RUNNING HEAD: ORAL CARE IN THE CRITICAL CARE SETTING

Oral Care in the Critical Care Setting

Ciera Pilcher, Kayla McCollum, Lauren Friend, Kristen Finley, Nathan Knight, Rosabel Berkley
Troy University School of Nursing

ORAL CARE IN THE CRITICAL CARE SETTING

Ventilator associated pneumonia is the most common acquired infection among ventilated
patients. In the critical care unit, it is not uncommon for the majority of the patients in the unit to
be intubated as a result of their critical care needs. Through our clinical experience, we have
made these observations, and have seen first-hand the benefits and patient progress that occur
from strict oral hygiene and the prevention of ventilator associated pneumonia.
Flowers hospital currently implements an evidence based practice by using Toothette
packages specifically designed for each patient that is ventilated. These packages are a
comprehensive 24 hour system that contains cleansing and suctioning components and solutions
for oral care. This system is intended to decrease bacterial and plaque colonization in the oral
cavity, which in turn decreases the risk for pathogens entering the respiratory system. It is
evident that this practice of strict oral hygiene has become an important task for nurses and
patient safety; because of this, we have chosen this topic and wish to further educate our peers on
its growing importance and significance in the critical care setting.
Ventilator associated pneumonia (VAP) is a potential complication that develops in
already critically ill patients who have received mechanical ventilation for at least 48hours. (Shi,
Z., Xie, H., Wang, P., Zhang, Q., Wu, Y., Chen, E., ... Furness, S., 2013) VAP can significantly
increase the mortality of critically ill patients in intensive care units (ICU); therefore, prevention
is the best method to improve patient related outcomes, patient safety, increase quality of care,
and help to reduce health care associated costs as well. (Jansson, M., Ala-Kokko, T.,
Ylipalosaari, P., Syrjl, H., & Kyngs, H., 2013) Some of the important measures to prevent and
or decrease the incidence of VAP are: continuous suctioning of subglottic secretions, semi-

ORAL CARE IN THE CRITICAL CARE SETTING

recumbent position, oral hygiene, selective decontamination, and continuous medical education.
(Jess, Muoz, P., Heras, C., Snchez, G., Rello, J., & Bouza, E., 2013)
Oral care protocols have been implemented and have been proven to reduce the incidence
of VAP anywhere from 46% to 90%. (Booker,S., Murff,S., Kitko,L., & Jablonski,R., 2013)
Ventilator Associated Pneumonia can increase mortality rates forty to eighty percent in ventilated
patients. Chlorhexidine is an antiseptic that is effective against many gram positive organisms,
and is used during oral care in the critical care setting. One study showed an 89.7 % reduction in
VAP with the use of 0.12% CHX, suction swabs, and mouth moisturizer. (Cuccio,L., Cerullo,E.,
Paradis,H., Padula,C., Rivet,C., Steeves,S., & Lynch,J., 2012)
In the United States, ventilator associated pneumonia is the second most common
nosocomial infection and it develops rapidly after a patient is intubated. (Parsons, S., Lee, C.A.,
Strickert, D., & Trumpp, M., 2013) A primary concern of care in ICU nurses is prevention of
ventilator-associated pneumonia becasues the occurrence of a nosocomial infection often results
in a lengthened hospital stay, increased cost of patient care, and further complications of an
already critical patient status. Therefore, the nurse must recognize symptoms of this nosocomial
infection, as well as implement procedures to prevent the possibility of these infections. Signs
and symptoms of VAP include: signs of respiratory infection, fever or hypothermia (>38C or
<36C), leukocytosis or leukopenia (>12000 mm or <4000mm WBC), purulent sputum,
hypoxia, and infiltrates. (Nussenblatt, V., Avdic, E., Berenholtz, S., Daugherty, E., Hadhazy, E.,
Lipsett, P. A., & ... Cosgrove, S. E., 2014) Proper oral hygiene plays a very important role in the
prevention of ventilator-associated pneumonia.

ORAL CARE IN THE CRITICAL CARE SETTING

Toothettes comprehensive approach addresses key ventilator-associated risk factors, such

