Evidence-Based Practice in Nursing Health Care Essay

Evidence-Based Practice in Nursing Health Care Essay

In the critically ill patients (p), how does hand washing before and after attending to a patient (I), compared to no hand washing (C) reduces the incidence of hospital acquired infections (O) over a period of six months (T). Evidence-Based Practice in Nursing Health Care Essay

Introduction

Evidence based-evidence is a problem-solving approach to clinical practice continuously to incorporate the best evidence from well researched studies, patient’s values and preferences, and clinician expertise in making decision about patient’s care (Kim, et al, 2020). Evidence based practice works hand in hand with clinical enquiries to raise question and solutions of a certain practice element used in nursing practice. Clinical inquiries is the process in which a nurse or a healthcare professional raises a questions about a certain practice whose efficacy is not yet proved by any study. Clinical enquiries are facilitated by the PICOT model which stands for problem or population, interventions, comparison, outcome, and time frame (Kim, et al, 2020). For example, the nurse inquired about the effect of hand hygiene when handling patients. The Evidence-Based Practice in Nursing Health Care Essay

PICOT model in this case; the problem is critically ill patients, interventions is hand washing or hand hygiene, comparison is between the patients who are attended after hand washing with those who do not. Outcome is the decrease in new cases of hospital acquired infection, and timeframe is within a specific period in which the research will be conducted. The clinical enquiries are proven through continuous research studies and observation during clinical work. When doing the clinical inquiries, the care provider’s focus is on the quality indicators that can have the best interventions to prevent their occurrence as a quality improvement issue (Kim, et al, 2020). Hospital acquired infections are the leading causes of prolonged hospitalization, hospital readmissions, and mortalities. These infections are caused by the care providers to the patients when handling patients. These infections can also be transmitted from one patient to the other through poor hand hygiene of the care provider. A research study will provide a positive feedback regarding hand hygiene in the prevention of the infection thus improving the quality of care and achieving patient satisfaction. Evidence-Based Practice in Nursing Health Care Essay

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Rationale For Undertaking This Project

The reason for taking this project is due to the increase in the number of hospital acquired infection due to poor hand hygiene when handling critical patients. In the United States of America, over 11,000 hospitalized patients in over 183 hospitals suffered from one of the HAI (Monegro, et al, 2020). Hospital acquired infections HAI are nosocomially acquired illnesses whose incubating period is within the hospital stay. HAI includes urinary tract infections due to catheterization, ventilator associated pneumonia, hospital acquired pneumonia, surgical site infection, and clostridium difficile infections. Causes of HAI are septic procedures and poor hand hygiene. Septic procedures are such as septic surgical procedure, septic wound cleaning technique, and septic catheterization technique. Poor hand hygiene of care providers from one patient to the other causes more incidences of HAI (Monegro, et al, 2020). HAI leads to prolonged pain and suffering, prolonged hospital stay, increases the risks of patient’s readmission within 21 days after discharge, and increases the cost of hospital bills and resources. The onset of hospital acquired infections is usually within 48 hours of hospital admission and it may present with fever, tenderness at the surgical site, abdominal pain, polyuria, dysuria, altered mental status and rebound tenderness (Monegro, et al, 2020). Hand hygiene is the art of washing hands with running water and soap before and after attending to a patient, before handling personal items, and before feeding (Robles, A. 2020). In a hospital set up, hand washing reduces the transmission of the infections. Maintaining hand hygiene decreases the excessive growth of the microorganisms hence reducing infection risks, overall healthcare cost, readmissions, and length of hospital stay. According to Robles, A. (2020) hand washing is the most important element of infection control activities due to the growing burden of hospital acquired infections.

