Elevating the head of bed (HOB) reduces risks for aspiration and ventilator associated pneumonia (VAP) in the adult population. Educational interventions have resulted in improvements in achieving a target HOB elevation of 30° in adults. Limited research has addressed this intervention in the pediatric intensive care unit (PICU). The aim of this study was to determine if an educational intervention for the PICU staff would result in improvement in the HOB elevation in the PICU. Four research questions were studied: 1) What is the common practice related to the elevation of the HOB in the PICU? 2) Is there a difference in the mean HOB elevation before and after an education intervention? 3) Is there a difference in the percent of time the HOB is at or above 30° after the intervention? and 4) What factors influence HOB elevation in the PICU? A quasi-experimental, pre, and post measurement, with nonequivalent comparison group design was used. The angle of the HOB elevation was measured with the “Pitch and Angle Locator” (PAL) (Johnson, Mequon, WI). Baseline measurements (n = 99) were obtained for patients admitted to a PICU at various days and times over a 2-week period. An educational intervention was done for the staff members in the PICU, with a focus on the importance of keeping the HOB up and strategies for measuring the HOB elevation. Posters to reinforce the information were placed on the unit. Post-intervention, measurements (n = 98) were obtained for another 2-week period. At the time of data collection, staff members caring for the PICU patients were asked to provide responses for what influenced them to place the patient at the documented HOB elevation. Children were older in the post-intervention group than in the pre-intervention (8.8 yrs, vs. 3.7, yrs, respectively, t = -6.67, df = 195, p= .000). The children also weighed more in the post-intervention group than in the pre-intervention (32.0 kg vs. 19.7 kg, respectively, t = -4.19, df= 195, p = .000). The mean HOB elevation was 23.5° before the intervention. After the intervention, the mean HOB increased to 26.5° (t = -1.19, df 195, p = .033). For ventilated patients, the mean HOB elevation went from 23.6° to 29.1° (t = -3.25, df 95, p= .001), and for patients mechanically ventilated and in an adult bed, the mean increased from 26° ± 7.89°, pre- intervention to 30° ± 8.59° postintervention (t = -1.80, df 63, p = .038). The percent of the time the measures were greater than 30° increased from 26% to 44% pre- and post-intervention respectively (χ2 6.71, df 1, p= .005). Responses (n = 230) related to the factors that influenced positioning were categorized as follows: physician order (3%), safety (7%), found this way (11%), therapeutic intervention (16%), comfort (24%), and patient condition (39%). An educational intervention can impact the practice of elevation of the HOB in a PICU, thus decreasing the risks of developing aspiration and VAP. Although the mean HOB increased statistically, the HOB was less than 30° in more than half of the post intervention measurements, indicating the need for ongoing reinforcement of the education. The PAL device was a new, reliable method for recording HOB elevation in both adult beds and cribs. Follow-up research is needed to determine if these gains in HOB elevation have been sustained over time and their impact on VAP.

