Hello and thank you for coming to watch our presentation today. My name is Stephanie Yates, and I will be giving our presentation this afternoon. I would like to introduce the rest of my group. We have Ashley Grey, Krista Keuchel, and Jennifer Crawford. Our presentation today will be covering the best practice for preventing ventilator associated pneumonia in mechanically ventilated patients.
When we began this project, we were presented with the question of what are the best practices to prevent ventilator associated pneumonia. We began by focusing our target population to mechanically ventilated adult ICU patients. The intensive care setting is where most ventilator-assisted patients are located and that our evidence would best help these patients. After much debate on what interventions we wanted to compare, we decided to compare oral care versus the use the antiseptic agent, chlorhexidien gluconate. For the purpose of this project, we have defined oral care as tooth brushing and the use of toothettes. The outcome that we wanted to see was a decreased incidence of VAP in our ICU patients.
After selecting our population, interventions, and desired outcome, we can up with the PICO question “What is the most effective intervention to decrease ventilator-associated pneumonia (otherwise known as VAP) in adult ICU patients: performing oral care (through use of tooth brushes or Toothettes) versus the use of the antiseptic agent, chlorhexidine gluconate?”
Let me begin this discussion by defining VAP. VAP is defined as a hospital-acquired pneumonia occuring within 48 hours after initiation of mechanical ventilation with trachael intubation. A definitive diagnosis of VAP occurs when at least one of these findings are present: a new or persistent infiltrate on a chest X-ray, an organism isolated from sputum or pleural fluid, or a positive culture from a bronchoalveolar lavage. A diagnosis of VAP can also be made when 2 of the following symptoms develop (in conjunction with the previously named findings): a fever higher than 38.8C, leukocytosis, leukopenia, or the presence of purulent trachael secretions.
VAP has become a huge problem in the hospital and especially in the ICU settings. Studies have shown that patients can become colonized with pathogenic bacteria within 24 hours of admission to a critical care unit. VAP is the most common nosocomial infection in mechanically ventilated patients, affecting 9-28% of mechanically ventilated pts. VAP also contributes to an increase in length of hospital stay, increase in healthcare costs, and increase in mortality rates. VAP carries a mortality rate ranging from 40 to 89%. VAP can increase hospital length of stay by 4-9 days which leads to an increased hospital cost of $29,000 - $40,000 per patient. Mechanically-ventilated patients are at an increased risk for developing pneumonia due to decreased salivary sections. This reduction in self-cleansing of the oral cavity leads to worsening of oral hygiene and causes the number of bacteria within the oral cavity to increase, ultimately leading to bacterial colonization of the oropharynx. Artificial airways place the patient at an increased risk for direct introduction or microaspiration of pathogens into the lower part of the respiratory tract.
So what guidelines are currently in place to help fight the VAP problem? The National Guideline Clearinghouse has recommendations in place for the prevention of VAP. The guidelines say that there is consistent evidence that the use of an antiseptic agent can decreased the incidence of VAP, although not the overall ICU length of stay or overall mortality. The guidelines also say that the optimal concentration and formulation of this antiseptic agent remains an unresolved issue. Although they don’t specify a particular antiseptic agent, they encourage health care facilities to incorporate the regular use of an oral antiseptic agent into the routine care of patients receiving mechanical ventilation. The guidelines also recommended that oral hygiene be performed every 12 hours. They define oral hygiene as the removal of plaque from teeth and gums. They also recommend oral care be performed every 4 hours and before any manipulation of the ET tube or position change of the ventilated patient. They define oral care as removal of secretions from the oropharynx and moisturizing the mouth and lips.
