Ventilator-associated pneumonia (VAP) is one of the leading causes of increased hospital stays, morbidity and mortality rates. Many health institutions have been conducting improvement projects in order to reduce the incidence of VAP. Good oral care is one of the practices that can reduce the occurrence of VAP. Despite the link between oral care and the prevention of VAP, there has been limited attention to the application of oral care in preventing VAP. The following paper presents a project on evidence-based practices of oral hygiene, ventilator discontinuation and extubation to prevent VAP.
Keywords: VAP, oral care, ventilator discontinuation and extubation.
VAP is a significant problem in acute and critically ill patients. It results in increased cases of mortality; hence, oral care is considered to be an important intervention. A study conducted by Oliveira, Zagalo, and Cavaco-Silva (2014) established that dental plaque, stomach, and oropharyngeal cavity are major places for the growth of micro-organisms in patients who are critically ill. The study established that in the ICU, the patients undergoing mechanical ventilation are at high risk of aspiration of oropharyngeal contents that are contaminated. Aspiration of the microorganisms contained in the oropharyngeal has become the source of major concern because it adds in the weakening the defense of the already ill patients. Therefore, it is more logical to adopt measures that reduce the concentration of the microorganisms in the mouth to prevent and reduce cases of VAP. The combination of oral care, ventilation discontinuation and extubation has produced promising results.
The Frame of Problem
The growths of microbial pathogens in the oral cavity provide a substantial amount of infections related to bacteria in the mouth. These bacteria have been shown to be responsible for the development of VAP. According to Seckel (2010), the microorganisms in the mouth colonize the lungs, which then result in VAP. Therefore, measures to improve oral care should be used as one of the best options to prevent the incidences of VAP. For example, the use of daily oral care with Chlorhexidine rinse, mouthwash and or moisturizing gel every shift has been shown to significantly reduce the rates of VAP infection in ventilator-dependent patients (Seckel, 2010).
The prevention of ventilator-associated pneumonia in various acute care facilities requires the health workers to integrate evidence-based practices. This calls for a concerted effort by the various stakeholders in health care delivery to educate the health personnel. To implement the project, I will involve the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC). The organization provides a safer world in preventing infection by advances in patient safety, patient advocacy, and health care competency. It is also involved in educating the public and the health personnel about the best ways to control the spread of diseases.
Ventilator Discontinuation and Extubation
Invasive mechanical ventilation has been found to contribute to the development of VAP. Thus, one of the important control measures is ventilator discontinuation and extubation. A study conducted by Prendergast, Hallberg, Jahnke, Kleiman, and Hagell, (2009) to investigate the changes in oral health and the association with VAP during intubation found that oral health deteriorated significantly during the process of intubation. However, the health increased to baseline following extubation for 48 hours. Yeast and gram-negative bacteria were found to increase considerably during the intubation. Consequently, the VAP incidence was 24% among the study participants who were followed for 4 to 10 days. As a result, noninvasive mechanical ventilation is advocated as VAP preventive measure. According to Frost and Wise (2008), the mechanical ventilation should be avoided whenever possible. Also, studies have shown that intubation increases the risk of pneumonia by 6-21 times. After extubation, noninvasive MV can prevent the process of re-intubation and hence reduce the chances of VAP development.
Implementation and Evaluation Plan
The implementation of the plan will entail a campaign targeting the health personnel working in the intensive care units. The project is to be implemented in a duration of fourteen weeks. The following table is a summary of the implementation plan.
|1||Development of the project materials and messages||Preceptor|
|2||Review of resources (time, money and personnel)||Preceptor|
|3 & 4||Development of audit surveys||Preceptor and APIC staff|
|5||Compilation of the project and approval||Nurse manager and preceptor|
|6||Meeting all stakeholders and presentation of the work schedule||APIC staff and administration, and nurse manager|
|7 to 14||Training sessions||APIC staff|
|16-17||Summative evaluation||External evaluators|
The implementation will entail online training sessions for the targeted personnel on how to prevent the incidence of VAP in critical care. The training personnel will comprise of staffs from APIC. The evaluation of the implementation will involve continuous assessment to determine whether the set indicators are met as the project progresses.
The alternative solution will be directly lobbying governments to enact policies that will promote nosocomial infections such as VAP. Besides, it is worth noting that a viable short term solution to VAP is the adoption of simple oral hygiene procedures such as cleaning the patients’ mouth at least twice a day for all patients in the critical care. The long term solution is setting up systems in the critical care facilities to facilitate regular training. Also, the systems should provide regular alerts to remind the critical care nurses the need to uphold the oral hygiene for their patients. In the case of time constraints and limited financial support, the implementation plan will have to be reduced to two months.
The overall evaluation will entail a summative assessment to determine the outcome of the project. This will be carried for two weeks after the completion of the project. In order to ensure objectivity, external evaluators will carry out the assessment. The parameters to be evaluated will entail investigating whether project was completed within the stipulated timelines and finances. Establish whether the targeted health workers were reached and an analysis of the results to determine the progress of the training and its impacts in reducing the ventilator associated pneumonia.
The preceptor provided critical guidance and information about my research. For instance, the preceptor provided me with abundant research that relates to oral care for prevention of VAP. The mentor gave firsthand experience. In addition, my confidence and competence were boosted by the help provided by the preceptor. I believe that the assistance play an immense role in completing the project as I had planned. The preceptor has also been willing to spend extra time to guide me through and she is readily available to give insights through an open channel of communication via email, text, phone, as well as in person.
Review of various studies has shown a concerted effort in the endeavor to put in place measures to reduce the incidence of VAP. Improvement of oral care, the ventilation discontinuation and extubation have shown remarkable improvements. Despite the progresses in the evidence-based studies, VAP has remained to be a challenge in the ICU, and it is a major contributor to increased hospital stay, morbidity and mortality rates. As a result, projects to sensitize health personnel on ways to reduce the incidences of VAP through oral care, ventilation discontinuation and extubation can contribute in better care delivery.
Frost, P., & Wise, M. (2008).Tracheotomy and ventilator-associated pneumonia: the importance of oral care. European Journal of Respiration, 31(1), 221-224.
Oliveira, J., Zagalo, C., & Cavaco-Silva, P. (2014). Prevention of ventilator-associated pneumonia. Revista Portuguesa de Pneumologia, 20(3), 152-161.
Prendergast, V., Hallberg, I. R., Jahnke, H., Kleiman, C., & Hagell, P. (2009). Oral health, ventilator-associated pneumonia, and intracranial pressure in intubated patients in a neuroscience intensive care unit. American Journal of Critical Care, 18(4), 368-376.
Seckel, M. A. (2010). AACN protocols for practice. AACN Advanced Critical Care, 17(4), 460-461.