PICOT Worksheet and Search Strategy Essay Paper

PICOT question, (P) Among critically ill adult patients under mechanical ventilation in the ICU (I) does oral hygiene with chlorhexidine gluconates swabs & toothbrush used every four hours (C) compared to no chlorhexidine gluconate swabs &toothbrush (O) prevent Ventilator-Associated Pneumonia (T) within six weeks.
BACKGROUND: • Paint a broad picture and rationale for undertaking this project (0-12 pts.) • Include any data and a targeted literature review of published papers written in the last FIVE years to support the need for the project (0-12 pts.)
• Describe the current practice/policy/procedure and outcomes/implications where you work that this project will effect (0-11pts.)Full Marks35 ptsNo Marks0 pts / 35 pts For this part I use to work in ICU otherwise you can use any polices or procedures related to the PICOT question that you find.
THE QUESTION: • Pose an answerable question in PICOT format (Melnyk & Fineout-Overholt, 2015) (0-15 pts.)
Use the PICOT templates to develop your full questions, and include it in the appendix of your paper (5 pts.)
Full Marks20 ptsNo Marks0 pts / 20 pts THE SEARCH (0-5 pts. each section) • Describe the search strategy per Melnyk and your lectures • Discuss how potential, relevant research reports were identified
• Explain what databases were chosen and used, and what studies were identified •
What were the inclusion and exclusion criteria? • How many studies were included in the final appraisal of the evidence?Full Marks20 ptsNo Marks0 pts / 20 pts
APA 7th ed. format concerning headings, title page, citations, references, and organization of the paper (Font Times New Roman 12 cpi) Correct use of grammar, sentence construction, spelling, etc. One point deduction for each error in grammar, formatting, punctuation, etc. on your paper. If the same error is repeated, no additional points will be deducted for the assignment, however, will be deducted in Assignment Two.
For this paper please follow above directions I need at least 3 LITERATURE sources that are level one which is described in the book. If you can not find 3 I than need at least 5 articles. Please included all DOI of URL for articles.  PICOT Worksheet and Search Strategy Essay Paper

Also you can access book for reference at YUZU sign in K ***** PW Gunner09$
LEVEL ONE is described in the book in definitions and other levels of reference I have also included both templates to be used

Clinical Inquiry on Ventilator-Associated Pneumonia or VAP

Clinical inquiry is the process in which a professional nurse raises questions about a practice element that is commonly used in nursing practice but whose efficacy is not ascertained. These are typically practices or interventions that are part and parcel of common practice in nursing. Clinical inquiry is however nowadays the norm because of the adoption by professional nursing practice of the concept of evidence-based practice or EBP. This is the practice whereby only those interventions that have evidence of efficacy from scholarly peer-reviewed scientific literature are used to manage patients. Because of this, EBP is usually also referred to as best practice. Clinical inquiry is facilitated by use of the PICOT model. His is an acronym that stands for Population, Intervention, Comparison, Outcome, and Timeframe. What happens is that the nurse making the clinical inquiry puts the identified clinical practice problem n question form to guide the evidence search from reputable research databases. This PICOT question will therefore incorporate the patient population concerned, the intervention in question, a comparison intervention, the expected outcome, and the timeframe of application of the intervention (Melnyk & Fineout-Overholt, 2019). All quality indicators in clinical practice provide an opportunity for clinical inquiry as to the best intervention that can prevent their occurrence as a quality improvement issue. Some of these quality indicators are pressure ulcer rates, patient fall rates, readmission rates, catheter-associated urinary tract infections or CAUTI rates, central line-associated blood stream infections or CLABSI rates, and ventilator-associated pneumonia (VAP) rates. Amongst these, VAP is an outcome measure that presents a big quality challenge in critical care units all over the United States. It is the leading hospital-acquired infection in patients in intensive care units. The purpose of this paper is to find out the most efficacious intervention that can prevent VAP by adopting the clinical inquiry strategy. This means the formation of a PICOT statement or question and searching for evidence from scholarly literature about the efficacy of the intended intervention in preventing VAP.

