EVIDENCE-BASED PRACTICE PROPOSAL PAPER 1

Evidence-Based Practice Proposal Paper

Aleena Thomas, Emilie McAllister, Sallie Green, Maryam Hasan, and Emily Grecco

College of Nursing, University of South Florida

Abstract
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Clinical Problem: For patients with ventilator-associated pneumonia (VAP), how efficient is the implementation of a ventilator bundle

compared to standard care (oral hygiene care) in reducing the incidence of VAP during a six-month period?

Objective: This synthesis aims to evaluate if ventilator care bundles are effective in reducing the rates of ventilator-associated

pneumonia cases compared to standard oral hygiene care through education and compliance of staff and patients in numerous

healthcare settings. The key search terms were ventilator-associated pneumonia, care bundles, critically ill patients, and outcomes.

Results: Through the studies, it showed that ventilator-associated pneumonia cases can be decreased through the usage of better oral

assessments and hygiene, elevation of the head of the bed, and cleaner usage of endotracheal cleaning as a few of the methods to

decrease rates in a span of populations from neonatal to geriatric patients. Patients were seen in multiple countries and units, such as

mixed intensive care units, pediatric intensive care units, and neurosurgical patients. Some of the studies reviewed were less reliable

than others because of the smaller control groups, but no evidence of patient risk for harm was seen, even if there was no significant

change in VAP rates.

Conclusion: Overall, ventilator care bundles are effective in reducing the rates of ventilator-associated pneumonia cases in patients in

numerous settings. Some factors should be modified to strengthen the creditability of sources, such as increasing the sample sizes to

analyze if it is more or less effective on a larger scale.

Evidence-Based Practice Proposal Paper

EVIDENCE-BASED PRACTICE PROPOSAL PAPER 3

Ventilator-associated pneumonia (VAP) is defined as “pneumonia associated with clinical, radiological, and laboratory criteria

evidenced 48 hours after the start of mechanical ventilation” (Alecrim et al., 2019). It is the second most prevalent healthcare-

associated infection (HAI) among patients in the ICU. VAP prevalence rates in mechanical ventilation patients are 9% to 68%, and its

mortality is between 30% and 70%. It increases the length of mechanical ventilation, extends hospital stay by about a week, and raises

healthcare costs by approximately $40,000 per patient. Moreover, it increases patient suffering, morbidity, and mortality.

This literature review addresses the following question regarding VAP reduction strategies: for patients with VAP, how

efficient is the implementation of a ventilator bundle compared to standard care in reducing the incidence of VAP during a six-month

period?

Literature Search

This study comprises randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. The databases

utilized were PubMed and CINAHL. Search terms included ventilator-associated pneumonia, care bundles, critically ill patients, and

outcomes. The publication years searched were 2018-2023.

Literature Review

Martinez-Reviejo et al. (2023) conducted a systemic review to summarize evidence concerning ventilator care bundles and

VAP. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were employed. The study was

comprised of 36 studies that were evaluated for quality using the Downs and Black 27-item questionnaire. Published studies from

1985 to 2022 from the MEDLINE, Cochrane Library, and Web of Science databases were included if they met four inclusion criteria:
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 4

1) randomized-controlled trials (RCTs) and controlled observational studies, 2) must be an adult age 18 and older 3) use of care

bundles for VAP prevention and 4) the comparator group did not receive a ventilator care bundle. The metanalyses were completed

using RevMan version 5.3. Odds ratios were used to analyze dichotomous outcomes, and mean differences were used for continuous

data. The authors used 95% confidence intervals (CI). The Mantel-Haenszel method was used for the random-effects model to

generate pooled treatment effects across the included studies. The results of the studies were then displayed as forest plots. Statistical

heterogeneity was evaluated using Higgins I.2 value. Overall, the study concluded ventilator care bundles significantly reduced the

VAP rates within adult ICU patients (OR=0.42, 95% CI: 0.33, 0.54) compared to non-bundled care groups. The authors note,

however, that the evidence quality was low (only two RCTs were included). Additional weaknesses of the study had a relatively small

sample size, and the study was underpowered to perform several subgroup analyses. The study’s strength was the highest level of

evidence, level I.

Mastrogianni et al. (2023) conducted a systemic review to identify combined interventions that have been used to reduce VAP

rates in ICU patients. The search yielded 38 studies from PubMed, Scopus, and Science Direct databases. The studies’ quality was

assessed through the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I). The criteria the studies had to meet were:

1) be published in the English language, 2) be pre-post observational studies, 3) include adult ICU patients that were intubated for at

least 48 hours, 4) evaluate the implementation of care bundles in VAP prevention by thoroughly presenting all the combined

interventions and calculating the pre and post-intervention VAP rate 5) compare with the individual intervention’s implementation for

VAP prevention and 6) be published after the implementation of “Institute for Healthcare Improvement (IHI) Ventilator Bundle”. In

conclusion, the results supported that IHI ventilator bundles and other bundles were valuable tools for reducing the VAP rate in ICU
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 5

patients on mechanical ventilators (MV). Limitations of the study included excluding publications not in English, using only three

databases, and heterogeneity of study settings and design. The study’s strength was the highest level of evidence, level I.

Triamvisit et al. (2021) conducted a prospective cohort study to identify if a modified care bundle was more effective in

preventing VAP than the standard bundle in critically ill patients. 291 patients were enrolled in this study; 146 were in the control

group, and 145 were in the cohort group. Patients in the cohort group were given modified care bundles, consisting of checking the

endotracheal tube cuff every four hours instead of six and oral care three times a day instead of four. Data was collected over 19

months in Thailand. The data was analyzed using Fischer’s exact probability test for comparison between the groups, and a

nonparametric test was used to compare the duration of mechanical ventilation. Utilizing the modified bundle effectively reduced

VAP in critically ill patients compared to the standard bundle. The occurrence of VAP in the cohort group was 0.88/1,000, and the

control group was 6.84/1,000, P= 0.036. The control group had nine patients with VAP, whereas the cohort group had one patient.

