Biology assignment essay help: Deaths in hospital – Pseumonia
INTRODUCTION
Out of all deaths occurring in hospital acquired infections ventilator associated pneumonia accounts for 15% of the total death rate. It not only increases the chances of mortality, but at the same time increases the cost of care and decreases the ventilator stay time. His complexity is not only difficult to cure but its diagnosis is a tough challenge. Thus the only way to save from this menace is prevention.(Leong , 2006, p 1409).
Today many hospitals have been able to control this problem and certain achieving great success by following a multidisciplinary approach in ventilation care. Even after great care is taken to treat this complication worldwide 30% deaths are registered due to this. Several institutions, governing bodies and health care research centres have proposed different methods and strategies to reduce the complexity of this condition. Evidence based guidelines (EBG’s) are also proposed, but there seem to be a difference existing between the nurses and doctors regarding the guidelines and real practice.
MAIN BODY
In this section, the difference between the bundled strategies and the bundles of VAP will be discussed, the evidence based care with current subject knowledge, nursing interventions and recommendations for nursing practice will be discussed.
Evidence Based Prevention of VAP.
The main reason behind evidence based practice to be implemented in hospitals for VAP is, the number of patients suffering from this condition is on rise against the shortage of staffs and nurses. So no new practices can be applied until and unless they are based upon evidence. The traditional interventions are not used anymore for the patient care. Because of the seriousness these conditions possess, researchers are trying to figure out a model based on the evidences which will be helpful for the nurses. Even though large numbers of data are available, based on the evidences and practice still a large gap do exist between the theory and practice.
The knowledge has to be transitioned to the clinical practice and evidence based guideline acts as a catalyst in this domain. These strategies are not only the manifestation to reduce the time of intubation of patients but also to prevent the main three causes of the VAP such as – Micro aspirations of colonized secretions, Use of contaminated hands and equipments, Digestive tract colonization.
Reducing the duration of ventilation.
The chances of VAP increases with increase in stay in intubation by the patients. So to prevent the critically ill patients to catch up with pneumonia, the non invasive method of ventilation must be used whenever required. If there is a need for endo tracheal tube, then it has to be planned as extubation and intubation are both harmful for the patients since they increase the chances of VAP.
Evidence suggest that when the patient is assessed daily and documented daily to check the readiness of the patient refraining from mechanical ventilations and sedative infusions, the duration of stay in mechanical ventilation and in ICU also decreases. These interventions are combined most of the time to have the best result as these are independent in their practice. Weaning from ventilator by the patients cannot be initiated without their cooperation. So it can be done by decreasing the sedatives which will increase the chances of weaning from mechanical ventilation. The patient can be put on breathing trials by stopping the sedative infusions long enough so that they can respond to the command and their alertness will be increased. But before that their restlessness and anxiety level must be checked. Spontaneous breathing capacity and capacity to go without ventilator is assessed and need to be documented. But there are many risks attached with this intervention also such as, it may lead to pain anxiety and dissynchrony due to the spontaneous extubation. Many unknown effects can also be observed as the patients is aroused and then again forcefully made to sleep. So they must be closely watched. (Coffin et al , 2008, p S41).
If there is a necessity of sedation, even after restraining from the ventilator, then interventions must be made to reduce the dosage of sedation at times reducing to half of the original dosage. The sedation scale must be used such as Riker scale.
Microaspiration of secretions.
In a normal human being, the oral cavity is inhabited by millions of bacteria, but they are constantly being flushed by the saliva production and rest gets digested in the stomach by swallowing. In a 24 hour period the secretion amounts upto 100-150 ml. But in case of these patients they do not take anything from their mouth, so the chances of producing saliva are meagre. There mouth can be colonized very fast within 24 hour of admission. Those micro organisms which were virulent can build reservoirs and dental plaques if not treated properly. The secretions which were accumulated at the aerodigestive tract can intrude into the lungs thus causing pneumonia. Intubated patients mostly gets affected by pneumonia by this way, but those who are suffering from neurologic disease they are at greater danger as they cannot control their own airways to build up secretions and fail to aspire oral secretions.
