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Running head: VENTILATOR-ASSOCIATED PNEUMONIA PREVENTION 1

A Quality Improvement Project: Investigate the Effect of an Educational Intervention on Acute

Care Advanced Practice Registered Nurses' Knowledge of Preventive Measures to Decrease Risk

of Patients Acquiring Ventilator-Associated Pneumonia

A Scholarly Project Presented to

The Faculty of the Maryville University

Catherine McAuley School of Nursing

In Fulfillment of the Requirements

For the Degree of Doctor of Nursing Practice

SHELLY YBANEZ

SPRING 2018

VENTILATOR-ASSOCIATED PNEUMONIA PREVENTION 2

TABLE OF CONTENTS

Title Page 1

Table of Contents 2

Abstract 3

Chapter I: Introduction 5

Chapter II: Review of Related Literature 8

Chapter III: Methods 18

Chapter IV: Findings 23

Chapter V: Discussion 26

References 31

Appendix 36


ABSTRACT



of Patients Acquiring Ventilator-Associated Pneumonia.

Background: Ventilator-associated pneumonia (VAP) is reported to affect approximately 15% of patients requiring mechanical ventilation (Branch-Elliman, Wright, & Howell, 2015). The negative outcomes of a patient acquiring VAP include an increased length of stay, increased medical cost, and potential long-term respiratory complications. In a cost-analysis study, the authors determined that the reduction of VAP from 9.47 to 1.9 per 1,000 cases produced an estimated savings of approximately $1.5 million (Rodrigues-Ferreira et al., 2016). The incidence of VAP remains high and is an ongoing problem seen in acute care settings. Advanced Practice Registered Nurses should be familiar with the identification, management, and prevention of ventilator-associated pneumonia due to the complications and negative outcomes associated with VAP. Objective: The purpose of this pilot project was to investigate the effect of an educational intervention on Advanced Practice Registered Nurses’ knowledge regarding prevention of ventilator-associated pneumonia (VAP) in acute care settings.

Design: The project utilized a nonprobability convenience sample from the Nurse Practitioner Association located in the state of Texas. The pilot project was a quantitative, exploratory design. Participants were asked to complete a pre-survey consisting of 10 multiple choice questions, view an educational presentation on ventilator-associated pneumonia, and complete a post-survey consisting of 10 multiple choice questions. The surveys and educational presentation were delivered through Qualtrics.

Results: A total of 74 survey participants entered in a response to the initial inclusion criteria screen. Only 19% of survey participants met inclusion criteria and could move forward with the project survey following consent. Overall, the response rate of TNP members to this scholarly project was 2%. All 14 participants (100%) eligible to complete the survey finished the project in its entirety. The mean score percentage for the pre-survey of the 14 participants was 89%. The mean score percentage for the post-survey was 97%. The mode score of the pre-survey was 90% while the mode score for the post-survey was 100%.

Conclusions: The incidence of VAP remains high and is an ongoing problem seen in acute care settings. Advanced Practice Registered Nurses should be familiar with the identification, management, and prevention of ventilator-associated pneumonia due to the complications and negative outcomes associated with VAP. The power of an educational intervention in producing favorable outcomes is underestimated or not utilized to its full potential. This capstone project


proved that the study should be repeated with efforts towards collecting more data to be able to run statistical analyses to determine if any clinically significant results could be produced.

Key words: Ventilator-associated pneumonia, VAP, knowledge, prevention




of Patients Acquiring Ventilator-Associated Pneumonia.

Chapter I: Introduction

Introduction to Problem

Ventilator-associated pneumonia (VAP) can occur as the result of many compounding

factors and is unfortunately common in the mechanically-ventilated patient (Burk & Grap, 2012).

The authors also note that VAP affects 10-65% of ventilated patients and is responsible for 90%

of hospital-acquired infections. VAP is a hospital-acquired infection as it originates and is

acquired by the patient during the hospital stay. Specifically, ventilator-associated pneumonia

occurs in the intubated patient and occurs at that given time or before 48 hours of ventilation

(Centers for Disease Control and Prevention, 2016). Ramirez, Bassi, and Torrence (2012)

defined the occurrence of this infection as due to the reflux of gastric contents into the lower

airways, which then colonizes and causes bacterial infection. Also, due to the endotracheal tube

(ETT), clearance and expectoration of these aspirated contents becomes impaired leading to

increased colonization of bacterial pathogens.

Infections acquired within the hospital setting are deemed an adverse event as well as an

unfortunate circumstance that affects not only the patient, but has its effects within the healthcare

system. It is considered an adverse event and a failure within the intervention pathway by those

involved in the care of the patient (Nyeo, Ting, & Tho, 2016). As the statistics that involve VAP

remain high and is an ongoing problem that can be seen in many facilities, many surveillance

organizations are monitoring these numbers closely in a fight against the issue. Alternatively,

individual facilities can track the occurrence of VAP and set benchmarks for improvement. The

complications that arise from VAP can increase hospital stay in the intensive care unit (ICU),


complicate comorbidities, decrease overall recovery of lung function, and increase mortality

(Burk & Grap, 2012).

Purpose, Goal, and Aims

The purpose of this pilot project was to investigate the effect of an educational

intervention on Advanced Practice Registered Nurses’ knowledge regarding prevention of

ventilator-associated pneumonia (VAP) in acute care settings. Common barriers to best practices

in mobilizing and positioning the patient appropriately include lack of evidence-based

knowledge, a shortage of time to perform these tasks, understaffing, and lack of managerial

support.

The goal of this project was to improve the knowledge of VAP preventive measures in

Advanced Practice Registered Nurses in Texas. The question of this quality improvement project

was: In Advanced Practice Registered Nurses, does an educational intervention regarding VAP

preventive measures increase post- as compared to pre-survey scores?

