Dissertations / Theses on the topic 'Ventilator-associated pneumonia (VAP)'

Patients who require mechanical ventilation (MV) are at risk for developing ventilator associated pneumonia (VAP). Nurses’ adherence to sedation vacations (SVs) has a direct impact on the development of VAP, because SVs have been shown to reduce patients’ average duration of MV and length of stay (LOS) in the intensive care unit (ICU). The purposes of this study guided by Donabedian’s (1966) model were to quantify nurses’ level of adherence to SVs, in relation to the health outcomes of critically ill patients, and identify the barriers and facilitators to performing SVs. A correlational design was used. The design included three components: abstraction of patient data from the electronic medical record (EMR) (n=79 with VAP and n=79 without VAP), administration of surveys to ICU nurses (N =34), and vignettes related to SVs. Analyses included descriptive statistics, t-tests, correlations, and analyses of covariance. Most nurses held a Bachelors degree (70.6%), had < 9 years of ICU experience (52.9%), worked in a medical ICU (47.1%), and reported high confidence in managing SVs (M =8.88, SD =1.25). The majority of patients (N =158) were Black (58.2%), males (56.3%), and on average middle-aged (M =61.5, SD =14.91), with a long ICU LOS (M =15.5, SD =11.84), extended duration of MV (M =9.5, SD =8.47), and high acuity (APACHE III) (M =70.2, SD =25.42). The nurses’ education, advanced certification, and ICU experience were not associated with the appropriate implementation of SVs in the vignettes. On average nurses’ had low scores on the vignettes (M =6.97, SD =2.21; possible range =0-14). The adherence rate of nurses’ implementation of SVs, determined using EMR data, was also low (M =24%; SD =23%). There were higher rates of SV adherence in patients without VAP (p (p < .01), and a duration of MV < 6 days (p =.04). These findings indicate that even with established protocols, nurses may not consistently implement the evidenced-based interventions that have been shown to prevent nosocomial infections. Future research is needed to improve nursing practice and the quality of care in this patient population.

Ventilator-associated pneumonia (VAP) is the leading healthcare-acquired infection among ventilated patients in intensive care units (ICU). VAP is a serious patient complication that results in increased hospital length of stay, cost, morbidity, and mortality. The accumulation of subglottic secretions above the endotracheal tube (ETT) cuff increases the risk of VAP, as these secretions may leak around the cuff of the ETT resulting in aspiration and an increased risk for infection. An in depth literature review was done to determine the effectiveness of subglottic secretion aspiration (by means of specialized ETT tubes with intrinsic suction lumens) in decreasing the incidence rate of VAP. Evidenced-based data were gathered from the CINAHL Plus with Full Text, PubMed, and Cochrane Database of Systematic Reviews databases for this review. VAP guidelines recommend subglottic secretion aspiration as a means to prevent its occurrence. However, important variables such as suction pressure, frequency, secretion viscosity, and ETT cuff pressure and volume need to be considered. The interaction among these variables determines the effectiveness of subglottic secretion removal. The goal of this review was to highlight these interactions and provide evidenced-based information for critical care nurses to expand their understanding of the dynamics involved in subglottic secretion aspiration and how to efficiently use this practice to prevent VAP.<br>ID: 030476101; System requirements: World Wide Web browser and PDF reader.; Mode of access: World Wide Web.; Accepted in partial fulfillment of the requirements for honors in the major in Nursing.; Adviser: Mary Lou Sole.; Thesis (B.A.)--University of Central Florida, 2011.; Includes bibliographical references (p. 37-42).<br>B.S.N.<br>Bachelors<br>Nursing<br>Nursing

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Background: Ventilator-associated pneumonia is a major cause of morbidity and mortality for patients in an intensive care unit. Once present, ventilator-associated pneumonia is known to increase the duration of mechanical ventilation, time in the intensive care unit, and length of hospital stay. Patients with acquired brain injury are commonly admitted to the intensive care unit and considered to be at a high risk for the development of respiratory complications such as ventilator-associated pneumonia, which could potentially impact on the intensive care unit costs and outcomes. Respiratory physiotherapy is often provided to prevent and/or treat ventilator-associated pneumonia in patients with acquired brain injury. The theoretical rationale of the respiratory physiotherapy is to improve airway clearance and enhance ventilation which may reduce the incidence of pulmonary infections and thus ventilator-associated pneumonia, and may in turn decrease the duration of mechanical ventilation, prevent the need for tracheostomy and hence result in reduced costs and shorter hospital stay. Although respiratory physiotherapy may be beneficial in reversing or preventing ventilator-associated pneumonia, to date there are no data concerning the effectiveness of respiratory physiotherapy in patients with acquired brain injury. Hence from an evidence-based perspective, at present there is no justification for the role of respiratory physiotherapy in the management of patients with acquired brain injury in the intensive care unit. Aim: This two-part, prospective randomised controlled trial aimed to investigate the effect of regular prophylactic respiratory physiotherapy on the incidence of ventilator-associated pneumonia, duration of mechanical ventilation, and length of intensive care unit stay in adults with acquired brain injury, as compared to a control group (Part A).The second part of the study (Part B) randomised those subjects from Part A who developed a ventilatorassociated pneumonia into a treatment or control group to establish if the provision of a regimen of