Effect of the Ventilator Care Bundle Occurrence of Ventilator-Associated Pneumonia among Pediatrics

doi:10.21203/rs.3.rs-5010435/v1

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Effect of the Ventilator Care Bundle Occurrence of Ventilator-Associated Pneumonia among Pediatrics

https://doi.org/10.21203/rs.3.rs-5010435/v1

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Background: In pediatric intensive care units (ICUs), ventilator-associated pneumonia (VAP) is one of the most prevalent infections linked to healthcare. VAP affects 10% of children on mechanical ventilation and is linked to severe morbidity and mortality.

Aim: The present study aimed to evaluate the effect of the ventilator care bundle (VCB) on the occurrence of ventilator-associated pneumonia among pediatric patients.

Design: A pre posttest quasi experimental research design was utilized in the present study.

Setting: Thisstudy was conducted in the Pediatric Intensive Care Unit (PICU) at Cairo University Specialized Pediatric Hospital (CUSPH).

Sample: A convenience sample of 30 nurses and a purposive sample of 60 ventilated children in the PICU participated in the present study. Children were divided into two equal groups: 30 as a control group and 30 as a study group. Nurses were the same for the study and control groups. Tools: Data collection was performed through 1) structured interview sheet, 2) the Nurses' Knowledge Assessment Questionnaire (pre-posttest), 3) the Ventilator bundle checklist, and 4) the Clinical Pulmonary Infection Scale (CPIS). Results: More than two-fifths of the children on MV participated in the present study, and half of the children in the control group were aged 1 year to less than 3 years. Less than two-thirds of the studied children and more than half of the control group were females. Two-fifths and half the order of the children in both groups were ranked as the second and third children, respectively, within the family, while more than one-third of the children in both groups complained of shock. More than one-quarter of the children in both groups complained of disturbance consciousness. There were statistically significant differences detected between the total mean scores of nurses' knowledge and practice before/after the use of the ventilator care bundle (P < 0.01). There was a statistically significant difference between the total mean score on the CPIS between the study group and the control group (t= - 3.692, p= .001). Conclusion: The study concluded that children who were cared for by nurses receiving VCB sessions were less likely to experience VAP than were those in the control group. Recommendation: Educational programs and in-service training courses for pediatric nurses to increase the quality of ventilator care for children and its benefits for the occurrence of VAP are essential.

Pediatrics

Ventilator- associated pneumonia

Ventilator Care Bundle

Pediatric Nurses Children.

The term "ventilator-associated pneumonia" (VAP) refers to pneumonia that develops 48–72 hours after endotracheal intubation or later. It is distinguished by the presence of a new or developing infiltrate, systemic infection symptoms, alterations in the characteristics of the sputum, and the identification of the causative agent. Approximately 50% of all cases of hospital-acquired pneumonia are caused by VAP. Approximately 9–27% of children on mechanical ventilation are thought to experience VAP (Kalanuria, Zai & Mirski, 2019).

According to Vijay et al. (2019), despite advancements in aseptic procedures, antibiotic therapy, and supportive care, ventilator-associated pneumonia (VAP) remains a significant cause of hospital-acquired infections. According to Alsodaa et al. (2022), VAP affects 17% of hospitalized newborns and children globally, posing a serious health risk.

According to Kumar (2019), there are numerous host-related factors that contribute to the incidence of VAP. Although the reported incidence of VAP is extremely high (38.4%), it is inappropriate to compare the incidence of VAP across centers unless there is consistency with regard to the study subjects, environmental factors, and infection control policy. According to several published reports, VAP accounts for 18–26% of all hospital-acquired infections in the unit, with a mortality rate of 10–20% as reported by Alsodaa in 2022, elevated rates of mortality and morbidity are linked to VAP, which prolongs hospital stays and drives up health care costs.

VAP is the second most common hospital-acquired infection in the PICU, and accounts for 12% of all ventilated patients (Riddick, Hemingway, and Lumsden, 2019). Prolonged use of a ventilator, inadequate stomach protection, and inadequate oral hygiene are risk factors for developing VAP. There was a clinical difference in mortality between VAP patients (83.3%) and non-VAP patients (35.1%) (Alsodaa, et al., 2022).

