The Role Of Oral Care In Reducing Ventilator Associated Pneumonia (VAP) - Evidence Based Practice

Discuss about the Role of Evidenced Based Oral Care in Reducing Ventilator Associated Pneumonia

Importance of Oral Hygiene in Reducing the rate of VAP

Background Information

The current study focuses on the role of oral care and its importance in reducing ventilator associated pneumonia (VAP). Ventilator associated pneumonia or VAP is the kind of complications developed in person who are under mechanic ventilation for more than 48 hours. Studies and evidence have established that effective oral hygiene measures reduce the rate of VAP significantly. A mouth rinse, gel or toothbrush containing chlorhexidine as the active ingredient has been proven to reduce the chances of VAP by 40% (El-Rabbany, Zaghlol, Bhandari & Azarpazhooh, 2015). Evidence Based practice can be of great significance when used in dealing with this condition. The use of scientific evidence from researchers can help in addressing the problem because such studies are done by professionals who have a sound knowledge on the treatment of VAP. The current study investigates the importance of implementing evidence-based nursing education programs on oral hygiene practices in reducing the chances of VAP. It uses the PICO system to analyze how Evidence Based Practice can be used as an effective strategy for the disease.

Question Guiding Inquiry (PICOT)

The current study will be conducted through the development of effective PICOT questions which has been represented as follows: Will implementing an evidenced based oral care education program decrease the risk of ventilator associated pneumonia in ventilated patients in ICU patients. PICOT is an acronym that refers to the problem, intervention, comparison, outcome, and time. These are components that must be incorporated in the formulation of the research question. PICOT must be used for this study because it will enable the researcher to be focused on exactly what to accomplish by the study.   

Significance of the Problem

There has been significant research on the role of oral healthcare in reducing the incidence of VAP in the Intensive Care Unit. According to Liao, Tsaiand & Chou (2015), one of the major factors causing VAP is the aspiration of the colonizedoral pathogens. It has been reported that patients with VAP have longer hospital stay, which also adds considerable to the healthcare costs. When the patients stay longer in the hospitals, they have to incur additional costs because the charges levied on them increase as time goes by. From surveys it has been reported that 36-60% of all health associated infection related deaths are attributable to VAP. His is a clear justification that VAP is a serious issue that must be given a due consideration by the stakeholders of the healthcare sector. Azab et al. (2015) asserts that the placement of the endotracheal tube (ET tube) impairs the defense mechanism against pneumonia. In the lack of nasal warming and humidification the ET bypasses the normal filtration capacity. The mucocilliary defense mechanism is also comprised on the insertion of the ET tube.

Using Evidence Based Practice as an Effective Strategy

Summary

The current study focuses on the importance of oral hygiene in reducing the rate of VAP within intensive care units. Research has established that VAP is related to hygiene because it is common in the healthcare facilities where cleanliness is not properly done as required. Kaneoka et. Al. (2015) asserts that 1 in 17 intubated patients are at risk of developing VAP within intensive care units. Some of these will be seen to result in fatal consequences claiming the life of the patient along with increasing the recovery time. Studies have suggested that practicing effective oral hygiene care can reduce the rate of VAP infections by almost 6% (Kaneoka et al., 2015).Several studies have been conducted where treatment will be done using antiseptics alone or a combination of antiseptics and tooth brushing.  It has been represented that a combination method is more effective in reducing the rate of VAP. That is why its use is recommended especially within the hospital setting where the chances of the spread of VAP are quite high.

On the other hand, some have argued that better immunity standards and not combination methods controls the rate of VAP infections. According to such people, research has established that the immunity standards can be more effective in dealing with the infection particularly if it is appropriately done as recommended. Meaning, to them, the combination methods have no place in providing a solution to the problem of VAP.  This indicates that there is a disparity in the research regarding the management of the condition. Since the researchers have not come into a consensus, it is no doubt that there are disparities regarding the benefits or the effect of the oral hygiene standard in reducing the rate of VAP infections. Hence, development of an effective evidence-based nursing pre-education program could reduce the chances of the contraction of VAP (Sen, Johnston, Greenhalgh & Palmieri, 2016)

Annotated Bibliography

In order to present a detailed view of the topic, a study of the literature was conducted. In this respect, different views will be presented from a number of articles and journals which will be presented in the form of an annotated bibliography. Here is the annotated bibliography that presents a brief, but insightful overview of the authorship, summary, relevance, and significance of the selected literature:

Article 1: Cutler, L. R., & Sluman, P. (2014). Reducing ventilator associated pneumonia in adult patients through high standards of oral care: A historical control study. Intensive and Critical Care Nursing, 30(2), 61-68.

