Role of Evidenced Based Oral Care in Reducing Ventilator Associated Pneumonia

Abstract

Ventilation Associated Pneumonia (VAP) is one of the diseases that has been troubling the society for so long. Despite its prevalence, the illness can be mitigated if appropriate measures are taken. One of the ways through which this can be achieved is by adopting the concept of Evidence-Based Practice. This is a strategy in which an intervention is decided upon based on the best available scientific evidence alongside the practitioner’s personal knowledge and experiences. The current study focuses upon the importance of nursing pre-education programs in controlling the rate of VAP. The annotated bibliography literature review presents detailed evidenced-based research studies on the ventilator-associated pneumonia in different health setups. Sometimes established guidelines lack evidenced based support, and sometimes the procedures are not done correctly. The study design adopted for the research is the quantitative study where the authors compared the relationship between diverse variables involved in the study. The study presents a detailed overview of the different interventions, methods and the limitations associated with each which could be used in future study design.

Key Words: Oral Hygiene, Ventilation Associated Pneumonia, Oral Care, Evidence Based Practice.

Chapter One: Overview of the Problem of Interest

Pneumonia is an inflammatory lung condition caused by pathogens, Ventilator Associated Pneumonia (VAP) occurs in patients who are mechanically ventilated (Cutler& Suman, (2013). Studies have shown that evidence-based oral care plays a significant role in reducing VAP. This paper seeks to examine if implementing an evidence-based oral care training program for intensive care unit (ICU) nurses will result in further decrease the incidence of VAP in the ICU. 

Background Information

The current study focuses on the role of oral care and its importance in reducing VAP. Ventilator-associated pneumonia or VAP is the kind of complications developed in a person who is 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). The current study investigates the importance of implementing evidence-based nursing education programs on oral hygiene practices in reducing the chances of VAP.

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 evidence-based oral care education program decrease the risk of ventilator-associated pneumonia in ventilated patients in ICU patients in a six- month period. 

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The significance of the Problem

There has been significant research on the role of oral health care in reducing the incidence of VAP in the Intensive Care Unit. According to Liao, Tsai, and Chou (2015), one of the major factors causing VAP is the aspiration of the colonized oral pathogens. It has been reported that patients with VAP have a longer hospital stay, which also adds considerably to the healthcare costs. From surveys, it has been reported that 36-60% of all health associated infection-related deaths are attributable to VAP. Azab et al. (2015) assert 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 mucociliary defense mechanism is also comprised of the insertion of the ET tube.

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 control 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 to 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).

Chapter Two: Literature Review

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.

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.

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 controlled 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. 

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. 

 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 the head while sleeping or performing activities such as brushing the teeth of the patient. Jordan, Badovinac, Špalj, Par, Šlaj, and Plančak (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 was properly done.

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 on 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 the 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 reduces the rate of infection by a 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. 

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. 

The study was conducted to compare the treatment of VAP before and after the implementation of the oral hygiene care practices. In conducting the study, a small sample group of 90 patients was selected. One group of patients was provided with effective oral hygiene care regimen such as tooth brushing, rinsing with an 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 a 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% in the control group. Additionally, the implementation of oral hygiene care was seen to reduce the time required for recovery along with reducing 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. 

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.

The study evaluated the effect of the 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 in the decontamination process produce much better results compared to 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. 

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.

The study conducted had a number of research aims such as the 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 of staff responses was 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 be a reliable source for the research topic. 

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.

The 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 a 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 healthcare. 

Summary

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 in 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. 

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Chapter Three: Methodology

In this chapter, the data research and collection will be explored. The chapter also contains a number of participants’ selection, important considerations, and limitations of the study. In addition, the research will also involve the study design and provide justifications for why the researchers chose the given research design.

Proposed Methods

For the study, secondary databases will be selected such as PUBMED and NCBI. The secondary databases compose data that analyzes the results and components of the primary data. These databases will be selected based on those with the most applicable resources for the study. The primary sources and databases will be the main sources for the study as the secondary databases will be used to analyze the primary data. By selecting the reference resources, the research will easily focus on a narrow a narrow parameter will be used for the search. After identification of the research topic and the databases, specific keywords will be used for generating an effective search.  Subsequently, the researcher will be using a primary research design to organize a survey in order to gather sufficient information on the methods of applying oral hygiene care 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

The research will involve 10 participants will be randomly selected. The participants will be identified based on past experiences of ventilated associated pneumonia. The hospitals and other health facilities will be the places to identify the participants. Patients with history or suffering from VAP. 