Researchers found that dental plaque harbors that bacteria that causes VAP, and the only effective means of removing this plaque is through mechanical removal through tooth brushing. VAP rate dropped to zero within a week of beginning the new protocol. The next study we looked at was done at Summa Health System in Akron, Ohio. The objective of this study was to support the premise that oral care, including timed tooth brushing, combined with the VAP bundle, can mitigate and prevent the occurrence of VAP. This researchers in this study began by establishing the importance of oral care through the discussion of the pathophysiology involved in VAP. The oral cavity and its components, especially plaque, are the perfect media in which bacteria can grown. They referenced several studies which said that removing this bacteria from the oropharynx requires the removal of plaque from teeth, and the only effective way to achieve this is through tooth brushing. They also referenced several other studies that said that Toothettes do not remove plaque as effectively as tooth brushes. They also mentioned the important aspect of nurse education. It is imperative that toothbrushing skills be taught to nurses and clinical support staff. In this study the intervention group received tooth brushing with a suction tooth brush every 8 hours. The control group received “usual care”, which included daily tooth brushing along with Toothette care PRN. Nurses were educated about the importance of oral care and given laminated cards with the basic instructions. They were taught to brush the patient’s teeth, tongue, and hard palate with a tooth brush and toothpaste for at least 1 minute. They were also instructed to use a Toothette to swab the patient’s teeth, tongue, and hard palate for at least 1 minute and to apply moisturizing ointment to the patient’s lips every 4 hours. An oral assessment was performed on each patient every 12 hours, which included full inspection of oral cavity, gums, lips, and teeth. The nurses were also shown how and when to document oral care on worksheets. “Initially, pts were tracked on the worksheets for 10 days and then dropped from the study, but when the VAP rate dropped to 0% per 1,000 ventilator days in the intervention group and was sustained at 0% for 6 months, the medical director asked the researcher to include all intubated pts in the study, and the control group was dropped.” This study began as a randomized controlled trial. Because of the success of the intervention group and the development of VAP in four of the control-group pts over a 6 month period, the control group was dropped and all intubated patients were placed in the intervention group, where they remained for as long as they were intubated. This study showed that toothbrushing is a more effective way to prevent VAP because it removes the plaque that harbors bacteria in the oropharynx. The simple nursing intervention of brushing the patients teeth TID and using the VAP bundle can be powerful tools for preventing VAP.
The next study we looked at was done in a medical-surgical ICU in a university hospital. The objective of this study was to examine whether oral care contributes to preventing VAP in ICU patients. Oral status of all patients in the oral care group was assessed at the time of ICU admission by a dentist or nurse, and then an oral care nursing plan was established. Oral care was provided 3 times daily or once every nursing shift. Oral care included: observation of the inside of the oral cavity and portion of the trachea above the cuff; cleansing the oral cavity using a tooothbrush and rinsing with 300 mL of weakly acidic water; swabbing of oral cavity with swab soaked in 20-fold diluted povidone iodine gargle, and suctioning of the oral cavity. The results of this study showed that the incidence of VAP was significantly lower in the oral care group than in the non-oral care group. (3.9 v 10.4 for 1000 ventilator days) The mean interval between the start of mechanical ventilation and the onset of VAP was 8 days in the oral care group, whereas it was 6 days in the control group. Time elapsed to onset of VAP was significantly longer in the oral care group. Researchers found no significant differences of duration of mechanical ventilation and the length of ICU stay between the two groups. The results of this study revealed that oral care can reduce the incidence of VAP in ICU pts, as well as the risk of VAP development, and delay the onset of VAP. Researchers also noted that dental plaque, which is the major cause of oral contamination, is the thickest biofilm in the living body and cannot be eliminated by gargling or wiping. Therefore, cleanliness of the oral cavity cannot be obtained by means other than mechanical cleaning including tooth brushing. This study revealed that oral care performed according to the protocol reduce the number of potentially pathogenic bacteria in the oropharynx. Furthermore, the reduced incidence of VAP and delayed onset of VAP in the oral care group support the effectiveness of this oral care protocol.
Let’s begin to look at the literature we reviewed. The first study we referenced was done in 5 Chicago area acute care hospitals, and the observations were made in 8 ICUs. The objective of this study was to observe the current practice of, define best practice for, and measure compliance with standardized oral care. The researchers had identified that a gap exists between what oral care measures are indicated and the actual oral care that patients receive. They also identified a disparity between what nurses think they do and what is actually being done. This raises a question about the reliability of documentation and the consistency of practice. None of the sites they were at had an oral cleansing protocol in that defined frequency and identified the tools need to care for patients receiving mechanical ventilation. Researchers came up with a new oral care cleansing protocol and implemented it with the help of 24-hour oral care kits mounted on the wall in each patients’ room. The nurses in this study were educated on the importance of oral care and taught appropriate oral care techniques. Researchers found that every aspect of oral care performance increased significantly after the educational intervention. The oral care protocol in this study called for oral care every 2 hours, although after the study was completed, observational results showed that oral care was actually provided every 4 hours. The researchers suggested that further research needs to be done to determine the ideal frequency of oral care and the relationship of frequency to preventing infection. The researchers also found that nurses were more likely to report that they had provided adequate and frequent oral care than was shown in documentation. The results of this study showed that without a standardized comprehensive protocol for oral care and hygiene, oral care was performed infrequently and that important aspects of care were not performed. This confirmed previous findings in earlier studies of the variability of oral care practices in critical care environments. The use of the protocol in this study decreased the variability of oral care provided among and between the nurses and the respiratory therapists. The results showed that implementing a standardized oral care protocol and providing adequate tools at the bedside will increase frequency and comprehensiveness or oral care provided.