regular respiratory physiotherapy influenced the outcome of ventilator-associated pneumonia. Additionally, this study also aimed to provide the first description of the financial costs of respiratory physiotherapy time in providing interventions to patients with acquired brain injury in the intensive care unit and investigated the cost effectiveness of respiratory physiotherapy interventions in decreasing the incidence of ventilator-associated pneumonia, duration of mechanical ventilation and length of intensive care unit stay. Subjects: 144 adult patients with acquired brain injury admitted with a Glasgow Coma Scale of nine or less, requiring intracranial pressure monitoring, and invasive ventilatory support for greater than 24 hours, were randomised to a treatment group or a control group. Methods: For subjects randomised to the treatment groups, the regimen of respiratory physiotherapy treatment was repeated six times per 24-hour period and continued until the subject was weaned from mechanical ventilatory support. Each respiratory physiotherapy intervention of 30 minute duration comprised a regimen of positioning, manual hyperinflation and suctioning. In both Parts A and B, the control group received standard nursing and medical care but no respiratory physiotherapy interventions. Results: Consent was obtained for 144 subjects, with 72 randomised for treatment in Part A. Part A groups were comparable with respect to demographic variables, with the exception of body mass index and gender distribution.Using intention to treat philosophy, there were no significant differences for incidence of ventilator-associated pneumonia [Treatment Group 14/72 (19.4%) vs. Control 19/72 (26.4%); p = 0.32], duration of mechanical ventilation (hr) [172.8 vs. 206.3); p = 0.18], or length of intensive care unit stay (hr) [224.2 vs. 256.4; p = 0.22]. For subjects with acquired brain injury receiving this prophylactic regimen of respiratory physiotherapy in the intensive care unit, in an attempt to prevent ventilator-associated pneumonia, the cost of physiotherapy was $487 per subject. Comparatively the intensive care unit mechanical ventilation bed day cost was $33,380 per subject. The cost of Part A respiratory physiotherapy time for Treatment Group 1 was 1.7 per cent of the cost of subject's intensive care unit mechanical ventilation bed days. Thirty-three subjects (22.9%) from Part A developed ventilator-associated pneumonia, and were transferred to Part B and re-randomised, 17 to the Treatment Group 3. Part B groups were comparable with respect to demographic variables. No significant differences were detected in the dependent variables for Part B of the study, with similar duration of mechanical ventilation (hr) [342.0 vs. 351.0); p = 0. 89], and length of ICU stay (hr) [384.7 vs. 397.9; p = 0.84] noted. In those subjects with acquired brain injury in whom ventilator-associated pneumonia developed, the regimen of respiratory physiotherapy for the remaining duration of mechanical ventilation following diagnosis of ventilator-associated pneumonia costed an average of $788. Comparatively the intensive care unit bed day cost for the period of mechanical ventilation was $43,865. The cost of Part B respiratory physiotherapy time for Treatment Group 3 was 1.8 per cent of the cost of their intensive care unit mechanical ventilation bed days.Subjects with a ventilator-associated pneumonia were significantly younger, were admitted with a lower Glasgow coma scale, and more likely to have been admitted with a chest injury than subjects without a ventilator-associated pneumonia. Duration of mechanical ventilation and length of intensive care unit stay were significantly increased in subjects with ventilatorassociated pneumonia, but length of hospital stay was not significantly different. Significant differences in the costs of respiratory physiotherapy and intensive care unit mechanical ventilation bed day costs were evident between those subjects with ventilator-associated pneumonia as compared to those without ventilator-associated pneumonia. For subjects with ventilator-associated pneumonia, the respiratory physiotherapy time cost was $1,029 per subject, compared to $510 for subjects without ventilator-associated pneumonia. The intensive care unit mechanical ventilation bed day cost for subjects with ventilator-associated pneumonia was $61,092 per subject, and $25,142 for those without a ventilator-associated pneumonia, giving an incremental health cost of $35,950 per episode of ventilatorassociated pneumonia. No significant differences were evident in the cost of respiratory physiotherapy as a per cent of the cost of their intensive care unit mechanical ventilation bed days, with findings of 1.4 per cent in those with ventilator-associated pneumonia and 1.1 per cent in those without ventilator-associated pneumonia.Conclusion: Use of a regular prophylactic respiratory physiotherapy regimen comprising of positioning, manual hyperinflation and suctioning, in addition to routine medical and nursing care, did not appear to prevent ventilator-associated pneumonia, reduce length of ventilation or intensive care unit stay in adults with acquired brain injury. Furthermore, in those acquired brain injury subjects with ventilator-associated pneumonia, regular respiratory physiotherapy did not appear to expedite recovery in terms of reducing length of ventilation or intensive care unit stay. It can be concluded from the findings of this study that the presence of ventilator-associated pneumonia has a significant influence on morbidity and costs in subjects with acquired brain injury. Whilst statistically significant results were not found with clinical variables, it is suggested that the provision of a prophylactic respiratory physiotherapy regimen costing $487 per subject is a worthwhile investment in attempts to avoid the incremental health cost of $35,950 per episode of ventilator-associated pneumonia. In subjects with ventilator-associated pneumonia it is concluded that the cost of respiratory physiotherapy would not appear to be justified in attempts to reduce the duration of mechanical ventilation.

