The Effects of a Nursing Care Plan Incorporated with a Decision

Support System on Ventilator Associated Pneumonia: A Case Study

Ozgur Bolat

, Nalan Gulenc

, Elife Ozkan

, Nuran Aydin

and Ilker Kose

Izmir Tire Public Hospital, Izmir, Turkey

Department of Midwifery, Istanbul Medipol University, Istanbul, Turkey

Department of Health System Engineering, Istanbul Medipol University, Istanbul, Turkey

Keywords: Ventilator Associated Pneumonia, Nursing Care, Decision Support System, Intensive Care Unit.

Abstract: The risk of pneumonia is high in patients who are ventilated in intensive care units (ICUs). Without proper

and adequate care, this risk and the mortality rate increases. In a study conducted by the infection committee

of our hospital (İzmir Tire State Hospital, the first digital (Stage 7) hospital in Turkey in 2016), it was found

that the rate of ventilator-associated pneumonia (VAP) cases increased had increased over three years (2015-

17) and was well above the national average. In this study, VAP prevalence in our ICU and the associated

extra medication costs were calculated. Furthermore, nursing care plans related to VAP were reviewed and

improvements were made according to international standards. The care plan was triggered by criteria defined

in a clinical decision support system (CDSS) on the hospital information management system (HIS), and

monitorization was conducted to ensure that nurses implement the care plan in a comprehensive and timely

manner. As a result of the change, the rate of VAP cases, which had risen to 4.5% in 2017, was reduced to

0.5% in 2018. Similarly, we achieved cost reductions of 90.87% for VAP-based extra medications. Based on

these results, it can be suggested that CDSS-supported nursing care can significantly reduce the risk of VAP

and increase patient safety in the ICU.

1 INTRODUCTION

Ventilator-associated pneumonia (VAP), defined as

pneumonia between 48 and 72 hours following

endotracheal aspiration, is the most common

infection among intensive care unit patients receiving

mechanical ventilatory support (Kapucu & Ozden,

2014). In a study conducted at the national level in the

USA, it was estimated that a significant 10% of

patients who are connected to mechanical ventilators

are diagnosed with VAP (Wang et al., 2014). Other

studies found that mortality rates of 20-50% in

patients connected to ventilators in intensive care

units may be reduced by 13% (Klompas & Li, 2013;

Melsen et al., 2013; Sara, Phillips, Kaur, & Isaac,

2015).

https://orcid.org/0000-0003-4411-1696

https://orcid.org/0000-0003-1696-9943

https://orcid.org/0000-0002-8805-9338

https://orcid.org/0000-0003-0582-1484

https://orcid.org/0000-0002-5549-5579

According to a recently published systematic

review of VAP, the aims of several studies to identify,

prevent, and treat VAP epidemiology were related to

the prevention of associated mortality and morbidity,

to reduce costs, and to improve the quality of care

(Gutiérrez et al., 2019). Studies in different countries

indicate that the development of VAP in patients

increases the duration of ventilator utilization and

hospital stay and increases patient care and treatment

costs (Kalil et al., 2016), (Başyiğit, 2017; Hayashi et

al., 2013; Luckraz et al., 2018; S et al., 2017).

There are many approaches to preventing the

development of VAP, such as infection control

measures, minimum possible intubation, re-training

of health personnel, and using care guidelines

(Gutiérrez et al., 2019). Alternative VAP care

management plans are prepared and recommended by

Bolat, O., Gulenc, N., Ozkan, E., Aydin, N. and Kose, I.

The Effects of a Nursing Care Plan Incorporated with a Decision Support System on Ventilator Associated Pneumonia: A Case Study.

DOI: 10.5220/0009164706930698

In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 693-698

ISBN: 978-989-758-398-8; ISSN: 2184-4305

693

recognized organizations, such as the European

Respiratory Society (ERS), the European Society of

Intensive Care Medicine (ESICM), and the European

Society of Clinical Microbiology and Infectious

Diseases (ESCMID) (Torres et al., 2018). The use of

care plans has consistently been found to decrease the

duration of VAP-related length of stay, reduce

complications, decrease antibiotic usage, and

decrease antibiotic resistance; all of which reduce the

amount of time and money lost due to VAP. The

move from handwritten care plans to digital plans is

effective in improving VAP control and reducing

VAP-associated length of stay, useful in decreasing

antibiotic use, and effective in reducing loss of time

and money (Kalil et al., 2016), (Wang et al., 2014),

(Klouwenberg et al., 2014), (Liao et al., 2019).

