This study assessed critical care nurses' knowledge and compliance with ventilator-associated pneumonia (VAP) bundle practices in Cairo university hospitals. The study found that the majority of nurses had unsatisfactory knowledge about VAP based on a 20-item questionnaire. Direct observation also found that nurses were not compliant with most VAP bundle elements. The study concluded that training programs are needed for nurses on VAP prevention to improve outcomes for mechanically ventilated patients.
This is a very simple presentation prepared for nurses. It will help nurses to understand the need of monitoring and the available methods. The presentation has been constructed on a clinical case base scenario and gradually different methods of monitoring has been introduced.
A "bundle" is a
group of evidence-based care components
for a given disease that, when executed together, may result in better outcomes than if implemented individually.
This is a very simple presentation prepared for nurses. It will help nurses to understand the need of monitoring and the available methods. The presentation has been constructed on a clinical case base scenario and gradually different methods of monitoring has been introduced.
A "bundle" is a
group of evidence-based care components
for a given disease that, when executed together, may result in better outcomes than if implemented individually.
Caring patient on Mechanical Ventilator Shanta Peter
Mechanical ventilators are used now in general wards , not only in ICU -to save patient's life. We need to care patient and ventilator while working with it ..
Importance of infection control in ICU
Ventilator-associated Pneumonia definition and bundles, Central line-associated infection and its bundles and foley's catheter-associated infection and its bundles
this presentation in reference to CDC and IMO
Caring patient on Mechanical Ventilator Shanta Peter
Mechanical ventilators are used now in general wards , not only in ICU -to save patient's life. We need to care patient and ventilator while working with it ..
Importance of infection control in ICU
Ventilator-associated Pneumonia definition and bundles, Central line-associated infection and its bundles and foley's catheter-associated infection and its bundles
this presentation in reference to CDC and IMO
Exploring Knowledge, Attitudes and Practices of ICU Health Workers Regarding ...QUESTJOURNAL
Background: Nosocomial Infection is a localized or systemic infection acquired at any health care facility including hospitals by a patient admitted for any reason other than the pathology present during admission. Including an infection acquired in a healthcare facility that manifest 48 hours after the patient's admission or discharge. Objective: Themain aim of this study is toassess the level of knowledge, attitudes and practice of ICU health personnel with regards to the spread of nosocomial infections. Methodology: A cross-sectional and facility based study was conducted from March to November 2016 at King Khalid hospital in Najran, Saudi Arabia. By adopting convenience technique, 50 subjects had been recruited to participate in this study. Results: 62% of respondentswere female. The mean age was 29 years. Concerning educational status, 54% of the participants have Bsc. professionally most of them (48%) were nurses. 60% of the participants have less than three year working experience in ICU.86% of them highlighted that hands must be washed with soap and water or even rubbed with alcohol before contacting with patients. Additionally, the result reveals that employees who had master degree or above displayed higher mean knowledge scores as compared to the other two groups (diploma or less & bachelor) (0.7147 & 4.6656) respectively. High significant statistical differences were found between the three academic groups in relation to sharp devices, personal protective equipment (gloves, gowns &masks), care of intravenous infusion therapy, central line care and urinary catheter care (F=4.594, F=7.982, F=5.539, F=4.471, F=15.310, F=4.345) respectively at p < 0.05. Recommendation & conclusion: Health workers in ICU (King Khalid hospital) showed adequate knowledge and faire attitude regarding universal precautions
KNOWLEDGE AND PRACTICES AMONG SURGEONS REGARDING CROSS INFECTION CONTROL PROC...Anil Haripriya
The study revealed good knowledge of infection control procedures but there were problems in practices of
sterilization. Most of them did not separate the needle from the syringe prior to disposal therefore needle
prick injuries were common. So more intensive and regular training programs to surgeons must be included
in the plans of quality control in all hospital and regular inspection from the ministry of health guarantees
good infection control practices
Evaluation of infection control at Butiru Chrisco Hospital in Manafwa Distric...PUBLISHERJOURNAL
Infection prevention and control is important for the improvement of quality care in hospital. This study aimed to identify risk associated with infection control, and to determine which infection control measures are available at Butiru Chrisco hospital and how these measures are put to use by the staff working in the hospital. This descriptive cross-sectional study was conducted at Butiru Chrisco hospital in Manafwa District. The study involved 100 respondents who were staff employed by Butiru Chrisco hospital. With different educational standards, awareness of infection control was assessed through a structured questionnaire that was administered to those who consented to participate. Random sampling was done on 10 staff, this helped correct the questionnaire making it suitable for the study but the results were not included in this study. The study revealed that out of 100 respondents, 72(72%) were nurses, 60(60%) were females and 78(78%) had been employed by the hospital for less than four years. Half 50(50%) revealed that airborne infections are the commonest infections in the hospital. The study also reveals that more than 80% reported positive response to infection control tasks with 80(80%) agreeing that practice of infection control reduces likelihood of infection spread to patients. From the study, it was concluded that, there is moderate awareness of infection control with more than half of the respondents having positive ideas about infection control and use of available measures like glove, apron, and hand washing. However, practice and compliance with standard precautions was less than optimal. The researcher recommends continuous health visits by ministry of health (MOH) of Uganda to the hospital and evaluation of the practices to ensure that the health workers practice infection control following the standard guidelines. Also, hand washing or use of hand sanitizers with alcohol or other antiseptics as a measure of disinfecting the hands before or after handling a patient is encouraged.
Keywords: Infection, health workers, hand washing, Manafwa District
Evaluation of infection control at Butiru Chrisco Hospital in Manafwa Distric...PUBLISHERJOURNAL
Infection prevention and control is important for the improvement of quality care in hospital. This study aimed to identify risk associated with infection control, and to determine which infection control measures are available at Butiru Chrisco hospital and how these measures are put to use by the staff working in the hospital. This descriptive cross-sectional study was conducted at Butiru Chrisco hospital in Manafwa District. The study involved 100 respondents who were staff employed by Butiru Chrisco hospital. With different educational standards, awareness of infection control was assessed through a structured questionnaire that was administered to those who consented to participate. Random sampling was done on 10 staff, this helped correct the questionnaire making it suitable for the study but the results were not included in this study. The study revealed that out of 100 respondents, 72(72%) were nurses, 60(60%) were females and 78(78%) had been employed by the hospital for less than four years. Half 50(50%) revealed that airborne infections are the commonest infections in the hospital. The study also reveals that more than 80% reported positive response to infection control tasks with 80(80%) agreeing that practice of infection control reduces likelihood of infection spread to patients. From the study, it was concluded that, there is moderate awareness of infection control with more than half of the respondents having positive ideas about infection control and use of available measures like glove, apron, and hand washing. However, practice and compliance with standard precautions was less than optimal. The researcher recommends continuous health visits by ministry of health (MOH) of Uganda to the hospital and evaluation of the practices to ensure that the health workers practice infection control following the standard guidelines. Also, hand washing or use of hand sanitizers with alcohol or other antiseptics as a measure of disinfecting the hands before or after handling a patient is encouraged.