A Targeted Literature Review on the Clinical Practice Problem of hand washing and hospital acquired infections

Among the hospital acquired infections, it is estimated that infections related to hand hygiene such as wound cleaning and catheterization have a higher mortality compared to other HAIs. According to Monegro, et al, (2020) the most common cause of surgical site infections in post cesarian section mothers is inadequate water supplies in the operating theatre therefore, making the surgical procedure septic. Same applies to catheterization because the care provider does not have sterilized equipment. Critically ill patients have a low immunity compared to other groups of patients. Therefore, they are at a higher risk of contracting infections such as methicillin resistant and vancomycin resistant enterococcus which are colonized in the arms of healthcare providers (Monegro, et al, 2020). Care providers acquire these strains of bacteria through direct contact of other patient’s gown, bedside furniture, and linen. These microorganisms are easily transferred from the arms of the care provider to the patient’s wound during cleaning and dressing. This causes slow wound healing, wound dehiscence, and finally sepsis. During catheterization, the resistant bacteria reside in the bladder causing chronic and frequent urinary tract infections.

HAIs is more prevalent in facilities whose hand hygiene practices remain irrelevant, unacceptably low, and rarely exceeding 40% of the situations in which hand hygiene is recommended (Monegro, et al, 2020). In these healthcare organizations, their culture, behaviors, beliefs, and attitude towards hand hygiene is usually diminished because of working in an environment that does not have a good water supply or lack of knowledge on protocols and guidelines. The general environment is unhygienic causing a HAIs thus prolonged hospitalization, increased cost of services, wastage of resources, and poor patient prognosis. Poor hand washing techniques among the patient in the ward may also cause cross infections that eventually result to HAI’s. Evidence-Based Practice in Nursing Health Care Essay

Current Practice Policies/ Procedures and Outcomes / Implications the Project Will Have or Impact at the Workplace

The study intends to improve compliance and bring change in the practice. Initiating practice policies in an organization is hectic to both the staff administration, and the patients due to the fear of the unknown. Therefore, the organization management should train the staff about the importance of hand washing to improve the prognosis of the patient (Robles, A. 2020). Successful implementation to transition of change by the organizational manager will have a positive impact due to the strict compliance of the policies set aside. For instance, installation of taps with running water and soap in all departments will lead hand washing compliance. Incorporation of the hand washing policy will result to all patients washing before leaving and entering the wards. Care providers are with hand sanitizers that kill the pathogens on the arms. The sanitizer is used before and after handling a patient. The organization should organize for training programs for the staff and patients that will enable change the perception of hand hygiene (Robles, A. 2020). The hospital should also have an infection control team that will disseminate the evidence based information in a comprehensible manner. Increasing the staff to fit the normal patient-nurse ratio will ensure compliance of hand hygiene because the nurse is assigned few patients to take care of during the shift. The outcome of the implication will be few cases of HAI’s mortalities, reduces pain and suffering, prolonged hospital stag, and facilitates quick recovery.

The PICOT Question

The picot question is a clinical enquiry that is related to finding of if the hand hygiene is effective and efficient in preventing the spread of hospital acquired infections. Below, is a table that summarizes the elements of the PICOT statement. The PICOT model is then explained at the appendix section.

Table 1:

The PICOT components

The PICOT question in full is, “In critically ill patients general ward or ICU for at least 48 hours (P), does the implementation of proper hand washing technique or hygiene (I) compared to usual care with no proper hand washing technique or hygiene (C) prevent the occurrence of hospital acquired infections (O) within six weeks (T)?”

Evidence In Support Or Otherwise Of Proper Hand Washing Technique Or Hygiene In A General Ward Or ICU

Evidence is obtained in the current peer reviewed articles or scholarly works to and other reputable database to yield good results. Evidence is searched after the PICOT questions formulation in the clinical enquiry process. During the research, key words such as hand hygiene, hand washing, and hospital acquired infections are entered in the research engine. The scholarly evident research engines are CINAL plus with full text, ProQuest, Embase, PubMed, Cochrane Data base of systemic reviews. The phrases are combined with the Boolen operator, AND, then entered into the database (Kim, et al, 2020). The study involved both the inclusion and exclusion criteria. The inclusion criteria has involves the articles published within 5 years, studies that had interventions of hospital acquired infections as an independent variable, the must either should have either of the randomized controlled trials, systemic reviews and meta-analysis, and or retrospective cohort study. The evidence should be of high quality and values. The exclusion criteria include data that was published over 5years, quantitative study methodology, and data with no hospital acquired infections as an independent variable.

