According to Laux and Herbert (2006), ventilator-associated pneumonia, an infection of the airway, is the most common infection acquired from hospitals among mechanically ventilated patients. It has been known to develop more than 48 hours after mechanical ventilation initiation. 6 to 52 of 100 patients requiring mechanical ventilation develop ventilator-associated pneumonia. Around 1 to 3 percent of mechanically ventilated patients are at risk of developing ventilator-associated pneumonia daily (Stonecypher, 2010). The aspect of ventilator-associated pneumonia that troubles health care professionals is the high associated mortality. Al-Tawfiq and Abed (2010) mentioned that 46 percent of patients requiring mechanical ventilation who developed ventilator-associated pneumonia die, while hospital mortality of patients without ventilator-associated pneumonia is only 32 percent. According to Cutler and Davis (2005), ventilator-associated pneumonia patients are more likely to add an estimated amount of $40,000 to their hospital charges against a typical hospitalization expense. This is due to the fact that these patients are required to undergo prolonged intensive care and services. In this case, health care professionals organized a procedure focusing on identifying ventilator-associated pneumonia at an early stage. In addition to this, they also adapted consistency in the application of evidence-based practices. These measures are performed for the reduction of ventilator-associated pneumonia incidence.
In the author’s medical facility, mechanically ventilated patients who have developed ventilator-associated pneumonia have experienced an increase in hospital mortality and morbidity, higher hospitalization charges, and longer hospitalization. According to their data review, the number of patients with ventilator-associated pneumonia reached 8 percent from August 2, 2010 to January 29, 2011. The review also revealed that health care professionals failed to place much emphasis on oral care, although they have a bundle program for ventilator-associated pneumonia to prevent its immediate development. Good oral care still proved its importance in the prevention of ventilator-associated pneumonia based on significant number of evidence-based researches.
According to Cutler and Davis (2005), most patients requiring hospitalization have pathogens in their respiratory tract, unlike normal healthy adults. When the respiratory condition of these patients worsens, the respiratory pathogens are more likely to micro aspirate into the respiratory tract. In this case, the patient’s risk of respiratory pathogenic micro aspiration can be intervened through proper oral care. This process is crucial in the prevention of ventilator-associated pneumonia development. The importance of proper oral hygiene maintenance is fundamental in the prevention and reduction of ventilator-associated pneumonia. However, this is traditionally the most neglected process. Health care professionals tend to consider it a lower priority intervention compared to other complex interventions.
Proper oral care and hygienic procedures for mechanically ventilated patients have long been a cause of major concern to health care professionals. At the author’s facility, for example, there are inconsistencies in the performance of systematic oral assessment during the patient’s stay in the Intensive Care Unit and also during the admission of these patients. Although most nurses and health care professionals are aware that proper oral hygiene is significant in the prevention of ventilator-associated pneumonia, they still tend to neglect to put it in practice in a consistent manner. As a result, ventilator-associated pneumonia has risen from 0 to 8 percent within a period of six months.
Usually, other health care professionals and nurses are challenged with changes to the current practices. But researches proved that the nursing profession has to change and improve their attitude towards oral hygiene measures. It has been recognized already that good oral hygiene is essential in the prevention of ventilator-associated pneumonia in mechanically assisted patients. However, nurses are usually less aware of this importance. Observational visual audits and electronic chart reviews alike distinguished the insufficiency of nurses and health care professionals in ensuring standardized oral hygiene for mechanically intubated patients. In this case, a standardized oral care protocol has to be developed to enhance nurses and other health care professionals’ compliance with the implementation of oral care. In response to this, health care professionals should formulate and encourage strict enforcement of systematic oral care protocol for the patients requiring mechanical ventilation. With this, the compliance of nurses in implementing oral care will increase.
The proposed solution will be discussed with the unit manager, director, and staff. After the discussion, the Institutional Review Board (IRB) will review the standardized oral protocol for approval. The IRB board assures that the proposed solution is not involved in any unethical modalities and protects the patient’s right. The IRB reviews all requests for approval on the 15th of every month, and notifications regarding the approval come within the week of the review. Upon the approval from the Institutional Review Board of the proposed solution, health care professionals will develop a standardized oral care protocol. Then, it will be implemented for three months as an admission protocol for all patients requiring mechanical ventilation.
Rationale for the Selection
Usually, proper oral hygiene procedures for patients requiring mechanical ventilation are rarely, if at all, prioritized by nurses and other health care professionals. In the author’s facility, for example, there are currently no consistent oral care method, frequency, and guidelines for nurses to follow in performing oral care.
Evidence from Literature
The risk of ventilator-associated pneumonia in patients requiring mechanical ventilation can be decreased with the implementation of comprehensive oral care. The protocol is an evidence-based solution to the said problem. Cason, Saunders, and Broom (2007) found out through research that more than half of all the hospitals do not have strict oral care protocol for patients requiring mechanical ventilation. In such a case, these hospitals very seldom perform the assessment of oral cavity (Cason et al., 2007). Several studies linked ventilator-associated pneumonia to dental plaque and colonization of microbes in the oropharynx. To decrease dental plaque colonization, tooth brushing plays a major role. However, even if current evidence shows that it has beneficial effects, the intervention is seldom used in most Intensive Care Units (Halm & Armola, 2009). According to the study of Cason, Saunders, and Broom (2007), oral care procedures were very seldom performed, and moreover, the important part of the procedure was not done properly, if no standardized oral care protocol exists. Garcia, Jendresky, Colbert, Bailey, Zaman, and Majumder (2009) showed in their study that an increase in the nurses’ compliance of oral care protocol has a positive effect in prevention of ventilator-associated pneumonia among mechanically ventilated patients. Different studies indicated that hospitals with comprehensive protocols are more consistent in performing oral care (Cason et al., 2007). For example, tooth brushing was proved to decrease microorganisms; however, this is not performed as a part of the oral care routine in critically ill patients.