Keywords: Infection, health workers, hand washing, Manafwa District
Running head RESEARCH PAPER1RESEARCH PAPER15.docxtodd521
Running head: RESEARCH PAPER 1
RESEARCH PAPER 15
Assessment of the knowledge, practice, and the associated factors of Healthcare Acquired Infection Prevention
Name
Institutional Affiliation
Date
Table of Contents
Table of Contents 2
Assessment of the knowledge, practice, and the associated factors of Healthcare Acquired Infection Prevention in Blessings Healthcare Facility 4
The Problem 5
Significance of the problem 6
Purpose of this study 7
Research Questions 8
Masters Essentials aligned with the topic 8
Design 10
Literature Review 10
Methodology and the design of the study 13
Sampling Methods 14
Necessary tools 14
Any logarithm or flow map developed 15
Healthcare Facility 15
Implementation 15
Stage 1: Assessment of the current practices (One Week) 16
Stage 2: Identification of the factors leading to high cases of healthcare-acquired infection (5 days) 17
Stage 3: Pre-Training (Two Weeks) 17
Stage 4: Training (5 weeks) 17
Stage 5: an ongoing process of assessing the situation 18
Materials, activities and the cost 20
Results 21
Socio-demographics features of the research population 21
Knowledge concerning the infection prevention 23
Aspects related to the knowledge of the healthcare professionals regarding the issue of preventing healthcare-acquired infections 27
Limitation of the study 28
References 30
Assessment of the knowledge, practice, and the associated factors of Healthcare Acquired Infection Prevention
Healthcare acquired infection/nosocomial infection/hospital acquired infections are becoming a major international challenge in many healthcare facilities especially in the low or middle income nations. It is anticipated that around 10 percent of patients in the healthcare facilities from developing nations are developing healthcare acquired infections and this subsequently leads to negative impacts on healthcare outcomes. It also leads to increase hospital stay, economic burden, morbidity cases, and increase in the mortality incidences. Some of the common healthcare acquired infections include Hepatitis B and C virus, HIV infections, and even Tuberculosis which are often transmitted by healthcare workers who are not observing the practice related to the infection prevention measures.
According to the United States Center for Disease Control and Prevention, there are about 1.7 million patients who have been hospitalized as a result of acquiring infection within the facilities while undergoing treatment for other healthcare concerns. Many studies reveal that simple infection control procedures like cleaning of the hands using alcohol-based hand rub is helping in the prevention of the spread of the disease. The increase in the infection rate caused by the healthcare acquired infection is due to the poor practices of infection prevention and control, lack of knowledge or failure to implement knowledge related to the process of preventing and controlling nosocomial illnesses, and other associated f.
Infection Prevention and Control in Hospitals by Dr DeleKemi Dele-Ijagbulu
Infection prevention and control is everybody's business! It is an essential, though often under-recognised and under supported part of the infrastructure of health care. However it saves lives and prevents avoidable morbidity and mortality. This presentation highlights the importance and the practical components of infection prevention and control in the hospital setting.
Running head hand hygiene compliance1hand hygiene compliance8.docxwlynn1
Running head: hand hygiene compliance1
hand hygiene compliance8Hand Hygiene Education Implementation and Nurses Compliance in Reducing Nosocomial Infections
Grand Canyon University NRS-490
March 31, 2019
Background
Hygiene is a very crucial factor in prevention of infection in any health care facility. Also, compliance of handwashing ensures patients safety, aids in the treatment and recovery of hospitalized patients. Hand hygiene is important action performed by healthcare works to prevent transmission of healthcare associated infection (Smiddy, O’Connell & Creedon, 2015). Health care professionals such as doctors, nurses, physical therapist and laboratory technicians, take the responsibility of providing efficient, effective and quality care that will improve the health of their patients.
The purpose of this paper is to discuss the change proposal project components the author has been working on throughout the course. The goal of health care works rendering a quality, effective and efficient care to their patient in the health care setting will be difficult to achieve if the rate handwashing adherence is below expectation. Unclean healthcare environments harbor germs that can cause disease, thereby placing the patient at risk of developing infection instead of recovering from their present health condition. Healthcare providers inability to comply with hand hygiene is one the main reason patient develop hospital acquired infections (HAIs). Healthcare employees have the lives of patient in their hands therefore, hand hygiene should not by any means be neglected or dominated out in any healthcare facility.
Approximately 250 health care specialists in a Metro Detroit facility happened to be watched and assessed directly; prior to the start of the exercise, participants were selected based on their hand washing comprehension and compliance. Partakers expresses that they observed improvement on handwashing practices and that most nurses complied to hand washing guidelines evidenced by some significant reductions in the rate of transmission of HAIs within the healthcare facility. HAIs are the infections a patient acquire during the period of hospitalization. The result of the research showed a huge decrease in the spread of nosocomial infections due to progress of hand hygiene training and nurses’ compliance to handwashing protocols. These infections mostly manifest during or after 48 hours of admission or thirty days after discharge from the hospital or health-care facility. The author of this research study sees HAIs as a dangerous disease with many complications. Because inadequate handwashing practices by healthcare workers are the main cause of spread of hospital acquire infections, it is important to educate staff members on proper hand hygiene, implement plan to encourage hand hygiene compliance in the healthcare settings. Blood-stream, ulcers / surgical wounds, CAUTI and respiratory infections are the most common types of HA.
HAP/VAP 2016 ATS/IDSA Guidelines. Our Data available at: https://rdcu.be/Mx8EDr Sandeep Kumar
Management of Adults With Hospital-acquired and
Ventilator-associated Pneumonia: 2016 Clinical Practice
Guidelines by the Infectious Diseases Society of America
and the American Thoracic Society.
To see our study results on HCAP and HAP, VISIT https://link.springer.com/article/10.1007/s00408-018-0117-7
SYSTEMS-LEVEL QUALITY IMPROVEMENTFrom Cues to Nudge A Knolisandrai1k
SYSTEMS-LEVEL QUALITY IMPROVEMENT
From Cues to Nudge: A Knowledge-Based Framework
for Surveillance of Healthcare-Associated Infections
Arash Shaban-Nejad1,2 & Hiroshi Mamiya2 & Alexandre Riazanov3 & Alan J. Forster4 &
Christopher J. O. Baker2,5 & Robyn Tamblyn2 & David L. Buckeridge2
Received: 3 June 2015 /Accepted: 30 September 2015 /Published online: 4 November 2015
# Springer Science+Business Media New York 2015
Abstract We propose an integrated semantic web framework
consisting of formal ontologies, web services, a reasoner and a
rule engine that together recommend appropriate level of
patient-care based on the defined semantic rules and guide-
lines. The classification of healthcare-associated infections
within the HAIKU (Hospital Acquired Infections – Knowl-
edge in Use) framework enables hospitals to consistently fol-
low the standards along with their routine clinical practice and
diagnosis coding to improve quality of care and patient safety.
