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I ntervention to Decrease Risk of Ventilator Associated Pneumonia Among Patients on

Mechanical Ventilation

Ryan Auger
December 7
th
, 2013












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For patients on mechanical ventilation, does routine oral care help reduce the risk of
Ventilator Associated Pneumonia, compared to patient who receive no oral care.

Population: Patients on mechanical ventilation
Intervention: Routine oral care
Comparison: No oral care provided
Outcome: Decreased risk of Ventilator Associated Pneumonia

Background

Pneumonia is a prevalent concern among healthcare professionals when caring for
patients. It can cause tremendous damage to the respiratory system and coupled with
comorbidities can even lead to death. Pneumonia is the second most common
nosocomial infection in critically ill patients, affecting 27% of all critically ill patients.
Eighty-six percent of nosocomial pneumonias are associated with mechanical ventilation
and are termed ventilator-associated pneumonia (VAP). Between 250,000 and 300,000
cases per year occur in the United States alone, which is an incidence rate of 5 to 10 cases
per 1,000 hospital admissions. The mortality attributable to VAP has been reported to
range between 0 and 50% (Koenig, Truwit, 2006) To further understand Ventilator
Associated Pneumonia it is important to understand what it is and what characterizes it.
Ventilator-associated pneumonia is defined as pneumonia occurring more than 48 hours
after patients have been intubated and received mechanical ventilation. (Koenig, Truwit,
2006)
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With concerns raised regarding the prevalence of VAP among the mechanically
ventilated patient, intervention and prevention are amongst the highest priority. With up
to 86% of nosocomial pneumonias being associated with mechanical ventilation there is a
clear need among healthcare professionals to prevent them from happening in the first
place, and to improve patient outcomes. By implementing the most up to date evidence-
based practice regarding routine oral care this can be done, and the risk of Ventilator
Associated Pneumonia can be decreased in patients on mechanical ventilation.

Search Methods

Several searches were conducted during the course of my data collection. The
databases utilized were CINAHL, The Cochrane Database of Systematic Reviews, and
MEDLINE for the majority of my gathered information. I also used the search engine
Google to further aid in collecting information. Lastly NCBI was used. The key words
searched consisted in multiple pairings and arrangements of the words and phrases of
VAP, Ventilator Associated Pneumonia, pneumonia, prevention, rates, efficacy, oral
care, and hygiene. The search was conducted with the limiting parameters of English
text, within the last 13 years, and had to have full text available to aid in thorough
analysis. This significantly narrowed and isolated my results. From these searches ten
articles were identified as potential articles for review, and after reviewing them 4 articles
were deemed most relevant for inclusion. Inclusion criteria for articles had to directly
address the benefits of routine implementation of prophylaxis oral care in mechanically
ventilated patients to decrease risk of VAP. Clinical relevance, availability of access, date
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of publication, and validity to the posed clinical question were also taken into
consideration.

Critical Appraisal of the Evidence

The pre-intervention and post-intervention observational study conducted in the
article titled The impact of a simple, low-cost oral care protocol on ventilator-associated
pneumonia rates in a surgical intensive care unit.(Sona,2009) followed mechanically
ventilated patients of an ICU at a University hospital. The study aimed at lowering the
incidence of VAP among mechanically ventilated patients by implementing a low cost
oral care protocol to limit bacterial colonization and growth in the oral cavity of the
patients. Care was provided at routine 12 hour intervals and done using, sodium
monoflurophosphate 0.7% paste and brush, rinsing with tap water, and subsequent
application of a 0.12% chlorhexidine gluconate chemical solution. It compared rates of
infection at the hospital before and after implementation of the oral care protocol and the
results found that During the pre-intervention period from June 1, 2003 to May 31,
2004, there were 24 infections in 4606 ventilator days (rate = 5.2 infections per 1000
ventilator days). After the institution of the oral care protocol, there were 10 infections in
4158 ventilator days, resulting in a lower rate of 2.4 infections per 1000 ventilator days.
This 46% reduction in ventilator-associated pneumonia was statistically significant (P =
.04). The statistical analysis was done using Mantel-Haenszel x2 analysis with Epi Info
(Centers for Disease Control and Prevention). Comparisons of demographics between
pre-intervention and post-intervention groups were performed using the Mann-Whitney
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test. A P value<.05 was considered statistically significant.(Sona,2009) Overall the
study came to the conclusion that the implementation of the protocol, led to a
significantly decreased risk of acquiring ventilator-associated pneumonia.(Sona,2009) A
weakness of this study is that it directly addressed the research question showing a
correlation between the implementation of oral care and a decreased incidence of VAP in
easy to read results, but did so on a one-institution basis. However with a cost effective
and easy to implement design the study showed success in decreasing VAP among
mechanically ventilated patients as its strength.
In the retrospective analysis by Kara Heck titled, Decreasing ventilator-
associated pneumonia in the intensive care unit: A sustainable comprehensive quality
improvement program (Heck, 2012) The intensive care unit of a Michigan hospital
implemented an oral care guideline that highlighted the use of an oral care bundle to
decrease risk and incidence of ventilator associated pneumonia. The care bundle
implemented a variety or oral care tools that were implemented at 4 and 12 hour
intervals. It consisted of suctioning, brushing teeth, oral moisturizers and others aimed at
minimizing bacterial colonization of the mouth, which could then spread to the lungs.
The study again retrospectively looked at data collected from a set time period before the
implementation of oral care bundles against data collected in like time periods [which]
revealed the VAP rate per 1,000 ventilator-days dropped significantly from 10.5 to 0 (P =
.016). The strength is shown in the decline of incidence of VAP, but a weakness of the
study is use of multiple oral care techniques prevent any definitive conclusions from
being made on the effectiveness on 1 specific aspect of this bundled approach to VAP
prevention.(Heck, 2012) Overall it can be noted that, VAP can be significantly
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decreased by adhering to evidence-based guidance on VAP prevention, placement of an
oral care kit at the bedside, and prompts within the electronic medical record to help
ensure staff compliance.(Heck, 2012)
In a randomized control trail conducted in the article Oral care intervention to
reduce incidence of ventilator-associated pneumonia in the neurologic intensive care
unit,(Fields, 2008) a Neurologic ICU developed two groups of patients that were on
mechanical ventilation. The control group was to receive routine oral care as anyone else
in the hospital would, while the intervention group was to receive complete toothbrush
oral care every eight hours. The results were immediate and startling, as the VAP rate
dropped to zero within a week of beginning the every-8-hours tooth brushing regimen in
the intervention group. The study was so successful that the control group was dropped
after 6 months, and all intubated patients' teeth were brushed every 8 hours, maintaining
the zero rate until the end of the study.(Fields, 2008) The study proved to be a success in
the short term reducing incidence of VAP to zero but a weakness was also highlighted in
its instant success. The control group was discontinued after only 6 months to receive the
intervention of routine tooth brushing. This can cause concern for validity, and as stated
in the study, To validate this study and support the relationship between toothbrushing
and VAP, this study needs to be replicated using a larger randomized sample over a
longer period.(Fields, 2008)
Lastly in a systematic review titled Oral hygiene care (OHC) for critically ill
patients to prevent ventilator-associated pneumonia a review team from the Cochrane
Oral Health Group completed an analysis of 35 Random Control Trials containing 5,374
participants to assess the efficacy of oral hygiene care in patients on mechanical
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ventilation. Data was synthesized and findings showed that chlorhexidine mouthwash or
gel was effective in decreasing risk for the development of VAP. The article concluded
Effective OHC is important for ventilated patients in intensive care. OHC that includes
either chlorhexidine mouthwash or gel is associated with a 40% reduction in the odds of
developing ventilator-associated pneumonia in critically ill adults.(Shi, 2013) As many
studies have done before the systematic review has highlighted he benefits of oral care in
the prevention of ventilator associated pneumonia. Although the review has data
collected from a large sample size, and statistical significance was shown, it is not clearly
or thoroughly represented as to how the data and statistical analysis was completed. This
may raise concern for interpreting the validity of the results initially, but coming from a
credible source of the Cochrane Database this validity is confirmed.