The overall aim of this project was to educate and improve knowledge by presenting

current practice guidelines to Advanced Practice Registered Nurses of preventive measures that

reduce the risk of VAP in acute care settings.

Background of Problem of Interest

There are several deficits in the current knowledge and practice of nurses providing care

to these patients at risk for VAP. These deficits in knowledge can be due to decreased

compliance with standards of care per facility protocols, inherent barriers encountered in day-to-

day practice due to the demands of a busy work environment, and complexity of patient needs.


What is known through research is that best practices of preventing VAP include

mobilizing the patient as well as proper head-of-bed (HOB) angling in conjunction with

ventilator bundles and protocols (Wiggerman, Kotowski, Davis, & VanGilder, 2015; Bassi et al.,

2015). Numerous facilities deploy bundles to combat the problem of VAP. These bundles are a

grouping of interventions that work in coordination for a common goal. VAP bundles typically

include strict oral hygiene at specified intervals with use of a chlorhexidine (CHG) rinse, patient

positioning to prevent reflux of gastric contents, histamine blocker medication use, special

coated endotracheal tubes, sedation vacations, proactive weaning protocols, and strict changing

of equipment such as ventilator and nebulizer tubing and oral hygiene equipment (Nyeo et al.,

2016).

Authors Wiggerman, Kotowski, Davis, and VanGilder (2015) address a common

occurrence of patients migrating downwards to the foot of the bed. In this occurrence, the patient

is no longer angled appropriately at 30 degrees, but rather, is supine which encourages VAP

infection. In trying to combat the prevalence, incidence, and occurrence of VAP as one of the

leading causes of hospital-acquired infections, many measures and initiatives have been taken.

These initiatives include following evidence-based pathways, surveillance and tracking of

patients affected by VAP, continuing education opportunities for staff, and proactive research

(Khan et al., 2016).

It is in these initiatives that VAP prevention measures and current research can be

explored in detail to develop opportunities for quality improvement, assess current knowledge to

implementing change in current practice, and provide teaching opportunities to optimize

outcomes. These initiatives and efforts have significance and importance related to healthcare

and nursing as it takes collaborative teamwork to change practice.


Chapter II: Review of Related Literature

Critical Analysis of Literature

Burk & Grap (2012) highlighted the efforts made by several associations and institutions

to educate on evidence-based research on mobility, positioning, and the prevention of ventilator-

associated pneumonia (VAP). Ramirez et al. (2012) differed from Burk and Grap’s (2012) article

in that it focused on many other bundled interventions that can reduce VAP such as a lack of

patients’ mobility. Also, Burk & Grap’s (2012) article denoted the conflicting evidence in patient

positioning for VAP prevention and pressure related injuries. Coppadoro, Bittner, and Berra’s

(2012) article had the least amount of information related to the scholarly project in that

positioning is only mentioned briefly. Qing, Cheng, and Chi (2016) provided a proactive

resource in aiming to actively achieve and reduce VAP rates within the chosen setting by 50%

and achieving 80% compliance. They accomplished this by implementing a pre-audit, training,

and practice evaluation and post-audit within their project setting. Lastly, Wiggermann et al.

(2015) studied patient body migration towards the foot of the bed that caused a decrease in head

elevation that contributed towards VAP.

Integrated Review of Literature

Semi-recumbent positioning is superior to supine positioning. Discussion of the semi-

recumbent position versus supine was discussed in varying depths as some authors specifically

examined patient elevation while other authors incorporated HOB angling within VAP

prevention bundling (Bloos et al., 2009; Keeley, 2007; Khan et al, 2016). The leading question

that drove the studies was that semi-recumbent positioning was superior to supine in the

prevention of VAP for a large number of studies. However, there are instances when positioning

besides supine served as an exclusion factor for patients.


Michetti, Prentice, Rodriguez, and Newcomb’s (2017) study is amongst unique research

in the literature review as they delved into patient populations that were unable to maintain a

semi-recumbent positioning. The inability to maintain this positioning could be from trauma

status in which semi-recumbence was contraindicated, hemodynamic instability, spinal injuries

requiring supine immobilization, and those patients with open abdomens. Keeley (2007) also

reviewed factors for patients being unable to be in an upright position and added intolerance to

lying flat due to body habitus, pregnancy, and flow alterations with renal replacement therapy.

Wiggermann et al. (2015) focused on patient positioning; however, HOB angling was not

included in the study’s variables. Rather, patient migration or inadvertent downward shift in bed

caused a decrease in head-over-body elevation that was near or equal to supine, thus potentially

contributing to VAP. More technical methods of measuring HOB angling via crude or more

advanced technical devices were utilized (Keeley, 2007; Rose, Baldwin, & Crawford, 2010a;

Williams, Chan, & Kelly, 2008; Wolken, Woodruff, Smith, Albert, & Douglas, 2012). Examples

of these technical methods of measuring the HOB included plumb lines, special bed-dials, angle

indicators, and continuous measuring devices that measured the angle and transmitted to a

monitoring station. Rose et al. (2010b) stated that without standardized devices to measure the

HOB, nurses incorrectly overestimated the angle.

Beyond incorrect angling of the patient’s bed, compliance amongst nurses was a barrier.

Keeping a patient at 30 to 45 degrees at all times was not always achievable and during

observation, the patient was often found with the head of the bed less than 30 degrees (Balanov,

Miller, Lisbon, & Kaynar, 2007; Bloos et al., 2009). To support the findings of noncompliance,

Rose et al. (2010b) conducted another study that documented patient positioning three times a

day. With that, they cited that patients were not maintained at the recommended semi-recumbent


position 85% of the time, and the charts within their study showed that the predominant

positioning of the patient was documented to be supine. Patient positioning and HOB angles

were often included as part of protocols referred to as care bundling.

