Evidence-Based Nursing Research Vol. 3 No.

3 July 2021

Evidence-Based Nursing Research

Vol.Volum4no3 July2022

Effect of a Designed Bundle Protocol about Ventilator Associated Pneumonia on

Nurses Performance, Compliance and Patient Outcomes
Sohier M. Weheida1, Eman Sobhy Omran2 , Amal Said Taha3

1
Medical Surgical Nursing Department, Faculty of Nursing,Alexandria University,
Egypt.
2,3
Medical Surgical Nursing Department, Faculty of Nursing, Benha University, Egypt.

Received June 1, 2021, accepted July 1, 2021

doi: 10.47104/ebnrojs3.v3i3.209
ABSTRACT
Context: Ventilator-associated pneumonia (VAP) is considered to be one of the leading
cause of morbidity and mortality due to nosocomial infections among ventilated
patients.
Aim: To evaluate the effect of a designed bundle protocol about ventilator associated
pneumonia on nurses performance, compliance and patient outcomes.
Methods: A quasi-experimental research design was utilized to conduct of the study.
Setting: This study was conducted at the intensive care unit of Benha University
Hospital. Subjects: Convenience sample of 50 critical care nurses and a purposive
sample consisted of 66 patients were enrolled in the current study. Tools: three tools
were used to collect data (1) Nurses performance assessment checklist (2) The VAP
bundle compliance checklist and (3) Patient outcomes assessment record.
Results: The present study revealed that 70% of nurses age was less than 30 years old,
88 % were married, 76 % were staff nurse, 46 % had secondary nursing education,
92% had never participated in any training sessions related to VAP prevention. 74% of
studied nurses had total unsatisfactory knowledge level pre-designed bundle protocol
implementation. However, 60% of studied nurses had good knowledge level
immediately post designed bundle protocol implementation .70 % of studied nurses had
total unsatisfactory practice level pre-designed bundle protocol implementation.
However, 66% of studied nurses had good practice level immediately post designed
bundle protocol implementation .Also,64 % of studied nurses had total unsatisfactory
compliance level pre-designed bundle protocol implementation. However, 58% of
studied nurses had good compliance level immediately post designed bundle protocol
implementation .. As well, immediately after a designed bundle protocol implementation
on study group patients , there is a statistical significant difference between all variables
of clinical pulmonary infection scores except for oxygenation status and radiographic
findings
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Conclusion: The study group nurses who received designed bundle protocol training
would get higher knowledge, practices and compliance scores than pre deigned bundle
protocol training. Also, the study group patients who cared by a designed bundle
protocol would get better outcomes such as better score of CPIS, shorter length of stay
in intensive care unit , less duration on mechanical ventilation compared to the control
group who received routine hospital nursing care. Recommendation : the study
recommended the training of the nurses on application of VAP bundle strategy . Further
research is suggested on a larger sample size & estimate its effect on nurses‟
performance

Keywords: Bundle, Compliance, Nurses Performance, Outcomes, Ventilator Associated

Pneumonia
1. Introduction mortality rate attributable to VAP is 27%
and length of stay in the intensive care
Ventilator-associated pneumonia (VAP) unit is increased by 5 to 7 days. The cost
is nosocomial lung infections that occur in of VAP is estimated to be an additional
patients connected to mechanical $40000 per hospital admission per patient
ventilation. VAP is recognized as a major with the disease and an estimated to be
health issue worldwide, and common $1.2 billion per year where as in
healthcare-associated infection (HAI) developing countries (Augustyn, 2007).
among the developing countries that are Furthermore, VAP is also associated with
associated with mortality, longer length of prolonged stay in the ICU and hospital,
hospital stay, and associated cost burden increased mortality and morbidity, and
among patients (Ghimire & Neupane, increased use of healthcare resources
2018). The VAP is defined as infection of (Rakhi & Navita,2020).
the pulmonary parenchyma developed Risk factors about VAP can be
after 48 hours of intubation with classified into ventilation-related factors
mechanical ventilation or within 48 hours (for example ,instrumentation of the
after disconnecting the ventilator airway with an endotracheal tube and
(Schauwvlieghe et al., 2018). subsequent microaspirations) and, patient-
The VAP incidence depending on case related factors (for example, pre-existing
mix and the diagnostic criteria used, and pulmonary disease) (Klompas, 2017).
the highest rates are in Nurses play a vital role to prevent VAP
immunocompromised, surgical, and and improve the patient`s outcome if
elderly patients (Torres et al., 2017). The they are knowledgeable. The relevance of
worldwide incidence of VAP is about 10– knowledge to the care of critically ill
28%, where in developing countries, it patients is a hallmark of professional
varied from 10 to 41.7 cases/1000 nursing practice. The bedside critical care
ventilator days (Kalil et al., 2016). The nurse has a direct responsibility for many
non-pharmacological techniques to avoid
1
Correspondance author: Amal H. S. Albalawi

2 2[Type text] [Type text] [Type text]

Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

VAP, which can be easily implemented at to be an effective approach achieving

the lowest cost. Neglecting any of these better patient outcomes.
could put the patient at danger of 2. Significance of the study
complication (Boltery et al., 2017).
The perception of the care „„bundle‟‟ Ventilator-associated pneumonia has
works to help the application of best been associated with great morbidity,
practices and evidence-based care. A mortality, increase length of stay at ICU,
bundle is „„a structured way of and increased hospitalization costs. In
humanizing the processes of care and developing countries which reported a
patient outcomes that, when performed higher VAP rates compared with the
collectively and reliably, are proven to developed countries (Khalil et al., 2021).
improve patient outcomes‟ by facilitating, In Egypt, Surveillance programs for
promoting changes in patient care and hospital acquired infection (HAI) or
encouraging guideline compliance antimicrobial resistance (AMR), the
(Rodrigues et al., 2016). The components United States Agency for International
of Ventilator Bundle include: i) Elevating Development in Egypt in June 2011 until
head of the bed to 30-45 degree, ii) Daily January 2012. A surveillance project
„sedation vacation‟ to assess readiness to examining HAI and AMR in 11 hospitals
extubate, iii) Peptic ulcer disease in Egypt, including 43 intensive care units
prophylaxis, iv) Deep venous thrombosis (ICUs) representing both the Ministry of
prophylaxis (Institute for Healthcare Health and University Hospitals. The
Improvement, 2020).the later two are result was 50% of the HAIs were
pharmacological intervention? pneumonia 20% bloodstream infections,
Nurses represent the largest percentage and 15% urinary tract infections. A high
of the health care workers and they are the proportion of the overall infections (64%)
“core of the health care system”. Because were device-associated infection, where
they spend more time with patients than VAP constituted 92% of the overall
any other health care workers, their hospital-acquired pneumonia (USAID
compliance with bundle protocol assist project, 2018).
guidelines seems to be more crucial in The intensive care unit at Benha
preventing the disease complications University Hospital documented an
(Abdelazeem et al ., 2019). The study admission number of ventilator associated
done by Osti et al. (2017) documented pneumonia by case definition as 82
that the ventilator bundle implementation patients in 2018 and 2019 (Benha
was associated with significant reduction University Office Census, 2019).
in VAP rates, duration of mechanical From the researchers experience in ICU
ventilation, antibiotic administration, found unsatisfactory nurses' knowledge
length of intensive care unit stay and and inadequate practices regarding
hospital costs. In conclusion, implementation of care bundle for
implementation ventilator bundle seems mechanical ventilated patients, which
elevating VAP rate. Consequently, The
purpose of this study is to evaluate the