Evidence Synthesis

From the literary review conducted, and the further analysis of essential articles a
vast amount of information was left for synthesis. After reviewing all the collected
information a clear trend has arisen. The use of routine oral care can, in fact can reduce
the risk of developing ventilator associated pneumonia in patients who are on mechanical
ventilation. Each study showed that by adding routine oral care to the patients there were
positive indicated outcomes, and in some cases there was an elimination of ventilator
associated pneumonia from the studies as a whole related to the oral care. As a whole the
articles detail a cost effective and easy to implement method to prevent the infections
from happening in the first place, and to help treat them if they are present. When paired
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with additional tools of Evidence-based practice oral care can prove to be a pivotal
implementation to care that can improve patient outcomes and reduce the amount of
infected patients.

Clinical and Research Recommendations
Although further research is always a part of cementing an intervention into
practice, and should be conducted, I believe that the clinical benefits of routine oral care
for patients on mechanical ventilation are clearly shown. My suggestion for clinical
organizations is that implementing a prophylaxis approach in preventing all nosocomial
infections is key, but specifically when it is cost effective and easy to implement. In
patients on mechanical ventilation there should be oral care bundles containing oral
care tools that are easily accessible to nurses and other staff alike to aid in prevention of
ventilator associated pneumonia. Additionally protocol involving strict hand hygiene;
head of bed elevations, and continuous implementation of evidence-based practice should
be followed. This care should be continued for the duration of the artificial ventilation to
decrease the risk of acquiring ventilator associated pneumonia.







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References

Fields, L. (2008). Oral care intervention to reduce incidence of ventilator-associated
pneumonia in the neurologic intensive care unit. The Journal Of Neuroscience
Nursing : Journal Of The American Association Of Neuroscience Nurses, 40(5),
291-298.

Heck, K. (2012). Decreasing ventilator-associated pneumonia in the intensive care unit: a
sustainable comprehensive quality improvement program. American Journal Of
Infection Control, 40(9), 877-879. doi:10.1016/j.ajic.2011.11.010

Koenig, S. M., & Truwit, J. D. (2006). Ventilator-Associated Pneumonia: Diagnosis,
Treatment, And Prevention. Clinical Microbiology Reviews, 19(4), 637-657.

Shi, Zongdao, Xie, Huixu, Wang, Ping, Zhang, Qi, Wu, Yan, Chen, E, Ng, Linda,
Worthington, Helen V, Needleman, Ian, Furness, Susan. Oral hygiene care for
critically ill patients to prevent ventilator-associated pneumonia. Cochrane
Database of Systematic Reviews 2013, Issue 8. Art. No.: CD008367. DOI:
10.1002/14651858.CD008367.pub2.

Sona, C., Zack, J., Schallom, M., McSweeney, M., McMullen, K., Thomas, J., & ...
Schuerer, D. (2009). The impact of a simple, low-cost oral care protocol on
ventilator-associated pneumonia rates in a surgical intensive care unit. Journal Of
Intensive Care Medicine, 24(1), 54-62. doi:10.1177/088506660832697

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