Ventilator care bundling. Interventions spanning nursing, pharmaceutical, and

prophylaxis were often utilized for mechanically-ventilated patients in an effort to minimize the

risk of acquiring VAP (Blamoun et al., 2009). Some examples of these interventions included

oral hygiene with chlorhexidine, histamine-2 blockers or “stress ulcer” prophylaxis, in-line

suctioning systems and subglottic suctioning, assessments of endotracheal cuff pressure, HOB

upright versus supine, and proactive assessment of readiness of extubation with daily

spontaneous or weaning breathing trials with sedation vacations. The article by Keeley (2007)

was one of the only articles that the reader had to assume the author was describing care

bundling. This is because the author did not clearly define a care bundle. Other studies reviewed

placed emphasis on importance of following ventilator care bundles (Bloos et al., 2009; Branch-

Elliman et al., 2015; Khan et al., 2016).

Safdar et al. (2016) contested that barriers to enforcing bundle management and nursing

interventions of VAP was due to physician barriers. Examples of physician barriers included

multiple physician groups managing the patient with VAP, variation of treatment when there is a

covering attending physician, and lack of antibiotic stewardship. Meanwhile, Branch-Elliman et

al. (2015) took the most in-depth analysis of the ventilator care bundle in their cost-benefit

analysis in determining the ideal strategy to decrease VAP. In their findings, they highlighted

that the silver coated ETT tubes were infrequently used and should be included in bundling. This

was the only study that had silver coated ETT tubes mentioned as part of bundle care, which

could correlate with why this type of tube was not frequently utilized or seen.


Increased mortality and cost implications. Mortality as a theme was typically

discussed in the introduction and background sections of each article. Across the review of

literature, a majority of the authors noted the correlation of ventilator-associated pneumonia and

increase in mortality rates (Keeley 2007; Rodrigues-Ferreira et al., 2016). In the critically-ill and

mechanically-ventilated patient, multiple medical interventions were typically utilized to

stabilize the patient. Acquiring a hospital-acquired infection is a preventable occurrence and the

critically-ill population is at risk for higher percentages of mortality that exceed 10% due to VAP

(Branch-Elliman et al., 2015). Rodrigues-Ferreira et al. (2016) agreed with the previous statistic

and noted 46% mortality in this patient population.

As many of the studies aimed towards improvement of benchmarks and decreasing the

incidences of VAP, a few authors mentioned that quality improvement efforts must be further

addressed for efficiency and implementation of care bundles. With this, mortality statistics will

decrease as the incidences of VAP are lowered.

The cost implications of a patient acquiring VAP increases length of stay and increases

resources to provide care. Rising costs of medical interventions are often another reason to strive

towards decreasing incidence of VAP. Each new case of VAP increases the hospital cost by

$40,000 to $50,000 dollars (Williams, Chan, & Kelly, 2008). In addition, another study

determined that a decline from 9.47 to 1.9 cases per 1000 ventilator days produced an estimated

savings of approximately $1.5 million (Rodrigues-Ferreira et al., 2016).

Branch-Elliman et al. (2015) performed a thorough cost-benefit analysis that supported

the previous information on VAP costs. The study determined that infection control programs

are cost efficient and that a generally accepted dollar amount that is accepted as “cost-effective”

is one that costs $50,000 to $100,000 per quality-adjusted life year saved.


Gastric aspiration and colonization. One of the most common compounding factors

that contributed to VAP in the patient with an endotracheal tube (ETT) and on mechanical

ventilation was the aspiration of gastric contents. Gastric contents refluxed into the airways and

colonized bacteria which contributed to pneumonia. Due to this pathophysiology, gastric

aspiration and colonization was a theme that was closely related and intertwined with the other

themes of care bundling and head-of-bed positioning.

Bassi et al. (2015) specifically studied the colonization of particular pathogens and

bacteria as biofilm on the endotracheal tube. Their study concluded that the colonization of P.

aeruginosa is the most common pathogen. However, what proved contradictory to most of the

references cited within this chapter is that the authors concluded that the lateral Trendelenburg

position is superior to semi-recumbent positioning in the prevention of VAP. Lateral

Trendelenburg was not mentioned in any other source.

One method of preventing colonization of bacteria as a result of reflux into the airways

was the administration of a histamine-2 receptor antagonists or proton pump inhibitor medication

such as ranitidine, famotidine, or pantoprazole. When references mentioned HOB angling, reflux

prophylaxis was closely followed. Khan et al. (2016) and Blamoun et al. (2009) supported the

need of gastric reflux prophylaxis within their study. Keeley (2007) further elaborated on two

seemingly contradictory arguments of gastric aspiration and reflux. The author noted that

nasogastric tubes may facilitate reflux of gastric bacteria but there has been a study that cited the

reduction of gastric reflux with nasogastric tube placement in surgery due to its venting

mechanism which in turn, reduces gastric contents and pressure (Keeley, 2007). This was an

important consideration in the temporarily mechanically-ventilated patient because presence of


an orogastric or nasogastric tube was most often present to provide a means of medication

administration and enteral feeding route.

Strengths

Beginning with the introduction sections, all references explained the background and

nature of the phenomenon to be studied with appropriate statistics from existing research.

Relationship of research and hypothesis design was relevant to each study. As an example of

how design and hypothesis correlate, Wolken et al. (2012) hypothesized that visual and audio

cues when the HOB fell below 30 degrees would increase compliance by 15%.

Another strength across the studies was that several authors agreed that non-compliance

in maintaining patients at proper elevation was often seen (Rose et al., 2010a; Rose et al.,

2010b). The most common methods of research included pre- and post-intervention studies and

observational studies. These research design types are useful when considering quality

improvement projects.

