1: Intensive Care Med. 2009 Sep;35(9):1518-25. Epub 2009 Jun 26.

Incidence and risk factors for ventilator-associated pneumonia after major heart 
surgery.

Hortal J, Giannella M, Pérez MJ, Barrio JM, Desco M, Bouza E, Muñoz P.

Department of Anesthesia, Hospital General Universitario Gregorio Marañón,
Madrid, Spain.

PURPOSE: Major heart surgery (MHS) patients are a particularly high-risk
population for nosocomial infections. Our objective was to identify risk factors 
for ventilator-associated pneumonia (VAP) in patients undergoing MHS. METHODS:
Prospective study including 1,844 patients operated from 2003 to 2006. RESULTS:
Overall 106 patients (140 episodes) developed one or more episodes of VAP (5.7%, 
22.2 episodes per 1,000 days of mechanical ventilation). VAP incidence was 45.9% 
in those patients requiring more than 48 h of MV. Enterobacteriaceae (32.8),
Pseudomonas aeruginosa (28.6%) and Staphylococcus aureus (27.1%, of which 65.8%
were methicillin resistant) were the principal microorganisms causing VAP. The
independent risk factors for VAP were: age >70, perioperative transfusions, days 
of mechanical ventilation, reintubation, previous cardiac surgery, emergent
surgery and intraoperative inotropic support. Median length of stay in the ICU
for patients who developed VAP or not was, respectively, 25.5 versus 3 days (P < 
0.001), and mortality was, respectively, 45.7 versus 2.8% in both populations (P 
< 0.001). We developed a predictive preoperative score with a sensitivity of 93% 
and a specificity of 40%. CONCLUSIONS: VAP is common in patients undergoing MHS
that require more than 48 h of MV. In that "high-risk" population, innovative
preventive measures should be developed and applied.


PMID: 19557389 [PubMed - in process]

Related Links

    Ventilator-associated pneumonia in patients undergoing major heart surgery: an
incidence study in Europe. [Crit Care. 2009] PMID:19463176

    Continuous aspiration of subglottic secretions in the prevention of
ventilator-associated pneumonia in the postoperative period of major heart
surgery. [Chest. 2008] PMID:18641114

    Ventilator-associated pneumonia complicating the acute respiratory distress
syndrome. [Semin Respir Crit Care Med. 2001] PMID:16088683

    Morbidity and cost burden of methicillin-resistant Staphylococcus aureus in early
onset ventilator-associated pneumonia. [Crit Care. 2006] PMID:16808853

    Bacteremia in patients with ventilator-associated pneumonia is associated with
increased mortality: A study comparing bacteremic vs. nonbacteremic
ventilator-associated pneumonia. [Crit Care Med. 2007] PMID:17581489

2: Nurs Res. 2009 Sep-Oct;58(5):374-7.

Validity and reliability of an oral care practice survey for the orally intubated
adult critically ill patient.

Feider LL, Mitchell P.

Nursing Research Service (MCHJ-CN-NR), Madigan Army Medical Center, Tacoma, WA
98431, USA. laura.feider@us.army.mil

BACKGROUND: Oral care is proposed as key to preventing ventilator-associated
pneumonia, yet little work has been done to measure reliably current oral care
practices nationwide. Five critical care oral care surveys are described in the
literature; however, their usefulness is diminished because of insufficient
validity or reliability measures and sampling limitations that limit
generalizability. OBJECTIVES: The aim of this study was to present a survey
instrument for oral care practices for the orally intubated adult critically ill 
patient and the attendant psychometric properties. METHODS: The oral care survey 
items were designed to elucidate information on the type and frequency of each
specific task for oral care (toothbrushes, foam swabs, suctioning, and
chlorhexidine gluconate oral rinse). The oral care survey was evaluated for face 
validity, content validity, and stability reliability psychometric properties.
RESULTS: Face validity was established by an expert panel. Content validity was
assessed using content validity index (CVI) and pairwise comparison. The overall 
CVI score was 97.5% agreement. A pairwise comparison for the three raters was
computed. The strongest rating agreements were between Rater 1 and Rater 2 (.86) 
and Rater 1 and Rater 3 (.83). Given these interrater reliability scores and the 
overall 97.5% CVI score, minor revisions were made for survey items as
recommended by the reviewers' comments. Test-retest reliability (.82-.86) showed 
a less than 10% difference between all items from Time 1 and Time 2.
IMPLICATIONS: This survey, tested for validity and reliability, can be used in
future critical care settings as an audit tool for oral care practices performed 
by nurses.


PMID: 19680163 [PubMed - indexed for MEDLINE]

Related Links

    [Psychometric characteristics of questionnaires designed to assess the knowledge,
perceptions and practices of health care professionals with regards to alcoholic 
patients] [Encephale. 2004] PMID:15627048

    The impact of an evidence-based practice education program on the role of oral
care in the prevention of ventilator-associated pneumonia. [Intensive Crit Care
Nurs. 2007] PMID:17204424

    An observational study on the open-system endotracheal suctioning practices of
critical care nurses. [J Clin Nurs. 2008] PMID:18205692

    Midwifery care: development of an instrument to measure quality based on the
World Health Organization's classification of care in normal birth. [J Clin Nurs.
2004] PMID:14687296

    Turkish version of the Jefferson Scale of Attitudes Toward Physician-Nurse
Collaboration: a preliminary study. [Contemp Nurse. 2006] PMID:17083318

3: Crit Care Med. 2009 Aug;37(8):2360-8.

Spectrum of practice in the diagnosis of nosocomial pneumonia in patients
requiring mechanical ventilation in European intensive care units.

