Organizational Culture and Readiness Assessment
Overview
The proposed evidence-based project entails the implementation of bundled practices to prevent ventilator-associated pneumonia (VAP), which is a common occurrence in intensive care settings (Sedwick, Lance-Smith, Reeder, & Nardi, 2012).
Readiness Level
The survey results show that the readiness level is high because the facility views Evidence-based practice (EBP) as central to the realization of its mission and philosophy, allows the practice of EBP, and puts in place mechanisms for nurses, physicians, and other healthcare professionals to use EBP in the provision of quality of care. Other survey indicators that confirm the facility’s readiness level is high include the presence of EBP champions, the entrenchment of EBP across the organization, and the availability of a critical mass of nurses with strong EBP knowledge and skills. These indicators show that the prevailing culture is supportive of EBP, which in turn translates to the fact that nurses will show more confidence in implementing the proposed project (Kaplan, Zeller, Damitio, Culbert, & Bayley, 2014).
Barriers and Facilitators
The low score on the use of fiscal resources to support EBP presents a monetary barrier due to the fact that successful EBP implementation may require significant financial investments (Melnyk & Fineout-Ouerholt, 2015). This barrier is nested in a lack of support from senior management. Another barrier concerns the low use of computers and library resources to support EBP, with the justification being that ICU nurses lack adequate time and skills to engage in research due to their ever-busy schedule (Sedwick et al., 2012). Lastly, the facility demonstrates an inability or unwillingness to generate decisions from direct care providers. Project facilitators include responsive organizational culture, dedicated EBP champions, alignment of the organization’s philosophy with EBP, and commitment shown by nurses in implementing EBP. These indicators scored highly in the survey, with the justification being that the facility has embraced a culture of evidence-based practice (van Patter Gale & Schaffer, 2009).
Integrating Clinical Inquiry
Research demonstrates that rules for mouth care and hand washing, installing bedside alarms, training ICU nurses on effective use of subglottic suctioning, and utilizing an electronic compliance feedback system can prevent ventilator-associated pneumonia in intensive care settings (Sedwick et al., 2012). Nurses within the unit need to be taught about these best practices to improve patient care outcomes (Melnyk & Fineout-Ouerholt, 2015). Based on the weaknesses identified in the survey, it is important to come up with strategies that ensure nurses recognize the value of research-based knowledge by, for example, funding and facilitating them to undertake research studies and share findings with the organization. Additionally, successful integration of the identified best practices requires the management to train nurses on effective use of library resources, empower them on the use of computers to search for information, and include them in making important decisions (van Patter Gale & Schaffer, 2009).
Problem Description
Problem Description
Research is consistent that VAP is a common occurrence in intensive care units of many healthcare facilities in the developed and developing world, leading to high patient mortality and morbidity (Sedwick et al., 2012). Numerous guidelines and policies have been developed, validated, and availed to nurses and medical professionals working in critical care settings to help them manage incidences of VAP. For example, the Centers for Disease Control (CDC) guidelines were initiated nearly 35 years ago to address the main infection-control issues related to VAP (Kubbara et al., 2015). Available literature demonstrates that nine in ten nosocomial infections in intensive care settings are associated with VAP and occur shortly after patients undergo intubation (Azab et al., 2015; Klompas et al., 2015). In many critical care settings, the disease is usually linked to adverse health outcomes such as high patient deaths and disabilities, high healthcare outlays, increased duration of intubation time and hospital stay, as well as low patient satisfaction and quality of life. The United States data show approximately 6-10 cases of VAP per 1,000 admissions to hospitals, with around 250,000 VAP cases being reported annually (Gupta, Singh & Sexsena, 2016; Kubbara et al., 2015). As such, it is of immense importance for healthcare organizations to come up with ways and strategies to reduce the incidence of VAP in intensive care settings.
Stakeholders
It is critical to involve the stakeholders in the discussion of VAP because they help pass the necessary information to the patient and hospital regarding the therapy. The main stakeholders for this project are the American Lung Association, ICU nurses, medical staff, and the Pulmonologist Association. The patients can benefit in the form of improved health-related outcomes. The CDC and Mayo Clinic are also included as key stakeholders. All the health centers and health care professionals should be educated and show their interests in the therapy because they are the frontline caretakers and deal with patients with VAP from day today.
The PICOT Clinical Question
The PICOT clinical question for the project is “how effective is the implementation of Ventilator-Associated Pneumonia Bundle (VAPB) in reducing incidences of VAP in mechanically ventilated ICU patients?” The PICOT components include: (P) – Mechanically ventilated ICU patients, (I) – Ventilation associated pneumonia bundle/Interventions, (C) – pretest-posttest scores to evaluate the effects of VAPB, (O) – decline in the incidence of ventilation associated pneumonia, and (T) – during intubation/mechanical ventilation.
Purpose and Project Objectives
The main purpose of the proposed project is to implement VAPB in the ICU of the facility with the view to reducing the incidence of VAP. The specific objectives of the project are to (1) evaluate the efficacy of the proposed interventions during intubation, (2) reduce adverse health outcomes for mechanically ventilated patients, and (3) assess how nurses are able to comply with the proposed interventions. It is hypothesized that a decline in the incidence of VAP cases should be noted when the various interventions comprising the EBP bundle are implemented together.
Rationale
Recent nursing research reveals that VAP is a serious infection affecting 46% of ventilated patients and, in turn, increases the mortality rate among critically ill patients by 6-30% (Azab et al., 2015). The authors further offer what they refer to as the VAP bundle that is meant to reduce the chances of contracting the disease. The VAP bundle incorporates the practices that nurses have to carry out every time they are performing mechanical ventilation, which include elevating the head of the patient’s bed by 30-45˚, checking for daily extubation, conducting decontamination with chlorhexidine and oral care, ensuring safe enteral nutrition when a patient is admitted to the ICU for the first 24-48 hours, and always using endotracheal tubes that have subglottic secretion drainage (Azab et al., 2015; Gupta et al., 2015). These bundled practices have the capacity to reduce the prevalence and incidence of VAP in intensive care units (Sedwick et al., 2012). Therefore, it is important for every healthcare facility to make the VAP bundle a culture by ensuring that any mechanical ventilation done within the ICU adheres to the VAP bundle.
Literature Support
Background
Research is consistent that nurses must have the capacity to use relevant data sources to integrate research evidence with clinical expertise in what is commonly known as evidence-based practice (Fachiano & Snyder, 2012). This section reviews and summarizes the data sources that have been used to guide the proposed EBP intervention. The databases used are EBSCOHOST, PROQUEST, COCHRANE, CINAHALL, and Medline.