Cohort studies are third on the hierarchy of scientific evidence making this source of evidence strong. However, this study was weak

in selection bias and inability to extrapolate intermittent cuff monitoring techniques.

Dale et al. (2021) conducted a randomized controlled trial to determine if de-adopting oral chlorhexidine was more effective in

reducing VAP incidence than the standard bundle. 3260 patients were enrolled in this study, 1560 in the control group and 1700 in the

intervention group. Researchers utilized integrated knowledge translation (iKT) in the intervention group. This group would receive

oral care, oral assessments, and mouth moisturization twice daily. Whereas the control group only received oral care once a day. The

study was designed using the consort cluster trial with guidelines of SW-cRct. Data were collected over 14 months in Canada. De-
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 6

adoption of oral chlorhexidine was ineffective in reducing VAP cases in patients; however, this intervention improved oral health

status. Mortality in the intervention group was 399 (23.5%), and the control group had 330 (21.2%). The time to infection is 1.06; 95%

CI 0.44 to 2.57; P = 0.90. Time to extubation 1.03; 95% CL 0.85 to 1.23; P= 0.79. Oral procedural pain 0.63; 95% CI 0.34 to 1.10; P=

0.10, which shows the similarity between intervention and control periods. There were differences in oral health dysfunction scores -

0.96; 95% CL -1.75 to -0.17; P= 0.02 improved in the intervention period. Therefore, more research is needed. Randomized controlled

trials are second on the evidence hierarchy, strengthening this evidence source. However, there was a lack of attainment of the

predetermined sample size, limiting the ability to differentiate outcomes.

Alecrim et al. (2019) conducted an integrative review of the literature to identify VAP prevention strategies currently deployed

in the ICU and analyze their level of evidence. The selection and identification of studies were performed using the PRISMA

recommendations. The article's pertinence about the research was determined by examining the titles and abstracts of the studies. The

review included 23 level II and III scientific articles from seven databases. The studies compared VAP rates before and after the

implementation of preventative measures. The most frequent preventive measures proposed in the studies included daily awakening

from sedation or sedation awakening whenever possible in 14 of the studies, oral hygiene with chlorhexidine in 16 of the studies, and

lying with the head elevated between 30 and 40 degrees in 22 of the studies. Of the 23 articles, 20 displayed positive results, one did

not demonstrate significant improvement, one reported similar rates in the two stages (before and after implementation), and one

reported a rise in VAP rated after bundle implementation. The study concluded that VAP strategies are most effective in conjunction.

Strengths of the study include the wide range of studies used (observational, quasi-experimental, and experimental) and the inclusion
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 7

of multiple countries (including the United States, Brazil, France, China, Chile, Cuba, Spain, India, Korea, and Taiwan). A limitation

of the study is the exclusion of the pediatric population.

Atashi et al. (2018) conducted a randomized controlled trial to examine the effect of oral care on the incidence of VAP in ICU

patients. The study was conducted on 80 randomly assigned participants to an intervention group and a control group. Data were

collected on days one, three, and five of the study using the Clinical Pulmonary Infection Score (CPIS) for detecting pneumonia and a

demographic and clinical characteristics questionnaire. Routine care was provided in the control group; this included using swabs and

chlorhexidine 0.2% solution every 12 hours by nurses. The Beck Oral Assessment Scale was used in the intervention group to score

the patient's oral condition. Based on the score, care frequency was determined every four, six, eight, and 12 hours for patients with

severe, moderate, mild, and no disorders, respectively. The study utilized the t-Test to examine the intervention and control groups

regarding quantitative variables and the Chi-square test to examine the differences between the groups regarding qualitative variables.

The study also utilized the Mann-Whitney U test to compare CPIS between the control and intervention groups. The statistical

significance level was set at p < 0.05. The Chi-square test showed no significant difference between the control and intervention

groups (p = 0.059). The Mann-Whitney test results revealed no significant difference in the three days regarding mean CPIS (p >

0.05). However, pneumonia frequency in the intervention group decreased compared with the control group. The results of the study

showed that the frequency of pneumonia on day three was 15.80% in the control group and 10.50% in the intervention group.

Moreover, the frequency of pneumonia on day five was 23.7% in the control group and 7.90% in the intervention group. The study

concluded that the incidence of pneumonia in the intervention group was lower than that of the control group, although there was no

significant difference between the two groups. A major strength of this study is that its evidence is classified as level I. The study had
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several limitations, including the limited setting of a single rather than multiple ICUs. Another limitation of the study was the lack of

adequate supervision of nurses’ performance concerning the implementation of oral care in the control group. Due to this, the

accuracy of the nurses’ practices cannot be confirmed, nor can it be assured that all participants received the same oral care.

Mogyoródi et al. (2023) performed a prospective observational cohort study to evaluate the effectiveness of ventilator-

associated pneumonia preventative care bundles by implementing education to nursing staff to decrease infection rates. The analysis

was performed on a 29-bed mixed surgical intensive care unit and evaluated 251 patients. The measurement of VAP incidence rates

aftercare bundle education was reviewed at three, six, and 12 months. The incidence rates of pneumonia before education were

29.3/1000, which decreased to 15.3/1000 after the implementation of ventilator care bundles, and the compliance rates of care bundles

increased to 62.2% with the reduction of 59% of the ventilator-associated pneumonia cases. The continuous variables (Independent:

education of ventilator care bundles; Dependent variables: ventilator-associated pneumonia cases) were measured by the Shapiro-Wilk

test for normality. The Mann-Whitney U test was used to compare continuous variables, while the Chi-square test was used to

compare categorical variables. The study analyzed patient and nurse data to view both sides of compliance rates to ventilator care

bundles to help increase the source’s credibility. The study lacks a multi-hospital perspective, with the small group of patients

analyzed over the period decreasing the source’s credibility. The study showed no risk for harm to the patients from the use of care

and a positive decrease in ventilator-associated pneumonia cases. The study showed effectiveness in reducing the incidence rates of

ventilator-associated pneumonia and could be implemented in practice since it helps reduce the rates from care bundles. Still, a larger

cohort is necessary to validate the study’s findings.

