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العنوان
Assessment of Health Care Burdens of
Ventilator Associated Pneumonia in
Pediatric Intensive
Care Units /
المؤلف
Mostafa, Samar Othman.
هيئة الاعداد
باحث / Samar Othman Mostafa
مشرف / Safy Salah El Din Al Rafay
مشرف / Randa Mohamed Adly
مناقش / Randa Mohamed Adly
تاريخ النشر
2019.
عدد الصفحات
241 P. :
اللغة
الإنجليزية
الدرجة
ماجستير
التخصص
طب الأطفال
تاريخ الإجازة
1/1/2019
مكان الإجازة
جامعة عين شمس - كلية التمريض - قسم تمريض الاطفال
الفهرس
Only 14 pages are availabe for public view

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Abstract

Ventilator-associated pneumonia (VAP) is the second most common healthcare-associated infection. VAP is a costly, preventable, and often fatal consequence of medical therapy that negatively affects clinical outcome and resource consumption among critically ill pediatric patients. It prolongs the length of mechanical ventilation and ICU stay, and increases the associated hospital mortality rates, and healthcare costs. The death rate from VAP exceeds the rate of death due to infections associated with central venous catheter, severe sepsis, and respiratory tract infections in nonintubated pediatric patients. VAP pediatric patients have an ICU stay that is around 4–19 days longer than that of intubated pediatric patients who did not acquire VAP. Among pediatric patients treated with mechanical ventilation (MV), the mortality rate reaches 46% of pediatric patients (Mansour and Al Bendary, 2018).
Both developed and resource-poor countries are faced with the burden of health care-associated infections. The prevention of VAP is primarily the responsibility of the bedside nurse whose knowledge, beliefs, and practices influence the health outcome of ICU pediatric patients. Unfortunately, little is known about the burdens of ventilator-associated pneumonia among children in the Pediatric Intensive Care units. However, nurses are responsible for evaluation and follow up of VAP burdens’ parameters to advocate children rights for safe and high quality care (Ahmed and Abosamra, 2015).
The Aim of the Study
To assess the health care burdens of ventilator associated pneumonia in Pediatric Intensive Care Units.
Research Questions:
1. What are the levels of nurses’ knowledge about the care of ventilated children?
2. What are the levels of nurses’ practices about the care of the ventilated children?
3. What are the parameters ofhealth care burdens of the ventilator-associated pneumonia in Pediatric Intensive Care Units?
Subjects and Methods
I- Technical design
The technical design for this study includes research design, research setting, subjects of the study, and the tools of data collection.
Research Design:
The descriptive design was conducted to achieve the aim of the study. First, it seeks to describe the current knowledge and performance of the PICU nurses who are the direct care providers of the children with critical health problems specially those who are on mechanical ventilation (assess the physical environment of the PICU). Second, a cross-sectional design was used to describe the burden of ventilator Associated Pneumonia among children at a period of six months. Variables were not manipulated; they were only identified and studied as they were in their natural settings, so the interpretation and analysis of the results did not prove cause and effect relationship.
Setting:
The study was conducted in Pediatric Intensive Care Unit at Children’s Hospital that is affiliated to Ain Shams University. The selection of this hospital for the study was due to the high flow of the pediatric patients on this place as it is referral hospital. In addition, it receives all pediatric patients’ age categories starting from 28 days age until 18 years old. There are two PICUs at the hospital; PICU 1 is at the first floor of the old building with total capacity of five beds. The second PICU is located at the fourth floor of the new building; it is divided into two sections the total capacity was seventeen beds.
Subjects: the study subjects included the following:
• A purposive sample of children suffering from VAP was included at this study from the previous mentioned settings throughout the period of data collection. All children who were admitted to the PICU at this period were scanned and then all children who were mechanically ventilated were identified which was (71 children). The immunocompromised pediatric patients were excluded from the study, while the number of the study sample was (40 children) suffering from VAP. In addition, the included age of the studied children was from 3 months to 14 years old days.
• A convenient sample of pediatric nurses working in the PICU was included in this study. The total number of nurses who are working at the two PICUs was 45 Nurses; while the number of the nurses who participated at the study were 40 nurses (excluding 5 nurses were either in maternity Leave or others who are not willing to participate at the study).
Tools of Data Collection:
To achieve the aim of the study, data were collected using the following 4 tools:
Tool 1: Structured Questionnaire Sheet for the Studied Nurses (Appendix II): It included data about:
a) Characteristics of the studied nurses and their demographic data, it is composed of 5 questions regarding nurses’ age, gender, educational level, years of clinical experience, and the attainment of training programs.
b) Knowledge of the nurses related to ventilator-associated pneumonia this part composed of two parts:
The first the first part was concerned with knowledge of nurses related to VAP; it is composed of 6 Essay questions regarding VAP definition, causes, Modes of Transmission, signs and symptoms, diagnostic studies, and complications.
The second part was concerned with knowledge of nurses regarding the preventive measures of VAP. It was composed of 12 multiple choice questions concerning infection control practices with the suction procedures, oral care, ventilator care, patient positioning, and VAP risk factors.
Scoring system: The correct answer scored one, and the incorrect scored zero. These scores were summed up and were converted into a percent score.