Summary of Findings
The article by Grap (2009) undertook a clinical review of other primary research studies to demonstrate several evidence-based practices that could be used to reduce the risks associated with mechanical ventilation. Evidence from the article suggests that ventilator-associated pneumonia can be significantly reduced through the use of higher backrest elevations (30° to 45°), ensuring proper oral health practices to minimize the colonization of the oropharynx by pathogens (e.g., by using oral applications of chlorhexidine at the time of intubation), and following recommended practices in sedating critically ill patients. The main strength of the article lies in its use of primary research sources and data to outline effective EBP interventions that could be used to reduce the risks associated with mechanical ventilation. However, the article’s findings are limited due to the use of a broad scope of the study, leading to issues of generalizability of findings in VAP contexts
The article by Gupta et al. (2016) detailed some of the best practices to prevent aspiration of oral colonization, which is a common cause of VAP in intensive care settings. The recommended oral care interventions include (1) conducting an initial admission and daily assessment of the patient’s oral cavity to allow for early identification of oral hygiene problems, (2) using unit-specific protocols to not only minimize the development of mucositis, but also to help the patient in maintaining normal saliva production and oral tissue health, (3) keeping the head of the bed elevated to at least 30° to assist in preventing reflux and aspiration of gastric contents, and (4) routinely suctioning the patient’s oral and subglottic discharges to reduce aspiration of infected secretion into the lungs. In strengths, the article relied on credible data sources and guidelines to discuss the relationship between the aspiration of oral colonization and VAP. Additionally, the article focused on ICU, hence reducing the challenges associated with data applicability. However, the recommended oral health care interventions are not supported by relevant literature as would be expected in EBP contexts.
The study by Kubbara et al. (2015) investigated the application and interpretation of CDC guidelines (VAC, IVAC, VAP) by diverse groups of healthcare providers in the assessment of ventilator-associated pneumonia. Evidence from the study suggests that the application of the CDC guidelines varies between different healthcare providers, hence the need to allow for the modification of the guidelines across settings based on clinical or professional judgment. In strengths, the study not only used validated CDC guidelines and appropriate methodological strategies but also recruited a diverse sample to identify attitudinal shifts in the application of the guidelines. A major limitation, though, lies in the fact that the authors failed to elaborate on how the application and interpretation of CDC guidelines influence VAP incidents in the ICU.
The study by Klompas et al. (2015) investigated the effectiveness of two clinical interventions (coordinated awakening and spontaneous breathing) in preventing the incidence of ventilator-associated events in intensive care settings. Evidence from the study suggests that coordinated awakening (e.g., by use of bedside alarms) and assisting patients to breathe impulsively without the use of sedation are positively associated with a reduction in duration of mechanical ventilation in the ICU and hospital length-of-stay. In strengths, this study used an appropriate research design to investigate the two interventions and is specific in its scope and applicability in the ICU. However, it is felt that the sample size used is not adequate to generalize the findings to larger contexts.
The study by Sedwick et al. (2012) aimed at investigating how the implementation of bundled practices in a hospital’s intensive care units affected the incidence of ventilator-associated pneumonia within the units. The bundled practices that were implemented in the units included elevation of head-of-bed (30° to 45°), prophylaxis for peptic ulcer disease, prophylaxis for deep-vein thrombosis, routine intermission of sedation, routine evaluation of readiness for extubation, daily oral care with chlorhexidine and daily assessments of the oral cavity, protocols for mouth care and hand washing, head-of-bed alarms, and subglottic suctioning. Evidence from the study demonstrates that strict adherence to the bundled practices not only reduces pneumonia-associated mortality and morbidity of patients receiving mechanical ventilation but also shortens hospital stays and ensures that healthcare costs are kept at a minimum. In strengths, the study’s scope is specific to VAP in intensive care contexts and the researchers used CDC guidelines on VAP to guide the research process. However, it is felt that the VAP bundle used in the study contains very many interventions that may be difficult to monitor in clinical contexts. Additionally, the study was carried out in one hospital, meaning that it may be difficult to generalize the findings to other contexts.
Lastly, the study by Azab et al. (2015) used the context of developing countries to evaluate the effectiveness of predesigned VAP bundled practices in reducing the incidence of ventilator-associated pneumonia in neonatal intensive care settings. The VAP prevention bundle used in the study consisted of head-of-bed elevation (30° to 45°), fortification of hand hygiene practices, sterile suction and handling of respiratory apparatus, intubation, re-intubation, and endotracheal tube (ETT) suction as stringently specified in the unit standards, changing ventilator circuit if noticeably dirty or mechanically faulty, implementing routine mouth care with normal saline and suctioning of oro-pharyngeal secretion, performing daily evaluations for readiness for extubation to nasal continuous air pressure (NCPAP) at the morning round, as well as sedation vacation for sedated patients (Azab et al., 2015). Evidence from the study demonstrates that the implementation of an all-inclusive VAP bundle consisting of the described solutions substantially reduces the length of institutional stay as well as the prevalence and incidence of VAP events in acute care settings. This article is specific in scope as it studied VAP in neonatal intensive care settings. Additionally, the study used an appropriate research approach, design, and data collection techniques to gather data from the field. However, the main findings are limited to one hospital and the sample size used is not adequate in ensuring that findings can be generalized to other contexts.
Solution Description
Proposed solution
The reviewed literature demonstrates that the prevention, treatment, and management of VAP can be addressed through the adoption of available evidence-based practices. In this respect, it is proposed that adherence to bundled practices is the best practice that will effectively prevent VAP among ICU patients. The VAP bundle selected for the proposed solution includes the following clinical interventions: prophylaxis for peptic ulcer and deep-vein thrombosis, sedation vaccination, the elevation of the head of the bed (30° to 45°), implementing proper oral health practices by using oral applications of chlorhexidine at the time of intubation and undertaking daily assessments of the patient’s oral cavity, hand washing, and effective subglottic suctioning.
The bundled practices require that the main microorganisms causing VAP infection should be detected early for treatment and management to be effective (Azab et al., 2015). Such a predisposition, according to these authors, allows for the selection of an appropriate treatment procedure that could be used in the management of VAP. Owing to the fact that the initial regimen or antibiotics given to patients should be considered active to inhibit the development of pathogens, it is important to administer the drugs based on factors such as hospitalization duration, presenting comorbidities, and exposure (Centers for Disease Control, 2016). The initiation of VAPB should be generally prompt, and antibiotics that have the capacity to act against a wide range of disease-causing microorganisms should be used based on the capacity of their active agents to penetrate the lungs.
The proposed solution is consistent with the current evidence demonstrating that VAP may be caused by several predisposed pathogens, hence identifying the main causative agent is very important in its treatment (Centers for Disease Control, 2016). Current evidence suggests that singling out the causative agent for VAP allows for selection of the correct kind of regimen and the right dosages to be given to patients depending on the seriousness of the condition and the duration the condition has persisted (Kalanuria, Zai, & Mirski, 2014). This approach also takes into account the current evidence suggesting that VAP may be caused by a multiage microorganism that may not be captured in a single test, hence the importance of initiating treatment with antibiotics with the capacity to act against a variety of disease-causing microorganisms (Kalanuria et al., 2014).
The proposed intervention is considerably realistic to the facility based on available resources and professionals. For example, the healthcare organization has a fully equipped laboratory that could be used to examine the condition and qualified professionals who could implement the VAP bundled practices. However, it may be difficult to interpret and implement the proposed intervention as the facility does not report bundle compliance rates (Centers for Disease Control, 2016). Additionally, the use of VAPB can be very costly. Overall, the facility will benefit from marked cost savings if it is able to use VAPB to significantly reduce the incidence of VAP in intensive care settings. Owing to the fact that the cost in intensive care units accounts for approximately 35% of the total hospital spending (Centers for Disease Control, 2016), it is prudent to argue that the project will assist the facility to save on healthcare costs.
