Question

Case Study 5

At a local hospital, the QI team identified three ventilator-acquired pneumonia (VAP) cases during the third quarter. This presents a huge concern for the hospital because  VAPs are considered preventable and nonreimbursable by Medicare-Medicaid. A team identified specific nursing interventions that research supported as decreasing the chance of the patient experiencing a VAP. Interventions included the following:

Elevating the head of bed 30 degrees

Mouth care every 4 hours

Preintubation respiratory culture

"Sedation vacation"

Cuff pressure of the endotracheal tube

Frequent suctioning, using strict sterile technique

A. You are head of the QI team investigating the nurse-sensitive indicators. What are the key performance indicators?

B.   What steps are essential to ensure that no further VAPs occur?

C.  It is identified that the primary problem contributing to the number of VAPs is that the head of bed is not always elevated to 30 degrees. The benchmark for this indicator is 20%. Of what is this an example?

Answer 1

Answer: Common causative pathogens of VAP include Gramnegative bacteria such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Acinetobacter species, and Gram-positive bacteria such as Staphylococcus aureus. The type of organism that causes VAP usually depends on the duration of mechanical ventilation. In general, early VAP is caused by pathogens that are sensitive to anti¬biotics, whereas late onset VAP is caused by multi-drug resistant and more difficult to treat bacteria.

Interventions to prevent VAP begin at the time of intubation and should be continued until extubation. With the extreme shortage of nurses and the resultant increase in the number of less experienced nurses in the intensive care unit, education on the prevention of VAP is essential, because the occurrence of nosocomial infections is directly related to the adequacy of staff. Nurses need to understand the pathophysiology of VAP, risk factors for this type of pneumonia, and strategies that may prevent the disease.

Nurses are the first line of defense in preventing bacterial colonization of the oropharynx and the gastrointestinal tract. Meticulous hand washing for 10 seconds should be performed before and after all contact with patients. In addition, gloves should be worn when contact with oral or endotracheal secretions is possible. Strategically placing a sign on a patient’s door to remind health-care workers to wash their hands and wear gloves is an easy and cost-effective measure that can help minimize transmission of bacteria between patients.