NURS5002 Middle Tennessee State Intubated Males in ICU PICO Question Defining a clinical question in terms of the specific patient problem aids the searche

NURS5002 Middle Tennessee State Intubated Males in ICU PICO Question Defining a clinical question in terms of the specific patient problem aids the searcher in finding clinically relevant evidence in the literature. The PICO Model is a format to help define your question. A “well-built” question should include four or five parts, referred to as PICO(T) that identify the patient problem or population (P), intervention (I), comparison (C) outcome(s) (O) and when appropriate time (T). This assignment takes you through steps in formulating an answerable question that is relevant to your clinical practice.

Your PICOT question must be formulated as an intervention/treatment question and you must use the template provided for this assignment. Failure to use the required template will result in a grade of zero.

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My PICO T question is formulated like this

Intubated Males in short stay ICU settings between the ages of 43 to 45 (P) how does the use of oral 0.2% Chlorhexidine every 8 hours (I) compared to use of normal saline (C)reduce the risk of ventilator associated pneumonia (O) within the duration of their hospital stay (T)

You can fine tune the PICOT question to make it easier for you.

I will upload the template that you need to use to submit your answers and the article pertaining to the pico-t question. Karbandi et al
15
Evidence Based Care Journal
http://ebcj.mums.ac.ir/
Evaluation of the Effects of Oronasal
Versus Oral Disinfections with
Chlorhexidine on Clinical Criteria of
Ventilator-associated Pneumonia
Mahdi Alimi, Zahra Sadat Manzari, Seyedreza Mazlom, Ahmad Bagheri Moghadam,
Hossein Rouhani
The online version of this article can be found at
http://ebcj.mums.ac.ir/article_7619.html
Evidence Based Care Journal 2016 06:19 originally
published online 01 October 2016
Online ISSN: 2008-370X
Address: Mashhad Nursing and Midwifery School, Ebn-e-Sina St., Mashhad, Iran
P.O.Box: 9137913199
Tel.: (098 51) 38591511-294
Fax: (098 51) 38539775
Email: EBCJ@mums.ac.ir
19
Evidence Based Care Journal, 6 (3): 19-30
Original Article
Evaluation of the Effects of Oronasal Versus Oral
Disinfections with Chlorhexidine on Clinical Criteria of
Ventilator-associated Pneumonia
Mahdi Alimi1, *Zahra Sadat Manzari2, Seyedreza Mazlom3, Ahmad Bagheri Moghadam4,
Hossein Rouhani5
Received: 27/07/2016
Accepted: 01/10/2016
Evidence Based Care Journal, 6 (3): 19-30
Abstract
Background: Ventilator-associated pneumonia (VAP) is the most prevalent and lethal form of
nosocomial infections in the ICU and oral disinfection is a nursing measure to prevent this condition.
Aim: this study aimed to evaluate the effect of oronasal versus oral disinfections with chlorhexidine
on the clinical criteria for diagnosis of VAP.
Method: This randomized clinical trial was conducted on 70 intubated ICU patients under mechanical
ventilation at Shahid Kamyab Hospital of Mashhad, Iran in 2016. Samples were divided into two
groups of intervention (mouthwash and disinfection of nostrils with 0.2% chlorhexidine every eight
hours) and control (mouthwash). Clinical criteria for VAP, including pulmonary infiltration, rectal
temperature, white blood cell (WBC) count and endotracheal discharge were recorded and compared
between the two groups from days 1-6. Data analysis was performed in SPSS version 11.5 using Chisquare test.
Results: In this study, mean age of intervention and control groups was 44.3±19.9 and 45.9±18.2
years, respectively. The results of Chi-square test indicated no significant difference between the
groups regarding rectal temperature (P=0.22), WBC count (P=0.33), purulent endotracheal discharge
(P= 0.47), pulmonary infiltration (P=0.21) and incidence of VAP (P=0.21).
Implications for Practice: According to the results of this study, no statistically significant
difference was observed between the two groups regarding clinical criteria and the incidence of VAP
despite clinical differences. Therefore, it is recommended that further studies be conducted in this
area.
