Prevention of Ventilator-Associated Pneumonia

Jennifer CrawfordAshley Grey

Krista KeuchelStephanie Yates

OU – Tulsa College of Nursing

PICO Question

• Population of Interest

Mechanically-ventilated adult ICU patients

• Intervention of Interest

Oral Care - tooth brushing and use of Toothettes

• Comparison of Interest

Use of antiseptic agent - Chlorhexidine

• Outcome of Interest

Decrease incidence of VAP

PICO Question

What is the most effective intervention to decrease ventilator-associated pneumonia (VAP) in adult ICU patients: performing oral care (use of tooth

brushes or Toothettes) versus use of an antiseptic agent (chlorhexidine)?

Ventilator-Associated Pneumonia (VAP)

• Defined: hospital-acquired pneumonia occurring within 48 h after initiation of mechanical ventilation with trachael intubation

• Diagnosis: Presence of a new, persistent, or progressive infiltrate on a chest X-ray

Identification of the Problem

• VAP Statistics – leading cause of death due to nosocomial

infection in ICUs.– Mechanically-ventilated patients: 9% to 28%– Mortality rate: 40% - 80%.– Hospital length of stay: 4-9 days.– Hospital cost: $29,000 - $40,000 per patient.

Current Guidelines

• Oral care with antiseptic agents can decrease the incidence of VAP.

– No optimal concentration or formulation is specified.

• Oral hygiene (removal of plaque from teeth and gums) is recommended every 12 hours.

• Oral care (removal of secretions from oropharynx and moisturizing the mouth and lips) is recommended every 4 hours.

Review of Literature

Review of Literature

• Summa Health System in Akron, OH

– Implementation of Q8H tooth brushing regimen

– VAP rate dropped to zero

– Control group dropped after 6 months due to the success of the intervention group

– Conclusion: Tooth brushing was found to be the most effective practice of removing dental plaque.

Fields (2008): Randomized controlled trial

Review of Literature

• Medical-surgical ICU in a university hospital

– Oral care protocol 3 times daily or once every nursing shift

– Mechanical cleaning including tooth brushing

– Conclusion: decreased the incidence and risk of VAP in ICU patients and delayed the onset of VAP

Mori et al. (2006): Nonrandomized trial

Review of Literature

• 5 Chicago area acute care hospitals

– Oral care cleansing protocol

– Oral care every 2 hours

– Conclusion: Increase frequency and comprehensiveness of oral care provided

Cutler & Davis (2005): Observational study

Review of Literature

• University hospital in Bangkok, Thailand

– Oral decontamination with 2% chlorhexidine solution 4 times daily

– Intervention was effective at preventing pneumonia in patients receiving mechanical ventilation

– Conclusion: Cost effective strategy for prevention of VAP

Tantipong et al. (2008): Randomized controlled trial with meta-analysis

Review of Literature

• 2 university hospitals and 3 general hospitals

– Chlorhexidine applied Q6H to buccal cavity

– Reduced and delayed the development of VAP

– Conclusion: highly attractive prevention of VAP

Koeman et al. (2006): Randomized controlled trail

Summary of FindingsOral Care

• Oral care

• Potentially pathogenic bacteria

• Dental plaque

• Toothettes

• Standardized oral care protocol

Summary of FindingsChlorhexidine

• Broad spectrum

• Oral decontamination with 2% chlorhexidine solution

• Modulation of oropharyngeal colonization

• Cost-effective strategy

Summary of Findings

“The disparity between what nurses think they do and what is actually documented raises

questions about the reliability of documentation and the consistency of practice.”

(Cutler & Davis, 2005)

What Are The PROS To Solving This Problem?

• Decreased:

– Incidence of VAP

– Risk of VAP

– Mortality rate

– Length of ICU stay

– Cost for patient

– Cost for hospital

What Are The CONS To Solving This Problem?

• Increased:

– Cost of oral care supplies

– Cost associated with implementation of new oral care protocol

Recommended ProtocolLiterature Recommendations

• Brushing: Every 3-4 Hours and PRN

– Tooth brushing for 1-2 minutes

– Gentle brushing of teeth, tongue, and hard palate

• Chlorhexidine

– Chemical decontamination with chlorhexidine at least twice daily

Recommended Interventions

• Establishment of new oral care protocol

• More comprehensive documentation

• More comprehensive oral care assessment

Recommended Protocol

• Tooth brushing: 4 times daily for a minimum of 1 minute

• Follow with use of chlorhexidine.

• To ensure oral care compliance:

– Available resources

– Supply kits and instructions

• Key Players: Nurses

Suggestions for Further Study

• Determine ideal frequency of oral care

• Effect of chlorhexidine on patient outcomes

• Frequency of use of chlorhexidine

• Determine optimal concentration and formulation of chlorhexidine

• Nurse education to improve quality and frequency of oral care

References

Cutler, C., & Davis, N. (2005). Improving oral care in patients receiving mechanical ventilation. American Journal of Critical Care, 14(5), 389-395.

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

Koeman, M., Van der Ven, A., Hak, E., Joore, H., Kaasjager, K., De Smet, A., et al. (2006) Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Critical Care Medicine, 173, 1348-1355.

References

Mori, H., Hirasawa, H., Oda, S., Hidetoshi, S., Matsuda, K., & Nakamura, M (2006). Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med, 32, 230-236.

Tantipong, H.Morckchareonpong, C., Jaiyindee, S., & Thamlikitkul, V. (2008). Randomized controlledtrial and meta-analysis of oral decontamination with 2 % chlorhexidine solution for theprevention of ventilator-associated pneumonia. Infection Control and Hospital Epidemiology , 29(2), 131-136.