PICOT System for Effective Research Question Formulation

The current study evaluates the impact of oral hygiene measures on the incidence of ventilator associated infections and on preventing the rate of occurrence of VAP along with reducing the cost of treatment.

In the current scenario, a control study was conducted over 1087 patients mechanically ventilated at least 48 hours. The incidence of VAP in 528 patients before practice change was compared with 559 patients after practice change. The clinical audit cycle was used to compare compliance with existing hygiene standards. The cost of changing the oral care regime and the treatment of VAP with antibiotics was calculated. Hence, a quantitative research design had been followed.

Before the preventive measures were implemented, 47 out of the 528 patients developed VAP, whereas after the implementation of the oral hygiene measure 24 out of the 559 patients developed VAP. Hence, statistically significant differences were noted which provided a positive result for the implementation of the VAP. The article is suitable for usage in the research because it contains relevant information that can be of great importance in understanding the research topic. It is a credible source that was written by authorities who have made an impact in this particular discipline.

Article 4: Gupta, A., Gupta, A., Singh, T., & Saxsena, A. (2016). Role of oral care to prevent VAP in mechanically ventilated Intensive Care Unit patients. Saudi Journal of Anaesthesia, 10(1), 95–97. https://doi.org/10.4103/1658-354X.169484

The purpose of this research was to study the significance of oral care in the prevention of VAP amongst one category of patients-those in Mechanically Ventilated Intensive Care Units. According to the research, ventilator associated pneumonia is the most prevalent nosocomial infection occurring in intensive care unit; the major contributory factor is the aspiration of oral colonization (Keyt, Faverio& Restrepo, 2014). The article discusses the importance of the implementation of oral care hygiene practices within the intensive care units by means of pre-education nursing programs. The researchers also found out that some of the oral care interventions for ventilated patients will be discussed include assessment of oral cavity, maintain saliva production, elevation of head while sleeping or performing activities such as brushing the teeth of the patient. Jordan, Badovinac, Špalj, Par, Šlaj and Plan?ak (2014) assert that an elevated position prevents the reflux and aspiration of gastric contents. Additionally, minimizations of the aspiration of the contaminated secretion into lungs will be proven to reduce the chances of the contraction of VAP. The article had to be included in the reference materials used for this study because it contains relevant information on VAP. It is reliable because everything in it including the design, data collection and analysis were properly done.

Article 3: Hua, F., Xie, H., Worthington, H. V., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene care for critically ill patients to prevent ventilator?associated pneumonia. The Cochrane Library.

 The article focused upon providing evidence-based care for the vulnerable patients. Critically ill patients who are unconscious or sedated and receiving ventilation support in intensive care units often develop the risk for the contraction of VAP. Multiple studies have emphasized the role of effective oral hygiene strategies for reduction in the rate of VAP infections (Branch-Elliman, Wright& Howell, 2015). In the study, participants from ICU units of the hospital were randomly chosen. A number of interventions were used as comparison methods for arriving at acceptable results. The interventions were grouped into use of chlorhexidine antiseptic mouth rinse, tooth brushing, powdered compared with manual tooth brushing, and oral care solutions .It was seen that chlorhexidine either as a mouthwash or in the form of gel reduce the rate of infection by considerable amount (Nicolosi et al., 2014). The article was used as a reference material for the study because it contains useful information that is of relevance to the research topic.  Its emphasis on oral care for the critically-ill patients makes it a reliable source that must be used when studying the research topic.

Article 5: Lev, A., Aied, A. S., & Arshed, S. (2015). The effect of different oral hygiene treatments on the occurrence of ventilator associated pneumonia (VAP) in ventilated patients. Journal of Infection Prevention, 16(2), 76–81. https://doi.org/10.1177/1757177414560252

This study was conducted to compare the treatment of VAP before and after the implementation of the oral hygiene care practices. For conducting the study, a small sample group of 90 patients were selected. One group of patients was provided with effective oral hygiene care regimen such as tooth brushing, rinsing with antiseptic solution containing 1.5% hydrogen peroxide.  On the other hand, patients in the control group were provided with a more conventional treatment, which included cleaning with sponge and a traumatic clamp. The research revealed that that out of the 90 patients studied, 8.9% of the study group developed VAP compared to 33.3% of the control group. Additionally, the implementation of oral hygiene care was seen to reduce the time required for recovery along with reduce the rate of hospital readmission. All these make the article to be an invaluable resource for the research topic. It has everything that makes it a valid and reliable resource that cannot be left out when conducting a study on the research topic.

