الفهرس 
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Abstract
Ventilator Associated Pneumonia (VAP) is the most common infectious complication among patients admitted to Intensive Care Units (ICUs). It results in high morbidity and mortality, increased duration of Mechanical Ventilation (MV), prolonged Length of Stay at Intensive Care Unit (ICU) and increased cost of hospitalization (Guillamet and Kollef, 2018). Ventilator Associated Pneumonia (VAP) is an airway infection that occurs later than 48 hours after endotracheal intubation. A bundle is a small set of evidence based preventive practices that when implemented collectively helps in the prevention of a healthcare associated infection. The VAP prevention bundle can reduce the incidence of VAP, duration of mechanical ventilation and length of ICU stay (Xie et al., 2018). Prevention of Ventilator Associated Pneumonia has become the priority of all ICUs, the key of patients’ safety and an indicator of the quality of care of mechanically ventilated patients (Campogiani et al., 2020).
Aim of the Study< >The aim of the current study was to examine the effectiveness of implementing ventilator associated pneumonia prevention bundle among mechanically ventilated patients. Research Design: A quasi-experimental design (study/control) was utilized.< Setting: The study was conducted at the Surgical Intensive Care Unit (SICU) and Anesthesia ICU at the University Hospital of Menoufia University.
Sample:
A convenience sampling of 104 adult patients was recruited. Patients were approached over a 12 months period from the beginning of March 2020 to the end of February 2021.
To Achieve the Aim of the Current Study the Following Instruments Were Used:
I) A Semi Structured Demographic Questionnaire Data about patient’s age, gender, marital status, duration of MV, ICU length of stay were extracted from the patient’s medical record by the researcher after admission to the surgical and anesthesia ICU.
II) Acute Physiology and chronic Health Evaluation II (APACHE II) Scale APACHE II was developed by Knaus et al., (1985). APACHE II was designed to measure the illness severity for patients within 48 hours of ICU admission. The APACHE II score ranged from 0 to 71 and was computed based on several measurements such as patient’s age and 12 routine physiological measurements
including: PaO2 (depending on FiO2), Body Temperature, Mean Arterial Pressure, Arterial pH, Heart Rate, Respiratory Rate, Serum Sodium and Potassium, Creatinine, Hematocrit, White Blood Cell Count, Glasgow Coma Scale. The scoring system of the scale interpreted as: 5 to 9 had 8% mortality risk, 10 to 14 had 15% mortality risk, 15 to 19 had 25% mortality risk, 20 to 24 had 40% mortality risk, 25 to 29 had 55% mortality risk, 30 to 34 had 75% mortality risk and >34 had 85% mortality risk.
III) charlson Comorbidity Index charlson Co-morbidity Index was designed to categorize co-morbidities of patients based on the International Classification of Diseases (ICD). It consists of 19 categories of co-morbidity and predicts the Ten year survival in patient with multiple co- morbidities. Each condition is assigned with score from 0 to 6 depending on the risk of dying associated with this condition. A score of zero indicates that no co-morbidities were found and higher scores indicating greater co-morbidity. Patients with a score >5 have essentially a 100% risk of dying at one year (Charlson et al., 1987). The scoring system of the scale interpreted as: 0 points had 98% estimated 10-year survival, 1 point had 96%, 2 points had 90%, 3 points had 77 %, 4 points had 53%, 5 points had 21%, 6 points had 2%, and 7 points or more had 0% estimated 10-year survival.
IV) Clinical Pulmonary Infection Score (CPIS) Clinical Pulmonary Infection Score was developed by Pugin et al., (1991) to simplify the diagnosis of VAP. The CPIS is calculated from five items including (Body Temperature, Leukocyte Count, Tracheal Secretions, Arterial Oxygenation (PaO2/FiO2) and Chest Radiograph). The CPIS cultures were calculated from the CPIS baseline score by adding two more points when gram stains or cultures were positive. The total CPIS range from 0 to 12. A score of more than six at baseline or after incorporating the culture result was considered suggestive of VAP and CPIS less than six indicating VAP free.
Procedure:
• Ethical Consideration: All necessary official permissions for conducting the study were obtained from the Research Ethics Committee at the Faculty of Nursing and University Hospital director to carry out the study after explaining the purpose of the study. A verbal consent was obtained from the patients’ relatives. Relatives were informed about the procedure and benefits of participating in the study.
Confidentiality and anonymity of patient’s information were assured through coding all data and put all collected data sheets in a secured cabinet.
Pilot Study: A pilot study was conducted on 10% of the study sample (10 patients) to test the practicality and applicability of the data collection tools and to estimate the time needed to fill in the study questionnaire. Subjects participating in the pilot study were excluded from the final analysis.
• A total sample of 104 adult mechanically ventilated patients was randomly assigned into two equal groups, 52 patients each (study and control group). The researcher handled the control group first. The control group followed the hospital usual routine care and the study group received the VAP prevention care bundle.
• The study group was assigned to receive the VAP prevention bundle interventions twice daily until the patient weaned from the mechanical ventilation or diagnosed with VAP. Ventilator Associated Pneumonia prevention bundle included the following items: hand hygiene, elevation of the head of bed (30-45 degree unless contraindicated), continuous removal of oropharngeal secretions, change of ventilator circuit every 48 hours and maintaining the endotracheal cuff pressure between 20 to 25 mmHg. To measure the endotracheal tube cuff pressure, the cuff manometer was connected to the pilot balloon of endotracheal tube then the cuff pressure appear on the screen of the endotracheal tube cuff pressure manometer to adjust endotracheal tube cuff pressure within the normal therapeutic range (25mmHg). The researcher checked the endotracheal tube cuff pressure twice daily.
• The control group was assigned to receive the hospital routine care which included oropharyngeal suctioning as needed and oral hygiene twice daily. Intermittent suctioning for 10 seconds was applied.