The HAI ontology (HAIO) groups over thousands of codes
into a consistent hierarchy of concepts, along with relation-
ships and axioms to capture knowledge on hospital-associated
infections and complications with focus on the big four types,
surgical site infections (SSIs), catheter-associated urinary tract
infection (CAUTI); hospital-acquired pneumonia, and blood
stream infection. By employing statistical inferencing in our
study we use a set of heuristics to define the rule axioms to
improve the SSI case detection. We also demonstrate how the
occurrence of an SSI is identified using semantic e-triggers.
The e-triggers will be used to improve our risk assessment of
post-operative surgical site infections (SSIs) for patients un-
dergoing certain type of surgeries (e.g., coronary artery bypass
graft surgery (CABG)).
Keywords Ontologies . Knowledge modeling .
Healthcare-associated infections . Surveillance . Semantic
framework . Surgical site infections
Introduction
Healthcare-associated Infections (HAIs) affect millions of
patients around the world, killing hundreds of thousands
and imposing, directly or indirectly, a significant socio-
economic burden on healthcare systems [1]. According
to the Centers for Disease Control (CDC) [2], hospital-
acquired infections in the U.S., where the point preva-
lence of HAIs among hospitalized patients is 4 %, result
in an estimated 1.7 million infections, which lead to as
many as 99,000 deaths and cost up to $45 billion annually
[3, 4]. Similar or higher rates of HAI occur in other coun-
tries as well with an estimated 10.5 % of patients in Ca-
nadian hospitals having an HAI [5]. Clinical assessment
and laboratory testing are generally used to detect and
confirm an infection, identify its origin, and determine
appropriate infection control methods to stop the infection
from spreading within a healthcare institution. Failure to
monitor, and detect HAI in timely manner can delay di-
agnosis, leading to complications (e.g., sepsis), and
allowing an epid ...
Literature Evaluation TableStudent Name Joyce NwakorPIC.docxcroysierkathey
Literature Evaluation Table
Student Name: Joyce Nwakor
PICOT Question: For patients and healthcare workers in the hospital (p) does hand washing protocol (I) compared to an alcohol-based solution (C) reduce hospital-acquired infection (O) within a period of stay in the hospital (T)
Criteria
Article 1
QUANT
Article 2
QUANT
Article 3
QUANT
Article 4
REVIEW
Author, Journal (Peer-Reviewed), and
Permalink or Working Link to Access Article
Daisy, V. T., & Sreedevi, T. R.
Link:
http://eds.a.ebscohost.com.lopes.idm.oclc.org/eds/detail/detail?vid=4&sid=72619044-c224-4bc5-9982-cf6c3953f7d2%40sessionmgr4007&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=110819455&db=ccm
Fox, C., Wavra, T., Drake, D. A., Mulligan, D., Bennett, Y. P., Nelson, C., … Bader, M. K. (2015). Use of a Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Nurses' Hand Washing. American Journal of Critical Care, 24(3), 216-224. doi:10.4037/ajcc2015898
Knighton, S. (2017). The Use of Instructional Technology to Increase Independent Patient Hand Hygiene Practice of Hospitalized Adults in an Acute Care Setting. Open Forum Infectious Diseases, 4(suppl_1), S411-S412. doi:10.1093/ofid/ofx163.1029
João Manuel Garcia do Nascimento Graveto, Rita Isabel Figueira Rebola, Elisabete Amado Fernandes, & Paulo Jorge dos Santos Costa. Link:
https://doi-org.lopes.idm.oclc.org/10.1590/0034-7167-2017-0239
Article Title and Year Published
Effectiveness of a Multi-Component Educational Intervention on Knowledge and Compliance with Hand Hygiene among Nurses in Neonatal Intensive Care Units. 2015Use of a Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Nurses' Hand Washing
Published May 2015
The Use of Instructional Technology to Increase Independent Patient Hand Hygiene Practice of Hospitalized Adults in an Acute Care Setting. Open Forum Infectious Diseases.
Published in 2017
Hand hygiene: nurses’ adherence after training.
2018
Research Questions (Qualitative)/Hypothesis (Quantitative), and Purposes/Aim of Study
The study was aimed to assess the effectiveness of a multi-component educational intervention on the knowledge and compliance with handhygiene guidelines among nurses working in Neonatal Intensive Care Units.
The research investigated the reduction of infections in the hospital through observation of hand hygiene.
What handwashing procedures were performed by the medical personnel before patient contact part 1.
What is the level of effectiveness of training (I) in improving nurses’(P) adherence to hand hygiene(O)?”.
Design (Type of Quantitative, or Type of Qualitative)
A pre-experimental pre-test post-test design was adopted for the study. QUANT
Pre-experimental study design
. QUANT
A quantitative study was done using quasi observational data
Qualitative/ quantitative studies
This is a review
Setting/Sample
This study was conducted in 3 level III NICUs of selected private hospitals in Kerala
Total sample compri ...
Similar to Critical care nurses' knowledge and compliance with ventilator associated pneumonia bundle at cairo university hospitals (20)
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
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(DSM-5) integrates alcohol abuse and alcohol dependence into a single
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comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Maxilla, Mandible & Hyoid Bone & Clinical Correlations by Dr. RIG.pptx
Critical care nurses' knowledge and compliance with ventilator associated pneumonia bundle at cairo university hospitals
1. Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.4, No.15, 2013
66
Critical Care Nurses' Knowledge and Compliance with Ventilator
Associated Pneumonia Bundle at Cairo University Hospitals
Nahla Shaaban Ali (corresponding author)
Lecturer of Critical Care and Emergency Nursing, Faculty of Nursing , Cairo university
Email of the corresponding author: nahlakhalil28@yahoo.com
Abstract
Ventilator-associated pneumonia (VAP) continues to be a common and potentially fatal complication of
ventilator care and often encountered within intensive care units (ICUs). Ventilated and intubated patients
present critical care nurses the unique challenge to incorporate evidence-based practices surrounding the delivery
of high-quality care. Bundled practices approach is composed of individual preventive measures for preventing
the incidence and prevalence of VAP and improving outcomes of patients. The aim of this study is to assess the
critical care nurses' knowledge and compliance with ventilator associated pneumonia bundle. A descriptive
exploratory study design was utilized. A sample of convenience of 45 critical care nurses was recruited from
different critical care units at Cairo university hospital for this study. Data were collected between March 2010
and September 2011. The participants initially, were instructed to complete a demographic data sheet and a
validated 20- items questionnaire; 15 items multiple-choice and 5 true/ false items covered the knowledge about
pathophysiology , risk factors and preventive VAP bundle practices. Then, direct observation of nurses who
provided nursing care to mechanically ventilated patients was carried out utilizing VAP bundle compliance
checklist that consisted of ventilator bundled practices for preventing VAP. The main bundle items were
infection control measures, patient positioning, endotracheal suctioning care, peptic ulcer prophylaxis, oral care,
weaning & extubatoin trials ,and ventilator care measures .The results of 20- items questionnaire revealed
unsatisfactory knowledge scores (mean= 7.46 + 2.37) and most of the nurses were not compliant with ventilator
associated pneumonia bundle practices (average mean = 8.62 + 7.9 out of 29) and there is no specific protocol to
follow for VAP prevention. The findings of the study recommended the need for developing and implementing a
protocol for VAP prevention in ICUs. Moreover, there is also a need for training programs for nurses on
infection control and VAP bundle preventive measures to lessen the prevalence of ventilator associated
pneumonia.
