling of staff, no comparisons were made between nurses who attended the sessions and those who did not.

One factor that may have affected the results was the nurses' awareness of being observed before and after the education sessions, which may have led to more conscientious practice. Moreover, few patients received feedings via a nasogastric tube. Most patients receiving mechanical ventilation were receiving total parenteral nutrition, which meant that the number of patients with nasogastric tubes to be checked was limited. As with all chart audits, data are limited to the entries that were made; practices may have occurred without being documented. Finally, other limitations of the clinical project included absence of a control group against which to compare findings, the unknown reliability of the test questions, and the use of documentation as a proxy for actual practice.

Future studies should focus on high-risk and higher acuity patients and those patients receiving mechanical ventilation who are admitted to chronic care facilities, which would involve a longer period of observation. Future studies are needed to examine nursing practices, including oral care and nasogastric tube feedings, as related to prevention of VAR Studies that would establish a direct relationship between oral care, checking of residual volume in the nasogastric tube, and the development of VAP are essential to formulating evidence-based protocols for these practices. Scientific inquiries are needed to determine whether continuous pump or drip feedings via a nasogastric tube should be turned off while patients are being repositioned or placed supine for procedures. The ventilator bundle should be used to implement practice changes for patients, with specification of a safe gastric residual volume and recommendation of a frequency for checking residual volume in the nasogastric tube to prevent pulmonary aspiration.