Oral Care Education in the Prevention of Ventilator-Associated Pneumonia: Quality Patient Outcomes in the Intensive Care Unit

Joyce Zurmehly, PhD, DNP , RN, NEA-BC

abstract
Background: Ventilator-associated pneumonia (VAP) is associated with high morbidity and mortality rates in mechanically ventilated patients in the United States. Routine oral care has been shown to have a direct effect on reducing VAP rates. Methods: Intensive care unit registered nurses attended educational sessions about oral care and also used online education modules. Nursing care involving 180 intubated patients was observed, and changes were noted in practices related to oral care. Results: After the education intervention, the frequency of oral care increased signicantly (p = .001) to tooth brushing every 4 hours and swabbing every 12 hours with 0.12% chlorhexidine solution. The evidencebased practice education intervention decreased VAP rates by 62.5%. Conclusion: Signicant reductions in VAP rates may be achieved through improved education and implementation of oral care protocols with 0.12% chlorhexidine solution. J Contin Educ Nurs 2013;44(2):67-75.

educing the rate of hospital-acquired pneumonia continues to be a patient safety challenge in health care. Pneumonia accounts for 47% of all hospital-acquired infections, second only to urinary tract infections (Augustyn, 2007). Ventilator-associated pneumonia (VAP) occurs as a result of pulmonary inammation after intubation. The mechanical process of intubation compromises the natural barrier between the oropharynx and the trachea, facilitating the entry of bacteria into the lungs (Berry, Davidson, Masters, Rolls, & Ollerton, 2011).
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The risk of pneumonia increases 6 to 21 times for patients receiving mechanical ventilation (Pruitt & Jacobs, 2006) and is often encountered within high-tech, high-touch environments, such as the intensive care unit (ICU). Critically ill patients have been identied as those primarily affected by VAP, with an incidence rate as high as 90% (OKeefe-McCarthy, Santiago, & Lau, 2008). The National Healthcare Safety Network reported the incidence rate for VAP within the ICU as 2.1 to 11.0 cases per 1,000 patient days in adults undergoing mechanical ventilation (Centers for Disease Control and Prevention [CDC], 2009). The presence of VAP is linked to increased patient mortality, morbidity, and length of stay, as well as increased patient and hospital costs (Berry, Davidson, Masters, & Rolls, 2007; Hawe, Ellis, Cairns, & Longmate, 2009). In a study reported by Eagye, Nicolau, and Kuti (2009), patients with VAP typically amassed medical costs ranging from $98,426 to $183,275, more than $40,000 over the average health care costs of ICU patients without VAP. These costs have been attributed to increased ventilator days and increased length of stay. According to Bingham, Ashley, De Jong, and Swift (2010), the United States alone spends $6.5 billion for the treatment of VAP each year. Many patients with VAP are admitted to an ICU with harmful bacteria already in their system. The CDC (2009) reported that 63% of patients admitted to an ICU
Dr. Zurmehly is Associate Professor, Wright State University, Chillicothe, Ohio. The author has disclosed no potential conicts of interest, nancial or otherwise. E-mail: jzurmehly@gmail.com. Received: March 11, 2012; Accepted: November 1, 2012; Posted: December 10, 2012. doi:10.3928/00220124-20121203-16

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have preexisting oral colonization with a pathogen. The study also showed that 76% of ventilated patients had the same bacteria colonizing both the mouth and the lungs (Zack et al., 2002). With VAP so prevalent, what steps are being taken to prevent the spread and severity of this infection in the ICU? In response to this growing concern, the Institute of Healthcare Improvement (IHI) launched its 5-Million Lives campaign. The IHI has identied the prevention of VAP as one of its top priorities for improving health care outcomes and quality, thereby reducing deaths (American Association of Critical Care Nurses, 2010; IHI, 2010). For a year, the IHI reviewed studies performed in hospitals throughout Scotland. These studies included a daily oral care regimen of 0.12% chlorhexidine solution for ventilator patients. In May 2010, after reviewing the Scotland studies that showed improved outcomes, the IHI added the same daily oral care regimen to the ventilator care bundles given to ICUs in hospitals throughout the United States. These care bundles have been promoted as a means of improving patient outcomes by grouping evidence-based interventions together with quality care (Tolentino-Delosreyes, Ruppert, & Shiao, 2007; Westwell, 2008). In a study by Zack et al. (2002), educational interventions to reduce VAP effectively decreased the incidence by 57.6% during a 12-month period. This successful intervention resulted in a savings of $425,000 to $4.5 million in health care costs. Therefore, an important deterrent to VAP is proper oral care (Halm & Armola, 2009; Kleinpell, 2009; Munro, Grap, Jones, McClish, & Sessler, 2009; Ross & Crumpler, 2007). Several studies have shown that implementation of educational interventions for registered nurses (RNs) and ICU staff can effectively reduce the occurrence of VAP (Halm & Armola, 2009; Sona et al., 2009; Zack et al., 2002). Although evidence-based interventions, such as oral care education, aid in reducing the incidence of VAP, it is recognized that effective interventions are not always consistently practiced. Nurses are the main caregivers in hospital ICUs, yet the effectiveness of nursing oral care interventions on patient outcomes is limited. Several studies further indicated that many nurses believe that oral care is simply a comfort measure that is benecial only for the patients state of mind (Berry et al., 2007; Cason, Tyner, Saunders, & Broome, 2007). The optimal approach to reducing the incidence of VAP is still unclear; however, many studies have focused on oral care and oral care education as a strategy to aid prevention (Bellissimo-Rodrigues et al., 2009; Garcia et al., 2009; Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004). Sona et al. (2009) reported a signicant improve68

