prevention of ventilator- associated pneumonia
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TRANSCRIPT
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Prevention of Ventilator-Associated Pneumonia
Jennifer CrawfordAshley Grey
Krista KeuchelStephanie 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.