Brushing Away Ventilator-Associated Pneumonia

One Evidence-Based Protocol Doesn't Fit All: Brushing Away Ventilator-Associated Pneumonia in Trauma Patients

Johnson K, Domb A, Johnson R
Intensive Crit Care Nurs. 2012;28:280-287

Oral Hygiene in Ventilator-Associated Pneumonia Prevention

Ventilator-associated pneumonia (VAP) is a common and preventable cause of morbidity and mortality in hospitalized patients. Johnson and colleagues examined the effectiveness of an oral hygiene regimen in reducing rates of VAP in trauma patients. They also examined the relationship between nurses' knowledge and attitudes about oral hygiene protocols, and between VAP and frequency of oral hygiene.

Methods. The study was conducted in the cardiovascular critical care and trauma critical care units at a level 1 community hospital. All registered nurses who provided direct patient care were eligible to participate. Eligible patients were adults who required endotracheal intubation for mechanical ventilation, excluding those with an admission diagnosis of pneumonia.

Patients were retained in the study until 48 hours after discontinuation of the ventilator or until they were discharged from the unit. Nurses completed a 27-item survey to measure attitudes, training, and perception regarding availability of materials and education about oral care practices.

During the study period, critical care educators conducted walking rounds to educate nurses about the oral care protocol. The researchers then conducted random observations to monitor for adherence to the protocol, which called for brushing every 12 hours or use of oral swabs every 4 hours; 75% of participating staff were observed. Finally, monthly VAP rates per 1000 ventilator-days were calculated before and after intervention.

Findings. The postintervention surveys indicated that after the study, nurses were more aware of the importance of preadmission oral colonization in the etiology of VAP. After the intervention, nurses were significantly more likely to report that they had received adequate training in oral hygiene. Moreover, the nurses were more likely to report that necessary oral hygiene supplies were readily available on their units, even though there was no change in the availability of supplies before and after the intervention. These changes in attitude were accompanied by significant changes in the observed frequency of oral hygiene.

Overall VAP rates declined from 4.9 cases per 1000 ventilator-days before the intervention to 2.7 cases per 1000 ventilator-days after the intervention. However, when analyzed by unit, it became clear that the overall reduction was a result of a statistically significant reduction in VAP rates in medical/surgical patients; VAP rates in trauma patients actually increased slightly.

Viewpoint

Preventing VAP is of critical importance, and to this end, several VAP prevention bundles have been promulgated by professional and governmental associations. Most -- although not all -- include an oral hygiene component. Although trauma patients are at an increased risk for development of early, late, and immunocompromised VAP, the same factors that increase risk (a higher incidence of head and neck injuries, neurologic deficits, emergency intubations, and a systemic inflammatory response) may also lessen the effectiveness of prevention strategies.

This one small study in a single institution cannot and should not change the focus on widespread implementation of bundles that include oral hygiene. However, it adds evidence to the investigators' conclusion that VAP prevention cannot be a one-size-fits-all strategy and that further evidence in broad populations of patients must be developed. The findings also lend weight to the argument that nurses' attitudes and education influence the adherence to oral hygiene practices and must be part of the solution.

Abstract