Design

The research will be a quantitative design.  In quantitative research design, the researcher examines the relationship between the variables (Godshall, 2015). In this study, the researcher will examine if the incidence of VAP will decrease post nurse education and implementation of evidence-based oral care.  A retrospective study will be used to analyze the data. The researcher needs to research oral care practices that have been proven to reduce VAP and reject standards that are not evidence-based. The data to support the research will be acquired from the patients’ charts and medical records in the hospitals of interest. Using a retrospective design will meet the research objective and it is cost effective.

Procedures

A research text will be consulted to ensure that the data is evidenced based (Godshall, 2015).  According to Godshall (2015) after assessing the results of the study, four other questions should be answered.

1. The validity of the research.
2. Reliability of the research. 
3. Will the research improve patient outcomes?
4. Is the research appropriate for the patient population?

       The data collected from the patient charts will be used for the presentation of statistically significant results. 

Proposed Implementation

The evaluation of the different articles will be focused upon the pre-nursing education programs which will train the healthcare professionals on the different and effective oral hygiene methods. Each of the articles chosen will have to be thoroughly evaluated for evidenced-based knowledge because that is the information that will be relied upon to answer the research question. The pre-nursing education and education on oral care will be evaluated through random tests on the nurses testing their understanding and ability to implement the education knowledge to nursing. 

Proposed Plan for Evaluation

The evaluation will be done using the mixed methodology, the researcher will use survey methods as well as secondary research articles or journals for the collection of clinical records which will help the researcher to understand the effectiveness of different oral hygiene care methods. The researcher will use both qualitative and quantitative data to assess the information acquired from the sources. 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 practicality of the process. 

Ethical Considerations and Project Limitations

Several ethical considerations need to be deliberated while conducting the research. According to Godshall (2015), the benefit of the study should outweigh the risk of harm to the patient. Additionally, the patient should be aware that they are participating in the study, and of the risk and benefits. Furthermore, vulnerable patients should not be taken advantage.

Only articles which will be fully made available for public access should be taken into consideration. Additionally, the patients’ privacy and healthcare information should be safeguarded. The researcher will have to strictly adhere to these ethical principles because they are necessary for such a study. 

The small size of the sample restricted the potential of the studies. The outcome of the study is dependent on the staff willingness to learn new information and administering the interventions correctly and consistently. The healthcare practitioners, nurses, should be willing to learn new information on how to oversee the healthcare practice and interventions during their time of practice. 

Summary

For the current research, mixed research design will be selected by the researcher.  Peer-reviewed journal articles will be chosen along with a survey for the gathering of statistically significant data. 

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Chapter Four: Conclusions and Recommendations

In Chapter Four, the research will provide an overview of the clinical problem as contained in the research topic. The study then provides a summary of the literature review and present the main points covered in the methodology of the research. Lastly, this chapter will present the practical implementations and recommendations to the study topic.

Overview of Clinical Problem

The Ventilated Associated Pneumonia is one of the most regular nosocomial infections in the ICU. The infection has the detrimental effect that leads to overstay in the ICU and the mechanically-instrumented ventilation duration for the patient (Zhang, et al., 2017). The VAP leads to increased mortality as the survival chances after the infection remains half probability situation. The lack of implementation of existing strategies to reduce the spread of VAP, more populations are at the verge of contracting complications in oral health and generally VAP. VAP reduces immunity in patients in the ICU and thereby enhancing the spread of infections and vulnerability to multiple diseases in the healthcare facilities.

Overview of Literature Findings

The literature reviewed for the study provides the resources and procedures required to perform oral care protocol for those suffering from the VAP. The sources evaluated the available procedures involved in the treatment processes of the infection. The resources in the literature review section provide background information about the Ventilator Associated Pneumonia and provide the prerequisite knowledge in addressing the challenges of the infection for the patients.

Overview of Methodology

The research methodology underlines the procedure for carrying out the study involving the target group or sample selection. The selection of the target group must meet the criteria for the research and which involved the patients with Ventilator-Associated Pneumonia and the considerable situations. The methodology presents the research design which involves quantitative design to carry out the study. All the three procedures involved in the study of making part of the methodology which explores the practical and routine-based process that the researchers will undertake throughout the process. 

Practice Implications and Recommendations

The research would impact the clinical field positively when effectively implemented. The research will outline the processes required to prevent the VAP infection in patients. The research will enlighten the nursing practitioners on the appropriate methods and practical means of reducing the infection rates of Ventilator-Associated Pneumonia in the Intensive Care Units in diverse hospitals. 

On the recommendations, the nurses handling the patients in the ICU should ensure that the patients undergo daily oral care with chlorhexidine which is often considered a basic nursing care for patients. The nurses should also ensure that the patients brush their teeth on daily basis to reduce the incidences of VAP. The subsequent and future studies should explore the implications of VAP on oral care delivery to different patients in ICU. The future studies should also investigate the implications of VAP on patients during transition care.