Consistency of the Proposed Solution to the Organizational Culture
The proposed intervention brings together different departments of the facility, including the laboratory, the nursing staff, and the multi-disciplinary care team. This is consistent with the interdisciplinary approach to the healthcare service delivery culture of the facility where healthcare professionals from different disciplines come together and work collaboratively to ensure that the patients admitted to the facility receive holistic, quality healthcare. On the other hand, the facility provides various resources in terms of infrastructure, drugs, and medicines to ensure that patients in the facility receive comprehensive and holistic care. In this sense, therefore, the intervention will utilize available resources in the hospital to ensure effective treatment of patients (Gupta et al., 2016). Lastly, the facility has a culture to continuously train its healthcare professionals on the most contemporary approaches to address various kinds of healthcare issues and infections. This is done through seminars, organized training, and workshops with the view to equipping healthcare professionals with contemporary skills needed in addressing emerging and challenging healthcare issues. This is in addition to the facility’s culture of employing highly qualified healthcare professionals. This means that the proposed intervention will make good use of the available highly qualified and trained healthcare professionals as well as resources.
In planning organizational change, the team leader needs to make sure the problem and project objectives are not only clearly defined but can be realistically measured. Drawing from this elucidation, the team leader will use Roger’s Diffusion of Innovation Theory that not only details how the leader is motivated to proceed with the new idea, but also reinforces the fact that the intervention must have added value over the idea or process that is being substituted (Ratcliff, Smith, & McKoon, 2015).
The Expected Outcomes
It is expected that the proposed intervention will reduce VAP incidence in the ICU and the number of patients who lose their lives while undergoing treatment in the facility as a result of VAP (Kubbara et al., 2015). This expectation is based on the fact that VAP is one of the serious healthcare-acquired infections that result in significant deaths during a hospital stay. In addition, the intervention will improve the quality of care offered in the facility, which in turn will enhance the competitiveness of the facility and also help in promoting the corporate image of the hospital in the eyes of the public. Lastly, it is expected that the provision of the intervention as a bundle will increase nursing compliance with VAP practices.
Method of achieving the outcomes
The following techniques will be used to achieve the intended project outcomes: (1) screening ICU patients according to the PICOT question, (2) ensuring pretest scores on VAP incidence, healthcare costs, quality of care, and compliance rates are taken and assessed, (3) exposing patients to the intervention, (4) assessing the incidence of VAP among patients on intubation/mechanical ventilation, and (5) assessing the impact of the intervention on key project outcomes (reducing VAP incidence and VAP-associated mortality, reducing healthcare costs, improving the quality of care, and increasing nursing compliance with the bundled practices) by comparing pretest scores with posttest scores.
The outcome impact
The reduction in VAP incidence and the number of deaths that occur among patients undergoing treatment for VAP will impact positively the quality of healthcare delivered in the facility. Additionally, improvements in nursing compliance with VAP bundled practices will increase patient satisfaction with services, minimize healthcare costs, and shorten the length of stay (LOS) in the ICU. It should be noted that the intervention will assist the facility to elevate its compliance rates when adhering to VAP bundled practices. According to Klompas et al. (2015), healthcare organizations should strive to achieve a VAPB compliance rate of more than 90% to be effective in reducing the incidence of VAP in intensive care settings.
Change Model
Introduction to the Change Model
The main objective of this section is to apply the Diffusion of Innovation Theory to the evidence-based practice (EBP) intervention of minimizing the prevalence of ventilator-associated pneumonia in intensive care settings. Justifications for using the model are also provided, along with the needed interpretations.
Diffusion of Innovation Theory
Available literature demonstrates that “the Diffusion of Innovation Theory supports the incorporation of capacity, infrastructure, facilitation, context, and evidence, and provides a framework for planned organizational change necessary to implement and sustain EBP” (Schultz, 2007, p. 12). The model is applicable in the present contexts as it ensures an enabling environment for the project facilitator and other stakeholders to diffuse the knowledge of the bundled practices across the social system (ICU) with the view to enabling nurses to implement practices that would substantially minimize the prevalence of VAP in clinical settings (Andrews, Tonkin, Lancastle, & Kirk, 2014). The main stages of the model and their justifications are provided as follows:
The Knowledge Stage
In this initial stage, the individual and the healthcare organization must be exposed to the proposed intervention of using bundled practices to minimize the prevalence of VAP in intensive care settings. Here, “the change agent (facilitator) must be prepared to answer questions regarding the what, why, and how of the proposed change” (Schultz, 2007, p. 12). The justification of this phase is anchored on the fact that it will provide the facilitator with the opportunity to use typical steps in the EBP process (e.g., developing PICOT questions, gathering baseline data, assessing research studies to note the strength of evidence, and preparing synthesis tables) to collect knowledge and evidence that will be shared across the facility with the view to gaining the support of other relevant stakeholders during the subsequent stage.
The Persuasion Stage
In this stage, individuals and other stakeholders in the facility will develop an opinion about the proposed intervention by asking questions that can determine the feasibility and application of the intervention. This stage is useful as it gives the facilitator the opportunity to discuss the benefits of the intervention to the unit, how it will achieve compatibility with the practice environment, and how outcomes will be observed. The stage will also help the facilitator to translate the evidence gained on the bundled practices into a practical guide that will oversee the implementation of the change effort (Dingfelder & Mandell, 2011).
The Decision Stage
In this stage, the EBP intervention will be pilot-tested in the ICU with the view to monitoring how the intervention is working and evaluating if the outcome change is a result of the piloted solution or other external variables. This stage will allow the facilitator and other stakeholders to make an informed decision on whether the practice change should be implemented fully or rejected based on the noted outcome change. Additionally, the stage allows the facilitator to train/educate other staff members on the practice change and also to collect and analyze data on how the bundled practices are able to minimize the prevalence of ventilator-associated pneumonia in the ICU (Keele, 2012).
The implementation Stage
Once the bundled practices have been adopted, the facilitator will use new team members and nurses to diffuse the practice change across the facility with the view to enhancing uptake. Here, the facilitator and other members must consider the facility’s structure, infrastructure, culture, or environment to ensure optimal diffusion of the practice change (Melnyk & Fine-Overholt, 2015). The justification of this phase is nested in the fact that it provides the facilitator with the opportunity to roll out the bundled practices across the unit and also to continuously monitor the intervention and associated outcome of reducing the prevalence of ventilator-associated pneumonia.
The Confirmation Stage
This stage of the model encompasses the incorporation of the practice intervention “as an approved written procedure with sign-off by all the disciplines involved in the change” (Schultz, 2007, p. 14). The stage will provide the facilitator with the opportunity to incorporate the outcomes of the bundled practices into the standard operating procedures of the ICU with the view to facilitating acceptance of the change and ensuring that data are constantly collected and assessed.
Summary of the Change Model
This section has not only discussed the implementation of the bundled practices EBP solution through each of the stages of the Diffusion of Innovation Theory but also provided justifications for use and interpreted the theory in relation to the implementation plan for the EBP intervention.
Implementation Plan
Background to the Implementation Plan
In nursing contexts, successful implementation of evidence-based practice (EBP) improves patients care outcomes by assisting to close the gap between research and clinical nursing practice (Beyea & Slattery, 2011). This section describes the methods to be used in implementing bundled practices to minimize the prevalence of ventilator-associated pneumonia.
