Implementing Chlorhexidine Oral Care To Reduce Ventilator-Associated Pneumonia In Adult Patients With A Mechanical Ventilator Essay.

Evidence-Based Health Care for Decision Making

Describe about the Evidence Based Health Care for Decision Making.

Evidence based practice is an approach to problem solving that aids in clinical decision making by integrating best evidence from relevant studies with clinical expertise (Grove et al., 2014). This form of practice involves considering patient assessment data, evidence based data on specific illness, patient’s preference and values. Research in evidence-based practice has shown that implementation of this approach led to the high standard of care, positive patient outcome and decreased medical cost (DiCenso et al., 2014). Evidence based practice in Hong Kong and many other countries have been implemented several decades ago. However, there is very little impact on daily clinical practice. Proper accountability and clinical reasoning skill are essential to eliminate barrier in clinical practice and integrate clinical evidence in daily practice. It gives new insight into patient's problem management and leads to better health care decisions. The essay brings into highlight the problem of the development of ventilator-associated pneumonia in adult patients with a mechanical ventilator. It describes the challenges faced by the nurse in treating patients with ventilator-associated pneumonia and explains the strategy adopted for evidence based approach to the use of chlorhexidine for oral care in such patients.    

In my daily clinical practice, the problem that I have faced is that many patients with mechanical ventilation develop ventilator-associated pneumonia (VAP). The National Nosocomial Infection Surveillance System data has shown that VAP is the most common nosocomial infection after urinary tract infection in critically ill patients (Scannapieco & Binkley, 2012). Pathogenic oral microflora plays a significant role in the pathogenesis of VAP. Oropharyngeal colonization with pathogenic microorganism leads to the development of VAP in patients receiving mechanical ventilation for more than 48 hours (Shi et al., 2013). Patients with mechanical ventilation have developed VAP in my workplace because they mainly stay in general ward instead of ICU. In the general ward, nursing staffs are very busy attending to different patients, and they do not get enough time to provide mouth care to patients on ventilators. Even if nurses provide oral care, they use thymol gargle for it. Chlorhexidine is very rarely used by them. I would like to implement the use of chlorhexidine for oral care to reduce ventilator-associated pneumonia in adult patients with the mechanical ventilator. This is because many studies and trial exist regarding the appraisal of routine oral care with chlorhexidine for patients receiving mechanical ventilation. It has also been approved by the American Food and Drug Administration (FDA) as the most effective anti-microbial mouthwash (Zhang et al., 2014). However, there are many factors that influence the application of evidence into practice.

Challenges in Implementing Evidence-Based Practice

There are several challenges in implementing evidence based approach to the use of chlorhexidine for oral care to reduce ventilator associated pneumonia in adult patients with a mechanical ventilator. Firstly, the barrier exists in implementing evidence based practice because medical staffs are not sure about how to achieve it. Although evidence based practice is theoretically accepted but there are very few nurses who integrate research evidence with clinical practice. Therefore, the potential barriers that become a challenge in implementing evidence based practice are individual nurse characteristics, characteristics of the organization, nature of evidence based data and the health care environment (Polit & Beck, 2013). 

A nurse or other medical staff may lack the technical skill to locate research information. They lack the skill to appraise research literature related to specific clinical practice critically. They do not prefer to look into journal articles or current research to know about evidence based clinical procedure. They may face problem in interpreting academic research articles on clinical practice. Even if individual nurses use evidence based information, they do not get the support of health care organization. The culture of the workplace is such that nurses lack inquisitiveness and the eagerness to continue to learn in professional practice (Hamric et al., 2013). In the case of implementing the use of chlorhexidine for mechanically ventilated patients, the challenge is that different nurses may have different view about oral care. One cross-sectional study investigated the opinion of nurse on oral care of mechanically ventilated patients. It showed that majority of them did not consider oral care as a priority in caring for intensive care patients. Some of them also suggested that research does not provide the desired level of clinical direction. Many of them reported they lack the motivation to use research themselves and they will use chlorhexidine only when strictly instructed by the health care organization. (Mohsen Adib-Hajbaghery, 2013). The commonly reported barrier in evidenced based practice is resistance to change traditional practice among nurses. There is a lack of authority to change practice, and many are not interested in adopting evidence based practice. Another study on the investigation of barrier suggested that 50% find it difficult to cope with changes in the workplace (Williams et al., 2015). Hence, continued education and change in the attitude of the nurse are essential for successful implementation of evidence based practice.