Background: Ventilator-associated pneumonia is a major cause of morbidity and mortality for patients in an intensive care unit. Once present, ventilator-associated pneumonia is known to increase the duration of mechanical ventilation, time in the intensive care unit, and length of hospital stay. Patients with acquired brain injury are commonly admitted to the intensive care unit and considered to be at a high risk for the development of respiratory complications such as ventilator-associated pneumonia, which could potentially impact on the intensive care unit costs and outcomes. Respiratory physiotherapy is often provided to prevent and/or treat ventilator-associated pneumonia in patients with acquired brain injury. The theoretical rationale of the respiratory physiotherapy is to improve airway clearance and enhance ventilation which may reduce the incidence of pulmonary infections and thus ventilator-associated pneumonia, and may in turn decrease the duration of mechanical ventilation, prevent the need for tracheostomy and hence result in reduced costs and shorter hospital stay. Although respiratory physiotherapy may be beneficial in reversing or preventing ventilator-associated pneumonia, to date there are no data concerning the effectiveness of respiratory physiotherapy in patients with acquired brain injury. Hence from an evidence-based perspective, at present there is no justification for the role of respiratory physiotherapy in the management of patients with acquired brain injury in the intensive care unit. Aim: This two-part, prospective randomised controlled trial aimed to investigate the effect of regular prophylactic respiratory physiotherapy on the incidence of ventilator-associated pneumonia, duration of mechanical ventilation, and length of intensive care unit stay in adults with acquired brain injury, as compared to a control group (Part A).<br>The second part of the study (Part B) randomised those subjects from Part A who developed a ventilatorassociated pneumonia into a treatment or control group to establish if the provision of a regimen of regular respiratory physiotherapy influenced the outcome of ventilator-associated pneumonia. Additionally, this study also aimed to provide the first description of the financial costs of respiratory physiotherapy time in providing interventions to patients with acquired brain injury in the intensive care unit and investigated the cost effectiveness of respiratory physiotherapy interventions in decreasing the incidence of ventilator-associated pneumonia, duration of mechanical ventilation and length of intensive care unit stay. Subjects: 144 adult patients with acquired brain injury admitted with a Glasgow Coma Scale of nine or less, requiring intracranial pressure monitoring, and invasive ventilatory support for greater than 24 hours, were randomised to a treatment group or a control group. Methods: For subjects randomised to the treatment groups, the regimen of respiratory physiotherapy treatment was repeated six times per 24-hour period and continued until the subject was weaned from mechanical ventilatory support. Each respiratory physiotherapy intervention of 30 minute duration comprised a regimen of positioning, manual hyperinflation and suctioning. In both Parts A and B, the control group received standard nursing and medical care but no respiratory physiotherapy interventions. Results: Consent was obtained for 144 subjects, with 72 randomised for treatment in Part A. Part A groups were comparable with respect to demographic variables, with the exception of body mass index and gender distribution.<br>Using intention to treat philosophy, there were no significant differences for incidence of ventilator-associated pneumonia [Treatment Group 14/72 (19.4%) vs. Control 19/72 (26.4%); p = 0.32], duration of mechanical ventilation (hr) [172.8 vs. 206.3); p = 0.18], or length of intensive care unit stay (hr) [224.2 vs. 256.4; p = 0.22]. For subjects with acquired brain injury receiving this prophylactic regimen of respiratory physiotherapy in the intensive care unit, in an attempt to prevent ventilator-associated pneumonia, the cost of physiotherapy was $487 per subject. Comparatively the intensive care unit mechanical ventilation bed day cost was $33,380 per subject. The cost of Part A respiratory physiotherapy time for Treatment Group 1 was 1.7 per cent of the cost of subject's intensive care unit mechanical ventilation bed days. Thirty-three subjects (22.9%) from Part A developed ventilator-associated pneumonia, and were transferred to Part B and re-randomised, 17 to the Treatment Group 3. Part B groups were comparable with respect to demographic variables. No significant differences were detected in the dependent variables for Part B of the study, with similar duration of mechanical ventilation (hr) [342.0 vs. 351.0); p = 0. 89], and length of ICU stay (hr) [384.7 vs. 397.9; p = 0.84] noted. In those subjects with acquired brain injury in whom ventilator-associated pneumonia developed, the regimen of respiratory physiotherapy for the remaining duration of mechanical ventilation following diagnosis of ventilator-associated pneumonia costed an average of $788. Comparatively the intensive care unit bed day cost for the period of mechanical ventilation was $43,865. The cost of Part B respiratory physiotherapy time for Treatment Group 3 was 1.8 per cent of the cost of their intensive care unit mechanical ventilation bed days.