Oral Care Intervention to Reduce Incidence of Ventilator-Associated Pneumonia in the Neurologic Intensive Care Unit

Lorraine B. Fields


J Neurosci Nurs. 2008;40(5):291-298. 

In This Article

Abstract and Introduction

Ventilator-associated pneumonia (VAP) is a preventable secondary consequence of intubation and mechanical ventilation. VAP is pneumonia that develops in an intubated patient after 48 hours or more of mechanical ventilator support. Mechanically ventilated patients in neurologic and other intensive care units (ICUs) are at an increased risk of VAP due to factors such as decreased level of consciousness; dry, open mouth; and microaspiration of secretions. VAP can be prevented by initiating interventions from the Institute of Healthcare Improvement's VAP bundle, including (a) elevating the head of the bed of ventilated patients to 30˚, (b) preventing venous thromboembolism through use of sequential compression devices or anticoagulation, (c) administering gastric acid histamine2 blockers, (d) practicing good hand hygiene, (e) initiating early mobilization, and (f) performing daily sedation interruption at 10 am to evaluate neurologic status. The one intervention not included in the IHI bundle is oral hygiene. The purpose of this project is to support the premise that oral care, including timed toothbrushing, combined with the VAP bundle can mitigate and prevent the occurrence of VAP. Our project specifically addressed timed oral care of mechanically ventilated patients on a 24-bed stroke, neurologic, and medical ICU. Patients were randomized into a control group that performed usual oral care or an intervention group that brushed teeth every 8 hours. The results were immediate and startling, as the VAP rate dropped to zero within a week of beginning the every-8-hours toothbrushing regimen in the intervention group. The study was so successful that the control group was dropped after 6 months, and all intubated patients' teeth were brushed every 8 hours, maintaining the zero rate until the end of the study.

Ventilator-associated pneumonia (VAP) is a preventable secondary consequence of intubation and mechanical ventilation and is the most common nosocomial infection in mechanically ventilated patients (Barclay & Vega, 2005; National Nosocomial Infections Surveillance System, 2000). Summa Health System, a 925-bed, level I trauma center in Akron, OH, embarked on a performance improvement (PI) project to decrease the incidence of VAP as part of The Institute of Healthcare Improvement's (IHI's) Protecting 5 Million Lives campaign. The campaign consists of evidence-based interventions including best practices in several disease processes such as VAP. The groups of interventions are called bundles. The goals of the IHI bundles are to improve treatment of specific disease processes and improve patient outcomes. Summa Health System embraced several of these bundles, the most successful of which was the VAP bundle, which decreased the VAP rate from 4.265% to 0% within 6 months.


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