oral care reduce the ventilator associated pneumonia

Ventilator-associated pneumonia (VAP) is a preventable secondary consequence of intubation and mechanical ventilation. VAP is pneumonia that develops in an intubated patient after 48 hours or more of mechanical ventilator support. Mechanically ventilated patients in neurologic and other intensive care units (ICUs) are at an increased risk of VAP due to factors such as decreased level of consciousness; dry, open mouth; and microaspiration of secretions. VAP can be prevented by initiating interventions from the Institute of Healthcare Improvement's VAP bundle, including (a) elevating the head of the bed of ventilated patients to 30˚, (b) preventing venous thromboembolism through use of sequential compression devices or anticoagulation, (c) administering gastric acid histamine2 blockers, (d) practicing good hand hygiene, (e) initiating early mobilization, and (f) performing daily sedation interruption at 10 am to evaluate neurologic status. The one intervention not included in the IHI bundle is oral hygiene. The purpose of this project is to support the premise that oral care, including timed toothbrushing, combined with the VAP bundle can mitigate and prevent the occurrence of VAP.

In ventilated patients, the normal defense system of the body, including the cilia in the nose and protective mucus, are circumvented, allowing the patient's mouth to be colonized with pathogenic bacteria such as Pseudomonas, Acinetobacter, and Methicillin-resistant Staphylococcus aureus (MRSA) within 24 hours of admission to an ICU (El-Solh et al., 2004; Rello, 2005). Mechanically ventilated neurointensive care patients are at an increased risk for VAP due to factors such as decreased level of consciousness and inability to protect the airway (Cohn & Fulton, 2006; Kollef et al., 2006). Neurologic patients with decreased level of consciousness or low Glasgow Coma Scale scores are prone to aspiration due to an unprotected airway and inability to swallow properly. Interventions for lowering intracranial pressure (ICP), such as raising the head of the bed, are a positive influence on prevention of VAP, whereas limited mobility because of ICP monitors, ventriculostomies, and disease processes such as spinal cord injury, can negatively affect VAP-prevention techniques (Cocanour et al., 2005). In addition, because it is difficult to temporarily stop sedation in neurologic patients who have increased ICP, the cessation of daily sedation cannot be used to prevent VAP in these patients. Other risk factors include gastric distension, presence of gastric or duodenal tubes, and trauma or chronic obstructive pulmonary disease (Harris & Miller, 2000).
Meticulous mouth care is crucial for preventing VAP. Rincón-Ferrari and colleagues (2004) found that in head-injured patients, 40%–60% of the gram-negative bacilli found were due to endogenous lung colonization after aspiration of oropharyngeal secretions. Twenty percent to forty percent of these bacteria were Staphylococcus aureus, and more than half of the Staphylococcus aureus were methicillin-resistant. This type of staphylococcus is exogenous, usually originating from the hands (Mori et al., 2006).
Studies have shown that patients can become colonized with pathogenic bacteria within 24 hours of admission to a critical care unit (Garcia, Jendresky, & Colbert, 2004; Sole, Poalillo, Byers, & Ludy, 2002). The oral cavity and its components—especially dental plaque—are the perfect media in which bacteria can colonize (Garcia et al.).
The American Association of Critical-Care Nurses published an evidence-based practice alert in 2006 that offered guidelines for oral care of the mechanically ventilated patient. In addition, Grap and Munro (2004) and Collard and Saint (2004) recommended raising the head of the bed to an elevation of 30˚ to 40˚, using endotracheal tubes that have a dorsal lumen above the endotracheal cuff, and sporadically changing ventilator circuits.
Grap and Munro (2004) presented supporting evidence indicating that critically ill patients who are intubated for more than 24 hours are at higher risk for VAP, and therefore, mouth care and oral health should be an important part of nursing care. Current literature identified a problem with adequate oral care in the intubated patient that included the definition and quantification of oral care (Fourrier et al., 2000). Bergmans and colleagues (2001) provided evidence that prevention of bacterial colonization of the oropharynx is the key to preventing VAP. The Centers for Disease Control and Prevention guidelines (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004) determined that the primary route of bacterial entry into the lungs is through the oropharynx during episodes of microaspiration.
Several studies (El-Solh et al., 2004; Schleder et al., 2002; Shinn, 2004) have verified that removing bacteria from the oropharynx requires the removal of dental plaque, and the only way to remove the plaque is with toothbrushing. Pearson and Hutton (2002) and others found that the majority of nurses use a soft Toothette® instead of toothbrushing and that the Toothettes do not remove plaque as effectively as toothbrushes; consequently, oral bacteria can proliferate (Baker, 2007; Binkley, Furr, Carrico, & McCurren, 2004).
Pearson and Hutton (2002) completed a controlled trial that compared the ability of foam swabs and toothbrushes to remove dental plaque and to quantify any differences. They concluded that toothbrushing skills must be taught to nurses and clinical support staff. Schleder (2003) reviewed the pathogenesis of bacteria; identified risk factors, including colonization of the oropharynx; and recommended the following approaches:
Use good oral hygiene, including toothbrushing, on all patients.
Implement oral-hygiene assessments and intervention strategies for all patients at risk for developing VAP.

