Patients on ventilator support are very prone to respiratory infections. These patients have no means or control over what enters their lungs or what does not. One prevalent infectious process that can occur in these patients is ventilator associated pneumonia (VAP), and affects many patients every year who require ventilator support. Ventilator associated pneumonia is a form of pneumonia, a lung infection, which occurs in mechanically ventilated patients. It develops at least 48 hours or more after the ventilator is utilized (Powers, 2006). Ventilator associated pneumonia is caused by bacterial organisms entering the patient’s lower respiratory tract usually by aspiration of oral pharyngeal secretions. The bacteria colonize within the lungs causing immune response or infection to occur (Powers, 2006). The development of this infection can lead to a decline in the patient’s outcome and increased healthcare cost to the patient as well as the health care facility (Mori, 2006). With all these problems VAP can produce it is important to the patient as well as healthcare providers to be able to find ways to reduce the development of VAP cases in patients. The purpose of this paper is to determine if routine oral care can decrease the incidence of ventilator associated pneumonia in mechanically ventilated patients. The picot question guiding this paper is what effect does routine oral care have on the incidence of ventilator associated pneumonia rates in mechanically ventilated patients.
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Background and Significance
Ventilator associated pneumonia is a serious infection affecting both the patient, healthcare facility, and staff. It is the second most common healthcare-acquired infection (Koening, 2006). Incidence of VAP is estimated as high as 65% and it occurs in up to 28% of patients who have been on the ventilator 48 hours or longer (Powers, 2006). The mortality rate associated with VAP ranges from 12-50% (Sona et al, 2009). Studies on the mortality rates of VAP also show that patients who develop VAP have a 2.2 to 4.3 times higher risk of death compared to other mechanically ventilated patients who do not have pneumonia (Powers, 2006).
A couple affects that VAP has upon the patient and healthcare facility are time of hospitalization and healthcare costs. Ventilator associated pneumonia causes the length of a hospital stay to increase significantly. It can increase the hospitalization time anywhere from four to nineteen days longer (Powers, 2006). This extra hospitalization can cause additional stress for the patient and their health. As the incidence of VAP causes longer hospitalizations to occur, patient and health care facility costs climb also. It is estimated that the average increase in hospital costs is around $57,000 per VAP occurrence (Powers, 2006). There are also increases to the hospital that occur due to increases in supplies used, staff that is utilized, and more medications used.
Since VAP has such a negative impact upon patients and healthcare facilities many interventions have been tried to prevent the incidence of VAP. One intervention utilized is keeping the head of the patient’s bed raised to at least thirty degrees to prevent aspiration of bacteria in secretions. Another is “sedation vacations” which consists of interrupting the patient’s sedation medication until patient shows signs of alertness, to assess if patients can be weaned off the ventilator more quickly. Other notable interventions that have been utilized in the past and some in today’s practice as well include: suctioning secretions, good aseptic techniques such as hand washing, and oral care (Pruitt & Jacobs, 2006).
Patients are continually developing VAP and having complications from the infection. If it is found that routine oral care, defined as teeth brushing with the use of an oral antimicrobial within this paper, can reduce the incidence of VAP in mechanically ventilated patients it could decrease length of hospital stay, keep costs due to incidence of VAP down for both patient and healthcare institution, as well as decrease mortality rates in these patients.
Ventilator associated pneumonia occurs way too often in the hospital setting. It causes significant stress on the patient’s already problematic health status. The writer of this paper has observed many nurses who are vigilant in providing oral care to ventilated patients, but has also observed other nurses who forego oral care as if it not important and has no affects upon the patient’s health. This made the writer question what the actual effectiveness of oral care has upon reducing the incidence of ventilator associated pneumonia in mechanically ventilated patients. This issue is very relevant to nursing because the ultimate goal of a nurse is to help the patient have the best possible outcome. Trying to achieve the best possible outcome for the patient makes infection control is a very high priority for nurses. Patients who have infections are more prone to get other infections and require more nursing care and more time to recover from their illnesses. Although VAP will continue to occur in patients, and oral care is not a cure for ventilator associated pneumonia, there is valuable information included in research studies included within this paper that shows the incidence of VAP can be reduced in mechanically ventilated patients by implementing routine oral care.