ment (p = .04) after the implementation of a low-cost oral care protocol within ICUs. After an educational intervention, Babcock et al. (2004) found a decrease in the rate of VAP cases from 8.75 to 4.74 per 1,000 patient ventilator days. In 2007, Ross and Crumpler investigated the differences in VAP rates before and after completion of an oral care education module within an ICU. Results showed a 50% decrease in cases of VAP after the educational intervention. Although these interventions are known to reduce the incidence of VAP, consistent implementation of lessons learned from the interventions remains a challenge. In one study by Feider, Mitchell, and Bridges (2010), the oral care policy in an ICU was compared with the actual practice of oral care by critical care nurses. Oral care policies were present; however, discrepancies were found within practice patterns. The nurses were reported as lacking in clarication of the best practice of care, even though polices were in place. As a result, Feider et al. (2010) recommended highlighting a practice alert for oral care with critically ill patients as an aid to reducing the number of cases of VAP. According to Kleinpell (2009), specic, evidencebased education and training is needed to maximize clinical application. One strategy for providing education and training is the use of technology-enhanced instruction. Roh and Park (2010) performed a metaanalysis evaluating the effectiveness of computerbased education compared with traditional teaching methods. In the computer-educated group, knowledge improved 21%, learning attitude improved 17%, and practice performance improved 34% compared with the traditional instructor-led group. Beavis, Morgan, and Pickering (2012) concluded that the benets of using online learning modules included exible delivery, time savings over staff attendance at in-service sessions, and cost efciency. Bloom and Hough (2003) evaluated nurses satisfaction with online learning and found that 75% of learners were satised with overall instruction. In addition, computer-based instruction with evidence-based modules further supports the Institute of Medicines report, Health Professions Education: A Bridge to Quality, which recommended integrating core competencies into health education. This includes informatics and evidence-based practices (Hundert et al., 2003). At the study hospital, the rates of VAP were tracked through hospital infection control surveillance. The VAP rate was dened by the National Healthcare Safety Network as the number of infections per 1,000 ventilator days (CDC, 2009). In 2009, surveillance showed that the VAP rate for the study hospital was 10.75 cases. The
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state and national rates were 6.49 cases and 5.50 cases, respectively (CDC, 2009). Therefore, this rate was approximately 50% above the state and national averages. THeoReticaL FRaMeWoRK The theoretical framework used for this study was the Iowa model of evidence-based practice to promote quality care. The model was chosen for this study because it promotes the integration of evidence into practice, with the goal of improving patient outcomes while providing an opportunity for bedside nurses to make a signicant contribution to quality care (Titler et al., 2001). The model can be used to identify areas where evidencebased practice should be implemented to keep procedures current within a changing health care environment (Titler et al., 2001). An evidence-based practice approach was used, outlining current nursing practices to improve oral care in accordance with CDC guidelines. The study began with an extensive literature review to determine the state of the science related to the oral care practices of ICU nurses caring for critically ill patients. Current nursing practices were evaluated against the CDC recommendations for prevention of hospital-acquired infections. Based on the study ndings, practice changes were identied and implemented, with the goal of improving oral care among ICU patients in the critical care setting. OBJective The study evaluated the effectiveness of a nursing quality education improvement program on oral care practice in reducing the incidence of VAP within the ICU. The study included all RNs implementing oral care education by using the 0.12% chlorhexidine gluconate (CHG) oral rinse solution within a 12-bed ICU setting. The study focused on oral care, staff education, and ongoing patient surveillance. METHODS This study used a quasi-experimental design to evaluate the effectiveness of an evidence-based practice education program, incorporating the nursing intervention of oral care with 0.12% CHG oral rinse solution. An evidence-based education intervention on oral care was instituted, and its effect was measured with a pretestposttest design that used a convenience sample. Specically, this study implemented a VAP prevention education program for all 60 nurses providing direct patient care in a 12-bed hospital ICU. Of these, a convenience sample of 44 nurses was selected, and their awareness and performance in VAP prevention was measured. The
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VAP occurrence rate for 180 mechanically ventilated ICU patients was also calculated. The standard for inclusion of nurses was more than 3 months of work experience in the ICU. Patients who had used a mechanical ventilator for more than 48 hours but did not have VAP at the time of admittance to the ICU were included in the study. Nurses transferring into or out of the ICU during the study and patients admitted to the ICU after being connected to a mechanical ventilator were excluded from the study. The review board determined this study to be exempt from institutional review board full review because the RNs were voluntarily registering for the program. Participants were assured that their responses would be condential and would not be released to their employer. Respondents were further informed that their participation was totally voluntary and would not inuence their employment. Data were reported to the hospital in aggregate, and no personal or patient information was disclosed. Patient data were gathered from existing electronic medical records (EMRs). Intervention This evidence-based practice project was conducted to transform evidence into practice by effectively using a unit-level education intervention. The effect of the intervention on the incidence of VAP in the unit was also evaluated. A matched pre- and posteducation intervention patient sample was collected during a 6-month period. Procedure With ICU nurses as the target, a VAP program was developed using evidence-based clinical guidelines. The researcher investigated literature on VAP management and analyzed the infection occurrence rate of the study institutions ICU and its guidelines for infection management. Findings from the American Association of Critical Care Nurses (2010), the IHI (2010), and the American Association for Respiratory Care evidencebased clinical practice guidelines (2011) were analyzed. The VAP prevention program was developed during the month of September by integrating the veried effective aspects of previous studies of intervention programs into a multidimensional program. After a review of evidence-based practice material and guidelines, the hospitals policy review committee implemented a new oral care protocol for mechanically ventilated patients. The recommendations included nursing interventions, specically, brushing the teeth of patients undergoing mechanical ventilation at least three times a day and oral swabbing every 12 hours with 0.12% CHG swabbing solution. The recommendation for oral care was inte69

