The Effects of Mouth Care on Ventilator Associated Pneumonia in Medical, Surgical, and Neurological ICU Patients Jimmy Dierkes R.N. Therese Fringer R.N. Cindy Grindstaff R.N. Tara Piovarchy R.N.

Clinical Significance of VAP Ventilator Associated Pneumonia (VAP) is a pneumonia that develops 48 hours after intubation or mechanical ventilation VAP is a serious nosocomial infection that accounts for 15% of all nosocomial infections Approximately 9% of all mechanically ventilated patients develop VAP (Sona, 2009) VAP increased length of stay up to 13 days (Sona, 2009) VAP increased health care costs $10,000 to $40,000 per infection (Sona, 2009)

Purpose Statement The purpose is to examine evidence to see how mouth care with chlorhexidine compares with mechanical tooth brushing on reducing VAP in ICU adult patients.

Integrated Review of Literature Munro’s study Chlorhexidine swabbing was effective in reducing early VAP in patients in medical, surgical/trauma, and neuroscience ICUs who did not have pneumonia at baseline Toothbrushing did not reduce the incidence of VAP, and combining toothbrushing and chlorhexidine did not provide additional benefit over the use of chlorhexidine alone

Integrated Review of Literature Garcia’s study Risk and incidence of VAP are significantly reduced by implementation of a multifaceted protocol that includes daily oral assessment combined with procedures and tools specifically designated for bacterial reduction in the oral cavity A comprehensive oral-dental care program has profound effects on reducing the duration of mechanical ventilation

Integrated Review of Literature Cason’s study According to nurses’ self-reports, evidence-based and the best practices as recommended in the CDC guidelines for the prevention of VAP are not consistently and uniformly implemented of nurses reported not always washing their hand between patients, and 23% reported not using gloves when providing oral care The results of this study suggest that best practices for the prevention of VAP are not consistently or uniformly implemented

Integrated Review of Literature Fields’ study Several studies have shown that toothbrushing and oral care, along with concurrent nursing interventions such as increasing the patient’s mobility, elevating the patient’s head, consistently washing one’s hands, and performing universal gloving Dental plaque can be removed only by toothbrushing, so this study demonstrated that toothbrushing is a more effective way to prevent VAP because it removes the plaque that harbors bacteria

Integrated Review of Literature Sona’s study Mechanical toothbrushing with Monophosphate and application of chlorhexidine every twelve hours The implementation of a simple, low cost oral care protocol in the surgical intensive care led to a significantly decreased risk of acquiring VAP

Ventilator bundle protocol: head of bed elevated to thirty degrees, a daily sedation vacation, peptic ulcer medication and deep vein thrombosis prophylaxis Oral care is required every two hours with use of an oral kit that contains hydrogen-peroxide rinse, mouth moisturizer and mechanical tooth brushing with monophosphate is performed every eight hours The study that Fields conducted is comparable to that of SWGH’s protocol of mouth care

VAP bundle protocol: head of bed elevated to thirty degrees, stress ulcer prevention, deep vein thrombosis prophylaxis, sedation vacation, and daily spontaneous breathing trials Mouth care every two hours which includes every twelve hour tooth brushing along with chlorhexidine rinse twice daily Munro’s study supports this procedure with the findings of reduction of VAP in patients without pneumonia at baseline with the use of chlorhexidine twice daily

Review of Literature in Clinical Practice Southwest General Health Center Based on IROL, this health center’s protocol for reduction of VAP is supported According to up-to-date literature this protocol without the use of chlorhexidine is outdated But, the protocol is cost effective and statistically supported with quality mouth care every two hours with monophosphate in the reduction VAP

Review of Literature in Clinical Practice The Cleveland Clinic The Cleveland Clinic’s protocol is supported by the ROL and is current with the use of chlorhexidine oral swabs twice daily and following the ventilator bundle According to Munro’s study, the incidence of VAP was significantly reduced with the use of chlorhexidine, which supports the Cleveland Clinic’s protocol

Recommendations Southwest General Health Center The Cleveland Clinic The protocol in place would be more appropriate with the addition of mouth care with Chlorhexidine twice daily The Cleveland Clinic The protocol instituted is current and no recommendations are to be made

Future Research Question The quality of care performed should be addressed in the incidence of VAP Future research in the education of the practitioners and their clinical capabilities and the effects of quality care in the reduction of VAP

IROL SUMMARY TABLE Author Title Nursing Journal Year Background of Clinical Problem Clinical Problem Question Clinical Practice Setting and Patient Population Findings Based on Evidence Recommendations for Practice Based on Evidence Implications for Practice Based on Evidence Cindy L. Munro, RN, PhD, ANP, Mary Jo Grap, RN, PhD, ACNP, Deborah J. Jones, RN, PhD, Donna K. McClish, PhD, Curtis N. Sessler, MD Chlorhexidine, Tooth brushing, and Preventing Ventilator Associated Pneumonia in Critically Ill Adults American Journal of Nursing, 2009 Ventilator associated pneumonia is associated with morbidity and mortality What is the relative effectiveness of mouth care with chlorhexidine in comparison to mechanical tooth brushing in the prevention of VAP? 249 Critically ill mechanically ventilated patients in three ICUs Chlorhexidine, but not tooth brushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline. Both chlorhexidine groups had reduced daily risk of ventilator associated pneumonia compared with control patients Chlorhexidine oral swab twice daily to reduce ventilator associated pneumonia in critical care patients Introduce the importance of mouth care with chlorhexidine swabs at least twice daily to reduce the occurrence of ventilator associated pneumonia in critical care adult patients in the setting’s VAP bundles

