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Strive-The Student View Ventilator-Associated Pneumonia
It is shocking to learn about hospital nurses’ standards for taking care of their patients’ oral cavities. The concern we as hygienists have for the health of our patients’ mouths is not shared by many nurses. This is an increasing problem within intensive care units because most of the patients are unconscious and cannot perform daily plaque removal for themselves. Nurses are not carrying out the duty for them, which allows the accumulation of pathogenic bacteria within dental plaque. The biofilm attaches to the endotracheal tube and is subsequently able to dislodge and travel into the patient’s lungs, causing ventilator-associated pneumonia (VAP). VAP is currently the most commonly occurring nosocomial infection developing among patients with endotracheal tubes. It occurs in patients who are on mechanical ventilators for longer than 48 hours and can become a costly and life-threatening problem. VAP is a real concern to us due to its association with poor oral hygiene in hospitals as well as the significant cost attributed to this illness. Poor oral hygiene in hospitals accounts for bacteria found within dental plaque and periodontal spaces that accumulates and is able to convert to a more virulent form that causes pneumonia. Gram-positive streptococci predominate in the normal flora in the oropharynx. If left undisturbed, these can convert to gram-negative organisms that are more pathogenic.[1] Specifically, VAP can be caused by Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Pseudomonas species.[2] As the oral cavity becomes colonized with aerobic gram-negative bacteria, contaminated secretions, such as saliva, access the trachea, as well as the surface of the endotracheal tube and can later be dislodged and aspirated into the lungs. Pneumonia – The Facts Pneumonia is the most common hospital-acquired infection in the intensive care unit. The need for mechanical ventilation increases the risk of developing pneumonia by as much as 21 times.[3] VAP has reported incidences as high as 78 percent and mortality rates that exceed 50 percent. Once the patient has developed VAP, additional treatment is required that increases the length of stay by up to 22 days and raises the cost of care.[1] It has been estimated that “250,000 annual cases of nosocomial pneumonia in the United States of America (USA) account for 1.75 million excess hospital days and $1.5 billion in extra health care costs.”[3] It is important to note that many patients who require a ventilator to breathe are already critically ill.[4] This may be a justification that the medical community uses for the increased death rate of intubated patients who develop pneumonia. This rationale is unfair to the ventilated patients and overlooks the fact that the occurrence of pneumonia can be reduced if certain steps are taken to care for the oral cavity of patients in hospitals.[4] Preventive measures need to be taken to reduce the occurrence and severity of VAP.
Nursing education regarding oral care practices has not been updated or modified for 120 years.[3] Oral care is often considered an intervention for patient comfort rather than a need to promote health. This contributes to the decreased priority and frequency of plaque removal and attention to the oral needs of both intubated and nonintubated patients. “The [American Association of Critical-Care Nurses] AACN procedure manual for critical care includes the following procedure: brush teeth with a pediatric or soft toothbrush twice daily; use oral swabs and apply mouth moisturizer to the oral mucosa and lips every two to four hours; and suction the oral cavity and pharynx frequently, changing oral suction equipment and tubing every 24 hours.”[1] Surveyed nurses have overreported their oral hygiene practices to patients on ventilators. They claim to clean the patient’s mouth more than four times a day, but actual documentation reveals it is performed only three times a day.[5] Even at the overreported number, they are well below the standard practice guidelines of once every two to four hours (12 times a day). It is a well-known fact that there is a nationwide shortage of nurses in hospital settings.[3] This results in overworked nurses with many duties to perform and a lack of time to complete their tasks. With numerous responsibilities, they must ration their time, and if caring for the oral cavity is given a low priority, it is typically one of the first tasks to be neglected. Toothbrushes are not easily accessible in the hospital setting, and the patient’s bedside is usually stocked with foam swabs and mouthwash. If toothbrushes are available, they are large and of poor quality.[3] The difficult adaptation of large toothbrushes around the endotracheal tube deters nurses from using them on ventilated patients and reinforces their preference for foam swabbing.[4] These swabs contain agents that are detrimental to the health of the oral environment. “Lemon and glycerine swabs stimulate production of saliva initially but are acidic, causing irritation and decalcification of the teeth and resulting in rebound xerostomia.”[4] Although the AACN recommends the use of a child-sized toothbrush, nurses are more comfortable using swabs for oral care. Essentially, the swabs are a sponge on a stick that can contain anything from hydrogen peroxide or moisturizer to lemon flavoring. Not only do the additives in the swabs cause oral problems for patients, but they are also ineffective at plaque removal. Imagine using a soft sponge for morning and night brushing instead of a toothbrush. This has become the standard of care for patients in the hospital. It should not be a surprise that with this sort of oral care, dental plaque is able to colonize and travel down the endotracheal tube to infect the patient’s lungs.