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impact of a ventilator associated practice score after bundle implementation

pneumonia tailored bundle protocol on compared to their level before
nurses' performance, compliance, and implementation.
patient outcomes. H3: Nurses exposed to
3. Aim of the study designed bundle protocol have higher
compliance score after bundle
was to evaluate effect of a designed implementation compared to their level
bundle protocol about ventilator before implementation.
associated pneumonia on nurses H4: Patients who are cared for by a
performance , compliance and patient designed care bundle protocol will exhibit
outcomes. decrease in both length of stay in ICU and
Operational Definitions duration on mechanical ventilator
compared to controls.
Nurses performance: Knowledge and
practice of the nurses under the study. 4. Subjects & Methods
Compliance is defined in this study as 4.1 Research design
the commitment of nurses to the VAP
bundle components. A quasi experimental research design
A designed care bundle protocol : A was used to compare the nurses‟
set of straightforward practices such as performance and compliance before and
following preventive precaution measures, after bundle implementation.
care of mechanical ventilator, enteral Study/control design was used to compare
feeding and care, patient positioning, the patient outcomes in the study and
suctioning and airway care, chest control groups). A quasi-experimental
physiotherapy. design aims to establish a cause-and-effect
Patient Outcomes: The patient relationship between an independent and
outcome in this study means clinical dependent variable. However, unlike a
pulmonary infection score to monitor true experiment, a quasi-experiment does
decrease the frequency of VAP rate post not rely on random assignment. Instead,
ventilator bundle protocol implementation subjects are assigned to groups based on
, patient length of stay (hospital or in non-random criteria. A quasi-experimental
ICU?), duration of mechanical ventilation. design is useful in situations where true
experiments cannot be used for ethical or
Research Hypothesis practical reasons (Reichardt,2019).
To fulfill this aim the following Variables: The independent variable is
research hypotheses were formulated: the designed care bundle protocol while
H1: Nurses exposed to designed bundle the dependent variables are nurse's
protocol have higher knowledge score knowledge , practices and patients clinical
after bundle implementation compared to outcomes regarding ventilator associated
their level before implementation. pneumonia.
H2: Nurses exposed to 4.2 Research Setting
designed bundle protocol have higher

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The study was conducted at the The sample size was calculated based
intensive care unit of Benha University on the previous year's census report of
Hospital. It consisted of 22 beds and is admission in the intensive care unit at
located at second floor. Benha University Hospital (Benha
4.3 Subjects University Office Census, 2019), utilizing
the following formula (Taylor, 2014).
Group A: A convenience sample of all
n= ( )
available nurses (50) working in the
intensive care unit and agreed to Description:
participate in the study regardless of their n= sample size (66)
demographic characteristics. N= total population (82)
Group B: A purposive sample of 66 e= margin error (0.05)
adult patients from both genders and were 4.4 Tools of data collection
divided randomly into two equal groups:-
Pre designed bundle protocol Three tools were utilized to collect
implementation group (control group=33) pertinent data
and post designed bundle protocol Tool (1): Nurses' Knowledge
implementation group (study group=33). assessment questionnaire: The researchers
Both study and control groups were developed it based on reviewing relevant
subjected to hospital routine of care. The recent literature Ahmed (2019); Gallagher
difference was that the control group (2012); Busi & Ramanjamma (2016) . It
received the care by the nurses before was developed in the simple Arabic
exposed to a designed bundle protocol. language and used to assess nurses'
However, the study group patients were knowledge regarding the prevention of
received routine care from nurses who ventilator associated pneumonias and
were enrolled in a designed bundle included three parts:
protocol implementation. Both groups of Part I: Nurses' demographic
the study were selected according to the characteristics: This part concerned with
following inclusion and exclusion criteria. assessment of demographic characteristics
of studied nurses related to their age,
Inclusion criteria:
educational level, job, marital status, years
 Patients of both gender and their
of experience, attending training courses
age between (20-65).
related to care of mechanically ventilated
 Patients on mechanical ventilation.
patients.
 A score of less than six on the Part II is concerned with nurses'
clinical pulmonary infection scale. knowledge assessment: It was utilized for
Exclusion criteria testing theoretical information of nurses
Patients were excluded if: - Patients related to all aspects of designed care
have a brain stem infarction. - Patients bundle protocol for ventilator associated
have neuromuscular diseases. - Patients pneumonia patients. It included 45 closed-
with multiple organ dysfunction end MCQ questions. It consists of four
syndromes - Patients with major cardiac- categories including: information related
thoracic or abdominal surgery.

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to anatomy and physiology of respiratory techniques & extubation) (70 steps) ,

system (5 questions), ventilator associated enteral feeding, removal, and care (38
pneumonia (definition, causes, signs and steps) , oral hygiene (13 steps), patients‟
symptoms, complications, nursing role positioning (10 steps), chest physiotherapy
and outcomes) (10 questions), nursing (percussion, vibration & postural
management of patients on mechanical drainage) (50 steps), closed suctioning
ventilation (10 questions), components of system (15 steps).
bundle related to ventilator associated Scoring system:
pneumonia prevention (precaution Three levels of scoring for practice
measures, care of mechanical ventilator, were used: completely done was scored
enteral feeding and care, patient (2), incompletely/incorrectly done was
positioning, suctioning and airway care, scored (1), and the items that were not
chest physiotherapy (20 questions). This done were scored (0). The total scores for
tool was used at the pre and post all items were 500 (100%). The total score
intervention. was then converted into percentage as
Scoring system: follow:
The total score of knowledge was 45 Less than 60% (299 score) is considered
marks equal (100%). Each correct answer poor practice.
was given one mark, and the incorrect From 60% to 75% (300 to 375 score)
answer was given zero. The total score are considered average practice.
was then converted into percentage as >75 % (376 score and above) is
follow: considered good practice.
< 60 % (less than 27 score) was Tool (3): Nurses' compliance checklist
considered poor level of knowledge for VAP bundle:
60% to 75 % (27 to 34 score) was It was adapted developed by the
considered average level of knowledge researcher from Ali (2013); Osti et al.
> 75 % (35 score or above) are (2017). It was used for assessing critical
considered good level of knowledge. care nurses' compliance regarding a
Tool (2): Nurses' practice assessment designed care bundle protocol for
checklist prevention ventilator associated
Nurses' practice observational checklist: pneumonia. It covered 8 main areas
Was utilized to assess and evaluate the including infection control practices (5
nurses‟ practices regarding the prevention items), positioning strategies (1 item),
of ventilator associated pneumonia Deep Vein Thrombosis (DVT)
pre/post implementation of a designed prophylaxis (1 item) please add such as
care bundle protocol. It included of 9 ….,….,…. (as they are a pharmacological,
categories of care which covered the please clarify that was nursing
actual nurses‟ practices of hand hygiene prophylactic procedures not
(12 steps), wearing protective clothes pharmacological, so give an examples),
(gloves, gowns and mask) (12 steps), care ventilator circuit care (5 items), endo
of mechanical ventilator & settings (30 tracheal suctioning and care (10 items),
steps), endotracheal tube (care, suctioning oral care (2 items), peptic ulcer

