Effect of ventilator bundle implementation on weaning

[Downloaded free from http://www.enj.eg.net on Thursday, July 13, 2017, IP: 156.194.94.55] 50

Original article

Effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients at a selected private healthcare sector

Mohamed Abd Elmonem El-Sharkawya, Warda Youssif Mohamedb, Nahla Shaban Alic a Department of Critical Care and Emergency Nursing, bProfessor of Critical Care and Emergency Nursing, cAssistant Professor of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Giza, Egypt

Correpondence to Mohamed Abd Elmonem El-Sharkawy, MSc, Department of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Giza, Egypt Tel: +20 106 999 6352; e-mail: [email protected] Received 15 January 2017 Accepted 2 February 2017 Egyptian Nursing Journal 2017, 14:50–57

Background Mechanical ventilator (MV) has serious complications; thus, the ultimate goal of MV is ventilator discontinuation. Ventilator bundle is a group of practices aimed to improve the patient outcomes. Aim The aim of this study was to examine the effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients. Research design A quasiexperimental design was utilized. Sample A purposive sample of 60 mechanically ventilated patients was enrolled. Patients were matched for age, sex, and medical characteristics and then randomly assigned to two groups. The study group included patients for whom all elements of the ventilator bundle were applied completely, whereas the control group included patients for whom the ventilator bundle elements were not applied completely. Setting This study was conducted in the ICUs of a selected private hospital in Cairo. Tools of data collection Three tools were utilized: sociodemographic and medical data sheet, ventilator bundle compliance checklist, and Burns’ Wean Assessment Program checklist. Results There was a significant statistical difference between the compliant (study group) and the noncompliant (control) group as regards weaning indicator scores (t=4.20; P=0.001). There was a significant difference between patients of the two groups as regards the compliance with individual ventilator bundle elements with respect to head-of-bed elevation (χ 2=4.85, P=0.046), sedation interruption (χ2=6.4, P=0.03), and assessment of readiness to extubate (χ2=5.2, P=0.02). Conclusion Implementation of ventilator bundle plays a pivotal role in weaning from a MV. Recommendation Applying the ventilator bundle practices with focusing on the head-of-bed elevation, daily sedation interruption, and assessment of readiness to extubate is highly recommended. Moreover, the use of a structured tool to assess readiness for weaning can help in managing the mechanically ventilated patients. Furthermore, replication of the study on a larger probability sample from different geographical locations in Egypt ensures generalizability of the study. Keywords: mechanically ventilated patients, ventilator bundle, weaning, weaning indicator Egypt Nurs J 14:50–57 © 2017 Egyptian Nursing Journal 2090-6021

Introduction Mechanical ventilation (MV) may be indicated for many reasons. These reasons may include controlling the patient’s respirations during surgical procedures or during treatment of severe traumatic brain injury, to oxygenate the blood when the patient’s ventilatory efforts are inadequate, and to rest the respiratory muscles (Suzanne and Bare, 2010). Although the majority of the patients require MV for a short © 2017 Egyptian Nursing Journal | Published by Wolters Kluwer - Medknow

duration, ∼30% of those patients may require MV support for more than a week, and this prolongation of the MV period may increase the risk for serious complications (Figueroa-Casas et al., 2015). This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work noncommercially, as long as the author is credited and the new creations are licensed under the identical terms. DOI: 10.4103/ENJ.ENJ_10_17

[Downloaded free from http://www.enj.eg.net on Thursday, July 13, 2017, IP: 156.194.94.55] Effect of ventilator bundle on weaning Abd Elmonem El-Sharkawy et al.

Although MV is a lifesaving procedure, there are many complications that should be considered in the mechanically ventilated patients; these complications include barotrauma, volutrauma, aspiration and ventilator-associated pneumonia (VAP), tracheoesophageal fistula, stress ulcer and gastrointestinal bleeding, deep venous thrombosis, and other problems related to immobility (Jones and Fix, 2014). Thus, the main challenge of nurses in critical care units is mechanically ventilated patients and the failure to wean them from machine support (Grap, 2009). This is related to the high occupancy rate of ventilated patients, which constitutes onefourth to one-half of critically ill patients who require MV (Blackwood et al., 2009; Grap, 2009). Weaning is a process that aims to discontinue the support that patient receives to start breathing spontaneously (Epstein and Walkey, 2013). It is the removal of patients from ventilatory support to breathe without the assistance from ventilation (Hemant et al., 2006; Epstein and Parsons, 2013) Many risk factors affect the weaning process. Over the past several years, there has been controversy about the timing and role of tracheostomy in the ICU in reducing the development of VAP and delayed weaning (Möller et al., 2005). Placing mechanically ventilated patients in a semirecumbent body position (45°) has been demonstrated to reduce the incidence of VAP to more than 75% compared with those placed in a completely horizontal position (0°) (Drakulovic et al., 1999).