Article 7: Pileggi, C., Bianco, A., Flotta, D., Nobile, C. G., & Pavia, M. (2011). Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units. Critical Care, 15(3), R155.

This study evaluated the effect of topical digestive or respiratory tract decontamination with antibiotics in the prevention of VAP. One of the  tropical treatment  methods were chosen out of the following such as oropharyngeal decontamination using antibiotics, gastrointestinal tract disinfection using  antibiotics, oropharyngeal and gastrointestinal  tract decontamination using antibiotics, respiratory tract decontamination using antibiotics. It was found that the antibiotics used for the decontamination process produce much better results compared antiseptics (Hua, Xie, Worthington, Furness, Zhang& Li, 2016). In this respect, much better results were produced when oropharyngeal tract disinfection was followed by gastrointestinal tract disinfection. The article was used in the study because it has got enough information that would be incorporated into the study.

Article 2: Prendergast, V., Kleiman, C., & King, M. (2013). The Bedside Oral Exam and the Barrow Oral Care Protocol: translating evidence-based oral care into practice. Intensive and Critical Care Nursing, 29(5), 282-290.

This study conducted had a number of research aims such as introduction of evidence based oral hygiene care methods such as Barrow Oral Care Protocol (BOCP) and explores quality improvement data for the incidence of VAP, the cost-effectiveness of oral hygiene practices and the response of the staff to change in practices. Over here incidence of VAP before and after implementation along staff responses were compared.

It was later found that the incidence of VAP fell from 4.21 to 2.1 per 1000 ventilator days. A cost saving of 25% was noted on a monthly basis. Additionally, the staff reported increased satisfaction in the provision of oral hygiene with a combination of oral products (Seguin et al., 2014). The BOCP helped in providing effective oral hygiene care by using a range of instruments such as tongue scraper, electric toothbrush and non-foaming toothpaste (Kalanuria, Zai& Mirski, 2014). Hence, using these methods a significant reduction in the rate of occurrence of VAP was noted. A   meta-analysis had been followed over here, which is a part of secondary research design. The article was used in the study because it is useful and relevant. Its validity made it to be a reliable source for the research topic.

Article 6: Zhang, Z., Hou, Y., Zhang, J., Wang, B., Zhang, J., Yang, A., … Tian, J. (2017). Comparison of the effect of oral care with four different antiseptics to prevent ventilator-associated pneumonia in adults: protocol for a network meta-analysis. Systematic Reviews, 6, 103.

This study focused upon the different antiseptics used in controlling the rate of VAP. In this respect, different antiseptics were selected for conducting a comparative analysis such as- chlorhexidine, providone –iodine, five percent sodium bicarbonate, herbal mouthwash of matrica. The outcomes studied through the experimental setup were reduction in the rate of morbidity along with reducing the length of hospital stay.  It was found that administration of chlorohexidine followed by five percent sodium bicarbonate could reduce the rate of VAP infections (Lim et al., 2015). The article is suitable for use in this study since it contains relevant information that can be relied upon to understand much about VAP. Its reliability cannot be doubted whatsoever since it was written by credible authors who are renowned authorities in the field of health care.

The study will be an extensive one. Meaning, it will be done using a high standard that is acceptable of such a research.  A number of methods of VAP reduction will be discussed through the following sections with the help of different evidence-based journal articles. The cost-effectiveness and the benefits of various oral hygiene care methods have been evaluated over here.

Proposed Methods

For the purpose of the study, secondary databases will be selected such as PUBMED and NCBI. These databases will have to be selected because they are the ones which contain the best resources that are needed for the research topic. Therefore, to ensure that the required reference materials are retrieved, a well-outlined procedure will have to be used for the search. After identification of the research topic and the databases, search words will have to be chosen. A number of keywords will be used over here for generating effective search.  Additionally, the researcher will be using a primary research design at a later stage here where he will organize a survey in order to gather sufficient information on the method of application of the oral hygiene care methods and its effectiveness in controlling the rate of VAP. However, not all the resources will have to be used in the study because only the ones which meet the inclusion criteria will be selected for usage.

Sample

For the current study, a small sample size of seven to eight secondary journal articles will be taken into consideration. In this aspect, strict inclusion and exclusion criteria will be applied. The articles which will be searched using keywords such as oral hygiene, Ventilator associated Pneumonia (VAP) prevention, cost effectiveness of oral hygiene, etc.  additionally, strict filters will be applied such as only peer reviewed articles, printed in English within the last 12 years will be taken into consideration. In this respect, the search results generated other than the specific keywords will be excluded. For the survey, a small focus group of 10-12 respondents will be selected.