When the subglottic secretions are continuously suctioned, it has shown to decrease the rate of VAP. Evidence suggest that, if before the position of the patient is changed if intermittent suction is done from the oral cavity then it greatly reduces the dependency on mechanical ventilation, cost of care as well as stay in ICU. Costs do matter when continuous suction has to be done, but it has been shown to be very protective against the VAP. Even after wide evidence are there for the subglottic secretion suction but still they are not implemented. In a survey in USA, out of the 729 hospitals only 21% of them seem to be using this strategy.
Oral Hygiene.
If traditionally the ventilated and critically ill patients are considered, then oral care is a matter of concern. Because it has not been taken seriously for these patients. Nurses at times view oral care as a measure to provide comfort to the patient and lack the knowledge that it decreases the risk of VAP.
Even though it has to be done frequently, but it decolonizes the gum, mouth, tongue, Evidence shows the risk of VAP has reduced greatly when oral care is done continuously and dedicatedly. In one of the study conducted by a group, it have been seen that 8 hour of routine tooth brushing with proper oral care reduces the chances of VAP to zero level in the intervention group.
There exist many guidelines for the nurses to take proper oral care for the critically ill patients. They may varry from country to country but the basics remain the same. Those basic elements include assessment of the oral hygiene, brushing of teeth, gums, and tongue with a soft tooth brush. This has to be repeated twice daily. The lips and the oral mucosa must be moistures with proper agents and if required antiseptic rinse must be made to the selected patients. Foam tipped swabs doesn’t seem to be efficient with comparisons to other stuffs such as tooth brush. At times certain hospitals go for the suction toothbrush that can both suction the oral cavity as well as clean the teeth. Gloves must be worn while providing oral care as chances of transfer of microorganisms from the care giver hand is always there. (Chao Yf et al, 2009, p 28).
The oral cavity can be decontaminated by the use of cholrhexidine that greatly reduces oropharyngeal colonization. This has been shown by evidence that it prevents VAP especially in cardiac injury patients.
CARE of ENDOTRACHEAL TUBE
At times bacteria form a bio film at endo tracheal area that can lead to the VAP especially late infections. But those endotracheal tubes which were coated with silver or antiseptic have shown to help in the decolonization process. Most experts believe that orotracheal tubes should be used rather than nasotracheal tubes as this induces sinusitis thought to be the precursor of the VAP. Proper attention should be given to maintain the orotracheal pressure so that migrations of oral secretions to the lungs are prevented. The endo tracheal tube must have lumen for the continuous and subglottis suctioning. Evidences still lack to recommend whether open or closed suction systems are advantageous in VAP.
OTHER EVIDENCE BASED CARE IN VAP
When the head of the patient indirectly the bed is elevated, then they reduce the chances of elevation by reducing the aspiration both from the nasopharyngeal ands oropharyngeal pathway. A research was conducted regarding the position where semi recumbent position was found to be more potential remover of the VAP when compared to the supine position. This is very advantageous for the patients who are fed eternally. So it is recommended that the bed of the patients should be elevated at a degree of 35 and 40 degree. Even though there is no evidence which suggest that elevation can lead to the decolonization of oral cavity, but till today it is one of the most sought recommendations for the VAP. Additional advantages of this recommendation are it helps to prevent gastric aspirations and helps to facilitate continuous ventilation. (lAbeau S et al, 2007, p 371).
Even though these angles has been shown to prevent VAP, but in practice it has been seen that in hospitals the bed was raised much less than 30 degree mark and mostly the patients lie in supine position. The reason being the angle reader of the medical beds is at such place it is very difficult to read, and nurses do not pay much attention to this.