Rationale for Undertaking the Project

The rationale for undertaking this project is very solid. To start with and as stated above, VAP is the leading hospital-acquired infection among mechanically ventilated intensive care patients. This means that it is a very serious quality improvement problem that needs to be addressed as a matter of urgency. There is thus need to determine which practice elements are required to be perfected in order to reduce the rates of VAP in intensive care units. In other words, evidence-based interventions must be found and adopted as policy by organizations in the spirit of evidence-based practice. According to Ghezeljeh et al. (2017), up to 28% of ICU patients on mechanical ventilation are affected by the problem of VAP in the United States. As a matter of fact, VAP is the second most commonly occurring hospital-acquired infection generally in the US. By definition, VAP is pneumonia that occurs in a mechanically ventilated patient in an intensive care setting after a period of 48 hours of being on the mechanical ventilator (Wu et al., 2019; Ghezeljeh et al., 2017; Villar et al., 2016). With no clear efficacious intervention against the development of VAP, ICU mortality increases and quality reduces as a consequence. This has an impact on patient satisfaction, reimbursement rates (revenue), accreditation by regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO, and staff morale and job satisfaction. It is for these reasons that a rationale emerges for tackling the clinical practice problem of VAP.


A Targeted Literature Review on the Clinical Practice Problem of VAP

It is estimated that among the hospital-acquired infections, VAP has a mortality rate of about 10%. Salmon et al. (2019) state that the second highest prevalence of VAP comes from Asia-Pacific countries such as South Korea at 16%, while Latin America is third with 13.8%. What their study shows is that the epidemiological picture of VAP varies from country to country and reflects the quality of intensive care in those countries. They also determined that the causative organisms for this kind of hospital device-acquired pneumonia vary from region to region. For instance, the authors of the study by Salmon et al. (2019) determined that in the US, the most common causative organisms of VAP are predominantly Staphylococcus aureus and Pseudomonas aeruginosa.

The incidence of VAP has been reported in studies to be dependent on the particular healthcare setting being referred to as well as the patient’s diagnosis. Papazian et al. (2020) report it to be ranging from 5% to a whopping 40%. This is a very high incidence; meaning that the clinical problem of VAP is a very important quality mater that must be addressed definitively.  They agree with Salmon et al. (2019) that the mortality due to VAP in ICUs is 10%. An important observation that Papazian et al. (2020) make is that because of VAP, the patent will have a longer hospital stay (which translates to higher hospitalization costs) and a longer stay on the ventilator. This is increased mortality which is undesirable. It should of course be observed that with an increased duration of hospitalization, the patent is also put at a higher risk of pressure ulcers.

Wu et al. (2019) also hold that VAP has a very high mortality rate; and observe (in agreement with Salmon et al., 2019 and Papazian et al., 2020) that VAP makes it difficult to wean the patient off the mechanical ventilator. The result as already observed by the other authors above is that the patient stays longer in hospital and incurs extra hospitalization and medication costs. Wu et al. (2019) observe that some of the challenges with VAP in the current practice environment include resistance o antibiotics, the lack of universal diagnostic guidelines (clinical practice guidelines), and the unavailability of universally acceptable preventive strategies. Of note is that Wu et al. (2019) mention chlorhexidine as one of the agents that have the potential to prevent VAP incidence in intensive care units.

