ssORAL CARE IN THE PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA

Oral Care In The Prevention Of Ventilator Associated Pneumonia

Oral Care In The Prevention Of Ventilator Associated Pneumonia

Abstract

Background

Ventilator-associated pneumonia (VAP) is a nosocomial pneumonia that develops in patients on mechanical ventilation for =48 hours. VAP develops at an estimated rate of 1% to 3% per day of mechanical ventilation.

Methods

Quality improvement project. Mechanically ventilated patients received the following oral care every 4 hours: the teeth were brushed with cetylpyridinium chloride (changed to 0.12% chlorhexidine gluconate in 2007) using a suction toothbrush, the oral cavity was cleansed with suction swabs treated with hydrogen peroxide, a mouth moisturizer was applied, deep oropharyngeal suctioning was performed, and suction catheters were used to control secretions. The primary efficacy variable was a diagnosis of VAP in patients mechanically ventilated for =48 hours.

Results

The historical average rate of VAP in 2004 was 12.6 cases/1000 ventilator-days. After the inception of the quality improvement project, VAP rates decreased to 4.12 (VAP cases/days of ventilation × 1000) for May to December 2005, to 3.57 for 2006, and to 1.3 for 2007.

Conclusion

The use of an oral care protocol intervention and ventilator bundle led to an 89.7% reduction in the VAP rate in mechanically ventilated patients from 2004 to 2007.

Introduction

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in patients who are critically ill,(Safdar, 2005) occurring at an estimated rate of 1% to 3% per day of mechanical ventilation. (Ibrahim, 2001) VAP is defined as a nosocomial pneumonia that develops in a patient who has been on mechanical ventilatory support (intubated) for =48 hours.3 The hospital mortality of patients with VAP is significantly higher than that of patients without VAP.( Institute for Healthcare Improvement) In addition to VAP being associated with increased morbidity and mortality, VAP is associated with higher medical care costs.

Bacterial infection of the lower respiratory tract typically occurs when the upper respiratory tract is colonized with pathogens, which is followed by aspiration of the oropharyngeal secretions. (Garcia, 2005) Patients in the intensive care unit (ICU) are at particular risk of oropharyngeal colonization with pathogens because of exposure to pathogens endemic to the ICU environment, exposure to multiantibiotic regimens, impaired mucosal defenses (desiccation, decreased salivary secretion, and immunoglobulin A content), accumulation of secretions as a result of intubation, and the unique environment that the endotracheal tube creates for dispersing pathogenic bacteria. (Youngquist, 2007)

An organized approach to VAP prevention can reduce the rate of VAP. A “ventilator bundle” is a group of interventions for the intubated patient found to be effective in reducing the rate of VAP. (Carroll, Farber, Macy, Cocanour, 2007 and Resar, 2006)The interventions are recommended by the Institute for Healthcare Improvement (IHI) and include elevating the head of the bed, daily “sedation vacations,” daily assessment of readiness for extubation, and prophylaxis for peptic ulcer disease and deep venous thrombosis. (Institute for Healthcare Improvement) The ventilator bundle may be further enhanced by oral care, which may play a role in reducing the incidence of VAP. (Richards, Edwards, culver, 2000)

Problem

At Mercy Medical Center in Springfield, MA, ...