Benchmark- Capstone Project Change Proposal
Admission of patients into the intensive care unit (ICU) is a common health practice across the world. In the US alone, over 5 million people were admitted to the ICU (Suljevic et al., 2020). Patients in ICU are provided with specialized care that requires close monitoring of medications and equipment. Because most of the patients are unconscious due to either sedating medications or severe disease, they require close monitoring to stabilize all body systems to improve outcomes.
As a result, ICU patients require life-saving invasive procedures aimed at stabilization. Among the common procedures includes central lines, urinary catheters, endotracheal intubation, tracheostomy, feeding tubes, and cardiac monitors (Suljevic et al., 2020). Ironically, despite these procures being paramount in saving lives, they contribute to infections and other complications that are major contributors to death. For instance, catheters are associated with catheter-associated urinary tract infections (CAUTIs); central lines cause central line-associated bloodstream infection, while mechanical ventilators are associated with mechanical ventilators (VAP).
The presence of VAP or either of the infections in ICU patients complicates their clinical outcomes while increasing the risk of mortality and morbidity and increasing the cost of care. Therefore, preventing the incidence of such infections remains a priority issue in health care. Some of the nurse-led evidence-based practice preventive measures include encouraging early ambulation, hourly turning, installation of orotracheal as opposed to nasotracheal tubes, spontaneous breathing trials, sedation, head elevation, staff education, infection surveillance, and prophylaxis for stress ulcers and venous thromboembolism (Xu et al., 2019).
These methods have helped in reducing the incidents of VAP but are not sufficient. The need to improve patient outcomes has led to various pieces of research using chlorohexidine (CHG) mouthwash to evaluate its effectiveness in preventing VAP while improving patient outcomes. There have been mixed findings from evidence. Most studies have proposed using CHG to prevent VAP and other infections, while some show contradictory results. Therefore, in my quest to understand the subject matter, I decided to undertake this project to find more evidence that will help in improving patient outcomes. This paper will address the following: problem statement, PICOT statement, the purpose of the change proposal, literature search strategy, literature evaluation, and barriers to implementation, as well as how to overcome them.
Clinical Problem Statement
By definition, VAP is a lower respiratory tract disorder that develops within 48 hours or more of being on mechanical ventilation in a patient that originally did not have the condition. VAP is among the most common nosocomial infection in ICU, accounting for 9 to 27% of all infections in the ICU. It is the second commonest hospital-acquired infection (HAI) after CAUTIs (Xu et al., 2019). Because up to 300,000 patients admitted to the ICU require mechanical ventilation to support breathing and necessitate gaseous exchange, up to 20% of all VAP associated with mechanical ventilators is the major risk factor (Suljevic et al., 2020)r.
The ventilators act as a breach in the natural immunity that allows bacteria and other micro-organisms to access the lower respiratory tract and multiply to cause VAP. In addition, intubation compromises the integrity of the trachea and oropharynx, allowing oral and gastric secretions to access the respiratory tract leading to irritation that further increases the risk of VAP.
The incidences of VAP increase with the duration of ventilation, with an estimated rate of 3% in the first days, 2% per day between days 6 and 10 and 1% per day after day 10 (Suljevic et al., 2020). Notably, an infection caused by Pseudomonas contributes to crude mortality of 27 to 67% with VAP which is higher than all other bacteria except for actinobacteria (Xu et al., 2019). In addition to mechanical ventilation, other risk factors combine to increase the risk, such as advanced age, immobilization, supine position, immunosuppression, and increased ICU stay.
Various microorganisms are implicated in the pathophysiology of VAP. Both gram-positive and gram-negative bacteria can colonize the lower respiratory tract, multiply, and cause pneumonia (Kohbodi et al., 2022). Comparing the timing of infection, early-onset VAP is associated with drug-sensitive bacteria, while late-onset VAP is associated with drug-resistant bacteria.
