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Research Critique

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ORAL CARE AND PNEUMONIA

References
Arroliga, A. C., Pollard, C. L., Wilde, C. D., Pellizzari, S. J., Chebbo, A., Song, J., & ... Meyer, T. (2012). Reduction in the Incidence of Ventilator-Associated Pneumonia: A Multidisciplinary Approach. Respiratory Care, 57(5), 688-696.
Abstract

BACKGROUND: We report the process implemented in our institution by a task force focused on the reduction of ventilator-associated pneumonia (VAP). METHODS: Retrospective cohort study of all adults admitted to one of our 4 adult ICUs, intubated on invasive mechanical ventilation. We implemented a ventilator bundle in April of 2007; we report the incidence of VAP in 2008, and, after adjustment in the process (oral care performed by respiratory therapists), the incidence in 2009. The primary outcome was reduction of the microbiologically confirmed VAP rate over a 2 year period. Other outcomes were duration of mechanical ventilation, antibiotic days, ICU and hospital stay, and mortality. RESULTS: During the study period, 2,588 patients received invasive mechanical ventilation in the adult ICUs. The VAP rate during 2008 was 4.3/1,000 ventilator days, and the 2009 rate was 1.2/1,000 ventilator days. The 2008 to 2009 VAP rate ratio was significantly greater than 1 (rate ratio 3.6, 95% CI 1.8-8.0, P < .001). Antibiotic days were less in 2009 versus 2008 (Hodges-Lehmann estimate of difference between 2008 and 2009, 1.0, 95% CI 0.0 -1.0, P = .002). The median stay in the ICU was unchanged, and in the hospital was decreased in 2009 (Hodges- Lehmann estimate of difference between 2008 and 2009, 1.0, 95% CI 0.0 -1.0, P < .001). The hospital mortality was 26.1%, and there was no difference between the 2 years. Adherence with the ventilator bundle was above 92% during the study period, but the oral care adherence improved from 33% to 97% after respiratory therapists assumed oral care. CONCLUSIONS: Reduction of the incidence of VAP occurred with an intervention that included respiratory therapists doing oral care in patients receiving invasive mechanical ventilation. Oral care done by respiratory therapists may be associated with reduction of VAP.

References
Soh, K., Soh, K., Japar, S., Raman, R., & Davidson, P. (2011). A cross-sectional study on nurses' oral care practice for mechanically ventilated patients in malaysia. Journal Of Clinical Nursing, 20(5/6), 733-742. doi:10.1111/j.1365-2702.2010.03579.x
Abstract
This study sought to determine the strategies, methods and frequency of oral care provided for mechanically ventilated patients in Malaysian intensive care units. The study also described nurses' attitudes to providing oral care and their knowledge of the mode of transmission of ventilator-associated pneumonia. Oral care is an important nursing intervention in the intensive care unit to reduce dental plaque. Dental plaque provides a repository for respiratory pathogens contributing to ventilator-associated pneumonia in the critically ill. Cross-sectional study. This study used both survey and observational methods. The observational study was conducted by a nurse, trained in the study protocol. The observation period a selected shift over three weeks in 2007. Intensive care unit nurses ( n = 284) participated in the survey. Respondents had a positive attitude towards providing oral care. On a 10-point Likert scale, aspiration of contaminated secretions from the oropharynx was identified by nurses as the highest risk factor for ventilator-associated pneumonia (mean response 6·8, SD 2·0). The majority of nurses used cotton and forceps for oral care. Toothbrushes were not used in any of the study sites. Although nurses had a positive attitude to oral hygiene, this study found no intensive care units incorporated a soft toothbrush in oral care protocols which is recommended in best practice guidelines. A review of strategies to implement evidence-based practice in the intensive care unit is warranted. This study has identified a failure to adhere with evidence-based practice. Implementing and evaluating protocols for oral hygiene in the intensive care unit has the potential to improve patient outcomes

References
Durgude, Y., & Cocks, N. (2011). Nurses' knowledge of the provision of oral care for patients with dysphagia. British Journal Of Community Nursing, 16(12), 604-610.
Abstract
There has been little research on the provision and adaptation of oral care for patients with dysphagia in nursing homes. This study collected data via a questionnaire specifically on the knowledge of oral hygiene and the current oral care practices for patients with dysphagia. Fifty-three registered nurses (RNs) completed the questionnaires. The results of the questionnaire indicated that although RNs gave more oral care daily to their patients with dysphagia than to their patients without dysphagia, they had limited knowledge of drugs that affect oral care and of medical conditions associated with poor oral hygiene. Of particular concern was the limited knowledge of the link between dysphagia, oral hygiene and pneumonia and that some of the current oral care practices may be putting patients who have dysphagia at increased risk of developing pneumonia. These results are discussed in light of previous research on the topic and recommendations are made with regards to oral care training.

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