Studies Included in the Final Appraisal of the Evidence

The study produced more than 14,000 scholarly articles that were systemically taken through exclusion process to arrive at the final number of 25 studies in the final appraisal of evidence. Other studies were duplicated and hence they were not fit for the study. Some documents did not meet the criteria and others did not pass the eligibility tests. Below is a list of four out of the 25 studies that passed the eligibility test.

Haverstick, et al, (2017) is a statistical analysis study assessing whether hand hygiene among patients would prevent hospital acquired infections. This study provides level 11 for the hand washing interventions. The outcome of the study proved that patient hand hygiene reduced the spread of infections.

de Barra, et al, (2021), is a cohort interventional study that is giving an insight about hand hygiene in prevention of hospital acquired infections. The study method was direct observation and questionnaires. The outcome of the study shows that hand washing is key in reducing the incidence of hospital acquired infections. It recommends convenient availability of sinks, SOAP, hand gel, hand towels, and hand sanitizers. This study provides high level of evidence rated at level 11.

Kiersnowska, et al, (2019) is a randomized controlled trial that limits the sources of nosocomial clostridium difficile infection to hand hygiene. The author states that during the study, they found out that microbes resides in the hands of the care providers hence the higher prevalence of HIA’s in facilities that  do not comply to hand washing. The author concludes that proper hand washing is the solution to the phenomenon. He recommends proper training of the healthcare facilities on proper techniques of hand washing to reduce mortalities associated with HAIs.

Kuti, B. P., et al, (2021) is a meta-analysis data that determined effectiveness of hand hygiene in preventing hospital acquired infections among infants. The selection criteria involved mothers, care givers, and pregnant women. The research methods used were retrospective controlled trials, quasi-experimental trials, and cross over trials. The purpose of the study was due to the increased deaths in children due to HAIs that was associated with lack of proper hand hygiene. The author concludes that hand washing was proved to be effective in preventing hospital acquired infections.

References

de Barra, M., Gon, G., Woodd, S., Graham, W. J., de Bruin, M., Kahabuka, C., … & Penn-Kekana, L. (2021). Understanding infection prevention behaviour in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar. Social Science & Medicine, 272, 113543.

https://doi.org/10.1016/j.socscimed.2020.113543

Haverstick, S., Goodrich, C., Freeman, R., James, S., Kullar, R., & Ahrens, M. (2017). Patients’ hand washing and reducing hospital-acquired infection. Critical care nurse, 37(3), e1-e8.

https://doi.org/10.4037/ccn2017694

Kiersnowska, Z. M., Lemiech-Mirowska, E., Michałkiewicz, M., & Marczak, M. Hand hygiene as the basic method of reducing Clostridium difficile infections (CDI) in a hospital environment. Annals of Agricultural and Environmental Medicine.

https://doi.org/10.26444/aaem/131121

Kim, M., Mallory, C., & Valerio, T. (2020). Statistics for evidence-based practice in nursing. Jones & Bartlett Publishers.

Kuti, B. P., Ogunlesi, T. A., Oduwole, O., Oringanje, C., Udoh, E. E., & Meremikwu, M. M. (2021). Hand hygiene for the prevention of infections in neonates. Cochrane Database of Systematic Reviews, (1).

https://doi.org/10.1002/14651858.CD013326.pub2

Monegro, A. F., Muppidi, V., & Regunath, H. (2020). Hospital acquired infections. StatPearls [Internet].

Robles, A. (2020). Handwashing in healthcare settings in low-and middle-income countries: Literature review on handwashing in maternal care.

http://urn.fi/URN:NBN:fi:amk-2020120726571

Template for Asking PICOT Questions

PICOT Worksheet and Search Strategy

Name___________________

1. Define your question using PICO by identifying: Problem, Intervention, Comparison

Group and Outcomes.Your question should be used to help establish your search strategy.