Yankov and Shmiley (2019) posit that pneumonia arises from the spread of pathogens within the lung parenchyma and mucosa. The colonization of the digestive and respiratory systems as well as the microaspiration of contaminated secretions is the two main pathogenic factors of VAP. According to Catherine (2019), the most common way for a patient to contract VAP from pathogens found in the PICU is through oropharyngeal colonization, particularly from contaminated respiratory equipment and healthcare providers' hands. However, pneumonia can result from aspiration of stomach contents into the lungs due to gastroesophageal reflux disease. Therefore, using H2 blocks for mechanically ventilated patients and bloodstream infections also poses a risk for VAP in children.

A mean VAP rate of 3.6 cases per 1000 ventilator days in PICUs in the United States has been reported by the Centers for Disease Control. To stop the morbidity and death linked to this illness, there is still a great need for quality improvement programs in many different nations (Rosenthal et al., 2019). These bacteria frequently react well only to TGC. Maintaining good hand hygiene is crucial for reducing the spread of microorganisms and preventing overgrowth and colonization infections in children on ventilators (Mladenov, 2020).

Reda et al. (2019) identified a number of risk factors, including genetic syndrome, re-intubation, invasive procedures such as central venous lines and urinary catheter sources for infection transmission, and immunosuppressive conditions or medications. In their 2022 study, Mohammed, Ali, and Refaat examined VAP in pediatric patients at Assiut University Children's Hospital. They found that 76% of patients with crepitation underwent chest auscultation, 24% of patients had wheezing, and 64% of patients had leukocytosis.

The idea of a "bundle" of care makes it easier to implement evidence-based medicine and best practices. A bundle is a methodical approach to enhancing patient outcomes and care processes (Montasser, 2019). Consequently, using a pediatric ventilator bundle in conjunction with an evidence-based, safe, multidisciplinary approach is thought to be a practical way to improve clinical and patient outcomes (Alcan et al., 2020).

VAP has remained a significant burden in the PICU despite improvement initiatives that include the adoption of VAP prevention measures, active surveillance, and early detection and the subsequent decline in VAP rates. The hospital administration saw this as a turning point in terms of quality indicators, necessitating a significant investment in patient safety and quality programs. According to Khan, Al-Dorzi, and Al-Attas (2020), hospital administration should implement a ventilator care bundle for VAP prevention and for lowering the incidence of VAP in the PICU.

A bundle concept for the prevention of VAP was created by the Institute for Healthcare Improvement (IHI) in Cambridge in 2006. The hospital consists of four parts: daily sedation-vacation, prophylactic treatment for deep vein thrombosis, prophylactic treatment for peptic ulcer disease, and head of bed elevation. A hand hygiene campaign and an oral care protocol were two additional interventions that were probably complementary to the ventilator bundle. The ventilator day-by-day rate decreased from 2.66 to zero with these interventions.

The use of bundled care, education, and performance metrics to track the occurrence of infection or surveillance are crucial components in the prevention of VAP in the pediatric population. Nursing education is fundamental for understanding "incidence, risk factors, and prevention protocols" and serves as the cornerstone for interprofessional VAP management. The incidence of VAP can be reduced, and interventions such as hand hygiene, bundled care participation, and staff member communication about infection can be improved through education for nurses and other PICU workers (Gupta, Kapil & Kabra, 2020).

Significance of the study

According to Mostafa, Rafay, and Adly (2020), the incidence of ventilator-associated pneumonia (VAP) was 563 per 1000 children. Prolonged hospital stays and long-term disability can be indicative of the healthcare burden associated with VAP. The high prevalence of VAP among mechanically ventilated children in the PICU is closely linked to inadequate training and practice. According to Latef, Kamel, and Abdallah (2022), the incidence of VAP was 22.3 per 100 children in the study, and the incidence was 37.56 per 1000 ventilation days in the PICU.

AnwrAk, Saadoon, and Sayed (2023) concluded that VAP is also connected to death and extended hospital and ICU stays. In children in critical care, VAP is the second most common infection among those hospitalized in pediatric and neonatal intensive care units. Care bundles have been widely recommended for patients on mechanical ventilation in clinical practice. To improve children's health outcomes, a care bundle identifies a number of crucial interventions derived from evidence-based guidelines.

