Running head: THE PREVENTION OF VENTILATOR-ASSOCIATED PNEUMONIA
Oral Care practices and the Prevention of Ventilator-Associated Pneumonia
Kelly Price
Ferris State University
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VENTILATOR-ASSOCIATED PNEUMONIA
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Abstract
Mechanical ventilation is a life-saving measure utilized when the respiratory status of a critically
ill patient has become compromised. Ventilator-Associated Pneumonia (VAP) is a complication
of mechanical ventilation. This paper will discuss oral care practices and their aid in the
prevention of Ventilator-Associated Pneumonia. This is examined using three research studies
discussing the effects of oral care practices in the prevention of Ventilator-Associated
Pneumonia. Findings will provide information regarding oral care practices among nurses and
if such practices reduce the incidence of Ventilator Associated Pneumonia.
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Oral Care Practices and the Prevention of Ventilator-Associated Pneumonia
“Ventilator-associated pneumonia (VAP) is defined as pneumonia in patients receiving
mechanical ventilation that was neither present nor developing at the time of intubation” (Munro,
Grip, Jones, McLeish, & Sesser, 2009, p.429). According to Munro et al (2009), VAP is
associated with increased mortality, hospital length of stay, and health care costs. Among
ventilated patients prevalence rates of VAP are consistently in the 10% to 20% range and
mortality rates in the intensive care unit (ICU) are two to three times greater in patients with
VAP. Estimates of healthcare costs for individuals with VAP ranges from $11, 897 to $150,000.
Oral health can be compromised by critical illness, mechanical ventilation, and is influenced by
nursing care (Munro, Grip, Keswick, McKinney, Sesser, & Hummel, 2006).
Working in the critical care unit, I frequently care for ventilated patients. In our unit, we
incorporate the use of the VAP bundle to improve patient outcomes and to prevent VAP. This
bundle includes using Sage Oral Care Kits and Chlorhexidine, as well as elevating the head of
the bed thirty degrees or more, using oral gastric tubes over nasogastric tubes, deep vein
thrombosis (DVT) prophylaxis, peptic ulcer disease (PUD) prophylaxis and daily sedation
awakening (sedation vacation). In addition many of the critical care physicians use a subglottic
evacuation endotracheal tube when intubating patients.
According to Munro et al (2009), many risk factors for VAP have been identified. Major
ones include poor hand washing by staff, supine positioning of patients without backrest
elevation, previous antibiotic therapy, presence of a nasogastric tube, and gastric alkalization.
The interventions include elevating the head of the bed 30 degrees or more, peptic ulcer disease
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(PUD) prophylaxis, deep vein thrombosis (DVT) prophylaxis, daily sedation awakening, and the
assessment of readiness to extubate.
Another risk factor for VAP, according to Munro et al (2009) is the colonization of the
oropharynx by potential pathogens. These pathogens include Staphylococcus aureus,
Streptococcus pneumonia, or gram-negative rods. “The major route for acquiring endemic VAP
is oropharyngeal colonization by endogenous flora or by pathogens acquired exogenously from
the intensive care unit environment…” (Garcia et al, 2009, p. 524).
In this first research study, illustrated by Garcia et al (2009), patients at least 18 years old
were admitted between January 1, 2001, and December 31, 2004, to a 10-bed medical intensive
care unit (MICU). These patients were eligible for the study if they were intubated for more than
48 hours. Patients in the study were followed up for VAP occurrence until they were weaned off
mechanical ventilation in the MICU, for 48 hours after their transfer, or until they died. The
standards of care for all patients during the 48-month study period included changes in the
ventilator circuit every 7 days, replacement of the heat moisture exchange every 24 hours, a
closed suctioning system, head of bed 30 degrees of more, peptic ulcer disease prophylaxis, and
an active weaning protocol. Oral Chlorhexidine was not used in this study.
During the intervention phase between January 1, 2003 and December 31, 2004, a
comprehensive oral and dental care system was implemented (Garcia et al, 2009). This system
reduces secretions that accumulate in the oral cavity after the introduction of the endotracheal
tube and reduce plaque on the surface of the teeth. The protocol for the system included
oropharyngeal suctioning every 6 hours, oral cleaning of the tissue and gums every 4 hours or as
needed, and tooth brushing twice a day. The outcome measures were as follows: During the
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intervention, VAP rates decreased by 33.3%. Both duration of mechanical ventilation and length
of stay decreased after implementation of an oral care regimen.
