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Evidence-based intervention paper

Tolentino-De los Reyes et al. (2007) presented the findings from an-evidence based intervention among critical care nurses in a coronary care unit (CCU) and a surgical ICU (SICU). The research was grounded in data from previous researches which have consistently highlighted the impact of poor clinical practice with respect to mechanical ventilation on the health outcomes of patients, specifically ventilator-associated pneumonia (VAP). Evidence reveals that nosocomial pneumonia accounts for 15 percent of all hospital acquired infections (CDC, 2007).

However some cases of VAP, like other HAIs, are preventable by as much as 33 percent (Mohr, Peninger, & Ostrosky-Zeichner, 2005). The researchers in the current research examined existing evidence and clinical practice with respect to mechanisms to limit the development of nosocomial pneumonia and thus improve the mortality and morbidity of patients accessing this treatment methodology. The researchers examined empirical data, dating from 1992 to2005, which examined the practices that would contribute to decreasing the incidents of VAP.

All of the researches were from primary sources and very relevant to the purpose of the current research. In addition the researchers examined multiple sources with data from a wide range of clinical experiments and observations. This helped add validity to the research. They looked at practices that contribute to VAP including failure to wash hands prior to and after caring for patients, failure to elevate the back rest to between 30o and 45o except in cases where that was contraindicated, the wearing of one or more rings and failure to adopt appropriate oral care practices for patients on mechanical ventilators.

The researchers examined best techniques to improve nurse compliance with correct practices when dealing with patients on mechanical ventilation. From their examination of previous research the current researchers discovered that staff education was an effective means of improving patient outcomes by decreasing the incidence of VAP. This finding was supported by three separate and up-to-date researches – Babcock et al (2004), Salahuddin et al (2004) and Zack et al (2002).

The American Association of Critical-Care Nurses has outlined a comprehensive set of steps, referred to as the ventilator bundle, which incorporates the findings of the preceding research. The purpose of the current research was therefore to determine the impact that an educational intervention would have on the practice of critical care nurses in dealing with patients on mechanical ventilation. The educational intervention involved a 30 minute PowerPoint® presentation on the ventilator bundle which included the information discovered in the literature review and the guidelines provided by the AACN.

Nurses are to elevate the head of the bed (HOB) to 30? to 45? unless medically contraindicated, remove subglottic secretions often, change ventilator circuit no more often than every 48 hours, and wash hands before and after contact with each patient (Tolentino-De los Reyes et al. (2007). Sixty one nurses from the SICU (28) and CCU (33) units of a large, metropolitan hospital were first given a pretest to determine their knowledge of VAP, its definition, causes, diagnosis, contraindications and the use of the ventilator bundle.

The nurses were recruited equally from the two shifts, 7am to 7pm and 7pm to 7am, with 14 nurses from each shift in the SICU and 15 day and 18 night shift nurses from the CCU. These nurses varied in terms of their age, education, sex and experience. Most were female (82%), had a bachelor’s degree (69%) and with over five years nursing (64%) and critical care (66%) experience. In terms of age 26 percent were between 20 and 30, 30 percent 31-40, 28 percent 41-50, 13 percent 51-60 and 3 percent over 61. This shows a relatively even distribution in age. Both units were relatively similar in all these regards.

The 30-minute educational intervention using a PowerPoint® presentation then followed and a posttest was administered to determine the change in knowledge. Additionally a poster containing the information delivered during the 30-minute session was displayed in each of the units involved in the study. Another aspect of the research involved observations of nursing practice prior to and after the educational intervention to determine the extent to which nurses were compliant with guidelines A total of 99 nurses in these units were observed, this includes nurses who were unable to attend the intervention.

The research methodology and choice of participants for this study were quite appropriate to the research question. First the use of an educational intervention, as highlighted by the current researchers, was grounded in previous research attesting to its usefulness in decreasing VAP incidences. Thus this intervention methodology is justified, useful and effective. Second the researchers conducted pre and post tests of nurses’ knowledge of VAP and the ventilator bundle.

This technique ensured that the researchers had a baseline from which to compare any improvements that would be demonstrated in nursing knowledge. Furthermore this knowledge was also matched with practice, to determine if knowledge had an impact on practice. To examine this, the researchers observed the nurses both before and after the intervention. Again this technique ensures that any data gathered on the impact of the educational intervention on nursing practice would be valid and reliable and the observers would have data on previous practice with which to compare the new results.