Design

A mixed research design will be chosen for the study where evidence will be collected from peer reviewed journals along with survey conducted for the benefits of pre-education nursing programs on oral hygiene to reduce the incidents of VAP. Mixed research is a methodology in which the collection and analysis of the data is done using a combination of qualitative and quantitative research tools. It is recommended for the study because it can help in collecting comprehensive descriptive and numerical data for the research

Procedures

The articles will be reviewed for the presence of similar and dissimilar ideas. The similar ideas presented will be used for conducting a thematic analysis, whereas the dissimilar ideas will be used for conducting a comparative study, whereas the data collected from the survey will be used for the presentation of statistically significant results. Thematic and comparative analyses will have to be done because they would help in synthesizing the data and making it appropriate for use in responding to the research question and main objectives.

The evaluation of  the different articles have focused upon the importance of pre-nursing education programs which  could train  the healthcare professionals on the  different  and effective oral hygiene methods. Each of the article s chosen will have to be thoroughly evaluated to get the information that will be relied upon to answer the research question.

Proposed Plan for Evaluation

The evaluation will be done using mixed methods where the researcher had used survey methods as well as secondary research articles or journals for the collection of clinical records which will help him in understanding the effectiveness of different oral hygiene care methods. However, in order to support the nursing pre-education programs on oral hygiene the researcher will conduct a primary survey where the healthcare professionals will be interviewed regarding the feasibility of the process.

Ethical Considerations and Project Limitations

A number of ethical considerations need to be taken into consideration while conducting the research. For example, only the articles which will be fully made available for public access should be taken into consideration.  Additionally, no confidential or restricted details of the patients should be disclosed during the course of the study. The small size of the sample restricted the potential of the studies. The researcher will have to strictly adhere to these ethical principles because they are necessary for such a study.

Summary

For the current research mixed research design will be selected by the researcher where a number of peer reviewed journal articles will be chosen along with survey for the gathering of stoichiometricllay significant data.

Final Conclusions

Overview of Clinical Problem

The ET tube inserted through oropharyngeal tract in ventilation assistance disrupts normal mucous clearance capacity which drain into the trachea and are aspired into the lungs. In the lack of effective oral hygiene dental plague deposits develop over the teeth which are potentially respiratory pathogens.

Overview of Literature Findings

It has been seen that the VAP infections increases recovery time of the patients along with increasing further complications. Reports and studies have suggested that for every 17 people in ICU under ventilation the use of mouthwash or oral rinse will prevent at least one person from developing VAP (Godshall, 2015). The use of instruments such as electric toothbrush will be seen to reduce colonization of pathogens which are aspired into the lungs. Additionally, preventive measures such as assessment of oral cavity along with elevation of head will be seen to reduce the rate of contraction of VAP. The randomized control trials conducted over in this study  have  further  demonstrated  that administration of  chlorhexidine  either as powder or in gel  form have better VAP prevention  effects  compared to  conventional  methods.

Overview of Methodology

For the current research, a mixed research design will be followed by the researcher. The researcher will use both survey and article review for the gathering and presentation of adequate information over the topic. Mixed research method is the best design for the study because it can help in collecting comprehensive descriptive and numerical data for the research.

Practice Implications and Recommendations

A number of implications are associated with practice of the oral hygiene care methods. Some of these are related to lack of interest and expertise within the healthcare professionals for the implementation of evidence-based care approaches. Additionally, the lack of proper infrastructure may hinder the implementation of the pre-nursing education programs.

A number of recommendations could be suggested over here such as:

• Regular reeducation of nursing staffs in relation to oral care protocol
• The educators need to take into consideration the concern of the nurse which prevent them for  performing oral care
• Monitoring of patient positioning and ventilator bundles are important concerns which need to be addressed.

References

Azab, S. F., Sherbiny, H. S., Saleh, S. H., Elsaeed, W. F., Elshafiey, M. M., Siam, A. G., ... & Ismail, S. M. (2015). Reducing ventilator-associated pneumonia in neonatal intensive care unit using “VAP prevention Bundle”: a cohort study. BMC infectious diseases, 15(1), 314.

Branch-Elliman, W., Wright, S. B., & Howell, M. D. (2015). Determining the ideal strategy for ventilator-associated pneumonia prevention. Cost–benefit analysis. American journal of respiratory and critical care medicine, 192(1), 57-63.

Cutler, L. R., & Sluman, P. (2014). Reducing ventilator associated pneumonia in adult patients through high standards of oral care: A historical control study. Intensive and Critical Care Nursing, 30(2), 61-68.