Koulenti D, Lisboa T, Brun-Buisson C, Krueger W, Macor A, Sole-Violan J, Diaz E, 
Topeli A, DeWaele J, Carneiro A, Martin-Loeches I, Armaganidis A, Rello J;
EU-VAP/CAP Study Group.

Collaborators: Annane D, Amaya-Villar R, Armaganidis A, Blot S, Brun-Buisson C,
Carneiro A, Deja M, DeWaele J, Diaz E, Dimopoulos G, Cardellino S,
Garnacho-Montero J, Guven M, Komnos A, Koulenti D, Krueger W, Lisboa T, Macor A, 
Manno E, Mañez R, Marsh B, Martin C, Martin-Loeches I, Myrianthefs P, Nawynck M, 
Papazian L, Putensen C, Regnier B, Rello J, Sole-Violan J, Spina G, Topeli A,
Wrigge H.

Critical Care Department, Attikon University Hospital, Athens, Greece.

OBJECTIVES: Information on clinical practice regarding the diagnosis of pneumonia
in European intensive care units is limited. The aim of this study was to
describe the spectrum of actual diagnostic practices in a large sample of
European intensive care units. DESIGN: Prospective, observational, multicenter
study. SETTING: Twenty-seven intensive care units of nine European countries.
PATIENTS: Consecutive patients requiring invasive mechanical ventilation for an
admission diagnosis of pneumonia or receiving mechanical ventilation for >48 hrs 
irrespective of admission diagnosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN
RESULTS: A total of 2,436 patients were evaluated; 827 were admitted with or
developed nosocomial pneumonia (hospital-acquired pneumonia [HAP], 27.1%;
ventilator-associated pneumonia [VAP], 56.2%; very early onset VAP, 16.7%). Mean 
age was 59.4 +/- 18.1 yrs, 65.0% were men, and mean admission Simplified Acute
Physiology Score II was 46.7 +/- 17.1. Worsening oxygenation (76.8%),
purulent/changing respiratory secretions (72.1%), and new temperature elevation
(69.2%) were the most frequent clinical signs of nosocomial pneumonia.
Etiological diagnosis was based on noninvasive respiratory specimens in 74.8% of 
episodes. Bronchoscopy was performed in 23.3% of episodes. Bronchoscopy
performance, after adjustment by severity of illness, age, and type of hospital, 
were predicted by worsening oxygenation (odds ratio 2.03; 95% confidence
interval, 1.27-3.24) and male sex (odds ratio 1.77; 95% confidence interval,
1.19-2.65). Definite cause was documented in 69.5% of nosocomial pneumonia cases.
The most common isolates were Staphylococcus aureus (16.3% methicillin-sensitive 
S. aureus and 16.0% methicillin-resistant S. aureus), Pseudomonas aeruginosa
(23.1%), and Acinetobacter baumannii (19.1%). Presence of nosocomial pneumonia
significantly prolonged mean length of mechanical ventilation (10.3 days, p <
.05) and mean intensive care unit length of stay (12.2 days, p < .05) in
intensive care unit survivors. Mortality rate was 37.7% for nosocomial pneumonia 
vs. 31.6% for patients without pneumonia (p < .05). CONCLUSIONS: Etiological
diagnosis of nosocomial pneumonia in a large sample of European intensive care
units was based mainly on noninvasive techniques. However, there was high
variability in bronchoscopy use between the participating intensive care units.


PMID: 19531951 [PubMed - indexed for MEDLINE]

Related Links

    Bacteremia in patients with ventilator-associated pneumonia is associated with
increased mortality: A study comparing bacteremic vs. nonbacteremic
ventilator-associated pneumonia. [Crit Care Med. 2007] PMID:17581489

    Mortality rate attributable to ventilator-associated nosocomial pneumonia in an
adult intensive care unit: a prospective case-control study. [Crit Care Med.
2001] PMID:11801831

    [Staphylococcus aureus nosocomial infections in critically ill patients admitted 
in intensive care units] [Med Clin (Barc). 2006] PMID:16759562

    Incidence and outcomes of ventilator-associated pneumonia in Japanese intensive
care units: the Japanese nosocomial infection surveillance system. [Infect
Control Hosp Epidemiol. 2007] PMID:17326021

    Risk factors for nosocomial pneumonia in critically ill trauma patients. [Crit
Care Med. 2001] PMID:11246310

4: Expert Opin Pharmacother. 2009 Jun;10(9):1461-7.

Ventilator-associated pneumonia: an overview.

DiCocco JM, Croce MA.

University of Tennessee Health Science Center, Department of Surgery, 910 Madison
Ave. #219, Memphis, TN 38163, USA. mcroce@utmem.edu

Despite aggressive efforts to reduce nosocomial infections, many intubated
patients develop ventilator-associated pneumonia (VAP). VAP has been an area of
intense research; however, there is still little consensus in the literature on
how to accurately diagnose or treat VAP. VAP complicates the course of 8 - 28% of
mechanically ventilated patients and mortality varies greatly from 8 to 76%,
depending on the specific population being studied. Once pneumonia is suspected, 
bacteriologic confirmation should be obtained and empiric therapy must be
instituted as soon as possible, as a delay in therapy or inappropriate therapy
greatly increases mortality. Initial antibiotic therapy should be based on the
most common organisms in each hospital or unit, and the most likely pathogens for
that specific patient. Constant surveillance of the responsible pathogens through
the use of antibiograms allows clinicians to make educated choices for
antibiotics. When final cultures and sensitivities are available, de-escalation
to less broad spectrum antibiotics should be performed. If cultures show no
bacterial growth, antibiotics should be discontinued so that patients are not
exposed to unnecessary antibiotics. Following these practices will help to
decrease multi-resistant strains of bacteria and can improve the morbidity and
mortality of VAP.


