الفهرس 
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Abstract
Ventilator-associated pneumonia is the foremost problem in ICUs worldwide and dramatically causing an increase in morbidity and mortality rates. The VAP is a sub-grouping of HAIs that refers to the development of pneumonia after the insertion of an artificial airway. The VAP represents the second most common nosocomial infection in the ICU. It refers to an infection that develops during mechanical ventilation after 48 hours of intubation. The pathophysiology of VAP involves two main processes: colonization of the respiratory and digestive tracts and microaspiration of secretions of the upper and lower parts of the airway.
The onset of VAP can be divided into two types: early and late onset VAP. Early onset VAP occurs 48-96 hours after intubation. The risk factors for VAP can be divided into 3 categories: host related, device related, and staff related factors.
Critical care nurses have an important role in preventing VAP by decreasing risk factors, recognizing early symptoms and assisting in diagnosis. VAP can be reduced with the implementation of a best practices program with these three principles: staff education, colonization reduction and aspiration avoidance.
Aim of study
A descriptive design was used to identify the risk factors contributing to ventilator-associated pneumonia in critically ill patients.
This study was carried out in the ICUs at Alexandria Main University Hospital, namely; Casualty care unit (Unit I) and the general ICUs (Unit III).
All newly admitted to the ICUs will be included in the study except those patients who are immunocompromised, or have Community-Acquired Pneumonia.
A Convenient sample of 50 patients was enrolled in this study during the period of data collection start from the beginning of November 2017 till the end of to January 2018.
Materials and methods
To accomplish the aim of the current study; One tool were used for data collection. Ventilator-associated pneumonia risk factors assessment for mechanically ventilated patients.
Part I & II was developed by the researcher after reviewing the relevant literature(49,155-157,159) and part III adopted from Pugin and coworkers to identify(161) the risk factors of VAP for mechanically ventilated patients. It consists of three parts:
Part I: Demographic and clinical data.
Part II: Ventilator-associated pneumonia risk factors:
This part was used to assess the patient’s risk factors for VAP. It included 12 items grouped into 3 categories as followed:
• Host-related risk factors: included 5 items.
• Device-related risk factors: included 4 items.
• Staff related risk factors: included 3 items.
Part III: Clinical pulmonary infection score record (CPIS):
This part was adopted from Pugin and coworkers and used for clinical diagnosis of VAP. It included clinical criteria such as temperature, tracheal secretions, blood leukocytes, PaO2/FiO2 ratio, culture of tracheal aspirate and pulmonary radiography. Total CPIS = 12 in which score more than six is associated with a high likelihood of VAP with a sensitivity of 93% and specificity of 100%.
The study design was accomplished as following:
An official letter from the Faculty of Nursing was sent to appropriate authorities in Alexandria Main University Hospital and a permission to conduct the study with explanation of the aim of the study. Parts I &II of tool was developed by the researcher after reviewing the related literature and part III was adopted from Pugin and coworkers.
A pilot study was carried out in order to assess feasibility of the study and applicability of the tools. Reliability of the tool was done before conducting the study using Cronbach’ Alpha reliability, the reliability coefficients were (r =0.90) which is acceptable. Newly admitted mechanically ventilated patients were included in the study according to the previously mentioned exclusion criteria, and then patients’ characteristics and clinical data were recorded upon the admission using part I of the tool. Using part II of the tool, Ventilator-Associated Pneumonia risk factors were observed by the researcher. Host-related risk factors were recorded in which patients’ position were observed each shift from the admission and till the occurrence of VAP. Four score was done for each patient and calculated on a daily basis, medication that may lead to VAP were recorded regularity using scale of Yes (present) NO (not present); using part II of the tool. In addition, the presence of endotracheal tube and gastric tube were observed by the researcher and recorded using a scale of Yes (present) No (not present). Cuff pressures were measured by the researcher daily from admission and till the occurrence of VAP. The performance of hand washing and using personal protective equipment such as wearing gloves, wearing eye mask, wearing cover head, wearing face mask and wearing gown for critical care nurses who were caring for each patient, were observed by the researcher on admission and each time repeated at the morning and evening shift using part II of the tool.
Clinical pulmonary infection score was screened by the researcher with each patient to assess the occurrence of VAP using part III twice; the first time after 48 hours of the start of mechanical ventilation. The second time at the 8th day of mechanical ventilation to clinically diagnose the occurrence of VAP.
The main results of the study:
More than half of studied patients were males, 46% of them were between the age group of 50 to less than 60 years. Furthermore, 34% of the studied patients admitted to ICUs with had the cardiovascular disorder, 26% of them had neurological disorders while 26% had other disorders mainly poisoning and only 2% had hepatic disorders. The severity of disease for the majority of studied patients were scored as APACHE II score on admission ranging from 5 to 36 and the length stay of ICU ranging from 8 to 48 days. Most of the studied patients (72%) were without sedation. More than half of the studied patients (58%) had late VAP, 24% of them had early VAP and only 18% of the studied patients had no VAP.
Regarding to the studied patients’ position throughout the three shifts. It was found that the morning shift had the highest mean of studied patients who assuming the fowler, semi-fowler and supine positions (0.86±1.88, 6.72±1.39 and 0.76±1.02 respectively). Also, it was found that the right lateral positions had the highest mean 2.04±1.13 at the evening shift and the highest mean 1.48±1.28 of the left lateral positions at the night shift.
More than half of studied patients (56%) were unconscious. Majority of studied patients (94%) were intubated for less than two times. All studied patients (100%) were taking antibiotics. Also, the majority of them (94%) were taking other medications such as B-blocker. More than one-quarter of the studied patients were taking H2-blockers, corticosteroids and sedatives (28%, 30% and 26% respectively).
All the studied patients (100%) had endotracheal tube and gastric tube as well. More than half of the studied patients (52%) had oral gastric tube, while 48% of them had nasogastric tube. Concerning the mean percentage of hand washing practices. It was found that the highest mean was at the morning shift 3.76±3.70, while the lowest mean were at the evening and the night shifts (0.0 ± 0.0 and 0.04 ±0.20 respectively).
In relation to personal protective equipment related practices throughout three shifts. it can be noted that the practices of wearing was not done (100%). Whereas at evening and night shifts more than half of wearing face mask practices (52% and 62% respectively) was not done.
There was a statistically significant association between the occurrence of VAP and sex P=0.001. There was no statistically significant difference between the occurrence of VAP and age.
There was no statistically significant association between the occurrence of VAP and admission diagnosis except there was a statistically significant association between the occurrence of VAP and gastrointestinal disorder p=0.000. There was no statistically significant association between the occurrence of VAP and co-morbidities disorders.
Recommendations
The main recommendations are:
• Apply evidence-based guidelines for management of critically ill patients with VAP.
• Implement standard precautions for the prevention of transmission of infectious agents causing VAP.
• Include the closed suction system in the care of MVP rather than the open suction system.
• Educational programs for CCNs should be established and conducted for the prevention of VAP.
• Continuous in-serve training programs for CCNs in the ICUs to update and raise their stander of care in the application of evidence base guidelines for management of patients with VAP.
• Establish ventilator-associated pneumonia quality improvement team in the ICUs.
• Further studies about nursing care practices that may lead to VAP.
• Replication of the current study on large sample size, longer duration of data collection and different setting for generalization of the result.