This document summarizes a critique of a pneumonia prevention policy at The University of Texas Medical Branch. The policy aims to prevent nosocomial pneumonia through measures such as preventing person-to-person transmission, aspiration prevention, postoperative pneumonia prevention, and equipment sterilization. However, the evidence review found that the policy was missing key elements like a comprehensive oral care plan, requirements for continuous endotracheal cuff pressure maintenance, and fully implementing ventilator bundle practices. The critique makes recommendations to update the policy based on current evidence, such as including an in-depth oral care regimen, specifying ventilator bundle elements, and providing more education resources to reduce non-compliance.

1. Running head: PNEUMONIA PREVENTION POLICY CRITIQUE 1
Pneumonia Prevention Policy Critique
Rachel Bowe
NURS 411: Evidence-Based Practice for Nurses
May 3, 2016
Professor Alison Pittman

2. PNEUMONIA PREVENTION POLICY CRITIQUE 2
Abstract
The policy on nosocomial pneumonia prevention by The University of Texas Medical Branch
covers the topics of person to person transmission of bacteria, prevention of aspiration,
prevention of postoperative pneumonia, and the proper disinfection and sterilization of
equipment. The evidence revealed key elements of the policy were not up to par with current
evidence based practice. There was no comprehensive oral care plan, no requirement for
continuous cuff pressure at a set range, and there were ventilator bundle practices missing. The
policy will reduce the incidence of nosocomial pneumonia once it is updated to reflect current
evidence based practices.

3. PNEUMONIA PREVENTION POLICY CRITIQUE 3
Pneumonia Prevention Policy Critique
Nosocomial pneumonia has the “highest mortality among all nosocomial infections
ranging from 20% to 50%,” (Nair & Niederman, 2013). Nosocomial pneumonia is a costly,
deadly, and preventable complication that can affect many susceptible patients in health care
facilities. Decreasing the incidence of nosocomial pneumonia would decrease patient mortality,
as well as decrease the extra costs to hospitals that could be put to use in other health care areas.
Nosocomial pneumonia can be linked to various unsafe practices in health care from simple poor
hand hygiene to improper management of at risk patients such as postoperative and high
aspiration risk patients. The prevalence of nosocomial pneumonia in health care facilities is a
testament to the need for hospitals to update policies and procedures to current evidence based
practices on a regular basis.
The University of Texas Medical Branch has created a policy to prevent nosocomial
pneumonia in their health care facilities. The policy is designed to address all areas of care from
general healthcare professionals to specialties. The policy is meant to be comprehensive in
nature by directing attention to the main causes of nosocomial pneumonia in health care
facilities. Evidence has been compiled and synthesized, and realistic recommendations have
been made to improve the policy based on current evidence based practices. The evidence can
be accessed in an evidence grid found in Appendix B.
Policy Overview
“Prevention of Nosocomial Pneumonia”, provided in Appendix A, is a hospital policy
designed to decrease the cases of pneumonia and other respiratory infections during hospital
stays (University of Texas Medical Branch, 2004/2009). The policy focuses on preventing the

4. PNEUMONIA PREVENTION POLICY CRITIQUE 4
spread of bacteria, aspiration prevention, postoperative pneumonia prevention, and proper
sterilization of equipment.
Nurses in any clinical department will adhere to this guideline throughout normal shift
work by following standard precautions of care and proper hygiene. This includes effective amd
timely cleaning of the equipment used or patient centered interventions to improve lung function
and decrease the risk of infection. Nurses are expected to be knowledgeable on proper procedure
and timelines for sterilizing and cleaning the equipment used by the patient to prevent the spread
of infection. The target population for the policy includes any hospital inpatients with a focus
on patients at risk for aspiration or postoperative patients. Nurses treating these patients may use
more direct interventions focused on preventing pneumonia.
The Center for Disease Control’s guideline on prevention of noscomial pneumonia
published in 2003 is the only cited source for the policy. One reference for an important policy
such as this is not sufficient. The reference is from a credible source but is more than a decade
old. The policy was drafted in 2004 and last reviewed and revised on 04/06/09.
Synthesis of Evidence
There were 5 research studies found to be relevant to the topic of nosocomial pneumonia
prevention, this included 3 qualitative studies, 1 quantitative study, and 1 national guideline. All
of the studies discussed ways to improve nosocomial pneumonia prevention within the
healthcare field. Information on all articles in the form of an evidence grid can be found in
Appendix B.
The policy includes information on oral care using an antiseptic agent, such as
chlorhexidine, which complies with the research that Jaiyindee, Morkchareonpong, Tantipong,
and Thamlikitkul (2008) published discussing the use of 2% chlorhexidine rather than normal