grated into the prevention program for nurses in the ICU. Ventilator-Associated Pneumonia Prevention Program The VAP prevention program was implemented from October to December. The focus of the education initiative was a self-study module and a 10-item questionnaire. The ICU manager, a respiratory therapist, an educator, and the hospitals infection control nurse, as well as two nursing school professors, evaluated the program. A 10-item VAP questionnaire with an evidence-based protocol was developed, and four experts in the eld conrmed its validity. To support evidence-based practice, a professional online teaching module was used as the educational tool. The online education module included best practice techniques, with information on topics related to VAP: epidemiology and scope of the problem, risk factors, denitions, strategies to reduce VAP, and prevention. The program was initiated with a number of different strategies. The 44 RNs in the sample were notied of its availability via weekly e-mails until the module was completed. In addition to online availability, study materials were also available in an educational tool kit. The tool kit materials included one complete study module booklet and oral care packets containing a toothbrush and swabbing supplies for any RN to use. Online pre- and posttests to assess participants understanding of the content and educational objectives were administered immediately before and after delivery of the module educational content. The module took an average of 30 minutes to complete. The test consisted of 10 questions on the content of the module, emphasizing a specic nursing intervention or oral care procedure. Questions were designed to best examine whether optimum comprehension and synthesis of information was achieved. Multiple-choice, true-or-false, and matching question formats were used. After the educational intervention, examination scores were downloaded from the server database onto a staff education competency database specically designed for this study. A code number was used to record test results, with any potential staff identiers removed. Patient Selection After a review of the EMR, patients who met the inclusion criteria were enrolled in the study. The EMR included an initial assessment completed on the day of ICU admission or the rst day of mechanical ventilation. The following data were recorded from the patient EMR: enrollment date, time of observation, study code number, age, date of birth, gender, diagnosis category,
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date of admission, date of intubation, chest x-ray report, Acute Physiology and Chronic Health Evaluation IV (APACHE IV) score, and components of comorbidity. Patient state characteristics included days of ventilation. Each patient was evaluated daily through the EMR for ongoing assessment of pneumonia symptoms as well as the frequency of oral care. Daily assessment surveillance data included time of observation, study code number, intubation in the past 24 hours, chest x-ray, temperature, white blood cell count, and sputum culture and sensitivity results. All of the surveillance variables were used to identify suspected cases of VAP. A diagnosis of VAP was made if the patient had a new, persistent, or progressive inltrate on a chest x-ray, in combination with at least three of the following: fever, leukocytosis, leukopenia, purulent tracheal aspiration, or positive culture ndings. Patients were excluded from the study for any of the following reasons: extubation, discharge to another facility, or sudden death. Data Analysis Data were analyzed with the Statistical Package for the Social Sciences, version 16.0 (SPSS Inc., Chicago, IL). The sample and outcome variables of the patients general characteristics and related disease were veried using the chi-square test on frequency, percentile, and homogeneity. To compare the difference in nurses awareness and performance of VAP prevention before and after the intervention, data were analyzed with repeated measures analysis of variance. Rates of VAP were compared with chi-square analysis. All tests were two-tailed, with a p value of less than .05 being signicant. Demographic data for all RNs were collected at the beginning of the study. The data were compiled and analyzed, along with the results of the posttest and the VAP rates of patients. RESULTS Overall, 44 RNs completed the educational program. Demographic data showed a range in participants age, educational level, years of experience in critical care, and total hospital experience. The majority of RNs who worked in the ICU were female (98%) compared with male (2%), with an average age of 44 years, approximately 4 years younger than the national average (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2010). Most RNs in the ICU had an associates degree (66%) in nursing, followed by a bachelor of science degree (27%), and a masters degree (7%). Most of the RNs (68%) had at least 8 years of hospital experience, and most (69%) had 6 years or more of critical care nursing experience.
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TABLE 1

