Journal of Intensive Care Medicine http://jic.sagepub.com/

The Impact of a Simple, Low-cost Oral Care Protocol on Ventilator-associated Pneumonia Rates in a Surgical Intensive Care Unit
Carrie S. Sona, Jeanne E. Zack, Marilyn E. Schallom, Maryellen McSweeney, Kathleen McMullen, James Thomas, Craig M. Coopersmith, Walter A. Boyle, Timothy G. Buchman, John E. Mazuski and Douglas J. E. Schuerer J Intensive Care Med 2009 24: 54 originally published online 17 November 2008 DOI: 10.1177/0885066608326972 The online version of this article can be found at: http://jic.sagepub.com/content/24/1/54

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Original Research

The Impact of a Simple, Low-cost Oral Care Protocol on Ventilator-associated Pneumonia Rates in a Surgical Intensive Care Unit

Journal of Intensive Care Medicine Volume 24 Number 1 January/February 2009 54-62 # 2009 SAGE Publications 10.1177/0885066608326972 http://jicm.sagepub.com hosted at http://online.sagepub.com

Carrie S. Sona, MSN, Jeanne E. Zack, PhD, Marilyn E. Schallom, MSN, Maryellen McSweeney, PhD, Kathleen McMullen, James Thomas, RN, BSN, Craig M. Coopersmith, MD, FCCM, Walter A. Boyle, MD, Timothy G. Buchman, MD, PhD, FCCM, John E. Mazuski, MD, PhD, and Douglas J. E. Schuerer, MD
Objective: The purpose of this study was to determine the effects of a simple low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Design: Preintervention and postintervention observational study. Setting: Twentyfour bed surgical/trauma/burn intensive care units in an urban university hospital. Patients: All mechanically ventilated patients that were admitted to the intensive care unit between June 1, 2004 and May 31, 2005. Interventions: An oral care protocol to assist in prevention of bacterial growth of plaque by cleaning the patients’ teeth with sodium monoflurophosphate 0.7% paste and brush, rinsing with tap water, and subsequent application of a 0.12% chlorhexidine gluconate chemical solution done twice daily at 12-hour intervals. Measurements and main results: During the preintervention period from June 1, 2003 to May 31, 2004, there were 24 infections in 4606 ventilator days (rate ¼ 5.2 infections per 1000 ventilator days). After the institution of the oral care protocol, there were 10 infections in 4158 ventilator days, resulting in a lower rate of 2.4 infections per 1000 ventilator days. This 46% reduction in ventilator-associated pneumonia was statistically significant (P ¼ .04). Staff compliance with the oral care protocol during the 12-month period was also monitored biweekly and averaged 81%. The total cost of the oral care protocol was US$2187.49. There were 14 fewer cases of ventilatorassociated pneumonia, which led to a decrease in cost of US$140 000 to US$560 000 based on the estimated cost per ventilator-associated pneumonia infection of US$10 000 to US$40 000. There was an overall reduction in ventilator-associated pneumonia without a change to the gram-negative or gram-positive microorganism profile. Conclusions: The implementation of a simple, low-cost oral care protocol in the surgical intensive care unit led to a significantly decreased risk of acquiring ventilatorassociated pneumonia. Keywords: pneumonia; oral care; plaque removal; chemical removal; mechanical removal

From the Departments of Nursing (CSS, MES, MM, KM, JT) and Infection Control (JEZ), Barnes-Jewish Hospital, St Louis, Missouri; and Departments of Surgery (CMC, TGB, JEM, DJES) and Anesthesiology (CMC, WAB, TGB), Washington University School of Medicine, St Louis, Missouri. Address correspondence to: Carrie S. Sona, MSN, Barnes Jewish Hospital, 1 BJH Plaza, Mailstop 90-59-346, St. Louis, MO 63110; e-mail: css1719@bjc.org.

Introduction
Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection and is a leading cause of morbidity and mortality in intensive care units (ICUs) with an estimated attributable mortality rate

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A Simple, Low-cost Oral Care Protocol / Sona et al 55

that ranges from 12% to 50%.1-10 Approximately 9% of mechanically ventilated patients develop VAP.4 This potentially fatal complication of mechanical ventilation can increase the patient’s length of stay (LOS) by up to 13 days and is estimated to cost US$10 000 to US$40 000 per infection.1,6,11,12 Because of these costly and serious complications and in an effort to meet patient safety initiatives, decreasing nosocomial infections has been a primary goal in ICUs across the country. The 2003 Centers for Disease Control and Prevention (CDC) Guidelines for Preventing Health-Care-Associated Pneumonia (HAP) recommendations focus heavily on strategies to decrease VAP.6 These best practice guidelines have all been previously implemented in our ICU and our education initiatives that led to a decreased VAP rate of 5.9 infections per 1000 ventilator days have been published.13 This educational program was aimed at nursing and respiratory therapy providers and addressed risk factors for the development of VAP, elevation of the head of the bed, hand hygiene, cost and incidence of VAP, and ventilator circuit maintenance among others.13 This educational intervention is mandatory for all new staff to the ICU and also an annual competency requirement. These interventions led to annual VAP rates in the years from 2000 to 2003 of 16.2, 6.1, 9.2, and 5.9 per 1000 ventilator days, respectively. To decrease VAP rates even further, the quality improvement (QI) team identified oral care practices in our ICU as an area for improvement. The hospital policy offered no specific guidelines on what products to use or how to perform oral care and it was inconsistently done. Bacterial colonization of the oral cavity is a risk factor for VAP and the primary mode of transmission of VAP appears to be microaspiration of pathogenic aerodigestive secretions in intubated patients.14-16 Bacterial colonization of the oral cavity by VAPcausing organisms occurs more rapidly in critically ill patients than in healthy participants.14,15,17 Removal of dental plaque can be achieved by either mechanical or chemical methods. Mechanical removal of plaque involves brushing the teeth using a toothbrush, a toothette sponge or swab with or without toothpaste. Despite evidence that brushing the teeth with a toothbrush and paste is superior to toothettes in removing oral plaque, toothbrushes are rarely used in intubated patients.18-24