Keywords: Ventilator-associated pneumonia, Mouthwash, Chlorhexidine, Mechanical ventilation
1. MS in Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
2. Evidence Based Care Research Centre, Assistant Professor of Nursing, Department of Medical-Surgical Nursing, School
of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
3. Evidence Based Care Research Centre, Instructor of Medical-Surgical Nursing, School of Nursing and Midwifery,
Mashhad University of Medical Sciences, Mashhad, Iran
4. Assistant Professor, Department of Anaesthesiology and Critical Care, Imam Reza Hospital, Mashhad University of
Medical Sciences, Mashhad, Iran
5. Anesthesiologist, Shahid Kamyab Hospital, Mashhad University of Medicals Sciences, Mashhad, Iran
* Corresponding author, Email: ManzariZ@mums.ac.ir
Downloaded from http://ebcj.mums.ac.ir/ at Mashhad University of Medical Sciences on October 01, 2016
Alimi et al. Oronasal Versus Oral Disinfections with Chlorhexidine on Clinical Criteria
20
Introduction
Nosocomial infections are some of the major and common challenges in healthcare centers and
mainly lead to prolonged hospitalization, increased medical costs and patient mortality (1). Ventilatorassociated pneumonia (VAP) is the most prevalent and lethal form of nosocomial infection in the ICU
(2). VAP is considered as a subgroup of nosocomial pneumonia and occurs in approximately 10-20%
of patients undergoing mechanical ventilation 48-72 hours after endotracheal intubation and initiation
of mechanical ventilation (3, 4). In addition, this disease is responsible for 27-47% of infection in the
ICU throughout the US (5). In this regard, a study was conducted in Shohadaye Tajrish hospital,
Tehran, Iran in 2005 and the results portrayed VAP as the most prevalent infection (46%) in the ICU
(6).
One of the most important risk factors for the development of VAP is the duration of mechanical
ventilation. While prolonged mechanical ventilation is associated with reduced risk of early-onset of
VAP, the possibility of infection decreases after the fifth day admission. According to the literature, it
is estimated that risk of VAP is three percent per day during the first five days of ventilation, while it
reduces to two percent per day during the second five days and one percent per day thereafter. Risk
for VAP is greatest during the first five days of mechanical ventilation (7, 8).
Pathogens, carried in the mouth and nose, play an important role in the incidence of VAP (9-12).
Mouth and nose meet at pharynx and are important sites of pathogen colonization. These body parts
harbor concavities, leading to colonization of bacteria during the times of compromised immunity
(e.g., trauma and surgery) (13). On the other hand, most patients in the ICU experience endotracheal
intubation during mechanical ventilation (1).
Endotracheal intubation causes dysphagia, resulting in mucus accumulation in the oral and nasal
cavity and accelerated colonization of bacteria (9). However, this mucus accumulation in oral and
nasal cavities cannot be avoided in patients undergoing mechanical ventilation due to their
compromised consciousness, as well as disturbed cough and swallowing reflexes.
Furthermore, ineffective defense mechanisms, caused by compromised immune system in patients,
lead to the colonization of microorganisms, which is carried as normal flora of nasal and oral cavities
during 24 hours after admission to the ICU. These colonies, along with oral and nasal discharge,
migrate through the endotracheal tube and alongside with the trachea itself toward lower airways and
overcome innate host defense system, which finally leads to pneumonia (14).
According to the instructions published by the centers for disease control and prevention (CDC), the
most important strategy for prevention of VAP is oral hygiene (15). Among oral rinses, chlorhexidine
has been recognized as the golden standard and the most effective antibacterial oral rinse in the
market (13). According to several reports, chlorhexidine decreases oral colonization (16-19), leading
to reduced incidence rate of pneumonia by 10-30% (4).
Chlorhexidine (a widely used skin and mucous membrane antiseptic) is an effective, inexpensive and
well tolerated solution and has sustained antibacterial activity (up to 12 hours) (20, 21). To date, there
are no reports of a chlorhexidine?resistant strain of bacteria. Therefore, chlorhexidine can be
considered as a proper oral rinse for hospitalized patients (6).
On the other hand, pathogens carried in nostrils have been known as the main risk factor for the
incidence of nosocomial infections and VAP, especially in patients hospitalized in the ICU (5). The
main entry to the nasal passageway for pathogens is through the nostrils. Moreover, this area is
exposed to microbes carried in the sinus and nasal cavity mucus, which provides a desirable surface
for the colonization of microorganisms (13). Aspiration of colonized nasopharyngeal discharge
around endotracheal tube leads to the colonization of lower airways and subsequent VAP (16).
In a report by the national healthcare safety network (NHSN) in the US, Staphylococcus aureus was
introduced during 2009-2010 as the leading cause of VAP and surgery site infection (22). Studies
have shown that Staphylococcus aureus colonizes both nostrils and mouth, and nostrils are the
primary reservoir for the colonization of the bacteria (13, 22). Rusha et al. (2013) demonstrated in a
study that colonization of Staphylococcus aureus in nostrils was associated with increased incidence
rate of VAP in patients; therefore, it is considered as a risk factor for the VAP (5).
The mupirocin nasal ointment is commonly used to eliminate nasal golden staph bacteria. However,
excessive use of this substance could cause a significant resistance (22) Efforts to treat infections
caused by this pathogen, made resistance to most commonly available antibiotics (23).