Health care system might also act as a barrier because there is a lack of commitment in health care organization about the implementation of evidence based practice. The available information technology is not accurate, and goal for practice between nurse and administrators also differs. Many nurses omit oral care for mechanically ventilated patients because of time constraints, excessive workload, demanding workload, lack of adequate staff and attention towards ICU patients.  Lack of hospital protocols also impedes oral care for intubated patients (Jansson et al., 2013). The patient barrier may also exist in the implementation of the use of chlorhexidine in ICU patients. Studies on ICU patient have shown that routine oral care is least likely to be delivered in the first two days after admission when patients are most likely to develop an oral infection. This happens because there is false perception that oral care is not as important apart from other interventions. The health care team is busy stabilizing patient’s condition (Jordan et al., 2014). Another concern for nurses is that oral care increases intracranial pressure. However, studies have suggested that there is no adverse effect of oral care on the intracranial patient (Williams et al., 2015). Another challenge for nurses in implementing the use of chlorhexidine in mechanically ventilated patients is uncooperative patients does not wish to take oral care when they already suffer due to chronic ailments (Booker et al., 2013). Thus, remodeling of health care organization, as well as medical staff, is needed with more stress on evidence based practice. 

Strategies to Overcome Challenges

The potential strategies that can be taken to overcome challenges in implementing evidence base practices includes developing a culture of inquisitiveness and stressing on professional learning through the implementation of best evidence based practice. To implement the use of chlorhexidine for oral care of ICU patients, it is necessary that organization focus on infection prevention practices in ICU patient too. This is important because there is a wrong perception that oral care is not a priority in the care of mechanically ventilated patients. Using chlorhexidine should be a priority because a study by Klompas et al., (2014) has demonstrated that incidence of VAP is reduced by 50% after introducing change in oral care practices. Health care organization can take a step to implement evidence based guideline that explicitly explains professional responsibility of all clinical staff. They can impose strict rule regarding following evidence based practice by educating them about the importance of evidence-based practice. In around to change the organization culture around practice, it is necessary that the change is consistent with organization philosophy. Another prerequisite is adequate resources should be made available to healthcare professionals so that they easily adopt evidence based practice. 

For oral mouth care of critically ill patients in ICU, many nurse use lemon glycerin swabs or they rinse the mouth of critically ill patients. However, lemon glycerin swab decreases saliva production and promotes the growth of bacteria. The rinsing of mouth may also be harmful to immunologically suppressed patients in the ICU who may develop infection due to bacteria present in water. Thus skill training should be delivered to nurses so that they develop critical thinking skills and explore the knowledge gap in their clinical expertise by reviewing evidence based research articles. Health care organizations and management should look at the availability of evidence based practices related to the effectiveness of chlorhexidine and then take adequate steps to implement those practices in acute care setting. Change in accountability and attitude of both clinical staff and organization is needed to make specific practice routinely available through support with relevant literature (Scannapieco & Binkley, 2012).

Thus, from the essay on the implementation of evidence based practice in clinical care, it can be concluded that addressing the barrier in implementation is necessary to evaluate practice change. This essay focused more on the use of chlorhexidine on oral care for patient with ventilators, and identification of barrier in evidence based practice in clinical staff helped to determine the strategies needed to support practice based on best evidence. Various studies also exist regarding the significant reduction in VAP after use of Chlorhexidine and reducing the cost associated with the VAP. Thus, it can be adopted as a preventive strategy by staffs to reduce VAP in   ICU setting. Evidence based practice is a necessary competency for health professionals. The effort to implement evidence based practice is essential because many people have a negative attitude towards evidence based practice as they feel it is time-consuming and cannot be realistically implemented in the clinical practice setting.

Chlorhexidine Oral Care to Reduce Ventilator-Associated Pneumonia

Reference

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