51

bundle, to enable the implementation of evidencebased preventive approaches for healthcare-associated infection (Evans, 2005). The Ventilator Bundle comprises head-of-the bed elevation 30°–45°, oral care with chlorhexidine, daily sedation interruption and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis, aimed to improve outcome in mechanically ventilated patients. Daily spontaneous awakening and breathing trials are associated with early weaning from MV and VAP reduction. Thus, ventilator bundle application enhanced early weaning, decreased the length of stay in the ICU, and improved patient outcome (O’Keefe-McCarthy et al., 2008). The IHI had defined the ventilator bundle compliance as the percentage of intensive care patients on MV for whom all elements of the ventilator bundle are documented on daily goal sheets and/or elsewhere in the medical record, with a target compliance of 95% (Resar et al., 2005). Many studies have shown that implementation of the elements of IHI bundle alone or with other preventive measures are associated with reduced VAP rates. Moreover, a relatively fewer number of studies emphasized on investigating the relationship between the ventilator bundle compliance and ventilator utilization with differing results (Al-Thaqafy et al., 2014). Significance of the study

In a study carried out by Ibrahim et al. (2002) comparing early and late enteral feeding in medical ICU patients receiving MV, there was no mortality difference between the early and late enteral feeding groups. However, the group of patients who were fed earlier had a greater incidence of VAP and longer ICU stay.

Through empirical observations, literature review, and clinical experience in the ICUs for many years, it is noticed that many of ICU patients were connected to the MV, and weaning trials from MV are associated with many complications to the patient and increase the cost of care.

Readiness for weaning from MV may include many criteria that ensure the willingness to liberate the patient from the ventilator. These criteria include the following: resolution of the critical condition for which the patient was subjected to MV, adequate respiratory efforts and cough reflex, and absence of excessive tracheobronchial secretion; stabilization of the cardiovascular status; stabilization of metabolic and respiratory functions; adequate oxygenation; and absence of sedation to ensure the cooperation of the patient (Pu et al., 2015).

Many studies were conducted in the USA to assess the ventilator use and revealed that 33% of the admitted patients were receiving MV for a mean±SD duration of 5.9±7.2 days (Esteban et al., 2002). However, in Egypt the average duration of MV was 12.8±4.9 days (Mohamed, 2014).

The Institute for Healthcare Improvement (IHI) developed the bundle practices, including ventilator

Failed weaning trials result in respiratory muscle fatigue, VAP, and lung injury that result in delayed extubation. Few research studies were conducted nationally on the ventilator bundle practices and its effect on weaning from mechanical, and their findings revealed that implementation of evidenced ventilator bundle practices may reduce the incidence of such


Egyptian Nursing Journal, Vol. 14 No. 1, January-April 2017

complications and improve the quality of patient care. In addition, compliance with evidence based guidelines on weaning among nurses is not valued within the variety of clinical settings. Therefore, the investigator aimed to test the relationship between implementation of ventilator bundle practices and weaning from MV, which may improve the prognosis of those patients, and this in turn would decrease the average length of ICU stay and hence decrease the cost of care. Moreover, the application of ventilator bundle practices by the nurses would improve their performance and enhance their systematic approach of thinking while dealing with the critically ill patients. Eventually, this research might generate an attention and motivation for further studies in this area. Aim The aim of this study was to examine the effect of ventilator bundle implementation on weaning indicator among mechanically ventilated patients. Research hypothesis

To fulfill the aim of this study, the following research hypothesis was formulated: The study group of patients for whom all elements of the ventilator bundle was applied completely would get higher weaning scores compared with the control group of patients for whom the ventilator bundle elements were not applied completely.