EVIDENCE-BASED PRACTICE PROPOSAL PAPER 9

De Neef et al. (2019) conducted a meta-analysis of eleven articles to determine whether ventilator care bundles effectively

prevent VAP. The data collected from the eleven articles includes twenty pediatric intensive care units. The 27-item scoring system of

Downs and Black assessed the quality of these studies. Selected studies included the implementation of ventilator bundle care and

standard care as a comparison. Researchers measured the outcome by documenting the incidence of VAP in the studies per 1,000

days. There was statistically significant evidence that showed a reduction of VAP when using ventilator bundle care versus standard

care. There was a mean of 9.8 (IQR, 5.8-18.5) pneumonia incidence per 1,000 ventilator days. In comparison, when bundle care was

implemented, there was an incidence of 4.6 (IQR, 1.2-8.6) per 1,000 ventilator days (incidence risk ratio = 0.45; 95% CI, 0.33–0.60; p

< 0.0001; I2 = 55%). Overall, they found that a VAP bundle may improve patient outcomes in the PICU. There should be further

research to apply these findings to the adult population. Through a critical appraisal process, this study was determined to be valid,

reliable, and applicable to healthcare and to the PICOT question. This study was related to the PICOT question because the

researchers analyzed and compared ventilator bundle care with standard care. The aim was to find whether it is effective when related

to ventilator-associated pneumonia.

Pileggi et al. (2018) conducted a meta-analysis of 13 articles to assess the ventilator bundle's effectiveness in reducing patient

mortality in an ICU. The studies focus on adult patients in the intensive care unit in a hospital setting. The quality of these studies was

assessed by the Cochrane study quality assessment tool for RCTs and the Downs and Black scale for nonrandomized intervention

studies. The included studies implemented a ventilator bundle and recorded patient outcomes in eight-week intervals. When analyzing

the results of the studies, there was a statistically significant reduction in patient mortality when ventilator bundles were implemented.

The bundle significantly reduced mortality rates (odds ratio, 0.90; 95% CI, 0.84–0.97). It can be noted that there was low observed
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 10

heterogeneity (p = 0.24; F = 25.4%). Bundle care can be implemented, but research should be done to establish a baseline for

maintenance. A critical appraisal was conducted, which showed that this study is valid, reliable, and applicable. Regarding the relation

to the PICOT question, this study does address care bundles and VAP patients. It is different because researchers focused on VAP

patients' mortality rates in the ICU rather than prevention. The results can be applied to the PICOT question because there is an

outcome that compares ventilator bundles and other types of care.

Niedzwiecka et al. (2019) conducted a systematic review to analyze ventilator care bundles' impact to help decrease ventilator-

associated pneumonia rates in mechanically ventilated pediatric and neonatal patients. Eight studies of observational and

nonrandomized interventional methods were included in the setting of pediatric and neonatal intensive care units. The ventilator care

bundles included elevating the head of the bed, clean endotracheal suctioning practice, minimal ventilator circuit changes, peptic ulcer

prophylaxis, and proper oral care to help reduce the number of VAP cases. The measurement of outcomes was the rates of VAP post-

implementation of care bundles. Also, the number of PICU days, mechanical ventilator days, mortality rates, and cost savings were

measured to determine the effectiveness of the outcomes. Each study underwent a quality appraisal employing the standardized critical

assessment tool known as the EBL checklist. Data from studies included standardized data extraction forms adapted from Bettany‐

Salticov and McSherry. Five of the eight studies reported the use of ventilator care bundles resulting in statistical decreases in

ventilator-associated pneumonia rates in the post-intervention phase of the patients. According to the authors, the p-value varied from

<.0001 to <.028, and p < .05 was considered statistically significant by all. The study used a broader range of patients in the RCT to

strengthen the results. Still, not all studies examined in the RCT were used since they were not statistically significant, causing

limitations in the study. There were no signs of risk for harm in pediatric and neonatal patients, but it is unsure of the results in older
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 11

populations decreasing the effectiveness of the study. The study showed that ventilator care bundles positively impact the incidence

rates of ventilator-associated pneumonia in mechanically ventilated patients in the NICU and PICU. Still, more information about the

specifics of each age group is needed to strengthen the study.

Synthesis

The ten studies synthesized were mixtures of randomized controlled trials, systemic reviews, meta-analyses, cohort studies,

and literature reviews. Triamvisit et al. (2021), Martinez-Reviejo et al. (2023), and Mogyorodi et al. (2023) study considered gender in

the collected data, while the other studies did not; however, the majority of the studies did consider participants that were adult age 18

and older. De Neef et al. (2019) conducted a meta-analysis, while Niedzwiecka et al. (2019) conducted a systemic review; conversely,

they considered newborns/infants up to the age of 11 and 18 in their studies. Dale et al. (2021) was the only study with a large sample

size of 3,260 participants for an RCT, while Atashi et al. (2018) had only 85 participants for an RCT. When it comes to the highest

level of evidence, which is level I, Mastrogianni et al. (2023) study along with Martinez-Reviejo et al. (2023) and Atashi et al. (2018)

were the only studies to meet the highest level of evidence; additionally, Pileggi et al. (2018) and De Neef et al. (2019) are the only

two studies with a level of evidence of V. Although Niedzwiecka et al. (2019) is a systemic review, it only analyzed eight studies

which is a very small sample size. Furthermore, Mastrogianni et al. (2023) and Martinez-Reviejo et al. (2023) are systemic reviews

that utilized different databases to collect their data; in addition, Mastrogianni et al. (2023) pulled studies from PubMed, Scopus, and

Science Direct databases but must have been published in English while Martinez-Reviejo (2023) collected studies from MEDLINE,

Cochrane Library, and Web of Science databases. All ten studies utilized different measuring tools to assess participants or individual

studies within a study.