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Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

prophylaxis (3 items) (as they are a (temperature), blood leukocyte count,

pharmacological, please clarify that was amount of tracheal secretions, oxygen
nursing prophylactic procedures not saturation, radiographic finding on chest
pharmacological, so give an examples) radiography, and culture result of
and extubation & Weaning trials and (2 pathogenic bacteria. It was used for
items) give example. Each area has sub measuring the frequency of ventilator
items. associated pneumoni
Scoring system of VAP bundle Scoring system: Each of the six sub
compliance checklist: item was scored from zero to two. They
The score of each item of the previous were evaluated as follows: 0 = normal , 1
tool was ranged as the following: = moderate and 2 = severe. The with
Compliant (2), partially compliant (1), non total score of (12). The total score were
compliant (0). The total scores = 58 (29 categorized as follows, a score ≥ 6 is
question x2 scores). considered suggestive of pneumonia. If ≤
The total score was then converted 6 probably doesn‟t have pneumonia.
into percentage as follow: Part (3): The length of patient stay in
Less than 60% (34 score) is considered intensive care unit and duration of patient
non compliant. on ventilation were recorded for each
From 60% to 75% (35 to 43 score) are patient. They were counted in days.
considered partially compliant. 4.5. Procedures
> 75 % (44 score and above) is
considered good compliant. Tool Validity
Tool (4): Patient‟ Outcomes record The data collection tools were revised
The researchers constructed it after for comprehensiveness, appropriateness,
reviewing the relevant literature Boltery et and legibility by a panel of five experts
al. (2017); Kao et al. (2019); Khalil et al. (one professor in critical care nursing, one
(2021); Mishra & Rani (2020); Osti et al. professor in critical care medicine, and
(2017). It was used to assess patients‟ three professors in medical surgical
outcomes before and after implementing a nursing) to test the face and content
designed bundle protocol. It included two validity. The same experts validate a
parts: designed bundle protocol contents. The
Part (1): Demographic data of the modification was carried out according to
studied patients (e.g. age, gender, marital the panel's judgment on the clarity of
status, occupation, and residence) and sentences, appropriateness, and
medical data that related to patient‟s status completeness of the content and the
( e.g. diagnosis, smoking history, correctness of the bundle protocol.
causative organism). Tool Reliability:
Part (2): The clinical pulmonary Cranach‟s Alpha coefficient test tested
infection score (CPIS). It was adopted the reliability of the tools (I, II), which
from Zilberberg and Shorr (2010). It revealed that each tool consisted of
assessed six variables such as vital signs relatively homogenous items. It was 0.92
for nurses‟ knowledge assessment

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questionnaire, 0.955 for the nurses‟ study before data collection; then, the
practice observational checklist. Nurses' researcher assessed the nurses‟ knowledge
compliance checklist for VAP bundle and practice level regarding caring for
reliability was = 0.866. The reliability of mechanically ventilated patients by using
the clinical pulmonary infection score was nurses‟ knowledge assessment
(0.888) questionnaire and nurses‟ practice
Pilot study: observational checklist). the researchers
The pilot study was carried out on 10% assess compliance level through observed
of the total study subjects (6 nurses and 5 nurses‟ practice regarding the main eight
patients). This was done to test clarity, nursing practices that included in the
applicability, feasibility & relevance of all designed bundle (before bundle
tools used and to estimate the length of implementation) This period is called
the required time for data collection. A (Pre-test) before implementing a designed
modification on all tools were made based bundle protocol which takes one month.
on the results of the pilot study. Hence, For patients:
pilot study sample was excluded from the Assessment was carried out by the
final sample. researchers for all ventilated patients, to
Field of work: The data collection assess the patients who met the inclusion
process extended over 12 months, from criteria of this study. Sixty six,
August 2019 to August 2020. The study mechanically ventilated patients, fulfilling
was carried out through four phases the inclusion criteria were selected and
(preparatory and assessment, planning, assigned randomly (you did not recruited
implementation, and evaluation). them randomly, randomly means you take
Assessment phase included reviewing one patient in the study and the next
the available literature and studies related admitted patient in the control, which was
to the research problem and theoretical not happen. They were classified into two
knowledge using textbooks, evidence- groups according to the phase of a
based articles, internet periodicals, and designed protocol implementation as
journals. follows: Group I: (pre intervention group)
For Nurses: The researchers visited the consisted of 33 patients who received
intensive care unit three days weekly routine care from the nurses before a
(morning & afternoon) to collect the data designed bundle protocol implementation.
using previous tools. The researchers Group II: (post intervention group) consist
interviewed the available nurses, an of other 33 patients fulfilling the same
average of three to four nurses were inclusion criteria, receiving care from
interviewed per/day. This interview took nurses after (they are trained on the bundle
about 20-30 minutes. At the beginning of protocol implementation????) (clarify how
the interview, the researchers greeted the nurses learn the bundle before
nurses in the intensive care unit , implementation) a designed bundle
explained the character, aims, and protocol implementation.
expected outcomes of the study, and took The researcher used the patient record
their verbal approval to participate in the firstly at the time of patients admission for

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Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