Patients and methods Research design

A quasiexperimental design was utilized. Setting

The current study was carried out at different ICUs affiliated to a selected private healthcare sector in Cairo, Egypt, which implemented the ventilator bundle practices, but the compliance is variable. There are about 55 ICU beds in the hospital distributed between medical intensive care, surgical intensive care, neurocritical, chest pain unit, and coronary care units. The nurse : patient ratio is usually 1 : 1. Sample

A purposive convenience sample of 60 mechanically ventilated adult male and female patients were enrolled in the study. Patients were matched for age, sex, and medical characteristics, and then those patients were divided randomly into two groups. The first group

(study) of patients received compliance with the VAP bundle more than or equal to 95%, whereas the second one group (control group) did not receive ventilator bundle practices or the compliance is less than 95% during the MV period. These exclusion criteria include patients who have brain stem infarction, patients with neuromuscular disorder, patients with chronic debilitating and terminal diseases, patients with BMI less than 18 kg/m2 or more than 32 kg/m2, and patients younger than 18 years and older than 60 years of age. Tools

Three tools for data collections were utilized: (1) Tool 1: Background data sheet: It included patient’s age, sex, smoking status, current medical diagnosis, comorbidities, and the main reason for ICU admission. (2) Tool 2: Ventilator bundle compliance checklist: It was adopted on the basis of the guidelines of IHI (Resaret al., 2005) to assess the compliance with ventilator bundle practices. This tool was examined by a panel of three medical and three nursing experts to assess its validity and reliability. (a) The key components of the ventilator bundle checklist are as follows: (b) Elevation of the head of the bed. (c) Mouth care with chlorhexidine. (d) Daily sedation interruption. (e) Assessment of readiness to extubate. (f) Peptic ulcer disease prophylaxis. (g) Deep venous thrombosis prophylaxis. This tool was reviewed by a panel of three medical and three nursing experts to assess its validity and reliability. The compliance rate is calculated by dividing actual daily compliance with the number of days the patient has been receiving ventilation. This figure is multiplied by 100 to calculate percentage compliance (Beattie et al., 2012). Calculation for ventilator-associated pneumonia bundle compliance

The numberoftimes the patientreceives thebundle The number of opportunitiesthe patient couldreceive the bundleðnumberofventilated daysÞ × 100 The final percentage of ventilator bundle compliance for the patient shall be calculated on the basis of the total percentage of nurses’ compliance with all ventilator


bundle practices together throughout the ventilator days. Thereafter, the sample will be categorized on the basis of the cumulative compliance into two groups: the compliant group, whose total compliance percentage is more than or equal to 95%, and the noncompliant group, whose total compliance percentage is less than 95%.

53

maintained using codes. The purpose and significance of the study were explained to all participants. All patients and their families were assured that their participation is voluntary and that they can withdraw at any time without compromising their care. Procedure

Tool 3: Burns’ Wean Assessment Program checklist

This tool was developed by Burns (1990) and is used to systematically assess and track weaning progresses of the mechanically ventilated patients through general assessment and respiratory assessment. The Burns Weaning Assessment Program is a 26-factor scoring instrument. It is used to decrease variability in managing patients on MVs. The instrument consists of three components: general assessment, respiratory assessment, and arterial blood gas results. The response of each component of these subscales is yes, no, or not assessed. A cutoff point for the instrument is 50. If the score is more than 50 the patients are more likely to be weaned successfully. This means that a score more than 50 is a predictor for successful weaning. Further, if the score is less than 50 the patient is more likely to have unsuccessful weaning. The Burns’ Wean Assessment Program (BWAP) is an indicator for successful weaning process and is considered valid; the interrater reliability of the instrument is 95% (Epstein et al., 2002). Validity and reliability of tools

Content validity was determined to identify the degree to which the used tools measure what was supposed to be measured. Tools were examined by a panel of three medical and three critical care nursing experts to determine whether the included items were clear and suitable to achieve the aim of the current study. Pilot study

A pilot study was carried out on six patients to test the feasibility, objectivity, and the applicability of the study tools. Carrying out the pilot study gave the investigator experience to deal with the included participants and use the data collection tools. On the basis of the results of the pilot study, needed refinements and modifications were made and pilot study participants were excluded from the actual study sample. Protection of human rights

The approval of the ethical committee boards of the affiliated university and the targeted hospital was granted before the study commenced. The confidentiality and anonymity of the information in the records were

The current study was conducted in two phases: the designation phase and implementation phase. Designation phase

It is concerned with the construction and preparation of different data collection tools (sociodemographic and medical data sheet, patient assessment sheet, ventilator bundle compliance checklist, and BWAP checklist). In addition, managerial arrangements were carried out and the investigator prepared formal requests to selected private hospitals. The purpose and nature of the study were explained to gain acceptance and support. This stage required about 2 months and ended by carrying out the pilot study. Implementation phase