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Although all ten studies had differences, some similarities should be pointed out. All ten studies focused on VAP in ICU

patients on an MV to examine the effectiveness of care bundles in reducing the VAP rate. The feasibility of the ten studies was high,

which means the usage of care bundles could be implemented in a healthcare setting. All ten studies concluded that implementing

VAP care bundles significantly reduced the VAP rate in ICU patients on MV, which should be examined further to get a concrete

conclusion.

Clinical Recommendations

Considering all the reviewed studies, some clinical recommendations can be made for the target populations. All ten studies

focused on ventilated ICU patients and addressed the effectiveness of care bundles in reducing VAP. These studies all showed high

feasibility, meaning ventilator care bundles are effective when associated with VAP. Patient populations differed between studies;

factors like age, gender, and location were not always present. Most studies focused on adult patients, but some only included

pediatric patients. All the studies included patients in a hospital setting, though geographical locations differed. Considering this, the

clinical recommendation for the target population (patients with VAP) is that bundle care can be an effective treatment intervention.

Many studies showed a reduced incidence of VAP during the study time frames. Practicing bundle care in intensive care units could

be effective, but more research is needed. There is variance in the bundle care process and implementation; therefore, a baseline for

care should be established. Research should also focus on cost and applicability to different populations. A common limitation was the

limited sample size and lack of demographic information, which should be considered in future research. Since there are no identified
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 13

risks for implementing this care, it can be used as treatment. There is an overall conclusion that bundle care effectively reduces the

incidence of VAP in patients. However, there should be more research on the previously mentioned topics.

In the case of bundle care, the practices can be changed to become evidence-based. These studies' clinical questions have been

narrowed down and focused on a specific population. To answer the question, evidence should be gathered and critically appraised.

This ensures a high level of evidence and that the studies are valid, reliable, and applicable to the question. Finding the best evidence

related to the question is vital in ensuring patient outcomes. With sufficient evidence, clinical expertise and hospital policies should be

included to determine if the change is appropriate. It can be implemented once there is evidence, and the difference is applicable. An

essential part of this process is selecting the patient’s individual preferences. Ventilator bundle care can be implemented as evidence-

based practice if it meets the criteria with the proper population and hospital policies. Overall, it can be recommended that ventilator

care bundles can be used when appropriate to decrease the incidence of VAP. It is also recommended that further research should be

done to ensure that this care can be applied to different populations. A baseline for implementing bundle care should be needed to

produce higher-quality evidence. This problem can become evidence-based if it follows the process and is appropriate for the specific

patient.
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 14

References

Alecrim, R. X., Taminato, M., Belasco, A., Longo, M. C., Kusahara, D. M., & Fram, D. (2019). Strategies for preventing ventilator

-associated pneumonia: An integrative review. Revista Brasileira de Enfermagem, 72(2), 521–530.

https://doi.org/10.1590/0034-7167-2018-0473.

Atashi, V., Yousefi, H., Mahjobipoor, H., Bekhradi, R., & Yazdannik, A. (2018). Effect of oral care program on prevention of

ventilator-associated pneumonia in intensive care unit patients: A randomized controlled trial. Iranian Journal of Nursing and

Midwifery Research, 23(6), 486. https://doi.org/10.4103/ijnmr.ijnmr_164_17.

Dale, C. M., Rose, L., Carbone, S., Pinto, R., Smith, O. M., Burry, L., Fan, E., Amaral, A. C., McCredie, V. A., Scales, D. C., &

Cuthbertson, B. H. (2021). Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for

mechanically ventilated patients in the Intensive Care Unit (choral): A multi-center Stepped Wedge Cluster-randomized

controlled trial. Intensive Care Medicine, 47(11), 1295–1302. https://doi.org/10.1007/s00134-021-06475-2.

De Neef M., Bakker L., Dijkstra S., Raymakers-Janssen P., Vileito A., & Ista E. (2019). Effectiveness of a ventilator care bundle to

prevent ventilator-associated pneumonia at the PICU. Pediatric Critical Care Medicine. https://doi.org/

10.1097/pcc.0000000000001 862.
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Martinez-Reviejo, R., Tejada, S., Jansson, M., Ruiz-Spinelli, A., Ramirez-Estrada, S., Ege, D., Viceli, T., Maertens, B., Blot, S., &

Rello, J. (2023). Prevention of ventilator-associated pneumonia through care bundles: A systematic review and meta analysis.

Journal of Intensive Medicine, 3(2), 1–13. https://doi.org/10.1016/j.jointm.2023.04.004.

Mastrogianni, M., Katsoulas, T., Galanis, P., Korompeli, A., & Myrianthefs, P. (2023). The impact of care bundles on ventilator

-associated pneumonia (VAP) prevention in Adult ICUS: A systematic review. Antibiotics, 12(2), 2-19.

https://doi.org/10.3390/antibiotics12020227.

Mogyoródi, B., Skultéti, D., Mezőcsáti, M., Dunai, E., Magyar, P., Hermann, C., Gál, J., Hauser, B., & Iványi, Z. D. (2023). Effect of

an educational intervention on compliance with care bundle items to prevent ventilator-associated pneumonia. Intensive &

Critical Care Nursing, 75, 103342–103342. https://doi.org/10.1016/j.iccn.2022.103342.

Niedzwiecka, T., Patton, D., Walsh, S., Moore, Z., O’Connor, T., & Nugent, L. (2019). What are the effects of care bundles on the

incidence of ventilator‐associated pneumonia in pediatric and neonatal intensive care units? A systematic review. Journal for

Specialists in Pediatric Nursing, 24(4), e12264–n/a. https://doi.org/10.1111/jspn.12264.