Patient/Problem:

Intervention:

Comparison:

Outcome:

Time frame:

2. Write out your question:
3. Type of question/problem: Circle one: Therapy Prevention Diagnosis Etiology Prognosis
4. Type of studies (research design) to include in the search:

Check all that apply:

Meta-Analysis Systematic Review Randomized Controlled Trial

Cohort Study Case Control Study Case series or Case Report

Editorials, Letters, Opinions Animal Research In Vitro/Lab Research

5. List main topics and alternate terms from your PICO question that can be used for your search
6. List your inclusion criteria –gender, age, year of publication, language
7. List irrelevant terms that you may want to exclude in your search
8. List where you plan to search, i.e. EBM Reviews, Medline, AIDSLINE, CINAHL, PubMed

Clinical Inquiry on Ventilator-Associated Pneumonia or VAP

Clinical inquiry is the process in which a professional nurse raises questions about a practice element that is commonly used in nursing practice but whose efficacy is not ascertained. These are typically practices or interventions that are part and parcel of common practice in nursing. Clinical inquiry is however nowadays the norm because of the adoption by professional nursing practice of the concept of evidence-based practice or EBP. This is the practice whereby only those interventions that have evidence of efficacy from scholarly peer-reviewed scientific literature are used to manage patients. Because of this, EBP is usually also referred to as best practice. Clinical inquiry is facilitated by use of the PICOT model. His is an acronym that stands for Population, Intervention, Comparison, Outcome, and Timeframe. What happens is that the nurse making the clinical inquiry puts the identified clinical practice problem n question form to guide the evidence search from reputable research databases. This PICOT question will therefore incorporate the patient population concerned, the intervention in question, a comparison intervention, the expected outcome, and the timeframe of application of the intervention (Melnyk & Fineout-Overholt, 2019). All quality indicators in clinical practice provide an opportunity for clinical inquiry as to the best intervention that can prevent their occurrence as a quality improvement issue. Some of these quality indicators are pressure ulcer rates, patient fall rates, readmission rates, catheter-associated urinary tract infections or CAUTI rates, central line-associated blood stream infections or CLABSI rates, and ventilator-associated pneumonia (VAP) rates. Amongst these, VAP is an outcome measure that presents a big quality challenge in critical care units all over the United States. It is the leading hospital-acquired infection in patients in intensive care units. The purpose of this paper is to find out the most efficacious intervention that can prevent VAP by adopting the clinical inquiry strategy. This means the formation of a PICOT statement or question and searching for evidence from scholarly literature about the efficacy of the intended intervention in preventing VAP.

Rationale for Undertaking the Project

The rationale for undertaking this project is very solid. To start with and as stated above, VAP is the leading hospital-acquired infection among mechanically ventilated intensive care patients. This means that it is a very serious quality improvement problem that needs to be addressed as a matter of urgency. There is thus need to determine which practice elements are required to be perfected in order to reduce the rates of VAP in intensive care units. In other words, evidence-based interventions must be found and adopted as policy by organizations in the spirit of evidence-based practice. According to Ghezeljeh et al. (2017), up to 28% of ICU patients on mechanical ventilation are affected by the problem of VAP in the United States. As a matter of fact, VAP is the second most commonly occurring hospital-acquired infection generally in the US. By definition, VAP is pneumonia that occurs in a mechanically ventilated patient in an intensive care setting after a period of 48 hours of being on the mechanical ventilator (Wu et al., 2019; Ghezeljeh et al., 2017; Villar et al., 2016). With no clear efficacious intervention against the development of VAP, ICU mortality increases and quality reduces as a consequence. This has an impact on patient satisfaction, reimbursement rates (revenue), accreditation by regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO, and staff morale and job satisfaction. It is for these reasons that a rationale emerges for tackling the clinical practice problem of VAP.

A Targeted Literature Review on the Clinical Practice Problem of VAP

It is estimated that among the hospital-acquired infections, VAP has a mortality rate of about 10%. Salmon et al. (2019) state that the second highest prevalence of VAP comes from Asia-Pacific countries such as South Korea at 16%, while Latin America is third with 13.8%. What their study shows is that the epidemiological picture of VAP varies from country to country and reflects the quality of intensive care in those countries. They also determined that the causative organisms for this kind of hospital device-acquired pneumonia vary from region to region. For instance, the authors of the study by Salmon et al. (2019) determined that in the US, the most common causative organisms of VAP are predominantly Staphylococcus aureus and Pseudomonas aeruginosa.