Empirical Review 1
The purpose of the first study, conducted by Sona et al, 2005 was to determine the effect of a routine oral care protocol upon incidence of ventilator-associated pneumonia. The research design was a quantitative, experiment, quasi-experimental study which utilized a non-equivalent control group before and after the design. The study had no conceptual framework stated by the researchers. Within the study, the variables of significance to the clinical question being looked at were the routine oral care protocol and the ventilator-associated pneumonia rates. The independent variable of new oral care protocol was defined as the mechanical cleansing of the teeth or gums to remove plaque with a tooth brush and the application of an oral antimicrobial. The study went on to further discuss the protocol as brushing the teeth for one to two minutes with a regular toothbrush and then applying .12% chlorahexidine to all oral surfaces every twelve hours. The dependent variable was the ventilator associated pneumonia rates. It was defined as a common hospital acquired infection and is the leading cause of death in ICU patients who are ventilator dependent. Ventilator associated pneumonia rates were measured using the National Nosocomial Infections Surveillance System (NNIS) criteria.The reliability nor the validity of this instrument was addressed within the study. Another variable that was studied was length of stay. This was just measured by the number of days that the patient spent within the ICU after a ventilator associated pneumonia infection occurred (Sona et al., 2009).
This study took place at Barnes Jewish Hospital on a 24 bed intensive care unit (Sona et al., 2009). The study focused particularly on patients that were admitted to the surgical intensive care unit (SICU) whom required mechanical ventilation. The subjects consisted of all patients who had mechanical ventilation between June 1, 2003 and May 31, 2005. Subjects were chosen using non-probability convenience sampling. The pre-intervention was implemented for patients that were admitted between June 1, 2003 and May 31, 2005. The size of this sample was 777 patients. The pre-intervention phase consisted of standard care the nurse provided to the patients, no changes were provided during this time; only observation took place. One month before the end of the pre-intervention phase all nursing staff working on the SICU were debriefed and educated on the aims of the study as well as the new routine oral care protocol by two clinical nurse specialists and a nurse educator. This was to help prevent discrepancies in the intervention. During the post intervention phase of the study which took place between June 2004 until May 2005 the sample size consisted of 871 patients who were all nil per os (NPO) (Sona et al., 2009)
On June 1, 2004 the new routine oral care protocol was implemented (Sona et al., 2009). The intervention/protocol consisted of the nurse brushing the teeth of the patient for one to two minutes with a regular toothbrush, rinsing the mouth with water and suctioning it out, and then using 15 mL of .12% chlorahexidine to cleanse the mouth. The intervention was repeated every 12 hours by the registered nursing staff. Compliance of the protocol was estimated to be around 90% and the implementation was carried out for 12 months before results were analyzed(Sona et al., 2009).
For this study the level of significance was expressed using p-values. A p value of less than .05 was considered significant (Sona et al., 2009). For the data analysis, two statistical tests were used: The Mantel-Haesnel Chi Squared . After the analysis of data, it was determined that p=.04 showing that the routine oral care protocol did cause a significant reduction in the ventilator-associated pneumonia rates within the subjects studied. The pre-intervention rate for VAP was 5.2 infection per 1000 ventilator days while post-intervention rate for VAP showed 2.4 infections per 1000 ventilator days (Sona et al., 2009). Other statistics for the study showed the patient’s number of days the patient was on ventilator was decreased(Sona et al., 2009).
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From the statistical analysis within the study, the researchers derived certain findings and conclusions (Sona et al., 2009). One of the findings was that the post intervention group had trends toward shorter time on the ventilator, as well as length of hospital stay. The main finding within the study found that when the routine oral care protocol was being utilized, the rates of ventilator-associated pneumonia were significantly decreased. The researcher makes it a point to state that although the finding suggests that the implementation of the protocol reduces rate of VAP this cannot be proven (Sona et al., 2009).
This study is a nonrandomized controlled trial. The quality of this evidence was convincing and significant. It was a consistent study and it is considered to be of Level II quality. Certain extraneous variables that could have had an effect upon the outcome of the study, as identified by the student, could have been the condition the patient was in before the ICU admission, any pre-existing conditions that could alter health and increase the risk of infection, and the nurses attitude toward performing oral care.
Although the study was a strong and consistent one, it did have both strengths and weaknesses. There were no strengths identified by the researchers. However, the student did identify some strengths within this study. One of the first strengths was the education that was given to the nursing staff prior to the implementation of the protocol. This helped the study to be more valid by increasing the continuity of the care and way the nurses performed the protocol. The other strength of the study was the design being a quasi-experimental. This is because quasi-experimental studies usually can be generalized to the population that is being studied. Weaknesses that were addressed within the study by the researchers was that the researchers themselves did not evaluate the teeth brushing portion of the intervention to make sure that the nurses were being consistent in the way they did it, and if the nurses performed it for the correct amount of time (Sona et al., 2009). This resulted in the lack of control over nursing techniques. Another weakness of the study recognized by the researcher was the study did not take into account the change in the patient population over the duration of the study (Sona et al., 2009). Some weaknesses the student identified within this study was that the study was very susceptible to bias because no blinding or masking was used within this study. Everyone knew what was occurring and this could have had the researchers looking as if the intervention helped more than it actually did.