Key Words: Critical care nurses' knowledge, compliance, ventilator associated pneumonia bundle
Ventilator associated pneumonia (VAP) is defined as nosocomial pneumonia in ventilated patients that develop
more than 48 hours after initiation of mechanical ventilation (MV). VAP is the second most common
nosocomial infection after urinary tract infection in intensive care unit patients accounting for 20% of
nosocomial infection in this population. VAP can be of two types. Early onset VAP which develops within 5
days of mechanical ventilation and late onset VAP which develops 5 days or more after mechanical
ventilation. (Tripathi ,2012).
Traditional signs and symptoms of VAP are chest X-ray showing new or progressive diffuse infiltrate which is
not attributable to any other causes, onset of purulent sputum, fever greater than 38.50
C, leucocytosis, and
positive sputum or blood cultures. The single largest risk factor for VAP is the presence of endotracheal tube.
Patient related risk factors include underlying chronic illness, immunosuppression, depressed consciousness,
thoracic or abdominal surgery, previous antibiotic therapy and previous infection. Devise, treatment and
personnel related risk factors include nasogastric tube placement, bolus enteral feeding, gastric over distension,
stress ulcer treatment, supine patient position, nasal intubation route, instillation of normal saline, understaffing,
non-conformance to hand washing protocol , indiscriminate use of antibiotics and lack of training in
VAP prevention (Hoosre,. 2002 )
Risk factors for development of VAP can be classified in to modifiable and non modifiable conditions. Risk
factors can be patient related or treatment related. Modifiable risk factors are obvious targets for improved
management and prophylaxis in the comprehensive Guidelines for preventing Health care associated pneumonia,
published by centre for disease control. Effective strategies include strict infection control, alcohol based hand
disinfection, monitoring and early removal of invasive devices and programs to reduce or alter antibiotic
prescribing practices (Michael, 2005) . In addition, VAP occurs in up to 15% of patients receiving mechanical
ventilation. Risk factors include tracheostomy, multiple central line insertions, reintubation, and the use of
antacids. The hospital mortality rate of ventilator patients who develop VAP is 46%, compared to 32%
for ventilator patients who do not develop VAP ( Ibrahim, 2001)
Interventions to prevent VAP begin at the time of intubation and should be continued until extubation. Nurses
need to understand the pathophysiology of VAP, risk factors and strategies that may prevent VAP. Use of study
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education modules on nursing care of patients at risk of VAP and use of ventilator pathways or protocols with
pre-printed order sets and monitoring tools can lead to improved outcome for patients. (Augustyn , 2007) .
Critical care nurses have an important role in preventing VAP by decreasing risk factors, recognizing early
symptoms, and assisting in diagnosis (Myrianthefs et al (2004) .Centres for Disease control and Prevention
(CDC), 2003 guidelines for the prevention of VAP recommends hand washing, elevation of head end of bed,
suctioning of subglottic secretions, use of hand gloves and implementation of comprehensive oral hygiene
programme. The guidelines specify that an antiseptic agent be used as part of the oral care programme and oral
chlorhexidine gluconate rinse is solely recommended for adults undergoing cardiac surgery.
The prevention of ventilator Assisted Pneumonia (VAP), a hospital acquired infection, among intensive care
patients is a major clinical challenge. It is a condition that is associated with high rates of morbidity, mortality,
length of stay and hospital costs. Throughout empirical observation ,Nurses’ lack of knowledge may be a
barrier to adhere to evidenced based guidelines for preventing ventilator-associated pneumonia and translating
evidence based findings into consistent delivered care at the bedside remains a challenge. However, many
studies have shown that, educational interventions, staff development programmes and multi – module
programmes led to a substantial reduction of ventilator associated pneumonia. Therefore this study aimed at
examining critical care nurses’ knowledge and compliance to the ventilator associated pneumonia bundle.
2. Material and Methods
2.1 Aim of the study:
To assess the critical care nurses' knowledge and compliance with ventilator associated Pneumonia
bundle at Cairo university hospitals.
2.2. Research questions
1-what do the nurses know about ventilator associated pneumonia bundle practices at Cairo university hospitals?
2-How do the critical care nurses comply with ventilator associated pneumonia bundle practices at Cairo
university hospitals?
2.3. Subjects:
A sample of convenience of 45 critical care nurses was recruited for this study. It included nurses working at
different concerned critical care units. The inclusion criteria were nurses who provided direct care to
mechanically ventilated patients regardless of their demographic characteristics. The exclusion criteria were
the nurses whose years of experience less than 6 months and didn’t accept to participate in the study.
2.4. Research Design:
A descriptive exploratory design was utilized in the current study. Polit & Beck, (2006) mentioned that
descriptive research provides an accurate account of characteristics of a particular individual, event or group in
real-life situations. Exploratory research examines the relevant factors in detail to arrive at description of the
reality of the existing situation.
2.5. Setting:
The study was conducted at three critical care units (medical, coronary and surgical critical care units) at Cairo
university Hospitals in Egypt
2.6. Tools:
2.6.1 Tool (1): Self administered questionnaire sheet: it was designed and utilized by the researcher. It
included two parts:
Part 1: Socio demographic and background data: it included data related to subjects’ characteristics namely; age,
sex, years of experience, and educational level.
Part 2: 20- items knowledge Questionnaire: was developed by the researcher based on the CDC guideline
(Centers for Disease Control and Prevention 2003; Tablan et al 1994 in addition to Some items were adopted
from a reliable questionnaire developed by Blot, Labeau, Vandijick, Claes, and Van Aken , 2007. It included 15
multiple choice and 5 true/ false questions that covered pathophysiology (4 items), risk factors (3 items) and
preventive bundled practices (13 items) of ventilator associated pneumonia. The Scoring system for the
questionnaire was as follows; the correct answer was given the score of “ONE” and the wrong answer was given
the score of “ZERO. Based upon scoring system utilized, the knowledge level was categorized as follows:
satisfactory level is ≥ 60% and unsatisfactory level was < 60%..
2.6.2 Tool (2): VAP bundle compliance checklist was adapted based on CDC evidence based
guidelines, 2003; Tablan et al 1994) .The adapted ventilator bundled practices checklist covered 8 main areas
including infection control measures(5 items), positioning strategies(1 item), Endo tracheal Suctioning care(10
items), ventilator circuit care(5 items), Oral care(2 items), testing of enteral feeding &Peptic ulcer prophylaxis(3
items), Weaning trials and extubation (2 items), and DVT prophylaxis(1 item). Each area has sub items. The
Scoring system for the developed observational checklist had two responses, ' comply ' response was given the
score of “ONE” and 'not comply ' response was given the score of “ZERO". Based upon scoring system utilized,
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the performance level was categorized as follows: satisfactory level is ≥ 60% and unsatisfactory level was < 60%.