Few studies on the use of VCB for caring for children have been performed in Egypt. Therefore, the goal of the current study was to assess how a ventilator care bundle for pediatric nurses affects the incidence of pediatric ventilator-associated pneumonia. This ventilator care bundle should help reduce the incidence of VAP in children while also enhancing nurses’ knowledge and practices in child care. Additionally, directions and suggestions should be included in pediatric nursing education, and data should be obtained based on evidence that can advance nursing practice and research in the area of pediatric critical care.

Aim of the study

The current study aimed to evaluate the effect of the use of a ventilator care bundle for pediatric nurses on the occurrence of ventilator-associated pneumonia among children.

Research Hypotheses

1. Nurses who use the ventilator care bundle will have a higher mean score for knowledge and practice than will those who did not.

2Children who receive care from nurses after receiving the ventilator care bundle will have less exposure to ventilator-associated pneumonia than the control group.

Research Design

A pre/posttest quasi experimental research design was utilized to achieve the aim of the current study. A quasi experimental design is a type of experimental design that is very similar to the true experimental design except that one criterion is lost as randomization (Grove & Cipher, 2019). The clinical trial number is not applicable.

Setting

Nurses and children were selected from the Pediatric Intensive Care Unit (PICU) on the ground floor at Cairo University Specialized Pediatric Hospital (CUSPH). The intensive care unit receives children of different ages as well as different diagnoses in critical situations that require careful nursing care.

Sample

All available pediatric nurses who were working in the PICU (30) and agreed to participate in the current study were included regardless of their age, qualification, sex, years of experience and purposive sample of 60 children on mechanical ventilation in the. The first 30 children were considered the control group received routine mechanical ventilator care in the hospital, and the second 30 children were subjected to VCB performed by nurses.

Inclusion criteria

All the children were admitted to the PICU and intubated within 24 hours.
Children up to 5 years.

Exclusion criteria

Children diagnosed with pneumonia at the time of admission
Children re-intubation.
Children complain of immune diseases such as rheumatoid disease and DM or receive immune drugs.

Ethical considerations

Primary approval was obtained from the Scientific Research Ethics Committee of the Faculty of Nursing at Cairo University. All nurses and caregivers of children provided written consent and verbal explanations about the nature of the study, voluntary participation, what study involvement would entail, anonymity and confidentiality issues, and the right to withdraw from the study at any time without any effect on their child’s care. For ethical reasons, data were collected first from children in the control group and then from those in the study group. Final approval was obtained from the scientific research ethical committee of the faculty of nursing at Cairo University FWA00026458.

Data collection tools

The required tools were developed after reviewing the related literature and will be completed by the researcher:

1. Structured Interview Sheet: This tool was developed by the researchers after reviewing the related literature. It includes 20 items classified under three parts:

Part I: This part included six (6) items about the characteristics of the children, such as age, diagnosis, sex, rank, place of residence, and reason for putting the child on MV.

Part II included seven items related to the child's medical history and present history, such as previous illness, previous diagnosis, previous admission to the PICU, cause of admission, duration of PICU stay, symptoms on admission, and diagnostic evaluation.

Part III: This part included seven items related to the personal and professional data of the pediatric nurses, such as age, sex, qualification, years of experience, training courses in the PICU and MV, and frequency of training courses.

2. Nurses' Knowledge Assessment Questionnaire (pre/posttest): This questionnaire included twenty questions developed by the researchers to assess pediatric nurses’ knowledge about mechanical ventilation, such as the assessment of MV, which includes 6 questions; the care of a child on MV, which includes 9 questions; the weaning of MV, which includes 3 questions; and the medication, which includes 2 questions.

Scoring system:

For nurses’ knowledge each correct and complete response was given a “2” score, an incomplete response was given a “1” score and the wrong response were given a value of zero. The total score was 40, and the data were converted to 100% and then categorized as follows:

Excellent (85% to 100%).
Very good (75% to < 85%).
Good (65% to < 75%).
Pass (60% to <65%).