Drug resistance pneumonia is difficult to treat and impairs patient outcomes. Furthermore, VAP increases the risk of mortality, morbidity for those who survive and increased hospital stays. For instance, every patient spends an extra $40,000 on each extra day spent in the hospital leading to an increased healthcare burden (Pawlik et al., 2022). Therefore, there is a need to prevent VAP and increase patient outcomes.
The purpose for Change.
Because of the burden caused by VAP in terms of increased hospital stay, mortality, morbidity, and increased cost of care, there is a need to implement a nurse-driven protocol to prevent infection. Among the various protocols used in the prevention, chlorohexidine (CHG) has been applied in various setups, yielding promising results.
CHG is an antiseptic antimicrobial with a bactericidal effect against both gram-positive and gram-negative bacteria. Appropriate use of CHG mouthwash reduces the microbial load and helps in reducing the incidences of VAP, as reported by various pieces of evidence (Kohbodi et al., 2022). Therefore, this project change aims at improving nursing knowledge about the use of CHG in preventing infections in the ICU. This will help reduce the rate of nosocomial infections while improving patient outcomes and reducing mortality, hospital stay, and cost of care.
Various levels of evidence reviewed in the literature provide vital information about the use of CHG and its impact on reducing VAP. This project will focus on teaching nurses to adhere daily application of CHG to intubated patients to prevent VAP. I came up with a PICOT to address to help me complete this project. The PICOT states: In adult patients intubated in ICU (P), how does daily use of Chlorohexidine (I) compared to not using (C) reduce the risk of Ventilator Acquired Pneumonia (VAP) (O) over three months? (T)
Because this project aims to improve nursing care and patient outcomes, I undertook a rigorous search to identify published evidence that could help support the change. Various sources with reputable information were searched. Such include Medline, ProQuest, google scholar, PubMed, Scopus, CINAHL, and Science Web. The initial step of the search involved finding the overall information about VAP. Keywords such as prevention of VAP uses of Chlorohexidine and effects of VAP in ICU patients were used. Besides, using Medical Subject Headings (MeSH) helped find more evidence. Various levels of evidence, including systemic reviews, meta-analysis, quantitative, clinical trials, and qualitative publications, were identified, with sources published within the past five years meeting the inclusion criteria.
Evaluation of the Literature.
The various publications identified aimed at addressing various issues while answering some clinical questions. Therefore, the different objectives attracted various research questions. To begin with a study by D’Journo et al. (2018), the authors aimed to evaluate the impact of CHG on preventing complications for post-surgery patients.
The question stated, `Does the use of CHG prevent respiratory complications post-surgery for patients with lung cancer? In another meta-analysis by Jackson and Owens (2019), the question stated,` How does the use of CHG prevent VAP among intubated patients? While mathematical analysis by Reagan et al. (2019) aimed at finding out the effectiveness of CHG in reducing the cost of care, a study by Pallotto et al. (2019) sought to find out the effectiveness of using a soap-like solution of CHG would be effective in reducing the incidences of hospital-acquired infections. Finally, Deschepper et al. (2018) stated, Does the use of chlorohexidine oral care in critical and non-critical patients reduce mortality? While Triamvisit et al. (2021) questioned whether the risk of VAP in the neurosurgical unit could be reduced by using CHG.
Every study that was evaluated had various interests; hence diverse populations were recruited to meet the objectives of each study. The studies comprised nurses and patients admitted to the ICU. For instance, the survey by D’Journo et al. (2018) and Pallotto et al. (2019) were done in different settings, but the sampled population was 450 and was randomized with a simple method. A study by Triamvisit et al. (2021) had only 291 patients despite being done in two different units. A simple randomization technique was used to divide the patients into control and intervention groups. A mathematical model by Reagan et al. (2019) used a simulated sample size of 850 to estimate the cost. Lastly, a study by Deschepper et al. (2018) used a larger sample size of 82,274 compared to the other studies.