Pileggi C., Mascaro V., Bianco A., Nobile C., Pavia M. (2018) Ventilator Bundle and Its Effects on Mortality Among ICU Patients: A

Meta-Analysis. Critical Care Medicine 46(7), p.1167-1174. DOI: 10.1097/CCM.0000000000003136.

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Triamvisit, S., Wongprasert, W., Puttima, C., Chiangmai, M. N., Thienjindakul, N., Rodkul, L., & Jetjumnong, C. (2021). Effect of

modified care bundle for prevention of ventilator-associated pneumonia in critically-ill neurosurgical patients. Acute and

Critical Care, 36(4), 294–299. https://doi.org/10.4266/acc.2021.00983

EVIDENCE-BASED PRACTICE PROPOSAL PAPER 17

Studies Design Sample Outcome

Triamvisit et Cohort study N= 291 Gender: VAP reduction

al. (2021)
Age: 18 and older 42% Female

56% Male

Dale et al. RCT N= 3260 N/A VAP reduction

(2021)
Age: 18 and older

Alecrim et al. Integrative/Literature Review N= 23 articles N/A VAP reduction

(2019)
Age: 18 and older

Atashi et al. RCT N= 80 N/A VAP reduction

(2018)
Age: 18-65

Martinez- RCT (Within the Systemic Review N=76 VAP reduction

Reviejo et al. of Atashi et al [2018] research) Gender:
(2023). Age: 18 and older 31% Female

69% Male

Mastrogianni Systemic Review N=38 N/A VAP reduction

et al. (2023).
Age= 18 and older

Meta-analysis N= 13 studies N/A VAP mortality

Pileggi et. al. reduction
(2018) Age: 18 and older

De Neef et. Meta-analysis N= 20 PICUs N/A VAP reduction

al. (2019)
Age: 5 months - 11 years old
EVIDENCE-BASED PRACTICE PROPOSAL PAPER 18

Mogyoródi et Prospective observational cohort N- 251 patients Gender: VAP reduction

al. (2023) study
Age- 18 or older 56% Male

44% Female

Niedzwiecka Systematic Review N= 8 studies N/A VAP reduction

et al. (2019)
Age= neonates and children up to 18 years
old
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 19

CLINICAL QUESTION: For patients (P) with ventilator-associated pneumonia (VAP), how efficient is the implementation of a ventilator bundle (I) compared to
standard care (oral hygiene care) in reducing the incidence of VAP (C) during a six-month period (T)?

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
Triamvisit, S., The purpose of N/A Prospective A total of 291 Independen Primary The data was The Level of evidence- III
Wongprasert, the study is to cohort patients were t variable outcome: analzyed modification
W., Puttima, C., assess the study enrolled, 146 (s): using of the Strengths- The hierarchy of scientific evidence
Chiangmai, M. impact of in the control change in Fischers ventilator has seven sections ranging from the strongest to
N., modified group and 145 Type VAP exact bundle was weakest evidence. Cohort studies are third on
Thienjindakul, ventilator in the cohort ventilator infections probaility more the pyramid, strengthening the evidence
N., Rodkul, L., bundles group. In an bundle- between test for effective in (Melnyk & Fineout-Overholt, 2018). Therefore
& Jetjumnong, compared to a eight-bed Standard cohort and comparison reducing the modified bundles need to be implemented to
C. (2021). standard bundle critical care care bundle control between the incidence of prevent the rate of VAP.
Effect of in reducing unit and a and group. groups ventilator-
modified care ventilator- nine-bed modified associated Weakness- This study was weak because the
bundle for associated intermediate care bundle The rate of pneumonia control group was subject to selection bias and
prevention of pneumonia unit during a (checking VAP was in could not extrapolate intermittent cuff
ventilator- 19-month endotrache considerably neurosurgica monitoring techniques
associated period in al cuff low in the l patients.
every four cohort group Feasibility- High
pneumonia in Thailand.
critically-ill hours and (0.88/1,000 The cohort
vs Conclusion- The analysis shows that the
neurosurgical oral care group had
6.84/1,000). incidence of ventilator-associated pneumonia
patients. three times 0.88/1,000
The rates of decreased with the modified ventilator bundle
pneumonia in a day) ventilator
critically-ill re-intubation, days
Dependent day of Recommendation- This practice would be
neurosurgical compared to
(outcomes) intubation, recommended because VAP was found in nine
patients. Acute the control
variables: and stay was patients in the control group and only one in the
and Critical group, which
cohort group. The occurrence rate of VAP was
Care, 36(4), similar had
Incidence significantly reduced in the cohort group
294–299. 6.84/1,000.
of VAP in compared to the control group (0.88/1,000 vs
https://doi.org/1 6.84/1,000 ventilator days, P= 0.036.
0.4266/acc.2021 patients
.00983
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 20

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION

Dale, C. M., This study N/A Randomize A total of Independen Primary ICU ICU Level of evidence- II
Rose, L., d control 3260 patients t variable outcomes: mortality mortality for
Carbone, S., was
trials were enrolled, (s): Change in was the Strengths- The hierarchy of scientific evidence
Pinto, R., developed to 1560 control, ICU analyzed intervention has seven sections ranging from the strongest to
Smith, O. M., determine if 1700 Type of mortality using a and control weakest evidence. Randomized controlled trials
Burry, L., Fan,
E., Amaral, A. chlorhedixine intervention. ventilator between generalized periods were are second on the pyramid, strengthening the
C., McCredie, Recruited bundle: control linear mixed 399 (23.5%) evidence (Melnyk & Fineout-Overholt, 2018)
with
V. A., Scales, from siz groups and model with a and 330
D. C., & ventilator Standard Weakness- lack of attainment of the
adults ICUs in intervention binary (21.2%),
Cuthbertson, B. bundles can university care bundle periods. distribution repsectively predetermined sample size limited the ability to
H. (2021). minimized vs. the de- detect differences in outcomes.
hospitals over and logit link ratio 1.13.
Effect of oral adoption of
capacity in a 14-month Secondary with random Time to
chlorhexidine Feasibility- High
period in chlorhexidi outcomes: intercept to IVACs 1.06,
de-adoption and critically ill
implementation Canada. ne within Included account for time to
of an oral care patients bundles time to clustering of extubation
Conclusion- The de-adoption of chlorhexidine
bundle on within oral care bundles showed no effect on
IVACs patients 1.03, oral
mortality for Dependent ICU mortality.
between within sites procuedural
mechanically (outcomes) control group and adjusted pain 0.62. Recommendation-This practice should not be
ventilated variables: and secular were similar
patients in the Incidence recommended because the analysis showed that
Intensive Care intervention. trends with between
of VAP in it had no impact on ICU mortality. It only
Unit (choral): A Oral health time in days control and
patients improved oral health care. Therefore, more
multi-center status from start of intervention research is needed.
Stepped Wedge dysfunction the study as periods.
Cluster- measuring linear effect
randomized
using the
controlled
trial. Intensive BOAS,
Care procedural
Medicine, 47(11 oral pain
), 1295–1302. measured
https://doi.org/1 using the
0.1007/s00134- CPOT
021-06475-2
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 21

