Nursing Practice Research


TABLE 1. STUDIES INCLUDED IN THE REVIEW Author Study design


Study aims


Berra et al (2008)


Randomised control trial


Assess efficacy of silver- coated endotracheal tubes (ETTs) in preventing bacterial colonisation


Coffin et al (2008)


Kollef et al (2008)


Systematic review Identify recommendations to implement evidence- based VAP prevention efforts


Randomised control trial


Determine whether silver-coated ETTs reduce incidence of VAP in patients intubated >24 hours


Results/key findings


Absence of bacterial colonisation in silver-coated ETT lumens (n=23, p<0.01) Presence of bacterial colonisation in 35% of non-coated ETTs (n=23, p<0.01)


Unsubstantial evidence for recommendation


Study limitations


Study was limited to a 24-hour period Additional VAP preventive measures not used


Authors’ conclusion not to recommend silver-coated ETTs was based on two studies conducted in 2004; later studies not considered


Use of silver-coated ETTs=2.7% reduction and 35.9% reduced risk of VAP >24 hours (n=1,509, p=0.03). Use of silver-coated ETTs=3.2% reduction and 48% reduced risk of VAP development within 10 days of intubation (n=1,509, p=0.005)


Rello et al (2006)


Shorr et al (2009)


Randomised control trial


Assess the effects of silver-coated ETTs on bacterial colonisation in patients intubated ≥24 hours


Retrospective decision model cohort


Analyse costs of silver- coated ETTs in the reduction of VAP


Delayed development and reduced bacterial colonisation in silver-coated ETT lumens (n=121, p=0.02) and in tracheal aspirates (n=67, p=0.04)


Silver-coated ETTs associated with significant hospital cost savings (n=1,000)


VAP prevention measures not standardised among participating centres (54 in US)


Infection control measures not standardised among participating centres (one in US and three in Spain)


Study lacked rigour in methodology – hypothetical patient cohort employed. Input figures for VAP incidence and hospital costs were estimated. Input estimates for relative risk reduction were derived from a previous study


ventilation. These include the following: » Suctioning techniques; » Oral care; » Sedation interruption; » Patient positioning (Chastre, 2008; Coffin et al, 2008; Girard et al, 2008; Chlebicki and Safdar, 2007; Gastmeier and Geffers, 2007). These techniques are called VAP bun-


dles when used in combination (Wip and Napolitano, 2009; Chastre, 2008). A relatively new VAP prevention tech-


nique is the use of an ETT coated with silver sulfadiazine on the inner and outer lumens of the tube (Kollef et al, 2008). Silver sulfadiazine is non-toxic and


effective in preventing infection in wounds and burns (Kollef et al, 2008; Lansdown, 2006; Rello et al, 2006). It has also been shown to be effective in reducing urinary tract infections when used in indwelling catheters (Rello et al, 2006; Karchmer et al, 2000). Kollef et al (2008) speculated that when silver sulfadiazine is used as a coating in


ETTs, it prevents the colonisation of bac- teria and the formation of biofilms within the ETT components, thereby reducing the likelihood of VAP development. In the US, nursing efforts are concen-


trated on exploring interventions that con- tribute to managing VAP, as well as reducing its incidence. In 2004, the Amer- ican Nurses Association’s (ANA) National Center for Nursing Quality (NCNQ) desig- nated VAP as a priority nursing-specific indicator (Montalvo, 2007). This distinc- tion by the ANA requires nurses to become more accountable for tracking VAP-related patient outcomes, costs and prevention protocols. In the UK, the Department of Health


has established a high-impact interven- tion policy for use in the prevention of VAP (Department of Health, 2011). Compliance with high-impact interventions is man- dated by law for registered health profes- sionals and those who use them must com- plete staff-compliance audits with these clinical protocols (DH, 2010).


22 Nursing Times 04.09.12 / Vol 108 No 36 / www.nursingtimes.net


Searching the literature A thorough literature review was con- ducted using the dates 2000-2010 and the following databases: CINAHL; Medline; Health Source: Nursing and Academic edi- tion; ProQuest Nursing and Allied Health; Cochrane Database of Systematic Reviews; TRIP Database; and the National Guideline Clearinghouse. Search terms included: VAP; ventilator-associated pneumonia; silver- coated endotracheal tubes; VAP bundle; mechanical ventilation; intubation; preven- tion; reduction; and cost-effectiveness. Thirty-two references were obtained.


Exclusions were employed including in- vitro, animal and paediatric studies, and studies with unsubstantial experimental evidence. A total of 22 references remained for review. Five primary studies were appraised for the evidence-based review; these are summarised in Table 1.


Results Of the five studies appraised, two of the three randomised control trials found a


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