3. Ventilator bundle checklist: This tool was adopted based on the guidelines of the Institute of Health Care Improvement by Resaret et al. (2005) to assess the of 8 items for ventilator care bundle practices. The key components of the ventilator care bundle checklist are as follows: washing hands, care of the ventilator machine, elevation of the head of the bed 30 degrees, mouth care with normal saline 9% or distilled water, daily sedation interruption, assessment of readiness to extubation, peptic ulcer disease prophylaxis and deep venous thrombosis prophylaxis.

Scoring system:

Regarding nurses’ practices (ventilator bundle checklist) each item was scored as follows: complete/correct practice took a “2” score, incomplete/incorrect took a “1” score, and not done/missed took a “0” score. The total score was 16, and the total score was converted to 100%. The patients were subsequently categorized as follows:

A total score less than 75% which is less than 12 was considered an unsatisfactory level of practice.
A total score of 75%, which was 12 or more, was considered to indicate a satisfactory level of practice.

4. Clinical Pulmonary Infection Score (CPIS): This score was adopted from Pugin, Auckenthaler & Mili (1991). It has been proposed for the diagnosis and management of VAP based on 6 clinical assessments, each worth 0–2 points, including fever, leukocyte count, quantity and purulence of tracheal secretions, oxygenation, type of radiographic abnormality, and results of sputum culture. Total scores from 0 to 6 points indicated that pneumonia was less likely, a score from 7 to 12 indicated that pneumonia was more likely, and the reliability of the CPIS was 96%.

CPIS	Score
1- Patient temperature
1. ≥36.5 degrees C and ≤38.4 degrees C	0 points
2. ≥38.5 degrees C and ≤38.9 degrees C	1 point
3. ≥39 degrees C ≤36 degrees C	2points
2- Leukocyte count
1. ≥4,000/mm^-3 and ≤11,000/mm^-3	0 points
2. <4,000/mm^-3 or >11,000/mm^-3	1 point
3. <4,000/mm^-3 or >11,000/mm^-3	2points
3- Tracheal secretions (summed over 24 hours)
1. Rare	0 points
2. Abundant	1 point
3. Abundant+ purulent	2 points
4- PaO2(mmHg)/FIO2
1. >240 or ARDS present	0 points
2. ≤240 or no evidence of ARDS	2points
5- Chest X-ray
1. No infiltrate	0 points
2. Diffuse	1 point
3. Localized	2 points
6- Microbiology (culture growth from tracheal aspirate)
1. Negative	0 points
2. Positive	2points
CPIS Interpretation 0 to 6 points= Pneumonia less likely 7 to 12 points = Pneumonia more likely

Validity and Reliability:

The data collection tools used in the study were given to a group of 5 experts in the field of pediatric intensive care and pediatric nursing to test the content validity of the tools, and modifications were made by the experts to increase tool validation. The reliability of the tools was assessed to confirm tool consistency, for which the Cronbach’s alpha was 0.80.

Procedure

Before conducting the study, official permission was obtained from the directors of CUSPH, and permission from the head of the PICU was also obtained after the nature of the study was explained. Informed consent was obtained from the caregivers of children in both the study and control groups. Clear and simple explanations about the aim and nature of the study were given by the researchers to the nurses, and written consent was obtained from those who agreed to participate in the study. Then, the caregivers and nurses completed a structured interview sheet (tool 1). A pretest was performed to assess nurses’ level of knowledge about care for children and MV. Additionally, nurses were observed to assess their level of practice using an observational checklist about the use of a ventilator care bundle for nurses on an individual basis depending on working time with a child. Data from the nurses and children in the control group were collected before the study group of children and the control groups were receiving routine ventilator care in the PICU.

The researchers will then present two sessions. The first session will consist of a theoretical section about the knowledge of MV and child care on MV. Pediatric nurses were provided this information on an individual basis depending on the work schedule in the waiting room in the PICU. The session lasted approximately 30-45 minutes according to the data provided during the experiment, and after one week, the posttest was administered to assess the knowledge of the nurses (tool 2).