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
De Neef M., To determine N/A Meta- Twenty Independen The primary There was Ventilator LOE- XI
Bakker L., whether analysis Pediatric t variable outcome, 9.8 (IQR, bundle care
Dijkstra S., ventilator care Intensive Care (s): the difference in 5.8-18.5) has potential Strengths- There was sufficient information
Raymakers- bundles are Units. Eleven implementa incidence of pneumonia to reduce the about how data was extracted and assessed.
Janssen P., effective to articles were tion of VAPs per incidence incidence of There were detailed explanations about overall
Vileito A., & prevent included. ventilator 1,000 per 1,000 ventilator- conclusions drawn from the data. Includes
Ista E. (2019). ventilator- bundle care ventilator ventilator associated randomized controlled trials and nonrandom
Effectiveness of associated compared days, was days.When pneumonia trials. The studies were pre and post
a ventilator care pneumonia. to standard expressed as bundle care in ventilated interventional.
bundle to care. an incidence was children.
prevent risk ratio implemented This is Weakness- Lacking data about participants
ventilator- Dependent (IRR) with a , there was evidenced by from each study (gender, individual ages).
associated (outcomes) 95% CI. The 4.6 (IQR, the reduction
pneumonia at variables: quality of the 1.2-8.6) of VAP per Feasibility- High
the PICU. Incidence studies was incidence 1,000 days
Conclusion- The analysis shows that a VAP
Pediatric of assessed with per 1,000 with bundle
bundle for patients in the PICU may prevent
Critical Care ventilator- the 27-item ventilator care.
VAP.
Medicine. associated scoring days
https://doi.org/ pneumonia system of (incidence Recommendation- There is significant evidence
10.1097/pcc.0 defined by Downs and risk ratio = that bundle care is effective against ventilator-
000000000001 reported Black. 0.45; 95% associated pneumonia. Some research about
862. cases per CI, 0.33– best techniques and implementation would be
1,000 0.60; p < beneficial.
ventilator 0.0001; I2 =
days. 55%).

Martinez- To summarize N/A Systemic Thirty-six VAP Quality Summarized There was a Level of evidence: I
Reviejo, R., evidence Review studies represents assessment evidence significant
Tejada, S., concerning including one of tool utilizing from ICU decrease in
Jansson, M., ventilator care 116,873 MV the modified patients on a VAP
Ruiz-Spinelli, bundles to participants the most Downs and MV incidence for
A., Ramirez- prevent VAP. met the common Black 27- receiving patients
Estrada, S., Ege, inclusion ICU- item care bundles receiving
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 22

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
D., Viceli, T., criteria acquired questionnaire vs not care bundles Strengths: Mixture of RCTs and Controlled
Maertens, B., (including . infections to determine receiving vs non-care Observations, data collected was not influenced
Blot, S., & adult (≥18 the quality of care bundles. bundles by COVID-19.
Rello, J. (2023). years) ICU in patients each article receivers.
Prevention of patients requiring
ventilator- undergoing MV for
associated RevMan Weaknesses: High heterogeneity, sample size,
pneumonia MV for at at least 48 version 5.3, incomplete data endpoints, and non-
through care least 48 h). h. Higgins I2, consideration of the effect of the reason leading
bundles: A odd ratios, to MV on the efficacy of VAP prevention
systematic and 95% bundles.
review and confidence
Care level.
meta-analysis.
bundles
Journal of
utilized for Feasibility: High
Intensive
patients on
Medicine, 3(2),
MV.
1–13.
https://doi.org/1 Conclusion: Care bundles are effective in
0.1016/j.jointm. reducing VAP incidences.
2023.04.004 Patients not
on MV.

Recommendations: Consider interventions that

have proven to be effective for VAP
prevention, for inclusion in the ventilator
bundle may be important.

To identify the N/A Systemic Thirty-eight IHI ROBINS-I Compared The Level of evidence: I
Mastrogianni, combined Review studies of Ventilator care bundles combination
M., Katsoulas, interventions Adult ICU Bundles VAP of care
T., Galanis, P., that have been patients that were in the reduction bundles and
Korompeli, A., used to by ICUs are 18 and rates. their Strengths: study design type and analyzation
& Myrianthefs, that have older ranging implementati of care bundles effectiveness.
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 23

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
P. (2023). The reduced VAP from 43 independen on in VAP
impact of care incidence. intubated t variable. decreased in
bundles on patients to adult ICUs. Weaknesses: Selecting studies that were only
ventilator- 171,237 VAP was in English, utilizing three databases, and
associated intubated the heterogeneity.
pneumonia patients. dependent
(VAP) variable.
prevention in
Feasibility: High
Adult ICUS: A
systematic Pre/post
review. observational
Antibiotics, studies
Conclusion: The findings are not enough to
12(2), 2-19. establish a solid conclusion due to the variation
https://doi.org/1 of interventions which prevents comparability
0.3390/antibioti between the studies.
cs12020227

Recommendation: Utilize more databases and

other studies in different languages.

