Evidence Based Practice
Western Governors University
Tracy Wallace

Hospital-acquired pneumonia has a very high morbidity and mortality rate here in the United States and is the second most common nosocomial infection. HAP consists of approximately fifteen percent of all hospital-acquired infections and occurs in five to fifteen percent of every 1,000 admissions. Critical care nurses are presented with unique challenges when caring for patients who are at risk for developing VAP. Strategies must be developed using evidence-based practice and incorporated into daily care in order to prevent VAP in patients receiving mechanical ventilation. ICU Doctors, Nurse Educators and the DON on the ICU unit are currently responsible for our current oral care practice. Our hospital is currently using (OAG), which stands for Eiders’ Oral Assessment Guide, it measures a patient’s oral health status and the frequency of oral hygiene. This tool measures oral health by using 8 different categories: swallow, lips, tongue, saliva, mucous membranes, gingiva, teeth, and voice. They are graded 1 (best), 2, or 3 (worst). Normal findings would be a score of 8, whereas 24 would be the total worst score in all 8 categories. I will now explain how using evidence based practice and OAG can improve the oral health of patients on ventilators. The conclusion will be supported by the research that I have obtained in this research project, which is decreasing the risk of pneumonia on patients who are on ventilators. The provided back ground information was relevant and direct. Hospitals could save millions of dollars by preventing nosocomial infections and using evidence based practice to do so.
This particular study was intended to show this, that VAP can be prevented. The goal was to prove that by decreasing the amount of microorganism in the mouth and throat that cause infection, that HAP could be decreased, or even prevented in some cases.
Ethics were addressed during this research. Change can be difficult, so one way to involve key stake holders in the decision to change the current practice of oral care to comply with the recommended change, would be to have the Infection Control department meet with nurses, doctors and performance improvement, to discuss and explain the study and the proposed changes. Explain to them that in this study, there were very strict criteria, in order to be enrolled. To be eligible for the research project, the patient had to be intubated for more than 48 hours and be admitted into the ICU unit. Although there was not a discussion for an informed consent for this study, the consent for treatment that was signed during the admission process may include consent for study. Ventilated patients are considered a vulnerable population, and this study would not do any harm to the patient. In our first group study, the patients received oral care using foam swabs dipped in a mixture of saline and hydrogen peroxide. We choose the foam swabs because they are more flexible than a toothbrush and are easier to manipulate around the curvatures in the mouth, the only problem is that they do not remove as much plaque as a toothbrush does. Research has found that patients who mouth breath have adapted well in using tongue scrappers, due to the tongue being the major source malodor and halitosis. Manual toothbrushes have been proposed as the ideal method of promoting the oral hygiene of orally intubated patients (Chan E, Ruest A, Meade, 2011). Due to the electric toothbrush having an oscillating rotary head and a smaller surface area, it has been found to minimize the manual dexterity needed to clean the teeth and gingival margins and it makes it easier to navigate around the oral area. Oral health in the ICU setting may also be influenced by the type of toothpaste used. Tooth paste with fluoride is often used due to its ability to resist decay on tooth enamel, but the problem arises when the oral cavity is not thoroughly rinsed and the tooth paste adheres to the teeth and oral mucosa, causing a xerostomic condition that can lead to mucosal desquamation. Thus, during intubation, ordinary toothpastes may not be the product of choice. Toothpastes free of sodium lauryl sulfate are commercially available. These toothpastes and alcohol-free oral care products contain moisturizing polymers and are specifically formulated for patients with xerostomia. In order to make the research as accurate as possible, the groups were as close in size and character as possible, such as age, sex, APACHE score and comparable hospitalizations. Proposing a change can be a difficult challenge, and barriers can occur, such as, finding a suitable time that everyone can attend, the analysis can be very time consuming, and another barrier is that there may not be a skilled facilitator available to make sure that everyone is able to express their views. It is very important to provide the stake holders with evidence based practice results, so that can see the importance for the proposed change, which is very time consuming. One of the biggest barriers to change is that not all stake holders are willing to make a change. Changing clinical practice can cause a lot of upset patients