<br>Subjects with a ventilator-associated pneumonia were significantly younger, were admitted with a lower Glasgow coma scale, and more likely to have been admitted with a chest injury than subjects without a ventilator-associated pneumonia. Duration of mechanical ventilation and length of intensive care unit stay were significantly increased in subjects with ventilatorassociated pneumonia, but length of hospital stay was not significantly different. Significant differences in the costs of respiratory physiotherapy and intensive care unit mechanical ventilation bed day costs were evident between those subjects with ventilator-associated pneumonia as compared to those without ventilator-associated pneumonia. For subjects with ventilator-associated pneumonia, the respiratory physiotherapy time cost was $1,029 per subject, compared to $510 for subjects without ventilator-associated pneumonia. The intensive care unit mechanical ventilation bed day cost for subjects with ventilator-associated pneumonia was $61,092 per subject, and $25,142 for those without a ventilator-associated pneumonia, giving an incremental health cost of $35,950 per episode of ventilatorassociated pneumonia. No significant differences were evident in the cost of respiratory physiotherapy as a per cent of the cost of their intensive care unit mechanical ventilation bed days, with findings of 1.4 per cent in those with ventilator-associated pneumonia and 1.1 per cent in those without ventilator-associated pneumonia.<br>Conclusion: Use of a regular prophylactic respiratory physiotherapy regimen comprising of positioning, manual hyperinflation and suctioning, in addition to routine medical and nursing care, did not appear to prevent ventilator-associated pneumonia, reduce length of ventilation or intensive care unit stay in adults with acquired brain injury. Furthermore, in those acquired brain injury subjects with ventilator-associated pneumonia, regular respiratory physiotherapy did not appear to expedite recovery in terms of reducing length of ventilation or intensive care unit stay. It can be concluded from the findings of this study that the presence of ventilator-associated pneumonia has a significant influence on morbidity and costs in subjects with acquired brain injury. Whilst statistically significant results were not found with clinical variables, it is suggested that the provision of a prophylactic respiratory physiotherapy regimen costing $487 per subject is a worthwhile investment in attempts to avoid the incremental health cost of $35,950 per episode of ventilator-associated pneumonia. In subjects with ventilator-associated pneumonia it is concluded that the cost of respiratory physiotherapy would not appear to be justified in attempts to reduce the duration of mechanical ventilation.

Made available in DSpace on 2014-12-17T14:46:36Z (GMT). No. of bitstreams: 1 CristianeRM.pdf: 5245197 bytes, checksum: e2a591b692b29f0a98a345fa8cdc01ad (MD5) Previous issue date: 2008-05-29<br>Quasi-experimental study, prospective with quantitative approach, performed at the Hospital do Cora??o in Natal, aimed at verified the existence of difference between the care given by health professionals to the patients under mechanical ventilation (MV) in the Intensive Care Unit, before and after an educative intervention. The population was of 31 professionals, with data collected between november 05 of 2007 to march 27 of 2008. The results show a yong population, female gender, middle level of education, nursing technique, working between 05 and 09 years on nursing profession, and 01 to 04 years on Intensive Care Unit; almost all, never had an kind of training over prevent pneumonia associated to mechanical ventilation; from those that had training, occur on the work place with duration from 12 to 24 hours. About endotracheal intubation, the cuff was tested with a sterilized syringe had a positive change after a educative intervention, increased from 75,0% to 100,0%; the sterile guide was used on 75,0% before and 100,0% after an educative intervention. Regarding endotracheal suction procedure, was not informed to the patient on 72,7% before, however was informed on 56,7% after; the hands was not previously washed 68,5% before, however was 63,3% after the procedure; mask was used on 74,2 % opportunities before and 76,7% after; the aspiration catheter had adequated size on 98,9% observation before and 100,0% after; the gaze was sterilized on 95,7% before and 100,0% after; the ventilator was connected to the patient during the aspiration intervals on 94,4% observation before and 100,0% after; the ambu bag was clean and protected on 76,1% before and 85,7% after; the aspiration catheter was discarded after be used on 98,9% before and 100,0% after; FIO2 was turned to the begging value on 32,9% observation before and 12,0% after; before the procedure 71,9% professions washed their hands and 