A frequent treatment for VAP is systemic antibiotics. There is little research to suggest the optimum length to use these antibiotics for effective treatment. Due to the limited information, many physicians prescribe antibiotics for an extended period of time, for example a 14-21 day regimen.[6] We as health care professionals are concerned about these clients developing opportunistic infections, as well as acquiring resistant strains of bacteria. A key way to reduce the occurrence of bacterial resistance is to reduce the amount of time the patients are on antibiotics. Results of a comparison study showed comparable effectiveness of an antibiotic regimen of only eight days versus that of 15 days.[6] If patients could have their antibiotics reduced by almost half, this could prolong treatment with current medications used to fight VAP and decrease the chance of resistant forms of bacteria becoming established. Another study researched the decrease in VAP cases among intubated patients by preventing colonization within the oral cavity using localized antibiotic prophylaxis rather than systemic antibiotic prophylaxis. This resulted in a reduced incidence of VAP by 67 percent.[2] An additional concern is the effect on patients’ oral flora. If patients are exposed to antibiotics, the normal flora in their mouths can be eliminated and the pathogenic flora can thrive. This concern was made evident by results that showed “…the dental plaque of patients with recent exposure to antibiotics had a much greater chance of being colonized by respiratory pathogens than did the plaque of those who were not receiving antibiotic treatment.”[7] Using prolonged antibiotics allows an increased chance of virulent bacteria as well as resistant strains to exist and creates an even more difficult situation for treating these already critically ill patients. Despite the routine use of antibiotics, we question their effectiveness in eradicating the biofilms implicated in VAP. “Antibiotic doses that kill free-floating bacteria, for example, need to be increased as much as 1500 times to kill biofilm bacteria (and at these high doses, the antibiotic would kill the patients before the biofilm bacteria!).”[8] Obviously, antibiotics are not the safest course of treatment for these patients.
It is apparent that VAP is directly related to infection from poor oral hygiene and has the potential to be prevented. We feel that this detrimental problem can be solved with education, resources, collaboration and/or hospital-employed hygienists. Currently, there are some nurses who realize the significance of their patients’ oral care, but lack adequate resources and confidence in their education and skills. We know it is in their best interest to provide their patients with optimum care. As dental hygienists, we need to help educate and collaborate with the medical field. Several studies showed that “the implementation of educational programs reduced one facility’s VAP rate by more than 57 percent, and a multidisciplinary performance improvement team in another institution was able to decrease its VAP rate by 95 percent over a period of six years.”[1] The cost of such a program is minimal as compared to the cost to treat VAP. VAP typically costs facilities $40,000 or more per case to treat, but the cost of an education program to prevent the occurrence of VAP would be only $1,200 per program.[9] One study found that VAP rates were decreased by more than 50 percent and saved anywhere between $425,606 and $4.05 million with the implementation of a simple education module.[9] Implementing education programs within hospital settings can be accomplished by required continuing education courses containing oral health information, oral care lectures in nursing schools, or self-study modules given to the nursing staff. Once an educational foundation is laid, nurses will gain confidence in their skills, recognize the significance of good oral hygiene among patients with VAP, and be more inclined to follow regular oral care schedules. Hospital administrators could also benefit from the education and collaboration. Educating them on the detrimental effects that their current practices and instruments are creating might prompt beneficial changes in the products they order. The most effective preventive measure, however, is going to be getting a hygienist employed in the hospitals who could provide direction for any necessary improvements in product selection. VAP has been and is currently overlooked by the medical field as a treatable condition. This lack of concern has caused an increase in mortality rates, medical costs and work for the medical staff. By raising awareness about VAP, we hope to bridge the gap between dental and medical professionals. With their ongoing collaboration, comprehensive care can be provided to the patients, nurses will have more time for other duties and hospital costs would ultimately decrease. If we start with education and create a general concern and value for oral care, the rest will soon follow. 1. Seckel M. Implementing evidence-based practice
guidelines to minimize ventilator-associated pneumonia. AACN News 2007;
24(1), 8-10.
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