Despite various levels of evidence chosen for the literature review, all authors agreed that VAP is a serious health concern that, if not addressed, will continue being a healthcare model while increasing the rates of mortality. Additionally, nursing-driven care protocols are essential in improving the quality of care and health outcomes. The findings from a retrospective study by Deschepper et al. (2018) were complemented by a systematic review by Jackson and Owens (2019), as both found that the use of CHG leads to a significant reduction in HAIs such as VAP in intubated patients. Additionally, patient outcomes improved with a reduction in the hospital stay.
Likewise, while assessing the role of CHG on the cost of care, Reagan et al. (2019) found that the use of CHG leads to a reduction in the incidences of VAP leads, a reduction in hospital stays, and a lowering cost of care. Furthermore, findings from D’Journo et al. (2018) showed a significant reduction in HAIs. However, there was no significant difference in the length of stay between the control and the intervention group. Therefore, various authors recommended the implementation of CHG use in multiple settings to prevent various HAIs and improve patient outcomes.
Nursing Theory Utilized
This project adopted Rodger`s Change theory. As an extension of Lewin`s theory, this theory states that change is exciting and good. However, the adoption of changes is the main issue (Lingerfelt & Hutson, 2021). While Lewin`s theory appreciates the presence of resistance and forces that require the forces the push through to overcome resistance, Rodgers agrees that people may reject change but may accept it once they have seen the impact.
This concept is applicable in nursing and especially when introducing a change that contradicts the existing norm. Individuals will always stick to what they are used to despite appreciating that the contrary is better. To implement change and make it appreciated, Rodger`s theory presents a five-step model that, if followed, can improve change adoption.
The stages in their order include awareness which involves acquiring knowledge about a new change; interest stage involves an individual seeking more information about an issue they have just discovered; assessment involves making a decision based on the accessed information either to accept or reject; execution involves accepting a change and putting it into practice, and adoption involves the continuous practice of the new idea making it a routine (Lingerfelt & Hutson, 2021). This theory is applicable to this project and allows nurses to adopt the use of CHG daily. Therefore, mastery of all the stages is paramount to enabling people to adapt to change.
Implementation Plan with Outcomes
Having an appropriate implementation plan ensures the stepwise introduction of the change and maintaining it within an organization. This project aims at implementing the use of CHG mouthwash on patients on mechanical ventilation to reduce the incidences of VAP. The initial plan in implementation will be identifying the stakeholders who are essential in implementation.
The second thing would be surveying nurses to assess their level of knowledge about the change project. This aims at identifying the gaps that would be addressed while making adjustments. Furthermore, nurses will be educated through demonstrations and presentations on how to administer CHG to help in improving knowledge and skills about the change project. Thereafter, nurses will be allowed to demonstrate the skills based on the training.
Nevertheless, the expected outcome would be improved knowledge and skills for nurses on the application while adhering to the procedure daily. Another expected outcome would be a reduction in the incidences of VAP with improved clinical outcomes, reduced mortality and morbidity, and a reduction in hospital stay and cost of care. Finally, I would expect the nurses to share their knowledge and skills with other healthcare personnel to enhance patient safety.
Evidenced-based Practice used in the Intervention Plan
Various levels of evidence have shown how effective CHG is in the prevention of VAP and other HAIs. Because the population of concern is intubated patients, the intervention plan aims at reducing the microbial load. Therefore, the intervention will include the application of CHG mouth daily to improve oral hygiene and kill micro-organisms. Besides, CHG wipes would be used to wipe and disinfect equipment used in mechanical ventilation.
Plan for Evaluating the Intervention
Upon implementation of the project, an evaluation will be paramount to monitor progress. Evaluation provides an opportunity for comparing the results of the pre-and post-intervention period. Data would be collected three months after implementing the change. Both qualitative and quantitative data collection methods would be used. Performing interviews with nurses to assess their experience using the intervention would form the qualitative data. Quantitative data will include structured questions with a clinical pulmonary intervention scale. A positive outcome would be marked by increased knowledge, adherence to daily bathing, and a reduction in incidences of VAP. Contrary results would mean failure, which requires adjustments to ensure that primary objectives are met.
