Patients With Ventilator-Associated Pneumonia
Method of obtaining necessary approval and securing support for the proposal
Obtaining support for the proposal is a crucial part of the implementation plan. One cannot go ahead with proposal implementation without getting the proper approval, authority and support (funding and technical assistance). The way to go about this problem is mainly through dialogues. Holding meetings with representatives from academic institutions, political, professional, and any other organizations that may be willing to support the project is very important. The type of support accorded to the project is very crucial not only in the initial stages, but also in the review stage of the project implementation. The project can get support through letters of support, for example, a student in a university may need a letter of support and an introduction letter from the university in order to carry out or implement a project outside the University. Even within the University, the same student may be required to get a letter of support from his or her supervisor in order to implement a given project. A mutual agreement to share the benefits of the project can also act as an incentive to gain approval. If for example, one is implementing a project on sanitation or water treatment in a given locality, the government agencies are bound to support the project as they are also benefiting from the project, that is, they are being assisted in their work. The project must be able to address a given problem or fill in existing gaps in research if it is to receive support. Otherwise, one may be forced to redraft the project proposal. Realistic budget and implementation duration are also important factors in winning the support of the stakeholders. No one wants to support a project whose end is stretched for a long time. People need to see results and value for their money and they want it sooner than later. Therefore, a project with a short implementation period has better prospects of securing approval and support. The project must clearly spell out the modalities for achieving the laid down goals and the general study objectives.
Description of the current problem
Early and accurate diagnosis of patients with ventilator-associated pneumonia (VAP) is important in the management of patients suffering from this disease (Rea-Neto et al., 2008). Amanullah et al. (2011), describes Ventilator-associated-pneumonia as the pneumonia that develops within 48 hours or longer after mechanical ventilation by either endotracheal tube or by tracheostomy. The early diagnosis of VAP for timely intervention is a major problem and the implementation of this project is aimed at improving the situation. According to Rea-Neto et al. (2008), VAP is a common disease in the intensive care unit (ICU) of many hospitals affecting 8% to 20% of ICU patients and up to 27% of mechanically ventilated patients. According to a study conducted by Fàbregas et al. (1999), the accurate diagnosis of VAP remains controversial in spite of more than a decade of clinical studies. In the study, they argued that the use of quantitative cultures of endotracheal aspirates (QEA) has a similar diagnostic value as compared to invasive techniques such as protected specimen brush (PSB) and bronchoalveolar lavage (BAL). According to the authors, QEA has the advantage of being resilient on simplicity and is also cost-effective while at the same time the method has no side effects. The major problem in the treatment of VAP is that results are not ready immediately and as such the medical practitioners have been relying on prior antibiotic treatment for patients suspected to have contracted VAP. Prior antibiotic treatment is risky and may result in the development of infection with high-risk microorganisms such as Pseudomonas aeruginosa.
According to Bird et al. (2010), although invasive techniques performed through fiber optic bronchoscopes using PSB or BAL offer good diagnostic information for VAP patients, however these techniques are expensive, time-consuming and have some complications. Rajasekhar et al. (2006), proposes a rapid diagnosis of VAP and the initiation of the appropriate antibiotic treatment as a delay or inadequate antibiotic treatment may hurt the patients’ prognosis. Liang et al. (2002) in their study were able to show that quantitative cultures can be performed on endotracheal aspirates either bronchoscopically or non- bronchoscopically. Zaccard et al. (2009), argue that sampling of the lower airways bronchoscopically by the use of either PSB or BAL is still the accepted method of diagnosing VAP up to now as it is the most accurate.
A detailed explanation of the proposed solution
The diagnosis of pneumonia in VAP patients is still very difficult and up to now, no standard diagnostic method has been agreed upon (Alp & Voss, 2006). Diagnosis of VAP should be based on a combination of clinical, radiological, and microbiological criteria as suggested by Alp and Voss (2006). However, these criteria have low sensitivity and specificity especially for systematic signs (fever and leukocytosis among others) of infection which can be seen in any condition in the ICU. There is thus the need to use a highly accurate method that is highly specific and thus can be able to quickly and accurately diagnose VAP. Sanchez et al. (1998) found out that clinical diagnosis of VAP is associated with 30% to 35% false-negative and 20% to 25% false-positive results. They also noted that patients do not always have systematic signs of infection due to their underlying diseases such as chronic renal failure and immunosuppression among others. According to Croce et al. (2004), radiological infiltration also has limited value especially when you consider the mirroring signs of other conditions such as cardiogenic pulmonary edema, adult respiratory distress syndrome (ARDS), electracy which have similar signs to those of VAP and are common in the ICU. Zaccard et al. (2000) say that these confusing symptoms can result in delays in the diagnosis of VAP and thus the need to come up with a more specific mode of diagnosis. According to Wunderink (1998), no radiographic sign has a diagnostic accuracy of more than 68%. The best method to apply as proposed by Rea-Neto et al. (2008) is a combination of seven variables