2.7 Content validity:
Face, content and concurrent validity for the previously mentioned tools were revised and ensured by five
experts in infection control , critical care medicine and critical care nursing. Based on the experts' opinions
responses, the researchers developed the final validated form of the tools.
2.8. Pilot study
A pilot study was carried out on 10 subjects to obtain information regarding clarity of the wording and
presentation of the questionnaire, and time needed for completing the revised tools. No further alterations were
needed according to participants' responses in the pilot study. The subjects included in the pilot study were
included in the study sample.
2.9. Reliability assessment:
The developed and validated tool for the knowledge questionnaire was tested for reliability on a sample of 10
subjects. Test retest results using Alpha Cronbach revealed that all items are significantly differed and has a
correlation coefficient above the threshold of significance (r=0.87). On the other hand, the alpha value for the
performance checklist in the sample was (r=0.85).which indicating strong reliability of both tools.
3-Procedure:
Once permission was granted to proceed with the current study from responsible and authoritative parties at El-
Manial university hospital, the researcher initiated data collection and contacted each potential nurse to explain
the purpose and nature of the study. The researcher emphasized that participation in the study is entirely
voluntary, the anonymity and the confidentiality of their responses were assured. Nurse participants were asked
to sign a consent form .The socio demographic and knowledge questionnaire sheet was administered, the total
time allowed to fulfill it by each nurse was 45 to 60 minutes. The time for collecting data through this tool lasted
2 weeks. After that, VAP bundle compliance checklist was utilized to observe each individual nurse who
is caring for mechanically ventilated patient throughout shift (morning and afternoon) for three consecutive
times, one week apart.
4-Ethical consideration
Permission to conduct the study was obtained from the administrative authorities. All the nurses were assured
that participation in the study was voluntary. Verbal consent was obtained from nurses who accepted to take part
in the study. In order to maintain the confidentiality of the participants, the responses were collected
anonymously, data were coded, and the name of the hospital from which data were collected was not being
referred to in any published work.
5-Results:
5.1. Table (1) Shows Subjects' demographic characteristics. As can be seen from, the majority of
studied sample (75.6%) was females. Their age ranged between 20 to more than 30 years with
mean age of 27.26 ± 5.69.In reference to the level of education; the subjects were mostly internship
(44.4%). Related to the years of experience, the studied sample varied between less than one year (44.4%). and
more than 10 years (33.39%). The highest percentage of subjects (44.4%) was working in medical critical care
unit.
5.2. Figure (1) shows percentage distribution of knowledge level about VAP bundle among studied
sample. It is apparent from fig. (1) That the majority of studied sample (90%) had unsatisfactory knowledge,
while approximately 10% from internship category got satisfactory level.
5.3. Table (2) presents Comparison of means of knowledge scores about VAP Bundle among studied
sample by their educational level. As can be seen from table 2, that there is no significant statistical difference
among studied samples (f= 0.22, p=0.80).
5.4 Table (3): presents responses to knowledge questions regarding ventilator associated pneumonia and
preventive bundle practices. As can be seen from table 3, the nurses got incorrect responses in the majority of
questions. The only questions which obtained the high frequencies of correct answer were (Q1, Q6 and Q7).
5.5 Table (4): presents average mean performance scores of compliance with elements of ventilator
bundle practices among studied sample. It is apparent from table 4 that all nurses at different work areas
(Medical ICU, coronary ICU, surgical ICU) didn't comply with VAP bundle elements. Out of 29 items ,Their
means were as follows; 9.40 + 8.10, 9.72 + 9.2 & 5.99 + 7.13 respectively. In addition, it shows that
there is no significant statistical difference between means of three work areas regarding compliance with
elements of ventilator bundle practice (f= 0.82; p= 0.44).
5.6 Table (5): presents average percentage distribution of nurses' compliance with VAP bundle
practices in different ICUs. Observations showed that there is no significant differences among ICU
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nurses regarding washing hands between patients (x2 =28.42 ,p=6.7), maintaining patient's position in semi-
recumbent (x2=3.12,p=0.20), replacing the saline solution used for suction (x2=28.42 , p=6.7), However,
minimal significant statistical difference was noted among the studied ICUs regarding Ventilator care measures,
endotracheal suctioning care. As the as most nursing staff of medical ICU nurses were compliant than coronary
and surgical ICU nurses with some of the VAP bundle practices .On the other hand, closed suctioning, sub-
glottic suctioning ,extubation & weaning trials and Peptic ulcer prophylaxis practices were not done by nurses.
6.Table (6): illustrates the relationship between knowledge and selected
variables. As can be seen from the table 6 that there is no significant correlation
what so ever between knowledge and practice (r= 0.02) and between knowledge
and age and years of experience (r= - 0.02, r= -0.09 respectively).
7-Discussion
The following discussion focus upon the findings related to the stated research questions of the study. Discussion
is presented in the following sequence: (a) nurses ' knowledge about VAP bundle, (b) nurses' compliance with
VAP bundle practices c) Relationship between the nurses' knowledge and nurses' compliance with VAP bundle
practices.
7.1. Nurses ' knowledge about VAP bundle
The present study findings revealed that all critical care nurses with different educational levels, irrespective of
their years of experience or area of work had unexpectedly unsatisfactory knowledge scores about ventilator
associated pneumonia and VAP bundle preventive measure. It has been suggested by a study that nurses usually
lack knowledge of the research and evidence for the prevention of VAP. Majority of the nurses in this part
acquire their knowledge of taking care of critically ill patients from their basic educational programs, or from
hospital policies and procedures. Moreover, the demographic profiles of the participants also mentioned that
majority of the nurses in the study group were diploma holders, and internship nurses who had less than 2 years
of nursing experience. The present study finding is consistent with Blot & Labeau (2007) & Gomes (2010)
who conducted a study about knowledge among intensive care nurses on Evidence-based guidelines for the
prevention of ventilator-associated pneumonia and the results revealed Overall knowledge results were poor.
As regards, nurses responses to knowledge questions regarding ventilator associated pneumonia and
preventive bundle practices , it showed that all the nurses gave correct answer regarding the preference of Oral
to nasal route for end tracheal intubation. The possible factor that may explain this finding is that Oral
intubation route is most common in the studied ICUs. As they acquired that knowledge from work experience
and knowing this is an evidence based guideline. This finding is consistent with Kollef( 2004) that
emphasized based on evidence based studies that oral intubation is preferable to nasal route as it prevents
aspiration of contaminated secretions, hence reduces the incidence of VAP.