In this case, a multidisciplinary approach is required for the improvement of quality oral care in Intensive Care Units. Education, sufficient time, prioritizing and positive attitude towards oral care have a direct effect on the quality of the oral care provided for the patients. Therefore, it is important to educate nurses to reinforce proper oral care, give them enough time to perform the procedures, and help them unlearn the usually perceived unpleasantness of oral care (Furr et al. 2004).
The personnel required for the implementation of the proposed solution are the staff nurses and respiratory therapists. The materials needed are pamphlets, posters, and power point presentations. The assessment tools necessary for comprehension and feedback before and after implementation are surveys and questionnaires. Computers are also needed for presentations and communications, and some space for presentation should be provided as well. Funds must be made available for the initiation, supervision, and evaluation of changes of the staff, the cost of education, the production of educational and other materials, gathering and analyzing data, and other expenses including refreshments.
Implementation Process and Logistics
When nurses follow a strict oral care protocol, they are more likely to improve the initiation of oral care and, what is more importantly, prevent the occurrence of ventilator-associated pneumonia. For this to be possible, a measurable goal is needed for the improvement of implementation of the proposed solution. To have it implemented in a timely manner, the organization and the solution itself should have a clear and solid intention. Moreover, the objective should be measurable and time-specific. It should also consider a specific population involved. For its success, a mutual agreement between the upper management and the staff is necessary. Both the personnel and the resources must be distributed properly for the accomplishment of the task. The solution is successful if it includes a careful development, testing, necessary modifications, re-testing, and careful implementation of the process. The program will, therefore, be included as part of the admission requirements and processes for patients requiring mechanical intervention. The process includes the following procedures:
- Assessment of the oral cavity upon admittance and every 12 hours thereafter.
- Administration of oral care every 4 hours to all patients requiring mechanical ventilation. The procedures will be repeated as needed on an 8-12-4 program with or without 0.12% chlorexidine.
- Prior to repositioning and every 2 hours assessment of all mechanically ventilated patients for the identification of necessary removal of oral secretions.
- Suction tooth brushing with antiseptic oral rinse for 1-2 minutes every 12 hours.
- Cleaning the teeth and tongue using suction swab between brushing or as needed.
- Application of mouth moisturizer every 2 hours and as needed.
- Provision of deep orophhyrangeal suction as needed to remove secretions in intubated patients.
Once the Institutional Review Board approved the proposed solution, it would be introduced and presented at scheduled meetings for the education department, nursing administration, nurses assigned in infection control, Intensive Care Unit director, and respiratory director. During the presentation, the cost, mortality, and morbidity rates of ventilator-associated pneumonia would be pointed out. Upon the approval of the respiratory care director and nursing administration, the solution will be presented during weekly meetings to the Intensive Care Unit respiratory therapists and nurses. The ancillary staff will also be informed during monthly staff meeting. The procedures prior to implementation include:
- Selection of personnel and venue. All Intensive Care Unit respiratory therapists and nurses are part of the team.
- Approval acquisition from the chief nursing officer for the funds used for printing, power point presentations, pamphlets, and refreshments with minimal costs involved. The created budget will be presented for approval to the chief nursing officer.
- Assessment and evaluation of the present oral care status.
- Collaboration with the respiratory department for the commencement of the preparation and implementation procedures.
- Organization of the educational program through power point presentations and handouts. Every part of the proposal should be taught to the Intensive Care Unit staff, and the respiratory therapy department. Feedback should be enhanced.
- Arrangement of simulation terminals for demonstration and training of the involved personnel.
- Introduction of the oral care procedures to the key stakeholders.
- Identification of a process owner for operation of the procedure after implementation and onwards to preserve long-term integrity.
Strategies for a Good Outcome
- Periodic oral care should be discussed during daily patient rounds to enhance awareness and positive attitude toward the procedures.
- Oral care applications should be recorded after every administration for further documentation, study, and modification. It can be used as a solid tool for further measurements and checking procedures.
- Nurses should be offered comment and suggestion sheets, and questionnaires. This will aid them in the continuation and development of oral care. Moreover, nurses will also develop a sense of ownership to the oral care procedures.
- A discussion of the oral care processes, necessities, and modifications in strategy should be conducted with the involved nursing staff and the education department.
- Staff meetings should also be conducted monthly to share modifications and other information.
Because the nursing staff is accustomed to the current procedures, changes are often difficult to accept. However, concern over the proposed solution can be relieved by providing enough information about the deficiencies of the current procedures. Moreover, if possible benefits of the proposed process are discussed thoroughly, hopefulness may be developed in them. The initial implementation procedure may be difficult at first, but if necessary measures are taken, the implementation will run smoothly. One aspect that can impede the change is poor communication. The failure to communicate freely may prevent the personnel from following through with the implementation of the change. All hospital personnel, including the stakeholders, should cooperate in the implementation of the proposed change to encourage continuity of the newly-adopted solution. Contention should not be encouraged either. All possible barriers that will prevent the application of the procedures should be settled and resolved prior to implementation. If these measures are followed, the possibility of a successful outcome increases.
Oral care hygiene process is crucial to ventilator-associated pneumonia patients, and therefore immediate action is required. The initial implementation may be difficult and demanding and may cost money and time, but the effect on the patient will be rewarding. The additional time that nurses will spend on oral care proceedings will actually cut the time they need to provide care for the patient in the long run. The amount of time that the patients will spend in the hospital will be reduced. Moreover, the overall expense of the hospital itself will be reduced. In this given situation, most of the patients, if not all, will find cure, and therefore their lives will be saved.