PMID: 19505213 [PubMed - in process]

Related Links

    The influence of mini-BAL cultures on patient outcomes: implications for the
antibiotic management of ventilator-associated pneumonia. [Chest. 1998]
PMID:9498961

    Ventilator-associated pneumonia complicating the acute respiratory distress
syndrome. [Semin Respir Crit Care Med. 2001] PMID:16088683

    Comprehensive evidence-based clinical practice guidelines for
ventilator-associated pneumonia: diagnosis and treatment. [J Crit Care. 2008]
PMID:18359431

    Conference summary: ventilator-associated pneumonia. [Respir Care. 2005]
PMID:15972117

    De-escalation therapy in ventilator-associated pneumonia. [Curr Opin Crit Care.
2006] PMID:16943725

5: Rehabil Nurs. 2009 Mar-Apr;34(2):47-50, 83.

Hydration and nosocomial pneumonia: killing two birds with one stone (a
toothbrush).

Farrell JJ, Petrik SC.

Baptist Hospital East, Louisville, KY, USA. james.farrell@bhsi.com

Clear and compelling evidence exists in the literature to suggest that nosocomial
pneumonia is linked to poor oral care. In nursing homes and intensive care units,
practicing good oral care has been demonstrated to reduce the risk of aspiration 
pneumonia (Furr, Binkley, McCurren, & Carrico, 2004). In an oral care program
implemented in a 29-bed rehabilitation unit, lung status was improved in 77% of
patients who were admitted with aspiration pneumonia. Key components of the
forces of magnetism (American Nurses Credentialing Center, n.d.) were used to
implement the program, including autonomy and interdisciplinary relationships.
The rehabilitation unit also applied the theory proposed by Higgins and Howell,
which promotes using champions to make important process changes (1990). This
article reviews the steps one rehabilitation unit took to implement an oral care 
plan.


PMID: 19271657 [PubMed - indexed for MEDLINE]

Related Links

    Implementation of an evidence-based feeding protocol and aspiration risk
reduction algorithm. [Crit Care Nurs Q. 2005] PMID:16239821

    Predictors of aspiration pneumonia: how important is dysphagia? [Dysphagia. 1998]
PMID:9513300

    Nosocomial infections in neurosurgery intensive care units. [J Clin Nurs. 2004]
PMID:15317514

    Oral care reduces pneumonia in older patients in nursing homes. [J Am Geriatr
Soc. 2002] PMID:11943036

    Prevention of pneumonia in elderly stroke patients by systematic diagnosis and
treatment of dysphagia: an evidence-based comprehensive analysis of the
literature. [Dysphagia. 2001] PMID:11720404

6: J Neurosci Nurs. 2008 Oct;40(5):291-8.

Oral care intervention to reduce incidence of ventilator-associated pneumonia in 
the neurologic intensive care unit.

Fields LB.

Neurosurgical Unit, Summa Health Systems, Akron, OH, USA.
fieldsl@summa-health.org

Ventilator-associated pneumonia (VAP) is a preventable secondary consequence of
intubation and mechanical ventilation. VAP is pneumonia that develops in an
intubated patient after 48 hours or more of mechanical ventilator support.
Mechanically ventilated patients in neurologic and other intensive care units
(ICUs) are at an increased risk of VAP due to factors such as decreased level of 
consciousness; dry, open mouth; and microaspiration of secretions. VAP can be
prevented by initiating interventions from the Institute of Healthcare
Improvement's VAP bundle, including (a) elevating the head of the bed of
ventilated patients to 30 degrees, (b) preventing venous thromboembolism through 
use of sequential compression devices or anticoagulation, (c) administering
gastric acid histamine2 blockers, (d) practicing good hand hygiene, (e)
initiating early mobilization, and (f) performing daily sedation interruption at 
10 am to evaluate neurologic status. The one intervention not included in the IHI
bundle is oral hygiene. The purpose of this project is to support the premise
that oral care, including timed toothbrushing, combined with the VAP bundle can
mitigate and prevent the occurrence of VAP. Our project specifically addressed
timed oral care of mechanically ventilated patients on a 24-bed stroke,
neurologic, and medical ICU. Patients were randomized into a control group that
performed usual oral care or an intervention group that brushed teeth every 8
hours. The results were immediate and startling, as the VAP rate dropped to zero 
within a week of beginning the every-8-hours toothbrushing regimen in the
intervention group. The study was so successful that the control group was
dropped after 6 months, and all intubated patients' teeth were brushed every 8
hours, maintaining the zero rate until the end of the study.


PMID: 18856250 [PubMed - indexed for MEDLINE]

Related Links

    A randomized trial of dental brushing for preventing ventilator-associated
pneumonia. [Chest. 2009] PMID:19482956

    Oral care reduces incidence of ventilator-associated pneumonia in ICU
populations. [Intensive Care Med. 2006] PMID:16435104

    Bundles to prevent ventilator-associated pneumonia: how valuable are they? [Curr 
Opin Infect Dis. 2009] PMID:19276975

    Adoption of a ventilator-associated pneumonia clinical practice guideline.
[Worldviews Evid Based Nurs. 2006] PMID:17177928

    Intermittent suction of oral secretions before each positional change may reduce 
ventilator-associated pneumonia: a pilot study. [Am J Med Sci. 2008]
PMID:19011396

7: J Bras Pneumol. 2008 Sep;34(9):707-14.

Oral hygiene with chlorhexidine in preventing pneumonia associated with
mechanical ventilation.

[Article in , ]

Beraldo CC, Andrade D.

Department of Basic Nursing. Escola de Enfermagem de Ribeirão Preto da
Universidade de São Paulo, Ribeirão Preto, SP, Brasil.

