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significant reduction in bacterial colonisa- tion in the silver-coated ETTs. Specifically, there was reduced colonisation in patients’ trachea and bronchial aspirates, as deter- mined by microscopic assessment (Berra et al, 2008). In addition, for patients intu- bated for longer than 24 hours, bacterial colonisation was delayed and reduced in the silver-coated ETT lumens and in tra- cheal aspirates (Rello et al, 2006). Kollef et al’s (2008) investigation found
a reduction in actual VAP incidence when silver-coated ETTs were used with patients intubated for longer than 24 hours. Although the systematic review com- pleted by Coffin et al (2008) did not sup- port changing practice change because the evidence was insubstantial, the authors noted additional VAP prevention measures for best practice. These included: » Continued surveillance and data collection;
» Staff education on VAP epidemiology, risk factors and patient outcomes;
» Direct observation of staff compliance with VAP prevention measures. The study conducted by Shorr et al
(2009) indicated cost savings associated with the use of silver-coated ETTs.
Discussion and recommendations Continued active surveillance and data col- lection of VAP is considered best practice for VAP prevention (Coffin et al, 2008). One example of a programme that allows for compliance with this recommendation is the ANA’s NCNQ. The NCNQ has included VAP as a priority nursing-specific indicator and tracks institution-specific data related to VAP, paying particular attention to patient care and outcomes (ANA, 2012). Even with current or future scientific
research into the effectiveness of silver- coated ETTs, staff-education and compli- ance issues need to be addressed. Addi- tional best practices for VAP prevention include staff education on epidemiology, risk factors and patient outcomes as well as direct observation of staff compliance with VAP prevention measures (Coffin et al, 2008). Research has demonstrated that the use of multimodule interventions involving staff-education workshops and subsequent staff surveillance may lead to significant increases in staff compliance with VAP prevention bundles as well as a reduction in VAP (Hawe et al, 2009). Another novel strategy to increase staff
knowledge and strengthen compliance with VAP bundle protocols is the use of morbidity and mortality peer-review con- ferences (MMPRCs) (Nolan et al, 2010).
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These are composed of peer-discussion sessions that include active clinical thinking and reasoning among the group members about the care of specific patients in relation to VAP prevention. A study conducted by Nolan et al (2010) demonstrated that the use of MMPRCs increased nurses’ accountability and compliance when using VAP prevention bundles.
QUICK FACT
≥85% People who develop
pneumonia in ICU who are on mechanical ventilation
Conclusion Based on the review of the literature, the use of silver-coated ETTs is effective at reducing VAP in intubated patients receiving mechanical ventilation. However, further research is needed
before changes to practice can be recom- mended. Additional randomised con- trolled studies using patients with diverse diagnoses should be carried out to demon- strate the reduction of VAP with the use of silver-coated ETTs in combination with evidence-based VAP bundles. In addition, future research efforts need
to prioritise and package the various individual strategies that have demon- strated best practice to date in VAP preven- tion. There is also a paucity of evidence that addresses fiscal feasibility and resources as they relate to methods used in VAP prevention. As frontline, bedside clinicians, nurses
are ethically responsible for improving patient safety, promoting optimal patient outcomes and reducing long-term hos- pital costs and complications. Increasing nurses’ knowledge of VAP and their accountability with the implementation of VAP prevention measures is imperative. Of equal importance is the need for the nursing profession to participate in fur- ther VAP research to advance knowledge of the benefits and cost-effectiveness of the use of silver-coated ETTs within bundled care that is aimed at preventing VAP. NT
References American Nurses Association (2012) National Database of Nursing Quality Indicators. www.
nursingquality.org American Thoracic Society, Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated and healthcare-associated pneumonia. American Journal of Respiratory and Critical Care Medicine; 177: 388-416. Berra L et al (2008) Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to
prevent bacterial colonization: a clinical trial. Intensive Care Medicine; 34: 1030-1037. Chastre J (2008) Preventing ventilator-associated pneumonia: could silver-coated endotracheal tubes be the answer? Journal of the American Medical Association; 300: 7, 842-844. Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine; 165: 867-903. Chlebicki MP, Safdar N (2007) Topical chlorhexidine for prevention of ventilator- associated pneumonia: a meta-analysis. Critical Care Medicine; 35: 2, 595-602. Coffin SE et al (2008) Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infection Control and Hospital Epidemiology; 29: Suppl 1, 31-40. Department of Health (2011) High Impact Interventions. London: DH.
tinyurl.com/DH-high- impact-HCAI Department of Health (2010) The Health and Social Care Act 2008. Code of Practice on the Prevention and Control of Infections and Related Guidance. London: DH.
tinyurl.com/ healthandsocialcareact Gastmeier P, Geffers C (2007) Prevention of ventilator-associated pneumonia: analysis of studies published since 2004. Journal of Hospital Infection; 67: 1-8. Girard TD et al (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. The Lancet; 371: 126-134. Hawe CS et al (2009) Reduction of ventilator- associated pneumonia: active versus passive guideline implementation. Intensive Care Medicine; 35: 1180-1186. Karchmer TB et al (2000) A randomized crossover study of silver-coated urinary catheters in hospitalized patients. Archives of Internal Medicine; 160: 3294-3298. Kollef et al (2008) Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. Journal of the American Medical Association; 300: 7, 805-813. Lansdown AB (2006) Silver in healthcare: antimicrobial effects and safety in use. Current Problems in Dermatology; 33: 17-34. Montalvo I (2007) The national database of nursing quality indicators (NDNQI). The Online Journal of Issues in Nursing; 12: 3.
tinyurl.com/ NursingQualityIndicators Nolan SW et al (2010) Effect of morbidity and mortality peer review on nurse accountability and ventilator-associated pneumonia rates. The Journal of Nursing Administration; 40: 9, 374-383. Rello J et al (2006) Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study. Critical Care Medicine; 34: 11, 2766-2772. Rello J et al (2002) Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest; 122: 2115-2121. Rotstein C et al (2008) Clinical practice guidelines for hospital-acquired pneumonia and ventilator- associated pneumonia in adults. The Canadian Journal of Infectious Diseases and Medical Microbiology; 19: 1, 19-53. Shorr AF et al (2009) Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumonia. Infection Control and Hospital Epidemiology; 30: 8, 759-763. Wip C, Napolitano L (2009) Bundles to prevent ventilator-associated pneumonia: how valuable are they? Current Opinions in Infectious Disease; 22: 159-166.
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