Implementation Barriers and Measures to Overcome.
Implementation of the project requires the support of both the leadership of the organization and fellow members, failure to attain either can impair the implementation. Regarding the organization, various barriers include a lack of support from the organization, limited resources, and limited time to allow EBP changes. Because resources form a vital part of care, a lack of resources such as money and materials can impair demonstration or adherence to protocols. Besides, an inadequate resource is a trigger for nursing burnout which can limit implementation and reduce the quality of care.
Therefore, there is a need to address organizational challenges ad improve the chances of success. One of the ways is through the identification of stakeholders who will mobilize the resources required for implementation. Another way is through holding genuine discussions with leadership while stressing the importance of the change project, why it should be implemented, and how it will influence clinical outcomes and patient experience. This aims to convince the leadership and enhance the implementation process.
Looking at the personal factors that impair implementation, resistance to change by members is the most common. Resistance to change can be attributed to a lack of knowledge about the change project, lack of interest, poor communication strategies, personal differences, and ignorance (Chen et al., 2022). Other personal factors include impaired teamwork, poor coordination, increased workload, limited time, and the view that a particular change will not cause maximum effects.
Therefore, adopting good communication techniques will help pass the information about the project to enhance knowledge and understanding. Another strategy includes allowing for inclusivity of all members to allow them to provide their contribution, having a flexible implementation plan, solving any differences that arise, and having a resistance plan. The resistance plan allows one to appreciate other people`s different opinions while addressing them to attain understanding. Failure to identify and address the barriers on time can impair the implementation process while weakening the project.
Despite the presence of various driven protocols to increase patient outcomes in the ICU, various nosocomial infections, such as VAP, continue to affect ICU patients. Such conditions impair their life and increase the risk of death due to complications. The fact that most patients are immunocompromised, sedated, and with low sensorium further increases the risk of VAP, in addition to the use of mechanical ventilation. Sadly, VAP interferes with recovery and increases hospital stay by increasing the cost of care. Therefore, implementing a nurse-driven protocol such as daily bathing with CHG is essential in every setup to reduce infection rates while improving clinical outcomes. However, anticipating implementation barriers and measures to overcome them can in addressing various barriers that arise.
Chen, R., Liu, Y., Zhang, X., Yang, Q., & Wang, X. (2022). Risk factors and nursing countermeasures of ventilator-associated pneumonia in children in the intensive care unit. Journal of Healthcare Engineering, 2022, 9055587. https://doi.org/10.1155/2022/9055587
D’Journo, X. B., Falcoz, P.-E., Alifano, M., Le Rochais, J.-P., D’Annoville, T., Massard, G., Regnard, J. F., Icard, P., Marty-Ane, C., Trousse, D., Doddoli, C., Orsini, B., Edouard, S., Million, M., Lesavre, N., Loundou, A., Baumstarck, K., Peyron, F., Honoré, S., … Thomas, P. A. (2018). Oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate in lung cancer surgery: a randomized clinical trial. Intensive Care Medicine, 44(5), 578–587. https://doi.org/10.1007/s00134-018-5156-2
Deschepper, M., Waegeman, W., Eeckloo, K., Vogelaers, D., & Blot, S. (2018). Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study. Intensive Care Medicine, 44(7), 1017–1026. https://doi.org/10.1007/s00134-018-5171-3
Jackson, L., & Owens, M. (2019). Does oral care with chlorhexidine reduce ventilator-associated pneumonia in mechanically ventilated adults? British Journal of Nursing (Mark Allen Publishing), 28(11), 682–689. https://doi.org/10.12968/bjon.2019.28.11.682
