• Evidence-Based Project, Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews PowerPoint

• Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews
• NURS – 6052: Essentials of Evidence-Based Practice
• Clinical Issue of Interest

oVentilator-associated pneumonia (VAP) is a serious public health concern

oVAP is the principal complication of artificial ventilation among patients in ICU

oProlongs hospital and ICU stay

oIncreases the risk for inpatient mortality and morbidity

oIncreases healthcare expenses

oThe outburst of COVID-19 elevated the prevalence and incidence of VAP

oThere is an urgent need for evidence-based interventions to address VAP

Ventilator-associated pneumonia (VAP) is among the most fatal nosocomial infections worldwide that not only prolongs hospital and intensive care unit (ICU) stay but also attributed to elevated risk of in-hospital mortality and morbidity, as well as increased healthcare cost (Wu et al., 2019). VAP is considered the major complication of mechanical ventilation and intubation (Lim et al., 2018). It is projected that there are >3.5 VAP cases/1000 ventilator days, and the outburst of COVID-19 pandemic enhanced the prevalence of VAP since critically ill patients testing positive for the SARS-CoV-2 required assisted ventilation and intubation (Maes et al., 2021).

• EBP Process

The development of an EBP intervention entails assessing the patient to determine the problem stemming from available patient care approaches and developing a focused clinical question derived from the assessment (Katowa-Mukwato et al., 2021). The third step is acquiring empirical evidence to support the clinical question, appraising the evidence for its applicability and validity is the fourth step, while fifth step involves incorporating the evidence with patient preference and clinical expertise into practice. The final step is evaluation of the effects of the EBP on clinical outcomes (Katowa-Mukwato et al., 2021)

• Problem Identification: PICOT Question

oAssessment of available interventions to prevent VAP among mechanically intubated patients led to the recognition of IHI’s VAP care bundle (VCB)

oPICOT question:

oIs VCB superior than usual care in reducing VAP cases among mechanically ventilated and/intubated patients in ICU six-months after implementation?

oPopulation: ICU patients on mechanical ventilation

oIntervention: VCB

oComparator: Usual care

oOutcomes: Occurrence of VAP, VAP-related mortality or morbidity, length of hospital stay

oTime: 6 months

A preliminary review assessment of current interventions of preventing VAP in critically ill patients led to the recognition of the VAP care bundle recommended by the Institute of Health Improvement (IHI) (IHI, n.d.). Thus, my EBP project seeks to answer the PICOT question (population, intervention, comparator, time) states that: is VCB superior than usual care in reducing VAP cases among mechanically ventilated and/intubated patients in ICU six-months after implementation? Evidence-Based Project, Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews PowerPoint

• Evidence Search

o

oFour databases searched

oEmbase = 10 articles

oCINAHL Plus = 6 articles

oCochrane Library = 1 scoping review and 22 randomized clinical trials (RCTs)

o PubMed = 44 articles

o

oThe search was limited to articles published:

oEnglish language

o2017 – 2022

oPeer-reviewed articles

oFull-texts

I performed an advanced search of four academic databases: namely, Embase, CINAHL Plus, Cochrane Library, and PubMed, through the Walden University Library (n.d.) to identify articles that support the clinical question. The following Boolean phrases (‘ventilator-associated pneumonia OR VAP’) AND (‘ventilator’) AND (‘care’ AND bundle) AND (‘critically ill patients OR mechanically ventilated OR intubated patients). The search was limited to peer-reviewed articles published in the English language between 2017 and 2022 with available full texts.

• Level of Evidence

oBurja, S., Belec, T., Bizjak, N., Mori, J., Markota, A., & Sinkovič, A. (2018). Efficacy of a bundle approach   in preventing the incidence of ventilator associated pneumonia (VAP). Bosnia Journal of Basic Medical   Science, 18(1), 105–109.

oA retrospective analysis Evidence-Based Project, Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews PowerPoint

oLevel III evidence as data collection preceded formulation of the clinical question

oLimitations: The extrapolation of the results is restricted by the single-center, small sample size.

oDe Neef, M., Bakker, L., Dijkstra, S., Raymakers-Janssen, P., Vileito, A., & Ista, E. (2019). Effectiveness of   a ventilator care bundle to prevent ventilator-associated pneumonia at the PICU: A systematic   review and meta-analysis. Pediatric Critical Care Medicine, 20(5), 474–480.   https://doi.org/10.1097/PCC.0000000000001862

oA systematic review and meta-analysis

oLevel II evidence: It involved meta-synthesis of findings from RCTs and non-randomized studies

oStrengths: Asked a focused clinical question

• Hierarchical HR structure enable the HR professionals to manage the most essential asset of the XYZ, therefore, it is necessary to offer comprehensive training to exploit the potential of hierarchical management framework (Barry et al., 2016).

