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INTRODUCTION
Nosocomial pneumonia is the
leading cause of death from hospital-acquired infections and is considered
as the most common ICU-acquired infection (Craven, Steger and Barber,
1991; Sole-Violan et al, 2001). VAP, as a type of nosocomial pneumonia, is
one of the concerns of ICU nurses as it has a great chance to develop
within a critically ill person. Mayhall (2001) defined
Ventilator-associated pneumonia (VAP) as a nosocomial pneumonia in a
patient on mechanical ventilatory support (by endotracheal tube or
tracheostomy) for >48 hours. In other words, VAP is pneumonia
in a patient receiving mechanical ventilation
that was neither present nor developing at the time of intubation (Grap et
al, 2005). This definition is based from diagnosis by the clinical
criteria of Johanson et al (1972), which includes progressive pulmonary
infiltrate, fever, leukocytosis, and purulent tracheobronchial secretions.
Currently, there is still difficulty in diagnosing VAP as it remains
controversial (Gould et al, 2003). Techniques for accurate diagnosis such
as bronchoscopically directed techniques and nonbronchoscopically directed
diarnosis face certain issues such as being invasive, high cost and lack
of validation (Mayhall, 2001).
One of the issues in VAP is
its relationship with backrest elevation, as researchers were trying to
link the development of the former with the latter. A recent research by
Grap et al (2005) showed that backrest elevation, combined with a severe
illness, most likely to develop VAP. This confirms previous findings of
the same topic – basically about the relationship between VAP and backrest
elevation. However, it did not confirm previous findings that “the greater
the length of time in lower backrest positions, the greater was the
incidence of aspiration of gastric contents” (Torres et al, 1992).
Furthermore, Grap et al’s (2005) findings were limited in a sense that
they only covered a small sample size
and they lack bronchoscopic evaluation for
diagnosis of pneumonia. Grap et al
(2005) suggested that future studies should be conducted to confirm the
results of their work. They also evaluated only those who have early onset
VAP and not those who have later onset VAP. There is a need to evaluate
the impact of backrest position on later onset VAP as well because this
may show other implications.
This paper proposes to explore and re-assess the
relationship between VAP and backrest position on patients, specifically
the impact of the latter to the former. Previous studies show positive
relationships between the two. However, those findings were based on
limited methods and procedures. Thus, there is a need for continuous
evaluation so as findings can be confirmed and to make sure that there
will be no contradictions among findings.
The aim of this investigation
is to confirm previous findings regarding the impact of backrest position
on VAP. This study will be addressed through quantitative and qualitative
research methods so as to have a variety of data options to analyze, to
increase the validity of the findings. In this approach, observations,
surveys and interviews on nurses will be conducted, as well as simple
tests performed by Grap et al (2005) in their study.
PROBLEM STATEMENT
The problem that will be
investigated in the study is the controversy regarding the effects or
impact of backrest positioning on the onset of VAP. Studies show that
“supine position is an independent risk factor for mortality in patients
receiving mechanical ventilation” (Craven et al, 1986; Kollef, 1993).
Mortality in the ICU is found greater with supine patients than with
semirecumbent patients. There were findings that height of backrest
position and time spent supine are both critical factors in the occurrence
of aspiration, and such aspiration increases the risk of pneumonia in
patients receiving mechanical ventilation (Kollef, 1995; Torres et al,
1992). Thus, bed angles should accurately be estimated so as the nurses
can position the patients better while on critical care (Grap et al,
2002). Lower backrest positions and higher backrest positions are both
required for different tasks such as hemodynamic monitoring and
measurement. Grap et al (2002) stated that higher backrest positions are
inadequate for patients in critical care and lower backrest positions are
more preferred. However, decisions are still based on the nurses’ accurate
estimates of the patients’ positions (Grap et al, 2002).
Because of the belief that
patient positioning is critical when it comes to mortality risks, and that
VAP is usually associated with such positioning, specifically backrest
positioning, many researchers investigated the relationship between the
two and came up with similar positive findings with slight differences.
However, their findings were limited with the number of samples they
included and the methods they used to conduct the study. Thus, there is a
need to confirm the findings further with new studies. This problem
statement is given priority in this study.
AIMS AND OBJECTIVES
The aim of the study is to confirm the
positive relationship between VAP and backrest positioning of patients.
However, unlike previous studies that performed only clinical trials, this
study will also examine the issue with the use of traditional data
collection approaches such as surveys and interviews. Clinical trials will
also be performed such as diagnosis for VAP and observation of patients
that are in the backrest positions.
The objectives of the study are as
follows:
1.
To conduct a diagnosis of
patients with early and later onset VAP.
