VAP - Amber Rhodes, RN



INTRODUCTION

Inadequate oral care in intensive care units (ICU) can lead to ventilator-associated pneumonia (VAP), which is a possible fatal complication that affects an estimated 9% of mechanically ventilated patients (Sona et. al, 2009). The Center for Disease Control and Prevention (CDC), a leading national organization in infection prevention, considers pneumonia to be ventilator-associated when a patient is diagnosed with pneumonia within 48-hours of being intubated and ventilated (CDC, 2011). The CDC reported in 2002 that the average rate of VAP per one-thousand ventilator days was 14.7 in intensive care units (CDC, 2003). The extra days in an intensive care unit are extremely costly for hospitals. The CDC has issued guidelines for prevention of VAP, including oral care treatment standards for ventilated patients since it is national problem (Pyrek, 2010). It is estimated that additional days in the hospital due to mechanical ventilation problems can cost around $10,000 to $40,000 per patient (Sona et al., 2009).

Patients on ventilators are at higher risk for VAP because the bacteria travels to the respiratory tract via endotracheal tube (Munro & Grap, 2004). Microorganisms are a part of the oral cavity’s normal flora, and dental plaque creates a perfect environment for microbial growth. Adults over the over the age of 65 years-old account for 52.2% of ventilated patients in additional to co-morbid conditions that reduce the rate of survival (Wunsch et al., 2010). Older adults have a decreased alveolar surface area (compared to younger adults) which reduces lung capacity, in addition to respiratory conditions such as chronic obstructive pulmonary disease; therefore this population does not have the same capability of fighting off infection (Mauk, 2010). Complications of VAP can lead to morbidity and mortality rates of 12% to 50% (Sona et al., 2009).

The incidence of VAP can be attributed to poor oral hygiene in intensive care units (Munro & Grap, 2004). Poor oral hygiene allows various organisms to flourish in one’s oral cavity, which can cause infections to major organs in the body. Poor oral hygiene can be defined as the build-up of dental plaque and microorganisms caused by the lack of tooth-brushing or rinsing of the mouth with antimicrobial products (Munro & Grap, 2004). The major population affected by poor oral hygiene is critically ill patients in intensive care units, primarily patients on ventilators. There is also great concern for patients who already have prior dental problems such as those who are poor, and persons of ethnic and racial minorities (Munro & Grap, 2004). This predisposes those members to poor outcomes when medical interventions are necessary such as endotracheal intubation.

Patients on ventilators are unable to provide oral care for themselves; therefore, nurses have a major role in caring for patients who require frequent oral care. The term “frequent” is vague and does not define how often oral care needs to be provided. Oral care can improve patient outcomes in intensive care units and decrease the spread of unwanted organisms to various parts of the body. The Joint Commission guidelines are based off of The Society for Healthcare Epidemiology of America's (SHEA) and the Infectious Diseases Society of America (IDSA) recommendations which state that oral care should be performed regularly, however there is no determination on how frequent oral care should be performed (Coffin et al., 2008). The CDC guidelines do not mention how often oral care should be provided as well.

There is evidence indicating that toothbrushes are more effective in removing plaque on teeth; however nurses still choose to use foam swabs (Ross & Crumpler, 2006). This reason may be due to convenience, inadequate time to complete the task, lack of education on the importance of preventing hospital-acquired infections, or fear of performing the task. ICU nurses were surveyed and they provided oral care using a tooth brush 38.9% of the time with intubated patients (Munro & Grap, 2004). This percentage is rather low, especially if hospitals have protocols in place regarding oral care in intubated patients. Surveys and studies show that nurses have a fear of brushing critically ill patient’s teeth due to the possibility of dislodging endotracheal tubes (Binkley et al., 2004; Grap et al., 2003; Cutler & Davis, 2005). It is important to address the nurse’s fears and discover how oral care standards can be improved, as well as providing education on how to perform oral care correctly.