INTENSIVE CARE UNIT NURSING TEST SCORES TWO-SAMPLE T TEST

Variable Oral care Oral care Group Pre Post N 44 44 Mean 8.45 9.84 Median 8.0 10.0 SD 0.97 0.37 p .001

TABLE 2

FREQUENCY OF ORAL CARE DOCUMENTATION

Preintervention (n = 85) VariableOral Care Not documented Every 2 hours Every 4 hours > Every 4 hours
Note. Signicance dened as p < .05.

Postintervention (n = 95) N (%) 2 (2.05) 26 (27.69) 57 (60.00) 10 (10.26) Results (Change) -49.06% +21.02% +52.22% -24.18% p < .001 < .001 < .001 < .001

N (%) 44 (51.11) 5 (6.67) 6 (7.78) 30 (34.44)

Before the VAP education program, the mean total score on oral care was 8.45 out of a possible 10 (SD = 0.97). Directly after the education intervention, the mean level of education had increased to 9.84 (SD = 0.37). Posttest analysis showed a statistically signicant (p < .05) difference in the total oral care educational level after the oral care intervention (F = 0.541, p = .009). Comparison of RNs scores on the pretest and posttest is shown in Table 1. Most of the RNs (95%) had a perfect score on the posttest, whereas the rest (5%) scored 90%. No scores of less than 90% were reported on the posttest. The changes in the test scores indicate that the 30-minute education module increased RNs knowledge of VAP and oral care with 0.12% CHG (t test, p < .001). In terms of changes in practice patterns, examination of patient EMRs showed that the frequency of oral care increased signicantly (p = .001). Preintervention oral care was documented at an interval of greater than every 4 hours (34%) or not at all (51%). Postintervention documentation showed an improvement, with oral care administered consistently at 2-hour (28%) and 4-hour intervals (60%) (Table 2). The results showed that 44% (SD = 7.46) of the nurses were practicing oral care procedures properly before the intervention, whereas after the intervention, 95% (SD = 7.93) were noted as providing oral care. The nurses were reported to be providing statistically signicant (F = 13.63, p < .05) oral care. Therefore, after the education sessions, 80% of the audited records showed an increase in documented oral care,
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Figure. Improved practice of oral care every 4 hours after education.