collection of the baseline data within the developed by researchers based on nurses‟
first 24 hours of intubation and continued and patients‟ needs assessment, literature
daily for 10 days of ICU stay . In review, international guidelines (mention
addition, the researchers measured which international guideline you use to
(remove the word incidence as it need design your bundle, mentioning the
special measure to evaluate the incidence, reference, for example if it from the CDC,
use the word frequency of instead) of European scocieties or American and so
pneumonia using clinical pulmonary on, it will raise the value of your work)
infection score for each patient on Boltery et al. (2017); Kao et al. (2019);
ventilator for more than 48 hours to Khalil et al. (2021), researchers‟
exclude the patients who had infection at experience, and experts‟ opinions. The
the time of admission this through researchers designed a nurses‟ guidelines
estimation of Clinical pulmonary infection booklet including all bundle protocol in
score as follows: At the first 24-48 hour of Arabic language with illustrations
patients‟ intubation, throat swap and involving theoretical background about
endotracheal aspirate specimen for gram the VAP and bundle protocol practices :
stain and culture will was firstly obtained The theoretical background included
and send to laboratory as routine patient general knowledge regarding anatomy and
investigations within intensive care unit physiology of respiratory system,
.This accompanied by chest X- ray. The Ventilator associated pneumonia as
score calculated based on the first six definition, risk factors, causes, signs and
clinical variable (temperature, white blood symptom, nursing management of
cells, secretion, oxygenation status, ventilator associated pneumonia, plus
radiograph, culture of pathogenic components of designed bundle protocol
bacteria). The result of this score revealed such as: positioning, infection control
the probability of the infection either measures, peptic ulcer prophylaxis,
present or absent. If it less than 6 those weaning trials, deep venous thrombosis
were included on the sample. If the result prophylaxis.
of this score was, more than 6 it The bundle protocol practices included
considered as high probability of hand hygiene, wearing protective clothes
pneumonia and those patients treated as (gloves, gowns and mask), care of
they had pneumonia and excluded from mechanical ventilator patient and
the study sample. ventilator settings, endotracheal intubation
As well as to detect the frequency of tube care, suctioning techniques &
occurrence of ventilator associated extubation), enteral feeding and removal,
pneumonia, length of hospital stay and oral hygiene, patients‟ positioning, chest
duration on mechanical ventilator through physiotherapy (percussion, vibration &
filling the patient outcomes record3 . postural drainage), closed suctioning
This phase took three months. system.
Planning phase (Bundle protocol The implementation phase was
development): A designed bundle was achieved through training sessions at a

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period of 3 weeks for each sub-group of knowledge, practice level before and after
nurses. This phase took six months. Each a designed bundle protocol
session started with a summary of the using the same format of the study tools
previous session and the objectives of the pre and immediately post a designed
new one. Motivation and reinforcement bundle protocol implementation. Observed
during the session were used to enhance compliance of nurses to designed bundle
motivation for participation in this study. protocol was assessed two times pre and
Grouping the nurses, 10 nurses in each immediately post a designed bundle
group according they to their shifts‟ protocol implementation. This phase took
distribution. Sessions were given to 5 two months.
groups (10) nurses in each group divided For patients: The researchers met the
to „‟sub group‟‟ 5 in each one. study group patients post a designed
The total numbers of sessions were bundle protocol implementation who
seven. It is divided as follows: three received care by nurses based on
sessions for knowledge and four sessions implementing a designed bundle protocol
for practice. The time of knowledge to complete the socio-demographic and
sessions ranged between 30 minutes to 55 medical history sheet (Tool 3 part 1) as
minutes according to the workload of the well as to detect the frequency of
unit, the number of the patient assigned to ventilator associated pneumonia (The
each nurse and the patient critical clinical pulmonary infection score) (Tool
condition. The nurses are were divided 3 part 2). And to evaluate length of
into ten groups. Each group contains 5 hospital stay and duration of patient stay
nurses to acquire the related information. on ventilator (tool 3 part 3). This phase
Each nurse was supplemented with took three months. What about the control
guidelines booklet. The researchers group, when they are assessed??????
continued to reinforce the gained Where is the section for data
information, answered any raised analysis, describe how the data categorize,
questions, and gave feedback. The what is the test used and for what purpose
duration of practical sessions ranged it was used??????????????
between 45-60 minutes, and the numbers 5.Results
of sessions were four sessions for each
group (5 nurses). Teaching methods were Table (1): It is clear from table (1) that ,
lecture, group discussion, demonstration, 70% the of nurses were less than 30 years
and re-demonstration. The media utilized old with the mean of age of 30.82 ± 8.88
were handouts, power point presentation, . Regarding educational level, 46% had a
videos, poster presentation for ventilator- secondary school nursing education. Also,
associated pneumonia protocols. 76 % were working as staff nurses.
Evaluation phase: Concerning marital status, 88 %were
For nurses: The researchers evaluated married. Regarding years of experience
the effect of implementing the a designed 56% of them had 5-10 years of
bundle protocol by comparing the nurse‟s experience, While, 92% of them not
receiving any previous training.

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Table (2): represents the comparison of pre-and post designed bundle protocol
the studied nurses‟ knowledge mean score implementation.
before and after bundle implementation. Table 6 represents the comparison of
The table reveals a statistically significant the studied nurses‟ compliance with
improvement in all knowledge elements at bundle practices before and after bundle
p <0.001 and for the total knowledge implementation. The table reveals a
mean score after bundle implementation significant improvement in mean
compared to the mean score before the compliance with all practices at p <0.001
implementation and for the total practice compliance mean
Table 3 documents the comparison of score after bundle implementation
nurses‟ total knowledge pre and post compared to the mean score before the
implementation of the bundle protocol that implementation.
(74%) of the nurses had unsatisfactory Table 7 illustrates that 64% were non-
knowledge level pre-designed bundle compliant to bundle practices pre-
protocol implementation. However, designed bundle protocol implementation.
immediately post designed bundle However, immediately post designed
protocol implementation (save the bundle protocol implementation more than
estimation to the discussion section, half of nurses (58%) got a good
mention only the percentage) of nurses compliance level. There is a highly
(60%) got a good knowledge level. statistical significant difference between
Statistical significant differences were nurses' total compliance level in pre/ post
found at p-values of >0.001 between pre- designed bundle protocol implementation
and post designed bundle protocol (P ≤ 0.001). .
implementation. (Mention this in the Table 8 demonstrates that, there is no
discussion not here). statistical significant correlation between
Table (4) represents the comparison of total compliance and nurses‟ knowledge,
the studied nurses‟ practice mean score practice score pre designed bundle
before and after bundle implementation. protocol implementation. While, there is a
The table reveals a statistically significant statistically significant positive correlation
improvement in all practices at p <0.001 between compliance and total nurses‟
and for the total practice mean score after knowledge, practice score post designed
bundle implementation compared to the bundle protocol implementation
mean score before the implementation. (P<0.001).
Table (5): Documents that 70 % of the It is clear from table (9) that patients‟
nurses unsatisfactory practice level bundle age were more than 40 years old among
practices pre-designed bundle protocol 75.8 & 72.7%, of the control and study
implementation. However, immediately group respectively. More than half (51.5
post designed bundle protocol & 54.5%, respectively) of both control and
implementation, 66 % got a good practice study patients were females. Concerning
level. Statistical significant differences marital status, The majority of both
were found at p-values of >0.001 between control and study patients were married