73,3% after; before, notes of aspiration results were performed on 70,8% observation and 86,7% after. Regarding devices used on respiratory tract, aspirator flasks were not swapped on 84,6% observations before and 71,0% after; daily l?tex extention change was not performed on 93,6% observation before and 87,1% after; the ambu bag change was not performed on 50,0% observation before even if was duty or unprotected and on 75,8% opportunities was changed, after; nebulization was not prepared with sterile fluids or manipulated aseptically on 65,2% observation before, perhaps was on 71,7% after; before nebulizers were not changed on 65,2% observations, perhaps were on 60,9% after. Concerning ventilator breathing circuits, condense fluids cumulated on circuits were removed on 55,0% opportunities before, and 64,0% after; moisturizer was not filled with sterile water when already had small amount of liquid inside on 78,4% observations before, and 90,2% after; MV circuits were changed on 97,0% observations on presence of visible duty or when presents some kind of failure, before and 98,4% after. About body position, on 51,3% observations the decubitus position change were done before and 78,2% after; fowler position was maitened on 95,5% observations before and 98,2% after; Regarding respiratory physiotherapy, enteral diet was not interrupted before respiratory physiotherapy on 94,9% before and 90,0% after; respiratory physiotherapy devices were not disinfected or sterile on 69,6% observations before but they re on 60,0% after; before the cateter was not tested before introduction enteral diet or medications on 100,0% but after was done on 15,2%. About enteral feeding, intestine motility and measure of stomach contents were not done on 100,0% observations before, but was 15,2% after. We conclude that 05 of 07 valuated procedures in relation to MV, had a significant improvement on quality of care given after educative intervention, when compared before intervention<br>Estudo quase-experimental, com abordagem quantitativa, delineamento tempo-s?rie e dados prospectivos, realizado no Hospital do Cora??o de Natal, objetivando verificar a exist?ncia de diferen?a entre a assist?ncia prestada pelos profissionais de sa?de aos pacientes sob ventila??o mec?nica (VM) internados na UTI, antes e ap?s uma interven??o educativa. A popula??o fo de 31 profissionais, com dados coletados entre 05 de novembro de 2007 e 27 de mar?o de 2008. Os resultados mostram uma popula??o jovem, entre 20 e 30 anos de idade, do sexo feminino, ensino n?vel m?dio completo, na maioria, t?cnicos de enfermagem, trabalhando entre 05 e 09 anos na profiss?o, e 01 e 04 anos em UTI; a maioria nunca realizou treinamento acerca da preven??o de PAV; dos que realizaram, participaram em eventos da institui??o com dura??o entre 12 e 24 horas. Quanto ? intuba??o endotraqueal, o teste do cuff com seringa est?ril sofreu modifica??o positiva, ap?s a interven??o educativa, aumentando de 75,0% para 100,0%; o fio guia est?ril foi usado em 75,0% das ocasi?es antes e em 100,0% ap?s. Sobre aaspira??o endotraqueal, n?o foi explicado ao paciente sobre esse procedimento em 72,7% das situa??es antes, mas foi em 56,7% das vezes ap?s; a higieniza??o das m?os n?o foi realizada previamente em 68,5% das vezes antes, mas foi em 63,3% ap?s; a m?scara foi utilizada em 74,2% das oportunidades antes e em 76,7% ap?s; o cateter de aspira??o tinha o tamanho adequado em 98,9% das observa??es antes e em 100,0% ap?s; a gaze usada estava est?ril em 95,7% antes e em 100,0% ap?s; o ventilador foi conectado ao paciente durante os intervalos da aspira??o em 94,4% das oportunidades antes e em 100,0% ap?s; o ambu estava limpo e protegido em 76,1% das situa??es antes e em 85,7% ap?s; o cateter de aspira??o foi descartado ap?s o uso em 98,9% das oportunidades antes e em 100,0% ap?s; a extens?o de l?tex foi limpa em 86,5% das observa??es antes e em 93,3% ap?s; a FIO2 foi retornada ao valor inicial em 32,9% das vezes antes e em 12,0% ap?s; a higieniza??o das m?os ao t?rmino do procedimento foi feita em 71,9% das situa??es antes e em 73,3% ap?s; as anota??es referentes ? aspira??o foram feitas em 70,8% das observa??es antes e em 86,7% ap?s. Quanto aos dispositivos, a troca di?ria dos frascos aspiradores n?o foi obedecida em 84,6% das oportunidades antes e em 71,0% ap?s; a troca di?ria da extens?o de l?tex n?o foi realizada em 93,6% das vezes antes e em 87,1% ap?s; o ambu n?o foi trocado em 50,0% das observa??es, embora estivesse sujo e/ou desprotegido antes, mas em 75,8% das oportunidades esse dispositivo foi trocado ap?s; a nebuliza??o n?o foi preparada com flu?dos n?o est?reis e/ou manipulada assepticamente em 65,2% das ocasi?es antes; entretanto em 71,7% das vezes foram realizados ap?s; os nebulizadores n?o foram trocados em 65,2% das situa??es antes, mas foram em 60,9% ap?s. Acerca dos circuitos do VM, o condensado acumulado nos circuitos foi descartado em 55,0% das vezes antes e em 64,0% ap?s; o preenchimento do umidificador com ?gua, n?o foi feito em 78,4% das vezes em que possu?a l?quidos remanescentes antes e em 90,2% ap?s; os circuitos do VM foram trocados em 97,0% das oportunidades em que apresentavam