5. PNEUMONIA PREVENTION POLICY CRITIQUE 5
saline in oral care. In the randomized control trial there were 207 patient participants, 102 of the
patient participants received chlorhexidine while the other 105 patient participants received
normal saline during mechanical ventilation. The rate of VAP went form 11.4% with normal
saline oral cleansing to 4.9% with 2% chlorhexidine oral cleansing (p=0.08) (Jaiyindee,
Morkchareonpong, Tantipong, and Thamlikitkul, 2008).
There are no specific guidelines regarding the oral or dental care regimen which refutes
the research in the experiment conducted by Garcia et al. (2009). There were 759 adult patient
participants that were mechanically ventilated for more than 48 hours. The rate of VAP went
from 12 per 1000 ventilator days to only 8 per 100 ventilator days (p=0.06), proving that the
dental and oral care protocol was successful in reducing the incidence on VAP (Garcia et al.,
2009).
There is no mention of maintaining continuous cuff pressure or a set cuff pressure
guideline in mechanically ventilated patients within the policy. Lorente et al. (2014) revealed in
a study that continuous cuff pressure helped to decrease VAP incidence of mechanically
ventilated patients. There were 248 patients observed, 150 of those patients received continuous
pressure while 138 received intermittent cuff pressure. Results revealed that the incidence of
VAP went from 22.0% with intermittent cuff pressure to 11.2% with continuous cuff pressure
(p=0.02) (Lorente et al., 2014).
Gurses et al. (2008) performed semi-structured interviews to determine the main reasons
for non-compliance for four hospital acquired infections, one of which is VAP. There were 20
interviews with various medical professionals including attending physicians, infection control
practitioners, respiratory therapists, and pharmacists. The results revealed that there were five
main areas of confusion that increased task non-compliance. These five areas include the task,

6. PNEUMONIA PREVENTION POLICY CRITIQUE 6
their responsibility, the expectation, the methods, and exception ambiguity. The policy itself
existing could help to prevent non-compliance by providing an education reference; it includes
exceptions, specific responsibilities, methods, and tasks (Gurses et al., 2008). The hospital
included no other information regarding required education on the subject. There were no points
of contact for further education on the subject as well.
The policy includes portions of the ventilator bundle suggested in the Institute for
Clinical Systems Improvement (2011) national guideline on VAP prevention. There are
specifics for head of bed angle, oral antiseptic care, and less frequent circuit changes. There are
not any specifics for endotracheal cuff pressure, use kinetic bed therapy, or venous
thromboembolism prevention (Institute for Clinical Systems Improvement, 2011).
Recommendations for Practice
There are no specific guidelines regarding the oral or dental care regimen which refutes
the research in the level III quasi-experiment conducted by Garcia et al. (2009). There should be
a detailed regimen of dental and oral care in the policy which can reduce the risk of VAP in
mechanically ventilated patients. This is based on the statistically significant (p=0.06) results of
the experiment performed (Garcia et al., 2009). This could include cleaning products,
procedures, exceptions, and time frames.
There is no mention of maintaining continuous cuff pressure or a set cuff pressure
guideline in mechanically ventilated patients in the policy which should be included in a
ventilator bundle. Lorente et al. (2014) revealed statistically significant results (p=0.02) in a
Level IV perspective observational study that continuous cuff pressure helped to decrease VAP
incidence in the mechanically ventilated patients (Lorente et al., 2014). There should be a set

7. PNEUMONIA PREVENTION POLICY CRITIQUE 7
range for the cuff pressure to be maintained and a time frame for what is considered continuous
for mechanically ventilated patients in the policy.
The policy includes portions of the ventilator bundle suggested in the Institute for
Clinical Systems Improvement (2011) Level I national guideline on VAP prevention. There are
specifics for head of bed angle, oral antiseptic care, and less frequent circuit changes. There are
not any specifics for endotracheal cuff pressure, use kinetic bed therapy, or venous
thromboembolism prevention (Institute for Clinical Systems Improvement, 2011). The inclusion
of these practices into the ventilator bundle could reduce the risk of VAP by preventing
pulmonary embolisms from venous thromboembolisms, preventing atelectasis and fluid build-up
in the lungs from immobility, and reduce the risk of aspiration of secretions. The policy should
include specifications on kinetic bed therapy including frequency and procedure, venous
thromboembolism prevention including medications and devices used, and the range for the cuff
pressure that should be maintained (20-25 cm H2O).
According to the level VII evidence from the semi-structured interview and grounded
theory based qualitative study by Gurses et al. (2008) including information on areas of
ambiguity and providing additional resources reduces non-compliance to key policies (Gurses et
al., 2008). To accomplish this, the hospital should provide information on proper procedure,
responsibilities, and exceptions for new requirements such as the oral and dental care of
mechanically ventilated patients. Educational resources that are simple such as overviews or
pictorial aides should be placed in areas of the hospital that will be performing these procedures
frequently. The policy should contain a point of contact for further questions and education on
the topic as well.