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(87.9&90.9%), working 63.6% & 57.6%, control and study group are
and the highest percentage of both groups Staphylococcus aureus (54.5%, & 60.6 %
from rural areas (66.7% &60.6%,). respectively).
Regarding to medical history, the No significant statistical differences
majority of both control and study group were seen between the two groups in
had a medical history of cerebrovascular relation to the above mentioned
stroke (30.3% & 36.4%), diabetes demographic and medical variables which
(45.45%&30.3%), cerebral hemorrhage indicates that the two groups were nearly
(21.2%, 18.2%) and without history of homogenous.
smoking among 75.75% & 81.8% of Table 10 shows that, there was a
control and study group respectively. The statistical significant difference between
most common causative organism in both control and studied group
patients related to all items of clinical pulmonary infection score before and after
pulmonary infection score such as implementation of the bundle protocol
temperature, white blood cells count, with p-value <0.001
secretion and Culture of pathogenic Table 12 a statistical significant
bacteria when comparing between pre and difference between control and study
post implementation of bundle protocol group patients related to length of stay
with, respectively at P – value ≤ 0.05 within intensive care unit and duration of
.Except related to oxygenation status & patient on mechanical ventilator
radiographic findings respectively with p respectively. At P – value (≤ 0.001).
> 0.05. please merge this table to table 11in one
Table 11 a statistical significant table as they are all representing the
difference between total clinical patients‟ outcomes (collected in one tool)

Table (1): Frequency and Percentage distribution of the studied nurses’

demographic characteristics.
Frequency No Percentage %
(n = (100%)
Demographic data 50)
Age (years) :
- <30 35 70 %
- 30 and more 15 30 %
± SD 30.82 ± 8.88
Educational level
- Secondary school nursing 23 46 %
- Technical institute of nursing 15 30 %
- Baccalaureate 12 24 %
Job :
- Staff Nurse 38 76 %
- Head nurse 12 24 %

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Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

Marital status :
- Married 44 88 %
- Unmarried 6 12 %
Years of experience
- <5 years 12 24 %
- 5-10 Years 28 56 %
- > 10years 10 20 %
± SD 9.58 ± 9.44
Attendance of previous training courses about
prevention of ventilator associated pneumonia
- Yes
- No 4 8%
46 92%
Table (2): Comparison of the nurses’ knowledge before and after implementation
of the bundle protocol training (N= 50).

No of Time
Knowledge items items Pre (n=50) Post (n=50) T- Test P- Value
X SD X SD
- Anatomy and physiology 5
of respiratory system 1.24 0.618 2.96 1.248 8.7333 <0.001***
- Ventilator associated 10
7.04 0.937 8.84 0.987 9.3524 <0.001***
pneumonia
- Nursing management of 10
patients on mechanical 7.14 0.895 8.84 1.007 8.9225 <0.001***
ventilation
- Components of bundle 20
protocol about ventilator 10 3.549 15.38 3.736 7.3826 <0.001***
associated pneumonia
-Total Knowledge: 45
25.42 5.70 36.08 6.672 8.5898 <0.001***

Table (3): Comparison of the nurses’ total knowledge pre and post implementation
of the bundle protocol (N= 50)

Study phases
Knowledge items Pre (n=50) Post (n=50) X2 P-value
N % N %
Poor 37 74% 9 18 %

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Average 8 16% 11 22 % 35.3743 <0.001***

Good 5 10% 30 60%
(*) Statistically significant at p < 0.05 (***) Highly statistically significant at p<0.001.

Table (4): Comparison of the nurses’ practice pre and post implementation of the
bundle protocol training (N= 50

No of Time
Practice items items Pre (n=50) Post (n=50) P- Value
X SD X SD T- Test
Hand hygiene 12 9.82 0.622 18.34 4.30 13.8663 <0.001***
Wearing protective clothes 12 9.78 0.64 17.24 5.125 10.2134 <0.001***
Care of mechanical ventilator & 30 41.18 3.620 50.9 7.029 9.1368 <0.001***
settings
Endotracheal tube care, suctioning 70 80.28 12.18 119.66 23.86 10.3945 <0.001***
techniques, extubation
Enteral feeding, removal & care 38 16.3 2.137 21.88 6.005 6.1903 <0.001***
Oral hygiene 13 46.82 3.855 64.46 9.259 12.4367 <0.001***
Patients‟ positioning 10 18.16 5.49 20.36 1.79 2.6940 <0.001***
Chest physiotherapy 50 11.14 2.078 13.94 3.84 4.1135 <0.001***
Closed suctioning system 15 65.08 7.42 85.7 12.33 10.1321 <0.001***
Total practice: 250 300.76 32.68 410.28 73.79 9.5960 <0.001***

* VAP indicate ventilator associated pneumonia (*) Statistically significant at p < 0.05
(* **) Highly statistically significant at p < 0.001

Table (5): Comparison of nurses’ total practice levels before and after bundle
implementation training (N= 50).
Time
Practice items Pre (n=50) Post (n=50) X2 P- value
N % N %
Unsatisfactory 35 70% 10 20%
Satisfactory 8 16% 7 14 % 35.3743 <0.001***
Good 7 14% 33 66%
(*) Statistically significant at p < 0.05 (***) Highly statistically significant at p < 0.001

Table (6): Comparison of the nurses’ compliance to practice bundle practices before
and after VAP bundle protocol implementation (N= 50).
No of Time

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 Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

Compliance items the Pre (n=50) Post (n=50) T P- value

items X SD X SD
Infection control practices 5 6.1 1.345 8.58 1.744 7.962 <0.001***
Positioning strategies 1 0.8 0.4 1.46 0.498 7.306 <0.001***
Deep venous thrombosis 1 0.84 0.366 1.44 0.496 6.883 <0.001***
prophylaxis
Ventilator care 5 4.88 1.595 7.66 1.762 8.271 <0.001***
Endotracheal Suctioning 10 9.74 2.979 15.82 4.897 7.500 <0.001***
care
Oral care protocol 2 2.82 0.38 3.7 0.458 10.456 <0.001***
Peptic ulcer prophylaxis 3 3.5 0.64 4.58 0.751 7.740 <0.001***
Extubation and weaning 2 2.58 0.493 3.66 0.514 10.723 <0.001**
trials *
Total compliance: 29 31.34 6.547 46.96 10.217 9.1020 <0.001**
*
* ***
A statistical significant difference (P ≤ 0.05) A highly statistical significant p < 0.001

Table (7): Comparison of total nurses’ compliance before and after implementation
of the bundle protocol (N= 50).

Pre Post
implementation implementation X2
Items P - value
n=50 n=50
No. % No. %
non compliant 32 64 10 20
partially compliant 15 30 11 22 66.528 <0.000***
Good compliant 3 6 29 58

Table (8): Correlation coefficient between total knowledge, practice and

compliance score of the studied nurses related to designed bundle protocol (n=50).
Total knowledge score Total practice score
Variables Pre Post Pre Post
implementation implementation implementation implementation
(n=50) )n=50) (n=50) )n=50)
r p r P r p r P
Total 0.62948 >0.05 0.94229 <0.001*
>0.05
complian 0.68992 0.89633 <0.001*** n.s **
n.s
ce score

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n.s: not statistically significant at p value >0.05 ***highly statistically significant at

p value=0.001
Table (9): Comparison of control and study group patients demographic and
medical characteristics (N=66).