The second session, containing the practical part of the ventilator care bundle, was subsequently conducted for the nurses through demonstration and re-demonstration of the doll to master the required skills. The session lasted approximately 40-60 minutes, and the ventilator care bundle was applied twice daily for one week for children in the PICU. The researchers will evaluate the nurses’ performance regarding the use of the ventilator care bundle for children in the study group through an observational checklist administered twice, once on the third day and once on the sixth day (tool 3). The tool (4) was completed by the researchers for children in the study one week after the implementation of ventilator care bundle intubation to assess the occurrence of VAP. The data were collected over twelve months from July 2022 to July 2023.

Statistical analysis

The collected data were tabulated and summarized. The data were computerized and analyze using the appropriate descriptive frequency and percentages are expressed as qualitative information. The parametric chi-square test was used to compare qualitative variables. For comparisons of means, paired-sample t tests and inferential statistical tests were used to test the study hypotheses. The level of significance was set at p < 0.05.

Table (1) reveals that two thirds (43.3%) of the children on MV participated in the present study, and 50% of the children in the control group were aged 1 year to less than 3 years. The mean age was 2.5±1.32 years for children in the study group and 2.1±1.31 years for those in the control group. Less than two thirds (63.3%) of the studied children and more than half (53.3%) of the control group were females. The same table shows that 40% and 50%, in order of children in both groups, were ranked as the second and third children within the family, respectively. It was found that 70% and 56.7%, respectively, of the children in the study and control groups lived in urban areas. The same table indicates that there was a statistically significant difference between children in both the study and control groups regarding sex and place of residence (X²= 7.33., p=.010; X²= 9.36, p= .006, respectively).

Table 2 clearly shows that 36.7% and 33.3%, respectively, of the children in both groups complained of shock, while more than one quarter (23.3%) and 26.7% of the children in both groups were diagnosed with respiratory distress syndrome. Only 20% of the children in the study group complained of accidents and postoperative complications. One-third (33.3%) of the children in the control group were diagnosed with accidents. Similarly, more than one-third of the children in the study group had respiratory and non-respiratory causes of MV, while half (50%) of the children in the control group had non-respiratory causes of MV, and the majority of the children in both groups did not suffer from other diseases. Ten percent of the children in the study group and 16.7% of those in the control group had been admitted to the PICU before admission, and two-thirds of the children in the study group complained of pneumonia as a reason for their admission to the PICU, while less than two-thirds of those in the control group were suffering from dehydration.

Table 3 clearly shows that more than two-fifths (46.3%) of the children in the study group and half (50%) of those in the control group had lived in the PICU for three weeks. With regard to symptoms on admission to the PICU, 30% and 26.7% of the children in both groups complained of disturbance consciousness, respectively, while 23.3% and 33.3%, respectively, in both groups, had respiratory distress. More than two-thirds (70%) of the children in the study group were diagnosed with both radiological images and ABGs, whereas more than half (53.3%) of the children in the control group were diagnosed with these conditions.

Table (4) shows that more than half of the nurses ranged in age from 20 to less than 30 years, with a mean age of 6.23 ±25.66 years, and more than half of them were females. Regarding nurses’ qualifications, 46.7% of them graduated from the Technical Institute of Nursing. Concerning nurses’ years of experience in the PICU, more than half (53.3%) of the nurses had less than 5 years of experience. More than half (56.7%) of the nurses attended training courses in pediatric intensive care, and only one-third (33.3%) of them attended mechanical ventilator training courses.

Table 5 shows that highly significant differences were detected between the total mean scores of nurses' knowledge (assessment of MV, care of a child on MV, weaning of MV, and medications) for the pre- and post-treatments at P < 0.01.

Table (6) illustrates that 6.7% of the nurses had an excellent level of knowledge regarding MV before the implementation of the ventilator care bundle, and this percentage increased to 53.3% after receiving the ventilator care bundle. Twenty percent of them had a poor level of knowledge before receiving the ventilator care bundle compared to no one after receiving the ventilator care bundle. A statistically significant difference was detected between nurses’ level of knowledge before and after the implementation of the ventilator care bundle (X²= 21.46, p≤ 0.01).