INCREASING THE MOBILITY OF THE PATIENT
Immobility is one of the major causes of the VAP. The patients who are immobile their secretions as well as the mucus tend to accumulate and as they go down to the lungs area they affect the pulmonary functions more often. Even though initiating mobility in a ventilated patient is not that easy, but evidence suggest that it may help to improve the condition marginally. It may promote weaning of ventilation thus reducing the time of stay in ICU. There is a standard protocol for the mobility initiation where the patient can sit and stand beside the bed. The author of this protocol admits that even though it is not easy for the nurses to follow such protocols, but patient having tubes in their body cannot do this is also a wrong fact which has been taken as a rule. Even though repositioning seems to be a simple step but it has high degree of importance in prevention of VAP. Some hospitals provide the facility of the kinetic beds where the patient body is rotated so that the secretions will not accumulate in the patient body. Evidence suggest that these type of modern facilities may reduce the complications of VAP , but the cost as well as other complications associated with this facility has restrained this from being used widely.
CONTROLLING OF GASTRIC SECRETIONS
The gastric contents need to be aspired from time to time , for those patients who shows the following conditions such as consciousness is much low, dysphagia which can be due to the oesophageal disorder, endotracheal tube, indwelling enteral tube, tracheostomy etc. If an enteral tube is present then it may cause gastric contents to aspire by colonizing the nasopharynx area. If the enteral solution during its preparation gets contaminated then it will lead to the colonization inside the gastric area.
So to avoid this semi upright position is advocated so that it will prevent the gastric reflux. Over distension of the gastric must also be avoided. But any such guidelines which recommends routine decontamination of gastric cavity, avoidance of proton pump inhibitors and H2 agonists is still a debatable issue.
PREVENTION OF CONTAMINATION OF INSTRUMENTS USED
If any instrument that is used is reusable, then there are chances that they can be contaminated and can spread the pathogens into the different pathways. The health care infection control practices advisory committee provides a set of guidelines regarding the maintenance of medical equipments and equipments to be used for the respiratory patients. That instrument which can be reutilised must be sterilized before reuse. For sterilization procedure the sterilized water must be used. The changing of ventilator circuits adds extra costs to the patient as well as to the hospital, and no evidences are found that it reduces the chances of VAP. (Safdar et al, 2005, p 2184). So it has to be changed when it will be found soiled totally. The condensates must be removed from the ventilator tube without opening the circuits also proper care should be taken so that they won’t enter into the patient body or airways. Humidifiers and moisturisers may be used so that the condensates do not go into the patient’s body and its formation can be limited. (Safdar et al, 2005, p 725)
So these are some of the evidence based practices which are followed to reduce the risks of VAP. Next is the recommendation for the nurses to put this strategies and guidelines into practice.
RECOMMENDATIONS
The nurses are asked to elevate the bed at an angle of 30 degree or above in mechanical ventilated patients, an endotracheal tube must be used along with suction for the patients to avoid any type of secretion accumulation. The ventricular circuits must be changed regularly and must be documented. (CDC, 2004, P 1).
The ICU must confirm that they have practice of writing the policy standards and guidelines that has to be pasted on walls regularly with proper updates. This helps in proper intervention taken by both the nurses and the other health care related professionals.
The units rate of compliance must be checked when the elevation of head of bed is taken into account, if the compliance level is < 90% then it must be improved through proper planning. (Cason et al, 2007, p 28).
To bring about necessary changes in structural guidelines the team has to be multidisciplinary which consist of nurses, respiratory therapists, physicians, clinical pharmacists etc.
The education program must be their so that staff will able to know what are the consequences of the not following the specified guidelines and how their advantageous in preventing the VAP.
The communication strategies must be improved so that all the staff must know what the recent changes are done through regular auditing of interventions put into practice.
The HOB elevation standards must be documented with rationale mentioned for each elevation why it was done, and if not done also why it was not carried out.
All these strategies will help in improving the outcomes for the patient suffering from the VAP and also it reduces the timing of stay in ICU and cost incurred.
Team work and proper collaboration is required to make every intervention adopted from evidence based guidelines into practice to be successful. Along with proper feedback is a must so that the efficiency of all the interventions can be figured out and necessary changes can be done.
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