Pathophysiology:Decontaminate devices that come into contact with the respiratory tract.
Implement the hand-hygiene guidelines released by the CDC in 2003. The guidelines include decontaminating hands by washing them with antimicrobial soap and water or by using an alcohol-based, waterless antiseptic agent if hands are not visibly contaminated. In addition, gloves should be worn when handling respiratory secretions or objects contaminated with the respiratory secretions of any patient (Schleder, 2003; Tablan et al., 2004).
Grap, Munro, Ashtiani, and Bryant (2003) have substantiated the need to standardize oral care for a variety of reasons, the most compelling of which is to prevent or lower VAP rates in mechanically ventilated patients. Oral care is not only part of a standard of care that lowers infection rates by removing plaque-harboring organisms, but is also a comfort care issue (Fourrier et al., 2000; Munro & Grap, 2004). Using evidence-based outcomes and research, the CDC and its Hospital Infection Control Practices Advisory Committee have developed a set of guidelines for VAP prevention that are beneficial for any institution. The guidelines include preferential use of orotracheal tubes over nasotracheal tubes, use of endotracheal tubes with a dorsal lumen to allow drainage, elevating the head of the bed to 30˚ or 40˚, routinely verifying placement of feeding tubes, and preventing or modulating oropharyngeal colonization with implementation of a comprehensive oral hygiene program (Dodek et al., 2004; Tablan et al., 2004).
Implementation of the VAP Bundle: The VAP bundle was implemented over a period of 2 years and included (a) elevating the head of the bed of ventilated patients to 30˚, (b) preventing venous thromboembolism with the use of sequential compression devices or anticoagulation, (c) administering gastric acid histamine2 (H2) blockers, (d) practicing good hand hygiene, (e) initiating early mobilization, and (f) performing daily sedation interruption at 10 am for evaluating neurologic status. Other precautions also were initiated and include the following: (a) the practice of universal gloving was observed (i.e., as staff in all hard-wire units enter a patient's room [after having meticulously washed their hands], they put on gloves. At the bedside, they used hand sanitizer.), (b) in-services regarding VAP and its consequences were held on all shifts and weekends, and (c) dual lumen endotracheal tubes were implemented.
The first intervention in the bundle was to keep the head of the bed above 30˚ in intubated patients (Shorr & Kollef, 2005). When the head of the bed is flat, more secretions can pool in the back of the airway, become colonized, and then aspirate into the lungs (Safdar, Crnich, & Maki, 2006). In conjunction with in-services about VAP, posters with a picture of a 30˚ angle showing what the height of the head of the bed should be were put up at patients' bedsides.
The next pieces of the bundle that were put into place were hand washing and gloving. Universal gloving requires any staff member walking into a patient's room to put on gloves as they enter. Sinks are available in the front of every room in critical care, so in-services were held on all shifts to encourage universal gloving, as well as frequent hand washing before and after putting on gloves, before and after suctioning, and before and after touching ventilator equipment or coming into contact with patients' respiratory secretions. In addition, alcohol-based hand sanitizer dispensers were placed outside all rooms and around the units.
The third intervention was to increase mobility. Rehabilitation services staff were intimately involved with nursing and respiratory personnel to develop an activity flow sheet and protocols for progressive ambulation. Every patient admitted to critical care received a physical and occupational therapy screen within 24 hours and then received appropriate rehabilitation services, even if those included only range of motion services. Even intubated patients without contraindications such as back injury were encouraged to sit on the edge of the bed or to try to ambulate a few steps with the assistance of ceiling lifts.
Daily sedation interruption (i.e., a "sedation vacation") was the fourth part of the bundle incorporated into our policy. A multidisciplinary group including pharmacists, intensivists, and nurses met over several months to develop a system to ensure a daily sedation reprieve for mechanically ventilated patients (Simmons-Trau, Cenek, Counterman, Hockenbury, & Litwiller, 2004). If a patient was on a sedative drip, it was turned off at 10 am every morning to allow the patient to wake up to a level whereby he or she could be assessed neurologically. The Richmond Agitation Sedation Scale (RASS) was used to measure the level of sedation. After the patient reached the predetermined score on the RASS, the drip was then restarted at 75% of the rate. This decreased side effects of the drugs, prevented oversedation, allowed the patient to wake up sooner, and allowed the doctors to assess the patient's neurologic status more accurately.
In addition to the other bundle recommendations, a dual lumen endotracheal tube (ETT) was introduced. Dual lumen ETTs are much more expensive than ordinary endotracheal tubes ($14 versus $1), but some studies have shown that the dual lumen ETT's extra subglottic port decreases VAP by as much as 20%–40%, thereby decreasing the overall costs associated with VAP (Shorr & O'Malley, 2001; Smulders, van der Hoeven, Weers-Pothoff, & Vandenbroucke-Grauls, 2002). Although the dual lumen ETTs have an extra port for subglottic secretions, and some hospitals use continuous suction, our hospital did not have any of the low-volume, low-pressure suction the manufacturer suggested (Hijazi & Al-Ansari, 2004). Nurses and respiratory therapists devised a plan to have only respiratory suction from the port with a 10-ml syringe every 2 hours with ventilator checks. These endotracheal tubes were enthusiastically accepted by the staff and placed on all emergency carts.
The final portion of the bundle was the use of H2 blockers or sucralfate to prevent ulcers, as well as preventive measures against deep vein thrombosis (Berriel-Cass, Adkins, Jones, & Fakih, 2006; Collard, Saint, & Matthay, 2003). Fortunately, our institution had been following current guidelines, so it was not necessary to take further action with ulcer and DVT prevention.
Summery:VAP is a preventable and expensive nosocomial disease. Literature has covered its pathophysiology and the myriad reasons that patients develop VAP, but solid evidence that supports nursing interventions has not been forthcoming. Oral-care interventions have been suggested as a preventive technique, but there are few evidence-based studies that report exactly how and when to perform oral care. A multidisciplinary approach (Salahuddin et al., 2004) is the most efficient and efficacious way to effect change in a system; such an approach was used to implement the timed oral-care and toothbrushing regimen to change nursing practice. This study changed nursing practice, saved lives, and saved more than $724,000 for Summa in 2006, as indicated in the 2007 Summa financial scorecard. The study showed that the simple nursing intervention of brushing the teeth three times a day and using the IHI VAP bundle can be powerful tools for preventing VAP.