Garcia et al (2009) found the 48-month study yielded 4 important findings:
(1) Risk and incidence of VAP are significantly reduced by the implementation of
a multifaceted protocol that includes daily oral assessment combined with
procedures and tools specifically designated for bacterial reduction in the oral
cavity, subglottic space, and on teeth, and conducted on a daily schedule; (2)
infection avoidance can be sustained for considerable periods; (3) despite the
establishment of other evidence-based interventions such as elevation of the
head of the bed and prophylaxis of stress ulcers, VAP rates of zero did not
occur until the new protocol was instituted; (4) a comprehensive oral-dental
program has profound effects of reducing the duration of mechanical
ventilation (from 7.2 days to 5.1 days) (p.529).
In this study, it would have been beneficial to see the results on random patients. The
types of patients admitted to the intensive care unit can vary and there can be extenuating
circumstances such as an emergent intubation. Overall though, the findings of this study support
that an oral care regiment reduces and prevents VAP.
The second research study shows insight in the prevention of VAP using Chlorhexidine
and tooth brushing. In this research study, Munro et al (2009) tested the effect of each individual
intervention using Chlorhexidine alone and tooth brushing alone. Chlorhexidine is a broad
spectrum antibacterial agent that is used in healthy populations to control dental plaque and
prevent gingivitis. Patients were older than 18 years in medical, surgical/trauma/ and
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neuroscience ICU’s. Patients receiving mechanical ventilation were enrolled within 24 hours of
intubation and those with preexisting pneumonia were excluded. “Patients were randomly
assigned to 1 to 4 treatments: a 0.12% solution of Chlorhexidine 5 ml by oral swab twice daily,
tooth brushing 3 times a day, combination care (tooth brushing 3 times a day and Chlorhexidine
every 12 hours), or control (usual care)” (Munro et al, 2009, p.430). According to Munro et al
(2009), every patient’s mouth was divided into four quadrants (right upper, right lower, left
upper, left lower), and each quadrant was brushed in a defined pattern. This pattern included
every quadrant and tooth brushed for 5 strokes on lingual, buccal, and biting services.
Chlorhexidine was applied in a defined pattern by using a green Toothette swab to evenly coat
each tooth, tongue and palette.
Munro et al (2009) found that Chlorhexidine oral swabbing was effective in reducing
early VAP. Tooth brushing did not reduce the incidence of VAP and the combination of
Chlorhexidine and tooth brushing did not provide any additional benefit. I found this study to be
beneficial in supporting the use of Chlorhexidine in an oral care regiment. At my place of
employment in the intensive care units, the facilitation of Chlorhexidine is incorporated with the
VAP Bundle.
The third research study includes research on oral comfort and hygiene measures. This
article focuses on the impact of nursing care and the prevention of VAP. At the time of this
article no comprehensive guidelines existed that defined the method and frequency of oral care.
Practices varied from site to site. “The disparity between what nurses think they do and what is
actually documented raises questions about the reliability and the consistency of practice”
(Cutler & Davis, 2006, p.390). Cutler and Davis (2006) found that healthcare settings with
specific protocols and procedures facilitated consistency and quality care through
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standardization. In this study, observations were made in 8 ICUs, with varying patient
diagnoses. None of the study sites had an oral cleansing protocol that defined frequency and the
tools for oral care on patients receiving mechanical ventilation. According to Cutler and Davis
(2006), nurses and respiratory personnel were educated and trained to follow a standardized oral
cleansing regimen for all patients receiving mechanical ventilation. During this period, 24-hour
oral kits were mounted on the wall near the patient’s bedside. Observation of nurses and
respiratory staff was conducted. The observers noted the frequency, tasks, and tools used for
oral care. Also, they recorded the types of oral care cleanser used. The results concluded that
with education to the staff, every aspect of oral care performance increased and VAP decreased
significantly among patients (Cutler & Davis, 2006).
I agree with this article in that education among staff helped patients have better
outcomes. In my own professional practice, the nurses and respiratory staff have been educated
on effective oral care. Every month, we have critical care classes that discuss evidence based
practice in preventing VAP and other respiratory issues. These classes stress education in
prevention and effective nursing care to provide better outcomes for patients. Also, the critical
care units have an outcomes specialist who provides us with statistics and keeps the nurses up to
date on their progress.
After reviewing the three research articles, I found that they support the ideas of the
nursing theorist Betty Neuman. Oral care practices and their role in the prevention of VAP
reflect her model of prevention as the primary nursing intervention (“Nursing Theories”, 2010).
Her vision of prevention includes health promotion and maintenance of wellness. Her nursing
theory focuses on a “comprehensive flexible holistic and system based perspective for nursing”
(“Nursing Theories”, 2010). Neuman theorized that “prevention focuses on keeping stressors
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and the stress response from having a detrimental effect on the body” (“Nursing Theories”,
2010). In addition, Neuman’ theory consists of concentric lines of defense, protecting
individuals from negative external and internal variables. When a patient is mechanically
ventilated, their body is put through multiple stressors and oral care interventions are imperative
for the prevention of VAP. Using Neuman’s model system along with nursing interventions can
help eliminate the episodic events of VAP, promoting better patient outcomes.