Current Practice Policies/ Procedures and Outcomes / Implications the Project Will Have or Impact at the Workplace

This PICOT project is intended to bring change in practice. Change by its very nature is expected to disturb the status quo. For this reason, in many organizations change is resisted by many as a matter of course. The reason for this is usually complacency and fear of the unknown. The procedures and policies of the organization in which I work will be profoundly impacted. This is because with successful implementation and translation into practice of the EBP recommendations; the organizational culture will have to change to reflect the change. Policies are what drive the strategic objectives of an organization. Therefore, the change in policies and procedures sanctioned by the top management or directors of the organization will mean that the strategic objectives of the institution are redirected towards the redefined goal. For instance, the policy on nurse-patent ratio in the organization’s ICUs may have to be reviewed, just as is the policy on routinely performing oral care for every patient on mechanical ventilation in the ICU. In this case, the important policy change will be the incorporation into the standard operating procedures of the use of chlorhexidine mouthwash for every critical patient on mechanical ventilation. There may also be training required to help the staff correctly implement the practice change related to VAP management. This means that the organization must set aside a budget for this.

The outcomes and implications of the project will be that the quality of the care given in the ICU will be increased. This will be shown by favorable outcome measures such as reduced length of stay on the mechanical ventilator, reduced length of stay in the hospital, lower hospitalization costs, and better patient satisfaction scores. Patient turnover is going to be higher and the facility will do better in terms of getting higher reimbursements. Higher reimbursements will be possible because of the pay-for-performance doctrine of the Patient Protection and Affordable Care Act or ACA 2010 (Holmström, 2017). This provision is premised on delivering quality-based care as opposed to volume-based care as a provider. These are just some of the implications that the project will have at the workplace.  PICOT Worksheet and Search Strategy Essay Paper

The PICOT Question

The clinical inquiry as has been stated in the introduction above is related to the need to find out whether daily oral care with chlorhexidine mouthwash solution is effective and efficacious in preventing the development of VAP in mechanically ventilated critical patents in the ICU. The table below summarizes the different elements of the PICOT statement and the full ICOT question is restated at the bottom of the table. In the Appendix section, the PICOT model for this paper is explained and illustrated further.

Table 1: The PICOT components for clinical inquiry into the prevention of VAP in the ICU

P Population of patients concerned Adult patients being cared for in the intensive care unit and who have been on a mechanical ventilator for more than 48 hours.
I Intervention to be administered to the ICU patients to prevent VAP Maintenance of a daily routine of 4-hourly oral mouth care with chlorhexidine gluconate mouthwash and toothbrush for all patients in the ICU on mechanical ventilation.
C Comparison intervention The usual care where no chlorhexidine gluconate or toothbrush is used in a pre-planned routine manner
O Outcome or result of the intervention Prevention of the occurrence of VAP
T Time or duration within which the intervention will be implemented in the hope of getting the outcome above. Six weeks or one and a half months

The PICOT question in full therefore is: “In critically ill adult patients on mechanical ventilation in the ICU for at least 48 hours (P), does the implementation of 4-hourly oral hygiene with chlorhexidine gluconate swabs & toothbrush (I) compared to usual care with no chlorhexidine gluconate swabs &toothbrush (C) prevent the occurrence of ventilator-associated pneumonia or VAP (O) within six weeks (T)?”.

The Search for Evidence in Support or Otherwise of Chlorhexidine in the Prevention of VAP in the ICU Setting

After formulation of the PICOT question in the clinical inquiry process, the next step was to embark on the search for evidence in current published peer-reviewed scholarly works from reputable research databases. This search was facilitated by the identification of key search words and phrases that were then entered into the search engines of the databases to yield pertinent results. In this case, the research databases that were searched for scholarly evidence were CINAHL Plus with Full Text, ProQuest, Embase, PubMed, and Cochrane Database of Systematic Reviews. The search terms used were “ventilator-associated pneumonia,” “VAP,” “prevention,” “chlorhexidine,” and “oral care.” These words and phrases were then combined with the Boolean operator “AND” and entered into the database search engines.