Within the study the researcher did not address if the study could be generalized. However, the writer of the paper believes that this study can be generalized. The intervention is a very simple one. Most cultures have no problems with utilizing oral care. Also, most hospitals have intensive care units and/or ventilator dependent patients which were the population within the study. This intervention within the study does not have a lot of risks. The only risks mentioned were possible tooth staining from the antimicrobial and poor taste (Sona et al., 2009). Also, this intervention is very feasible. To implement oral care there is no special training needed, although education should be provided. The oral care routine is a relatively quick intervention that takes no more than 5 minutes to implement, which would allow nurses with busy schedules to still be able to perform the intervention. Also, this intervention is very low cost compared to the cost of ventilator associated pneumonia cases. Therefore, the cost-benefit ratio would be a great benefit to health-care facilities.
This study suggests that oral care can be very effective in decreasing the incidence of ventilator-associated pneumonia rates. Although a very valid study, one study is not enough evidence to implement a new protocol into a nurse’s practice. One must look for more studies and literature to support the finding in order to attempt to implement it into practice. The next study that was appraised by the writer of this paper seems to support the findings that were found in this study.
Empirical Review 2
The next study examined by the writer of this paper was a research study conducted by Mori et al.,2005. The purpose of the study was to determine if oral care of mechanically ventilated patients contributed to the prevention and reduction of the incidence of ventilator associated pneumonia (Mori et al., 2005). The research design utilized for this study was a quantitative, experimental, quasi-experimental which used a non-equivalent before and after approach. Within the study the researcher did not state any theoretical framework to guide the study. The study was not randomized, and used a non-probability convenience sample method (Mori et al., 2005).
The research study took place on a medical/surgical intensive care unit in an urban university hospital which was not named by the researcher (Mori et al., 2005). The population of interest was ventilator dependent patients with tracheal intubation. Since subjects were chosen by convenience sampling, they were chosen as they became available on the unit. Inclusion criteria for subjects were that they must have been receiving mechanical ventilation and have tracheal intubation. Exclusion criteria for the study were patient’s whose conditions contraindicated oral care, patients with severe bleeding tendencies, or patients with iodine allergies. The sample for the oral care group was patients admitted to the intensive care unit between January 1997 and December 2002, and consisted of 1,248 patients. The sample for the non-oral care group, or the control, was patients admitted during January of 1995 until December of 1996; this sample size was 414 subjects (Mori et al., 2005)
For this study, the independent variable was the oral care being delivered (Mori et al., 2005). This variable was defined as cleansing of the oral cavity three times a day by nursing employees following the specified new protocol. The protocol was that the nurse would check the patient’s vital signs and then do oral suctioning, followed by positioning the patient’s head to the side to prevent asphyxiation and determine the condition of the oral mucosa. After this the nurse would clean the mouth with a 20-fold diluted solution of providone-iodine gargle (antimicrobial). Then the use of a standard toothbrush was used to brush the teeth; the patient’s mouth was rinsed with water. Directly following the brushing and rinsing, the providone-iodine was utilized again by swabbing the mouth and teeth. Finally, oral suctioning was done one final time. The dependent variable in the study was the incidence of ventilator associated pneumonia. This variable was defined as a hospital-acquired pneumonia that becomes present after 48 hours of the patient being mechanically ventilated. Ventilator associated pneumonia was suspected if patch infiltrates were present upon the patient’s chest x-ray and two of the following were present: a temperature of 100.4 degrees Fahrenheit, white blood cell count of 10,000 m3 or higher, or purulent respiratory secretions were observed. A definite diagnosis of ventilator associated pneumonia, which was used for evidence of the incidence in this study, was determined by trancheobronchial secretion cultures showing a result of 1+ or more. Other variables were duration of hospitalization defined as length of stay measured by the number of days and the causative agent of the pneumonia identified by bacterial cultures (Mori et al., 2005). Reliability and Validity of the cultures and radiography used to measure if ventilator associated pneumonia was present and causative agent were not addressed within the study by the researcher, so the validity is unknown.
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