o

• Level of Evidence

oMahmoodpoor, A., Hamishehkar, H., Hamidi, M., Shadvar, K., Sanaie, S., Golzari, S. E., Khan, Z. H., &   Nader, N. D. (2017). A prospective randomized trial of tapered-cuff endotracheal tubes with   intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill   patients. Journal of Critical Care, 38, 152–156. https://doi.org/10.1016/j.jcrc.2016.11.007A   retrospective analysis

oLevel I evidence : The achieves narrow confidence interval or shows a significant difference between treatment and control cohorts

oRetrospective analysis

oStrengths: A focused clinical question, all respondents who were enrolled in the study were accounted for at the conclusion

oTriamvisit, S., Wongprasert, W., Puttima, C., Chiangmai, M. N., Thienjindakul, N., Rodkul, L., &   Jetjumnong, C. (2021). Effect of modified care bundle for prevention of ventilator-associated   pneumonia in critically-ill neurosurgical patients. Acute and Critical Care, 36(4), 294–299.   https://doi.org/10.4266/acc.2021.00983

oA cohort study

oLevel II evidence: Authors formulated the question before collecting data

oStrengths: Asked a focused clinical question

oSome of the authors  work in the research setting which reduces the validity of findings.

• Hierarchical HR structure enable the HR professionals to manage the most essential asset of the XYZ, therefore, it is necessary to offer comprehensive training to exploit the potential of hierarchical management framework (Barry et al., 2016).

o

• References

oBurja, S., Belec, T., Bizjak, N., Mori, J., Markota, A., & Sinkovič, A. (2018). Efficacy of a bundle approach in   preventing the incidence of ventilator associated pneumonia ( VAP ). Bosnia Journal of Basic Medical   Science, 18(1), 105–109.

oDe Neef, M., Bakker, L., Dijkstra, S., Raymakers-Janssen, P., Vileito, A., & Ista, E. (2019). Effectiveness of a   ventilator care bundle to prevent ventilator-associated pneumonia at the picu: A systematic review   and meta-analysis. Pediatric Critical Care Medicine, 20(5), 474–480.   https://doi.org/10.1097/PCC.0000000000001862

oKatowa-Mukwato, P., Mwiinga-Kalusopa, V., Chitundu, K., Kanyanta, M., Chanda, D., Mbewe Mwelwa, M.,   Ruth, W., Mundia, P., & Carrier, J. (2021). Implementing Evidence Based Practice nursing using the   PDSA model: Process, lessons and implications. International Journal of Africa Nursing Sciences, 14(1),   100261. https://doi.org/10.1016/j.ijans.2020.100261

oLim, K. P., Kuo, S. W., Ko, W. J., Sheng, W. H., Chang, Y. Y., Hong, M. C., Sun, C. C., Chen, Y. C., & Chang,   S. C. (2018). Efficacy of ventilator-associated pneumonia care bundle for prevention of ventilator-  associated pneumonia in the surgical intensive care units of a medical center. Journal of Microbiology,   Immunology and Infection, 48(3), 316–321. https://doi.org/10.1016/j.jmii.2013.09.007

• References
• Maes, M., Higginson, E., Pereira-Dias, J., Curran, M. D., Parmar, S., Khokhar, F., Cuchet- Lourenço, D., Lux, J., Sharma-Hajela, S., Ravenhill, B., Hamed, I., Heales, L.,   Mahroof, R., Solderholm, A.,   Forrest, S., Sridhar, S., Brown, N. M., Baker, S., Navapurkar, V., … Conway Morris, A. (2021).   Ventilator-associated pneumonia in critically ill patients with COVID-19. Critical Care, 25(1), 1–11.   https://doi.org/10.1186/s13054-021-03460-5
• Mahmoodpoor, A., Hamishehkar, H., Hamidi, M., Shadvar, K., Sanaie, S., Golzari, S. E., Khan, Z. H., & Nader, N. D. (2017). A prospective randomized trial of tapered-cuff endotracheal tubes with   intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill   patients. Journal of Critical Care, 38, 152–156. https://doi.org/10.1016/j.jcrc.2016.11.007
• Triamvisit, S., Wongprasert, W., Puttima, C., Chiangmai, M. N., Thienjindakul, N., Rodkul, L., & Jetjumnong, C. (2021). Effect of modified care bundle for prevention of ventilator-associated pneumonia in   critically-ill neurosurgical patients. Acute and Critical Care, 36(4), 294–299.   https://doi.org/10.4266/acc.2021.00983
• Wu, D., Wu, C., Zhang, S., & Zhong, Y. (2019). Risk factors of ventilator-associated pneumonia in critically III patients. Frontiers in Pharmacology, 10(MAY), 1–7. https://doi.org/10.3389/fphar.2019.00482 Evidence-Based Project, Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews PowerPoint