The current evidence based guidelines mentioned in VAP bundle by Labeau (2007) that Heat and moisture
exchangers are recommended, and must change humidifiers every week (or when clinically indicated). When
comparing these guidelines with nurse's answers, the finding showed that more than half of the studied ICU
nurses reported that they don’t recommend heat moisture and change humidifiers every 48 hours as it
contradict with evidence based guidelines. This study finding is in accordance with Sierra et al. (2005) who
found that in 75% of the ICUs ventilator circuits were changed every 72 h or later . As well, this finding is in
accordance with Blot & Labeau (2007) who indicated to change ventilator circuits weekly or later in 76% of
respondents. on the other hand, the present study finding contradicted with Heyland et al (2002), Ricart et
al(2003), and Sierra et al.(2005) respectively, who mentioned that 80%, 84%, and 96% of the respondents used
heat and moisture exchangers.
The present study finding revealed that less than half of the nurses recognized closed systems as recommended
and the rest of nurses reflect unfamiliarity with closed systems. This finding is in accordance with Heyland
(2002) & Sierra (2005) who mentioned in their studies that In Canada, closed suction systems are used in 88%
of the ICUs, whereas in Spain open tracheal suctioning was reported in 96% of the ICUs and added that
closed suction systems are not commonly used, and thus the results reflected nurses’ unfamiliarity with those
systems.
More than half of the nurses in the present study knew that frequent change in suction systems, and kinetic
beds decrease the risk and occurrence of pneumonia. While only 48% of nurses knew that semi-recumbent
positioning help in prevention of pneumonia. This finding agreed with Heyland (2002) & Sierra (2005)
who mentioned that the beneficial effect of kinetic beds was recognized by about half of the nurses. While
semi-recumbent positioning was well acknowledged to prevent VAP.
Finally, The study finding revealed that more than three fourth of nurses had low knowledge regarding
predisposing, risk factors, signs and symptoms, diagnosis , treatment and components of ventilator bundle
practices in ventilator associated pneumonia
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7.2. Nurses' compliance with VAP bundle practices
The findings of Nurses' compliance with VAP bundle practices indicate that a large percentage of critical care
nurses implemented some preventive measures for VAP while didn't comply with most VAP bundle practices.
Although an infection control measure is not a component of ventilator bundle practices, it plays an important
role in reducing the risk of ventilator associated pneumonia. Hand Hygiene is considered a cornerstone of all
infection control practices. The Center for Disease Control strongly recommends hand washing before and after
direct patient care or when handling articles that could be contaminated with respiratory secretions (Tablan et
al.& CDC, (2004). Hand Hygiene is an effective way of removing transient bacteria from the hands; however,
nurses' compliance with hand hygiene in the current study has been poor .Moreover, the nurses were not
compliant with changing gloves between patients, not disinfecting the Ambu-bag before and after contact with
patient and some ICU nurses use the Ambu-bags between patients. There are several reasons may explain this
phenomenon; may due to the frequency of patient care contact, heavy workload, understaffing, overcrowding,
poor access to hand washing facilities, inadequate institutional commitment to good hygiene practice All these
reasons may adversely affect hand hygiene compliance. This finding is consistent with Augustyn (2007) who
mentioned that Failure to wash hands and change gloves between patients has been associated with an increased
incidence of VAP. Moreover, the study finding is supported by a study done by Bingham et al., in 2010 who
revealed that that no differences was observed in hand hygiene behavior even after the implementation of a unit-
level interventions to reduce VAP .
According to the evidence based guidelines (EBG’s) on prevention of VAP, semi- recumbent positioning is
recommended to prevent VAP. Amongst all participants of nurses in medical critical care units, coronary care
units and surgical critical care units in the current study; only 50%, 38.4%, 33.3% respectively showed
compliance to maintaining head of bed elevation .This finding is consistent with Jiménez & Vega (2009) in
pre-education component , they found that 14% of evaluated cases were compliant with the elevation of the bed
at or more than 30º from the horizontal plane and following the educational strategies 74% of the cases were
compliant to HOB elevation with an increase in 60%.
According to the EBG’s on prevention of VAP & Grap et al (2012), a cuffed endotracheal tube with at least
20 cm of H2O should be maintained to reduce the chance that the patient will aspirate secretions that accumulate
above the cuff. Secretions are common in the upper airways of intubated patients and pool above the
endotracheal tube cuff, allowing for leakage of contaminated secretions into the lower airway. The effect of
using an endotracheal tube that has a separate dorsal lumen, which allows continuous aspiration of the subglottic
secretions in those patients receiving mechanical ventilation for more than 48 hours, reduced the incidence of
ventilator-associated pneumonia as well as ICU stay, duration of mechanical ventilation and antibiotic
consumption.
The results of this study in relation to maintaining a cuffed endotracheal tube with at least 20 cm of H2O and
continuous aspiration of the subglottic secretions showed that all the studied ICUs nurses did not maintain
adequate pressure in endotracheal tube (ETT) cuff in those patients receiving mechanical ventilation for more
than 48 hours which reflects their inadequate knowledge about the importance of this action in prevention of
VAP. This finding is in congruent with Gonçalves & Brasil (2012) who studied Nursing actions for the
prevention of ventilator-associated pneumonia in an Intensive Care Unit of a teaching hospital in Goiania that
revealed an important precaution was not properly done by the team concerning the calibration of intra cuff
pressure of endotracheal tube, drawing attention for its low frequency (18.1%) and recommended that this
pressure should be measured at least three times per day.
Care related suctioning including wearing sterile gloves with open suction system, using sterile technique
when applying tracheal suctioning, replacement of suction systems, replacing suction tubes, replacing the
solution used for suction are not part of the ventilator bundles , however, the lack of asepsis during suctioning
care predominated among nurses . This finding could be due to lack of training surveillance on infection control
measures. This study finding agreed with Kandeel and Tantawy (2012) who Studied Nursing Practice for
Prevention of Ventilator Associated Pneumonia in ICUs and Observations illustrated that most nurses did not
implement infection control measures when applying tracheal suctioning or when dealing with suction
equipment and indicated the need for infection control training programs for all critical care nurses
working the studied ICU.
Another way of preventing VAP is performing frequent mouth care. It is a critical measure to inhibit
bacterial growth in the oral cavity, which increases the risk of developing VAP (Pruitt & Jacobs, 2006).
Maintaining the patient's oral hygiene is important because contaminated oral secretions would flow to the sub-
glottic area, where small amounts of these secretions might be aspirated causing VAP (Pruitt & Jacobs, 2005).
Adequate suctioning is recommended as it prevents oral secretions from pooling and maintaining good oral
hygiene which reduces oropharyngeal colonization (Schleder, 2004). The findings of nurses' observations in
the current study showed that there was no oral care protocol available in all the studied ICUs. In the current
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study, most nurses in medical critical care unit (61.5%) use Saline as a mouth wash solution while the coronary
care unit (35%) and surgical critical care (33.3%) used tap water and not on a regular base. This may be due to
unavailability of written oral care protocols in the studied ICUs in addition to the loss of nurses' awareness about
the benefit of delivering timely oral care and its relation to the incidence of VAP. This is similar to the
findings of a study conducted in Alexandria Main University Hospital in Egypt which reported absence of oral
care protocol in the ICUs who found that oral care is carried out without the use of tooth brushing or antiseptic
solutions. (Alhirishi, 2010 , O’Keefe-McCarthy ,2006& Scott &Vollman, 2011)).