To assess the N/A Meta- Adult ICU Independen The primary To appraise The LOE- XI
Pileggi C., effectiveness of analysis patients t variable outcome was the quality of implementati
Mascaro V., the ventilator (s): mortality the research on of a Strengths- Analyzed randomized controlled
Bianco A., bundle in the Implementa rates of ICU included in ventilator trials or any kind of nonrandomized
Nobile C., Pavia reduction of tion of care patients the meta- bundle intervention studies. The selected studies
M. (2018) mortality in ICU bundles vs during the analysis, significantly involved a ventilator bundle approach on ICU
Ventilator patients. other implementati each study reduced patients.
Bundle and Its treatments/ on of was read and mortality
Effects on care ventilator scored by (odds ratio, Weakness- The data extracted from these
Mortality strategies. bundles. two 0.90; 95% studies may contrast because of differing
Among ICU independent CI, 0.84– implementation of evidence-based procedures
Patients: A Dependent investigators 0.97). There in bundle care.
Meta-Analysis. (outcomes) , who were was low
variables: Feasibility- High
Critical Care blinded to observed
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 24

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
Medicine 46(7), Mortality authors, heterogeneit Conclusion- There is some evidence that
p.1167-1174. rates in institutions, y (p = 0.24; ventilator bundled care may lead to decreased
DOI: VAP country, and F = 25.4%). mortality in ICU patients on ventilators.
10.1097/CCM.0 patients. journal for
0000000000031 the purpose Recommendation- Ventilator care bundles are
36 of shown to be effective in reducing mortality and
decreasing improving outcomes. However, there should be
the detection more research to establish a baseline for this
bias. The care.
Cochrane
study quality
assessment
tool (18) was
identified to
assess RCTs
quality, and
the Downs
and Black
scale to
assess
nonrandomiz
ed
intervention
studies
quality (19).
Consensus
was reached
by
discussion if
initial
assessments
differed.
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 25

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
Mogyoródi, B., To evaluate the N/A Prospective A total of 251 Independen The The The study • Level of evidence- III
Skultéti, D., effectiveness of Observation patients were t Variable: measurement continuous showed the
Mezőcsáti, M., a ventilator- al Cohort analyzed. 29 Education of VAP variables implementati • Strengths and limitations- The
Dunai, E., associated Study bed mixed material of incidence were on and study analyzed both the patient
Magyar, P., pneumonia medical ventilator rates after analyzed by compliance and nurse data to highlight the
Hermann, C., prevention surgical care care bundle the Shapiro- of ventilator diversities of the groups to help
Gál, J., Hauser, bundle Intensive Care bundles education Wilk test for care bundles determine the effectiveness of
B., & Iványi, Z. implemented by Unit. Dependent was analyzed normality. is effective ventilator care bundles education.
D. (2023). education of the (outcome) at 3 months, Within the in reducing The study was limited to the
Effect of an nursing staff, Variable(s): 6 months, continuous the incidence smaller group analyzed in the
educational and to describe ventilator- and 12 data as of ventilator hospital and an unclear
intervention on the tendency of associated months. The medians and associated reevaluation style for compliance
compliance knowledge pneumonia incidence of interquartile pneumonia of care bundles through nurses
with care retention. incidences, pneumonia ranges, cases in and patients.
bundle items to risk of decreased categorical varying adult
prevent ventilator- from data as ICU patients. • Risk or harm if study
ventilator- associated 29.3/1000 to absolute After intervention or findings
associated pneumonia, 15.3/1000 numbers of implementin implemented- The precise
pneumonia. and nursing after the cases and g care education materials used for
Intensive & compliance implementati percentages bundles with nurses and the exact patient status
Critical Care to on of the were education was not explained if some
Nursing, 75, preventive prevention reported. there was a variables could be at risk for
103342– measures program The Mann- 59 % patients and nurses performing
103342. comparing Whitney U decrease in unnecessary aspects of care
https://doi.org/1 the test was used VAP rates bundles.
0.1016/j.iccn.20 effectiveness for the and an
22.103342. (Mogyoródi comparison improvement • Feasibility of use in your
practice- High- Although there
et al., 2023). of to 62.2 % in
are some limitations the article
continuous compliance
has a high feasibility proving the
variables, to care
effectiveness of ventilator care
while the bundles after
Chi square implementati bundles.
test was used on
• Conclusion from the study- The
to compare
study showed an effectiveness in
reducing the incidence rates if
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 26

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
categorical (Mogyoródi ventilator associated pneumonia
variables. et al., 2023). is able to implement in practice,
since it helps reduce the rates
from care bundles.

• Recommendation- Including a
bigger sample size to evaluate a
larger scale of patients to help
increase the effectiveness of care
bundles in other populations
besides what was examined.

Niedzwiecka, To analyze the N/A Systematic Eight studies Independen The Each study The study • Level of evidence- II
T., Patton, D., impact of Review of t Variable: measurement underwent a showed that
Walsh, S., ventilator care observational Ventilator of outcomes quality in • Strengths and limitations- in this
Moore, Z., bundles to and care were rates of appraisal mechanically study the usage of multiple RCTs
O’Connor, T., decrease the nonrandomise bundles VAP post employing ventilated to review helps aid in a more
& Nugent, L. incidence rates d usage implementati the patients in diverse area of patients to help
(2019). What of ventilator interventional including on of care standardized the NICU include more diversity in the
are the effects associated methods head of the bundles. critical and PICU study. Some articles were not
of care bundles pneumonia cases design were bed Also, the assessment the usage of used and not analyzed statistically
on the incidence in mechanically included in elevation, number of tool known ventilator which can cause limitations in the
of ventilator‐ ventilated the review. clean PICU days, as the EBL care bundles study.
associated pediatric and Setting: endotrache the number check list. positively
pneumonia in neonatal Pediatric and al of Data from impacts the • Risk or harm if study
pediatric and patients. Neonatal suctioning mechanical studies incidence intervention or findings
neonatal Intensive Care practices, ventilator included rates of implemented- The evidence is
intensive care Unit. minimal days, standardized ventilator vague in some areas such as bed
units? A ventilator mortality data associated elevation in different age groups
systematic circuit rates and extraction pneumonia. from a mechanical ventilator,
review. Journal changes, cost savings form adapted 5 of the 8 since there is a lack of research in
for Specialists peptic ulcer were from studies pediatric versus adult patients
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 27