sujidade vis?vel ou estavam defeituosos antes e em 98,4% ap?s. Quanto ? mudan?a de dec?bito, em 51,3% das vezes antes foi realizada e em 78,2% ap?s; a cabeceira do leito do paciente foi mantida elevada em 95,5% das observa??es antes e em 98,2% ap?s. Sobre a fisioterapia, a dieta enteral n?o foi interrompida antes das manobras fisioter?picas em 94,9% das situa??es antes e em 90,0% ap?s; os materiais usados durante a fisioterapia n?o estavam desinfetados e/ou est?reis em 69,6% das observa??es antes, mas estavam em 60,0% ap?s. Quanto ? nutri??o enteral, o teste da sonda antes de iniciar a dieta enteral ou de administrar medicamentos n?o foi realizado em nenhuma das oportunidades antes, entretanto foi em 15,2% ap?s; a motilidade intestinal e aferi??o do conte?do (residual) g?strico n?o foram verificadas em nenhuma das observa??es, mas foi em 15,2%, ap?s. Conclu?mos que, em 05 dos 07 procedimentos avaliados em rela??o ? VM, houve melhora significativa na qualidade da assist?ncia prestada quando comparados ao momento anterior ? interven??o educativa

Ventilator-associated pneumonia (VAP), catheter-related blood stream infection (CRBSI) and pressure ulcers (PU) are well recognized complications in intensive care units (ICUs). Many of these are preventable but can also complicate patient recovery, prolong length of stay, increase costs, morbidity and mortality. In Malaysia, the majority of studies investigating VAP and CRBSI in Malaysia have focussed on identifying risk factors, diagnostic criteria and treatment of ICU-related complications. Further, in spite of the burden of PU there are limited studies undertaken in Malaysia and few of these have been nurse-led. Importantly, to date there has been limited investigation of the efficacy and effectiveness of quality improvement initiatives and the contextual issues impacting on clinical practice improvement in Malaysia.In spite of the increasing emphasis on quality assurance in Malaysian ICUs there has been a limited focus on nurse-specific interventions and the majority of projects have been initiated by physicians. This study has evaluated the utility of a nurse-led action research project to drive clinical practice improvement in the ICU and is significant in demonstrating the capacity of nurses to critique and control their practice. The project conducted for this thesis was called the Improving health outcomes by preveNting intensiVe care related infEction in Malaysia intenSive care uniT - INVEST study. The INVEST Study as reported in this thesis has been undertaken using an action research approach to improve the uptake of evidence-based strategies to prevent infection in the ICU in the Malaysian cultural context.The aims of this thesis were to identify best practices, evaluate the current nursing practice in prevention of VAP, CRBSI and PU in ICU patients in a single Malaysian ICU, and evaluate the impact of the evidence-based interventions to improve patient outcomes. The specific and research objectives of this study were to:1. Identify best practice interventions for preventing VAP, CRBSI and PU in the ICU. 2. Document the current rates of VAP, CRBSI and PU in an ICU in Malaysia. 3. Implement an action research intervention to collaboratively develop and implement strategies for improvement 4. Assess the impact of the intervention on clinical outcomes, staff dynamics, work place culture and sustainability of practice change An action research approach was used in this study to involve and empower nurses and drive practice change. A literature review identified that many action research studies conducted in the ICU were mainly most focused on process measures and not outcomes. In this study the data were collected in three phases following the action research cycles which comprised of a period of planning, acting, observation, reflecting and re-planningIn Phase I of the thesis current best practice interventions for the prevention of VAP, CRBSI and PU in ICU are described. A literature search was conducted to identify evidence-based practices (EBP) that were recommended by bodies to improve the prevention of VAP, CRBSI and PU. A core set of nursing activities was identified in preventing the complications of VAP, CRBSI and PU. These were hand washing, hygiene care, positioning of patient, elevation of the head of bed and providing adequate nutrition.Pre- intervention data collection consisted of an environmental scan, including interview with the key stakeholders, patient profiling and a nurse survey. Twenty-one cases of ICU complications were identified in 18 of the 91 patients (19.8%) admitted in December 2009. Of the patients, three developed two complications - PU and VAP (two patients) or CRBSI (one patient). The findings indicated that this ICU had a high case load due to the high ICU bed demand. Patients needing ICU care were being nursed in general wards due to the unavailability of ICU beds.Nurses reported a good knowledge of prevention strategies with a mean score of 124.84 ±SD14.66 and reported a high level of positive regard for their professional practice environment based on the results of Revised Professional Practice Environment (RPPE). Three