Another recommended care for prophylaxis of VAP is checking the gastric residual volume (GRV) every 4
to 6 hours; administer intermittent rather than continuous enteral feeding and performing Routine acidification
of gastric feeding. In the current study, all the nurses in studied critical care units did not comply and follow
what is recommended in evidence based guidelines in this issue. The possible explanation for this finding may
due to lack of knowledge and absence of protocol to follow in these units. This finding agreed with Tolentino -
DelosReyes & Ruppert (2007) & Oliveira & Burgos (2010) who stated that verification of the amount of
residual volume occurred in less than half of the observations, with suspension of the diet in case of vomiting
and GRV between 50 and 300 mL. This shows that the team did not follow what is recommended for routine or
proposals from other studies that, in case of GRV> 150 mL, one must suspend the diet.
Using daily "sedation vacations" and assessing the patient’s readiness to extubate are an integral part of the
ventilator bundle and have been correlated with reduction in the rate of ventilator-associated pneumonia (Kunis
& Puntillo ,2003). Sedation and NMBA impede the patient’s ability to swallow effectively, which prevents
effective clearance of saliva from the oral cavity and can migrate via micro aspiration into the lungs. Measures
such as daily interruption of sedation and pursuing a protocol for early extubation are associated with shorter
duration of mechanical ventilation and prevention of ventilator associated pneumonia (Wood et al. 2007) In this
study, it is these important measures were not done by all nurses in the studied units. the possible explanation
for non adherence to these guidelines that nurses in most critical care unit never initiates weaning trials , and the
physician is the only one who is responsible for initiation of weaning trials and interruption in sedation
utilizing sedation scale.
However it is unclear if there is any association between DVT prophylaxis and decreasing rates of
ventilator-associated pneumonia, our experience is that when DVT prophylaxis is applied as part of a package of
interventions for ventilator care, the rate of pneumonia decreases precipitously. The intervention remains
excellent practice in the general care of ventilated patients. However, the results of this study in relation to
DVT prophylaxis by nurses in the form of Applying anti-embolic stockings or sequential compression showed
that less than half of the nurses didn't comply with this guideline. The possible interpretation for this finding is
that nurses apply these measures only in the case of DVT in addition to initiation of this measure is prescribed by
the physician.
7.3. Relation between nurses' knowledge and selected variables
The researcher examined the relationship between the total knowledge and total performance scores. The
present study findings revealed no correlation what so ever between knowledge and practice. Lack of
association between the total knowledge scores and performance scores may be partially interpreted in the light
of lack of training courses, updating pre-existing knowledge, lack of time, workload, and lack of equipment as
the reasons for non compliance ventilator bundle practices.
It has been postulated that years of experience is directly proportional to the level of education, i.e.; the higher
the level of education the more the years of experience. The finding of this study didn't support this postulation
and showed that there is no correlation what so ever between knowledge and practice irrespective of their years
of experience and educational level. This study finding is contrary to Geri (2005) who concluded that more
experience increase the cognitive resources available for interpretation of data resulting in increased knowledge.
In the present study findings Significant differences were found among the studied ICUs nurses concerning
some aspects of care, such as Ventilator care measures, endotracheal suctioning care ,as the as most nursing
staff of medical ICU nurses were compliant than coronary and surgical ICU nurses with some of the VAP
bundle practices .On the other hand, no significant differences were found among ICU nurses regarding closed
suctioning, sub-glottic suctioning , extubation & weaning trials and Peptic ulcer prophylaxis practices as these
practices were not done by ICU nurses. The possible interpretation for this finding could be due to the absence of
a unified protocol for VAP prevention in the studied ICU, and lack of nurses' training in this area. This finding is
agreed with Babcock et al (2004) & Augustyn (2007) who mentioned that Variations in nursing practice among
ICUs, and not implementing all evidences into practice could be due to the absence of protocol for VAP
prevention in the studied ICU and Gallagher's (2012) study findings emphasized that education of nurses can
improve mechanically ventilated patient outcome, and improve the quality of care.
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8-Conclusion and recommendations
Nurses' knowledge regarding VAP bundle was inadequate and they did not implement the latest evidenced
VAP bundle practices as reported CDC recommendations (CDC, 2004) in their current practice and the study
illustrated an absence of a uniform protocol for prevention of VAP in the studied ICU. Based on the results of
the present study, the following recommendations were made:
-The need for in- service education and integration of evidence based guidelines regarding prevention of
ventilator associated pneumonia.
- The need for developing a unified protocol for VAP prevention based upon current evidence based guidelines.
-The need for establishing a system to ensure that VAP prevention protocol will be implemented consistently in
all ICUs.
-There is a need implement all the individual elements of a bundle evidence-based practices when applied
together they result in significantly better outcomes than when implemented individually
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9. Journal of Education and Practice
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.4, No.15, 2013
Table (1) Socio demographic characteristics of the nursing staff
Variables
Gender
- Male
- Female
Age
- 20 - < 25
- 25 - < 30
- ≥30
Level of education
- Internship
- Technical diploma
- Baccalaureate (BSc.N)
Years of experience
- < 1 year
- 1-5
- 6-10
- >10
Area of work
- Medical critical care
- Coronary care unit
- Surgical critical are
Figure (1): percentage Distribution of knowledge level about VAP Bundle among Studied sample (n=45).
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Satisfactory ≥ 60%
10.00%
urnal of Education and Practice
288X (Online)
74
Table (1) Socio demographic characteristics of the nursing staff of Critical Care Units (n = 45)
N
11
34
20
9
16
Mean 27.26 SD ± 5.69
20
14
11
20
4
6
15
20
13
12
Distribution of knowledge level about VAP Bundle among Studied sample (n=45).
Satisfactory ≥ 60% unsatisfactory <60%
10.00%
90%
internship
diploma
baccalureate
www.iiste.org
of Critical Care Units (n = 45)
%
24.4
75.6
44.4
20
35.6
44.4
31.1
24.5
44.4
8.88
13.33
33.39
44.4
28.8
26.8
Distribution of knowledge level about VAP Bundle among Studied sample (n=45).
internship
diploma
baccalureate
10. Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.4, No.15, 2013
75
Table 2: Comparison of means of knowledge scores about VAP Bundle by educational level among
studied sample (N=45).
variable
Educational level
F. test P -
value
internship Post secondary technical
diploma
Baccalaureate
(BSc.N)
Mean SD Mean SD Mean SD
0.22 0.80
NS
Knowledge score
7.55 2.85 7.69 1.65 7.08 2.27
NS= not significant
Table (3): knowledge questions responses regarding ventilator associated pneumonia and preventive
bundle practices (N=45).
