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  1. 1. INTRODUCTIONThe aim of this report is to support the evidence of prevention of Ventillator AssociatedPneumonia(VAP), by providing appropriate oral care in mechanical ventilated patient ofIntensive Care Unit(ICU)Ventilator Associated Pneumonia is the infection caused by nosocomial bacterial pneumoniawhich develops in patient receiving mechanical ventilation says Kollef(1999). According toauthor Zack et al.(2002), Ventilator Associated Pneumonia is the main reason for mortalityand extended hospital stay for the ICU patients who are mechanically ventilated. Accordingto Doyle, A.(2011), the incidence and mortality rate of VAP is estimated 10-20% and15-50% respectively. In order to prevent the incidence and prevalence of VAP bundledpractices associated with preventive strategies are need for improving the health of thepatients, says Pruitt & Jacobs(2006). Thus VAP being an essential aspect for nurses in ICUfor adaption of current research on evidence based practises for the prevention of VentillatorAssociated Pneumonia.LITERATURE SEARCH METHODOLOGYThe data base used for the research are Cinahl Plus; the British Nursing Index; the CochraneLibrary; Medline and Psych Info. Results on search option included Full text, ReferenceAvailable, Abstract Available, Publication date 2006-2011. The search word is nosocomialinfection, critical care unit, Intensive Care Unit Nurses, Ventilator Associated Pneumonia,prevention, Evidence Based Practice for nurses.RESULTS FROM LITERATURE SEARCHSearch on nosocomial infection produced 1567 results. In this wide aspect of infectionacquired in hospital, I short listed the research on ventilator associated pneumonia inintensive care unit. This brought the results to 487 and on the issue of its prevention I got 47results. In various ways of prevention strategies I took oral care in prevention of VAP whichsorted 10 reliable research articles for critiquing.KEY WORDS: nosocomial infection, ventilator associated pneumonia, intensive care unit,prevention, critically ill, ICU nurses.THE EVIDENCE: TOOTH BRUSH Vs CHLORHEXIDINE.In Munro et al(2009), the research article is done critically ill adults. The subjects are thepatients of three different ICU’s (medical , surgical/trauhe effect ma, neuro). The study isabout the effect of tooth brushing and chlorhexidine in the prevention of VentilatorAssociated Pneumonia(VAP). Out of (n = 10913) the total patients in all the ICU’s only (n =
  2. 2. 547) were selected for the study. The inclusion criteria for the study is no previouslyintubated patients, patients with dental problem, patients in ventilation were included within24 hours, no present history of pneumonia during intubation. This is a randomised controlledtrial done on 2 by 2 factorial experimental design. Ethical rights reserved from Office ofResearch Subjects of Virginia Common Wealth University, Richmond, Virginia. The fourtreatments include for the study are 0.12% chlorhexidine solution given by oral swab, toothbrushing thrice a day, chlorhexidine twice a day and usual care. In tooth brushing technique,all the four quadrants of the mouth is thoroughly brushed by five strokes in each quadrant.Whereas the palate and tongue were rinsed with Biotine 2.5ml per area. In applyingchlorhexidine solution method, tooth swab was used to coat all the tooth, tongue and palate.Using descriptive statistics, the data analysis is done for the percentages for discrete variablesand mean. Used standard deviation, the data analysis for continuous variables is done to thestudy population. The sample number (n = 547) is reduced to (n = 192) on day 3 and againreduced to (n =158) on day 5 out of 158 patients 116 remained in analysis sample and 51patients without pneumonia at baseline. Clinical Pulmonary Infection Score (CPIS)evaluating on the effect of prevention of pneumonia, (CPIS>_6) is presence of pneumoniaand (CPIS_<6) absence of pneumonia. On day 5 the samples count has been brought to (n =76) in analysis sample and (n = 37) of patients without pneumonia at baseline. The results ofthe study is delivered as tooth brushing did not have any effect on prevention of pneumoniawith the mean (SD) value showing (Pa = 0.21%). Chlorhexidine has mean (SD) value of (Pb= 0.46%) in the prevention of pneumonia. Chlorhexidine technique only had the bactericidalactivity which helped in preventing pneumonia to occur in intubated patients. But toothbrushing technique had just helped in reduction of micro organism thus not able to preventpneumonia iv intubated patients. According to Zack et al(2002), he in his observational studyfound within a year the prevalence of VAP in ICU’s i brought down by (P< 0.001). this ismade by providing oral care atleast once in