Digital care plans have been shown to have an impact

on decreasing VAP-related complications and the

number of ventilator-associated tracheobronchitis

(VAT) events (Neuville, Mourvillier, Bouadma, &

Timsit, 2017).

Completing VAP checklists on paper is not

efficient due to errors and omissions. Missing data in

manually generated records may cause insufficient

evaluations. Studies have shown that the transfer of

checklists to digital media helps to reduce these

problems (Liao et al., 2019), (De Bie et al., 2017),

(Klompas, Kleinman, & Platt, 2008).

Although it is controversial whether the

development of VAP and VAP-related complications

should be used to measure the quality of patient care

(Kalil et al., 2016), (Klompas & Berra, 2016),

particularly in developing countries, there are

significant costs associated with VAP (Alp et al.,

2012). The results of studies conducted in Turkey are

consistent with other studies in the literature.

According to 2017 data from the business intelligence

application of the Ministry of Health, the average rate

of VAP in Level 2 ICUs in Turkey was 3.8%, while

İzmir Tire State Hospital had a VAP rate of 4.5%,

which is 18.42% higher than the national average

(Kapucu & Ozden, 2014), (Alp et al., 2012; Grassie

& Gevrek, 2016; Karaoglan et al., 2010; Torres et al.,

2017).

In 2016, İzmir Tire State Hospital was designated

as the first digital hospital (Stage 7) according to

Healthcare Information and Management Systems

Society (HIMSS) Electronic Medical Record

Adoption Model (EMRAM) reguirements (HIMSS

Analytics, 2018). This study examines the effects of

incorporating VAP care plans and patient monitoring

with a clinical decision support system (CDSS)

application within the hospital information

management systems (HIS).

2 METHODS

In the first stage of the study, the incidence of VAP,

the number of patients diagnosed with VAP, and the

cost of extra medications associated with VAP were

tracked between 1 January and 31 December, 2018.

The Level 2 intensive care unit at İzmir Tire State

Hospital has 15 ventilators and 17 beds. All nursing

forms and nursing care plans related to VAP

prevention and care that were used in the hospital

were reviewed. The hospital's infection control

committee reviewed patient monitoring charts and

nursing care plans completed manually by nurses on

paper. The committee then developed a single nursing

care plan based on the recommendations of

international guidelines (Torres et al., 2018). The new

care plan and related forms were transfered to the

hospital’s HIS so that medical records related to VAP

prevention and care would be digital instead of paper-

based.

During our review of current practice, we found

that some VAP prevention and care activities were

not performed in the unit even though they were

mentioned in the nursing care plan. As such, the

following elements were added to the nursing care

plan: correct hand washing and use of aseptic

technique, continuous control of tracheal cuff

pressure, postural drainage, and endotracheal tube

direction change and level control. Then, the HIS

vendor developed a CDSS application for the HIS

system. The new CDSS was rule-based and triggered

when relevant conditions are met, such as entering

predefined diagnoses or interventions. Our CDSS

was triggered when a nurse indicated on the

respiratory system evaluation screen that a patient had

an endotracheal tube (intubated) placed. The CDSS

responds to this trigger by automatically adding the

necessary care, follow-up, and nursing interventions

to the care plan at appropriate frequencies. The HIS

then prompts the nurses to follow the ventilator care

plan scheduled by the CDSS. The CDSS generated

plan includes the following tasks:

Ventilator Care Plan

1. Deep venous thrombosis and peptic ulcer

prophylaxis

2. Raising the head of the bed

3. Subglottic secretion drainage

4. Cleaning ventilator circuits and preventing

fluid build-up

5. Oral care

6. Extubation readiness assessment

7. Aspiration with aseptic technique

8. Cuff pressure monitorizition

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Figure 1: VAP Care scheduling screen on HIS.