Question item Correct Incorrect
N (%) N (%)
Multiple choice questions
1-Oral vs. nasal route for endotracheal intubation 45 (100) 0 (0)
2-Frequency of ventilator circuit changes 15 ( 33.3) 30 (66.7)
3. Type of airway humidifier 22 (48.8) 23 (51.2)
4. Frequency of humidifier changes 17(37.7) 28 (62.3)
5. Open vs. closed suction systems 20(44.4) 25 (55.6)
6. Frequency of change in suction systems 26(57.7) 19 (42.3)
7. Kinetic vs. standard beds 25(55.5) 20 (44.5)
8. Patient positioning in (30º-45º) 22 (48.8) 23 (51.2)
9- statements best describes recommendations for duration of antibiotic therapy for VAP 12(26.6) 33(73.4)
10- anatomic areas is the primary route for ventilator-associated pneumonia (VAP) 11(24.4) 34 (75.6)
11-Risk factors for ventilator-associated pneumonia (VAP) 15 ( 33.3) 30 (66.7)
12- The signs and symptoms of VAP 25 (55.5) 20 (44.5)
13- Components of VAP care bundle 7 (15.5) 38 (84.5)
14- VAP (ventilator associated pneumonia) is defined as pneumonia that develops in an intubated patient after
_______hours or more of mechanical ventilation support
15 ( 33.3) 30 (66.7)
15- statements best describes the recommendations for the treatment of VAP 7 (15.5) 38 (84.5)
True / false questions
1-Positive sputum culture indicate the likelihood of VAP 9 (20) 36 (80)
2- Peptic Ulcer Disease Prophylaxis help in prevention of VAP 11(24.4) 34 (75.6)
3-Head of bed elevation prevents aspiration from the stomach into the airways 17(37.7) 28 (62.3)
4-Endotracheal aspirate with non-quantitative cultures can be used to diagnosis VAP. 12(26.6) 33 (73.4)
5-Endotracheal tubes with extra lumen for drainage of subglottic secretions increase risk for VAP 0 (0) 45 (100)
Table (4) Average means performance scores of compliance with elements of ventilator bundle
practices among studied sample by their areas of work (n=45)
practices
Maximum
potential
score
Area of work
F test P value
Medical ICU Coronary ICU Surgical ICU
X +SD X +SD X +SD
Infection control measures 5 1.8 + 2.01 1.61 + 2.21 0.69 +1.18 1.35 0.26
Maintaining patient's position in
(30º-45º)
1 0.50 + 0.51 0.38 + 0.50 0.2 +0 .45 1.39 0.25
Ventilator care measures 5 3.2 + 2.16 2.46 +2.29 1.75 + 2.30 1.61 0.21
End tracheal Suctioning care 10 2.90 + 2.61 3.84 +2.76 2.75 + 2.30 0.70 0.50
Peptic ulcer prophylaxis practices 3 0.00 0.00 0.00 - -
Oral care practices 2 0.7 + 0.9 1.2 + 1.01 0.6 + 0.9 1.57 0.2
Weaning and extubation trials 2 0.00 0.00 0.00 - -
DVT prophylaxis practices 1 0.25 + 0.44 0.23 + 0.43 0.00 1.84 0.17
Total 29 9.40 + 8.10 9.72 + 9.2 5.99 + 7.13 0.82 0.44
11. Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.4, No.15, 2013
76
Table (5) Average percentage distribution of Nurses' compliance with bundled preventive
practices for ventilator associated pneumonia in different units (n=45).
practices
Area of work
Tests of
significance
Medical
ICU
N=20
Coronary
ICU
N=13
Surgical
ICU
N=12
% % % X2 P
Infection control measures
1 wash hands before and after patient contact 40 38.46 25 6.45 0.03*
2 wash hands between patients 15 23 0.0 28.42 6.7
3 change gloves between patients 50 38.46 16.6 7.52 0.02*
4 Use sterile ambu bag/ disinfect it before use 25 23 0.0 23.56 0.00*
5 Change ambu bag between patients 50 38.46 0.0 13.12 0.001*
Patient positioning
1 maintain continuously patient's position in (30º-45º) if not contraindicated 50 38.46 33.3 3.12 0.20
Ventilator care measures
1 drain and discard Periodically any condensate that collects in the tubing of a
mechanical ventilator
50 38.46 25 5.12 0.07 *
2 humidify respiratory circuit using humidity and heat exchange filter 60 61.5 33.3 5.8 0.05 *
3 Replace humidifiers 65 38.46 33.3 7.14 0.02 *
4 replace the ventilator circuit regularly 65 46 41.6 5.85 0.05 *
5 Change a heat moisture exchanger that is used by a patient when it becomes
visibly soiled
80 61.5 41.6 38.37 0.000
*
End tracheal Suctioning care
1 Maintain adequate pressure in endotracheal tube cuff 25 38.46 33.3 9.792 0.007
*
2 Wear clean gloves with Closed suctioning NA NA NA - -
3 Wear sterile gloves with an open suction system 25 38.46 25 11.79 0.002
*
4 Using sterile technique when applying tracheal suctioning. 10 15.38 0.0 33.58 0.000
*
5 Use sterile suction equipment. 25 38.46 16.6 14.19 0.002
*
6 Replacement of suction systems 40 61.5 33.3 5.13 0.076
*
7 Replace suction tubes 60 69.2 25 12.25 0.002
*
Con. of Table (5)
End tracheal Suctioning care
8 use Saline/ distilled water prior to suctioning 90 100 100 128 0.0
9 replace the solution used for suction 15 23 0.0 28.42 6.7
10 -continuous aspiration of sub glottic secretions if ventilator
more than 48 hours
-- NA NA - -
Oral care
1 perform oral hygiene with antiseptic mouth wash 35 61.5 33.3 6.56 0.03*
2 use topical antimicrobial agents for oral decontamination
regularly
35 61.5 33.3 6.56 0.03*
Peptic ulcer prophylaxis
1 check the gastric residual volume (GRV) every 4 to 6 hours 0 0 0 0 -
2 administer intermittent rather than continuous enteral
feeding
0 0 0 0 -
3 Perform Routine acidification of gastric feeding 0 0 0 0 -
Extubation and Weaning trials
1 interruption in sedation utilizing sedation scale 0 0 0 0 -
2 Perform daily assessments of readiness to wean and extubate 0 0 0 0 -
DVT prophylaxis
1 Apply anti-embolic stockings or sequential compression 25 23 0 23.56 0.00
* Significant
12. Journal of Education and Practice www.iiste.org
ISSN 2222-1735 (Paper) ISSN 2222-288X (Online)
Vol.4, No.15, 2013
77
Table (6): Relationship between total knowledge and total average performance scores and selected
demographic variables
Variables R value P value
Total knowledge &Performance -0.02 ns
Total knowledge & Age -0.02 ns
Total knowledge & Years of experience -0.09 ns
NS = not significant
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