Original articleThe impact of an evidence-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia
Introduction
The evidence in the literature is robust on the role of oral care in the prevention of ventilator-associated pneumonia (VAP), yet nurses continue to believe oral care is a comfort measure (Grap et al., 2003, Kite, 1995, Munro and Grap, 2004), unpleasant (Furr et al., 2004, Kite, 1995) and prioritize as such (Grap et al., 2003, Hixson et al., 1998, Jones et al., 2004, Kite, 1995, McNeill, 2000, Munro and Grap, 2004). Despite the evidence that toothbrushes are superior in the removal of dental plaque, nurses still prefer to use foam swabs (Cutler and Davis, 2005, Grap et al., 2003, Jones et al., 2004, Kite, 1995, Sole et al., 2003). Additionally, the fast paced, high-tech, low-touch environment of the intensive care unit has overshadowed the hands on provision of basic nursing care (Simmons-Trau, 2006).
Although there was an existing best practice oral care protocol for the mechanically ventilated patients in the institution and the best-practice tools available to provide the care, the VAP rates had not decreased since implementation even though nursing staff reported providing the oral care. It was thought if the oral care was being provided as described in the protocol, then the VAP rates would have declined. The VAP rate is reported as the number of infections per 1000 ventilator days and is defined by the National Nosocomial Infection Surveillance (NNIS) System (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention) as the first positive bacterial respiratory culture finding 48 h after the onset of mechanical ventilation (Tablan et al., 2004).
In order to determine the quality of oral care being delivered, an oral assessment would need to be conducted. Moreover, the frequency of oral care documentation would need to be reviewed as disparities are known to exist between what nurses report versus what is documented (Cutler and Davis, 2005, Grap et al., 2003). The hypothesis was if the nursing staff were able to see the “big picture” or in other words the evidence on the role of oral care in the prevention of VAP rather than just another task to be performed, there would be improvement in the oral care provided; thus, a decline in the VAP rates. To promote the change from task to outcome orientation, an evidence-based education programme was developed to answer the research question: does an evidence-based practice education programme on the role of oral care in the prevention of VAP improve oral care?
Evidence-based practice (EBP) refers to the “conscientious, explicit and judicious use of theory-derived, research-based information in making decisions in care delivery” to patients (Fain, 2004, p. 75). Using EBP provides a consistent approach to quality patient care thereby resulting in less variability (Ervin, 2005). The major components of the EBP education programme were a review of the literature on the role of oral care in the prevention of VAP and a competency checklist inclusive of an observed performance of oral care by each member of the staff. Feedback was given during the observation. The intent of this method of education was to improve nursing staff skills and strengthen areas of their practice that would result in improved patient outcomes (Ervin, 2005).
Section snippets
Methods
This quantitative study with a pre- and post-intervention design was conducted at an 854 bed tertiary academic medical centre in the southeastern United States. The population studied consisted of all adult intensive care unit patients mechanically ventilated for at least 24 h. The adult intensive care units consist of pulmonary/medicine, general surgery, vascular surgery, cardiothoracic surgery, neurosurgery and trauma patients. The total bed capacity for these units is 75. An assessment of the
Data/results
Patients mechanically ventilated for at least 24 h in any of the adult intensive care units were included in the sample. The pre-education sample size was 55. Three patients were excluded (N = 52) from the oral care assessment for inability to visualise the oral cavity, i.e. bite blocks and patient uncooperativeness. In the post-education phase, the sample size was 61. A total of four patients were excluded (N = 57) from the oral assessment for inability to visualise the oral cavity, i.e. jaws
Discussion
There are several limitations in this study. The convenience sample in addition to the small size limits generalisability. Yet, in spite of the sample size, a statistically significant difference exists. The modified OAG used in this study has not been validated in the critical care setting with mechanically ventilated patients. Furthermore, the OAG was designed to obtain a baseline assessment and to follow patients along a continuum of care to guide oral care needs. In this study, a baseline
Conclusion
The EBP educational programme demonstrated an improvement in the quality of oral care provided to the patients in the adult intensive care units as indicated by the decrease in the median OAG scores. Futures studies are needed in this patient population to validate the modified OAG tool. Based upon our statistically significant results, we recommend an EBP educational programme that reinforces the role of oral hygiene in the prevention of nosocomial infections among mechanically ventilated
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Interventions to promote oral care regimen adherence in the critical care setting: A systematic review
2022, Australian Critical CareCitation Excerpt :Outcome measures were primarily related to oral care adherence behaviours, level of oral care knowledge, beliefs, self-report of oral care adherence, and recordings documented in electronic medical records. This included preintervention and postintervention auditing of oral care documentation,30,31,34,36,39,41,43–46 observation of oral care being completed using structured checklist,33 audit of oral care product supplies used,37 or a combination of these strategies.35,38,40,42,48,49 Oral care adherence was measured as a proportion of actual oral care provision contrasted to prescribed criteria for oral care,31–34,36,39–41,43,44,48,49 frequency of reported oral care delivery,30,35,38,46,50 or percentage of oral care supplies used.37,42
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2020, International Journal of Nursing StudiesImpact of an education program on the performance of nurses in providing oral care for mechanically ventilated children
2019, Australian Critical CareCitation Excerpt :Some researchers have acknowledged that tools such as checklists can increase adherence to evidence-based practice guidelines.30 The effectiveness of using clinical practice guidelines in the reduction of ventilator-associated infections has been suggested in a study on adults.19 The checklist was developed for three age groups and according to the teeth development chart of the children: (i) infants aged less than 1 year with no teeth; (ii) infants aged less than 1 year with teeth; and (iii) children aged above 1 year with teeth.
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2013, Intensive and Critical Care NursingEffectiveness of educational programmes in preventing ventilator-associated pneumonia: A systematic review
2013, Journal of Hospital InfectionCitation Excerpt :The primary clinical outcomes were the incidence of VAP (87.5%), causative micro-organism (75.0%), crude mortality (37.5%), length of stay (25.0%), and monthly hospital antibiotic and hospitalization costs (25.0%).20,21 The primary learning outcomes were nurses' level of knowledge (25.0%) and adherence to guidelines (37.5%).18–25 Educational programmes consisted of repeated (37.5%) or weekly lectures (12.5%), validated self-study modules (25.0%) or several brief and standardized sessions (75.0%), which dealt with the definitions, epidemiology, aetiology as well as pathogenesis and clinical outcomes of VAP, modifiable and non-modifiable risk factors and nursing interventions for the prevention of VAP.18–25
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