The incidence of VAP has been reported in studies to be dependent on the particular healthcare setting being referred to as well as the patient’s diagnosis. Papazian et al. (2020) report it to be ranging from 5% to a whopping 40%. This is a very high incidence; meaning that the clinical problem of VAP is a very important quality mater that must be addressed definitively.  They agree with Salmon et al. (2019) that the mortality due to VAP in ICUs is 10%. An important observation that Papazian et al. (2020) make is that because of VAP, the patent will have a longer hospital stay (which translates to higher hospitalization costs) and a longer stay on the ventilator. This is increased mortality which is undesirable. It should of course be observed that with an increased duration of hospitalization, the patent is also put at a higher risk of pressure ulcers.

Wu et al. (2019) also hold that VAP has a very high mortality rate; and observe (in agreement with Salmon et al., 2019 and Papazian et al., 2020) that VAP makes it difficult to wean the patient off the mechanical ventilator. The result as already observed by the other authors above is that the patient stays longer in hospital and incurs extra hospitalization and medication costs. Wu et al. (2019) observe that some of the challenges with VAP in the current practice environment include resistance o antibiotics, the lack of universal diagnostic guidelines (clinical practice guidelines), and the unavailability of universally acceptable preventive strategies. Of note is that Wu et al. (2019) mention chlorhexidine as one of the agents that have the potential to prevent VAP incidence in intensive care units.

Current Practice Policies/ Procedures and Outcomes / Implications the Project Will Have or Impact at the Workplace

This PICOT project is intended to bring change in practice. Change by its very nature is expected to disturb the status quo. For this reason, in many organizations change is resisted by many as a matter of course. The reason for this is usually complacency and fear of the unknown. The procedures and policies of the organization in which I work will be profoundly impacted. This is because with successful implementation and translation into practice of the EBP recommendations; the organizational culture will have to change to reflect the change. Policies are what drive the strategic objectives of an organization. Therefore, the change in policies and procedures sanctioned by the top management or directors of the organization will mean that the strategic objectives of the institution are redirected towards the redefined goal. For instance, the policy on nurse-patent ratio in the organization’s ICUs may have to be reviewed, just as is the policy on routinely performing oral care for every patient on mechanical ventilation in the ICU. In this case, the important policy change will be the incorporation into the standard operating procedures of the use of chlorhexidine mouthwash for every critical patient on mechanical ventilation. There may also be training required to help the staff correctly implement the practice change related to VAP management. This means that the organization must set aside a budget for this.

The outcomes and implications of the project will be that the quality of the care given in the ICU will be increased. This will be shown by favorable outcome measures such as reduced length of stay on the mechanical ventilator, reduced length of stay in the hospital, lower hospitalization costs, and better patient satisfaction scores. Patient turnover is going to be higher and the facility will do better in terms of getting higher reimbursements. Higher reimbursements will be possible because of the pay-for-performance doctrine of the Patient Protection and Affordable Care Act or ACA 2010 (Holmström, 2017). This provision is premised on delivering quality-based care as opposed to volume-based care as a provider. These are just some of the implications that the project will have at the workplace.

The PICOT Question

The clinical inquiry as has been stated in the introduction above is related to the need to find out whether daily oral care with chlorhexidine mouthwash solution is effective and efficacious in preventing the development of VAP in mechanically ventilated critical patents in the ICU. The table below summarizes the different elements of the PICOT statement and the full ICOT question is restated at the bottom of the table. In the Appendix section, the PICOT model for this paper is explained and illustrated further.

Table 1: The PICOT components for clinical inquiry into the prevention of VAP in the ICU

The PICOT question in full therefore is: “In critically ill adult patients on mechanical ventilation in the ICU for at least 48 hours (P), does the implementation of 4-hourly oral hygiene with chlorhexidine gluconate swabs & toothbrush (I) compared to usual care with no chlorhexidine gluconate swabs &toothbrush (C) prevent the occurrence of ventilator-associated pneumonia or VAP (O) within six weeks (T)?”.