Downloaded from http://ebcj.mums.ac.ir/ at Mashhad University of Medical Sciences on October 01, 2016
21
Evidence Based Care Journal, 6 (3): 19-30
Prevention is a priority to improve the quality of patient care because of serious consequences and
complications of VAP (17).
It is obvious that preventing these infection, not only may reduce costs but also improve the results
related to patient and patient safety and even increase the quality of patient care (24).
According to the literature, nurses play an important role in prevention of VAP (9).
Diagnosis ability of healthcare teams for VAP is extremely limited despite its clinical importance (4).
Several intensive care researchers have tried to establish criteria for a more precise diagnosis of
pneumonia for more than 50 years (2). In this regard, Johanson et al. described clinical criteria for
diagnosis of VAP to facilitate this process (25). Literature review revealed only two studies with the
aim of evaluating the effects of chlorhexidine solution in mouth and nostrils on reduced respiratory
infections, both carried out in patients after cardiac surgery. In a study by Segers et al. (2006), a
significant decrease was observed in the incidence of pulmonary complications after open heart
surgery (21). On the other hand, the results obtained by Rostami et al. (2011) were indicative of no
significant reduction in spite of decreased respiratory infection after open heart surgery (26).
To the best of our knowledge, there has been no research on the effect of simultaneous disinfection of
mouth and nostrils on the incidence of VAP. Prevention of ventilator-associated respiratory infections
is of paramount importance and nurses have a key role in this regard. In addition, it has been
confirmed that nasal pathogens are recognized as risk factors for VAP and chlorhexidine has a
significant role in disinfection of mucous membrane for VAP prevention. Given the fact that the
effects of nasal disinfection with chlorhexidine has not been thoroughly studied, compared to mouth
rinsing, the present study aimed to compare the effects of oronasal versus oral disinfections with
chlorhexidine on the clinical criteria for the diagnosis of VAP.
Methods
This randomized clinical trial was conducted on 70 intubated patients under mechanical ventilation in
the ICU of Shahid Kamyab hospital, Mashhad, Iran in 2016. Participants were divided into two
groups and post-test was used to evaluate the results. Due to the lack of similar studies and
qualification of dependent variables based on Johansson’s criteria, sample size was estimated based
on the results obtained from a pilot study (on 10 cases in each group) and the comparison of two ratios
formula with 95% confidence level and 80% test power. Subsequently, the criterion used to estimate
the highest sample size was pulmonary infiltration in this study. In total, sample size was calculated at
29 in each group; however, 45 individuals were assigned to each group for more accuracy and due to
possible sample loss.
Exclusion criteria were unplanned endotracheal extubation (UE) on day one or two of mechanical
ventilation (elimination of four and five individuals from intervention and control group,
respectively), patient mortality on day one and two of mechanical ventilation (elimination of two
patients in each group) and meeting at least two out of three criteria of Johansson’s criteria (e.g.,
rectal temperature, WBC count and purulent endotracheal discharge) on day one or two of mechanical
ventilation (elimination of four and five patients in intervention and control group, respectively),
which led to a total elimination of 10 patients from the study and conduction of data analysis on 35
individuals per each group. Other exclusion criteria were allergy to chlorhexidine, observation of
obvious aspiration and probable presence of pneumonia prior to intubation and mechanical ventilation
(6, 12, 17, and 27).
Participants were among the eligible patients hospitalized in the Shahid Kamyab hospital at the time
of research and were selected through convenience sampling. Afterwards, patients were assigned to
the intervention and control groups using random number table. Accordingly, random numbers (0-9)
were drawn and then allocated to each group. Subsequently, the tip of a pen was placed on a number
with closed eyes in the random numbers table and the following numbers were recorded in the table.
The sequence of numbers determined the sequence of individuals enrolled in each group based on the
previous assignment of numbers to individuals. Since individuals were allocated to groups before the
start of the experiment, the minimum level of bias was achieved.
Inclusion criteria were agreement of patient’s relatives (because of compromised consciousness of
patients), aged ?18 years, orotracheal intubation, at least 48 hours of expected mechanical ventilation,
lack of proper nasogastric intubation for nasal disinfection by swab, lack of immunodeficiency or
underlying lung diseases and lack of symptoms of respiratory infection upon admission to the ICU
Downloaded from http://ebcj.mums.ac.ir/ at Mashhad University of Medical Sciences on October 01, 2016
Alimi et al. Oronasal Versus Oral Disinfections with Chlorhexidine on Clinical Criteria
22
(i.e., lack of pulmonary infiltration in chest radiography and lacking at least two out of three clinical
criteria of VAP).