<p>Ventilator-associerad pneumoni (VAP) är den vanligaste infektionen på intensivvårdsavdelningar. Det är en komplikation som orsakar stort lidande, ökad mortalitet och medför höga vårdkostnader. Det finns många evidensbaserade riktlinjer för att förhindra att VAP uppstår, där sjuksköterskan har en betydande roll. Flera studier har visat att det finns brister i sjuksköterskans kunskap att tillämpa de evidensbaserade riktlinjerna för att förhindra uppkomsten av VAP. Syftet med studien var att beskriva intensivvårdsjuksköterskors tillämpning av de evidensbaserade riktlinjerna för att förhindra uppkomsten av ventilatorassocierad pneumoni hos intensivvårdspatienter samt att jämföra tillämpningen av riktlinjer mellan subgrupper. En strukturerad enkät delades ut till alla intensivvårdsjuksköterskor (N=40) på en intensivvårdsavdelning i mellansverige, varav 30 besvarade enkäten. Resultatet visade att intensivvårdsjuksköterskorna tillämpar de evidensbaserade riktlinjerna i hög utsträckning utifrån självskattningar. Det framkom inga signifikanta skillnader mellan de med kort (0-5 år) och lång (>5 år) erfarenhet som intensivvårdsjuksköterska, vad gäller i vilken utsträckning de använder de evidensbaserade riktlinjerna för att förhindra uppkomsten av VAP. Kunskapen och tillämpningen av de evidensbaserade riktlinjerna kan anses vara god hos respondenterna i föreliggande studie utifrån självskattningar. I det närmaste alla respondenter hade fått utbildning/information om VAP vilket kan vara orsaken till det resultat som framkom. Många tidigare studier har visat att utbildning ökar tillämpningen av de evidensbaserade riktlinjerna.</p> / <p>Ventilator-associated pneumonia is the most common infection in the intensive care unit. It is a complication that causes major morbidity, increased mortality and growing healthcare costs. There are many evidence-based clinical practice guidelines in order to prevent that VAP arises, where the nurse has a significant role. Several studies have established that there is deficiencies in the nurse's knowledge to apply to the evidence-based guidelines in order to prevent the origin of VAP. The aim with the study was to describe intensive care unit nurses' application of the evidence-based guidelines in order to prevent the origin of VAP at intensive care patients and to compare the application of the evidence-based guidelines between subgroups. A structured questionnaire was distributed out to all intensive care nurses (N=40) on an intensive care unit in the middle of Sweden, of which 30 responded to the questionnaire. The result showed that the intensive care nurses apply to the evidence-based guidelines in a high extent on the basis of self-reports. There were no significant differences between they with short (0-5 year) and long (> 5 year) experience as an intensive care nurse, as regards in what extent they use the evidence-based guidelines in order to prevent the origin of VAP. The respondents knowledge and application of the evidence-based guidelines can be considered to be good in this study, on the basis of self-reports. Most of the respondents had got education/information about VAP, what can have caused the result that appeared. Many previous studies have shown that education increases the application of the evidence-based guidelines.</p>

Ventilator-associerad pneumoni (VAP) är den vanligaste infektionen på intensivvårdsavdelningar. Det är en komplikation som orsakar stort lidande, ökad mortalitet och medför höga vårdkostnader. Det finns många evidensbaserade riktlinjer för att förhindra att VAP uppstår, där sjuksköterskan har en betydande roll. Flera studier har visat att det finns brister i sjuksköterskans kunskap att tillämpa de evidensbaserade riktlinjerna för att förhindra uppkomsten av VAP. Syftet med studien var att beskriva intensivvårdsjuksköterskors tillämpning av de evidensbaserade riktlinjerna för att förhindra uppkomsten av ventilatorassocierad pneumoni hos intensivvårdspatienter samt att jämföra tillämpningen av riktlinjer mellan subgrupper. En strukturerad enkät delades ut till alla intensivvårdsjuksköterskor (N=40) på en intensivvårdsavdelning i mellansverige, varav 30 besvarade enkäten. Resultatet visade att intensivvårdsjuksköterskorna tillämpar de evidensbaserade riktlinjerna i hög utsträckning utifrån självskattningar. Det framkom inga signifikanta skillnader mellan de med kort (0-5 år) och lång (&gt;5 år) erfarenhet som intensivvårdsjuksköterska, vad gäller i vilken utsträckning de använder de