Setting and Subjects
The solution will be implemented in the intensive care unit, which caters to critically ill patients and those requiring specialized attention due to the nature of their illness. A meeting will be held to inform nurses working in the unit about the solution and also to request their participation through informed consent. The ICU unit has a capacity of 160 beds and the average number of patients on mechanical ventilation is 45 per day.
Timeline
This project is expected to take six months to complete. The first month will be used to obtain baseline data on the project (pre-test data), develop a data documentation tool (virtue dashboard), train staff members, and design strategies for implementation with the relevant stakeholders. In the second month, the project will be piloted in the unit to identify challenges and make adjustments (Gallagher-Ford, Fineout-Overholt, Melnyk, & Stillwell, 2011). Full rollout to the ICU unit and other areas will begin in the third month and continue for three months, after which post-test data will be collected to evaluate the efficacy of the project.
Solution Process and Resources
Financial resources are needed to cover the costs of staff salary, training materials, transportation and logistics, and refreshments. Human resources required include EBP advocates, nurses, and health consultants to train nurses on the bundled practices. The clinical shifts needed include changing the duty roster and installing bedside alarms to ensure round-the-clock monitoring of patients, initiating a process improvement aimed at ensuring oral hygiene care and adoption of proper handwashing techniques, elevating the head of the patient’s bead, and training ICU nurses on effective use of subglottic suctioning (Sedwick et al., 2012). These clinical process changes can minimize the development of ventilator-associated pneumonia (Munro & Ruggiero, 2014).
Solution Methods and Instruments
Nurses will use the feedback form to provide comments and opinions on how they are implementing the solution and the challenges faced. An alternative method is to use daily report cards to monitor how the implementation is progressing. Although the feedback system may lack credibility due to its subjective nature, it is less costly to use and increases the motivation of nurses participating in the process (Sedwick et al., 2012).
Data Collection and Management
Data will be collected by the team leader using a structured virtue dashboard, after which it will be sorted out for analysis. The leader will have the responsibility for managing the data by using security protocols to avoid unauthorized access. Descriptive statistics will be used to analyze data with the view to demonstrating how the solution has influenced patient outcomes in terms of reducing pneumonia-associated mortality (Sedwick et al., 2012). Pretest (before intervention) and post-test (after the intervention) scores on VAP rate and other indicators (e.g., healthcare costs, quality of care, and nursing compliance with VAPB practices will be compared to evaluate if the intervention has achieved its intended outcomes.
Strategies to Deal with Barriers
Journal clubs and EBP rounds will be used to address any barriers to successful implementation. The journal clubs will assist in reviewing and discussing available scholarly resources on the issue to address any barriers, while EBP rounds will use EBP advocates to search for, critique, and appraise the evidence with the view to solving any barriers that may present (Melnyk 2002; Melnyk & Fine-Overholt, 2015).
Budget
The costs involved in implementing the bundled practices include (1) consultation fees for pneumonia experts ($250), (2) administrative fees for poster development and printing training materials ($600), (3) human resource fees for speaker’s salary and nurses’ salary ($2,500), material costs for installing bedside alarms and other process changes ($10,000), training on the use subglottic sanctioning and prophylaxis administration for peptic ulcer and deep-vein thrombosis ($3000), transportation and logistics ($2,500), and research fees for accessing databases and libraries ($1,200). The total cost is approximately $20,050.
Plans to Maintain, Extend, Revise, and Discontinue Proposed Solution
An evaluation will be undertaken in the sixth month to assess the efficacy of the bundled practices in minimizing the prevalence of ventilator-associated pneumonia in intensive care settings. The results of the evaluation process will provide important insights on how the project is meeting its intended objectives and what needs to be done to increase its efficacy.
Summary of the Implementation Plan
This section has described the methods that will be used in implementing bundled practices to minimize the prevalence of ventilator-associated pneumonia in intensive care settings. It is hoped that the solution will be effective in reducing the high rates of mortality and morbidity associated with this health condition.
Evaluation
Background to the Evaluation Process
The main objectives of this section are to describe the justification for the methods used in collecting outcome data for the EBP implementation, how the outcome measures are able to assess the extent to which intervention objectives are realized, and how project outcomes will be measured and evaluated based on existing evidence. Additionally, this section not only details the strategies that will be used to deal with negative project outcomes but also elucidate implications for nursing practice and future research areas.
Justification for Methods Used
A computerized audit tool (real-time VAP bundle compliance dashboard) will be used to calculate weekly nursing compliance with VAP bundled practices and its effect on outcome measures, such as hospital costs, length of hospital stay, ventilator days, and VAP rates (Sedwick et al., 2012). The justification for using the dashboard is grounded on the fact the tool has the capacity to create user-defined measurement systems and provide healthcare professionals with timely and focused information that can then be summarized and compared using the most important indicators (Aydin, Bolton, Donaldson, Brown, & Murkerji, n.d.; Fine-Overholt & Johnston, 2007).
Outcome Measures
Since the main objective of the EBP prevention is to reduce the prevalence of VAP by implementing bundled practices in intensive care contexts, figures of average hospital costs, length of hospital stay, ventilator days, and VAP rates will be compared pre-test and post-test (before and after the project implementation) to identify any shifts or trends. If post-test scores show a declining trajectory in these outcome measures relative to pre-test scores, it will be possible to assume that the project objectives were achieved.
Evaluating Outcomes Based on Evidence
Important outcome measures will be measured and evaluated against the recent National Healthcare Safety Network (NHSN) VAP risk assessment data and the National Nosocomial Infections Surveillance System (NNISS) to provide “the information needed to identify whether VAP is increasing, decreasing, or remaining the same in the ICU” (Greene & Sposato, 2009, p. 21). These tools provide guidelines and risk scores on VAP rate (not exceeding the 25th percentile), mortality and morbidity attributable to VAP, financial cost considerations, and length-of-stay (LOS) in the ICU (Gallagher, 2012; Greene & Sposato, 2009; Sedwick et al., 2012). Validity and reliability will be guaranteed by utilizing conventional definitions and ensuring that the processes used to collect data are standardized so that statistical evaluation is relevant and comparative over time, while applicability will be addressed by comparing the trends in outcome measures with what is contained in the literature (evidence) to note similarities and/or differences.
Strategies for Addressing Negative Project Outcomes
Close monitoring and evaluation of any changes in outcomes will be undertaken after the EBP intervention is fully implemented with the view to supporting positive outcomes and remedying negative ones to achieve consistency with the initial project objectives (Melnyk, Fine-Overholt, Stillwell, & Williamson, 2010). As demonstrated by these authors, “monitoring the effect of an EBP change on health care quality and outcomes can help clinicians spot flaws in implementation and identify more precisely which patients are most likely to benefit” (p. 53).
Implications for Practice and Future Research Areas
The bundled practices contained in the EBP intervention could be used as a standard for clinical decision-making in intensive care contexts. Additionally, this intervention could be used to not only improve patient care outcomes (reduced LOS, ventilator days, and VAP rates) but also to generate marked cost savings for hospitals, patients, and families. An important area of interest for future research is to evaluate the efficacy of the bundled practices across patient age groups and racial orientations.