Control group Studygroup X P

Frequency (n=33) (n=33)
No % No %
Sociodemographic
*Age (years)
<40 8 24.2 9 27.3 0.0792 n.s
>40 25 75.8 24 72.7
Ẍ ± SD 52.666 ± 9.678 51.969 ± 9.955
Gender
Male 16 48.5 15 45.5 0.0608 n.s
Female 17 51.5 18 54.5

Marital status
Married 29 87.9 30 90.9 0.6893 n.s
Unmarried 4 12.1 3 9.1
Working
Work 21 63.6 19 57.6 0.2538 n.s
Not work 12 36.4 14 42.4
*Residence
Rural 22 66.7 20 60.6 0.6088 n.s
Urban 11 33.3 13 39.4
*Diagnosis
- cerebrovascular 10 30.3 12 36.4
stroke
- pulmonary disease 5 15.15 2 6
- Hepatic 5 15.15 3 9
encephalopathy & 0.6432 n.s
Liver failure.
- Myocardial 6 18.2 5 15.15
infarction.
- Diabetes Mellitus. 15 45.45 10 30.3
- Cerebral 7 21.2 6 18.2
haemorrhage.
- Renal failure. 3 9 2 6
- Heart failure . 2 6 1 3
*Smoking history

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Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

Yes 8 24.25 6 18.2

No 25 75.75 27 81.8 0.3626 n.s
Causative organism
- Staphylococcus 18 54.5 20 60.6
aureus 0.67631
- Klepsiella pneumonia 6 18.2 7 21.2 7
- Pseudomonas 9 27.3 6 18.2
aeruginosa

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Table (10): Comparison of clinical pulmonary infection score between control and
study groups pre and post implementation of bundle protocol (n=66).

Variable Before After implementation X2 P-

implementation value
Score Control(n=33) Study (n=33)

N % N %
Temperature
36.5-37.5 0 6 18.2 16 48.5 7.4714
37.5-38.9 1 13 39.4 13 39.4 <0.05*
> 39 2 14 42.4 4 12.1
 SD 1.24 0.739 0.5150.499
White blood
cells(WBCs)
4.0-11.0 0 4 12.1 15 45.4
11.0-17.0 1 17 51.5 12 36.4 7.2 <0.05*
>17.0 2 12 36.4 6 18.2
 SD 1.180.625 0.8780.477
Secretion
None 0 4 12.1 16 48.4
Mild/non purulent 1 13 39.4 12 36.4 8.2549 <0.05*
Purulent 2 16 48.5 5 15.2
Oxygenation status
> 100mmHg 0 9 27.2 14 42.4
75-< 80mmHg 1 12 36.4 13 39.4 2.1773 >0.05
< 75mmHg 2 12 36.4 6 18.2
 SD 1.2720.663 10.246
Radiograph
No infiltrate 0 7 21.2 17 51.5
4.3663 >0.05
Diffuse 1 17 51.5 12 36.4
Infiltrate 2 9 27.3 4 12.1
Culture of
pathogenic
bacteria
0
No or mild growth
13 39.4 20 60.6
Moderate of florid 1 10 30.3 7 21.2 7.7912 <0.05*
growth
Pathogen 2 10 30.3 6 18.2

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consistent

Table (11) : comparison of total mean score of CPIS before and after
implementation of the bundle protocol

Items Before After T- Test P- Value

implementation implementation
Control group study group
Total score
Min- Max 4.0-10.0 0.0-7.0 9.3856 <0.001***
Mean  SD 7.08  1.56 3.51  1.53

Table (12): Mean and standard deviation of the studied patients according to
length of stay and duration on mechanical ventilator

Variable Before After intervention

intervention T- test P-value
Control(n=33) Study (n=33)

 SD  SD

Length of stay 15.030  0.797 9.787  0.844 20.7041 <0.001*

**
in
Intensive care
unit
Duration on 12.727  1.023 7.606 1.099 20.0506 <0.001*
**
mechanical
ventilator

T- test between control and study group pre and post intervention
n.s = not significant at p < 0.05 * = statistical significant at p value ≤ 0.05
6. Discussion

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Ventilator associated pneumonia (VAP) and noticed that nurses‟ age was between
is a common nosocomial infection in 31 and 39 years.
critically ill patients that is associated with Regarding the level of education for
poor clinical outcomes and economic, nurses, the present study's finding
including longer duration of intubation, indicates that the highest percentage of
longer ICU and hospital stay, high rate of nurses had a secondary school diploma in
mortality, and increased hospital charges nursing and more than three quarter of
(Ghimire & Neupane (2018). So the aim nurses job was as a staff nurse . From the
of the present study was to evaluate effect researchers point of view, this might be
of a designed bundle protocol about due to intensive care nurses are registered
ventilator associated pneumonia on nurses nursing personnel, formally trained in
performance, compliance and patient intensive care medicine and emergency
outcomes medicine (unclear rational). Supporting to
this study findings Hassan et al. (2021),
The current study findings reported who studied "Assessment of knowledge
that, nearly three quarters of nurses were and practice of ICU nurses regarding
of less than 30 years old with a mean age prevention of Ventilator Associated
of 30.82 ± 8.88 . The majority were Pneumonia (VAP) at a tertiary care
married and more than half of them had hospital " and reported that nearly half of
between (5-10 ) years of experience. From nurses carries Diploma in nursing. This
researcher point of view, The more critical result disagrees with ALaswad &
care nurses experience, the more liable to Bayoumi (2022), who studied "
increase capacities related to cognition, Improvement of the nurses‟ awareness
clinical judgment and decision making toward ventilator-associated pneumonia
concerning care of critically ill patients. based on evidence guidelines" and
Supporting to this study findings reported that the bachelors degree holders
Alkhazali, (2017) in his study entitled were a large proportion.
"Critical care nurses‟ knowledge on The current study findings illustrate
prevention of ventilator associated that, the majority of studied nurses not
pneumonia and barriers of compliance to receiving any previous training about
preventive measures" Near East ventilator associated pneumonia
University, Institute of Health Sciences, prevention bundle. This might be due to
who reported that, the mean ages of lacks hospital financial resources, shortage
studied group was 30 years old, their of nursing staff, and work overload which
experiences within critical care unit started considered a barrier for nurses to leave the
from 5 years and the majority of studied work and attend a training course and this
group were married. might be the reason behind their
This result disagrees with Bankanie et unsatisfactory knowledge, practices before
al. (2021) who carried out a cross bundle protocol training. In agreement
sectional study to identify ICU nurse‟s with this finding Khalifa & Seif Eldin
knowledge and compliance toward (2020) whose study about " The impact of
evidence based guidelines to prevent VAP an educational training program on nurses