The chemical or pharmacologic method uses antimicrobial agents applied topically to oral surfaces to reduce the formation of plaque. Several studies have been published on pharmacological interventions that reduce oral microorganisms, thereby decreasing VAP rates.25-36 The most successful pharmacological agent reported at reducing plaque and gingivitis is 0.12% chlorhexidine gluconate (CHX)–containing gel, paste, or solution.26-28,34,37 Chlorhexidine gluconate is a broadspectrum antimicrobial effective against gram-positive and gram-negative organisms including resistant organisms. Oral care in ICUs has historically been done at nurses’ discretion for patient comfort without specific guidelines or protocols.18-22,38,39 Two surveys and an observational study done on nursing staff from ICUs in the United States highlight the problems of inconsistent procedure, frequency, and documentation for oral care.18-20 Nurses believe that cleaning the oral cavity is difficult, is an unpleasant task, and have fears of dislodging endotracheal tubes.18,19,21 Based on the reviewed evidence, we implemented an oral care protocol of mechanical removal of plaque using hospital floor stock sodium toothpaste, active ingredient sodium monoflurophosphate 0.7%, and toothbrush done every 12 hours followed by the application of 0.12% CHX oral rinse. Outcome measures were protocol compliance, VAP rates, organism profile, and cost.

Materials and Methods
Study Location and Patient Population
Barnes-Jewish Hospital is a 1344-bed tertiary care, university-affiliated teaching hospital. All patients admitted to the surgical ICU (SICU) requiring mechanical ventilation between June 1, 2004 and May 31, 2005 were enrolled in the study. The SICU admits all non-cardiothoracic and non-neurosurgical critical care surgical and trauma patients in the hospital. Unit admissions during the 12-month preintervention were 1520 and during the study period were 1747. The average ICU LOS for intubated patients was constant throughout the study at 8.9 versus 9.8 days. Nursing and physician staffing ratios were also constant. Demographic data was retrieved from the Project IMPACT database (Cerner, Kansas City, Mo).

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Journal of Intensive Care Medicine / Vol. 24, No. 1, January/February 2009

Preintervention and throughout the study, all patients admitted to the SICU were prospectively followed for VAP by an infection control team. Ventilator-associated pneumonia is tracked by the infection control department and is defined using the National Nosocomial Infections Surveillance System (NNIS) criteria for VAP. Updates on the unit’s VAP rates were reported monthly at the unit’s QI multidisciplinary meeting. Monthly graphs were reviewed comparing preintervention rates within the SICU as well as published NNIS rates in comparable units. Two consistent team members calculated the VAP rate preintervention and postintervention. The study was approved by the Washington University in St Louis School of Medicine Human Studies Committee; informed consent was waived.

Study Design
All patients admitted to the SICU that required mechanical ventilation were eligible for the protocol. A preprinted order set was designed and placed in all admission packets. The attending and fellow medical staff of the unit were educated on the protocol through the SICU QI meeting. Monthly updates were provided to all incoming residents about the oral care protocol and order set. Education of the 80-member registered nursing staff was completed between April 1 and May 31, 2004. Two clinical nurse specialists (CNSs) and a nurse educator trained 3 groups of staff who then assisted in training the remaining staff members. Education content and materials included rationale and aims of the study, review of the preprinted order sets, written protocol, and pictorials demonstrating all steps of the procedure including documentation. The pictorials were laminated and placed in resource manuals at every patient bedside. The previously implemented interventions to reduce VAP were maintained in the same fashion as they had been done in the previous 5 years.13 No other interventions or studies were implemented between study periods. The ICU intensivist and nursing personnel were consistent. The protocol involved mechanical cleansing of the teeth or gums to remove plaque and application of an oral antimicrobial. Nurses brushed teeth for 1 to 2 minutes using floor stock brush and paste containing the active ingredient sodium monoflurophosphate 0.7% every 12 hours. The mouth was then

rinsed with tap water with an irrigating syringe and suctioned with an oral suction handle. For patients without teeth, nurses cleaned the gums with toothpaste on a foam sponge, and then rinsed with water and suctioned as above. Immediately following water rinse, 15 mL of CHX was applied to all oral surfaces using a foam sponge, while all excess solution was suctioned from the mouth. Patient specific, multidose bottles of CHX were used because the cost for the pharmacy preparing 1 single-dose container was more than the entire 473-mL bottle of CHX. Following the protocol, each patient used 30 mL/d. This allowed each bottle to be used for approximately 2 weeks. All patients were nil per os (by mouth), and no further oral swabbing or liquids were allowed for 30 minutes after the procedure. The nurses performed and documented the full oral care protocol every 12 hours on the medication administration record. The only exclusion criteria for the protocol were known CHX allergy and/or oral ulcerations or abrasions. Two CNSs audited the compliance rates via biweekly review of the medication administration record and verification of oral care supplies. If a patient did not have an order and was an appropriate candidate, the nursing staff approached the medical team to obtain an order. If the order was present but the protocol had not been initiated, the CNS discussed it with the patient’s nurse and assisted with implementation of the protocol.

Statistical Analysis
Data were analyzed using Mantel-Haenszel 2 analysis with Epi Info (Centers for Disease Control and Prevention). Comparisons of demographics between preintervention and postintervention groups were performed using the Mann-Whitney test. A P value