Summary of the Evaluation Process
This section has provided the criteria to be used in the evaluation process of the EBP intervention. It is hoped that these standards will be effective in evaluating if the outcome measures are a result of the implemented EBP project demonstrates that nine in ten of nosocomial infections in intensive care settings are associated with VAP and occur shortly after patients undergo intubation (Azab et al., 2015; Klompas et al., 2015). In many critical care settings, the disease is usually linked to adverse health outcomes such as high patient deaths and disabilities, high healthcare outlays, increased duration of intubation time and hospital stay, as well as low patient satisfaction and quality of life. The United States data show approximately 6-10 cases of VAP per 1,000 admissions to hospital, with around 250,000 VAP cases being reported annually (Gupta, Singh & Sexsena, 2016; Kubbara et al., 2015). As such, it is of immense importance for healthcare organizations to come up with ways and strategies to reduce the incidence of VAP in intensive care settings.
Stakeholders
It is critical to involve the stakeholders in the discussion of VAP because they help pass the necessary information to the patient and hospital regarding the therapy. The main stakeholders for this project are the American Lung Association, ICU nurses, medical staff and the Pulmonogist Association. The patients can benefit in the form of improved health related outcomes. The CDC and Mayo Clinic are also included as key stakeholders. All the health centers and health care professionals should be educated and show their interests in the therapy because they are the frontline care takers and deal with patients with VAP from day to day.
The PICOT Clinical Question
The PICOT clinical question for the project is “how effective is the implementation of Ventilator Associated Pneumonia Bundle (VAPB) in reducing incidences of VAP in mechanically ventilated ICU patients?” The PICOT components include: (P) – Mechanically ventilated ICU patients, (I) – Ventilation associated pneumonia bundle/Interventions, (C) – pretest posttest scores to evaluate the effects of VAPB, (O) – decline in the incidence of ventilation associated pneumonia, and (T) – during intubation/mechanical ventilation.
Purpose and Project Objectives
The main purpose of the proposed project is to implement VAPB in the ICU of the facility with the view to reducing the incidence of VAP. The specific objectives of the project are to (1) evaluate the efficacy of the proposed interventions during intubation, (2) reduce adverse health outcomes for mechanically ventilated patients, and (3) assess how nurses are able to comply with the proposed interventions. It is hypothesized that a decline in the incidence of VAP cases should be noted when the various interventions comprising the EBP bundle are implemented together.
Rationale
Recent nursing research reveals that VAP is a serious infection affecting 46% of ventilated patients and, in turn, increases the mortality rate among critically ill patients by 6-30% (Azab et al., 2015). The authors further offer what they refer as the VAP bundle that is meant to reduce the chances of contracting the disease. The VAP bundle incorporates the practices that nurses have to carry out every time they are performing mechanical ventilation, which include elevating the head of the patient’s bed by 30-45˚, checking for daily extubation, conducting a decontamination with chlorhexidine and oral care, ensuring safe enteral nutrition when a patient is admitted to the ICU for the first 24-48 hours, and always using endotracheal tubes that have subglottic secretion drainage (Azab et al., 2015; Gupta et al., 2015). These bundled practices have the capacity to reduce the prevalence and incidence of VAP in intensive care units (Sedwick et al., 2012). Therefore, it is important for every healthcare facility to make the VAP bundle a culture by ensuring that any mechanical ventilation done within the ICU adheres to the VAP bundle.
Literature Support
Background
Research is consistent that nurses must have the capacity to use relevant data sources to integrate research evidence with clinical expertise in what is commonly known as evidence-based practice (Fachiano & Snyder, 2012). This section reviews and summarizes the data sources that have been used to guide the proposed EBP intervention. The databases used are EBSCOHOST, PROQUEST, COCHRANE, CINAHALL and Medline.
Summary of Findings
The article by Grap (2009) undertook a clinical review of other primary research studies to demonstrate several evidence-based practices that could be used to reduce the risks associated with mechanical ventilation. Evidence from the article suggests that ventilator-associated pneumonia can be significantly reduced through the use of higher backrest elevations (30° to 45°), ensuring proper oral health practices to minimize the colonization of the oropharynx by pathogens (e.g., by using oral applications of chlorhexidine at the time of intubation), and following recommended practices in sedating critically ill patients. The main strength of the article lies in its use of primary research sources and data to outline effective EBP interventions that could be used to reduce the risks associated with mechanical ventilation. However, the article’s findings are limited due to the use of a broad scope of study, leading to issues of generalizability of findings in VAP contexts
The article by Gupta et al. (2016) detailed some of the best practices to prevent aspiration of oral colonization, which is a common cause of VAP in intensive care settings. The recommended oral care interventions include (1) conducting an initial admission and daily assessment of the patient’s oral cavity to allow for early identification of oral hygiene problems, (2) using unit-specific protocols to not only minimize the development of mucositis, but also to help the patient in maintaining normal saliva production and oral tissue health, (3) keeping the head of the bed elevated to at least 30° to assist in preventing reflux and aspiration of gastric contents, and (4) routinely suctioning the patient’s oral and subglottic discharges to reduce aspiration of infected secretion into the lungs. In strengths, the article relied on credible data sources and guidelines to discuss the relationship between aspiration of oral colonization and VAP. Additionally, the article focused on ICU, hence reducing the challenges associated with data applicability. However, the recommended oral health care interventions are not supported by relevant literature as would be expected in EBP contexts.
The study by Kubbara et al. (2015) investigated the application and interpretation of CDC guidelines (VAC, IVAC, VAP) by diverse groups of healthcare providers in the assessment of ventilator-associated pneumonia. Evidence from the study suggests that the application of the CDC guidelines vary between different healthcare providers, hence the need to allow for the modification of the guidelines across settings based on clinical or professional judgment. In strengths, the study not only used validated CDC guidelines and appropriate methodological strategies, but also recruited a diverse sample to identify attitudinal shifts in the application of the guidelines. A major limitation, though, lies in the fact that the authors failed to elaborate how the application and interpretation of CDC guidelines influence VAP incidents in the ICU.
The study by Klompas et al. (2015) investigated the effectiveness of two clinical interventions (coordinated awakening and spontaneous breathing) in preventing the incidence of ventilator-associated events in intensive care settings. Evidence from the study suggests that coordinated awakening (e.g., by use of bedside alarms) and assisting patients to breath impulsively without the use of sedation are positively associated with a reduction in duration of mechanical ventilation in the ICU and hospital length-of-stay. In strengths, this study used an appropriate research design to investigate the two interventions and is specific in its scope and applicability in the ICU. However, it is felt that the sample size used is not adequate to generalize the findings to larger contexts.
The study by Sedwick et al. (2012) aimed at investigating how the implementation of bundled practices in a hospital’s intensive care units affected the incidence of ventilator-associated pneumonia within the units. The bundled practices that were implemented in the units included elevation of head-of-bed (30° to 45°), prophylaxis for peptic ulcer disease, prophylaxis for deep-vein thrombosis, routine intermission of sedation, routine evaluation of readiness for extubation, daily oral care with chlorhexidine and daily assessments of the oral cavity, protocols for mouth care and hand washing, head-of-bed alarms, and subglottic suctioning. Evidence from the study demonstrates that strict adherence to the bundled practices not only reduces pneumonia-associated mortality and morbidity of patients receiving mechanical ventilation, but also shortens hospitals stays and ensures that healthcare costs are kept at a minimum. In strengths, the study’s scope is specific to VAP in intensive care contexts and the researchers used CDC guidelines on VAP to guide the research process. However, it is felt that the VAP bundle used in the study contains very many interventions that may be difficult to monitor in clinical contexts. Additionally, the study was carried out in one hospital, meaning that it may be difficult to generalize the findings to other contexts.