El-Rabbany, M., Zaghlol, N., Bhandari, M., & Azarpazhooh, A. (2015). Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: a systematic review. International journal of nursing studies, 52(1), 452-464.

Godshall, M. P. R. C. C. (2015). Fast facts for evidence-based practice in nursing, Second Edition. New York: Springer Publishing Company.

Gupta, A., Gupta, A., Singh, T., & Saxsena, A. (2016). Role of oral care to prevent VAP in mechanically ventilated Intensive Care Unit patients. Saudi Journal of Anaesthesia, 10(1), 95–97. https://doi.org/10.4103/1658-354X.169484

Hua, F., Xie, H., Worthington, H. V., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene care for critically ill patients to prevent ventilator?associated pneumonia. The Cochrane Library.

Hua, F., Xie, H., Worthington, H. V., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene care for critically ill patients to prevent ventilator?associated pneumonia. The Cochrane Library.

Jordan, A., Badovinac, A., Špalj, S., Par, M., Šlaj, M., & Plan?ak, D. (2014). Factors influencing intensive care nurses' knowledge and attitudes regarding ventilator-associated pneumonia and oral care practice in intubated patients in Croatia. American journal of infection control, 42(10), 1115-1117.

Kalanuria, A. A., Zai, W., & Mirski, M. (2014). Ventilator-associated pneumonia in the ICU. Critical care, 18(2), 208.

Kaneoka, A., Pisegna, J. M., Miloro, K. V., Lo, M., Saito, H., Riquelme, L. F., ... & Langmore, S. E. (2015). Prevention of healthcare-associated pneumonia with oral care in individuals without mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. infection control & hospital epidemiology, 36(8), 899-906.

Keyt, H., Faverio, P., & Restrepo, M. I. (2014). Prevention of ventilator-associated pneumonia in the intensive care unit: a review of the clinically relevant recent advancements. The Indian journal of medical research, 139(6), 814.

Lev, A., Aied, A. S., & Arshed, S. (2015). The effect of different oral hygiene treatments on the occurrence of ventilator associated pneumonia (VAP) in ventilated patients. Journal of Infection Prevention, 16(2), 76–81. https://doi.org/10.1177/1757177414560252

Liao, Y. M., Tsai, J. R., & Chou, F. H. (2015). The effectiveness of an oral health care program for preventing ventilator?associated pneumonia. Nursing in critical care, 20(2), 89-97.

Lim, K. P., Kuo, S. W., Ko, W. J., Sheng, W. H., Chang, Y. Y., Hong, M. C., ... & Chang, S. C. (2015). Efficacy of ventilator-associated pneumonia care bundle for prevention of ventilator-associated pneumonia in the surgical intensive care units of a medical center. Journal of Microbiology, Immunology and Infection, 48(3), 316-321.

Longti Li, Z. A., Li, L., Zheng, X., & Jie, L. (2015). Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical ventilation? An update meta-analysis from 17 randomized controlled trials. International journal of clinical and experimental medicine, 8(2), 1645.

Nicolosi, L. N., del Carmen Rubio, M., Martinez, C. D., González, N. N., & Cruz, M. E. (2014). Effect of oral hygiene and 0.12% chlorhexidine gluconate oral rinse in preventing ventilator-associated pneumonia after cardiovascular surgery. Respiratory care, 59(4), 504-509.

Pileggi, C., Bianco, A., Flotta, D., Nobile, C. G., & Pavia, M. (2011). Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units. Critical Care, 15(3), R155.

Prendergast, V., Kleiman, C., & King, M. (2013). The Bedside Oral Exam and the Barrow Oral Care Protocol: translating evidence-based oral care into practice. Intensive and Critical Care Nursing, 29(5), 282-290.

Seguin, P., Laviolle, B., Dahyot-Fizelier, C., Dumont, R., Veber, B., Gergaud, S., ... & Malledant, Y. (2014). Effect of oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: a multicenter, randomized controlled trial. Critical care medicine, 42(1), 1-8.

Sen, S., Johnston, C., Greenhalgh, D., & Palmieri, T. (2016). Ventilator-associated pneumonia prevention bundle significantly reduces the risk of ventilator-associated pneumonia in critically ill burn patients. Journal of Burn Care & Research, 37(3), 166-171.

Zhang, Z., Hou, Y., Zhang, J., Wang, B., Zhang, J., Yang, A., … Tian, J. (2017). Comparison of the effect of oral care with four different antiseptics to prevent ventilator-associated pneumonia in adults: protocol for a network meta-analysis. Systematic Reviews, 6, 103. https://doi.org/10.1186/s13643-017-0496-