The Search for Evidence in Support or Otherwise of Chlorhexidine in the Prevention of VAP in the ICU Setting

After formulation of the PICOT question in the clinical inquiry process, the next step was to embark on the search for evidence in current published peer-reviewed scholarly works from reputable research databases. This search was facilitated by the identification of key search words and phrases that were then entered into the search engines of the databases to yield pertinent results. In this case, the research databases that were searched for scholarly evidence were CINAHL Plus with Full Text, ProQuest, Embase, PubMed, and Cochrane Database of Systematic Reviews. The search terms used were “ventilator-associated pneumonia,” “VAP,” “prevention,” “chlorhexidine,” and “oral care.” These words and phrases were then combined with the Boolean operator “AND” and entered into the database search engines. Evidence-Based Practice in Nursing Health Care Essay

The inclusion criteria for studies to be included into the evidence pool were:

1. They must have been published within the last six years
2. Should be randomized controlled trials with high evidentiary value

• The studies can be a systematic review or meta-analysis of randomized controlled trials

1. The studies can be systematic reviews or meta-analyses with the highest level of evidence at level I
2. They can also be a retrospective cohort study or prospective study
3. The studies must have had the intervention with chlorhexidine as the independent variable

• The studies must be quantitative in methodology

On the other hand, the exclusion criteria included that:

1. Studies must not be older than six years after publication
2. Studies must not be qualitative in methodology

• The studies must not have any other independent variable apart from chlorhexidine solution in the prevention of VAP

Studies Included in the Final Appraisal of the Evidence

The search produced a total initial number of 13,502 publications. These were then systematically taken through a thorough exclusion process to arrive at a final number of just 25 studies to include in the final appraisal of the evidence. First and foremost, a total of 6,021 studies were duplicates and were therefore removed from the search results. The remaining 7,481 titles and abstracts were then screened. This process of screening resulted in another 6,183 publications being excluded for failing to meet the strict inclusion criteria. The other remaining 1,298 full-text articles were then assessed for eligibility and 1,280 found to be ineligible. This left just 18 studies that met the ultimate eligibility test to be included n the final appraisal of evidence. The references (bibliography) of these 18 eligible studies were then examined and a further 7 records meeting the eligibility test were identified this way. In the end, the grand total number of eligible publications identified was 25 studies. Four of these studies are briefly outlined below. A flow diagram of the evidence selection process is also provided below.

As stated earlier in this paper, four studies chosen out of the 25 studies with incontrovertible evidence for evidence-based practice (EBP) will be outlined below. They are:

• Enwere et al. (2016): This was a retrospective cohort study assessing whether chlorhexidine mouthwash can prevent VAP. The results proved encouraging because they found that indeed chlorhexidine is effective in VAP prophylaxis. This study provides level II evidence for the intervention of chlorhexidine.
  

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Figure 1: Flow diagram of the result selection process for article inclusion into the final appraisal of the evidence

• Li et al. (2015): This was a meta-analysis of 17 randomized controlled trials. For this reason, it provides the highest possible level of evidence for the efficacy of chlorhexidine as a preventive intervention against VAP. The researchers in this study compared chlorhexidine with povidone-iodine and the latter did not produce the results that the former produced.
• Rabello et al. (2015): This study was an overview of systematic reviews and therefore also provided the highest level of evidence for chlorhexidine as the EBP intervention to prevent VAP.
• Villar et al. (2016). This is a systematic review and meta-analysis that places the level of evidence at its highest (level I).    Evidence-Based Practice in Nursing Health Care Essay

References

Enwere, E.N., Elofson, K.A., Forbes, R.C., & Gerlach, A.T. (2016). Impact of chlorhexidine mouthwash prophylaxis on probable ventilator-associated pneumonia in a surgical intensive care unit. International Journal of Critical Illness & Injury Science, 6(1), 3-8. https://doi.org/10.4103/2229-5151.177368

Ghezeljeh, T.N., Kalhor, L., Moghadam, O.M., Lahiji, M.N., & Haghani, H. (2017). The comparison of the effect of the head of bed elevation to 30 and 45 degrees on the incidence of ventilator associated pneumonia and the risk for pressure ulcers: A controlled randomized clinical trial. Iranian Red Crescent Medical Journal, 19(7), 1-10. http://dx.doi.org/10.5812/ircmj.14224

Holmström, B. (2017). Pay for performance and beyond. American Economic Review, 107(7), 1753–1777. https://doi.org/10.1257/aer.107.7.1753

Li, L., Ai, Z., Li, L., Zheng, X., & Jie, L. (2015). Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical ventilation? An updated meta-analysis from 17 randomized controlled trials. International Journal of Clinical and Experimental Medicine, 8(2), 1645–1657. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4402740/

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4^th ed. Wolters Kluwer.