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Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

in reduction of ventilator associated and role of nurses in its prevention", and

pneumonia" and reported that nearly all demonstrated that the occurrence of
the studied nurses were not participating ventilator associated pneumonia is directly
in the training sessions. Disagreement to related to insufficient knowledge and
this study finding Alkhazali et al. (2021), understanding about the pathophysiology
who studied " Knowledge and barriers of and risk factor regarding development,
critical care nurses regarding evidence- and prevention strategies of ventilator
based practices in ventilator-associated associated pneumonia. In contradiction
pneumonia prevention using descriptive with study finding Hassan et al. (2021)
cross-sectional design in two hospitals in mentioned that most of ICU nurses had
Jordan" and found that a majority of moderate knowledge about ventilator
nurses gained their knowledge not directly associated pneumonia preventive
from nursing schools but from in-service measures.
training program. While immediately post-
Regarding nurses knowledge: The implementation. The current study
current study reveals that Nurses' total findings reported that nearly two thirds of
knowledge level demonstrates that three them had a good level of knowledge
quarters of studied nurses had immediately post designed bundle
unsatisfactory total knowledge scores pre- protocol training with a statistically
designed bundle implementation. This significant difference between the nurses
might be due to one or more of the knowledge in the pre and post study
following reasons, lack of orientation phases. From the researchers point of
program prior to work as well lack care view, this might be due to the
conferences? during work, non- implementation of the educational session,
availability of procedure book specially supported with printed guideline booklet.
prepared for the critical care areas and Besides, the practical training that allow
lack of direction and nurse's appraisal the nurses to demonstrate and remonstrate
about ventilator patient's care in specific the bundle procedures . These findings are
areas like percussion, vibration, postural supporting the first research hypothesis.
drainage and ventilator apparatus settings In agreement with this study findings
and connections. ALaswad & Bayoumi (2022) indicated
Congruence with this study finding an improvement in the area of general
Bhandari et al. (2021). They studied " knowledge post ventilator associated
Knowledge of nurses working in critical pneumonia based evidence guidelines
care areas regarding ventilator associated implementation. Also, This agrees with
pneumonia prevention bundles in a tertiary Rakhi & Navita (2020), who concluded
level cardiac centre" and found that only that more than three quarter of their
few percentage of nurses had correct participants had poor level of total
knowledge about ventilator associated knowledge pre- intervention which
pneumonia. As well, Osti et al. (2017) improved to a good level at immediate
studied " Ventilator-associated pneumonia post test. As well, Khalifa & Seif Eldin

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(2020) documented that the level of (2021), who reported that majority of the
nurses' general knowledge was improved staff nurses had unsatisfactory practice,
post educational program and the result and they need for prevention of VAP
was statistically significant. guidelines to promote nurses‟
Regarding nurses practice, the current performance.
study findings demonstrate a statistically As well Getahun et al. (2022) whose
significant improvement in the total study about" Knowledge of intensive care
practice mean score and all the practice nurses‟ towards prevention of ventilator-
elements immediately post-bundle associated pneumonia in North West
implementation as compared by pre Ethiopia referral hospitals" and revealed
bundle implementation training. The that ICU nurses who had taken training on
current study reveals that majority had VAP prevention were higher skillful than
unsatisfactory level of practice pre VAP nurses who had not taken regular training.
bundle implementation; this might be due Findings were consistent with study
to most nurses had unsatisfactory conducted by Uma & Amoldeep (2022)
knowledge of pre bundle implementation whose study about" Effectiveness of
and lack of in-service training programs. nursing care bundle in terms of knowledge
However, post VAP bundle and practices regarding care of patients on
implementation more than two third of mechanical ventilator among nursing
nurses had a good level of practice with a personnel,” and reported that a
statistical significant difference between statistically significant difference in the
the two study phases. These findings are post test practices score among
supporting the second research hypothesis. experimental group than pre test practices
In the same line Sharma & Mudgal score.
(2018) whose study about" Knowledge Contradiction to these study findings
and skill regarding care of a patient on Busi & Ramanjamma (2016) whose study
mechanical ventilator among the staff about" the effectiveness of structured
nurses working in selected hospital " and teaching program on the level of
states that pre-test skill scores was lower knowledge and practice regarding
than the post test skill score and there was prevention of VAP among critical care
significant difference between the pre-test nurses of General Hospital, Guntur,
and post-test practice scores. This agree Andhra" and revealed that majority of the
with Abad et al. (2021) whose study staff nurses had moderate knowledge and
about" Assessment of knowledge and practice before implementing structured
implementation practices of the ventilator teaching program.
acquired pneumonia (VAP) bundle in the Regarding compliance to a designed
intensive care unit of a private hospital" bundle protocol, findings of the present
and reported that the lack of education and study reveals that near two third of the
practices were consistently identified as studied nurses were noncompliant to
the principal reasons precluding proper bundle procedures before bundle training.
implementation of the VAP bundle. This From the researcher point of view, due to
finding was consistent with Hassan et al. lack of knowledge, workload and lack of

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Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

strict monitoring protocols for compliance the mean self-reported compliance to

with ventilator associated pneumonia evidence based guidelines for the
bundle. While, improved to near two third prevention of ventilator associated
of them had a good compliance level after pneumonia was high but neither nursing
intervention, with a highly statistical level of education nor experience was
significance difference between pre and associated with significant variability in
post intervention compliance for all compliance.
procedures and the total . This might be Correlation between nurse’s
due to the improvement in the nurses performance and their compliance
knowledge and practice after bundle toward designed care bundle protocol
application . These findings are for prevention of VAP showed positive
supporting the third research hypothesis. correlations between nurses performance
Supporting to this study findings Neef (knowledge and practice) and their
et al. (2019) illustrated that a large compliance post bundle protocol
percentage of critical care nurses didn't implementation. From the researchers
comply with most VAP bundle practices point of view (remove this statement from
before intervention and improved after all discussion and replace by this might be
designed bundle protocol implementation. due to) this might be due to the
In the same line Aloush (2018) conducted compliance is enhanced with good
a study on "Nurses' implementation of knowledge and good practice and vice
ventilator-associated pneumonia versa. (it is a recommendation).
prevention guidelines: An observational Supporting to these study findings Bird et
study in Jordan" and showed that nurses‟ al. (2020) conducted a study on
compliance of nurses was found to be adherence to ventilator-associated
unsatisfactory before implementing pneumonia bundle and incidence of
ventilator associated pneumonia ventilator-associated pneumonia in the
prevention guidelines. As well Al-Sayaghi surgical intensive care unit. They found
(2021) in a study entitled " Critical care that compliance with the VAP bundle by
nurses‟ compliance and barriers toward the staff nurses increased over the study
ventilator associated pneumonia period after VAP bundle implementation
prevention guidelines: Cross-sectional than before with statistical significant
survey” showed that nurses who had prior correlation between nurses compliance
education regarding VAP prevention had a and their performance .
significantly higher compliance score than
the no education group. As regards patients’ socio
In contradiction to this study demographic characteristics, the
findings Bankanie et al. (2021) whose majority of both study and control patients
study about " Assessment of knowledge were married, from rural areas. Regarding
and compliance to evidence-based age, findings of the current study revealed
guidelines for vap prevention among ICU that three quarters of both study and
nurses in Tanzania" and documented that control group aged more than 40 years

