After reading this article, you will be able to:
- Describe oral care programs that helped two facilities lower ventilator-associated pneumonia (VAP) rates
- Discuss strategies for educating staff members about VAP prevention processes
The Institute for Healthcare Improvement (IHI) states that VAP kills more patients every year than any other hospital-acquired infection (HAI), and 46% of those diagnosed with the condition die from it.
Once considered a likely outcome for patients put on ventilators, evidence-based practice has shown that with a few key steps, nursing practice can help reduce—if not eliminate—VAP at your hospital.
“Nurses are the gatekeepers for the patients. They protect them and they get things done,” says Carrie Sona, RN, MSN, CCNS, surgical critical care clinical nurse specialist at Barnes-Jewish Hospital (BJH) in St. Louis. “Success wouldn’t happen without nurses.”
Sona coauthored a yearlong study at BJH showing that oral care for patients on ventilators can help reduce incidents of VAP by at least 50%. Nurses at BJH brush patients’ teeth and apply mouthwash every 12 hours for patients on ventilators, preventing bacteria in the mouth from being aspirated and ending up in the lungs.
Before BJH started the study in 2004, the surgical/burn/trauma ICU had 5.2 cases of VAP per 1,000 ventilator days. At the end of the study, that number was reduced to 2.4 cases per 1,000 ventilator days. Today, it is down to 1.5 cases per 1,000 ventilator days.
A proven bundle, plus
BJH nurses followed VAP prevention guidelines issued by the Centers for Disease Control and Prevention (CDC) and the IHI before the hospital began its oral care research.
“Our goal has always been to get to zero,” says Lynn Schallom, RN, MSN, CCNS, coauthor of the BJH study and surgical critical care clinical nurse specialist. “And when our program wasn’t getting [the VAP rate] to zero, we asked, ‘What else can we do?’ We were following the CDC guidelines and pretty much doing all of the high-grade interventions. But there were other lower-level recommendations that we weren’t doing, and one of those was oral care.”
A multidisciplinary team of clinical staff members formed from the unit’s quality improvement group, including staff nurses, nurse managers, and physicians, decided that brushing teeth and using mouthwash was a fairly inexpensive but effective way to prevent bacteria buildup and give ventilator patients a better chance of avoiding the HAI.
Oral care’s effect on VAP rates has been studied before, but results have been inconclusive.
“Our infection control specialist and I went through a lot of oral care literature, and it’s very obvious that there has been quite the variance in practice. There was no standardized way of providing oral care,” Sona says.
Nurses at BJH now brush the teeth and rinse the mouths of patients on ventilators every 12 hours and document their practice.
A new routine
A strong focus on oral care was also critical to the reduction in VAP at Doylestown (PA) Hospital, says Tish Lawson, MSN, RN, clinical process improvement specialist at the 200-bed hospital. Using the IHI bundle (see the sidebar on p. 5), along with oral care and limited use of saline lavage, the hospital was able to bring its VAP rate down from 11.9 cases of VAP per 1,000 ventilator days in 2003 to 0.78 cases per 1,000 ventilator days at the end of 2008.
Asking already overstretched nurses to add more to their daily routine can sometimes be met with resistance, but at BJH and Doylestown, staff educators focused on each step in the prevention process and how it would keep patients safe.
“We put up a fairly large poster board that had all the steps clearly described and our expectation for the staff,” says Lawson, who was Doylestown’s educator at the time the new protocol was implemented. “We also brought in a speaker who gave a continuing education lecture about pneumonia itself, how it’s acquired in the hospital, and outlined steps for prevention.”
Documentation aided nurses in remembering each of the new steps. Nurses were required to document each step as it was completed, allowing nurse managers to provide feedback about how they were doing.
“When there is a process change, it is very difficult to remember the new process if the process changes are not hardwired,” Lawson says. “Providing them measurement of the process elements and the outcomes helps reinforce the changes.”
According to Lawson, the following items can assist facilities in shifting a long-held process:
- A baseline measurement of the process you are trying to change.
- A way to measure the progress of the process change.
- Posted results and timely feedback to staff members.
- Celebration of success when improvement milestones are reached.
- Use of control charts to measure the process over time. Lawson says long-term results will keep natural variations from putting a negative spin on performance. Also, charts that show performance over time will allow you to easily see a drop in performance.
Weighing the evidence
Several studies from the late 1980s and early 1990s showed success in reducing cases of VAP with oral care for patients on ventilators. Although more recent studies haven’t been as conclusive, Lawson says, Doylestown decided to make oral care a key part of VAP prevention.
Another key for Doylestown was teaching its nursing staff to only suction ventilated patients when necessary, a step that was called a “sacred cow that should be put out to pasture” in an April 2008 Critical Care Nurse article. Other research has reinforced that use of saline lavage can introduce bacteria to the endotracheal tubes, priming the patient to develop VAP.
Spend a little, save a lot
Eliminating VAP is more than an issue of patient safety in hospitals. The cost of treating patients with VAP starts at $40,000, and although the Centers for Medicare & Medicaid Services hasn’t yet made it a no-pay condition, VAP has already been on the list of considered conditions twice.
The research committee at BJH calculated that providing oral care to patients in its surgical and trauma ICU costs less than $1 per day. Providing oral care every 12 hours cost the hospital approximately $2,200 during its study—small change when compared to the cost of treating a patient with VAP.
In addition, Schallom estimates that their oral care efforts saved their unit $27,000.
Rauen, C., et al (2008). “Seven Evidence-Based Practice Habits: Putting Some Sacred Cows Out to Pasture.” Critical Care Nurse 28 (2): 98–124.
Adapted from The Staff Educator, January 2009, HCPro, Inc.