components had mean scores of ≥3 and five <3 within the eight components. Three components of RPPE subscales with highest mean scores were Internal Work Motivation (M 3.24; SD 0.3), Relationship With Physician (M 3.22; SD 0.53) and Cultural Sensitivity (M 3.04; SD 0.24). The two lowest mean scores were for Handling Disagreement and Teamwork with 2.77 (SD 0.16) and 2.45 (SD 0.47), respectively. Nurses also showed positive attitudes toward the sustainability of the change process. The Sustainability Indices ranged from 13.4 to 100 with a mean of 75.21 (SD 21.71).In Phase 2 the intervention was conducted over six months from February to July 2010. The Center of Disease Control and Prevention (CDC) criteria for diagnosis of VAP and CRBSI, and the Waterlow Pressure Ulcer Risk Assessment Scale were promoted in the unit. Nurses were exposed and encouraged to implement evidence-based nursing interventions as identified in care criteria. All nurses were invited to the unit nursing education to increase their knowledge and awareness about evidence-based practice in prevention of the ICU complications. Nurses were encouraged to gain control of their practice. Evidence-based practice articles were also provided to increase their knowledge level and posters were distributed and placed in the unit to increase nurses awareness of the quality improvement initiativesFocus group discussions were conducted in Phase 2 and found that nurses in the unit were unaware of the importance of standardized assessment in their daily practice. They had a lack of understanding regarding the importance of standardised risk assessments. Despite the reluctance of many nurses to embrace the EBP, due to a perception of their workload, the focus groups also revealed nurses were optimistic that change will get easier and could be eventually achieved. Participants were positive about the change that could take place in the future. The hierarchical relationships with medical doctors were also identified as a factor limiting nurses from adopting the guidelines.Phase 3 of the project, the post-intervention phase was conducted from March to May 2011. The data collection process was repeated as Phase 1 and Phase 2. There were 11 cases of ICU complications identified during the post-intervention phase in 10 (8.7%) of the 115 patients admitted during March 2011. One patient developed both VAP and PU, while four developed VAP and another five PU. In the post-intervention group, no cases of CRBSI were detected. The total mean score of nurses’ knowledge was 121.45±SD16.85. An independent-samples t-test was conducted to compare nurses’ knowledge pre and post intervention, and found no significant differences, t (150) =1.32, P 0.189. The Sustainability Indices ranged from 41.3 to 100 percent with a mean of 76.81±SD21.45.Approximately 84% of the nurses in pre-intervention and 70% in post-intervention scored >55%. The nurses reported a positive regard for their practice environment in the pre- and post-intervention groups. The mean scores for each component were comparable for both the pre- and post-intervention groups except for Internal Work Motivation, Control Over Practice and Staff Relationship With Physician. The highest mean scores within the eight components for the post-intervention group were for Internal Work Motivation (M 3.13; SD 0.27), Relationship With Physician (M 3.04; SD 0.33) and Cultural Sensitivity (M 3.01; SD 0.23). The three lowest were for Handling Disagreement and Conflict (2.80; SD 0.20), Control Over Practice (2.71; SD 0.34) and Teamwork (2.48; SD 0.31).There was a reduction in overall complications from 19.8% to 8.7%. Few nurses in the focus group were optimistic that at least some changes had taken place, and positively improving their knowledge on assessment of patients and some of their common practices in the ICU. The challenge, which they were presently facing was the implementation of hospital information system because most of them were not knowledgeable in information technology.The main outcome of this study was that there was a reduction in number of patients with PU from 16 to 6 in pre and post intervention groups. This reduction of PU was statistically significant (χ[superscript]2=8.14, df=1, p=0.04).In conclusion whether there was a real improvement in patient care provided due to the interventions given was not able to be determined due to methodological considerations and inability to control for confounders. These data underscore the importance of considering cultural factors, both organisational and societal in quality improvement initiatives and empowering nurses for practice change. A risk management system which acknowledges competing demands in dynamic, real world environments is important to consider in future quality improvement studies. The series of studies presented in this thesis have contributed to understanding of factors influencing implementation and sustainability of quality improvement initiatives in a Malaysia ICU. Information acquired from the thesis will be useful information for further improvement targeting education, services, research, policy and future quality improvement project plans in Malaysia.

