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- 1Intensive Care Unit
- 2Quality Improvement Advocate, Good Shepherd Hospital Barrington, Illinois, USA
During the fall of 1999, an article appeared in the American Journal of Critical Care highlighting the importance of oral care. Using this article as a catalyst, the intensive care unit (ICU) clinical practice council conducted a detailed literature search. The findings of this search were compared with current practice, and opportunities for improvement were identified.
Studies have documented that patients in medical ICUs have poorer oral hygiene than non-hospitalised patients. This lack of oral hygiene contributes to the development of oral colonisation. Additionally, oral bacteria aspirated into the lung may result in aspiration pneumonia. Specifically, potential pathogens for ventilator associated pneumonia (VAP) are noted to be present in oral secretions in 67% of patients orally intubated for ⩾24 hours. Also, after 24 hours, most suction equipment is colonised with many of the same pathogens cultured from secretions.
Pneumonia is the second most common hospital associated infection and the leading cause of nosocomial death. Healthcare associated pneumonia increases a patient’s length of stay in the ICU by 6.1 days and hospitalisation by 10.5 days. This increase in length of stay and need for empiric antimicrobial treatment significantly impacts costs. The primary cause of healthcare associated pneumonia is mechanical ventilation. The estimated average costs associated with ventilator associated pneumonia are $29 369.
ORAL CARE POLICY/PROCEDURE
Appropriate oral care may be a preventative measure against acquiring VAP. A review of current practice demonstrated that foam swabs were the oral care tool of choice, and the frequency and method of oral care varied. The need for a comprehensive oral care procedure was identified.
A critical care clinical nurse specialist and an ICU registered nurse revised the hospital’s oral care policy and procedure. Current research and literature were used to develop this policy. To change practice, all staff were educated on the new policy and procedure, and the following points were communicated. Plaque allowed to accumulate along and below the gingival margin is reported to cause tissue changes within 2–4 days. Brushing a patient’s teeth is needed to prevent the formation of plaque, which can be a reservoir for pathogens. A soft suction toothbrush should be used minimally twice a day. Oral care is performed every 2–4 hours. Foam swabs can be utilised between brushings; they are effective for stimulation of mucosal tissues but are minimally effective in removing plaque. The antiseptic oral rinse is a 1.5% hydrogen peroxide mouth rinse for oral cleansing and reduction of respiratory pathogens. A dedicated oral suction line and covered tonsil suction device are required. The subglottic suction catheter is a single use catheter allowing removal of secretions above the cuff. No other change in practice related to preventing healthcare associated pneumonia was implemented at this time.
A major barrier to performing proper oral care was the lack of appropriate equipment. The staff worked with a manufacturing company to improve and develop oral care products.
Improving oral care for mechanically ventilated patients was expected to improve the patient’s oral health and comfort and decrease colonisation of respiratory pathogens. Measures were selected to evaluate compliance with the new oral care procedure and its impact on patient outcomes. 100% of mechanically ventilated patients in the ICU were included. The following measurements were utilised: (1) VAP rate, (2) frequency of providing oral care, (3) actual product use, and (4) product evaluation.
The first indicator measures the rate of VAP. Diagnosis was based on National Nosocomial Infections Surveillance System (NNIS) criteria. Baseline data for the previous 24 months were placed on a u-control chart and demonstrated common cause variation. Therefore, the process was in statistical control. The VAP rate during the baseline period was 5.6 VAPs per 1000 ventilator days. After implementation of the new oral care policy and procedure, the rate dropped to 2.0 VAPs per 1000 ventilator days. Comparative mean reference rates from the NNIS database were 9.9 and 8.7. 33 months of post-implementation data were placed on the u-control chart and demonstrate a positive shift in the process.
Also measured was the frequency of oral care pre-implementation and post-implementation. 71% of the nursing staff participated in this data collection. Prior to implementation, 60% of nurses reported that oral care was provided ⩾4 times per shift. After implementation of the new oral care policy and procedure, 93% of nurses provided oral care ⩾4 times per shift. The use of a toothbrush also correspondingly increased.
During the first 11 months of 2001, actual product usage was measured and compared with the projected product use per ventilator day. Actual oral care product use was 91% of predicted product use. This confirmed that the frequency of oral care and toothbrush use for the mechanically ventilated population had increased. The goal of changing practice was achieved.
The final indicator was to measure nursing staff’s satisfaction with the new oral care products. 76% of the ICU staff completed the survey. 94% indicated that the oral care system is easy to assemble, easy to use, efficient, and allows complete oral cleansing. 83% agree that this system saves time. The overall results indicate staff’s satisfaction with the redesigned oral care products.
After publication of the above study in the Advocate Journal of Health Care (Spring/Summer 2002), professional journals showed a repeated interest in oral care. Additional articles regarding the Advocate, Good Shepherd Hospital study are found in Geriatric Nursing (2002), RT The Journal for Respiratory Care Practitioners, and Hospitalist & Inpatient Management Report. Publications occurring in various medical journals targeting different audiences proved how important this patient outcome was to many disciplines.
Throughout this process, the following question must be asked: how is evidenced-based practice finalised? Currently, the Advocate, Good Shepherd Hospital study and several other research based outcome studies have been submitted to the Centers for Disease Control for consideration into their “Guidelines for Health-care Associated Pneumonia”. Submission to these guidelines would solidify the importance of oral care. Clinical excellence, however, can only be measured when care is actually performed, and positive patient outcomes are obtained.