Kohbodi, G. A., Rajasurya, V., & Noor, A. (2022). Ventilator-associated Pneumonia. https://pubmed.ncbi.nlm.nih.gov/29939533/
Lingerfelt, C. N., & Hutson, S. P. (2021). A concept analysis of dependence using Rodgers’ Evolutionary Method. Issues in Mental Health Nursing, 42(5), 451–462. https://doi.org/10.1080/01612840.2020.1820118
Pallotto, C., Fiorio, M., De Angelis, V., Ripoli, A., Franciosini, E., Quondam Girolamo, L., Volpi, F., Iorio, P., Francisci, D., Tascini, C., & Baldelli, F. (2019). Daily bathing with 4% chlorhexidine gluconate in intensive care settings: a randomized controlled trial. Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases, 25(6), 705–710. https://doi.org/10.1016/j.cmi.2018.09.012
Pawlik, J., Tomaszek, L., Mazurek, H., & Mędrzycka-Dąbrowska, W. (2022). Risk factors and protective factors against ventilator-associated pneumonia-A single-center mixed prospective and retrospective cohort study. Journal of Personalized Medicine, 12(4), 597. https://doi.org/10.3390/jpm12040597
Reagan, K. A., Chan, D. M., Vanhoozer, G., Stevens, M. P., Doll, M., Godbout, E. J., Cooper, K., Pryor, R. J., Hemphill, R. R., & Bearman, G. (2019). You get back what you give: Decreased hospital infections with improvement in CHG bathing, mathematical modeling, and cost analysis. American Journal of Infection Control, 47(12), 1471–1473. https://doi.org/10.1016/j.ajic.2019.07.003
Suljevic, I., Asotic, D., Surkovic, I., Turan, M., & Spahovic, H. (2020). Frequency of ventilator-associated pneumonia in patients in the intensive care unit. Medical Archives (Sarajevo, Bosnia, and Herzegovina), 74(4), 285. https://doi.org/10.5455/medarh.2020.74.285-288
Triamvisit, S., Wongprasert, W., Puttima, C., Chiangmai, M. N., Thienjindakul, N., Rodkul, L., & Jetjumnong, C. (2021). Effect of a modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients. Acute and Critical Care, 36(4), 294–299. https://doi.org/10.4266/acc.2021.00983
Xu, Y., Lai, C., Xu, G., Meng, W., Zhang, J., Hou, H., & Pi, H. (2019). Risk factors of ventilator-associated pneumonia in elderly patients receiving mechanical ventilation. Clinical Interventions in Aging, 14, 1027–1038. https://doi.org/10.2147/CIA.S197146
Benchmark- Capstone Project Change Proposal Instructions
In this assignment, students will pull together the capstone project change proposal components they have been working on throughout the course to create a proposal inclusive of sections for each content focus area in the course. For this project, the student will apply evidence-based research steps and processes required as the foundation to address a clinically oriented problem or issue in future practice. Develop a 2,500-4,000 written project that includes the following information as it applies to the problem, issue, suggestion, initiative, or educational need profiled in the capstone change proposal: Background Clinical problem statement. Purpose of the change proposal in relation to providing patient care in the changing health care system. PICOT question. Literature search strategy employed. Evaluation of the literature. Applicable change or nursing theory utilized. Proposed implementation plan with outcome measures. Discussion of how evidence-based practice was used in creating the intervention plan. Plan for evaluating the proposed nursing intervention. Identification of potential barriers to plan implementation, and a discussion of how these could be overcome. Appendix section, for evaluation tools and educational materials, etc. are created. Review the feedback from your instructor on the PICOT Question Paper, and Literature Review. Use this feedback to make appropriate revisions to these before submitting. Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance. Benchmark Information This benchmark assignment assesses the following programmatic competencies: RN to BSN 1.4: Implement patient care decisions based on evidence-based practice. 2.2: Manage patient care within the changing environment of the health care system.