Thus the researchers ensured that their findings were transparent and that the improvements in nursing practice and knowledge with respect to the ventilator bundle was indeed attributable to the educational intervention. The researchers found that nurses’ knowledge of VAP and the ventilator bundle was significantly enhanced after the educational intervention. Scores from the 10-item test administered pre and post intervention revealed that nurses’ scores improved considerably for eight of the questions. In terms of their knowledge of the microorganisms causing VAP scores went up from 28 percent to 87 percent correct (p = <.

001), similarly their knowledge of treatment related risk factors for VAP went up from 28 percent at pretest to 79 percent at posttest (p = <. 001). For the other two questions the nurses had already scored high on them. This means that the educational intervention was effective in developing nurses’ knowledge of VAP. However since knowledge should translate into practice the researchers compared actual practices of nurses with patients on mechanical ventilation to determine if they were adhering to what was taught.

Thirty four percent more nurses washed their hands before contacting patients (p = <. 001) and all nurses washed their hands after contacting patients as compared to 96 percent prior to intervention (p = . 08). In addition nurses began wearing fewer rings with 66 percent, up from 39 percent (p = <. 001), wearing no ring at all during contact. Thirty percent more nurses, up from 44%, elevated the bed to above 30o (p = <. 001). Additionally nurses stopped wearing nail polish and artificial nails (p = . 32).

These findings are of considerable importance to critical care nurses, particularly those working in the medical ICU. It is the job of these nurses in the ICU to mitigate possible complications for patients receiving mechanical ventilation. Thus this research serves to further exemplify that certain practices by nurses and other personnel involved in the care of patients can impact patient outcomes negatively. It is up to MICU nurses to ensure that they adopt the appropriate practices through self education and evaluation.

Education, as the current researchers emphasized, is probably one of the keys in addressing this issue. In the research education of personnel led to significant improvements in all aspects of care that have been found to contribute to decreased VAP incidence. Hospitals therefore need to ensure that their MICU nurses are properly educated on all HAIs and trained on ways to diminish their occurrence. Where group education is not possible or not available nurses should try to educate themselves by examining literature such as these and thereby develop their own evidence-based practice.

Another issue this research has brought into focus is the lack of knowledge of HAIs generally and the mechanisms nurses can employ to diminish their occurrence. While it is true that practice improved after education, it brings into question if the nurses were really not aware of VAP given the attention that has been paid to this and other HAIs in recent times. It could be that nurses have some knowledge but are either not aware of how to put it into practice or are not willing or able to do so given the demands of the critical care units.

Perhaps the nurses in this study were aware that they were being observed since they had already undergone the intervention and this, rather than any new knowledge gained, impacted their practice. It would be useful to reassess these nurses on a more longitudinal basis to see if they maintain these practices overtime. This situation thus calls for a more structured, ongoing mechanism of evaluation that would fall under the ambits of the hospital administrators. Hospitals need to develop mechanisms to assess nursing practice, specifically with respect to HAIs and VAP in particular, in order to determine the compliance with best practices.

Once administrators understand the true nature of the practice in their own institutions they can devise strategies to enforce them. If lack of adherence is due to lack of knowledge then programs such as the one in the current research would be appropriate. If it is that nurses are just negligent then an alternate approach will have to be devised where administrators try to develop solutions through open negotiations and discussions with all nurses involved in critical care.

The findings of the current research are, therefore, of significance to all critical care nurses, including those in the medical ICU. Hospital administrators who are looking for ways to improve patient outcomes by diminishing the development of preventable infections would be wise to take into consideration the position put forward by the researchers that proper nurse education can lead to significant improvements.


Centers for Disease Control (CDC). (2007). Estimates of health-care associated infections.Retrieved March 27, 2008, from http://www. cdc. gov/ncidod/dhqp/hai. html Mohr, J. , Peninger, M. , & Ostrosky-Zeichner, L. (2005). Infection control in intensive care units. Journal of Pharmacy Practice 18(2), 84-90. Tolentino-De los Reyes, A. F. , Ruppert, S. D. Shiao, S. P. , & School of Nursing, University of Houston Victoria and University of Houston System. (2007). Evidence-based practice: Use of the ventilator bundle to prevent ventilator-associated pneumonia. American Journal of Critical Care, 16(1), 20-27.

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