Data collection tools were checklist of VAP predisposing factors and daily patient examination
checklist using clinical criteria of VAP. In this regard, VAP risk factors included the level of
consciousness upon admission to the ICU (based on Glasgow coma scale), cause of hospitalization,
severity of disease (based on APACHE II scoring system), history of underlying diseases, antibiotic
consumption during hospitalization, smoking habit, bed head position, surgical operation during
hospitalization, enteral nutrition and use of sedative agents during mechanical ventilation (1, 4, 6, 28).
These confounding variables were controlled by randomized distribution and close monitoring of
participants in the study groups.
Clinical criteria of VAP (Johnson criteria) were pulmonary infiltration in chest radiography and
meeting at least two out of three criteria (e.g., rectal temperature 38°C, WBC count 12000/mm3 and purulent endotracheal secretion). Presence of each of the above-mentioned criteria
leads to VAP diagnosis (7).
These tools were prepared according to experimental methodology, previous studies and review of the
latest literature, validity of which have been confirmed by numerous studies inside and outside the
country. (7, 29, 30). Application of these criteria for VAP diagnosis is recommended by the American
Thoracic Association (25). In this study, the validity of study tools was evaluated and confirmed one
more time by 10 faculty members of the Department of Nursing and Midwifery of University of
Mashhad, Iran.
Mobile X-ray equipment (Siemens, Germany) was used for all the patients, validity of which was
confirmed based on its reputable brand and the reliability of this scale was assessed by regular quality
controlling by a radiologist. In addition, an anesthesiologist and ICU specialist checked chest
radiographs for pulmonary infiltration and rectal temperature was measured by a glass thermometer
with the aid of a nurse with five years of experience in the ICU. Validity (since it was brand-new and
belongs to a reliable company) and reliability (by regular comparison to similar tools) of thermometer
were also confirmed. WBC count of blood samples was measured by the author using Sysmex K1800 (Japan). Validity and reliability of the counter was confirmed based on its brand and the lab
technician who regularly calibrated the device with standard blood tubes. Endotracheal discharge was
assessed based on color, odor and viscosity with the aid of the nurse taking care of patients. Validity
and reliability of this method was confirmed by 10 experts and the assessor agreement method
(r=0.82), respectively.
Checklist of VAP risk factors consisted of objective and clear questions, which have been frequently
used in similar studies and their validity was already confirmed. The reliability of daily checklist of
patient examination of clinical criteria of VAP was assessed using assessor agreement method on 15
patients, which was confirmed with the coefficient of 0.85.
A form, consisting of demographic characteristics (e.g., age, gender and marital status) and risk
factors of VAP, was completed for all the participants by the researcher through interviews with
relatives, referring to medical histories and observing clinical criteria in the patients. In addition, the
severity of patients’ disease was evaluated based on APACHE II scale 24 hours after admission to the
ICU.
In the present study, respiratory infection indices were assessed based on Johnson’s criteria with the
aid of two physicians, who were not aware of the order of assignment of experimental units to
intervention and control groups. According to previous studies, examination of patients was continued
until day six due to the fact that daily risk of VAP is at its peak on day five of mechanical ventilation
and starts to decline thereafter.
Upon admission to the ICU and daily assessment until day six of mechanical ventilation (at 6-7 am),
all the participants were evaluated for three clinical criteria of VAP. In addition, presence of at least
two out of three criteria on day one or two could lead to sample exclusion due to probable pneumonia
before intubation and mechanical ventilation. If two criteria were observed through day 3-6 of
mechanical ventilation, patients were examined for pulmonary infiltration using portable chest
radiography. In case of presence of clinical criteria of VAP, intervention terminated and patients were
diagnosed with VAP. Otherwise, examination would continue until day six of mechanical ventilation
and on day six (in case of absence of at least two out of three clinical criteria of VAP) pulmonary
infiltration was considered to be negative (Figure 1).
Downloaded from http://ebcj.mums.ac.ir/ at Mashhad University of Medical Sciences on October 01, 2016
23
Evidence Based Care Journal, 6 (3): 19-30
The first intervention was performed for all the participants after 12 hours of connection to the
ventilator. Intervention process continued until the end of day five of mechanical ventilation or until
all clinical criteria of PAV became positive. Mouthwash (disinfection of vestibules, gums, palate, the
tongue and teeth) with chlorhexidine was performed every eight hours by the researcher for 30
seconds using applicator in both groups (6, 14, and 22).
In the intervention group, an additional disinfection was performed on nostrils immediately after
disinfection of mouth using a cotton swab dipped in 2% chlorhexidine.
Admission to the ICU
Examination of clinical indices upon admission
(Pulmonary infiltration in chest radiography, rectal temperature, WBC count and endotracheal secretion)
Enroll to
the study
No
Yes
(Presence of infiltration and two of the three clinical criteria)
Exclude from
the study
Daily examination of three clinical criteria
Yes
Pres…
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