The Impact Of Oral Care On Mechanically Ventilated Patients

VAP is defined as a patient who is mechanically ventilated for greater than 48 hours and exhibits three out the five symptoms: fever, increase leukocytosis, change in sputum color or amount, radiographic evidence of new/progressive infiltrates and worsening oxygen requirements along with a culture identifying a bacterial microorganism (CDC, 2008). Risk factors associated with the formation of VAP is the altered oral physiology where there is a decrease in saliva production decreasing the pH level forming an ideal environment for bacteria to grow, respiratory pathogens such as Staphylococcus aureus, Streptococcus pneumonia, Methicillin Resistant Staphylococcus aureus and Pseudomonoas aeruginosa which can form a biofilm on the teeth that we know as plaque that can then aspirate and travel down to the lungs (Koeman et al., 2006). Several studies (Munro et al., 2009) 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. Others found that the majority of nurses use a soft Toothette instead of toothbrushing and that the Toothettes do not

Clinical problem: Oral care and ventilator-associated pneumonia (VAP) is extremely important in all healthcare organizations and has gained increased attention. For this reason, oral care has been introduced in many hospital settings. However, there is not enough evidence on critically ill patients concerning the effect of oral care interventions on the development of VAP. In order to evaluate the effect of oral care on VAP for hospitalized patients, additional studies are required.

Ventilator-associated pneumonia (VAP) is a hospital-acquired condition that is currently not on the Centers for Medicare and Medicaid Services’ (CMS) list of non-payment hospital-acquired infections (CMS, 2015). However, the thought of adding VAP to the list occurred in past discussion by CMS (CMS, 2008). This may change when there is an improved definition with clearer inclusion criteria that is currently being constructed by the CDC (Klompas et al., 2014). Nonetheless, the goal is to prevent hospital-acquired illnesses, such as VAP. After performing a review of care interventions for the prevention of VAP, a collaborative team between the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, the American Hospital Association, the

In the ICU, an area of practice that has seen improved patient outcomes is through the use of Ventilator Associated Pneumonia (VAP) bundles. VAP is a pneumonia that affects patients who are on ventilation. It occurs when pathogens enter the patient’s lungs through the mouth, nose or throat. A ventilator strategy bundle was developed. In 1994, the Healthcare Infection Control Practices Advisory Committee (HICPAC) revised the CDC Guideline for Prevention of Nosocomial Pneumonia to address VAP, as there was growing concern regarding the mortality and morbidity associated with healthcare related pneumonia. In the report, the VAP strategy bundle was developed and included in the bundle are: elevation head of bed to help prevent aspiration, oral

odour, changes in voice and any difficulty or pain on swallowing. Assessing a patients should not only involve a nurse, but the member of the multidisciplinary team. The physiotherapy, dietitian, speech and language therapist, occupational therapist and the doctors involves in the patients care. Who all play an important role. A study was carried out by Horne et al (2014) to investigate the organisation, provision and practice of oral care in typical UK 11 stroke units; and explore stroke survivors’, carers’ and healthcare professionals’ experiences and perceptions about the barriers and facilitators to receiving and undertaking oral care in stroke unit. The senior nurse on each of the 11 stroke units completed and returned the questionnaire.

Ventilator –associated pneumonia (VAP) is a hospital acquired infection affecting the respiratory system which occurs on hospitalized patients in critical care unit on mechanical ventilator. VAP is the second most common hospital acquired infection (HAI) with high mortality and morbidity rate for ventilated patients in intensive care unit. (Bingham. Ashley, Jong & Swift, 2010). Patients on mechanical ventilator spend more days in the hospital which in turn affects health care cost. VAP prevention is ongoing for nurses working in Intensive care unit. It is the duty of the nurses to help in VAP prevention by adhering to the interventions in the ventilator bundle in their daily

Parisi, M. (2016). Use of Ventilator Bundle and Staff Education to Decrease Ventilator-Associated Pneumonia in Intensive Care Patients. Critical Care Nurse, 36(5), e1-e7. doi:10.4037/ccn2016520

Delivering high quality and safe healthcare to patients should be the number one priority for all Registered Nurses and all other healthcare professionals in the workplace and community. This applies whether it takes place in homes, schools, small community clinics or larger city hospitals. Over time guidelines and procedures are put in place, constantly monitored and often altered to ensure that proper care is received by each and every patient, no matter the situation or level of care required. Since the patient will spend most of their one on one healthcare time with the Registered Nurse (about one third). Allowing them to participate in their own care is an important part of their hospital stay and the impact of the therapeutic

