Original article
The impact of an evidence-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia

https://doi.org/10.1016/j.iccn.2006.11.006Get rights and content

Summary

Background

Despite strong evidence in the literature on the role of oral care in the prevention of ventilator-associated pneumonia (VAP), nurses continue to view oral care as a comfort measure with low priority and utilise foam swabs rather than toothbrushes. Although an evidence-based oral care protocol existed and best-practice oral care tools were available, the VAP rates had not significantly decreased even though nurses reported providing oral care.

Objectives

The aim of the study was to determine if an evidence-based practice (EBP) educational programme would improve the quality of oral care delivered to mechanically ventilated patients; thereby, reducing the VAP rate.

Results

Improvement in oral health was demonstrated by a decrease in median scores on the Oral Assessment Guide (pre (11.0), post (9.0)). A t-test analysis revealed a statistically significant difference (p = 0.0002). The frequency of oral care documentation also improved as demonstrated by a positive shift to the more frequent timeframes. The VAP rates have decreased by 50% following the EBP education intervention.

Conclusions

The implementation of an EBP educational programme focused on patient outcome rather than a task to be performed improved the quality of oral care delivered by the nursing staff.

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

References (16)

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