The inclusion criteria for studies to be included into the evidence pool were:

  1. They must have been published within the last six years
  2. Should be randomized controlled trials with high evidentiary value
  • The studies can be a systematic review or meta-analysis of randomized controlled trials
  1. The studies can be systematic reviews or meta-analyses with the highest level of evidence at level I
  2. They can also be a retrospective cohort study or prospective study
  3. The studies must have had the intervention with chlorhexidine as the independent variable
  • The studies must be quantitative in methodology

On the other hand, the exclusion criteria included that:

  1. Studies must not be older than six years after publication
  2. Studies must not be qualitative in methodology
  • The studies must not have any other independent variable apart from chlorhexidine solution in the prevention of VAP

Studies Included in the Final Appraisal of the Evidence

The search produced a total initial number of 13,502 publications. These were then systematically taken through a thorough exclusion process to arrive at a final number of just 25 studies to include in the final appraisal of the evidence. First and foremost, a total of 6,021 studies were duplicates and were therefore removed from the search results. The remaining 7,481 titles and abstracts were then screened. This process of screening resulted in another 6,183 publications being excluded for failing to meet the strict inclusion criteria. The other remaining 1,298 full-text articles were then assessed for eligibility and 1,280 found to be ineligible. This left just 18 studies that met the ultimate eligibility test to be included n the final appraisal of evidence. The references (bibliography) of these 18 eligible studies were then examined and a further 7 records meeting the eligibility test were identified this way. In the end, the grand total number of eligible publications identified was 25 studies. Four of these studies are briefly outlined below. A flow diagram of the evidence selection process is also provided below.


As stated earlier in this paper, four studies chosen out of the 25 studies with incontrovertible evidence for evidence-based practice (EBP) will be outlined below. They are:

  • Enwere et al. (2016): This was a retrospective cohort study assessing whether chlorhexidine mouthwash can prevent VAP. The results proved encouraging because they found that indeed chlorhexidine is effective in VAP prophylaxis. This study provides level II evidence for the intervention of chlorhexidine.

Figure 1: Flow diagram of the result selection process for article inclusion into the final appraisal of the evidence

Li et al. (2015): This was a meta-analysis of 17 randomized controlled trials. For this reason, it provides the highest possible level of evidence for the efficacy of chlorhexidine as a preventive intervention against VAP. The researchers in this study compared chlorhexidine with povidone-iodine and the latter did not produce the results that the former produced.

  • Rabello et al. (2015): This study was an overview of systematic reviews and therefore also provided the highest level of evidence for chlorhexidine as the EBP intervention to prevent VAP.
  • Villar et al. (2016). This is a systematic review and meta-analysis that places the level of evidence at its highest (level I).

PICOT Worksheet and Search Strategy

  1. Define your question using PICO by identifying: Problem, Intervention, Comparison

Group, and Outcomes.

Patient/Problem: The development of ventilator-associated pneumonia or VAP in mechanically ventilated adult critically ill patients after 48 hours of intubation.

Intervention: 4-hourly oral care with chlorhexidine mouthwash and a toothbrush.

Comparison: Usual care without chlorhexidine and toothbrush.

Outcome: A reduction in the rate of VAP in ICU patients on mechanical ventilation.

Time frame: Six weeks.

  1. Write out your question: In critically ill adult patients on mechanical ventilation in the ICU for at least 48 hours (P), does the implementation of 4-hourly oral hygiene with chlorhexidine gluconate swabs & toothbrush (I) compared to usual care with no chlorhexidine gluconate swabs &toothbrush (C) prevent the occurrence of ventilator-associated pneumonia or VAP (O) within six weeks (T)?
  2. Type of question/problem: Circle one: Therapy Prevention Diagnosis Etiology Prognosis
  3. Type of studies (research design) to include in the search:

Check all that apply:

X Meta-Analysis X Systematic Review X Randomized Controlled Trial

X Cohort Study Case Control Study Case series or Case Report

Editorials, Letters, Opinions Animal Research In Vitro/Lab Research

  1. Alternate terms from the PICO question that can be used for the search
  • Nosocomial pneumonia
  • Device-associated pneumonia
  1. Inclusion criteria:
  • Published within the last six years
  • Randomized controlled trials
  • Systematic reviews and/ or meta-analyses of randomized controlled trials
  • Retrospective cohort study or prospective study
  • Intervention with chlorhexidine as the independent variable
  • Quantitative in methodology
  1. Terms to be excluded in your search: nonspecific pneumonia
  2. Where the search will occur: CINAHL Plus with Full Text, ProQuest, Embase, PubMed, and Cochrane Database of Systematic Reviews.