Which may further lead to prioritising oral care as a less priority for nurses than other aspects of care (H. Jones et al., 2004). In turn, even the tapes that are used in the fixation of the tube quickly become heavily contaminated with the bacterium in the existence of salivary secretions and the hitches associated with cleaning the mouth (Abidia, 2007). So, they have greater susceptibility to nosocomial-acquired infections such as ventilator-Associated Pneumonia (VAP) (Zurmehly, 2013). Patients who are intubated are also forced to keep their mouths open which leads to xerostomia, caused due to dryness of oral mucosa (Miranda, de Paula, de Castro Piau, Costa, & Bezerra, 2016). Furthermore, patients who may have some medical conditions have oral manifestations such as diabetes, Crohn’s disease, Leukaemia (H. Jones et al., 2004). In order to prevent these life-threatening complications, it is important to prioritise oral care as an essential nursing priority in high acuity settings by doing appropriate and more frequent oral assessments followed by mouth care with an evidence-based approach.

The American Thoracic Society (1996) defines ventilator-acquired pneumonia or VAP as “the specified type of nosocomial pneumonia that occurs after the first 48 hours of initiating mechanical ventilation.” One of the major causes of mortality among infections acquired at the hospital is VAP. Once a patient develops VAP he/she will have to spend to longer amount of time in the ICU (Rello et al.,1996). VAP initiating bacteria are often categorized into two groups: those that cause early-onset VAP (usually with 4 days of mechanical ventilation) and those that cause late-onset VAP (usually after 4 days of mechanical ventilation) (Craven and Steger, 1996; George et

Ventilator associated pneumonia (VAP) is among the most fatal hospital acquired infections, with mortality ranging from 15% to 70%. Ventilator associated pneumonia is also known to increase length of stay which directly affects unit budgets. In 2010 the institute for health care improvement added daily oral care with chlorahexidine to the five evidence based interventions which include, “(1) head-of-bed elevation between 30 degree and 45 degree; (2) a daily “sedation vacation” and a readiness-to-wean assessment; (3) peptic ulcer disease prophylaxis; (4) deep vein thrombosis prophylaxis; (5) daily oral care with chorahexidine.” (Lim, et al., 2015)

“Ventilator -associated pneumonias are the leading cause of death for patients diagnosed with hospital acquired infections” (Sadeghi, Barzi, Mikhail, & Shabot, 2013, p. 223). Pneumonia rates are higher in mechanically ventilated patients because the artificial airway increases the opportunity for aspiration and colonization. The rate of VAP increases for patients ventilated more than three days resulting in length of stay in ICU and LOS after discharge from ICU (Sedwick, Lance-0Smith, Reeder, & Nardi, 2012).

Implementation of the VAP bundle has greatly decreased VAP at various facilities. Even if the patient is unable to tolerate certain interventions there are various other interventions that could be put in place that would help halt the process of proliferation before it starts. The quality of care in relation to ventilated patients has greatly increased due to the frequency in which oral care, turning and sitting the patient up is recommended. The VAP bundle at the Regional Medical Center at Memphis consist of elevating the head of the bed (HOB) to 30º to 45º, twice-a-day oral care with chlorhexidine mouth rinse, stress ulcer prophylaxis, washing of hands before and after contact with each patient, daily sedative interruption, and daily assessment of patients readiness to wean from mechanical ventilation.

Taba et al., stated that “Effective implementation of clinical practice guidelines requires a comprehensive approach beyond simply publishing and disseminating documents” (2012, 5). Other healthcare professionals beside the nurse and the respiratory who play a major role in the endotracheal intubation/mechanical ventilation is the physicians. The subcommittee set the clinical practice guidelines at the UMH for the physician in the intubation procedure to follow in maintaining and restoring the patient’s health. According to their healthcare practice guidelines, the physicians have to order an X-ray post intubation, to also order the medication to administer according to the patient’s needs.

During mechanical ventilation, sedation and analgesia are given to reduce discomfort, pain, and to minimize oxygen consumption, all of which are extremely important for critically ill patients. Risks exist for both under sedation and over-sedation. Overuse of sedation in patients treated with mechanical ventilation can increase the duration of ventilation and lengthen hospital stay. Although current principles of care include implementation of sedation protocols and/or daily interruptions in sedation to improve patients’ outcomes; these strategies still underuse (Rock, 2014). One criticism of light sedation or interruption in sedation is a concern that the experience3 of being awake while connected to a mechanical ventilator is uncomfortable,