and staff members. Another barrier to change are Nurses. Some feel that “They already have enough to do.” Nurses may threaten to leave the unit. Malpractice lawsuits could arise due to not treating the patient right away when it is needed. Strategies should be in place to overcome these barriers like, providing proof through EBP, and by allowing all persons involved in the care to see for themselves that the change is needed, in order to provide the best care possible to the patients, and also to decrease medical cost due to nosocomial infections and even death. Another way to overcome barriers would be to observe current clinical practice in action, and document the incidence of VAP. Then, observe the new practice, document the incidence of VAP, and compare the results. Did the incidence of VAP decrease with the new practice, increase, or did it stay the same? Once it is determined that VAP decreased, and all stake holders decide to implement this process, then the staff must be educated as how they came to the conclusion that change was needed and then the staff must be educated on how to perform the new process. Education using CD-ROM, leaflets and booklets are a very good way to educate staff. Booklets can be carried with the staff for future reference, and education materials raise awareness of the desired change. Explain the rationale behind the change, which is to decrease VAP in intubated patients. Show the stall the before and after results. When people understand the reason or rationale for the change, then the change becomes more widely accepted by staff members, therefore implementing this new process into their daily activities doesn’t seem like “just another assignment.”
(A2) Background Information
The risk of developing VAP is largely increased by colorizations of microbes in the mouth where pathogens settle in dental plaque. The oral flora changes within 48 hours of admission on patients in ICU. Most of the changes are due to gram-negative and other virulent organisms, according (Sessler CN). The oral mucosa and dental plaque can also provide an environment that attracts pathogens such as MRSA and Pseudomonas aeruginosa, which attacks the respiratory system. According to (Resar R, Pronovost ),the higher a person’s dental plaque score, the greater risk they have of developing VAP. They also determined that the level and volume of salivary lactoferrin also contributes to VAP due to it influencing oropharyngeal colonization. Results were presented from a meta-analysis of 11 trials that included 3242 patients receiving mechanical ventilation who were treated with oral application of antibiotics or antiseptics or with placebo or standard oral care alone indicated that the incidence of VAP was significantly reduced by use of oral antiseptics, such as chlorhexidine (relative risk, 0.56; 95% CI, 0.39–0.81), but not by oral applications of antibiotics (relative risk, 0.69; 95% CI, 0.41–1.18). The purpose of this study was to prove that there was a decrease in ventilator acquired pneumonia on patients who had oral care using an electric toothbrush for 2 minutes twice daily plus treated with oral application of antibiotics or antiseptics and has been deemed superior to a manual toothbrush for removing dental plaque and improving gingival health, Integrity and respect were given to each individual who were part of the study as their personal information was not released when results were published.
(A2) Methodology
A longitudinal quantitative descriptive study was used in this particular group study and provided information from an annual rate between nurses and physicians. The statistics that were analyzed were based on the number of patients who were on ventilators and on those who acquired pneumonia compared to those who didn’t and based on who received oral care using a standard toothbrush and toothettes verses and those who received oral care using an electric tooth brush, and the rational of the staffs’ decisions as to whether or not they received it or didn’t.

(A2) DATA ANALYSIS
The nature of the study was quantitative and consisted of 779 patients being studied before any interventions began. These patients received oral care using a standard toothbrush, toothettes, hydrogen peroxide and fluoride tooth paste verses those who received oral care using an electric toothbrush and toothpastes free of sodium lauryl sulfate, these toothpastes and alcohol-free oral care products contain moisturizing polymers and are specifically formulated for patients with xerostomia. During the intervention, 759 patients were studied, and all were given oral care per strict protocol such as every 12 hours and as needed. Because the study was not based on a phenomenon, I feel like a qualitative method worked best verses a quantitative method of study. References: Sessler CN. Effect of backrest elevation on the development of ventilator-associated pneumonia. Am J Crit Care. 2010;14(4):325–332
Chan E, Ruest A, Meade, 2011. Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD). Intensive Care Med. 2011;23(2):187–195.
Resar R, Pronovost., improving ventilator care process and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2012;31(5):243–248