Lastly, the study by Azab et al. (2015) used the context of developing countries to evaluate the effectiveness of a predesigned VAP bundled practices in reducing the incidence of ventilator-associated pneumonia in neonatal intensive care settings. The VAP prevention bundle used in the study consisted of head-of-bed elevation (30° to 45°), fortification of hand hygiene practices, sterile suction and handling of respiratory apparatus, intubation, re-intubation and endotracheal tube (ETT) suction as stringently specified in the unit standards, changing ventilator circuit if noticeably dirty or mechanically faulty, implementing routine mouth care with normal saline and suctioning of oro-pharyngeal secretion, performing daily evaluations for readiness for extubation to nasal continuous air pressure (NCPAP) at the morning round, as well as sedation vacation for sedated patients (Azab et al., 2015). Evidence from the study demonstrates that the implementation of an all-inclusive VAP bundle consisting of the described solutions substantially reduces the length of institutional stay as well as the prevalence and incidence of VAP events in acute care settings. This article is specific in scope as it studied VAP in neonatal intensive care settings. Additionally, the study used an appropriate research approach, design, and data collection techniques to gather data from the field. However, the main findings are limited to one hospital and the sample size used is not adequate in ensuring that findings can be generalized to other contexts.
Solution Description
Proposed solution
The reviewed literature demonstrates that the prevention, treatment, and management of VAP can be addressed through the adoption of available evidence-based practices. In this respect, it is proposed that adherence to bundled practices is the best practice that will effectively prevent VAP among ICU patients. The VAP bundle selected for the proposed solution includes the following clinical interventions: prophylaxis for peptic ulcer and deep-vein thrombosis, sedation vaccination, elevation of head of bed (30° to 45°), implementing proper oral health practices by using oral applications of chlorhexidine at the time of intubation and undertaking daily assessments of the patient’s oral cavity, hand washing, and effective subglottic suctioning.
The bundled practices require that the main microorganisms causing VAP infection should be detected early for treatment and management to be effective (Azab et al., 2015). Such a predisposition, according to these authors, allows for the selection of an appropriate treatment procedure that could be used in the management of VAP. Owing to the fact that the initial regimen or antibiotics given to patients should be considerably active to inhibit the development of pathogens, it is important to administer the drugs based on factors such as hospitalization duration, presenting comorbidities, and exposure (Centers for Disease Control, 2016). The initiation of VAPB should be generally prompt, and antibiotics that have the capacity to act against a wide range of disease-causing microorganisms should be used based on the capacity of their active agents to penetrate the lungs.
The proposed solution is consistent with the current evidence demonstrating that VAP may be caused by several predisposed pathogens, hence identifying the main causative agent is very important in its treatment (Centers for Disease Control, 2016). Current evidence suggests that singling out the causative agent for VAP allows for selection of the correct kind of regimen and the right dosages to be given to patients depending on the seriousness of the condition and the duration the condition has persisted (Kalanuria, Zai, & Mirski, 2014). This approach also takes into account the current evidence suggesting that VAP may be caused by a multiage microorganism which may not be captured in a single test, hence the importance of initiating treatment with antibiotics with capacity to act against a variety of disease causing microorganisms (Kalanuria et al., 2014).
The proposed intervention is considerably realistic to the facility based on available resources and professionals. For example, the healthcare organization has a fully equipped laboratory that could be used to examine the condition and qualified professionals who could implement the VAP bundled practices. However, it may be difficult to interpret and implement the proposed intervention as the facility does not report bundle compliance rates (Centers for Disease Control, 2016). Additionally, the use of VAPB can be very costly. Overall, the facility will benefit from marked cost savings if it is able to use VAPB to significantly reduce the incidence of VAP in intensive care settings. Owing to the fact that the cost in intensive care units accounts for approximately 35% of the total hospital spending (Centers for Disease Control, 2016), it is prudent to argue that the project will assist the facility to save on healthcare costs.
Consistency of the Proposed Solution to the Organizational Culture
The proposed intervention brings together different departments of the facility, including the laboratory, the nursing staff, and multi-disciplinary care team. This is consistent with the interdisciplinary approach to healthcare service delivery culture of the facility where healthcare professionals from different disciplines come together and work collaboratively to ensure that the patients admitted in the facility receive holistic, quality healthcare. On the other hand, the facility provides various resources in terms of infrastructure, drugs, and medicines to ensure that patients in the facility receive comprehensive and holistic care. In this sense, therefore, the intervention will utilize available resources in the hospital to ensure effective treatment of patients (Gupta et al., 2016). Lastly, the facility has a culture to continuously train its healthcare professionals on the most contemporary approaches to address various kinds of healthcare issues and infections. This is done through seminars, organized trainings, and workshops with the view to equipping healthcare professionals with contemporary skills needed in addressing emerging and challenging healthcare issue. This is in addition to the facility’s culture of employing highly qualified healthcare professionals. This means that the proposed intervention will make good use of the available highly qualified and trained healthcare professionals as well as resources.
In planning organizational change, the team leader needs to make sure the problem and project objectives are not only clearly defined but can be realistically measured. Drawing from this elucidation, the team leader will use the Roger’s Diffusion of Innovation Theory that not only details how the leader is motivated to proceed with the new idea, but also reinforces the fact that the intervention must have additional value over the idea or process that is being substituted (Ratcliff, Smith, & McKoon, 2015).
The Expected Outcomes
It is expected that the proposed intervention will reduce VAP incidence in the ICU and the number of patients who lose their lives while undergoing treatment in the facility as a result of VAP (Kubbara et al., 2015). This expectation is based on the fact that VAP is one of the serious healthcare acquired infections that results in significant deaths during hospital stay. In addition, the intervention will improve the quality of care offered in the facility, which in turn will enhance the competitiveness of the facility and also help in promoting the corporate image of the hospital in the eyes of the public. Lastly, it is expected that the provision of the intervention as a bundle will increase nursing compliance with VAP practices.
Method of achieving the outcomes
The following techniques will be used to achieve the intended project outcomes: (1) screening ICU patients according to the PICOT question, (2) ensuring pretest scores on VAP incidence, healthcare costs, quality of care, and compliance rates are taken and assessed, (3) exposing patients to the intervention, (4) assessing the incidence of VAP among patients on intubation/mechanical ventilation, and (5) assessing the impact of the intervention on key project outcomes (reducing VAP incidence and VAP-associated mortality, reducing healthcare costs, improving the quality of care, and increasing nursing compliance with the bundled practices) by comparing pretest scores with posttest scores.
The outcome impact
The reduction in VAP incidence and the number of deaths that occur among patients undergoing treatment for VAP will impact positively on the quality of healthcare delivered in the facility. Additionally, improvements in nursing compliance with VAP bundled practices will increase patient satisfaction with services, minimize healthcare costs, and shorten length of stay (LOS) in the ICU. It should be noted that the intervention will assist the facility to elevate its compliance rates when adhering to VAP bundled practices. According to Klompas et al. (2015), healthcare organizations should strive to achieve a VAPB compliance rate of more that 90% to be effective in reducing the incidence of VAP in intensive care settings.