Papazian, L., Klompas, M., & Luyt, C-E. (2020). Ventilator-associated pneumonia in adults: A narrative review. Intensive Care Medicine, 1-19. https://doi.org/10.1007/s00134-020-05980-0  

Rabello, F., Araújo, V., & Magalhães, S. (2018). Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilator-associated pneumonia in intensive care units: Overview of systematic reviews. International Journal of Dental Hygiene. https://doi.org/10.1111/idh.12336

Salmon, A.A., & Metersky, M.L. (2019). The current epidemiological landscape of ventilator-associated pneumonia in the intensive care unit: A multicenter prospective observational study in China—study critique, ventilator-associated pneumonia incidence rates, and pathogen distribution. Journal of Emergency and Critical Care Medicine, 3(23), 1-3. http://dx.doi.org/10.21037/jeccm.2019.05.01

Villar, C.C., Pannuti, C.M., Nery, D.M., Morillo, C.M., Carmona, M.J.C., & Romito, G.A. (2016). Effectiveness of intraoral chlorhexidine protocols in the prevention of ventilator-associated pneumonia: A meta-analysis and systematic review. Respiratory Care, 61(9), 1245-1259. https://doi.org/10.4187/respcare.04610

Wu, D., Wu, C., Zhang, S., & Zhong, Y. (2019). Risk factors of ventilator-associated pneumonia in critically ill patients. Frontiers in Pharmacology, 10(482), 1-7. https://doi.org/10.3389/fphar.2019.00482

Appendix

PICOT Worksheet and Search Strategy

Name Kim Arreola

1. Define your question using PICO by identifying: Problem, Intervention, Comparison

Group, and Outcomes.

Patient/Problem: The development of ventilator-associated pneumonia or VAP in mechanically ventilated adult critically ill patients after 48 hours of intubation.

Intervention: 4-hourly oral care with chlorhexidine mouthwash and a toothbrush.

Comparison: Usual care without chlorhexidine and toothbrush.

Outcome: A reduction in the rate of VAP in ICU patients on mechanical ventilation.

Time frame: Six weeks.

2. Write out your question: In critically ill adult patients on mechanical ventilation in the ICU for at least 48 hours (P), does the implementation of 4-hourly oral hygiene with chlorhexidine gluconate swabs & toothbrush (I) compared to usual care with no chlorhexidine gluconate swabs &toothbrush (C) prevent the occurrence of ventilator-associated pneumonia or VAP (O) within six weeks (T)?
3. Type of question/problem: Circle one: Therapy Prevention Diagnosis Etiology Prognosis
4. Type of studies (research design) to include in the search:

Check all that apply:

X Meta-Analysis X Systematic Review X Randomized Controlled Trial

X Cohort Study Case Control Study Case series or Case Report

Editorials, Letters, Opinions Animal Research In Vitro/Lab Research

5. Alternate terms from the PICO question that can be used for the search

• Nosocomial pneumonia
• Device-associated pneumonia

6. Inclusion criteria:

• Published within the last six years
• Randomized controlled trials
• Systematic reviews and/ or meta-analyses of randomized controlled trials
• Retrospective cohort study or prospective study
• Intervention with chlorhexidine as the independent variable
• Quantitative in methodology

7. Terms to be excluded in your search: nonspecific pneumonia
8. Where the search will occur: CINAHL Plus with Full Text, ProQuest, Embase, PubMed, and Cochrane Database of Systematic Reviews.