Ventilator-associated pneumonia (VAP) is a common infection in intensive care
units (ICUs), and oral antiseptic is used as a preventive measure. We reviewed
meta-analyses and randomized clinical trials indexed in the Medical Literature
Analysis and Retrieval System and Cumulative Index to Nursing and Allied Health
Literature databases regarding the topical use of chlorhexidine in the prevention
of VAP. Eight publications were analyzed. In seven (87.5%) chlorhexidine
diminished the colonization of the oropharynx, and in four (50%) there was a
reduction of VAP. Chlorhexidine seems to reduce colonization, thus reducing the
incidence of VAP.


PMID: 18982209 [PubMed - indexed for MEDLINE]

Related Links

    Randomized controlled trial and meta-analysis of oral decontamination with 2%
chlorhexidine solution for the prevention of ventilator-associated pneumonia.
[Infect Control Hosp Epidemiol. 2008] PMID:18179368

    A randomized trial of dental brushing for preventing ventilator-associated
pneumonia. [Chest. 2009] PMID:19482956

    Topical chlorhexidine for prevention of ventilator-associated pneumonia: a
meta-analysis. [Crit Care Med. 2007] PMID:17205028

    Oral decontamination with chlorhexidine reduces the incidence of
ventilator-associated pneumonia. [Am J Respir Crit Care Med. 2006] PMID:16603609

    [Preventing pneumonia in ventilated patients] [Ned Tijdschr Geneeskd. 2008]
PMID:18461887

8: Am J Crit Care. 2007 Nov;16(6):552-62; quiz 563.

Systematic literature review of oral hygiene practices for intensive care
patients receiving mechanical ventilation.

Berry AM, Davidson PM, Masters J, Rolls K.

Westmead Hospital, Westmed, Australia. angela_berry@wsahs.nsw.gov.au

BACKGROUND: Oropharyngeal colonization with pathogenic organisms contributes to
the development of ventilator-associated pneumonia in intensive care units.
Although considered basic and potentially nonessential nursing care, oral hygiene
has been proposed as a key intervention for reducing ventilator-associated
pneumonia. Nevertheless, evidence from randomized controlled trials that could
inform best practice is limited. OBJECTIVE: To appraise the peer-reviewed
literature to determine the best available evidence for providing oral care to
intensive care patients receiving mechanical ventilation and to document a
research agenda for this important activity in optimizing patients' outcomes.
METHODS: Articles published from 1985 to 2006 in English and indexed in the
CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, EMBASE, and DARE
databases were searched by using the key terms oral hygiene, oral hygiene
practices, oral care, mouth care, mouth hygiene, intubated, mechanically
ventilated, intensive care, and critical care. Reference lists of retrieved
journal articles were searched for publications missed during the primary search.
Finally, the Google search engine was used to do a comprehensive search of the
World Wide Web to ensure completeness of the search. The search strategy was
verified by a health librarian. RESULTS: The search yielded 55 articles: 11
prospective controlled trials, 20 observational studies, and 24 descriptive
reports. Methodological issues and the heterogeneity of samples precluded
meta-analysis. CONCLUSIONS: Despite the importance of providing oral hygiene to
intensive care patients receiving mechanical ventilation, high-level evidence
from rigorous randomized controlled trials or high-quality systematic reviews
that could inform clinical practice is scarce.


PMID: 17962500 [PubMed - indexed for MEDLINE]

Related Links

    Beyond comfort: oral hygiene as a critical nursing activity in the intensive care
unit. [Intensive Crit Care Nurs. 2006] PMID:16806933

    Improving oral care in patients receiving mechanical ventilation. [Am J Crit
Care. 2005] PMID:16120890

    Oral decontamination for prevention of pneumonia in mechanically ventilated
adults: systematic review and meta-analysis. [BMJ. 2007] PMID:17387118

    Oral hygiene with chlorhexidine in preventing pneumonia associated with
mechanical ventilation. [J Bras Pneumol. 2008] PMID:18982209

    Oral care intervention to reduce incidence of ventilator-associated pneumonia in 
the neurologic intensive care unit. [J Neurosci Nurs. 2008] PMID:18856250

9: J Nurs Care Qual. 2007 Oct-Dec;22(4):316-21.

Impact of oral hygiene on prevention of ventilator-associated pneumonia in
neuroscience patients.

Powers J, Brower A, Tolliver S.

Critical Care and Neuroscience, Methodist Hospital, Clarian Health Partners,
Indianapolis, Indiana, USA. jpowers@clarian.org

Ventilator-associated pneumonia is one of the most frequent complications among
critically ill patients. Growth of pathogenic bacteria in dental plaque may serve
as the source of these infections. This performance improvement initiative
evaluated an aggressive oral care approach to prevent the accumulation of plaque 
containing bacteria. Our data support the use of these oral care measures and
deep oral-pharyngeal suctioning for the prevention of aspiration of oral
contents.


PMID: 17873728 [PubMed - indexed for MEDLINE]

Related Links

    The impact of an evidence-based practice education program on the role of oral
care in the prevention of ventilator-associated pneumonia. [Intensive Crit Care
Nurs. 2007] PMID:17204424

    Ventilator-associated pneumonia. [Crit Care Nurse. 2008] PMID:18515611

    Beyond comfort: oral hygiene as a critical nursing activity in the intensive care
unit. [Intensive Crit Care Nurs. 2006] PMID:16806933

    Ventilator-associated pneumonia: risk factors and prevention. [Crit Care Nurse.
2007] PMID:17671243

    Subglottic secretion drainage: a literature review. [AACN Adv Crit Care. 2007]
PMID:17978611

10: Ann Pharmacother. 2007 Sep;41(9):1390-6. Epub 2007 Aug 14.