including; temperature, leukocytes, tracheal aspirate volume and purulence of tracheal aspirate for diagnosis of VAP. This approach is called the clinical pulmonary infection score (CPIS) and has been found to have a sensitivity up to 93% and specificity of up to 100% in some studies. The reason or rationale for selecting CPIS as the best option for VAP diagnosis is because of its high sensitivity and specificity hence making it possible to quickly and accurately identify patients suffering from VAP and consequently starting a timely antibiotic treatment that may save a lot of lives in the patients infected with VAP. There are limitations to this approach such as the requirement of a waiting period of 24-48 hours to get the results and a requirement of personnel who have progressive experience in intensive care. To overcome these impediments, El-Ebiary and Torres (2000), recommend the use of a modified CPIS (m-CPIS). The modified CIPS does not perform better in situations where the clinical suspicion of pneumonia is high. In this scenario, the authors proposed incorporating the results of specimen gram stain (through the addition of two more points when the grain stains are positive) to modify CIPS to raise the sensitivity of the score and the diagnostic accuracy. Rajasekhar et al. (2006) observed that in using modified CPIS or m-CPIS as it is sometimes called, empiric antibiotic treatment could be discontinued on day 3 if the scoring on m-CPIS is less than 6 and can take its normal full course if the m-CPIS is greater than 6. Bouza et al. (2007) concur with Rajasekhar et al. (2006) that modified CPIS baseline is calculated by the use of the first five variables of the original CPIS. Camargo et al. (2004) propose that the M-CPIS calculation be done by adding two points of them-CPIS baseline when the Gram result is positive for VAP. In a study conducted by Rajasekhar et al. (2006), results show that adding Gram stain results of lower respiratory samples to the m-CPIS augments its specificity and sensitivity in diagnosing VAP. Rajasekhar et al. (2006) also found out that CPIS had a high specificity of about 80% and sensitivity of 30% in diagnosing VAP as compared to quantitative BAL fluid. One major limitation in the use of BAL culture to validate the use of CPIS is that the BAL culture is not a true standard of measure. In their study Rajasekhar et al. (2006) argue that different authors modify the calculation of CPIS and use different cutoff points in the VAP diagnosis thus hindering the accomplishment of a common or standard way of the CPIS use. Rajasekhar et al. (2006) also noted that there was very little agreement in calculating CPIS between different observers. Because we aim to achieve quick results that are accurate at the lowest cost, the adoption of the modified CPIS is the better option as it is not only cost-effective but can also be highly specific and sensitive.
Description of implementation logistics
The project implementation will require the corporation of all the stakeholders including the practitioners, research institutions, and government departments. There will be a need to educate the general public about the project by use of various methods such as sensitization campaigns, pamphlets, posters and general media outlets. The practitioners will also need refresher courses to adopt and help patients suffering from VAP. There will thus be need for a transport and public address system during the sensitization campaigns. Posters will have to be printed and distributed in different hospitals and clinics that deal with VAP. Seminars will have to be organized for the practitioners and all these activities will cost money and time.
Resources required for implementation
There will be a need for vehicles to transport the trainers of trainers (TOT) during the implementation. Vehicles will also be used in the campaigns and they will be used in carrying the implementation team and the public address system. Of course, money and time are vital resources that will be needed in the implementation phase.
References
Alp, E., & Voss, A. (2006). Ventilator associated pneumonia and infection control. Annals of Clinical Microbiology and Antimicrobials, 5(7), 1-11.
Amanullah, S. et al. (2011). Ventilator-Associated Pneumonia’ medscape reference. Web.
Bird, D. et al. (2010). Adherence to Ventilator-Associated Pneumonia Bundle and Incidence of Ventilator-Associated Pneumonia in the Surgical Intensive Care Unit. Arch Surg, 145(5), 465-470.
Bouza, E. et al. (2007). Direct E-test (AB Biodisk) of respiratory samples improves antimicrobial use in ventilator-associated pneumonia. Clin Infect Dis, 43,382-7.
Camargo, L.F.A. et al. (2004). Ventilator associated pneumonia: comparison between quantitative and qualitative cultures of tracheal aspirates. Critical Care, 8, R422- R430.
Croce, M.A. et al. (2004). The Appropriate Diagnostic Threshold for Ventilator- Associated Pneumonia Using Quantitative Cultures. J Trauma, 56, 931–936.
El-Ebiary, M., & Torres, A. (2000). Bronchoscopic BAL in the Diagnosis of Ventilator- Associated Pneumonia. Chest, 117, 198S-202S.
Fàbregas, N., et al. (1999). Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax, 54(10), 867-73.
Liang, W.C. et al. (2002). Quantitative Culture of Endotracheal Aspirates in the Diagnosis of Ventilator-Associated Pneumonia in Patients with Treatment Failure. Chest, 122(2), 662-9.
Rajasekhar, et al. (2006). The Role of Quantitative Cultures of Non-Bronchoscopic Samples in Ventilator Associated Pneumonia’ Ind. J. of Med. Microb.,24, 07-113.
Rea-Neto, A. et al. (2008). Diagnosis of ventilator-associated pneumonia: a systematic Review of the literature. Critical Care, 12, 56.
Sanchez, J.M.N. et al. (1998). Impact of Invasive and Noninvasive Quantitative Culture Sampling on Outcome of Ventilator-Associated Pneumonia. Am J Respir Crit Care Med, 157, 371–376.
Wunderink, R.G. (1998). Mortality and the Diagnosis of Ventilator-associated Pneumonia: A New Direction. Am. J. Respir. Crit. Care Med., 157(2), 349-350.
Zaccard, et al. (2000). Efficacy of Bilateral Bronchoalveolar Lavage for Diagnosis of Ventilator-Associated Pneumonia. J. Clin. Microbiol., 47(9), 2918-24.
Zaccard, C.R. et al. (2009). Efficacy of Bilateral Bronchoalveolar Lavage for Diagnosis of Ventilator-Associated Pneumonia. J Clin Micr, 47(9), 2918-24.