Table 7 highlights that 80% and 73.3%, respectively, of the nurses performed complete hand washing before and after contact with mechanical ventilation in both readings after VCB implementation, whereas more than one quarter of the nurses performed incomplete hand washing in the 2nd reading. A total of 76.7% and 70%, respectively, of the nurses performed complete care of the ventilator machine in both readings after the implementation of VCB, whereas more than one quarter of the nurses performed incomplete care in the 2nd reading. With regard to children nursed in a semi recumbent position and daily sedation, more than three-quarters of the nurses completed the VCB in the 1^st reading, and the majority of them did so in the 2^nd reading after the implementation of VCB, while 10% and 6.7%, respectively, did not. The majority of the nurses performed regular oral hygiene maintenance every 4 hours and daily assessments of readiness to extubate during the 1^st reading; 80% and 93.3%, respectively, completed a 2^nd reading after the implementation of VCB, and less than one-quarter of those incomplete performed both readings.

The same table shows that the majority of nurses who completed both readings performed care for peptic ulcer disease prophylaxis,76.7% and 86.7% of the nurses who completed both readings performed deep venous thrombosis prophylaxis, and less than one-quarter of those incomplete performed both readings. There were statistically significant differences in two readings between the nurses who used the ventilator care bundle checklist (x²=3.91, p=. 057, x²= 7.74, p=. 001, x²= 3.70, p=. 054, x²=3.81, p= .051 in order) at p < 0.05 and < 0.01.

Table 8 shows that the mean total score for nurses’ preference after the ventilator care bundle was 1.93±.253 in the first reading and 1.83 ±.379 in the second reading. There was a statistically significant difference between the total mean score of nurses’ practices in the first and second readings (p= <0.01).

Concerning the occurrence of clinical pulmonary infection among children in the study and control groups, Table (9) clearly shows that more than two-fifths of the children in the study group had a normal temperature or fever, and there were rare tracheal secretions; moreover, 56.7% of the children in the control group had hyperpyrexia or hypothermia. It was found that in 43.3% of the children in the study group, the leukocyte count was normal compared to 40% of the children in the control group who had leucopenia or lymphocytosis. Nearly three-quarters (73.3%) of the participants in the study group did not have evidence of RDS, while less than two-thirds of the children in the control group had RDS. On chest X-ray, 56.7% of the children in the study group had no infiltrate, whereas half of those in the control group had localized signs on X-ray. The majority of children in the study group had negative culture growth, although 63.3% of those in the control group had positive culture growth. The results indicated that there were statistically significant differences between children in both the study and control groups regarding the clinical pulmonary infection score (p<0.5, P<0.01).

Table 10 shows that the mean total clinical pulmonary infection scores (CPISs) for the study and control groups were 5.800 ± 1.297 and 7.600 ± 2.044, respectively. There was a statistically significant difference between the total mean CPIS score in the study group and that in the control group (t= - 3.692, p=. 001).

Concerning the demographic data, it was evident from the results of the present study that two-thirds of the children on MV in the study group and half of the children in the control group were aged 1 year to less than 3 years. The current result contradicts that of Bhattacharya et al. (2023), who confirmed that 37 (36.2%) pediatric patients had VAP, with children aged one to five years being the most frequently affected age group. According to the current study, more than half of the control group and less than two thirds of the studied children were female. These findings contrast with those of Seifu1 et al. (2022), who reported that out of the 361 pediatric patients examined, 197 (54.6%) were boys and 164 (45.4%) were girls.

A total of 70% and 56.7% of the children in the study and control groups, respectively, lived in urban areas; more than one-third of the children in both groups complained of shock and more than one-quarter of the children in both groups were diagnosed with respiratory distress syndrome. This explanation aligns with the findings of Dendir et al. (2023), who reported that 165 (41.7%) of the 396 pediatric ICU patients included in the study were from urban areas. They also discovered that 39.2% of young patients admitted to the intensive care unit had acute respiratory distress syndrome. Conversely, in line with the findings of Bacha, Tsegaye, and Tuli, based on research conducted in India, septic shock (27.14%), respiratory disorders (20.9%), and cardiovascular illness (41.1%) were the most common causes of PICU.