Impact of a protocol for prevention of ventilator-associated pneumonia.

Omrane R, Eid J, Perreault MM, Yazbeck H, Berbiche D, Gursahaney A, Moride Y.

McGill University Health Center, Montreal, Québec, Canada.
rajae.omrane@umontreal.ca

BACKGROUND: Several interventions have been shown to be effective in reducing the
incidence of ventilator-associated pneumonia (VAP), but their implementation in
clinical practice has not gained widespread acceptance. OBJECTIVE: To determine
the impact of a protocol that incorporates evidence-based interventions shown to 
reduce the frequency of VAP on the overall rate of VAP, early-onset VAP, and
late-onset VAP in the intensive care unit (ICU) of a tertiary care adult teaching
hospital. METHODS: This pre- and postintervention observational study included
mechanically ventilated patients admitted to the Montreal General Hospital ICU
between November 2003 and May 2004 (preintervention) and between November 2004
and May 2005 (postintervention). A multidisciplinary prevention protocol was
developed, implemented, and reinforced. Rates of VAP per 1000 ventilator-days
were calculated pre- and postprotocol implementation for all patients, for
patients with early-onset VAP, and for those with late-onset VAP. RESULTS: In the
pre- and postintervention groups, 349 and 360 patients, respectively, were
mechanically ventilated. Twenty-three VAP episodes occurred in 925
ventilator-days (crude incidence rate 25 per 1000) in the preintervention period.
Following implementation, the VAP rate decreased to 22 episodes in 988
ventilator-days (crude incidence rate 22.3 per 1000), corresponding to a relative
reduction in rate of 10.8% (p < 0.001). The incidence of early-onset VAP
decreased from 31.0 to 18.5 VAP per 1000 ventilator-days (p < 0.001), while the
incidence of late-onset VAP increased from 21.9 to 24.1 VAP per 1000
ventilator-days (p < 0.001). However, when all covariates were adjusted, the
impact of the prevention protocol was not statistically significant. CONCLUSIONS:
Implementation of a VAP prevention protocol incorporating evidence-based
interventions reduced the crude incidence of VAP, early-onset VAP, and late-onset
VAP. However, when covariates were adjusted, the beneficial effect was no longer 
observed. Further research is needed to assess the impact of such measures on
VAP, early-onset VAP, and late-onset VAP.


PMID: 17698898 [PubMed - indexed for MEDLINE]

Related Links

    A prospective, randomized comparison of an in-line heat moisture exchange filter 
and heated wire humidifiers: rates of ventilator-associated early-onset
(community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of
endotracheal tube occlusion. [Chest. 1997] PMID:9377917

    The impact of a simple, low-cost oral care protocol on ventilator-associated
pneumonia rates in a surgical intensive care unit. [J Intensive Care Med. 2009]
PMID:19017665

    Efficacy of a pneumonia prevention protocol in the reduction of
ventilator-associated pneumonia in trauma patients. [Surg Infect (Larchmt). 2007]
PMID:17999583

    Adoption of a ventilator-associated pneumonia clinical practice guideline.
[Worldviews Evid Based Nurs. 2006] PMID:17177928

    Effectiveness of an educational program to reduce ventilator-associated pneumonia
in a tertiary care center in Thailand: a 4-year study. [Clin Infect Dis. 2007]
PMID:17712753

11: J Hosp Infect. 2007 Sep;67(1):1-8. Epub 2007 Aug 24.

Comment in:
    J Hosp Infect. 2008 Jun;69(2):189-90; author reply 190-1.

Prevention of ventilator-associated pneumonia: analysis of studies published
since 2004.

Gastmeier P, Geffers C.

Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical
School, Hannover, Germany. Gastmeier.Petra@mh-hannover.de

As the most recent guidelines for the prevention of ventilator-associated
pneumonia (VAP) were published four years ago, we have conducted a systematic
review to discover whether the recently published articles should further
influence existing guidelines. Articles published since 2004 dealing with
infection control measures for prevention of VAP were gathered and evaluated in
order to identify evidence for the possible modification of routine practice.
Special emphasis was placed on randomized controlled trials (RCTs), meta-analyses
or systematic reviews and studies applying multi-module interventions. A total of
15 RCTs and seven meta-analyses or systematic reviews were found. In addition to 
these, five cohort studies were identified where multi-module programmes were
introduced for reducing VAP rates. The data lead to the conclusion that topical
use of chlorhexidine for oral care is beneficial and subglottic secretion
drainage may lead to delayed onset of VAP. The remaining studies had only a minor
influence on existing guidelines for the prevention of VAP and confirmed the
earlier recommendations in several points. However, the studies investigating
multi-module programmes led to a substantial reduction of VAP of between 31 and
57%. The data show that many VAP cases are preventable and that there is room for
improvement in many institutions. Often simple interventions are useful for the
reduction of VAP rates, for which the best chances appeared to be the application
of multi-module programmes. On average a reduction of more than 40% seems to be
possible.


PMID: 17719133 [PubMed - indexed for MEDLINE]

Related Links

    Prevention of catheter-related bloodstream infections: analysis of studies
published between 2002 and 2005. [J Hosp Infect. 2006] PMID:16984806

    Topical chlorhexidine for prevention of ventilator-associated pneumonia: a
meta-analysis. [Crit Care Med. 2007] PMID:17205028

    Oral hygiene with chlorhexidine in preventing pneumonia associated with
mechanical ventilation. [J Bras Pneumol. 2008] PMID:18982209

    Randomized controlled trial and meta-analysis of oral decontamination with 2%
chlorhexidine solution for the prevention of ventilator-associated pneumonia.
[Infect Control Hosp Epidemiol. 2008] PMID:18179368

    [Prevention of ventilator associated pneumonia in an intensive care unit] [Ugeskr
Laeger. 2007] PMID:18208707

12: Intensive Crit Care Nurs. 2007 Jun;23(3):132-6. Epub 2007 Jan 3.