• Score less than 60% referred to poor level of knowledge.
• Score from 60:75 % referred to average level of knowledge.
• Score more than 75 % referred to good level of knowledge.
Tool 2: Assessment Sheet for the Studied Children (Appendix III): it included data about the child’s age, gender, weight, admission diagnosis, length of stay at the PICU, duration on mechanical ventilation, laboratory investigations and VAP treatment course.
Tool 3: Observational checklist (Appendix IV): this tool was adapted from a study done by Tabaeian, (2017) to assess:
A) The nurses’ practices regarding care of children suffering from VAP. It included oral, orophangeal and endotracheal suctioning; care of ventilator circuit and humidifier; and chest physiotherapy.
Scoring system: one score was given for each step, which was done correctly, while, zero score was given for each step which was not done or done incorrectly. These scores were summed-up and were converted into a percent score.
• Score less than 60% referred to incompetent practice.
• Score equal and more than 60 % referred to competent practice.
B) The environment of PICU to detect the parameters of health care burdens. This tool includes 56 items about the general work conditions (19 items), PICU ventilation (6 items), the water supply and cleanliness (4 items), furniture and equipment (11 items), material handling and storing (6 items), and lighting and electricity (10 items).
Scoring system: Each item that match the standard was given 1 point, while zero score was given to the item that not match the standard or that not available.
• Score less than < 60% unsatisfactory environmental standard
• Score more than 60% satisfactory environmental standard
Tool 4: Parameters of health care burdens of VAP (Appendix V) tools, it included:
1- Mortality (Causes of Specific Death Rate): Scoring system is obtained through using international standardized equation:
(D c/ p) × 100000
c: Number of deaths attributable to a particular cause that is divided by population at risk, usually expressed in deaths per 100,000
This equation is adopted by John Hopkins Bloomberg School of Public Health (2006)
2- Morbidity (Incidence for VAP): It was obtained through using international standardized equation: (Number of persons who have VAP at a given point in time/ population at risk ×K) Number of persons who have VAP at a given point in time per 1,000 population.
John Hopkins Bloomberg School of Public Health (2006)
3- Length of Hospital Stay (LOS): It was obtained through using international standardized equation:(Total discharge days / Total discharges) = average length of stay (in days)
This equation is adopted from Pennsylvania Department of Health, (2017)
4- Disability Adjusted Life Years (DALYs):This tool was adopted from (WHO, 2017) while it was estimated by using the international standardized equations: DALY = YLL + YLD
YLL= N × L where (N = number of deaths, L = standard life expectancy at age of death in years). YLD = I × DW × L where (I = number of incident cases, DW = Disability Weight, L = average duration of the case until remission or death (years).
5- Hospitalization Costs: A tool was adapted from a study done by (Edward, 2012) to estimate the hospitalization costs such as: Costs of antibiotics, diagnostic & laboratory studies, food, medical supplies, and wages of the unit staff.
Limitations of the study
• Collecting data from pediatric patients’ records was challenging because documentation system is not well established, and some vital information were removed from the archived pediatric patients’ records.
• Observations were made only on nurses. Patient care is a multidisciplinary task, and future studies are recommended to include other health care providers in order to achieve a more comprehensive understanding of the factors that affect VAP burden.
Results:
• The majority of the studied nurses had poor level of knowledge regarding VAP.
• As regards to the total level of competency of the nurses about care of children with VAP about two thirds of the studied nurses were incompetent.
• Total hospitalization costs of care of the studied children with VAP= 496696.8 LE.
• Cause specific death rate=22/71*100.000=31 per 100.000 children high risk for VAP (ventilated children).
• Incidence of VAP= 40/71*1000=563 per 1000 children high risk for VAP (ventilated children).
• Case fatality rate=22/40*100.000=55.000 per 100.000 children diagnosed with VAP.
• Average (LOS) duration 6 months = total inpatient days of care (PICU)/ total cases (with VAP) = 570/40= 14.25 days.
Conclusion
Based on the study findings, it could be concluded that, the great majority of the studied nurses had poor level of knowledge regarding VAP and its preventive measures. In addition, most of the nurses were incompetent concerning to the care of children suffering from VAP.
Moreover, the healthcare burden of VAP was enormous. The mortality and morbidity ratios among children with VAP were high. Consequently, the DALYs values were elevated as most of the children lost the great portion of their life expectancy. Besides, the children had prolonged length of PICU stay, and eventually high health care costs.
Recommendations
In the lights of the study findings, the following recommendations are proposed:
• Educational program for nurses should be designed in the light of their actual needs assessment regarding knowledge and practice of care for mechanically ventilated children.
• Conduct teaching class in every pediatric hospital for nurses working in PICUs on regular basis to update their knowledge and practice regarding care children suffering from VAP.
• Develop guidelines about care of children suffering from VAP for nurses, which includes VAP definition, clinical picture, diagnostic studies, treatment, and complications; these guidelines should be regularly updated based on the evolvement of the international evidence based criteria.
• Burden parameters of ventilator-associated pneumonia should be adopted as blueprints for PICU staff adherence to the guidelines.
• Replication of the study using a larger probability sample from different pediatric hospitals, and compare between the burden of VAP in governmental and private hospitals to generalize the findings.