Data were collected over a period of 18 months between March 2014 and September 2015. The researcher visited the assigned settings on a daily basis during the day and night shifts. The enrolled patients and their relatives were informed individually about the purpose and nature of the study. Thereafter, the researcher obtained written consent from those who accepted to participate in the study. Later, sociodemographic and medical data (tool 1), were obtained from patients on the first day. Concerning the compliance of the healthcare professionals with the ventilator bundle practices, it was assessed using tool 2 on a daily basis until the patient was extubated or the patient was for more than 10 consecutive days on MV. After 72 h of MV, the patient was started to be assessed for readiness of weaning on daily basis using BWAP checklist (tool 3) until extubation or for 10 consecutive days from initiation of MV. Results Demographic characteristics of the two groups of patients as regards compliance with ventilator bundle implementation are presented in Table 1. This table reveals that there was no significant difference between patients with compliance and those with noncompliance to VAP bundle application with regard to age (48.4±11.2 vs. 45.4±11.2 years, respectively, where t=1.03; P=0.4),



Table 1 Demographic characteristics of the studied patients (n=60) Demographic parameters

Age (mean±SD) Sex Male Female Smoking

Compliance with ventilator bundle (n=30) [n (%)]

Test

P value

t/χ 2=1.036

0.462

Compliant group

Noncompliant

48.4±11.2

45.4±11.2

21 (70)

21 (70)

0.370

0.441

9 (30)

9 (30)

0.370

0.441

16 (53.3)

13 (43.3)

0.475

0.374

Table 2 Medical characteristics of patients by their compliance to ventilator-associated pneumonia bundle implementation Variables

Compliance with ventilator bundle [n (%)] Compliant

Noncompliant

χ2

P value

Current diagnosis Cardiac

11 (36.6)

4 (13.3)

2.67

0.14

Respiratory Neurology

9 (30) 1 (3.3)

8 (26.6) 5 (16.6)

0.66 0.2

0.7 0.8

Gastrointestinal

1 (3.3)

4 (13.3)

0.15

0.8

Renal tubular acidosis

1 (3.3)

5 (16.6)

0.2

0.8

Renal

2 (6.6)

1 (3.3)

0.07

0.9

Length of mechanical ventilator (days) 3–6

18 (60)

8 (26.6)

0.02

0.6

7–10

9 (30)

11 (36.6)

0.06

0.57

>10 Comorbid symptoms

3 (10)

11 (36.6)

1.9

0.23

Chest infection

25 (83.3)

29 (96.7)

0.2

0.8

1 (3.3)

1 (3.3)

0.15

0.9

Nausea Vomiting

1 (3.3)

1 ((3.3)

0.15

0.9

Diarrhea

5 (16.6)

5 (16.6)

1.2

0.37

Constipation

3 (10)

1 (3.3)

0.11

0.9

Edema

13 (43.3)

12 (40)

4.4

0.04*

Pressure ulcer

4 (13.3)

13 (43.3)

6.6

0.01*

*Statistical significant difference.

sex (χ2=0.3; P=0.4), and smoking status (χ 2=0.47; P=0.3). Medical characteristics of the two groups of patients as regards compliance with ventilator bundle implementation are presented in Table 2. There was no significant difference between patients with compliance and those with noncompliance to VAP bundle implementation as regards current medical diagnosis, such as cardiac, respiratory, gastrointestinal, neurological, and renal diseases. Moreover, Table 2 reveals that there was no significant difference between compliant and noncompliant patients as regards both length of MV days and comorbid signs and symptoms except the presence of edema (χ 2=4.4; P=0.04). The distribution frequency of the studied patients by their compliance to individual ventilator bundle elements is presented in Table 3. It reveals that there was a significant difference between patients of the two groups as regards the compliance with individual ventilator bundle elements with respect to

head-of-bed elevation (χ 2=4.85; P=0.046), sedation interruption (χ 2=6.4; P=0.03), and assessment of readiness to extubate (χ2=5.2; P=0.02). Comparison between the compliant and the noncompliant group to VAP bundle implementation with respect to their weaning scores is presented in Table 4. It revealed that there was a significant difference between patients with compliance and those with noncompliance as regards weaning scores (t=4.20; P=0.001). Correlation between age and total BWAP score as a weaning indicator from MV is presented in Table 5. It reveals a positive correlation, and there was no statistical significance between age and total BWAP score as a weaning from MV (r=0.018; P=0.89). Correlation between length of MV BWAP score as a weaning indicator is presented in Table 6. It reveals correlation, and there was a highly

and total from MV a negative statistically


55

Table 3 Frequency distribution of the studied patients by their compliance to individual ventilator-associated pneumonia bundles Compliant group [n (%)]