The impact of an evidence-based practice education program on the role of oral
care in the prevention of ventilator-associated pneumonia.

Ross A, Crumpler J.

Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston 
Salem, NC 27157, United States. amross@wfubmc.edu <amross@wfubmc.edu>

BACKGROUND: Despite strong evidence in the literature on the role of oral care in
the prevention of ventilator-associated pneumonia (VAP), nurses continue to view 
oral care as a comfort measure with low priority and utilise foam swabs rather
than toothbrushes. Although an evidence-based oral care protocol existed and
best-practice oral care tools were available, the VAP rates had not significantly
decreased even though nurses reported providing oral care. OBJECTIVES: The aim of
the study was to determine if an evidence-based practice (EBP) educational
programme would improve the quality of oral care delivered to mechanically
ventilated patients; thereby, reducing the VAP rate. RESULTS: Improvement in oral
health was demonstrated by a decrease in median scores on the Oral Assessment
Guide (pre (11.0), post (9.0)). A t-test analysis revealed a statistically
significant difference (p=0.0002). The frequency of oral care documentation also 
improved as demonstrated by a positive shift to the more frequent timeframes. The
VAP rates have decreased by 50% following the EBP education intervention.
CONCLUSIONS: The implementation of an EBP educational programme focused on
patient outcome rather than a task to be performed improved the quality of oral
care delivered by the nursing staff.


PMID: 17204424 [PubMed - indexed for MEDLINE]

Related Links

    Adoption of a ventilator-associated pneumonia clinical practice guideline.
[Worldviews Evid Based Nurs. 2006] PMID:17177928

    Impact of oral hygiene on prevention of ventilator-associated pneumonia in
neuroscience patients. [J Nurs Care Qual. 2007] PMID:17873728

    Implementing a wound care resource nurse program. [Ostomy Wound Manage. 2007]
PMID:17726211

    Validity and reliability of an oral care practice survey for the orally intubated
adult critically ill patient. [Nurs Res. 2009] PMID:19680163

    Congestive heart failure education study. [J Nurses Staff Dev. 2006]
PMID:16760772

13: Crit Care Med. 2007 Feb;35(2):595-602.

Comment in:
    Crit Care Med. 2007 Feb;35(2):668-9.    Crit Care Med. 2007 Oct;35(10):2468.

Topical chlorhexidine for prevention of ventilator-associated pneumonia: a
meta-analysis.

Chlebicki MP, Safdar N.

Section of Infectious Diseases, Department of Medicine, University of Wisconsin
Medical School, Madison, WI 53792, USA.

OBJECTIVE: To assess the efficacy of topical chlorhexidine for prevention of
ventilator-associated pneumonia (VAP) in a meta-analysis. DATA SOURCE:
Computerized PubMed and MEDLINE search supplemented by manual searches for
relevant articles. STUDY SELECTION: Randomized controlled trials evaluating
efficacy of topical chlorhexidine applied to the oropharynx vs. placebo or
standard care for prevention of VAP. DATA EXTRACTION: Data were extracted on
patient population, inclusion and exclusion criteria, diagnostic criteria for
VAP, form and concentration of topical chlorhexidine used, incidence of VAP, and 
overall mortality. DATA SYNTHESIS: Data on incidence of VAP and mortality were
abstracted as dichotomous variables. Pooled estimates of the relative risk and
95% confidence intervals were obtained using the DerSimonian and Laird random
effects model and the Mantel-Haenszel fixed effects model. Heterogeneity was
assessed using the Cochran Q statistic and I. Subgroup analyses were used to
explore heterogeneity. RESULTS: Seven randomized controlled trials met the
inclusion criteria. Topical chlorhexidine resulted in a reduced incidence of VAP 
(relative risk, 0.74; 95% confidence interval, 0.56-0.96; p=.02) using a fixed
effects model. Using the more conservative random effects model, the point
estimate was similar (relative risk, 0.70; 95% confidence interval, 0.47-1.04;
p=.07), but the results failed to achieve statistical significance. The I test
showed moderate heterogeneity. Subgroup analysis showed that the benefit of
chlorhexidine was most marked in cardiac surgery patients (relative risk, 0.41;
95% confidence interval, 0.17-0.98; p=.04). There was no mortality benefit with
chlorhexidine although the sample size was small. CONCLUSIONS: Our analysis
showed that topical chlorhexidine is beneficial in preventing VAP; the benefit is
most marked in cardiac surgery patients. A large randomized trial is needed to
determine the impact of topical chlorhexidine on mortality.


PMID: 17205028 [PubMed - indexed for MEDLINE]

Related Links

    Randomized controlled trial and meta-analysis of oral decontamination with 2%
chlorhexidine solution for the prevention of ventilator-associated pneumonia.
[Infect Control Hosp Epidemiol. 2008] PMID:18179368

    Supplemental perioperative oxygen for reducing surgical site infection: a
meta-analysis. [J Eval Clin Pract. 2009] PMID:19335497

    Oral hygiene with chlorhexidine in preventing pneumonia associated with
mechanical ventilation. [J Bras Pneumol. 2008] PMID:18982209

    Clinical and economic consequences of ventilator-associated pneumonia: a
systematic review. [Crit Care Med. 2005] PMID:16215368

    Prevention of ventilator-associated pneumonia: analysis of studies published
since 2004. [J Hosp Infect. 2007] PMID:17719133

14: Am J Crit Care. 2007 Jan;16(1):28-36; discussion 37; quiz 38.