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
in Pediatric prophylaxis measured to Bettany‐ reported the causing a risk in increasing
Nursing, 24(4), and oral determine Salticov and use of incidence rates of ventilator
e12264–n/a. care the McSherry. ventilator associated pneumonia.
https://doi.org/1 effectiveness care bundles
0.1111/jspn.122 Dependent of the resulting in • Feasibility of use in your
64. (outcome) outcomes. statistical practice- High- The article proves
Variable(s): decreases in an effectiveness of lowering rates
ventilator- ventilator of VAP proving an effectiveness
associated associated of using standard ventilator care
pneumonia pneumonia bundles as used in the study.
incidences, rates in the
nursing post • Conclusion from the study-
compliance intervention Overall, the study was useful in
to phase of the evaluating the effectiveness of
ventilator patients. ventilator care bundles which can
care According to be utilized in the care of patients
bundles, the authors, and did not show to be negative
and risk the p-value on the incidence rates.
factors in varied from
patients for <.0001 to • Recommendation- The study
ventilator- needs to investigate proper
<.028, and
ventilator care adjustments per
associated p < .05 was
pneumonia age group to create a more
considered
positive effect on incidence rates
statistically
significant and safer patient care.
by all
(Niedzwieck
a et al.,
2019).

Alecrim, R. X., Identify N/A Integrative Intensive Care Independen Among all The article’s Of the LOE- II and III
Taminato, M., strategies for review of Units t variable the studies relevance in preventive
Belasco, A., prevention of literature (s): VAP that relation to measures
compared the
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 28

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
Longo, M. C., VAP deployed prevention VAP rates the research identified, 9 Strengths- range of studies used (observational,
Kusahara, D. in health strategies before and question was (39.1%) quasi-experimental, and experimental).
M., & Fram, D. services and after the determined correspond Includes multiple world regions.
Dependent implementati
(2019). classify their through the from three to
on of the set
Strategies for level of (outcomes) reading of five Weakness- pediatrics not included
of measures,
preventing evidence variables: 20 (86.9%) the studies’ strategies.
ventilator- Incidence showed titles and The most Feasibility- high
associated of VAP positive abstracts, frequent
results, 1 Conclusion- VAP prevention strategies are
pneumonia: An and those were: 22
(4.34%) did most effective when carried out in conjunction
integrative that had their (95.6%)
not identify
review. Revista adequacy to lying with
significant Recommendation- Study should consider the
Brasileira de improvement the topic of head
cost, adherence, and ease of deployment of the
Enfermagem, s, 1 (4.34%) interest elevated, 19
prevention strategies studied.
72(2), 521–530. reported ascertained (82.6%) oral
https://doi.org/1 similar rates were hygiene with
0.1590/0034- in the two evaluated chlorhexidin
7167-2018- stages and 1 through a e and 14
(4.34%)
0473 content (60.8%)
revealed an
increase in analysis and reduction of
the VAP classified sedation
rates after according to whenever
implementati level of possible.
on of the evidence
bundle

Atashi, V., Investigate the N/A Randomize Intensive Care Independen Chi-square Chi-square The results LOE- I
Yousefi, H., effect of oral d controlled Units t variable test was used test did not of this study
Mahjobipoor, care on the trial (s): oral to examine show a showed that Strengths- inclusion of control group
H., Bekhradi, frequency of care the significant the
R., & VAP of patients differences difference (p frequency of Weakness- pediatrics not included
Yazdannik, A. in intensive care Dependent between the = 0.059); pneumonia
(2018). Effect unit (outcomes) two groups however, the on the third Feasibility- high
of oral care variables: in terms of frequency of and fifth
 EVIDENCE-BASED PRACTICE PROPOSAL PAPER 29

Citation: Purpose of Conceptual Design/ Sample/Setti Major Measureme Data Study Worth to Practice:
Author, Date Study Framework Method ng Variables nt of Major Analysis Findings LOE
of Publication, Studied Variables Strengths/Weaknesses
& Title and Their Feasibility
Definitions Conclusion
RECOMMENDATION
program on Incidence qualitative pneumonia days was Conclusion- oral care decreased the incidence
prevention of of VAP variables. t- in the 15.80% (6) of VAP
ventilator- Test was intervention and 23.70%
associated used to group (9) in the Recommendation- Conduct a similar study for
pneumonia in examine the reduced control a longer duration with a larger sample size to
intensive care two groups compared group and yeild more accurate results
unit patients: A in terms of with the 10.50% (4)
randomized quantitative control and 7.90%
controlled trial. variables. group (3) in the
Iranian Journal Mann– intervention
of Nursing and Whitney U group,
Midwifery test was used respectively.
Research, for
23(6), 486. comparison
https://doi.org/1 of CPIS
0.4103/ijnmr.ijn between
mr_164_17 control and
intervention
groups. The
level of
statistical
significance
was set at p
< 0.05.

Legend- VAP = Ventilator-associate pneumonia, MV= Mechanical Ventilator, ICU= intensive care unit, ROBINS-I = Risk of Bias in
Non-randomized Studies of Interventions, Coronavirus disease 2019 = Covid-19, RCT= Randomized Control Trial, LOE = Level of
evidence, SW-cRCT = Stepped wedge cluster randomized control trials, CPIS= Clinical Pulmonary Infection Score, HAI= Healthcare
Associated Infection