a day, extubation of patients on ventilator as soonas possible, elevating the head end, reduction in more use of antibiotics and maintainingventilatory circuit management. The results also show that individual effect of tooth brushingalone would not have given this result of prevention of VAP. In an another study by Koemanet al(2006), he conducted a randomised control study which detected the effect of 2%chlorhedine or 2% chlorhexidine with colistin combination on prevention of VAP. Theresults show good effect on prevention of VAP ( chlorhexidine Vs control, P = 0.01) and( chlorhexidine + colistin , P = 0.03). this shows that chlorhexidine has greater effect in theprevention of Ventilator Associated Pneumonia.THE EVIDENCE: EFFECT OF ORAL CAREIn Cutler et al(2005), conducted an observational study conducted on patients in 8 differentICU’s ( medical, surgical, neurological, cardiac and trauma diagnosis). The sample size is (n= 253) out of that 139(55%) of patients were observed during the baseline phase and114(45%) during the intervention phase . Descriptive statistics, mean and SD were dataanalysis method used for valuating continuous data. Percentages and numbers used for all thevariables described in the study. In base line phase, observation of oral care is done in whichthe swabs impregnated with sodium bicarbonate combined with 1.5% hydrogen peroxide
  3. 3. solution. But no assessment has been done on oral cavity, whether tooth brushed, whetherlips and mouth moisturized, whether oropharyngeal suctioning done or tubing’s changedoften. In interview phase of observation all procedures pre and post care and assessment wasdone on oral care. These observations done by nurses were happened only for four hourswhich should have lasted from 11pm till 5am. Nursing staff thinking of not to disturb patientsand guessing on the effect of oral care made the study weak. This paved way for Hawthroneeffect. Thus this observational study had no effect in finding the effect of oral care inventilator patients for prevention of Ventilator Associated Pneumonia. In Cutler, C. J.(2005),in his observational study on 253 patients implementation of oral care on patients inmechanical ventilation has positive effect on health of patient. This adds to the evidencebased support on oral care in prevention of VAP. Feider, L.L.(2010), a descriptive, crosssectional study says that oral care practices prevail in nurses but not effective in prevention ofVAP.THE EVIDENCE: INTUBATED PATIENTS AND PNEUMONIAIn Prendergast, V. Et al, the research study was conducted in patients of NeuroscienceIntensive Care Unit to find the development of VAP due to the changes in oral health and itseffect on intracranial pressure. This is an experimental study done on 45 consecutive patientsin the Neuroscience ICU for 1 year. Patients bio-chemistry values are checked often to findthe growth of gram-negative bacteria before and after intubation. The occurrence of VAP waschecked particularly after 72 hours after intubation. Abnormalities in WBC cells eitherleuckocytosis or leukopenia, changes in body temperature, any purulent pulmonary secretionand chest radiography results. Results show that on day 4 out of 31 patients on experiment8(26%) developed VAP and on day 7 out of 21 patients 7(33%) developed VAP. Finally onday 10 out of 13 patients 6(46%) had VAP. The gram-negative bacteria detected on these 6patients is the reason for VAP in intubated patients of Neuroscience ICU. From this study itis evident on the need of oral care on intubated patients.BEST PRACTISEAccountability and reliability are the prime source for nurses on decision making saysNursing and Midwifery Council(2008). Decision making in life is done either by followingphilosophical contents of ones belief or by trial and error method of life. In nursing fielddecision making solely depends on the evidences, trends and issue, research. EvidencedBased Practice is the best way for practice and for the improvement in health status of thepatient. In preventing Ventillator associated Pneumonia among intubated patients there aremany practices that are followed in different hospitals in relevance to their policies. Lookingon to the evidences of research on the large number of samples for the effect of best care oralcare plays a major role in preventing VAP. Though there are many techniques involved inprevention like head end elevation of 30-40 degree, suctioning the endo-tracheal secretionperiodically, changing intubators periodically and by not extending hospital stay. It is acomplete care and preventive strategy for VAP to have a combined effect on oral care.Chlorhexidine plays the dominant role in prevention through oral care. The clinical research