For the methods section, strengths across the studies were that authors clearly identified

control groups if present within the study. An example of clearly identified control groups was

present in the study by Keeley (2007) where the treatment group maintained a HOB angle at 45

degrees and control group maintained a HOB angle at 25 degrees.

In results and findings, authors were able to state if they were able to accept or reject their

hypothesis and if any significant data or findings were available. For example, Williams et al.

(2008) reported to accept their hypothesis that an angle indicator increases compliance with best

practice guidelines to maintain the head-of-bed at 30 degrees. The obvious strength across all

studies regarding VAP prevention sought to explore interventions that were in the best interest of

the patient to optimize outcomes.


Weaknesses

A weakness identified was the lack of a guiding theoretical framework. It is typically

beneficial when authors can provide a description of a theory that helps the reader understand

what guided the study.

For data collection, a few studies were limited to data collection in single centers. This

could be problematic if results are not generalized and are only applicable to the chosen site.

Bias within the study, such as from sampling methods, was only announced, addressed, or

identified in three source (Khan et al., 2016; Lyerla, LeRouge, Cooke, Turnpin, & Wilson, 2010;

Wolken et al., 2012).

Gaps in practice, current knowledge, and the necessity for more future research were

often identified across the studies. The dynamic nature of healthcare and evolution of medicine

certainly contributed to gaps across the spectrum. Keeley (2007) demonstrated this when it is

cited that more research must be done on different variations of specific angles of the HOB and

VAP occurrence. Another instance was when it was cited that there is more investigation needed

to elucidate the decision-making process for nurses and real-time patient positioning and the

safety in semi-recumbence for those patients that are of high acuity (Rose et al., 2010a). This

was an important statement as it has significance to the project purpose in determining

perceptions and barriers to mobility and positioning in the prevention of VAP.

Limitations

The phenomenon of the Hawthorne effect stood out in two studies (Wiggermann et al.,

2015; Williams et al., 2008). This phenomenon described when subjects manipulated their

behavior due to the knowledge of being observed.

In instances when non-compliance was an issue where patients’ HOB was found lower


than semi-recumbent, limitations would include that researchers did not gather data on exactly

why there was non-compliance. For those authors’ that utilized visual or audio devices to

monitor head-of-bed elevation, the phenomenon of alarm fatigue over time could play a role in

compliance as well. Lastly, there was the obvious fact that patients could not ideally remain in

the semi-recumbent position at all times of the day that presents as a limitation.

Concepts and Definitions

Various concepts and definitions have been mentioned with regards to VAP. The

following is a list of relevant concepts and definitions related to this project:

Care bundle: A care bundle is a specified set or selection of interventions or procedures that

arise from evidence-based medicine and practices (Bloos et al., 2009). Specifically, the

ventilator-bundle consists of interventions that include head of the bed maneuvering, sedation

vacation, deep vein thrombosis prophylaxis, peptic ulcer disease or gastric reflux prophylaxis,

proactive assessment for readiness to be weaned, extubated, or spontaneous breathing trials, and

oral hygiene with chlorhexidine (Blamoun et al., 2009).

Hospital-acquired infection: Hospital-acquired infections are infections that occur after

admission into the hospital or were absent at time of admission and occur 48 hours after (Khan et

al., 2016).

Semi-recumbent position: Semi-recumbent positioning is defined as the backrest at 30 to 45

degrees above the horizontal (Rose et al., 2010b).

Supine position: Supine positioning is when patients are lying flat in bed on their back or dorsal

surface downward (Rose et al., 2010b).


Ventilator-associated Pneumonia (VAP): Ventilator-associated pneumonia is a type of

pneumonia or lung infection that occurs in the mechanically-ventilated patient after 48 hours

post-intubation with a new or progressive infiltrate on chest radiograph (Lyerla et al., 2010;

Rodrigues-Ferreira, 2016). Additionally, two or more clinical signs or findings to indicate

infection 48 hours post-ventilation must be present which could include fever greater than 38

degrees Celsius, leukocytosis less than 10,000mm or leukopenia less than 4,000mm, or purulent

tracheal sputum (Rodrigues-Ferreira et al, 2016).

Theoretical Framework

The Donabedian Model, or also called the Quality of Care Model, is a theoretical

framework that seeks to delve into the inner workings of the healthcare system and evaluate the

level of quality care as a result of the three dimensions within the model (Donabedian, 1988).

This is a conceptual model developed that can drastically improve outcomes and quality of care

for a patient. To note, this theory has a focus on methodology rather than findings. The three

dimensions of care will be broken down and explained in detail.

Structure. Structure is defined as a setting, provider qualifications, or systems through

which care delivery and implementation takes place (Ayanian & Markel, 2016). Additionally,

equipment, staff and ancillary teams involved in care, and organizational characteristics can be

incorporated within the definition of structure. Examples of organizational characteristics could

include staff education and training, as well as administrative personnel. Donabedian (1988)

noted that there are two elements that contribute to practitioner training and performance. These

two elements are described as technical and interpersonal. Structure and process are interrelated

and there is a forward movement of structure to the next dimension, process.


Process. Process is the cumulative outcome as a result of all care interventions. Care

interventions in the healthcare setting could include diagnosis, treatment, care delivery, including

how care is specifically delivered, referrals, patient teachings and education. Donabedian (2005)

has noted that it is a common finding for individuals to assess structure and outcome while

forgetting the intricate and complex processes that contribute to producing the outcome.

Additionally, care coordination is covered under the dimension of process where the setting can

influence the care coordination, and the quality of care coordination produces the health

outcome.