Template for Asking PICOT Questions

Evidence-Based Practice in Nursing Health Care Essay

University of St. FrancisMaster of Science in Nursing ProgramN613: Evidence-Based Practice in HealthcareGrading and Development Guidelines for Evidence Based Practice Project The purpose of the Evidence Based Practice (EBP) Project is to use the principles and context of EBP to evaluate a nursing practice, policy, or procedure in light of current evidence and make recommendations for change/improvement. Prepare the final project report using the following sections and guidelines. Use APA 7th edition format for all margins, citations, references, and headings as you prepare the paper. Title Page (3 points)Introduction (5 points)Background (10 points)Paint a broad picture and rationale for undertaking this projectInclude any data and a targeted literature review of published papers written in the last FIVE years to support the need for the projectDescribe the practice/policy/procedure and outcomes/implications Question (5 points)Pose an answerable question in PICOT format (Melnyk & Fineout-Overholt, 2011). Use the PICOT templates to develop your full questions, and include it in the appendix of your paper. Search (5 points)Describe the search strategy per Melnyk and your lecturesDiscuss how potential, relevant research reports were identifiedExplain what databases were chosen and used, and what studies were identifiedWhat were the inclusion and exclusion criteria?How many studies were included in the final appraisal of the evidence?Critically Appraise the Evidence (15 points) Evidence-Based Practice in Nursing Health Care Essay

A. Matrix (10 points). Develop an excel file (or a table in word) of the evidence. The matrix may include, if available, integrative reports, clinical practice guidelines, meta-analyses as well as single studies. Use the following columns (this may be slightly adapted or indicate N/A for practice guidelines, meta-analysis etc) Name of author, date, title of study, journalLevel of Evidence (Use Box 1.2, p. 10 in Melnyk & Fineout-Overholt)Hypothesis, if there is no hypothesis the question, if there is no question the purpose. Design. Must be specific. Sample: Size of sample, important demographics, inclusion and exclusion criteriaData Collection Instruments/Procedures including reliability and validityStatistical Results/FindingsImplications/Conclusions related to adoption to practiceB. State of the Science Summary addressing the following questions. Respond to the questions in paragraph form and cite the sources. (15 points)How much variation was there and how was the intervention delivered across the studies/reports?How much variation was there in the outcome(s) studied across the studies/reports?What findings are supported by more than one study/ reports?What findings are supported by just one study, but are compelling? Why are they compelling?What findings are inconsistent across the studies/reports?What findings are out right contradictory across the studies/reports?Note the level of evidence from the various the studies/reports and the findings associated with them. Of the consistent findings, how many the studies/reports have a treatment effect that was clinically significant?What outcome(s) is this intervention highly effective in bringing about?What side effects, harm, or burden is associated with this intervention?Is the evidence picture sufficiently complete (i.e. knowledge regarding: benefits, risk, burden, underlying mechanism, specifics of administration)?Make a determination of whether sufficient evidence exists to support either current practice or a need to change the practiceImplement a Change in Clinical Practice (12 points)Assess the environment for change. Consider:o The population in your specific setting and patient preferences and valueso Clinical expertise and preferenceso Available resources for implementing the change Identify a Change Team. Discuss who will be part of the team to implement the change and why you have chosen these individuals. Develop a Change Strategy. Use the following table to identify 2-3 objectives for the project that you could use to implement the change. These objectives must be measurable and specific. In the second column, state the specific methods or plans to meet the objectives. Specify who will be responsible and the timetable to implement each objective. In the last column, specifically state measurable outcomes of how you will evaluate whether or not you have successfully met the objective. (Add additional rows to this chart, if needed). Objectives Method/Plan Responsibility Completion Date Measurable Outcomes Evaluation Plan (10 points)From the last column of the above table, copy and paste the measurable objectives. Complete the rest of the columns. Add additional rows to this table if necessary Measurable outcomes Method and Tools for Measuring Responsibility Timelines Resources (8 points)Discuss the resources; you need for the first year of the change in practice. Project costs of additional supplies, equipment, and personnel as appropriate. Project costs savings. Use an Excel spreadsheet for this purpose Conclusion (5 points)WRITING STYLE AND APA (7 points) you completed the first part of this in order 277049 please use that paper as I guide to complete this second part Evidence-Based Practice in Nursing Health Care Essay