8. PNEUMONIA PREVENTION POLICY CRITIQUE 8
Polit and Beck (2014) provided the information for all the level of evidence for the
research provided (Polit & Beck, 2014).
Conclusion
The policy on preventing nosocomial pneumonia produced by The University of Texas
Medical Branch is designed to reduce the incidence of nosocomial pneumonia in the health care
setting. The policy covers many areas of health care from standard precautions to specialty
practices such as disinfection and sterilization of equipment or care of ventilated patients. The
policy is supported by the evidence provided in the instance of oral care with an antiseptic. The
policy should update the information to include an in-depth oral and dental care regimen, a
complete ventilator bundle including kinetic bed therapy, venous thromboembolism prevention,
and continuous cuff pressure at 20-25 cm H2O. To accompany these changes the hospital should
provide educational resources to reduce non-compliance. The hospital should conduct further
research into nosocomial pneumonia prevention to provide numerous current resources on
evidence based practices in this field. The research and policy should be updated at least every
3-5 years since this subject is not only of great importance but is constantly changing with
updated evidence based practices and procedures as well as current technology and
pharmacology.

9. PNEUMONIA PREVENTION POLICY CRITIQUE 9
References
Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009).
Reducing ventilator-associated pneumonia through advanced oral-dental care: a 48-
month study. American Journal of critical care, 18(6), 523-532.
Gurses, A. P., Seidl, K. L., Vaidya, V., Bochicchio, G., Harris, A. D., Hebden, J., & Xiao, Y.
(2008). Systems ambiguity and guideline compliance: a qualitative study of how
intensive care units follow evidence-based guidelines to reduce healthcare-associated
infections. Quality and Safety in Health Care, 17(5), 351-359.
Institute for Clinical Systems Improvement (ICSI). Prevention of ventilator-associated
pneumonia. Health care protocol. Bloomington (MN): Institute for Clinical Systems
Improvement (ICSI); 2011 Nov. 29
Lorente, L., Lecuona, M., Jiménez, A., Lorenzo, L., Roca, I., Cabrera, J., Llanos, C., & Mora, M.
L. (2014). Continuous endotracheal tube cuff pressure control system protects against
ventilator-associated pneumonia. Critical Care (London, England), 18(2), R77.
doi:10.1186/cc13837
Nair, G. B., & Niederman, M. S. (2013). Nosocomial pneumonia: lessons learned. Critical care
clinics, 29(3), 521-546.
Polit, D. F. & Beck, C.T. (2014). Essentials of nursing research: Appraising evidence in
nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Tantipong, H., Morkchareonpong, C., Jaiyindee, S., & Thamlikitkul, V. (2008). Randomized
controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution
for the prevention of ventilator-associated pneumonia. Infection Control & Hospital
Epidemiology, 29(02), 131-136.

10. PNEUMONIA PREVENTION POLICY CRITIQUE 10
University of Texas Medical Branch. (2009). Prevention of nosocomial pneumonia, 1.40.
Retrieved from http://www.utmb.edu/policies_and_procedures/Non-
IHOP/Healthcare_Epidemiology/01.40%20-%20Pneumonia%20Prevention.pdf
(Original work published 2004)

11. PNEUMONIA PREVENTION POLICY CRITIQUE 11
Appendix A: Prevention of Nosocomial Pneumonia Prevention

12. PNEUMONIA PREVENTION POLICY CRITIQUE 12

13. PNEUMONIA PREVENTION POLICY CRITIQUE 13

14. PNEUMONIA PREVENTION POLICY CRITIQUE 14

15. PNEUMONIA PREVENTION POLICY CRITIQUE 15

16. Running head: PNEUMONIA PREVENTION POLICY CRITIQUE 16
Appendix B: Evidence Grid
Citation (APA) Purpose Sample Design Measurement Results/Conclusions Level of
Evidence
Garcia, R., Jendresky, L.,
Colbert, L., Bailey, A.,
Zaman, M., & Majumder,
M. (2009). Reducing
ventilator-associated
pneumonia through
advanced oral-dental care:
a 48-month
study.American Journal
of critical care, 18(6),
523-532.
Determine if an
in-depth oral and
dental care
protocol reduces
ventilator-
associated
pneumonia
N=759
Adult patients
receiving
mechanical
ventilation for more
than 48 hours in
ICU at a university-
affiliated medical
center
Quasi-
experimental
 Collected intubation date,
extubation date, MICU
admission, transfer, or
death
 Measured temperature,
leukocyte levels
(leukocytosis), perform
sputumculture, and chest
radiography to diagnose
VAP
 Primary outcomes
measured is the rate of
VAP
 Secondary outcomes
measured include length
of stay in ICU, duration
of ventilation, and ICU
mortality
 Three tiers of review –
surveillance infection
control professional,
assistant directorof
infection control and 4
pulmonary specialists
 rate of ventilator-associated
pneumonia was 12 per 1000
ventilator days prior to the study
 rate of ventilator-associated
pneumonia was 8 per 1000
ventilator days during the study
 p=0.06
 the in-depth dental and oral care
protocol can decrease ventilator-
associated pneumonia incidence
and cost
Level III
Gurses, A. P., Seidl, K.
L., Vaidya, V.,
Bochicchio, G., Harris, A.
D., Hebden, J., & Xiao,
Y. (2008). Systems
Identify the main
reasons for non-
compliance of
guidelines for four
hospital acquired
N=20
3 attending
physicians,2
infection control
practitioners, 2
Semi-structured
interviews
Grounded
Theory
 Analyzed data collected
using open coding,axial
coding, and selective
coding
 Task, responsibility, expectation,
methods, and exception ambiguity
increase non-compliance
 Clarify expectations with
education, use visual cues,
Level VII