Noncompliant [n (%)]

χ2

P value

Head-of-bed elevation

29 (96.6)

13 (43.3)

4.85

0.046*

Oral care with chlorhexidine Deep vein thrombosis prophylaxis

29 (96.6) 30 (100)

29 (96.6) 26 (86.6)

0.00 0.02

0.9 0.7

Peptic ulcer prophylaxis

Components

28 (93.3)

29 (96.6)

0.07

0.9

Daily sedation interruption

24 (80)

5 (16.6)

6.4

0.03*

Assessment of readiness to wean

30 (100)

6 (20)

5.2

0.02*

*Statistical significant difference.

Table 4 Comparison between the compliant and the noncompliant group with ventilator-associated pneumonia bundle implementation by their weaning scores (n=60) Weaning score Compliant group

19.5

Noncompliant

14.94

t-Test 4.20

Table 5 Correlation between age and total Burns’ Wean Assessment Program score as a weaning indicator from mechanical ventilator (n=60)

P value 0.0001

Age

**

Total Burns’ Wean Assessment Program score

r

P

0.018

0.89

**High statistical significant difference.

Table 6 Correlation between length of mechanical ventilation, and total Burns’ Wean Assessment Program score as a weaning indicator from mechanical ventilator (n=60) Length of mechanical ventilation

Total Burns’ Wean Assessment Program score

r

P

−0.818

0.0001**

**High statistical significant difference.

significant difference between length of MV and total BWAP score as a weaning from MV (r=−0.818; P=0.0001).

Discussion The current study aimed to compare compliance versus noncompliance with VAP bundle implementation and its effectiveness on weaning among mechanically ventilated patients at a selected private healthcare sector. Our study findings revealed that there were no significant differences between compliant and noncompliant patients with respect to their demographic characteristics such age, sex, and smoking status. This finding is partially congruent with a similar study by Mohamed (2014), who studied compliance with VAP bundle implementation and its effectiveness on surgical and medical subpopulation in adult ICU and revealed that the mean age of patients who were studied after VAP bundle initiation was nonsignificantly lower than those before VAP bundle implementation, and there was no significant difference in sex distribution in the studied population. Similarly, the current study finding is consistent with the findings of Montasser et al. (2015), who studied the incidence of VAP with incomplete or complete adherence to bundle of

prevention; they revealed that there was no significant difference between cases with incomplete and those with complete VAP bundle application as regards age (49.57± 6.39 vs. 49.42±5.35 years, respectively), sex distribution (male patients represented 71.4% of cases with incomplete VAP bundle application and 65.0% of cases with strict application of VAP bundle). On comparing the compliant and noncompliant patients with VAP bundle implementation by their medical characteristics, our study findings revealed that there was no significant statistical difference between patients by their distribution of their diseases as regards respiratory, cardiovascular, neurological, and gastrointestinal diseases. This finding is consistent with Montasser et al. (2015), who found no significant statistical difference in cases with incomplete or complete VAP bundle application as regards cause of ICU admission: medical, postoperative, and traumatic (P=0.75). As regards comorbid signs and symptoms, there were only significant statistical differences between compliant and noncompliant patients with VAP bundle application as regards presence of lower limb edema (P=0.04) and pressure ulcer (P=0.01). On the same line, the current study finding revealed that there was no significant difference between the compliant and noncompliant groups of patients as regards duration of connection to MV. Our study finding is contradictory to Mohamed (2014), who found that the total VAP bundle compliance rate steadily increased from 63 to 84% during the period of implementation and reduction of duration of MV from 12.8±4.9 to 8.5±4.3 days for patients with VAP bundle compliance at the end of the study. Furthermore, Hawe et al. (2009) reported that the decrease in the mean length of stay and mean



duration of ventilation was statistically significant in their patients subjected to VAP bundle. However, another study evaluating these components of the bundle reported a 95% adherence with the bundle and an associated reduction in VAP, but investigators acknowledged that the reduction may have been related to a concurrent improvement program that focused on the care of the ventilated patients. The current finding is in agreement with Montasser et al. (2015), who revealed a significant statistical difference between cases with incomplete or complete VAP bundle application as regards duration of MV (P