As a critical care nurse, there are ways that I am able to implement VAP prevention. By
being a preceptor in my unit, I can share with new graduates the VAP bundle and the
interventions used to prevent VAP. Also by attending monthly respiratory classes, this will
impact my practice by keeping me up to date on the current guidelines in VAP prevention. In
the future, I will focus on educating staff about VAP prevention and future practice and continue
my research into effective oral care interventions to ensure better patient outcomes.
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References
Cutler, C. N., & Davis, N. (2005). Improving oral care in patients receiving mechanical
ventilation. American Journal of Critical Care, 14(5), 389-394.
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), 523-531.
Munro, C.L., Grap, M.J., Elswick, R.K., McKinney, J., Sessler, C. N., & Hummell R. S. (2006).
Oral health Status and development of ventilator-associated pneumonia: A descriptive
study. American Journal of Critical Care, 15(6), 453-460.
Munro, C. L., Grap, M. J., Jones, D. J., McClish, D. K., & Sessler, C. N. (2009).
Chlorhexidine, tooth brushing, and preventing ventilator-associated pneumonia
in critically ill adults. American Journal of Critical Care, 18(6), 428-437.
doi: 10.4037/ajcc2009792.
Nursing theories a companion to nursing theories and models. 2010, January 16. Retrieved
from http://www.currentnursing.com/nursing_theory/nursing_theorists.html.
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Appendix A
Checklist for submitting papers
CHECK
DATE, TIME,
& INITIAL
PROOFREAD FOR: APA ISSUES
1. Page Numbers: Did you number your pages using the automatic functions of your Word
program? [p. 230 and example on p. 40)]
2. Running head: Does the Running head: have a small “h”? Is it on every page? Is it less
than 50 spaces total? Is the title of the Running head in all caps? Is it 1/2” from the top of
your title page? (Should be a few words from the title of your paper). [p. 229 and example
on p. 40]
3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and
it is centered at the top of the page? Is it a single paragraph? Is the paragraph flush with
the margin without an indentation? Is your abstract a summary of your entire paper? Is it
written in the past tense? Remember it is not an introduction to your paper. Someone
should be able to read the abstract and know what to find in your paper. [p. 25 and
example on p. 41]
4. Introduction: Did you repeat the title of your paper on your first page of content? Do
not use ‘Introduction’ as a heading following the title. Do not bold your title. The first
paragraph clearly implies the introduction and no heading is needed. [p. 27 and example
on p. 42]
5. Margins: Did you leave 1” on all sides? [p. 229]
6. Double-spacing: Did you double-space throughout? No triple or extra spaces between
sections or paragraphs except in special circumstances. This includes the reference page.
[p. 229 and example on p. 40-59]
7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin
uneven, or ragged? [p. 229]
8. Paragraphs and Indentation: Did you indent the first line of every paragraph? See P.
229 for exceptions.
9. Spacing After Punctuation Marks: Did you space once at the end of separate parts of a
reference and initials in a person’s name? Do not space after periods in abbreviations.
Space twice after punctuation marks at the end of a sentence. [p. 87-88]
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10. Typeface: Did you use Times Roman 12-point font throughout, even in your header?
[p. 228]
9. Abbreviation: Did you explain each abbreviation the first time you used it? [p. 106-111]
11. Plagiarism: Cite all sources! If you say something that is not your original idea, it must
be cited. DO NOT COPY THE EXAMPLE AND USE IT AS YOUR OWN! You may be citing many
times…this is what you are supposed to be doing! Is there a citation for every paragraph?
[p. 170]
12. Direct Quote: A direct quote is exact words taken from another. An example with
citation would look like this:
“The variables that impact the etiology and the human response to various disease states
will be explored” (Bell-Scriber, 2007, p.1).
Please note where the quotation marks are placed, where the final period is placed, no
first name of author, and inclusion of page number, etc. Do all direct quotes look like this,
except for block quotes? [p. 170-172]
13. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are
40 words or longer? Did you place the period after the text rather than after the citation?
[p. 170-172]
14. Paraphrase: A paraphrase citation would look like this:
Patients respond to illnesses in various ways depending on a number of factors that will be
explored (Bell-Scriber, 2007). Do all paraphrased citations look like this? [p. 171 and
multiple examples in text on p. 40-59]
15. Headings: Did you check your headings for proper levels and format? [p. 62-63].
16. General Guidelines for References: Do not bold the word References!
A. Did you start the References on a new page? [p. 37]
B. Did you cut and paste references on your reference page? If so, check to make
sure they are in correct APA format. Often they are not and must be adapted.