Lorraine B. Fields American Association of Neuroscience 2008 Ventilator associated pneumonia is a preventable secondary consequence of intubation and mechanical ventilation and is the most common nosocomial infection in mechanically ventilated patients What is the relative effectiveness of mouth care with mechanical tooth brushing in the prevention of VAP A RCT was initiated on a 24 bed ICU with stroke patients. The desired sample size was 200 ventilator dependent patients or 2000 ventilator days. Per 1000 ventilator days the percent of patients acquiring VAP dropped form 8.2% in 2003 to 0.63% in 2008 Mouth care with ventilated Patientes using mechanical tooth brushing every 8 hours will reduce the incidence of VAP Mouth care every 8 hours with mechanical tooth brushing in VAP bundles shows evidence of reduction in intubated patients

Carolyn L. Carson, RN, PhD. Tracy Tyner, RN, MSN, CCRN Carolyn L. Carson, RN, PhD. Tracy Tyner, RN, MSN, CCRN. Sue Saunders, RN, MSN, CCRN. Lisa Broome, RN, MSN. Nurses’ Implementation of Guidelines For Ventilator-Associated Pneumonia from the Centers For Disease Control and Prevention American Journal Of Critical Care, 2007 Reducing the risk of ventilator associated pneumonia Chlorhexidine mouth care reduces the risk of VAP, but this is not consistently practiced as a common protocol nationwide Critical care nurses who provide care for adult patients receiving mechanical ventilation and who work in the united States in an acute care setting. CDC reported 63% of patients admitted to the ICU have colonization with a pathogen associated with VAP. CDC 2003 guidelines recommending implementation of a comprehensive oral hygiene program to prevent oropharyngeal colonization. Pathogens responsible for VAP in orally intubated patients are colonized in dental plaque and oral mucosa. Implementation of best practices for preventing VAP is inadequate and inconsistent. Teachings on proper mouth care and protocols must be set consistently to reduce the incidence of VAP nationwide

Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48 Month Study Robert Garcia, BS, MMT, CIC Linda Jendresky, MPH, CIC, CPHQ, Larry Colbert, MS, CIC, Althea Bailey, RN, MS, Mohammed Zaman, MD, and MujbarMajumder, MD American Journal of Critical Care, 2009 VAP is the most commonly reported health care acquired infection in patients receiving mechanical ventilation What is the effect of implementing a comprehensive oral and dental care system and protocol on the rate of ventilator associated pneumonia? Patients older than 18 years of age receiving mechanical ventilation for more than 48 hours in a medical intensive care unit at a university-affiliated medical center were studied in 2 consecutive 24 month periods Findings suggest that use of advanced tools, a comprehensive oral care protocol, and staff compliance with the protocol can significantly reduce rates of ventilator associated pneumonia Recommend treating patients under a protocol whereby the oral cavity was assessed, deep suctioning was done every six hours, oral tissue cleansing was done every four hours or as needed, and tooth brushing was done twice daily Introduce the evidence of effective mouth care into settings to reduce the occurrence of VAP

Carrie S. Sona, MSN, Jeanne E. Zack, PhD, Marilyn E. Schallom, MSN, Maryellen McSweeney, PhD, Kathleen McMullen, John E. Mazuski, MD, PhD, and Douglas J. E. Schuerer, MD “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” Journal of Intensive Care Medicine January/February 2009 Preventing and reducing the risk of ventilator associated pneumonia which is the leading cause of morbidity and mortality in intensive care units. Implementation of an oral care protocol to prevent bacterial growth by brushing teeth with toothpaste then rinsing with water, following with an application of chlorhexidine to prevent or reduce ventilator associated pneumonia. A 24 bed surgical/trauma/ burn intensive care unit at an urban university hospital that were mechanically ventilated. Ventilator days were decreased in post intervention group, and there was a significantly decreased risk of ventilator associated pneumonia rates in the post intervention groups. A protocol implementation involving mechanical cleansing of the teeth or gums to remove plaque. Then an application of the oral antimicrobial chlorhexidine immediately after, performed twice daily while patient is mechanically ventilated. Education of nursing staff to stress the importance of compliance of the protocol. Ensure that staffing is adequate to implement the intervention.

References Cason, C., Tyner, T., Saunders, S., & Broome, L. (2007). Nurses’ implementation of Guidelines for ventilator- associated pneumonia from the Centers for Disease Control and Prevention. American Journal of Critical Care, 16 (1), 28-38. Retrieved from CINAHL Plus with Full Text database. Fields, L. (2008). Oral Care Intervention to Reduce Incidence of Ventilator-Associated Pneumonia in the Neurological Intensive Care Unit. American Association of Neuroscience Nurses. Retrieved from CINAHL with Full Text database. Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing ventilator- associated pneumonia through advanced oral-dental care: a 48 month study. American Journal of Critical Care, 18 (6), 523-532. Retrieved from CINAHL Plus with Full Text database.

References Munro, C., Gap, M., Jones, D., McClish, D., & Sessler, C. (2009). Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care, 18, (5), 428-438. Retrieved from CINAHL Plus with Full Text database. Sona, C., Zack, J., Schallom, M.,McSweeney, M.,McMulen, K.,Thomas, J., et al. (2009). The impact of a simple low cost oral care protocol on ventilator associated pneumoniarates in a surgical intensive care unit. Journal of Intensive Care Medicine, 24 (1), 54-62. Retrieved from CINAHL Plus with Full Text database.