Nurses' implementation of guidelines for ventilator-associated pneumonia from the
Centers for Disease Control and Prevention.

Cason CL, Tyner T, Saunders S, Broome L; Centers for Disease Control and
Prevention.

The School of Nursing, University of Texas at Arlington, TX 76109-0407, USA.
CLCason@uta.edu

BACKGROUND: Ventilator-associated pneumonia accounts for 47% of infections in
patients in intensive care units. Adherence to the best nursing practices
recommended in the 2003 guidelines for the prevention of ventilator-associated
pneumonia from the Centers for Disease Control and Prevention should reduce the
risk of ventilator-associated pneumonia. OBJECTIVE: To evaluate the extent to
which nurses working in intensive care units implement best practices when
managing adult patients receiving mechanical ventilation. METHODS: Nurses
attending education seminars in the United States completed a 29-item
questionnaire about the type and frequency of care provided. RESULTS: Twelve
hundred nurses completed the questionnaire. Most (82%) reported compliance with
hand-washing guidelines, 75% reported wearing gloves, half reported elevating the
head of the bed, a third reported performing subglottic suctioning, and half
reported having an oral care protocol in their hospital. Nurses in hospitals with
an oral care protocol reported better compliance with hand washing and
maintaining head-of-bed elevation, were more likely to regularly provide oral
care, and were more familiar with rates of ventilator-associated pneumonia and
the organisms involved than were nurses working in hospitals without such
protocols. CONCLUSIONS: The guidelines for the prevention of
ventilator-associated pneumonia from the Centers for Disease Control and
Prevention are not consistently or uniformly implemented. Practices of nurses
employed in hospitals with oral care protocols are more often congruent with the 
guidelines than are practices of nurses employed in hospitals without such
protocols. Significant reductions in rates of ventilator-associated pneumonia may
be achieved by broader implementation of oral care protocols.


PMID: 17192524 [PubMed - indexed for MEDLINE]

Related Links

    Evidence-based practice: use of the ventilator bundle to prevent
ventilator-associated pneumonia. [Am J Crit Care. 2007] PMID:17192523

    Adoption of a ventilator-associated pneumonia clinical practice guideline.
[Worldviews Evid Based Nurs. 2006] PMID:17177928

    Attitudes toward practice guidelines among intensive care unit personnel: a
cross-sectional anonymous survey. [Heart Lung. 2007] PMID:17628198

    Critical care nurses' knowledge of evidence-based guidelines for preventing
ventilator-associated pneumonia: an evaluation questionnaire. [Am J Crit Care.
2007] PMID:17595369

    Prevention of ventilator-associated pneumonia: current practice in Canadian
intensive care units. [J Crit Care. 2002] PMID:12297991

15: Intensive Crit Care Nurs. 2006 Dec;22(6):318-28. Epub 2006 Jun 27.

Beyond comfort: oral hygiene as a critical nursing activity in the intensive care
unit.

Berry AM, Davidson PM.

Intensive Care Services, Westmead Hospital, University of Western Sydney, Sydney,
Australia. angela_ berry@wsahs.nsw.gov.au

BACKGROUND: The role of oral hygiene in maintaining the health and well being of 
patients in the intensive care unit (ICU) is indisputable. This importance is not
reflected in the body of research related to ICU practice. While a number of
studies have examined oral hygiene practices in oncological patients there is
significantly less attention devoted to these practices in the critically ill.
AIM: This paper has two discrete yet interrelated aims. Firstly, in relation to
current available evidence and based on a sound knowledge of oral physiology,
identify barriers to effective oral hygiene and subsequent effectiveness of the
most commonly used and recommended methods of providing oral hygiene in the
critically ill population. Secondly, informed by the critical review, identify
recommendations for practice and future intervention studies. FINDINGS: To date, 
there is no definitive evidence to determine the most appropriate method of oral 
hygiene including the use of beneficial mouth rinses. Barriers identified in this
review to providing optimal hygiene include: (1) mechanical barriers and
equipment issues, (2) perceptions of the importance of mouth care and empathy
with patient discomfort by nurses, (3) altered patient sensory perception and
discomfort and (4) difficulties in patient communication. In spite of these
challenges opportunities for collaborative research and increasing expertise in
nurse researchers creates a climate to derive solutions to these factors.
CONCLUSIONS: It is clearly evident from this review of oral hygiene practices in 
intensive care that the need for ongoing research is of paramount importance. ICU
nurses undeniably require rigorous research studies in order to inform their
practice in the provision of oral hygiene for critically ill patients.


PMID: 16806933 [PubMed - indexed for MEDLINE]

Related Links

    Impact of oral hygiene on prevention of ventilator-associated pneumonia in
neuroscience patients. [J Nurs Care Qual. 2007] PMID:17873728

    Systematic literature review of oral hygiene practices for intensive care
patients receiving mechanical ventilation. [Am J Crit Care. 2007] PMID:17962500

    The impact of an evidence-based practice education program on the role of oral
care in the prevention of ventilator-associated pneumonia. [Intensive Crit Care
Nurs. 2007] PMID:17204424

    Validity and reliability of an oral care practice survey for the orally intubated
adult critically ill patient. [Nurs Res. 2009] PMID:19680163

    Biting back at poor oral hygiene. [Intensive Crit Care Nurs. 2000] PMID:11091468

16: Am J Respir Crit Care Med. 2006 Jun 15;173(12):1348-55. Epub 2006 Apr 7.

Comment in:
    ACP J Club. 2006 Nov-Dec;145(3):68.    Am J Respir Crit Care Med. 2006 Jun 15;173(12):1297-8.    Am J Respir Crit Care Med. 2007 Feb 15;175(4):418.    Evid Based Nurs. 2007 Jan;10(1):19.    Pediatr Crit Care Med. 2009 Mar;10(2):242-5.