Outcome. Outcomes encompass the clinical effects of the care delivery process on the

patient or specified population. Examples of outcomes include patient satisfaction that could

result from provision of care, timeliness, attentiveness, efficacy of interventions, and increased

perceived quality of life. Additionally, outcomes could be demonstrated by clinical status or state

of the patient’s condition, behavior or current knowledge. Ayanian and Markel (2016) linked the

current practices of value-based payments and patient-centered outcomes to Donabedian’s

model.

The Behavior Model of Health Services can be easily applied to this quality improvement

project. As both seek to examine and optimize quality in care delivery processes, one could

dissect the components of each dimension and apply it to the project purpose.

Hospital staff, including bedside nurses and the chosen facility to implement the project,

comprises the structure dimension of the model. Additionally, staff education, organizational

culture, and motivation apply within this dimension. The training in the form of educational

presentations of evidence-based practices contributes to the advancement of learning for staff.


Care delivery following education of staff of proper HOB angling and strict compliance

by appropriately implementing and documenting these interventions encompasses the process

dimension of the Donabedian Model. As mentioned, structure setting can influence process. This

means proper education and training to eliminate barriers and misperceptions amongst nurses

will improve care delivery and coordination.

Conclusion

Timely, accurate, and effective provision of care in maintaining the head of the bed at the

semi-recumbent position as well as ensuring compliance can lead to a decrease in VAP rates. As

VAP is a modifiable risk factor, this simple nurse-implemented intervention relies on

compliance, optimizes outcomes for the patient, and is guided by evidence. Throughout all

dimensions across the model, emphasis is once again placed on methodology and quality.

Maintaining quality from the beginning and carrying the value throughout leads to quality

outcomes.

Chapter III: Methods

Methodology & Design

The project explored and investigated the current knowledge and understanding of

evidence-based guidelines for reducing VAP. This pilot project is a quantitative, exploratory

design that utilized a convenience sampling of Advanced Practice Registered Nurses in Texas

who were members of the Texas Nurse Practitioner (TNP) association. The study protocol was

approved by the Maryville University Institutional Review Board (IRB). The TNP association

provided approval of the principle investigator to conduct research on its association members

under supervision of Maryville IRB.


The nonprobability convenience sampling method utilized was best suited for this

unfunded study and produced results in a timely manner. Disadvantages of this sampling plan

included sampling bias with the potential for the sample not being representative of the entire

population. This limited the generalizability of the study.

The participants were asked to complete a pre-survey of ten questions before presentation

of the educational material. This served as baseline data on participants’ knowledge regarding

VAP and preventive measures. Following the pre-survey, an educational lecture was presented.

This educational lecture included the incidence and prevalence of VAP and current best

practices. Additionally, APRNs learned their role in implementing these bedside interventions

and how to maintain compliance. Lastly, a post-survey containing the same questions was given

to the participants following the educational lecture. All the surveys and educational material

was delivered electronically via Qualtrics. The total amount of time required for each participant

was approximately 30 minutes or less.

The project protocol consisted of several steps. A recruitment announcement was

distributed via email to all members of the TNP association following IRB approval. The

participants received an anonymous link to their registered email that redirected the site to the

Qualtrics program. The participants were prompted to turn their cell phones off and refrain from

recording, videotaping, or taking pictures. Informed consent was obtained via electronic

signature via Qualtrics. There was no option for the participants to include their names.

Following consent, the first question asked if they are fluent in the English language. If they

answered “no”, the survey automatically closed out. If they answered “yes” they could move

forward with the second inclusion criteria question. The next question asked if they practice as

an Advanced Practice Registered Nurse in acute care setting with mechanically-ventilated


patients. If they answered “no”, the survey automatically closed out. If they answered “yes” they

could move forward with the survey. The participants then were led through the pre-survey,

power point presentation, and post-survey

Presentation of educational material is an intervention that nurses are familiar with. This

is due to the fact that during daily practice, education is constantly being reinforced to each

patient in hopes of understanding. A common method to assess whether knowledge is understood

and absorbed is via a teach-back method or implementing changes to practice. Once the APRNs

understand that VAP is preventable and even nurse driven, these nurses can collaborate to

improve the facility’s benchmarks to be below the national average.

Research Question

This capstone project served to review the following PICO question: In Advanced

Practice Registered Nurses, does an educational intervention regarding VAP preventive

measures increase post- as compared to pre-survey scores?

Data Collection Instruments

The researcher used Qualtrics for the informed consent, pre- and post-surveys,

educational intervention, and data collection. The researcher was provided access to Qualtrics as

a student enrolled in the Doctor of Nursing Practice program at Maryville University. The pre-

and post-survey questions and the contents of the educational video were developed using

current guidelines for reducing the risk of VAP. Content validity was examined by three experts

with advanced degrees in nursing. All three experts concluded that the content was valid related

to reducing the risk of VAP. The readability of the pre- and post-surveys was at the eighth-grade

level.

Analysis Plan


This quality improvement project utilized a descriptive, quantitative design. The survey

utilized for the participants produced quantitative data by being able to take the responses of the

participants and placing them into necessary categories rather than interpreting open-ended

questions. The data was collected from Qualtrics and transcribed to an electronic spreadsheet

program for final analysis.

For this study, advice from an expert statistician was utilized for many aspects of data

collection and analysis. A two-week data collection period was utilized. Initially, for a power

of .80 or higher and an effect size of at least 0.35, at least 67 to closer to 100 participants were

needed.

Resources

Resources utilized for this scholarly project was limited to Maryville University

committee chair member and curriculum staff. Additionally, Qualtrics and TNP were utilized to

create the survey and facilitate research and project survey distribution.

Budget

The budget required for this scholarly project was minimal in expense. The researcher

utilized Qualtrics to create the survey and collect data which was of no expense to the researcher

and provided as a student of Maryville University. Distribution of the survey was $150 dollars

charged as a research request by the Texas Nurse Practitioner Association. The cost for

membership at a student discount was $60 for a one-year membership fee.