evidensbaserade riktlinjerna för att förhindra uppkomsten av VAP. Kunskapen och tillämpningen av de evidensbaserade riktlinjerna kan anses vara god hos respondenterna i föreliggande studie utifrån självskattningar. I det närmaste alla respondenter hade fått utbildning/information om VAP vilket kan vara orsaken till det resultat som framkom. Många tidigare studier har visat att utbildning ökar tillämpningen av de evidensbaserade riktlinjerna. / Ventilator-associated pneumonia is the most common infection in the intensive care unit. It is a complication that causes major morbidity, increased mortality and growing healthcare costs. There are many evidence-based clinical practice guidelines in order to prevent that VAP arises, where the nurse has a significant role. Several studies have established that there is deficiencies in the nurse's knowledge to apply to the evidence-based guidelines in order to prevent the origin of VAP. The aim with the study was to describe intensive care unit nurses' application of the evidence-based guidelines in order to prevent the origin of VAP at intensive care patients and to compare the application of the evidence-based guidelines between subgroups. A structured questionnaire was distributed out to all intensive care nurses (N=40) on an intensive care unit in the middle of Sweden, of which 30 responded to the questionnaire. The result showed that the intensive care nurses apply to the evidence-based guidelines in a high extent on the basis of self-reports. There were no significant differences between they with short (0-5 year) and long (&gt; 5 year) experience as an intensive care nurse, as regards in what extent they use the evidence-based guidelines in order to prevent the origin of VAP. The respondents knowledge and application of the evidence-based guidelines can be considered to be good in this study, on the basis of self-reports. Most of the respondents had got education/information about VAP, what can have caused the result that appeared. Many previous studies have shown that education increases the application of the evidence-based guidelines.

Bakgrund Ventilatorbehandling kan orsaka lidande i form av bland annat Ventilator Associerad Pneumoni (VAP) och delirium. Att avsluta behandlingen för tidigt kan också orsaka lidande och därför är tydliga kriterier för att verifiera urträning och extubation, borttagande av ventilatorn och endotrakealtuben är viktiga aspekter i vården och omvårdnaden av patienten. Syfte Syftet med studien var att identifiera kriterier för att verifiera lyckade eller misslyckade urträningar och extubationer hos intensivvårdspatienter och att undersöka vilka bedömningsprotokoll för detta som används. Metod Metoden har varit en (deskriptiv) litteraturöversikt med systematisk ansats. Sökning har gjorts i databasen PubMed. Vid sökningen hittades 627 artiklar och av dessa inkluderas 17 artiklar i studien. Resultat Resultatet visar att det finns flera kriterier för att verifiera lyckade eller misslyckade urträningar och extubationer, men de mest uttalade kriterierna var, hemodynamisk status, inställda/uppmätta ventilatorvärden, blodgasvärden, det mentala/neurologiska tillståndet hos patienten och spontant andningstest (SBT). Slutsats Kriterier och dess protokoll är viktiga redskap för vårdpersonalen för att avgöra när det är dags att börja urträning och förbereda för extubation av den ventilatorbehandlade patienten. / Background Mechanical ventilation can cause suffering in the form of, among other things Ventilator Associated Pneumonia (VAP) and delirium. Stopping treatment too early may also cause suffering and therefore clear criteria to assess extubation withdrawal and weaning of the ventilator are important aspects in the care and nursing of the patient. Purpose The purpose of the study was to identify criteria for verifying successful or unsuccessful weaning and extubations in ICU patients and to investigate assessment protocol. Method The method has been a descriptive literature review with a systematic approach. Conclusion The result shows that there are several criteria to verify successful or unsuccessful weanings and extubations, but the most explicit criteria were - hemodynamic status, set / measured values for the mechanical ventilations, blood gas status, mental / neurological state of the patient and spontaneous breathing test (SBT). Criteria and subsequent protocols are important tools for caregivers to determine when it is time to start weaning and prepare for extubation.