showing a positive shift in overall compliance with tooth brushing at least three times a day and oral swabbing every 12 hours with 0.12% CHG swabbing solution. This nding represents a signicant improvement compared with pre-education compliance (Figure). The measurement and monitoring components of the study also included evaluation of patient VAP rates during a period extending from 3 months before to 3 months after the intervention. During the 6-month period, a total of 180 mechanically ventilated patients were enrolled in the study. Of these, 60% were male, mean age was 57.9 years (SD = 17.5), and mean APACHE IV score was 67.58 (SD = 25.68). Patients were most likely to be admitted to the ICU with preexisting pulmonary disease. Overall, the clinical characteristics of the preand postintervention groups did not differ signicantly
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TABLE 3

PAIRWISE CORRELATION OF VENTILATORASSOCIATED PNEUMONIA AND INDEPENDENT VARIABLES

Variable Independent variable Patient trait characteristics Age Gender APACHE IV score Medical diagnosis Coma COPD CVA Degenerative neurological disease Immunosuppression Renal Patient state characteristics Days of ventilation Autonomous nursing intervention Oral care not documented Oral care every 2 hours Oral care every 4 hours Oral care > every 4 hours Outcome Ventilator days, total ICU length of stay 0.5334 0.4745 .0000* .0000* 0.0163 -0.0652 -0.1129 0.1879 .8128 .3451 .1041 .0061* 0.1374 .0440* 0.1304 0.0488 0.0357 -0.1737 0.1413 0.0212 0.3267 0.0014 0.1219 0.0143 .0803 .4716 .7186 .0161* .0264* .7690 .0014* .9856 .1075 .6463 Coefcient p

(1/1,000). During the preintervention period, a total of four episodes of VAP occurred during 471 ventilator days among 832 total patient days. Subsequently, during the postintervention period, only one episode of VAP occurred during a total of 421 ventilator days among 854 total patient days. This is equivalent to an infection rate of 4.8 patients per 1,000 ventilator patient days, or 2.7% of the total sample of 180 patients. Of the 180 patients in the ICU, 5 had VAP; 4 of 95 cases (2.2%) occurred preintervention and 1 of 85 cases (0.5%) occurred postintervention. During the postintervention period, the infection rate was 1.8 per 1,000 ventilator days, a decrease of 62.5% compared with the preintervention period. Table 3 shows pairwise correlation analysis conducted between individual independent variables of patient characteristics and VAP. At the bivariate level, analysis suggested that oral care with tooth brushing at least three times per day and oral swabbing every 12 hours with 0.12% CHG swabbing solution was signicantly correlated with a decreased incidence of VAP. Furthermore, several patient trait characteristics were signicantly correlated with the development of VAP, including a specic medical diagnosis, coma, and cerebrovascular accident. Limitations Because of the epidemiology of nosocomial infections such as VAP, occurrence rates may vary widely. When there is a small target group evaluated within a short study period, even a small number of occurrences can signicantly affect the infection rate, making statistical judgments difcult. This study was conducted for 3 months before and 3 months after the intervention, which was an insufcient period relative to previous studies (Augustyn, 2007; Berry et al., 2011; Eayge et al., 2009). Further limitations of this project, including RNs awareness of being evaluated before and after the education sessions, may have led to more conscientious oral care. To minimize the increase in performance as a result of the Hawthorne effect, the researcher randomly selected EMR reviews. Another limitation of this study was the nonevaluation of all IHI bundle outcomes other than those associated with pneumonia and oral care. Although the IHI recommends the VAP bundle, which is an important and proven strategy to reduce the incidence of VAP that includes oral care, it alone may not prevent VAP. Therefore, it was not possible to determine whether oral care alone specically inuenced VAP. However, although limitations were present, this study showed that a statistically signicant difference was attainable through educational interventions. Another limitation of this project
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Note. APACHE IV = Acute Physiology and Chronic Health Evaluation IV; COPD = chronic obstructive pulmonary disease; CVA = cerebrovascular accident; ICU = intensive care unit. *Signicance dened as p < .05.