  4. 4. evidences of Munro et al(2009), Koeman et al(2006) shows that it has greater effect thantooth brushing or suctioning.DISCUSSIONPrevention of Ventilator Associated Pneumonia has always been a challenge for nurse inICU. Because patients admitted without this infection after days of hospitalization developsVAP. Nurses have their accountability on this. Though any nurse follows possible step inpromoting the health, there are certain areas which cannot be guessed or predicted inaccordance to their experiences. Thus research on the problem faced by nurses on thisproblem is essential. Ventilator has both sides like a coin . it saves the life of patient bygiving oxygen and it helps in easy formation bacterial colonization. Researches havedescribed the effect of each step of the nurse on the prevention. They are less use ofantibiotics, head end elevation, suctioning oral secretion, changing intubators periodically,accepting aseptic technique, mechanical tooth brushing, using chlorhexidine solution. Amongthese nurse is ready to follow the appropriate care for the prevention. Thus there will be noplace for experienced staff ideas or hospital policies. Thus evidence based practice helps insolving the problem.LIMITATIONSThough Evidence Based practice have some wide range in its uses for nurses in providingcare for the patients. It also has some drawbacks on its effect and issue. In this research onpreventing VAP by providing appropriate oral care, the research has widely concentrated ononly the possible technique used for killing gram-negative bacteria. These bacterias are themajor causating agent for pneumonia. But the research have not explained how this particulargram-negative bacteria has got into patients circulatory. It have not explained the source ofdeveloping for these bacteria. Intensive Care Unit is supposed to have clean and sterileenvironment. Only nurses, physiotherapist and physician were supposed to be inside anyICU. Nurses handle the patients physically according to universal aseptic and steriletechnique. Also researchers have not explained about why there is increase in bacterial countafter three days for this particular infection VAP, even after administering specificantibiotics. Likewise the different techniques in prevention of VAP, using chlorhexidine isjust a simple technique in reducing the bacterial count. Research has to be made strong onavoiding completely the act of micro-organism.CONCLUSIONThe patients who took part in the study in very large number in the hospital sector has madethe research effective..Though there are many practices that have been widely used byclinicians and nurses which have less effect in the prevention of VAP. Using chlorhexidinehas a greater effect than all other techniques. Effective nursing care is based on following thelatest trends and issues in nursing that are really helpful in bringing betterment of the patientcondition. Nurse has the part in accountability of patient condition and acts as an advocatorfor the patient. Thus Evidence Based Practice helps the nurse to overcome clinical trial andplace the research on the right time for recovery of the problem
  5. 5. REFERENCESCutler, C.J. & Davis, N.(2005). ‘Improving oral care in patients receiving mechanicalventilation’. American Journal Of Critical Care. 14(5).pp.389-394.Doyle, A., Fletcher, A., Carter, J., Blunt, M. & Young, P.(2011). ‘The incidence of ventilator-associated pneumonia using the PneuX System with or without elective endotracheal tubeexchange: A pilot study’. BMC Research Notes.4(92).pp.1-5.Koeman M, van der Ven AJ, Hak E, et al(2006). ‘Oral decontamination with chlorhexidinereduces the incidence of ventilator associated pneumonia’. Am J Respir Crit Care Med. ;173(12):1348-1355.Kollef, M.H.(1999). ‘The prevention of ventilator-associated pneumonia’.New England Journal of Medicine.340.pp.627–634.Feider, L.L., Mitchell, P., Bridges,E.(2010). ‘Oral care practices for orally intubated criticallyill adults’. American Journal Of Critical Care. 19(2)Munro, C.L. , Grap M.J. , Jones, D.J. , Mclish, D.K. (2009). Chlorhexine, Toothbrushing andPreventing Ventilator Associated Pneumonia In Critically Ill adults’. American Journal Ofcritical Care.18(5).pp.428-437.Prendergast, V., Halberg, I. R., Jahnke, H., Kleiman, C.(2009). ‘Oral health, Ventilator-Associated Pneumonia and Intracranial Pressure in intubated patients in a NeuroscienceIntensive Care Unit’. American Journal Of Critical Care.18(4).pp.368-375.Pruitt B. & Jacobs M. (2006). ‘Best practice interventions: How can you prevent ventilator-associated pneumonia?’.Nursing. 2006, 36(2), 36–42Zack, J.E. & Garrison, T. & Trovillion, E. Et al(2002). Effect of an education programmeaimed at reducing the occurrence of ventilator associated pneumonia’.. Critical caremedicine. (30)pp. 2407-2412.