Figure 1 shows these tasks added to the nursing

care plan in the HIS work schedule.

In addition to the improvements in nursing care

plans (Klompas et al., 2014), (Resetar et al., 2014), it

is essential to train nurses on the new practices

(Mogyoródi, Dunai, Gál, & Iványi, 2016),

(Pneumonia, 2005). Once the improvement work was

finalized on the HIS, 24 nurses working in the Level

2 ICU received training on the new care plan. After

the nurses were trained and had used the new system

for one complete year (2018), the incidence of VAP,

the number of patients diagnosed with VAP, and the

cost of extra medications related to VAP for 2018

were calculated and compared with the previous

period (2015-17). When calculating the number of

VAP cases, only patients who developed VAP after

admission to the intensive care unit were taken into

account (including the ppatients who were already on

a ventilator when they arrived at the hospital (without

pneumonia), and patients who were already

diagnosed with pneumonia during hospitalization

were excluded. In the calculation of medication costs,

the costs of extra medications (antibiotics, etc.)

administred to the patient due to a VAP diagnosis

were taken into consideration. Costs were extracted

from the hospital’s HIS which is integrated with the

claims submission portal of the national health

insurance system.

3 RESULTS

Following a full year of implementation of the new

nursing care plans triggered by the CDSS, the rate of

new cases diagnosed with VAP decreased from 4.5%

in 2017 to 0.5% in 2018 (Figure 2).

Figure 2: Comparison of VAP Ratio in ICU.

Similarly, the total number of patients diagnosed

with VAP, dropped from 17 in 2017 to 2 in 2018

(Figure 3).

Figure 3: Comparison of the number of VAP incidence.

In our hospital, the cost of extra medication

(antibiotics, etc.) administrered to the patient due to

VAP decreased significantly (90.87%). Accordingly,

the cost of extra medications, which was 855,412

Turkish Lira (≈189,250€) in 2017, decreased to only

78,044 TL (≈12,900€) in 2018 (Figure 4).

1,80%

3,90%

4,50%

0,50%

0,00%

1,00%

2,00%

3,00%

4,00%

5,00%

2015 2016 2017 2018

VAP Ratio

2017 2018

#ofVAPIncidence

The Effects of a Nursing Care Plan Incorporated with a Decision Support System on Ventilator Associated Pneumonia: A Case Study

695

Figure 4: Comparison of extra medication costs related to

VAP.

4 CONCLUSIONS

VAP is associated with high mortality and morbidity

rates and high treatment costs. Managers of intensive

care units can improve the quality and cost of care

through prevention of VAP. This study produced

results consistent with previous studies showing that

the implementation of a comprehensive, evidence-

based, and safe care plan to prevent VAP can

significantly reduce the cost of care. This study also

confirmed that findings of other research showing the

economic benefits of using electronic systems in

patient monitoring and evaluation, early diagnosis,

and documentation are also valid for VAP (Prgomet,

Li, Niazkhani, Georgiou, & Westbrook, 2017),

(Schurink et al., 2007). Many studies reporting the

benefits of CDSSs on improving performance on

healthcare quality indicators (Johnston, Langton,

Haynes, & Mathieu, 1994; Kawamoto, Houlihan,

Balas, & Lobach, 2005). It can be suggested that

instead of implementing nursing interventions

individually, even if they are scientifically proven,

incorporating comprehensive care plans with CDSS

and following the activity plan can contribute to

preventing or reducing infections more efficiently.

Following this study, hospital managers decided to

develop new care plan packages using CDSS for

other care processes.

ACKNOWLEDGMENTS

The authors wish to thank the Chief Medical Officer

of İzmir Tire State Hospital, Dr. Fatih Hayali, for his

valuable support and encouragement during this

study. Care plans are routinely integrated with HIS

programs and used in hospitals throughout Turkey.

No permission was required from any individual or

institution. This research was carried out within the

scope of digital transformation in our hospital and no

financial support was received.

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