Ventilator Assisted Pneumonia
Ventilator Assisted Pneumonia
The Policy and Procedure Committee of St. Mary’s Hospital was presented with a literature review and presentation suggesting a policy change; the change regarded care of ventilated patients in the Intensive Care Unit. The change promoted addressed incorporating oral hygiene measures in an effort to reduce ventilator assisted pneumonia (VAP) in the patients. The use of manual cleaning with chlorhexidine swabs or brush in conjunction with suctioning enhances the removal of bacteria from the buccal cavity. The presence of the bacteria encourages development of VAP. The Committee requested an implementation plan for further evaluation of the proposal.
Approval for policy change regarding oral hygiene for mechanically ventilated adult patient in the ICU passes through various levels of administration. These levels include the ICU Manager and Director, the Policy and Procedure Committee, and the hospital Administrator and Executive Director. The process for obtaining the approvals may vary from one organization to the next, but presenting supporting documentation for the proposed change is critical.
Once executive management approves the implementation of the policy change, securing the support of floor staff is equally important. To lessen defensiveness or resistance to change, training and practice is introduced with the assistance of the physicians. Evaluation with positive reinforcement is conducted, with a specific date set for applied concentration on the change. Problems are immediately addressed, and achievement of landmarks is acknowledged and celebrated.
Description of Problem
Current policy for oral hygiene measures in ventilated patients in ICU is glycerine swabs and suctioning. The consensus of ICU staff and management is the incidence of VAP is too high and steps are required to lower the statistics. It is currently unclear the compliance rate among staff, and how frequent suctioning is performed.
A study by Cutter and Sluman (2014) found using oral care with swabs or manual brushing with 1% Chlorhexidine Gluconate combined with regular suctioning resulted in significant decrease in incidences of VAP. In addition, use of measures to encourage staff compliance showed the results were linked to a 91% compliance rate by caregivers. The proposed policy change concerning oral hygiene in the ICU patients includes the use of the solution and suctioning on specific intervals.
An experiment conducted by Tucker, Nembhard, and Edmondson (2007) found change of procedure policy was best implemented when staff was educated about the procedure rather than why it was needed. The “learn-how” transitioned psychologically safe environments into implementation success. Also, the new procedure was best taught when project team members promoted implementation throughout the unit.
The rationale for the proposed policy change is based on research literature review. A significant number of studies promote the procedures for prevention of VAP in ICU patients.
Fieder, Mitchell, and Bridges (2010) conducted a study of compliance in regards to the suggested policy change. According to self-surveys, nurses reported policies were present regarding oral care, but compliance was sporadic. More experienced nurses performed the care more often. Also, nurses with a Bachelor’s degree suctioned before and after care.
There are a number of studies addressing effectiveness in reduction of VAP in mechanically ventilated adults in ICU with oral care and the importance of staff compliance in its use. O'Keefe-McCarthy, Santiago, and Lau (2008) emphasized staff compliance. Guterres da Silva et al (2012) and Lawrence and Fulbrook (2011) studied VCB including oral care. Roberts and Moule (2012) and Nicolosi et al (2013) discussed types of oral care solutions.
A leadership team will monitor the process of change. Representatives from all pertinent departments will be included. The team members will be invited based on knowledge of the process and excitement for the change. To prevent the policy change from stalling, clear goals and a timeline will be determined by the leadership team.
The ICU will be informed early of the focus on the coming policy change and what it means to the staff. Change is more likely to take place smoothly if communication occurs often. The staff is empowered by stressing the importance of their compliance. Topics like cost savings, patient impact, reflection on staff performance, decreased work load when VAP incidences decrease, credibility of the facility, and so on. The momentum is maintained with celebration of short-term goals. Include the staff in discussions when problems occur and acknowledge their input for solutions.
Resources required for implementation of the proposed policy plan fall into four categories:
First, it is important for the Compliance Committee to determine baseline information regarding the extent of oral care currently used for mechanically ventilated patients in the ICU, what type of supplies are used, and how often the care is performed. Analysis of the data yields comparison opportunities for before and after implementation of the policy change. O’Keefe-McCarthy, Santiago, and Lau (2008) conducted a study stressing the importance of starting with a compliance audit by quality control to determine baseline information.
Second, it is essential appropriate supplies be readily available to staff. The equipment at bedside will be used more readily than if staff must go to a storage area to retrieve it. Supplies will also be kept in stock in Central Supply at all times.
Third, teams of mentors and staff managers training staff appropriately for technique and rationalization ensures correct education. In addition, staff members will be evaluated to determine if additional supervision is necessary. Consistent feedback on implementation and results encourages staff to continue compliance. Also, the Compliance Committee will take every step possible to insure compliance rates remain high.
Finally, incidences of VAP before and after implementation and on a continuous basis will be entered into the database and used for comparison studies. Attention to variables will allow management to address any changes over time. Real-time feedback continues to promote staff compliance.
Cutler, L., & Sluman, P. (2014). Reducing ventilator associated pneumonia in adult patients
through high standards of oral care: A historical control study. Intensive And Critical
Care Nursing, 30(2), 61-68. doi:10.1016/j.iccn.2013.08.005
Feider, L., Mitchell, P., & Bridges, E. (2010). Oral Care Practices for Orally Intubated Critically
Ill Adults. American Journal Of Critical Care, 19(2), 175-183. doi:10.4037/ajcc2010816
Guterres da Silva, S., Pereira do Nascimento, E., Kuerten de Salles, R., Enfermagem, T., &
Enfermagem, C. (2012). BUNDLE TO PREVENT VENTILATOR-ASSOCIATED
PNEUMONIA: A COLLECTIVE CONSTRUCTION, 4, 837-44.
Lawrence, P., & Fulbrook, P. (2011). The ventilator care bundle and its impact on ventilator-
associated pneumonia: a review of the evidence. Nursing In Critical Care, 16(5), 222-
Nicolosi, L., del Carmen Rubio, M., Martinez, C., Gonzalez, N., & Cruz, M. (2013). Effect of
Oral Hygiene and 0.12% Chlorhexidine Gluconate Oral Rinse in Preventing Ventilator-
Associated Pneumonia After Cardiovascular Surgery. Respiratory Care, 59(4), 504-509.
O'Keefe-McCarthy, S., Santiago, C., & Lau, G. (2008). Ventilator-Associated Pneumonia
Bundled Strategies: An Evidence-Based Practice. Worldviews On Evidence-Based
Nursing, 5(4), 193-204. doi:10.1111/j.1741-6787.2008.00140.
Roberts, N., & Moule, P. (2011). Chlorhexidine and tooth-brushing as prevention strategies in
reducing ventilator-associated pneumonia rates. Nursing In Critical Care, 16(6), 295-
Tucker, A., Nembhard, I., & Edmondson, A. (2007). Implementing New Practices: An Empirical
Study of Organizational Learning in Hospital Intensive Care Units. Management Science,
53(6), 894-907. doi:10.1287/mnsc.1060.0692