Les infections nosocomiales représentent la première cause de mortalité et le premier poste de prescription d’antibiothérapies. Les pneumopathies nosocomiales représentent la première cause de morbi-mortalité en réanimation. Dans un contexte de ressources antibiotiques limitées et une augmentation de l’incidence des germes résistants, nous avons étudié:1°) Les facteurs de risque de pneumopathies acquises sous ventilation mécanique (PAVM) en tenant compte de la durée de la ventilation mécanique2°) La différence entre les pneumopathies associées aux soins en réanimation chez les patients non ventilés et les pneumonies acquises sous ventilation mécanique en terme d’étiologie et de conséquences pronostiques.3°) L’impact de l’adéquation de l’antibiothérapie initiale et les facteurs de risque d’avoir un traitement inadéquat du fait de la résistance bactérienne dans les PAVM à germes gram négatifs.Nos résultats montrent que : Les pneumonies acquises en réanimation en dehors de la ventilation mécanique invasive (ICU-HAP) et les PAVM sont dues aux mêmes germes avec un risque de décès plus important chez les ICU-HAP. Les PAVM précoces et tardives sont associées à des facteurs de risques différents pouvant justifier de politiques de préventions différentes. L’antibiothérapie préalable et la colonisation préalable à des bactéries multi résistantes expliquent la survenue de PAVM à Gram négatifs résistants. La durée de ventilation invasive avant la survenue de la pneumopathie n’est pas un facteur de risque indépendant de survenue de PAVM à gram négatifs résistants. Un pourcentage d’infection ou de colonisation à bacille gram négatif (BGN) résistant supérieur à 10% dans le centre est associé à la survenue d’une PAVM à gram négatif résistant, indépendamment des facteurs individuels. Les PAVM à S. maltophilia surviennent très tardivement, sont très largement associées à une consommation d’antibiotiques élevée, en particulier les pénèmes. Elles sont plus souvent associées à une antibiothérapie initiale inadéquate.Notre travail confirme la nécessité d’un effort particulier afin d’optimiser le diagnostic et l’adéquation précoce des antibiothérapies, en particulier pour les pneumonies acquises en dehors de la ventilation mécanique et les PAVM à BGN potentiellement résistants aux antibiotiques<br>Healthcare-associated infections are the leading cause of death and the first prescription of antibiotics. Healthcare-associated pneumonia represents the first cause of morbidity mortality in ICU. In the context of limited antibiotic resources and an increase in the incidence of resistant germs, we studied:1) Risk factors for ventilator acquired pneumonia (VAP) taking into account the duration of mechanical ventilation (MV).2) If there is a difference between nonventilated and mechanically ventilated pneumonia in terms of etiology and prognostic?3) What is the impact of the adequacy of the initial antibiotic treatment, and what are the risk factors for inadequate treatment in gram-negative resistant VAP?Our results show that: Pneumonia acquired by no ventilated patient in the ICU (ICU-HAP) and VAP are due to the same germs with a higher risk of death in ICU-HAP. Early and late VAP are associated with different risk factors that may need different prevention policies. Previous-antibiotic therapy and prior-colonization with multiresistant bacteria explain the occurrence of resistant Gram Negative VAP. Duration of MV before the onset of pneumonia is no longer an independent risk factor for the occurrence of resistant gram-negative VAP. A percentage of infection or colonization with resistant BGN upper to 10% in the centre is associated with the occurrence of a gram-negative, resistant PAVM, regardless of individual risk factors. S. maltophilia VAP occurs belatedly and are very widely associated with high antibiotic consumption, especially penems. They are more often associated with inadequate initial antibiotic therapy.Our work confirms the need for further research to optimize the diagnosis and early adequacy of antibiotics, in particular in ICU-HAP and VAP caused by potentially antibiotic-resistant BGN

碩士<br>國立臺灣大學<br>健康政策與管理研究所<br>99<br>Background and objectives: Ventilator-associated pneumonia (VAP) not only is one of the important issues of infection control, but also an important complication affecting patients’ prognosis. The main purpose of this research is to analyze the risk factors of trauma patient with VAP and the association with medical care utilization. Methods: Data came from claims data file of 100 million sampled registry from Taiwan National Health Insurance Research Database from 2005 to 2007. A total of 1,010 trauma patients who received invasive mechanical ventilator for >48 hours were analyzed in this study. Differences were compared by using Wilcoxon signed-rank test and Chi-square test; Risk factors for VAP and assciation with medical care utilization were examined by using logistic regression and multiple linear regression. Results: Of the total of 1,010 patients, 166 (16.44%) developed VAP during hospitalization. Logistic regression analysis showed that age > 65, having sepsis and having longer duration of mechanical ventilation were factors associated with developing VAP. Trauma patients with VAP had significantly longer ICU stay (15 versus 10, P&amp;lt;0.001), and hospital stay (32 versus 23, P&amp;lt;0.001), and higher health care expenditure (NT$317,537 versus NT$255,427, P&amp;lt;0.001). Multiple linear regression analysis indicated that VAP significantly prolonged trauma patients’ ICU stay and hospital stay, but didn’t significantly increase patients’ expenditure and mortality rate after controlling for other factors. Conclusions: Age>65, suffering sepsis or long duration of mechanical ventilation were risk factors for developing VAP for trauma patients. VAP was associated with patients’ ICU stay and hospital stay.