Make sure all fonts are the same.
C. Is your reference list double spaced with hanging indents? [p. 37]
PROOFREAD FOR GRAMMAR, SPELLING, PUNCTUATION, & STRUCTURE
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13. Did you follow the assignment rubric? Did you make headings that address each major
section? (Required to point out where you addressed each section.)
14. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing
unless punctuation is present. If you become breathless or it doesn’t make sense, you need
to rephrase or break the sentence into 2 or more smaller sentences. Did you do this?
15. Wordiness: check for the words “that”, and “the”. Don’t use the terms ‘I feel’ or ‘I
think’. If not necessary, did you omit?
16. Conversational tone: Don’t write as if you are talking to someone in a casual way. For
example, “Well so I couldn’t believe nurses did such things!” or “I was in total shock over
that.” Did you stay in a formal/professional tone?
17. Avoid contractions. i.e. don’t, can’t, won’t, etc. Did you spell these out?
18. Did you check to make sure there are no hyphens and broken words in the right
margin?
19. Do not use “etc.” or "i.e." in formal writing unless in parenthesis. Did you check for
improper use of etc. & i.e.?
20. Stay in subject agreement. When referring to 1 nurse, don’t refer to the nurse as
“they” or “them”. Also, in referring to a human, don’t refer to the person as “that”, but
rather “who”. For example: The nurse that gave the injection….” Should be “The nurse who
gave the injection…” Did you check for subject agreement? Likewise, don’t refer to “us”,
“we”, “our”, within the paper…this is not about you and me. Be clear in identifying. For
example don’t say “Our profession uses empirical data to support ….” . Instead say “The
nursing profession uses empirical data…..
21. Did you check your sentences to make sure you did not end them with a preposition?
For example, “I witnessed activities that I was not happy with.” Instead, “I witnessed
activities with which I was not happy.”
22. Did you run a Spellcheck? Did you proofread in addition to running the Spellcheck?
23. Did you have other people read your paper? Did they find any areas confusing?
24. Did you include a summary or conclusion heading and section to wrap up your paper?
25. Do not use “we” “us” “our” “you” “I” etc. in a formal paper! Did you remove these
words? Only use these if you are the subject of your paper.
26. Does your paper have sentence fragments? Do you have complete sentences?
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27. Did you check apostrophes for correct possessive use. Don’t use apostrophes unless it
is showing possession and then be sure it is in the correct location. The exception is with
the word it. It’s = it is. Its is possessive.
28. Did you use proper punctuation, particularly commas? If you are unsure of when to
use them, please contact the writing center.
Signing below indicates you have proofread your paper for the errors in the checklist:
Kelly Price____________________________________________DATE: Feb. 10, 2010_______________
A peer needs to proofread your paper checking for errors in the listed areas and sign below:
Lori VanZoern_________________________________________DATE: Feb. 9, 2010_______________
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Evidence Based Practice Paper Grading Rubric
Name: __Kelly Price_________________________________
DESCRIPTION AND ANALYSIS OF PRACTICE ISSUE
POINTS
POSSIBLE
POINTS
AWARDED
Clear Introductory Description of Practice Concern/Interest:
Describes reason for interest or concern and description of issue.
Practice Environment:
10
10
5
5
Causal Factors: Personal Perspective and Description/Analysis of
Possible Contributing or Causative Factors for the Concern
10
10
Defined Area of Research Search: Narrows down and defines a
specific area for research review and provides a clear statement
of same.
5
5
Provides clear description of practice area.
RESEARCH REVIEW
Research Findings: Shares the findings of a minimum of 3
original research studies from professional journals on the
selected topic. Briefly describes the research approaches and
findings of each.
20
20
Critique of the Research: Attempts to point out any research
limitations/credibility of the studies.
5
5
Implications For Practice: Identifies potential practice
implications of research. This goes beyond implications included
in the study itself, to include perceptions of implications for
personal practice.
5
5
Critical Reflection: Identifies a nursing theory that this practice
concern/research findings is an appropriate fit. Includes
reflections on the significance/implications of integrating
research into practice. Great job with theory
10
10
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STANDARDS & APA CRITERIA
APA: Attaches and adheres APA checklist and APA manual
guidelines. Length appropriate (5-6 pages of typed content
excluding the reference page, abstract, and title page).
15
15
15
15
100
100
Did someone proof read your paper?
Writing: Development of a clear, logical, well-supported paper.
Overall presentation: Grammar, punctuation, clean and legible.
TOTAL POINTS
Hi Kelly: This is one of the very best Evidenced Based Practice Papers I have ever received. You
did a beautiful job and followed the rubric perfectly.
This paper was well written and a joy to read. Thank you for the time and effort.
You are an excellent writer.
Dr. J.