The CDC (CDC, 2011) reported that in 2006-2007, there were 5,400 documented cases of VAP just in facilities that report to the National Healthcare Safety Network (NHSN). The CDC monitors these cases and sets recommendations that focus on decreasing the prevalence of VAP. The first CDC guidelines for hospital-acquired pneumonia were created in 1981. The most recent guidelines were issued in 2003 due to an increase in demand for guidelines. This is presumed to be due to health care changes that shifted care from acute settings to outpatient health-care settings (CDC, 2003). Many practices in the guidelines do not have sufficient evidence; therefore no recommendation could be made. Recommendations are made based on evidence, theory, appropriateness, and the possible economic influence (CDC, 2003). Hand hygiene and removal of tubing devices as soon as clinically indicated were strongly recommended. A comprehensive oral hygiene program was suggested for implementation. Since there are guidelines in place for reducing the incidence of VAP, further research will help determine why the occurrence of this acquired infection still exists.

The focus of this paper will be to discuss the effects of poor oral hygiene amongst critically ill patients, investigate what the frequency of adequate oral care should be to obtain optimal results, and provide evidence that the use of a tooth brush is more effective than the use of oral swabs (Sona et al., 2009). Lastly, I will discuss the fears and barriers that nurses face in providing oral care to intubated patients, and what role organizations can take in educating the staff. There are a variety of other reasons that may contribute to causes of VAP in critically ill patients; however, for the purpose of this paper I will primarily discuss the reasons listed above.

REVIEW OF LITERATURE

There is a variety of research providing evidence that VAP can be reduced or even diminished by improving the standards of oral care and educational tools in ICUs. The importance of reducing the prevalence of VAP is discussed because of consequences leading to mortality and high costs. A review of literature was conducted to examine approaches to reduce infection in ventilated-patients, and some of these procedures suggested are simple and low-cost.

ROL: Low-cost oral care protocol

An observational study by Sona et al. (2009) during a 12-month period from June 1, 2004 through May 31, 2005 examined the post-intervention group that consisted of the time period when the oral care protocol was implemented. A pre-intervention group, also studied over a 12-month period from June 1, 2003 to May 31, 2004, assessed the number of infections based on ventilator days.

Their purpose was to determine the effects of a small-cost oral care protocol on VAP amongst mechanically ventilated patients in a surgical intensive care unit (SICU). The population of interest was solely patients who were mechanically-ventilated to serve as a comparison once an oral protocol was implemented. The study was performed at Barnes-Jewish Hospital, a university-associated teaching hospital. All subjects that were admitted to the hospital’s SICU and needed to be mechanically-ventilated were adequate for the study. The patients received a packet of information upon admission, and informed consent was waived per approval by the Washington University School of Medicine Human Studies Committee in St. Louis, Missouri.

The sample size of the pre-intervention group comprised of 777 mechanically-ventilated patients, and the post-intervention group contained a sample size of 871 mechanically-ventilated patients. The inclusion group was clearly identified in this study as subjects admitted to the SICU that were mechanically-ventilated. Exclusion criteria were allergies to chlorhexidine gluconate (CHX) and/or ulcerations of the mouth. Only 2 subjects were excluded due to oral trauma.

Throughout the oral protocol study, subjects were followed by an infection control team in which VAP was tracked using the National Nosocomial Infections Surveillance System (Sona et. al, 2009). Training was provided to the registered nursing staff and physicians on the unit. Two clinical nurse specialists (CNSs) were trained to educate staff members and monitor the study. The protocol required nurses to cleanse the teeth every 12 hours for 1 to 2 minutes with a tooth-brush and paste containing sodium monoflurophosphate 0.7%. After tooth-brushing, the nurses would rinse the oral cavity with tap water (using an irrigating syringe), and then suction the patients mouth. The last step that was implemented was the application of 15mL of CHX to the all areas of the mouth using a foam sponge.

The statistical analysis of this study was significant with a P=.04. The researchers deemed a P value of ................
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