| Learning Objective #1: Identify the significance of ventilator-associated pneumonia | |||
| Learning Objective #2: Determine the impact of providing oral care on patients' outcomes |
BACKGROUND
During the fall of 1999, an article appeared in the American Journal of Critical Care highlighting the importance of oral care. Using this article as a catalyst, the Intensive Care Unit (ICU) clinical practice council conducted a detailed literature search. The findings of this search were compared to current practice and opportunities for improvement identified.
Studies have documented that patients in medical intensive care units have poorer oral hygiene than non-hospitalized patients. This lack of oral hygiene contributes to the development of oral colonization. Additionally, oral bacteria aspirated into the lung may result in aspiration pneumonia. Specifically, potential pathogens for ventilator-associated pneumonia (VAP) are noted to be present in oral secretions in 67% of patients orally intubated for at least 24 hours. Also, after 24 hours, most suction equipment is colonized with many of the same pathogens cultured from secretions.
Pneumonia is the second most common hospital-associated infection and the leading cause of nosocomial death. Healthcare-associated pneumonia increases a patient’s length of stay in the ICU by 6.1 days and hospitalization by 10.5 days. This increase in length of stay and need for empiric antimicrobial treatment significantly impacts costs. The primary cause of healthcare-associated pneumonia is mechanical ventilation. The estimated average costs associated with ventilator-associated pneumonia are $29,369.
ORAL CARE POLICY/PROCEDURE
Appropriate oral care may be a preventative measure against acquiring VAP. A review of current practice demonstrated that foam swabs were the oral care tool of choice and the frequency and method of oral care varied. The need for a comprehensive oral care procedure was identified.
A critical care clinical nurse specialist and an ICU registered nurse revised the hospital’s oral care policy and procedure. Current research and literature were used to develop this policy. To change practice, all staff were educated on the new policy and procedure and the following was communicated. Plaque allowed to accumulate along and below the gingival margin is reported to cause tissue changes within 2-4 days. Brushing a patient’s teeth is needed to prevent the formation of plaque, which can be a reservoir for pathogens. A soft suction toothbrush should be used minimally twice a day. Oral care is performed every 2-4 hours. Foam swabs can be utilized between brushings; they are effective for stimulation of mucosal tissues but are minimally effective in removing plaque. The antiseptic oral rinse is a 1.5% hydrogen peroxide mouth rinse for oral cleansing and reduction of respiratory pathogens. A dedicated oral suction line and covered tonsil suction device are required. The subglottic suction catheter is a single use catheter allowing removal of secretions above the cuff. No other change in practice related to preventing healthcare-associated pneumonia was implemented at this time.
IMPLEMENTATION
A major barrier to performing proper oral care was the lack of appropriate equipment. The staff worked with a manufacturing company to improve and develop oral care products.
Improving oral care for mechanically ventilated patients was expected to improve the patient’s oral health, comfort and decrease colonization of respiratory pathogens. Measures were selected to evaluate compliance with the new oral care procedure and its impact on patient outcomes. One hundred percent (100%) of mechanically ventilated patients in the ICU were included. The following measurements were utilized: 1) Ventilator associated pneumonia (VAP) rate 2) Frequency of providing oral care 3) Actual product use 4) Product evaluation
RESULTS
The first indicator measures the rate of VAP. Diagnosis was based on National Nosocomial Infections Surveillance System (NNIS) criteria. Baseline data for the previous twenty-four months was placed on a u-control chart and demonstrated common cause variation. Therefore, the process was in statistical control. The VAP rate during the baseline period was 5.6 VAPs per 1,000 ventilator days. Following implementation of the new oral care policy and procedure, the rate dropped to 2.0 VAP’s per 1,000 ventilator days. Comparative mean reference rates from the NNIS database were 9.9 and 8.7. Thirty-three months of post-implementation data was placed on the u-control chart and demonstrates a positive shift in the process.
Also measured was the frequency of oral care pre and post-implementation. Seventy-one percent of the nursing staff participated in this data collection. Prior to implementation, 60% of nurses reported oral care was provided four or more times per shift. Following implementation of the new oral care policy and procedure, 93% of nurses provided oral care four or more times per shift. The use of a toothbrush also correspondingly increased.
During the first eleven months of 2001, actual product usage was measured and compared to the projected product use per ventilator day. Actual oral care product use was 91% of predicted product use. This confirmed that the frequency of oral care and toothbrush use for the mechanically ventilated population had increased. The goal of changing practice was achieved.
The final indicator was to measure nursing staff’s satisfaction with the new oral care products. Seventy-six percent of the ICU staff completed the survey. Ninety-four percent indicated the oral care system is easy to assemble, easy to use, efficient and allows complete oral cleansing. Eighty-eight percent agree this system saves time. The overall results indicate staff’s satisfaction with the redesigned oral care products.
CONCLUSION
Following publication of the above study in the Advocate Journal of Health Care, Spring/Summer 2002, professional journals showed a repeated interest in oral care. Additional articles regarding the Advocate, Good Shepherd Hospital study are found in Geriatric Nursing 2002, RT The Journal for Respiratory Care Practitioners and Hospitalist & Inpatient Management Report. Publications occurring in various medical journals targeting different audiences proved how important this patient outcome was to many disciplines.
Throughout this process, the question must be asked how is evidenced-based practice finalized? Currently, the Advocate, Good Shepherd Hospital study and several other research based outcome studies have been submitted to the Center for Disease Control for consideration into their “Guidelines for Health-care Associated Pneumonia”. Submission to these guidelines would solidify the importance of oral care. Clinical excellence however, can only be measured when actually performed and positive patient outcomes obtained.
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