17. PNEUMONIA PREVENTION POLICY CRITIQUE 17
ambiguity and guideline
compliance: a qualitative
study of how intensive
care units follow
evidence-based guidelines
to reduce healthcare-
associated
infections. Quality and
Safety in Health
Care, 17(5), 351-359.
infections respiratory
therapists,and 2
pharmacists in two
surgical intensive
care units in two
urban hospitals
 Final categorization
structure agreed on by all
authors of study
overview tools, standardized
orders, and role clarification
decrease ambiguity
Institute for Clinical
Systems Improvement
(ICSI). Prevention of
ventilator-associated
pneumonia.Health care
protocol.Bloomington
(MN): Institute for
Clinical Systems
Improvement (ICSI);
2011 Nov. 29
Ventilator-
associated
pneumonia
prevention
guideline
Hospitals should consistently use
ventilator bundles to decrease
ventilator associated pneumonia
incidence.
 Head of bed at 30-45 degrees
 Cuff pressure maintained at 20-25
cm H2O
 Less frequent circuit changes
 Provide oral care with an
antiseptic such as chlorhexidine
 Provide kinetic bed therapy
 Provide venous thromboembolism
prophylaxis to prevent pulmonary
embolism
Level I
Lorente, L., Lecuona, M.,
Jiménez, A., Lorenzo, L.,
Roca, I., Cabrera, J.,
Llanos, C., & Mora, M. L.
(2014). Continuous
endotrachealtube cuff
pressure control system
protects against
ventilator-associated
pneumonia. Critical Care
(London,England),18(2),
To determine if
the use of
continuous
endotrachealcuff
pressure has an
effect on the
incidence of
ventilator-
associated
pneumonia
N=248
150 Continuous cuff
pressure patients
138 intermittent cuff
pressure patients
Patients undergoing
mechanical
ventilation for more
Nonexperimental
(prospective
observational)
 Multivariate logistic
regression analysis
(MLRA) and Cox
proportional hazard
regression analysis used
to predict VAP.
 Tracheal aspirate samples
during intubation, twice
per week, and on
extubation.
 Throat swabs taken on
 Lower incidence of ventilator-
associated pneumonia with
continuous cuff pressure (11.2%)
rather than intermittent cuff
pressure (22.0%)
 P=0.02
 Therefore continuous cuff
pressure reduces the rate of VAP
in patients ventilated for more
than 48 hours.
Level IV

18. PNEUMONIA PREVENTION POLICY CRITIQUE 18
R77.doi:10.1186/cc13837 than 48 hours in
ICU.
admission to ICU, twice
per week, and at
discharge from the unit.
 Outcomes measured
include rate of VAP
Tantipong, H.,
Morkchareonpong,C.,
Jaiyindee, S., &
Thamlikitkul, V. (2008).
Randomized controlled
trial and meta-analysis of
oral decontamination with
2% chlorhexidine solution
for the prevention of
ventilator-associated
pneumonia. Infection
Control & Hospital
Epidemiology,29(02),
131-136.
To assess if use of
2% oral
chlorhexidine
decreases
ventilator-
associated
pneumonia
incidence
N=207
 102 chlorhexidine
patients
 105 normal saline
patients
Adult patients
receiving
mechanical
ventilation in ICU or
general medical
wards in a tertiary
university hospital
in Bangkok,
Thailand
Experimental
(Randomized
control trial) and
meta-analysis
 Measured the
development of VAP and
colonization of gram-
negative bacilli.
 Meta-analysis was
performed by combining
the results of the present
study with one other
RCT that used 2%
chlorhexidine
formulation for oral
decontamination
 2% chlorhexidine is effective for
oral care to reduce ventilator-
associated pneumonia
 rate of 4.9% ventilator-associated
pneumonia in chlorhexidine group
 rate of 11.4% ventilator-associated
pneumonia in normal saline group
 p=0.08
Level II