Change Model
Introduction to the Change Model
The main objective of this section is to apply the Diffusion of Innovation Theory to the evidence-based practice (EBP) intervention of minimizing the prevalence of ventilator-associated pneumonia in intensive care settings. Justifications for using the model are also provided, along with the needed interpretations.
Diffusion of Innovation Theory
Available literature demonstrates that “the Diffusion of Innovation Theory supports the incorporation of capacity, infrastructure, facilitation, context and evidence, and provides a framework for planned organizational change necessary to implement and sustain EBP” (Schultz, 2007, p. 12). The model is applicable in the present contexts as it ensures an enabling environment for the project facilitator and other stakeholders to diffuse the knowledge of the bundled practices across the social system (ICU) with the view to enabling nurses to implement practices that would substantially minimize the prevalence of VAP in clinical settings (Andrews, Tonkin, Lancastle, & Kirk, 2014). The main stages of the model and their justifications are provided as follows:
The Knowledge Stage
In this initial stage, the individual and the healthcare organization must be exposed to the proposed intervention of using bundled practices to minimize the prevalence of VAP in intensive care settings. Here, “the change agent (facilitator) must be prepared to answer questions regarding the what, why, and how of the proposed change” (Schultz, 2007, p. 12). The justification of this phase is anchored on the fact that it will provide the facilitator with the opportunity to use typical steps in the EBP process (e.g., developing PICOT questions, gathering baseline data, assessing research studies to note the strength of evidence, and preparing synthesis tables) to collect knowledge and evidence that will be shared across the facility with the view to gaining the support of other relevant stakeholders during the subsequent stage.
The Persuasion Stage
In this stage, individuals and other stakeholders in the facility will develop an opinion about the proposed intervention by asking questions that can determine the feasibility and application of the intervention. This stage is useful as it gives the facilitator the opportunity to discuss the benefits of the intervention to the unit, how it will achieve compatibility with the practice environment, and how outcomes will be observed. The stage will also help the facilitator to translate the evidence gained on the bundled practices into a practical guide that will oversee the implementation of the change effort (Dingfelder & Mandell, 2011).
The Decision Stage
In this stage, the EBP intervention will be pilot-tested in the ICU with the view to monitoring how the intervention is working and evaluating if the outcome change is as a result of the piloted solution or other external variables. This stage will allow the facilitator and other stakeholders to make an informed decision on whether the practice change should be implemented fully or rejected based on the noted outcome change. Additionally, the stage allows the facilitator to train/educate other staff members on the practice change and also to collect and analyze data on how the bundled practices are able to minimize the prevalence of ventilator-associated pneumonia in the ICU (Keele, 2012).
The implementation Stage
Once the bundled practices have been adopted, the facilitator will use new team members and nurses to diffuse the practice change across the facility with the view to enhancing uptake. Here, the facilitator and other members must consider the facility’s structure, infrastructure, culture, or environment to ensure optimal diffusion of the practice change (Melnyk & Fine-Overholt, 2015). The justification of this phase is nested in the fact that it provides the facilitator with the opportunity to roll out the bundled practices across the unit and also to continuously monitor the intervention and associated outcome of reducing the prevalence of ventilator-associated pneumonia.
The Confirmation Stage
This stage of the model encompasses the incorporation of the practice intervention “as an approved written procedure with sign-off by all the disciplines involved in the change” (Schultz, 2007, p. 14). The stage will provide the facilitator with the opportunity to incorporate the outcomes of the bundled practices into the standard operating procedures of the ICU with the view to facilitating acceptance of the change and ensuring that data are constantly collected and assessed.
Summary of the Change Model
This section has not only discussed the implementation of the bundled practices EBP solution through each of the stages of the Diffusion of Innovation Theory, but also provided justifications for use and interpreted the theory in relation to the implementation plan for the EBP intervention.
Implementation Plan
Background to the Implementation Plan
In nursing contexts, successful implementation of evidence-based practice (EBP) improves patients care outcomes by assisting to close the gap between research and clinical nursing practice (Beyea & Slattery, 2011). This section describes the methods to be used in implementing bundled practices to minimize the prevalence of ventilator-associated pneumonia.
Setting and Subjects
The solution will be implemented in the intensive care unit, which caters for critically ill patients and those requiring specialized attention due to the nature of their illness. A meeting will be held to inform nurses working in the unit about the solution and also to request for their participation through informed consent. The ICU unit has a capacity of 160 beds and the average number of patients on mechanical ventilation is 45 per day.
Timeline
This project is expected to take six months to complete. The first month will be used to obtain baseline data on the project (pre-test data), develop a data documentation tool (virtue dashboard), train staff members, and design strategies for implementation with the relevant stakeholders. In the second month, the project will be piloted in the unit to identify challenges and make adjustments (Gallagher-Ford, Fineout-Overholt, Melnyk, & Stillwell, 2011). Full rollout to the ICU unit and other areas will begin in the third month and continue for three months, after which post-test data will be collected to evaluate the efficacy of the project.
Solution Process and Resources
Financial resources are needed to cover the costs of staff salary, training materials, transportation and logistics, and refreshments. Human resources required include EBP advocates, nurses, and health consultants to train nurses on the bundled practices. The clinical shifts needed include changing the duty roster and installing bedside alarms to ensure round-the-clock monitoring of patients, initiating a process improvement aimed at ensuring oral hygiene care and adoption of proper hand washing techniques, elevating the head of the patient’s bead, and training ICU nurses on effective use of subglottic suctioning (Sedwick et al., 2012). These clinical process changes can minimize the development of ventilator-associated pneumonia (Munro & Ruggiero, 2014).
Solution Methods and Instruments
Nurses will use the feedback form to provide comments and opinions on how they are implementing the solution and the challenges faced. An alternative method is to use daily report cards to monitor how the implementation is progressing. Although the feedback system may lack credibility due to its subjective nature, it is less costly to use and increases the motivation of nurses participating in the process (Sedwick et al., 2012).
Data Collection and Management
Data will be collected by the team leader using a structured virtue dashboard, after which it will be sorted out for analysis. The leader will have the responsibility for managing the data by using security protocols to avoid unauthorized access. Descriptive statistics will be used to analyze data with the view to demonstrating how the solution has influenced patient outcomes in terms of reducing pneumonia-associated mortality (Sedwick et al., 2012). Pretest (before intervention) and post-test (after the intervention) scores on VAP rate and other indicators (e.g., healthcare costs, quality of care, and nursing compliance with VAPB practices will be compared to evaluate if the intervention has achieved its intended outcomes.
Strategies to Deal with Barriers
Journal clubs and EBP rounds will be used to address any barriers to successful implementation. The journal clubs will assist in reviewing and discussing available scholarly resources on the issue to address any barriers, while EBP rounds will use EBP advocates to search for, critique, and appraise the evidence with the view to solving any barriers that may present (Melnyk 2002; Melnyk & Fine-Overholt, 2015).
Budget
The costs involved in implementing the bundled practices include (1) consultation fees for pneumonia experts ($250), (2) administrative fees for poster development and printing training materials ($600), (3) human resource fees for speaker’s salary and nurses’ salary ($2,500), material costs for installing bedside alarms and other process changes ($10,000), training on the use subglottic sanctioning and prophylaxis administration for peptic ulcer and deep-vein thrombosis ($3000), transportation and logistics ($2,500), and research fees for accessing databases and libraries ($1,200). The total cost is approximately $20,050.