Protection of Human Subjects

Informed consent was obtained prior to the electronic educational seminar. The

researcher provided each participant with an informed consent along with an agreement clause.

The participants were informed by way of electronic written notification of the project’s purpose,


benefits, risks, and importance. The researcher emphasized, via written emphasis, that

participants may withdraw consent at any time during the project. If the participant decided not

to participate in the project, the participant checked the box indicating that they do not agree to

the informed consent. The participant was then prompted to close the Qualtrics’ program. There

was no way for a participant to complete the pre-survey without agreeing to the informed

consent using the Qualtrics’ program

Involvement in the project was voluntary and free of coercion. Care was taken to ensure

confidentiality of the pre- and post-survey responses by having each participant use the

anonymous Qualtrics’ link. In addition, the participants did not have the ability to include their

name. The researcher was solely privy to the responses of the pre- and post-surveys. The data

collected was downloaded from the secure encryption hypertext protocol transport secure

(HTTPS) Qualtrics’ site to an excel spreadsheet for final analysis. The excel spreadsheet was

downloaded to the researcher’s computer, and the file was protected by using a security code in

the form of numbers, letters, and special characters on a password protected computer in a

locked office. The researcher was the only one who has access to the password protected

computer, and locked office. Photography and videos were not allowed. The session was not

recorded. The researcher requested that the participants turn off their cell phones during the

project.

Individual responses were not published on social media. The Qualtrics’ data and

informed consents were housed in the Qualtrics’ link and will be permanently deleted after three

years. The results of this project have been shared with the researcher’s faculty advisor,

Maryville University community members, and may also be shared at a poster session of a

medical conference or submitted for publication in a reputable journal. Information may also be


shared with the Texas Nurse Practitioner Association. The sharing of this information with the

Nurse Practitioner Association would be without an individual breakdown of performance

scores. All information would be presented without any identifiers and in aggregate form.

There were no physical, psychological, social/economic, or legal risks that resulted from

participating in this project. A breach of confidentiality was a potential, but unlikely, risk. There

was no potential for embarrassment if the participant did not know the answer to the questions.

Participants were encouraged to complete the surveys independently, without peer interaction. In

addition, Qualtrics provided an anonymous link that could not be tracked to the participant’s

email address, and all potential identifiers were removed.

The risks of breaching confidentiality are reasonable and minimal. The information

gleaned from the pre- and post-surveys did not breach any ethical, moral, or legal boundaries.

Participants remained in charge of their own participation and can stop the Qualtrics’ surveys or

lecture at any time.

Chapter IV: Findings

Data Collection Method

Methodological congruence is defined as similarity of method and interpretative

precision (Thurston, Cove, & Meadows, 2008). This quality improvement pilot project

encompassed educational interventions as a means to improve patient outcomes or prevent the

incidence of VAP by means of evidence-based interventions. The data collected was gathered in

its intended setting of the Texas Nurse Practitioner Association. The data measured proposed that

educational interventions to increase knowledge in VAP preventive measures. The means of

distributing an electronic survey was an appropriate method of collecting data. Additionally, the


data collection process was appropriate for the methodology proposed and occurred in a

consistent manner.

Target Variables

The target variable examined was the advanced practice registered nurse’s knowledge on

preventing ventilator-associated pneumonia and comparing the pre- and post-survey scores to

determine if the educational intervention was effective in increasing participants’ knowledge.

The intended sample size was 67 participants for a medium effect size and to compensate

for participants who would drop out of the survey, close to 100 participants were needed. Due to

time constraints, timing of email distribution of project survey, and participant involvement, the

sample size was much less than anticipated.

Study Replication

The measurements collected had congruence with the collection method. There were no

overt outliers within the data set that could be identified. Following data collection, the

methodology could be analyzed by the researcher to identify what changes needed to be made

and identify successes and failures of the intervention. Another researcher would be able to

easily replicate the data collection plan as it is very simple in format and layout and information

to guide data collection could be easily followed.

Validity and Reliability

Content validity. In calculating the project’s content validity, the associated panel of

experts consisted of the scholarly project committee chair member and another Doctor of

Nursing Practice (DNP) advanced practice nurse. These two individuals were asked to review

each question on the survey instrument utilized in the project and assign a relevancy score

ranging from one to four in order for the principle investigator to calculate a content validity


index. One point was given if the question was not relevant, two points if it was somewhat

relevant, three points if it was quite relevant, and four points if it was highly relevant. The

average number of questions with either three or four points was ten out of ten questions. Thus,

the content validity index equaled 100 percent. The measurement of content validity was utilized

and was important because the principle investigator must determine if contents of the test were

relevant to the main foundations of the project. Panel experts reviewed the questions for

relevancy in the preliminary stages of development and revised them as necessary.

Descriptive Statistics

Descriptive statistics is utilized to describe and synthesize data (Polit & Beck, 2017).

Descriptive statistics were utilized to determine the knowledge of APRNs and preventive

measures for VAP prior to, and after, an educational intervention. This is to determine if an

educational intervention was able to increase knowledge of the project participants. No

demographical data was collected and survey participants were anonymous. Pre- and post-test

scores were graded on a percentage basis out of 100% from ten questions.

Results

The researcher obtained scores from individuals who took both the pre-survey and post-

survey. Only those individuals who completed the project in its entirety and only pairs of scores

were considered. This left 14 pairs of scores from 14 participants to utilize for data analysis.

A total of 74 survey participants entered in a response to the initial inclusion criteria

screen. Only 19% of survey participants met inclusion criteria and could move forward with the

project survey following consent. Overall, the response rate of TNP members to this scholarly

project was 2%. All 14 participants (100%) eligible to complete the survey finished the project in

its entirety. The mean score percentage for the pre-survey of the 14 participants was 89%. The


mean score percentage for the post-survey was 97%. The mode score of the pre-survey was 90%

while the mode score for the post-survey was 100%.