SAMMANFATTNING Titel: Sederingens betydelse för utvecklingen av ventilator associerad pneumoni hos intensivvårdspatienter. Fakultet: Hälsa, natur- och teknikvetenskap Kurs: Examensarbete - omvårdnad, 15 hp Författare: Sanna Willford Handledare: Anna Nordin Examinerande lärare: Inger James Examinator: Jan Nilsson Sidor: 32 Datum för examination: Juni 2022 Nyckelord: Pneumoni, ventilator associerad, Sedering, Intensivvård Introduktion: Ventilator associerad pneumoni (VAP) är en vårdrelaterad infektion som klassas som en vårdskada och som skapar ett vårdlidande för patienten. Vårdskador kan undvikas om rätt åtgärder vidtas av hälso- och sjukvården. Sedering är grundläggande för säkerhet och bekvämlighet hos respiratorbehandlade patienter. Utvecklingen av VAP förekommer oftare hos patienter som får kontinuerlig sedering än hos patienter som har en daglig sederingspaus. Även andra interventioner i sederingen kan ha betydelse för utvecklingen av VAP. Syfte: Syftet med denna studie var att undersöka sederingens betydelse för utvecklingen av VAP hos respiratorbehandlade patienter på IVA. Metod: I denna systematiska litteraturstudie har en narrativ sammanställning av kvantitativa studier genomförts. En induktiv innehållsanalys enligt Bettany-Saltikov och McSherrys niostegs modell samt SBUs riktlinjer för litteraturstudier har använts. Litteraturstudiens resultat har bedömts med GRADE. Resultat: Flera av de inkluderade studierna såg en statistisk signifikant minskning i antalet patienter som utvecklade VAP, trots att de använde sig av olika interventioner i sederingen. Förändringar i sederingsstrategi, sederingsgrad, val av sederande läkemedel och personalens följsamhet i de VAP preventiva interventionerna var av betydelse. Konklusion: Olika interventioner gällande sederingen har betydelse för utvecklingen av VAP. Att minska förekomsten av VAP kan förkorta tiden för respiratorbehandling, förkorta vårdtiden, minska mortaliteten och minska vårdkostnader. / ABSTRACT  Title: The significance of sedation for the development of ventilator-associated pneumonia in intensive care patients. Faculty: Health, Science and Technology  Course: Degree project - nursing, 15 ECTS  Authors: Sanna Willford Supervisor: Anna Nordin Examiner: Inger James Examiner: Jan Nilsson Pages: 32 Date for the examination: June 2022 Key words: Pneumonia, ventilator-associated, Sedation, Intensive care Introduction: Ventilator associated pneumonia (VAP) is a healthcare-associated infection that is classified as a healthcare injury and that creates a patient suffering. Healthcare injuries can be avoided if the right measures are taken by the health service. Sedation is essential for the safety and comfort of respiratory patients. The development of VAP occurs more often in patients who receive continuous sedation than in patients who have a daily sedation break. Other interventions in sedation can also be important for the development of VAP. Aim: The aim of this study was to investigate the significance of sedation for the development of VAP in ventilator-treated patients at IVA. Method: In this systematic literature study, a narrative compilation of quantitative studies has been conducted. An inductive content analysis according to Bettany-Saltikov and McSherry's nine-step model and SBU's guidelines for literature studies have been used. The results of the literature study have been assessed with GRADE. Results: Several of the included studies saw a statistically significant reduction in the number of patients who developed VAP, despite the fact that they used different interventions in sedation. Changes in sedation strategy and degree of sedation affected the presence of VAP. The choice of sedative drugs and the staff's compliance in the VAP preventive interventions were also important. Conclusion: Various interventions regarding sedation are important for the development of VAP. Reducing the incidence of VAP can shorten the time of ventilator treatment, shorten the care time, reduce mortality and reduce care costs.