Plans to Maintain, Extend, Revise, and Discontinue Proposed Solution
An evaluation will be undertaken in the sixth month to assess the efficacy of the bundled practices in minimizing the prevalence of ventilator-associated pneumonia in intensive care settings. The results of the evaluation process will provide important insights on how the project is meeting its intended objectives and what needs to be done to increase its efficacy.
Summary of the Implementation Plan
This section has described the methods that will be used in implementing bundled practices to minimize the prevalence of ventilator-associated pneumonia in intensive care settings. It is hoped that the solution will be effective in reducing the high rates of mortality and morbidity associated with this health condition.
Evaluation
Background to the Evaluation Process
The main objectives of this section are to describe the justification for the methods used in collecting outcome data for the EBP implementation, how the outcome measures are able to assess the extent to which intervention objectives are realized, and how project outcomes will be measured and evaluated based on existing evidence. Additionally, this section not only details the strategies that will be used to deal with negative project outcomes, but also elucidates implications for nursing practice and future research areas.
Justification for Methods Used
A computerized audit tool (real-time VAP bundle compliance dashboard) will be used to calculate weekly nursing compliance with VAP bundled practices and its effect on outcome measures, such as hospital costs, length of hospital stay, ventilator days and VAP rates (Sedwick et al., 2012). The justification for using the dashboard is grounded on the fact the tool has the capacity to create user-defined measurement systems and provide healthcare professionals with timely and focused information that can then be summarized and compared using the most important indicators (Aydin, Bolton, Donaldson, Brown, & Murkerji, n.d.; Fine-Overholt & Johnston, 2007).
Outcome Measures
Since the main objective of the EBP prevention is to reduce the prevalence of VAP by implementing bundled practices in intensive care contexts, figures of average hospital costs, length of hospital stay, ventilator days, and VAP rates will be compared pre-test and post-test (before and after the project implementation) to identify any shifts or trends. If post-test scores show a declining trajectory in these outcome measures relative to pre-test scores, it will be possible to assume that the project objectives were achieved.
Evaluating Outcomes Based on Evidence
Important outcome measures will be measured and evaluated against the recent National Healthcare Safety Network (NHSN) VAP risk assessment data and the National Nosocomial Infections Surveillance System (NNISS) to provide “the information needed to identify whether VAP is increasing, decreasing, or remaining the same in the ICU” (Greene & Sposato, 2009, p. 21). These tools provide guidelines and risk scores on VAP rate (not exceeding the 25th percentile), mortality and morbidity attributable to VAP, financial cost considerations, and length-of stay (LOS) in the ICU (Gallagher, 2012; Greene & Sposato, 2009; Sedwick et al., 2012). Validity and reliability will be guaranteed by utilizing conventional definitions and ensuring that the processes used to collect data are standardized so that statistical evaluation is relevant and comparative over time, while applicability will be addressed by comparing the trends in outcome measures with what is contained in the literature (evidence) to note similarities and/or differences.
Strategies for Addressing Negative Project Outcomes
Close monitoring and evaluation of any changes in outcomes will be undertaken after the EBP intervention is fully implemented with the view to supporting positive outcomes and remedying negative ones to achieve consistency with the initial project objectives (Melnyk, Fine-Overholt, Stillwell, & Williamson, 2010). As demonstrated by these authors, “monitoring the effect of an EBP change on health care quality and outcomes can help clinicians spot flaws in implementation and identify more precisely which patients are most likely to benefit” (p. 53).
Implications for Practice and Future Research Areas
The bundled practices contained in the EBP intervention could be used as a standard for clinical decision making in intensive care contexts. Additionally, this intervention could be used to not only improve patient care outcomes (reduced LOS, ventilator days, and VAP rates), but also to generate marked cost savings for hospitals, patients and families. An important area of interest for future research is to evaluate the efficacy of the bundled practices across patient age groups and racial orientations.
Summary of the Evaluation Process
This section has provided the criteria to be used in the evaluation process of the EBP intervention. It is hoped that these standards will be effective in evaluating if the outcome measures are as a result of the implemented EBP project.
References
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Aydin, C.E., Bolton, L.B., Donaldson, N., Brown, D.S., & Murkerji, A. (n.d.). Beyond nursing quality measurement: The nation’s first regional nursing virtual dashboards. Web.
Azab, S.F.A., Sherbiny, H.S., Saleh, S.H., Elsaeed, W.F., Elshafiery, M.M., Siam, A.G.,…Ghaith, T. (2015). Reducing ventilator-associated pneumonia in neonatal intensive care unit using “VAP preventive bundle”: A cohort study. BMC Infectious Diseases, 15(1), 1-7. Web.
Beyea, S.C., & Slattery, M.J. (2011). Evidence-based practice in nursing: A guide to successful implementation. Peabody, MA: HCPro, Inc.
Centers for Disease Control. (2016). Pneumonia (ventilator-associated [VAP] and non-ventilator-associated pneumonia [PNEU]) event. Web.
Dingfelder, H.E., & Mandell, D.S. (2011). Bridging the research-to-practice gap in autism intervention: An application of diffusion of innovation theory. Journal of Autism & Developmental Disorders, 41, 597-609. Web.
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Fine-Overholt, E., & Johnston, L. (2007). Evaluation: An essential step to the EBP process. Worldviews on Evidence-Based Nursing, 4(1), 54-59. Web.
Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B.M., & Stillwell, S.B. (2011). Evidence-based practice, step by step: Implementing an evidence-based practice change. American Journal of Nursing, 111, 54-60. Web.
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Grap, M.J. (2009). Not-so-trivial pursuit: Mechanical ventilation risk reduction. American Journal of Critical Care, 18, 299-309. Web.
Greene, L.R., & Sposato, K. (2009). Guide to the elimination of ventilator-associated pneumonia. Web.
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Klompas, M., Anderson, D., Trick, W., Babcock, H., Kerlin, M.P., Sincowitz-Cochran, R.,…Pratt, R. (2015). The preventability of ventilator-associated events. The CDC prevention epicenters wake up and breathe collaborative. American Journal of Respiratory and Critical Care Medicine, 191, 292-301. Web.
Kubbara, A., Khan, A.R., Alreefi, F., Abdelkarim, A., Rehman, S., Hariri, A.,…Assaly, R. (2015). Applications of CDC ventilator associated pneumonia surveillance guideline to the real world. In C49: Refining quality and communication in the ICU (pp. A4545-A4545).New York, NY: American Thoracic Society.
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Appendices
Appendix A: Critical Appraisal Checklists
- 25 peer-reviewed resources used to support the project
- 6 Sources used to review and evaluate evidence (see evaluation table in Appendix B)
2 multivariate clinical reviews
1 clinical guideline
3 Quantitative research studies (prospective/longitudinal design)
Appendix B: Evaluation Table
Appendix C: Conceptual Model (Based on the Diffusion of Innovation Theory)
Appendix D: Timeline
Appendix E: Resource List
Appendix F: Proposal Instrument
Appendix G: Data Collection Tools
Feedback Form
Please fill and return this form to help us monitor the implementation of the bundled practices in intensive care settings (ranking ranges from 1 to 5)
Virtue Dashboard (Data Collection)
Virtue Dashboard (Evaluation)
Appendix H: Budget
Appendix 1: Consent Form (Optional)