This study was done at a university hospital in Bangkok, Thailand. The objective was to determine the effectiveness of oral decontamination with 2% chlorhexidine solution for the prevention of VAP. Patients in the intervention group received oral care 4 times a day that involved brushing the teeth, suctioning any oral secretions, and rubbing the oropharyngeal mucosa with 15 mL of a 2% chlorhexidine solution. The control group received the same oral care except normal saline was used in place of CHX. The results showed an incidence of VAP of 4.9% in the CHX group and 11.4% in the normal saline group. In all patients, VAP was caused by gram-negative bacilli. Pts in the CHX group had less risk of developing VAP when compared to the normal saline group. The mortality rate for the CHX group was 32.2% and it was 35.2% for the normal saline group. This study was unable to be a blind study due to the odor and taste of the CHX solution. The results demonstrated that oral decontamination with 2% CHX solution was effective at preventing VAP. The rate of oropharyngeal colonization with gram-neg bacilli was reduce and the onset of VAP was delayed. The researchers concluded that 2% CHX solution alone should be sufficient enough for the prevention of pneumonia in patients receiving mechanical ventilation. Although this study showed that CHX could reduce the risk of VAP, no differences in duration of mechanical ventilation, length of stay, or mortality rate could be demonstrated. This study also demonstrated that oral decontamination with a 2% CHX solution for the prevention of VAP is a cost effective strategy. The mean total cost for the CHX intervention for all 14 pts was $34, whereas the mean total cost for antibiotic therapy to treat an episode of VAP was $400. The hospital in which this study was done ended up adopting a policy that recommended oral decontamination with a 2% chlorhexidine solution for prevention of VAP for adult pts receiving mechanical ventilation.
This study was done at 2 university hospitals and 3 general hospitals with mixed ICUs in the Netherlands. This was a randomized, double-blind, placebo-controlled trial. The objective was to determine the effect of oral decontamination with chlorhexidine on VAP incidence and time to development of VAP. In this study chlorhexidine was applied every 6 hours to the buccal cavity. CHX is an antiseptic with excellent antibacterial effects and resistance rates of nosocomial pathogens have remained exceptionally low, even despite long-term use. The results of this study showed that oropharygneal decontamination with CHX reduced and delayed the development of VAP in critically ill patients receiving mechanical ventilation. The daily risk of VAP decreased by 65% with the use of CHX. This study also found that CHX seems to be preferred for preventative implications. The safety profile and the presumed cost benefits of CHX make it a highly attractive intervention for the prevention of VAP.
Oral care consisting of tooth brushing and washing reduces the incidence and risk of VAP in ICU patients, and it delays the onset of VAP. Oral care reduces the number of potentially pathogenic bacteria in the oropharynx. Dental plaque, a major cause of oral contamination, can be removed only by tooth brushing. Implementation of a standardized oral care protocol and providing appropriate tools at the bedside will increase the frequency and comprehensiveness of oral care provided. Toothettes value in removing plaque formation is unproven and highly questionable.
Chlorhexidine is broad spectrum and is highly effective against gram-negative bacilli, which is the most common bacterial causative agent of VAP. Researchers found that oral decontamination with 2% chlorhexidine solution was effective at preventing pneumonia in patients receiving mechanical ventilation. Modulation of oropharyngeal colonization with chlorhexidine reduced the daily probability of VAP. Oral decontamination with chlorhexidine for the prevention of VAP is considered a cost-effective strategy.
As we did our research, we noticed an reoccurring problem associated with oral care. This problem is how much oral care is actually being provided versus what is documented. Researchers found that nurses documented that they performed oral care more than they actually did it in practice. This shows the need for better systems of documentation. It also shows the need for nurse education on the importance of oral care. It is imperative that nurses know how important oral care is to the health of their patients. If they truly understand how oral care effects their patients, they will probably see oral care as less of a burden and more as a duty.
There are obvious benefits in solving the VAP problem. Decreasing the occurrence of VAP leads to a decrease in mortality rate, length of stay, patient costs, and hospital costs.