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old. From the researchers point of view as pneumonia among patients on a

co-morbidity increase with age and mechanical ventilator at selected hospitals,
increase the risk of ICU admission. This Erode, and found that about half of both
result consistent with Ali et al. (2020) experimental and control groups, the
whose study about" Assessment the central nervous system diseases is the
Incidence of Ventilator -associated main reason for ICU admission and result
Pneumonia for Critically Ill Patients in the in a mechanical ventilator connection.
Intensive Care Unit" and found that Findings of the present study found the
Nearly three quarters of studied patient causative organism in both study and
had age more than forty years old. control group are Staphylococcus aureus.
The current study findings illustrated no This could due to Staphylococcus aureus
significant statistical differences were seen is the leading cause of infection in the
between the two groups in relation to the setting of critical illness and injury. This
demographic variables which indicates pathogen causes life-threatening infection
that the two groups were nearly in intensive care units. Also, due to
homogenous. Remove this part it is not aspiration of secretions or the use of
necessary to rationalize that both group contaminated equipment, organisms may
was homogenous and to decrease the spread through the oropharynx, sinus
length of the discussion as it . cavities, nares, dental plaque,
Regarding to medical history, the gastrointestinal tract, patient-to-patient
majority of both study and control group contact and ventilator circuit leading to
had a medical history of cerebrovascular bacterial colonization of the lungs (add a
stroke, diabetes, cerebral hemorrhage. recommendation regarding this
This could due to the natural of ICU information in the recommendation
admission as it was an emergency ICU section). Supporting to this study results
that received many patients traumatized in El-Saed et al. (2016) found
road traffic accident As well, the majority staphylococcus aureus was the most
of the patient were admitted because of frequently isolated causative agent for
disturbed conscious level as a ventilator associated pneumonia.
complication from chronic disease like Contradiction to this study findings
diabetes mellitus. This results agree with Othman et al. (2017) reported that,
Othman et al. (2017) in his study entitled Klebseilla pneumonia was isolated from
" Ventilator associated pneumonia, less than half of patients with VAP
incidence and risk factor s in emergency patients.
intensive care unit Zagazig university
hospitals" and showed that stroke and The current study findings illustrated
cerebral hemorrhage were the most that, before a designed bundle protocol
common diagnosis on ICU admission. In implementation, there is no statistical
the same line Kudiyarasu (2016), who significant differences between study and
conducted a study to assess the control group related to all items of
effectiveness of ventilator bundle on clinical pulmonary infection score tool
prevention of ventilator-associated before implementation. But immediately

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Evidence-Based Nursing Research Vol. 3 No. 3 July 2021

after a designed bundle protocol in the incidence and risk of VAP after the
implementation on study group patients implementation of the bundle.
(you did not compare between them pre A study found a substantial decrease in
and again compare between them post as the CPIS mean score (you did not compare
in the preintervention phase, the study neither rate or incidence) VAP after
group was not admitted yet), there is a implementation of the ventilator care
statistical significant difference between bundle. (Where is your rational for this
all items of clinical pulmonary infection findings?) In agreement with this study
score between study (patient admitted finding Beatriz (2017) in a entitled study"
after bundle application) and control group Nursing actions to prevent mechanical
(patients admitted before bundle ventilation pneumonia in the intensive
application). From the researcher point of care unit "who found that, before
view, (the training program was for the implementation of ventilator bundle, VAP
nurses not patients).This might be due to rate was increased ; and after
the implementation of the VAP bundle implementation of ventilator bundle VAP
protocol with trained compliant nurses. rate decreased with statistical significant
These findings are supporting the fourth difference .
research hypothesis. Related to length of stay within
Supporting to this study finding intensive care unit and duration of
Montasser (2017) in his study entitled " patient on mechanical ventilator, The
Decreasing the incidence of ventilator current study findings demonstrate
associated pneumonia with complete statistically significant differences
adherence to its prevention bundle" at Al– between study and control group regarding
Hayat Hospital, Jeddah, KSA. The study their length of stay within intensive care
illustrated that, the application of unit and duration of patient on mechanical
ventilator associated pneumonia (VAP) ventilator. But (again you did not compare
prevention bundle reduce the incidence of twice, take care, you compare once after
ventilator associated pneumonia. These versus before). These findings are
results indicated a positive impact on supporting the fourth research hypothesis.
patient outcome with strict application of This finding is consistent with Shi et
VAP bundle. al. (2022) in a study entitled" Analysis of
In the same line, Neef et al. (2019) the nursing effect of respiratory critical
stated that, the primary outcome of this illness based on refined nursing
study was the difference in incidence rate management" which found that post
of VAPs before and after the applying nursing management a
implementation of prevention bundle. In reduction in secondary infection, thereby
the same line with Mogyoródi et al. reducing the incidence of VAP in patients
(2016) in a study entitled "Ventilator- on mechanical ventilation, shortening the
associated pneumonia and the importance time of mechanical ventilation and ICU
of education of ICU nurses on prevention: stay time. This agrees with
Preliminary results", showed a reduction Radhakrishnan et al . (2021) whose

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study about "Effect of training and hospital policies should include updated
checklist based use of Ventilator guidelines for VAP prevention bundle and
Associated Pneumonia (VAP) prevention protocol from international evidence.
bundle protocol on patient outcome: A Further study is required to apply the
tertiary care center study" and stated that, VAP bundle strategy with larger sample
the implementation of the bundle size &estimate its effect on nurses‟
components, would translate into better performance regarding caring of critically
outcomes in terms of lower incidence of ill patients under mechanical ventilation
VAP, hospital mortality and hospital and also on patient outcomes.
length of stay in patients on mechanical 9. References
ventilation
Ab Manap N. (2019): Critical Care
7. Conclusion Nurses Knowledge in Prevention of
Based on the current study results and Ventilator-Associated Pneumonia.
research hypothesis, the following can be ILKKM Journal of Medical and Health
concluded: Sciences. 2019;1(1):25-30.
The study group nurses who received Abad, C.L., Formalejo, C.P., &
designed bundle protocol got higher Mantaring, D.L. (2021): Assessment of
knowledge, practices and compliance knowledge and implementation practices
scores than pre deigned bundle protocol of the ventilator acquired pneumonia
implementation. Also, the study group (VAP) bundle in the intensive care unit of
patients who cared by a designed bundle a private hospital, Antimicrobial
protocol exhibited better outcomes such Resistance & Infection Control, 10(1):161.
as significant lower score of CPIS, shorter https://doi.org/10.1186/s13756-021-
length of stay in intensive care unit, less 01027-1.
duration on mechanical ventilation Abdelazeem, E., Fashafsheh, I., &
compared to the control group who Fadllalah, H. (2019): Effect of Training
received routine hospital nursing care. Program on Nurses Knowledge and
8. Recommendations Competence Regarding Endotracheal
Based on results of the present study, Tube and Tracheostomy Care in
the following can be recommended: Mechanically Ventilated Patients.
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