Oral Care with Chlorhexidine
Ventilator Bundle and Oral Care Procedures
Ventilator Associated Pneumonia (VAP) is a healthcare acquired infection of concerning risk to patients who require mechanical ventilation. In fact, VAP is the most common nosocomial infection in patients who are mechanically ventilated (Barclay & Vega, 2005). The American Association of Critical Care Nurses (AACN) has recommended steps for the reduction of VAP and, when implemented together, are referred to as the “Ventilator Bundle”. These steps are based on best practice guidelines from the Centers for Disease Control and Prevention (CDC) and include head of bed elevation 30 to 45 degrees, continuos removal of subglottic secretions, change of ventilator circuit no more than every 48 hours and washing of hands before and after patient contact (AACN, 2008). In The Guidelines for Preventing Health Care Associated Pneumonia, 2003 the Centers for Disease Control and Prevention (CDC) also makes a key recommendation for the development of oral hygiene programs that may include the use of an oral antiseptic agent (CDC, 2004).
Oral Care Procedure in Need of Change
While oral care is present in many critical care unit’s ventilator policies and used in conjunction with the ventilator bundle, there is wide variance. In a 2007 cross sectional survey of critical nurses, 50% reported having oral care protocols in place within their hospitals but revealed variances in practices (Cason, Tyner, Saunders & Broome, 2007). In 2005 Peace Health St, Joseph’s Medical Center, a 243 bed rural hospital in Bellingham, WA formed a comprhensive ventilaor bundle that included oral care. The basis for the practice was determined by a multidisciplnary team that was formed to initiate efforts to reduce and prevent VAP and in conjunction with joining the Institute for Healthcare Improvment (IHI) 100,000 Lives Campaign (IHI, 2011). Rationale for the procedure of oral care on mechanically ventilated patients was based on the recommended IHI Ventilaor Bundle and on the CDC’s recommendation of an oral care protocol. Oral hygeiene is preformed twice daily with a soft toothbrush or swab (if a toothbrush causes bleeding) with water and toothpaste. In addittion oral swabs are used to clean the mouth as needed every 2-4 hours. Deep glottic suctioning is also preformed every 12 hours after toothbrushing and need for suctioning is assessed every 8 hours. The oral care protocol is based on best evidence based practice to prevent VAP by reducing plaque, maintaining integrity of oral tissues, and reduction in pooling of secretions. A missing component to the above oral care protocol is use of an anitseptic oral rinse, such as Chlorhexidine oral rinse. Use of Chlorhexidine rinse twice a day, on appropriate mechnaically ventialted patients, should be added to the protocol after brushing twice a day, to prevent and reduce bacterial loads on the oropharynx.
Review of Literature
Several studies have...