Chapter V: Discussion

Summary of Findings

The incidence of VAP remains high and is an ongoing problem seen in acute care

settings. Advanced Practice Registered Nurses should be familiar with the identification,

management, and prevention of ventilator-associated pneumonia due to the complications and

negative outcomes associated with VAP. The power of an educational intervention in producing

favorable outcomes is underestimated or not utilized to its full potential. This capstone project

indicated that the study should be repeated with efforts towards recruitment of more participants.

Interpretation of Findings

Comparing pre-survey scores to post-survey scores, an increase in knowledge would be

indicated if the individual achieved a better score percentage on their post-survey than their pre-

survey score. Based on this, 43% of the participants increased their knowledge, 29% achieved

scores that were the same for both surveys, and 29% of survey participants obtained post-survey

scores worse than their pre-survey scores.

Analysis

The evidence that was offered in support of the interpretation was that educational

interventions help to improve current knowledge. The results were interpreted considering other

studies that showed that current knowledge on evidence-based practice in prevention of VAP is

lacking or may present with gaps in theory and practice.

Limitations


Limitations of this project included a limited data collection period and a low response

rate. The data collection period was two weeks and recruitment emails were sent out twice.

Ideally, a longer data collection period would be favorable as the response rate from the Texas

Nurse Practitioners association to the survey was about 2%. Workable data sets were very small

for analysis. Additionally, convenience sampling was utilized and inherently, this type of

sampling method has the potential to introduce bias. Also, this would mean this study involved

only members of TNP. Another limitation is that due to the sample size, descriptive statistics was

utilized within my study as it was advised that inferential statistics is not best suited for the data

that was collected. Initial plans for utilizing t-Tests were abandoned and because of this,

inferences were unable to be made about the sample population.

Implications for Research and Practice

As an Advanced Practice Registered Nurse, one must employ the current evidence and

research available to recognize opportunities to optimize outcomes and change practice for the

better. These motivated advanced practice nurse leaders have the potential to take an idea, grow

it into a project that involves other like-minded individuals, and join top authorities within the

healthcare industry to reform patient care across the world. It is in turn that the advanced practice

nurse will develop innovative ways to develop new models of care that are patient-centered,

involve collaborative teamwork amongst interdisciplinary teams, streamline technology, and

keep up with the dynamic nature of the ever-evolving healthcare process (Newland, 2013).

Nursing and Healthcare

The significance of understanding the current knowledge of VAP preventive measures is

relevant in everyday practice. As nurses provide bedside care and are essentially the

“gatekeepers” of the patient’s plan of care, a nurse must understand the factors that are involved


in monitoring and preventing the occurrences of hospital-acquired infections and adverse events,

and in this project’s focus, VAP.

The significance of this project to nursing is that many interventions for a patient are

nurse driven. Unless specifically ordered otherwise, mobilizing the patient by angling the HOB

does not require a physician’s order. Thus, proper education to drive nurses towards evidence-

based interventions is one of the easiest means of achieving beneficial change.

Healthcare is dynamic and ever-evolving. Given those characteristics, transforming

healthcare should include the common purpose of implementing best practices for the overall

moral accomplishment of beneficence and nonmaleficence for the patient. Ventilator-associated

pneumonia is a non-discriminant disease and has no prejudice to which patients are affected. The

significance of this project lies in quality improvement within one given facility in hopes of

producing decreased infection rates, promoting education of nurses, and encouraging adherence

to best practices. If one facility has the potential to overcome barriers and incorrect perceptions,

there are endless boundaries for change to influence many other facilities. To add, Parisi et al.

(2016) noted the proactive efforts of the Institute for Healthcare Improvement in its “100,000

Lives Campaign”. This campaign specifically set aims for prevention of VAP which Parisi et al.

(2016) noted would dramatically improve the care of patients and reduce avoidable hospital

deaths.

Benefits of Project to Practice

Selection of an appropriate organization that strongly supported the goals of not only the

Doctor of Nursing Practice candidate but also the project proposal was paramount in being able

to establish measures for a means of quality improvement. The benefit of identifying nurses’

current knowledge in the prevention of ventilator-associated pneumonia allowed the DNP


student to identify gaps in practice and develop a project aimed at educating APRNs of these

gaps, informing them of best practices, and increasing compliance in evidence-based findings.

Additionally, a decrease in VAP rates greatly reduces healthcare costs for all parties involved.

Recommendations

There is a gap in practice amongst nurses implementing evidence-based interventions to

prevent ventilator-associated pneumonia. There is plenty of research and professional clinical

guidelines that prefer the patient to maintain the HOB at 30 to 45 degrees which prevents

colonization of bacteria as a result of aspiration of gastric contents into the airways. There are

several reasons that these gaps in practice occur.

Common barriers to nurses not implementing this simple intervention could stem from

lack of knowledge of what current guidelines and research states regarding the topic, lack of

formal training and education of what facility standards and protocols are or a facility that does

not have protocols in place altogether, lack of proper equipment to determine correct angling,

and even too busy to attend to basic patient care. A necessity to understand exactly what current

knowledge nurses have is needed to assess the potential for success in carrying out future

implementations of this project. By utilizing the guiding theoretical framework as previously

mentioned, the organization along with the nurses has the potential to influence the processes

that provide quality care. Delivering high quality care in an efficient and safe manner will

produce favorable and optimal outcomes that are in sync with the purpose and aim of the project.