We could only come up with a few cons when solving this problem. One con would be the cost of extra oral care supplies, but this cost would eventually be offset with the decreased in costs involved with treating VAP, such as the cost of antibiotic therapy. There would also be an increased cost associated with the implementation of the new oral care protocol due to extra staff and time involved with the implementation process.
The literature made clear the importance of meticulous oral hygiene. They recommended tooth brushing every 12 hours and as needed. They said tooth brushing should be done for at least 1 minute and include gentle brushing of the teeth, tongue, and hard palate. The literature also showed the value of oral decontamination through use of chlorhexidine. They recommend chemical decontamination of the oral cavity with chlorhexidine at least twice daily.
After sorting through the evidence, there are several interventions that can be recommended to help fight the VAP problem. There seems to be a growing need for the establishment of a new oral care protocol, which includes more comprehensive documentation and a more comprehensive oral care assessment. Another recommended intervention is manual tooth brushing, performed 3-4 times a day for at least one minute. Also use of chlorhexidine is another recommended intervention.
After comparing the evidence, we came up with a protocol that we feel would be effective for VAP prevention. Tooth brushing should be done 3-4 times daily for a minimum of 1 minute. Tooth brushing should the be followed with the application of chlorhexidine to the buccal cavity. The ensure compliance with the new oral care protocol resources such as an oral care kit should be integrated into practice. Kits can consist of supplies needed to complete efficient oral care, along with instructions on frequency and time given. Nurses are the key players in preventing VAP. It is up to nurses to perform comprehensive and proper oral care in a timely manner. Frequent oral care has to be a vital part of practice, especially in mechanically ventilated patients. It is so crucial. It is a life or death situation.
We noticed many opportunities for further study as we went through the literature. Further research needs to be done to determine the ideal frequency of oral care. Research also needs to be done to evaluate the effect of CHX on patient outcomes. Also, there needs to be research to determine the ideal frequency of CHX use. There also seems to be a need for research to be done on how to provide effective nurse education to improve the quality and frequency of oral care.
Prevention of Ventilator- Associated Pneumonia
Prevention of Ventilator-
OU – Tulsa College of Nursing
• Population of Interest
Mechanically-ventilated adult ICU patients
• Intervention of Interest
Oral Care - tooth brushing and use of
• Comparison of Interest
Use of antiseptic agent - Chlorhexidine
• Outcome of Interest
Decrease incidence of VAP
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)?
• 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
Identification of the
• 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.
• Oral care with antiseptic agents can decrease
the incidence of VAP.
– No optimal concentration or formulation is
• 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.
Review of Literature
• Summa Health System in Akron, OH
– Implementation of Q8H tooth brushing
– 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
Fields (2008): Randomized controlled trial
Review of Literature
• Medical-surgical ICU in a university hospital
– Oral care protocol 3 times daily or once every
– Mechanical cleaning including tooth brushing
– Conclusion: decreased the incidence and risk
of VAP in ICU patients and delayed the onset
Mori et al. (2006): Nonrandomized trial
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
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
– Conclusion: Cost effective strategy for
prevention of VAP
Tantipong et al. (2008): Randomized controlled trial with meta-analysis
Review of Literature
• 2 university hospitals and 3 general hospitals
– Chlorhexidine applied Q6H to buccal cavity
– Reduced and delayed the development of
– Conclusion: highly attractive prevention of
Koeman et al. (2006): Randomized controlled trail
Summary of Findings
• Oral care
• Potentially pathogenic bacteria
• Dental plaque
• Standardized oral care protocol
Summary of Findings
• Broad spectrum
• Oral decontamination with 2% chlorhexidine
• Modulation of oropharyngeal colonization
• Cost-effective strategy
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)
What Are The PROS To
Solving This Problem?
– Incidence of VAP
– Risk of VAP
– Mortality rate
– Length of ICU stay
– Cost for patient
– Cost for hospital
What Are The CONS To
Solving This Problem?
– Cost of oral care
– Cost associated
new oral care
• Brushing: Every 3-4 Hours and PRN
– Tooth brushing for 1-2 minutes
– Gentle brushing of teeth, tongue, and hard
– Chemical decontamination with chlorhexidine
at least twice daily
• Establishment of new oral care protocol
• More comprehensive documentation
• More comprehensive oral care assessment
• Tooth brushing: 4 times daily for a minimum of 1
• Follow with use of chlorhexidine.
• To ensure oral care compliance:
– Available resources
– Supply kits and instructions
• Key Players: Nurses
Suggestions for Further
• 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
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),
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.
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,
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.