as bacterial colonization of the oropharyngeal area, aspiration of subglottic secretions, and
colonization of dental plaque with respiratory pathogens. (Sage Products, 2014) If an ICU nurse
utilizes a Toothette every two hours as recommended, the risk for ventilator-associated
pneumonia is greatly decreased because bacteria are removed and the medium needed for the
bacteria to flourish in is minimized. Toothettes provides three types of solution used to cleanse
the oral cavity throughout the 24 hour oral care process every two hours. The first solution is an
anti-plaque, and this specific solution removes plaque from the patients teeth. The way the antiplaque solution works is that it draws the bacteria away from the patients teeth and gums. Next,
a solution called Perox-a-mint could be used. This solution helps cleanse the oral cavity of
secretions that normally would not be present, such as phlegm, mucus, or secretions from mouth
sores. The Perox-a-mint works by providing enzymes and releasing bubbles and oxygen that
help remove the debris located in the mouth. Finally, a solution known as alcohol-free
mouthwash can be used, which simply provides a refreshing cleanse to the patients oral cavity.
(Sage Products, 2014)
Prevention of healthcare associated infections is a key factor in improving patients
overall care and safety. As we know, ventilator associated pneumonia is the most frequent ICU
associated infection. Not only is VAP associated with increase susceptibility and mortality,
increase length of stay and health care costs are also affected. It is important to prevent health
care associate infections (HAIs) such as VAP, not only to provide quality care to the patients, but

ORAL CARE IN THE CRITICAL CARE SETTING

also to reduce unnecessary costs for the hospital. Studies made by the CDC state that HAIs
introduce significant economic penalties on hospitals around the world.
To put it into numbers, the annual cost for HAIs to United States hospitals is $28.4 to
$33.8 billion. Ventilator associated pneumonia alone increases the length of stay for patients by
4-19 days, compared to those who were also ventilated but did not acquire the infection. This
length of stay dramatically increases the cost of care for VAP patients by $40,000-$57,000. A
study done on Lankenau Hospital in relation to the of the use of a VAP bundle, which
contained a strenuous regime of oral care, showed a dramatic increase of quality care and a
significant saving estimated to be $1.5 million. Financially, you can now see the importance of
taking extra care and caution when providing oral care to critically ill patients. (Sedwick, M.,
Lance-Smith, M., Reeder, S. J., & Nardi, J., 2012 p.41-49)
Ventilator associated pneumonia is a burden in the health care setting for the patient,
healthcare staff, and patients family. Proper oral hygiene helps reduce the incidence of VAP and
improves the patients hospital stay and quality of life. Without nurses implementing this
evidence-based practice and providing the best care to the critically ill patient, medical expenses
and length of hospital stays would continue to increase. It is important for nurses to follow
hospital guidelines and evidence-based practice in regards to oral care to provide the patient with
a more positive outcome.

ORAL CARE IN THE CRITICAL CARE SETTING

REFERENCES:
Cuccio,L., Cerullo,E., Paradis,H., Padula,C., Rivet,C., Steeves,S., & Lynch,J. (2012). An
Evidence-Based Oral Care Protocol to Decrease Ventilator-Associated Pneumonia.
Dimensions of Critical Care Nursing, 31(5), 301-308.
Booker,S., Murff,S., Kitko,L., & Jablonski,R. (2013). Mouth Care to Reduce VentilatorAssociated Pneumonia. American Journal of Nursing, 113(10), 24-30.
Jansson, M., Ala-Kokko, T., Ylipalosaari, P., Syrjl, H., & Kyngs, H. (2013). Critical care
nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for
the prevention of ventilator-associated pneumonia -- A survey study. Intensive & Critical
Care Nursing, 29(4), 216-227. doi:10.1016/j.iccn.2013.02.006
Jess, Muoz, P., Heras, C., Snchez, G., Rello, J., & Bouza, E. (2013). Prevention of VentilatorAssociated Pneumonia: Can Knowledge and Clinical Practice Be Simply Assessed in a
Large Institution?. Respiratory Care, 58(7), 1213-1219. doi:10.4187/respcare.01854
Nussenblatt, V., Avdic, E., Berenholtz, S., Daugherty, E., Hadhazy, E., Lipsett, P. A., & ...
Cosgrove, S. E. (2014). Ventilator-Associated Pneumonia: Overdiagnosis and Treatment
Are Common in Medical and Surgical Intensive Care Units. Infection Control & Hospital
Epidemiology, 35(3), 278-284. doi:10.1086/675279
Parsons, S., Lee, C.A., Strickert, D., & Trumpp, M. (2013). Oral Care and Ventilator-Associated
Pneumonia. Dimensions of Critical Care Nursing, 32(3), 138.
Doi:10.1097/DCC.0b013e18286482a
Sage Products. Oral hygiene. (2014). Retrieved from
http://www.sageproducts.com/products/oral-hygiene/

ORAL CARE IN THE CRITICAL CARE SETTING

Sedwick, M., Lance-Smith, M., Reeder, S. J., & Nardi, J. (2012). Using Evidence-Based Practice
to Prevent Ventilator-Associated Pneumonia. Critical Care Nurse, 32(4), 41-51.
doi:10.4037/ccn2012964
Shi, Z., Xie, H., Wang, P., Zhang, Q., Wu, Y., Chen, E., ... Furness, S. (2013, August 13). Oral
hygiene care for critically ill patients to prevent ventilator-associated pneumonia. doi:
10.1002/14651858.CD008367.pub2