Future recommendations could include utilizing alternative sampling methods other than

convenience sampling. This could also decrease bias within the study. Additionally, an extended

period of data collection would be extremely beneficial in being able to run hypothesis testing

and statistical analyses in an ability to make inferences towards the target population. Lastly,


educating those APRNs who do not necessarily work directly with mechanically-ventilated

patients could be an option as there is potential for these individuals to work with them in their

future endeavors.

Conclusion

Ventilator-associated pneumonia can occur as the result of many compounding factors

and is unfortunately common in the mechanically-ventilated patient (Burk & Grap, 2012). VAP

is a hospital-acquired infection as it originates and is acquired by the patient during the hospital

stay. It is considered an adverse event and failure within the intervention pathway done by those

involved in the care of the patient (Nyeo et al., 2016)

It is imperative that preventive measures are instituted to decrease the risk of aspiration.

For example, unless contraindicated, elevating the patient’s HOB position to 30 degrees or more

can reduce the risk of bacterial pathogens from entering the lungs. Other preventive measures

include: meticulous oral hygiene, administration of medications that decrease stomach acidity,

removal of the endotracheal tube as soon as possible, and monitoring for deterioration in the

patient’s mental status. Thus, proper education related to preventive measures to reduce the risk

of VAP may facilitate APRNs to prescribe current, evidence-based practice guidelines to prevent

VAP.

A clear understanding regarding the preventive measures to decrease the risk of VAP is

imperative to successful patient outcomes. Following the appropriate preventative measures is

the initial step in decreasing the occurrence of VAP. The APRN has the responsibility to ensure

that evidence-based practice is used in all health care settings (Gerrish, McDonnell, Nolan,

Guillaume, Kirshbaum, & Tod, 2011)


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Appendix A

Pre- and Post-Survey Questions

Correct answers are highlighted.

1. What is a hospital-acquired infection?

a. A hospital-acquired infection is only limited to one specific type of infection a

patient can acquire while receiving care from a medical facility.

b. Infections a patient can acquire while receiving care from a medical facility such

as a hospital.

c. A type of infection a patient can acquire only if someone undergoes surgery in a

medical facility such as a hospital.

2. All of the following are true regarding the diagnostic criteria for ventilator-associated

pneumonia (VAP) EXCEPT:

a. The patient is intubated for less than 12 hours.

b. Development of new or progressive infiltrates after 48 hours post insertion of

endotracheal tube with initial mechanical ventilation.

c. If a patient has a negative culture, a pan culture should be obtained to rule out

other sources of infection.

3. The potential implications of a patient acquiring ventilator-associated pneumonia (VAP)

in the hospital includes all of the following EXCEPT:

a. Increased risk of mortality

b. Increased risk of complications such as acute respiratory distress syndrome, or

pneumothorax

c. Decreased length of stay in the hospital


4. Which organization allows for healthcare facilities to track healthcare process measures

related to hospital-acquired infection rates?

a. Occupational Safety and Health Administration (OSHA)

b. National Healthcare Safety Network (NHSN)

c. World Health Organization (WHO)

5. All of the following interventions are precautions to prevent ventilator-associated

pneumonia (VAP) EXCEPT:

a. Routinely verify placement of enteral feeding tubes

b. Routinely change breathing circuits

c. Perform routine oral hygiene

6. What is the recommended head-of-bed angling for the prevention of ventilator associated

pneumonia?

a. 30 degrees or more

b. 0 degrees, patient should remain flat in bed

c. 15 degrees

7. Each new case of VAP can increase hospital cost by 40-50 thousand dollars. True or

False?

a. True

b. False

8. What is an intervention that can be done to facilitate extubation of a patient when

clinically stable?

a. Daily spontaneous breathing trials

b. Heavy sedation of the mechanically ventilated patient


c. Restraining the patient so they do not pull out the endotracheal tube

9. Which is true of evidence-based guidelines in the management of ventilator-associated

pneumonia?

a. Collection of lower respiratory tract culture after giving broad spectrum antibiotics

b. Empiric regimen should include antibiotic/antimicrobials in a different class than

one the patient has received previously if antibiotics were given recently

c. All patients (complicated or uncomplicated) should receive the same duration of

antimicrobial therapy

10. A patient population at greatest risk for multi-drug resistant pneumonia/ventilator-

associated pneumonia is residents of long-term care facilities. True or False?

a. True

b. False


Appendix B

Comparison of Pre- survey Responses and Post Survey Responses

Q1 - What is a hospital-acquired infection?

Pre-Survey

Post-Survey

Q2 - All of the following are true regarding the diagnostic criteria for ventilator-associated pneumonia (VAP) EXCEPT:

Pre-Survey


Post-Survey

Q3 - The potential implications of a patient acquiring ventilator-associated pneumonia (VAP) in the hospital includes all of the following EXCEPT:

Pre-Survey

Post-Survey


Q4 - Which organization allows for healthcare facilities to track healthcare process measures related to hospital-acquired infection rates?

Pre-Survey

Post-Survey

Q5 - All of the following interventions are precautions to preventing ventilator-associated pneumonia (VAP) EXCEPT:

Pre-Survey


Post-Survey

Q6 - What is the recommended head-of-bed angling for the prevention of ventilator associated pneumonia?

Pre-Survey

Post-Survey


Q7 - Each new case of VAP can increase hospital cost by 40-50 thousand dollars. True or False?

Pre-Survey

Post-Survey

Q8 - What is an intervention that can be done to facilitate extubation of a patient when clinically stable?

Pre-Survey


Post-Survey

Q9 - Which is true of evidence-based guidelines in the management of ventilator-associated pneumonia?

Pre-Survey

Post-Survey


Q10 - A patient population at greatest risk for multi-drug resistant pneumonia/ventilator-associated pneumonia are residents of long-term care facilities. True or False?

Pre-Survey

Post-Survey

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