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Ventilator-associated pneumonia (VAP) has been attributed with lengthening patients' stay in the intensive care unit (ICU), is the leading cause of death among nosocomial infections, and leads to increased hospital cost. Various positional strategies in the prevention of VAP include head of bed (HOB) elevation, continuous lateral rotation therapy (CLRT), and kinetic bed therapy. However, poor compliance rates in critical care units have been reported. Mechanically ventilated patients develop nosocomial pneumonia at a rate 6 to 21 times greater than non-ventilated hospitalized patients. A HOB elevation of 30' to 45' and the turning of patients every two hours are two commonly accepted guidelines used to prevent respiratory compilations by facilitating the clearance of pulmonary secretions. Both HOB elevation and CLRT were explored as interventions that could be implemented to reduce the incidence of VAP. It is difficult to attribute reduced VAP rates to either modality alone. However, when HOB elevation and CLRT are utilized in concert with other modalities, clinically significant benefits become readily apparent. Implementation of both improves clinical outcomes. These modalities should not be considered as individual strategies to reduce VAP, but as part of a comprehensive approach to reduce the incidence of VAP and improve patient outcomes.

Severe infections, trauma or major surgery can each cause a state of systemic inflammation. These causes for systemic inflammation often coexist and complicate each other. Mechanical ventilation is commonly used during major surgical procedures and when respiratory functions are failing in the intensive care setting. Although necessary, the use of mechanical ventilation can cause injury to the lungs and other organs especially under states of systemic inflammation. Moreover, a course of mechanical ventilator therapy can be complicated by ventilator-associated pneumonia, a factor greatly influencing mortality. The efforts to avoid additional ventilator-induced injury to patients are embodied in the expression ‘protective ventilation’. With the use of pig models we have examined the impact of protective ventilation on systemic inflammation, on organ-specific inflammation and on bacterial growth during pneumonia. Additionally, with a 30-hour ventilator-associated pneumonia model we examined the influence of mechanical ventilation and systemic inflammation on bacterial growth. Systemic inflammation was initiated with surgery and enhanced with endotoxin. The bacterium used was Pseudomonas aeruginosa. We found that protective ventilation during systemic inflammation attenuated the systemic inflammatory cytokine responses and reduced secondary organ damage. Moreover, the attenuated inflammatory responses were seen on the organ specific level, most clearly as reduced counts of inflammatory cytokines from the liver. Protective ventilation entailed lower bacterial counts in lung tissue after 6 hours of pneumonia. Mechanical ventilation for 24 h, before a bacterial challenge into the lungs, increased bacterial counts in lung tissue after 6 h. The addition of systemic inflammation by endotoxin during 24 h increased the bacterial counts even more. For comparison, these experiments used control groups with clinically common ventilator settings. Summarily, these results support the use of protective ventilation as a means to reduce systemic inflammation and organ injury, and to optimize bacterial clearance in states of systemic inflammation and pneumonia.

Ventilator-associated pneumonia (VAP) is a healthcare-associated infection (HAI), or more specifically, a healthcare-associated pneumonia (HAP) that can lead to significant morbidity and mortality in hospitalized patients that are being mechanically ventilated. There are established evidence-based guidelines in existence designed to reduce or eliminate VAP from occurring and when properly maintained have been shown to reduce the incidence of VAP. Nurses are at the frontline adhering to the VAP protocol through its integration into their workflow. It is yet unknown what elements of the protocol and workflow contribute to a successful VAP reduction in occurrence and increased patient safety. This program evaluation project, guided by an adapted Systems Engineering Initiative for Patient Safety (SEIPS) model, takes a human-factors approach towards answering these questions. It specifically examines the VAP protocol in a large urban southwestern teaching hospital to evaluate program effectiveness using a human factors approach. Building on the work of Carayon, et al. (2006) and Jansson et al. (2013), I present the findings from this program evaluation project using an adapted SEIPS model that sought to evaluate the VAP prevention program from a human factors perspective addressing the following aims: Aim 1. Determine the effectiveness of using the adapted SEIPS model to evaluate a VAP quality improvement (QI) project; Aim 2. Evaluate a VAP QI program taking a human factors approach; and Aim 3. Using the adapted SEIPS model, identify elements of the VAP bundle that nurses perceive as strength and weaknesses. The project was completed with the following findings: Based on this work the adapted SEIPS model demonstrates usefulness for evaluating QI projects. It would be interesting to continue this work with QI projects to see how well it performs.