It was evident in the results of the present study that two-thirds of the children in the study group complained of pneumonia as a reason for the child’s admission to the PICU, whereas less than two-thirds of those in the control group suffered from dehydration. These results contrast with those of Arafah, Murni, and Rusmawatiningtyas (2020), who concluded that neurological diseases, which were statistically significant independent predictors of prolonged PICU stays, affected 26.7% of children.

The current study indicated that more than two-fifths of the children in the study group and half of those in the control group had lived in the PICU for three weeks. Fayed and AlYousef (2022) provided support for this finding, indicating that respiratory diseases accounted for the majority of long-stay patients (51.53%), with comorbidities and complications occurring during the stay (p < 0.001). Concerning the child's symptoms on admission to the PICU, nearly one-quarter and one-third of them in the two groups, respectively, experienced respiratory distress. This was supported by the findings of Nilofer, Sunil, and Punit (2017), who reported that respiratory failure was the most common indication 20.83%.

Concerning the diagnostic evaluation of the children, it was evident from the results of the present study that more than two-thirds of the children in the study group were diagnosed with both radiological images and ABGs, while more than half of those in the control group were diagnosed with ABGs. Similarly, Antalova et al. (2022) reported that, in the early stages of pneumonia development, there may be only a few signs of inflammation on X-ray. The authors recommended repeating the test over time in patients with a high clinical suspicion and other criteria for worsening of gas exchange.

The current study revealed that more than half of the nurses (with a mean age of 6.23 ± 25.66 years) were aged > 20 to < 30 years, and more than half of them were females. This result was similar to that of Abou Zed & Mohammed (2019), who reported that the mean age of the participants, which accounted for 74.3% of the sample, was 26.63 ± 4.25 years, with a range of 20 to less than 30 years. Additionally, these findings support the findings of Pena et al. (2021), who reported that 80% of all PICU working nurses were female.

Regarding nurses’ qualifications, the study results showed that more than two-fifths of them had graduated from the Technical Institute of Nursing and that more than half of the nurses had less than 5 years of experience. The current results agreed with the findings of El-Sayed et al. (2023) that more than 53.3% of nurses hold degrees from technical nursing institutes. Furthermore, these findings align with the findings of Ibrahim, Al-Rafay, and Tantawi (2021), who evaluated the effect of a bundled approach training program on pediatric and neonatal nurses in terms of preventing device-related infections in the PICU and NICU of Ain Shams University Specialist Hospital. Their findings showed that 61.4% of nurses had worked in the PICU and NICU for a minimum of 10 years.

According to the results of the present study, highly significant differences were detected between the total mean scores of nurses’ knowledge of the use of the ventilator care bundle pre- and post-intervention (P < 0.01). These findings supported Thompson's (2020) assertion that nurses knew more about VAP prevention after receiving instruction than they did prior to instruction (P < 0.05). Additionally, in practically every knowledge domain, there were highly statistically significant differences between the pre- and posttest total knowledge scores.

Concerning nurses’ knowledge, 6.7% of the nurses had an excellent level of knowledge regarding MV before the implementation of the ventilator care bundle, and this percentage increased to more than half after receiving the ventilator care bundle. These results were in line with those of Ahmed & Abosamra (2022), who investigated pediatric critical care nurses' knowledge of evidence-based recommendations for preventing ventilator-associated pneumonia (VAP) and found that 65.3% of the study sample knew insufficiently about these guidelines. From the researcher's view, this is because there is no written protocol regarding evidence-based guidelines for the prevention of VAP in units, and nurses are not aware of the importance of such interventions and their implementation.

In relation to nurses' level of knowledge regarding evidence-based guidelines

for preventing ventilator-associated pneumonia, the results of this study revealed that more than two-thirds

A total of 65.3% of the studied samples had unsatisfactory levels of knowledge regarding evidence-based guidelines for

preventing ventilator-associated pneumonia. This may be due to the lack of a written protocol regarding evidence-based

guidelines for the prevention of VAP in both units. This lack of knowledge is considered an enormous barrier to

implementation of evidence-based guidelines for VAP prevention, as resources are available at times but

Nurses are not aware of the importance of such interventions and their implementation. This result was supported by the

results of Gomes (2010), who reported that the majority of participants had adequate knowledge of

evidence-based guidelines for prevention of VAP.