Enwere, E.N., Elofson, K.A., Forbes, R.C., & Gerlach, A.T. (2016). Impact of chlorhexidine mouthwash prophylaxis on probable ventilator-associated pneumonia in a surgical intensive care unit. International Journal of Critical Illness & Injury Science, 6(1), 3-8. https://doi.org/10.4103/2229-5151.177368

Ghezeljeh, T.N., Kalhor, L., Moghadam, O.M., Lahiji, M.N., & Haghani, H. (2017). The comparison of the effect of the head of bed elevation to 30 and 45 degrees on the incidence of ventilator associated pneumonia and the risk for pressure ulcers: A controlled randomized clinical trial. Iranian Red Crescent Medical Journal, 19(7), 1-10. http://dx.doi.org/10.5812/ircmj.14224

Holmström, B. (2017). Pay for performance and beyond. American Economic Review, 107(7), 1753–1777. https://doi.org/10.1257/aer.107.7.1753

Li, L., Ai, Z., Li, L., Zheng, X., & Jie, L. (2015). Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical ventilation? An updated meta-analysis from 17 randomized controlled trials. International Journal of Clinical and Experimental Medicine8(2), 1645–1657. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4402740/

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4th ed. Wolters Kluwer.

Papazian, L., Klompas, M., & Luyt, C-E. (2020). Ventilator-associated pneumonia in adults: A narrative review. Intensive Care Medicine, 1-19. https://doi.org/10.1007/s00134-020-05980-0  

Rabello, F., Araújo, V., & Magalhães, S. (2018). Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilator-associated pneumonia in intensive care units: Overview of systematic reviews. International Journal of Dental Hygiene. https://doi.org/10.1111/idh.12336

Salmon, A.A., & Metersky, M.L. (2019). The current epidemiological landscape of ventilator-associated pneumonia in the intensive care unit: A multicenter prospective observational study in China—study critique, ventilator-associated pneumonia incidence rates, and pathogen distribution. Journal of Emergency and Critical Care Medicine, 3(23), 1-3. http://dx.doi.org/10.21037/jeccm.2019.05.01

Villar, C.C., Pannuti, C.M., Nery, D.M., Morillo, C.M., Carmona, M.J.C., & Romito, G.A. (2016). Effectiveness of intraoral chlorhexidine protocols in the prevention of ventilator-associated pneumonia: A meta-analysis and systematic review. Respiratory Care61(9), 1245-1259. https://doi.org/10.4187/respcare.04610

Wu, D., Wu, C., Zhang, S., & Zhong, Y. (2019). Risk factors of ventilator-associated pneumonia in critically ill patients. Frontiers in Pharmacology, 10(482), 1-7. https://doi.org/10.3389/fphar.2019.00482

PICOT Worksheet and Search Strategy

  1. Define your question using PICO by identifying: Problem, Intervention, Comparison

Group and Outcomes. Your question should be used to help establish your search strategy.





Time frame:

  1. Write out your question:
  2. Type of question/problem: Circle one: Therapy Prevention Diagnosis Etiology Prognosis
  3. Type of studies (research design) to include in the search:

Check all that apply:

Meta-Analysis Systematic Review Randomized Controlled Trial

Cohort Study Case Control Study Case series or Case Report

Editorials, Letters, Opinions Animal Research In Vitro/Lab Research

  1. List main topics and alternate terms from your PICO question that can be used for your search
  2. List your inclusion criteria –gender, age, year of publication, language
  3. List irrelevant terms that you may want to exclude in your search
  4. List where you plan to search, i.e. EBM Reviews, Medline, AIDSLINE, CINAHL, PubMed  PICOT Worksheet and Search Strategy Essay Paper





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