in acuity during the collection periods (p = .21). Patients who underwent mechanical ventilation for at least 24 hours were included in this study. The pre-education mean number of ventilator days for all patients was 4.91 (SD = 1.69). The postintervention mean number of ventilator days was 3.26 (SD = 1.55), for a difference of -1.65 days preintervention versus postintervention. Overall ventilator days were signicantly decreased in the postintervention group (p < .01). Although a trend was seen toward higher acute physiology and APACHE IV scores, patients in the postintervention group had fewer days on the ventilator (3.5) than those in the preintervention group (6.4). After the education was completed, a statically signicant difference (p < .003) was noted in VAP rates
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was the absence of a control group that could be used to compare ndings and evaluate the reliability of the test questions. DISCUSSION The occurrence of VAP increases the duration of mechanical ventilation, the overall length of stay in the ICU, and the length of the hospital stay (Berry et al., 2007; Hawe et al., 2009). In this study, the intervention of oral care appeared to be effective. After the nurses completed the education, their knowledge increased and their use of evidence-based oral care practice improved. Thus, the goals of the project were successfully met, as shown by the signicant improvement in the nurses test scores and the patient infection rate per 1,000 ventilator days. The results suggest that oral care with 0.12% CHG solution signicantly contributed to reducing the patients risk of VAP. These results show that an intensive 30-minute targeted education intervention can inuence RNs knowledge and clinical practice. Positive changes were noted in RNs oral care practices during patient care. The actual oral care used and noted in patients EMR improved signicantly, reecting increased levels of compliance and awareness among RNs of the validity of evidence-based, quality patient care. The ndings of this study support earlier studies of educational outcomes with VAP (Halm & Armola, 2009; Kleinpell, 2009; Munro et al., 2009; Ross & Crumpler, 2007). According to previous studies, when only informal training was provided, only short-term change occurred and lasted approximately 1 week (Feider et al., 2010). However, when formal education is provided, along with feedback, the reported effect may continue for several weeks to several years (Ross & Crumpler, 2007). Therefore, this study chose an intervention method that would be more likely to ensure long-term effects. This study has further implications for the education of ICU nurses. Educating nurses and providing them with opportunities to show competency in their care increases the likelihood of enhanced patient outcomes. In this study, educating nurses on how to use the oral care equipment and how to perform appropriate oral care for the intubated patient resulted in decreased VAP rates. This training is especially important for nurses who are new to the critical care environment. Orientation of these nurses must include oral care practices and the opportunity for the nurses to work with the equipment before working on the unit. Considerable efforts have been made to incorporate VAP prevention into routine care in many ICUs. Low rates of VAP are likely the result of many coordinated
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key points
Ventilator-Associated Pneumonia
Zurmehly, J. (2013). Oral Care Education in the Prevention of Ventilator-Associated Pneumonia: Quality Patient Outcomes in the Intensive Care Unit. The Journal of Continuing Education in Nursing, 44(2), 67-75.

The Institute of Health Care Improvement has identied the prevention of ventilator-associated pneumonia (VAP) as one of its top priorities for improving health care outcomes and quality, thereby reducing deaths. Without evidence-based guidelines, critical care nurses often perform oral hygiene according to their individual preferences. A 30-minute education session improved knowledge and use of VAP prevention strategies. Education programs should be more widely employed for infection control in the intensive care setting and can lead to a sustainable decrease in cost and patient morbidity attributed to hospital-acquired infections.

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efforts. However, the process of translating evidencebased guidelines into day-to-day practice varies. To facilitate evidence-based practice with the aim of achieving better patient outcomes, identifying and embracing the factors that facilitate best practices is critical. As this study found, nurses compliance with oral care increased after education sessions based on best practice. Therefore, it appears that educational sessions with pretest and posttest evaluations followed by evaluation of patient outcomes provide the most consistent predictor of adherence to the oral care guidelines. For patients who are critically ill within the ICU setting, VAP continues to be a signicant clinical problem. Clearly, there is a need for further education on oral care for intubated patients. This education should encompass all nurses who work in ICUs and should focus on oral care as a preventive measure for VAP instead of a task that only increases the patients comfort. Implementation of the VAP bundle, including oral care, can be improved with an active educational intervention and can lead to signicant changes in outcome measurement. Providing education to RNs and evaluating whether there is proper implementation of the lessons learned can dramatically decrease VAP rates. This study was conducted to support evidence that proper oral care practices can signicantly reduce the incidence of VAP in patients in the ICU. The ndings indicated that, with formal education, nurses who provided tooth brushing
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at least three times a day as well as oral swabbing every 12 hours with 0.12% CHG decreased the patients risk of VAP. Oral care may seem insignicant, but this basic hygienic procedure can limit hospital stays for patients receiving mechanical ventilation. This would limit the number of days a patient is in the ICU, which decreases hospital costs, reduces medical costs for the patient, and decreases recovery time. CONCLUSION Evidence-based practices, including oral care and VAP prevention, should help to shape nursing practices. Consistently, oral care not only saves time and money but also promotes patient safetyone of the six aims of the IHI, the Institute of Medicine, and The Joint Commission (Institute of Medicine, 2003; The Joint Commission, 2010). Improving the quality of care to patients improves health care systems, one ICU at a time. REFERENCES
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