2.
To measure the head
elevation using a 2 transducer system, similar to what Grap et al (2005)
used in their study.
3.
To determine the amount of
time spent by patients on backrest elevation.
4.
To interview nurses about
their experiences on backrest elevation leading or worsening a VAP.
5.
To survey the hospital about
the number of cases that relates backrest elevation with VAP.
6.
To categorize and analyze
data to form a coherent conclusion.
SIGNIFICANCE OF THE STUDY
The study will be significant for medical
and healthcare practitioners because it covers one of the most important
and controversial issues in nursing. The importance of positioning has
been well-emphasized by various studies, but its relationship with several
difficult-to-diagnose diseases such as VAP still fall short in terms of
confirmation of data. Through this study, previous findings can either be
strengthened or weakened, but either way, this can be a great help to the
healthcare sector. If ever previous findings will be supported, the
findings of this study may influences practitioners to take careful
measures on bed positioning of patients. On the other hand, if ever the
findings will contradict with previous studies, it may influence other
researchers to challenge its findings, which may contribute to the growth
of research in the topic, and ultimately may lead in the development of
more effective interventions.
The study will also be significant to
nursing students as this can serve them as reference to their studies.
This study may also used as reference for future studies that will tackle
the same topic.
METHODS
Design and Sample
The study will be categorized
into two samples: the patients and the nurses. The patients will undergo
specific measures specifically the level of head elevation using the 2
transducer system used by Grap et al (2005), and the measurement of their
time spent on backrest elevation. Other clinical data about the patients
will also be acquired such as the daily doctor’s report about the
patient’s condition. Similar to the study of Grap et al (2005), patient
respondents in this study will be kept in only the minimum of 10 because
of the difficulty to monitor a higher number of patients simultaneously.
The duration of the investigation will also be lesser than Grap et al
(2005) since the study will focus more on patients with later onset VAP.
Late-onset
VAP occurs after 4 days of continuous mechanical
ventilation (Grap et al, 2005).
Two variables will be measured
among the patients: this include backrest elevation and VAP. As mentioned,
the level of head elevation will be measured using transducer, while the
time patient spent on backrest position will be monitored and will later
be transformed to statistical figures. On the other hand, the diagnosis of
the VAP will be conducted using bronchoscopic techniques. A flexible
bronchoscope will be used to acquire tissue samples from the patients.
On the other hand, the nurse
samples will be interviewed and surveyed regarding their experiences and
observations on the relationship between VAP and backrest elevation. This
will include their views on backrest elevation and how they estimate the
position of the patients, and to which factors do they base their
decisions.
Data Analysis
Similar to Grap et al (2005),
the study will be analyzed using descriptive statistical analysis.
Similarly, percentages for discrete variables and means and SDs for
continuous variables will be calculated. Summaries for backrest elevation,
nutritional data, and oral care interventions will be generated for each
study day. The research will commit a total of 90 study days for the
investigation.
The formulas for the descriptive
analysis are as follows:
1.
Percentage – to determine the magnitude of the responses to the
questionnaire.
n
% = -------- x 100 ; n – number of responses
N N – total number of
respondents
2.
Weighted Mean
f1x1 + f2x2 + f3x3
+ f4x4 + f5x5
x = --------------------------------------------- ;
xt
where: f – weight given to each response
x – number of responses
xt –
total number of responses
On the other hand, interviews and surveys
with the nurses will be conducted with semi-structured questionnaires.
Interviews will be conducted informally and occasionally. The
questionnaires will be in the form of a 5-point Likert Scale where the
respondents will choose on whether they agree or disagree on a particular
statement. Other questions will be asked with an open question type so as
the respondents will have the option to further elaborate their answers.
The overall data will be
categorized and compared. Each result per day will be recorded and
computed after all the study days were conducted. This is similar with
what Grap et al (2005) did, but as the researchers stated, there is still
a need to confirm their findings with different samples. Conclusion will
be derived from the analyzed data.
Ethical
Considerations
Because this will be a
clinical research, ethical considerations will be well-observed in the
study. For instance, the confidentiality of data such as personal
information of nurses and patients will be observed. Furthermore, the
researchers will submit to requests of doctors and nurses if ever there is
a need for one such as those concerning the patient’s welfare. Tests such
the bronchoscopy will be conducted with the assistance of experts on the
machine.
Limitations
Like previous studies, this
current study is limited on patient respondents because of the restraint
in manpower and time to monitor a larger population sample. The study is
also limited only to descriptive data analysis, meaning it will just
present facts about the relationship between the two variables but not to
the point wherein personal and in-depth analysis will be provided.
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