Prevention of Ventilator Associated Pneumonia

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Prevention of Ventilator-Associated Pneumonia

• Jennifer Crawford
• Ashley Grey
• Krista Keuchel
• Stephanie Yates
• OU Tulsa College of Nursing

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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

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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)?

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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

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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.

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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.

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Review of Literature
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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

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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

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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

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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

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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

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Summary of FindingsOral Care

• Oral care
• Potentially pathogenic bacteria
• Dental plaque
• Toothettes
• Standardized oral care protocol

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Summary of FindingsChlorhexidine

• Broad spectrum
• Oral decontamination with 2 chlorhexidine
  solution
• Modulation of oropharyngeal colonization
• Cost-effective strategy

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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)

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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

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What Are The CONS To Solving This Problem?

• Increased
• Cost of oral care supplies
• Cost associated with implementation of new oral
  care protocol

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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

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Recommended Interventions

• Establishment of new oral care protocol
• More comprehensive documentation
• More comprehensive oral care assessment

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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

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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

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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.

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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.