Oral decontamination with chlorhexidine reduces the incidence of
ventilator-associated pneumonia.

Koeman M, van der Ven AJ, Hak E, Joore HC, Kaasjager K, de Smet AG, Ramsay G,
Dormans TP, Aarts LP, de Bel EE, Hustinx WN, van der Tweel I, Hoepelman AM,
Bonten MJ.

University Medical Center Utrecht, Department of Internal Medicine and
Dermatology, and Department of Internal Medicine and Intensive Care Medicine,
Rijnstate Hospital Arnhem, The Netherlands. groenendijk-koeman@wanadoo.nl

RATIONALE: Ventilator-associated pneumonia (VAP) is the most frequently occurring
nosocomial infection associated with increased morbidity and mortality. Although 
oral decontamination with antibiotics reduces incidences of VAP, it is not
recommended because of potential selection of antibiotic-resistant pathogens. We 
hypothesized that oral decontamination with either chlorhexidine (CHX, 2%) or
CHX/colistin (CHX/COL, 2%/2%) would reduce and postpone development of VAP, and
oral and endotracheal colonization. OBJECTIVES: To determine the effect of oral
decontamination with CHX or CHX/COL on VAP incidence and time to development of
VAP. METHODS: Consecutive patients needing mechanical ventilation for 48 h or
more were enrolled in a randomized, double-blind, placebo-controlled trial with
three arms: CHX, CHX/COL, and placebo (PLAC). Trial medication was applied every 
6 h into the buccal cavity. Oropharyngeal swabs were obtained daily and
quantitatively analyzed for gram-positive and gram-negative microorganisms.
Endotracheal colonization was monitored twice weekly. RESULTS: Of 385 patients
included, 130 received PLAC, 127 CHX and 128 CHX/COL. Baseline characteristics
were comparable. The daily risk of VAP was reduced in both treatment groups
compared with PLAC: 65% (hazard ratio [HR]=0.352; 95% confidence interval [CI],
0.160, 0. 791; p=0.012) for CHX and 55% (HR=0.454; 95% CI, 0.224, 0. 925;
p=0.030) for CHX/COL. CHX/COL provided significant reduction in oropharyngeal
colonization with both gram-negative and gram-positive microorganisms, whereas
CHX mostly affected gram-positive microorganisms. Endotracheal colonization was
reduced for CHX/COL patients and to a lesser extent for CHX patients. No
differences in duration of mechanical ventilation, intensive care unit stay, or
intensive care unit survival could be demonstrated. CONCLUSIONS: Topical oral
decontamination with CHX or CHX/COL reduces the incidence of VAP.


PMID: 16603609 [PubMed - indexed for MEDLINE]

Related Links

    [Less ventilator-associated pneumonia after oral decontamination with
chlorhexidine; a randomised trial] [Ned Tijdschr Geneeskd. 2008] PMID:18461894

    Randomized controlled trial and meta-analysis of oral decontamination with 2%
chlorhexidine solution for the prevention of ventilator-associated pneumonia.
[Infect Control Hosp Epidemiol. 2008] PMID:18179368

    Prevention of ventilator-associated pneumonia by oral decontamination: a
prospective, randomized, double-blind, placebo-controlled study. [Am J Respir
Crit Care Med. 2001] PMID:11500337

    Prophylactic chlorhexidine oral rinse decreases ventilator-associated pneumonia
in surgical ICU patients. [Surg Infect (Larchmt). 2001] PMID:12594876

    Effectiveness and cost of selective decontamination of the digestive tract in
critically ill intubated patients. A randomized, double-blind,
placebo-controlled, multicenter trial. [Am J Respir Crit Care Med. 1998]
PMID:9731025

17: Am J Infect Control. 2004 May;32(3):161-9.

Survey of oral care practices in US intensive care units.

Binkley C, Furr LA, Carrico R, McCurren C.

Departments of Surgical and Hospital Dentistry, University of Louisville Health
Care, Louisville, KY 40292, USA.

BACKGROUND: Research has shown that oral care involving toothbrushes and topical 
antimicrobials improves the oral health of medically compromised patients and may
reduce the incidence of nosocomial infections including pneumonia. This survey
research was undertaken to determine the type and frequency of oral care in
intensive care units (ICUs) in the United States and the attitudes, beliefs, and 
knowledge of health care workers. METHODS: A randomly selected survey of 102 ICUs
within the continental United States participated with 556 respondents; 97% of
respondents were registered nurses. MEASUREMENTS: Frequency and type of oral care
provided, attitudes and beliefs, and knowledge and training in oral care were
measured. RESULTS: Ninety-two percent of respondents perceived oral care to be a 
high priority. The primary methods of oral care involved the use of foam swabs,
moisturizers, and mouthwash. Toothbrushes and toothpaste were used infrequently
by almost 80% of respondents. The majority of nurses indicated a need for
research-proven oral care standards and desired to learn more. CONCLUSIONS: In
this random sample of ICUs, oral care methods were not consistent with current
research and oral care protocols. The translation of oral care research into
practice in the ICU may improve the quality of care and decrease the incidence of
ventilator-associated pneumonia.


PMID: 15153928 [PubMed - indexed for MEDLINE]

Related Links

    Factors affecting quality of oral care in intensive care units. [J Adv Nurs.
2004] PMID:15533083

    Oral care practices in intensive care units: a survey of 59 European ICUs.
[Intensive Care Med. 2007] PMID:17384927

    Cross-sectional survey of hand-hygiene compliance and attitudes of health care
workers and visitors in the intensive care units at King Chulalongkorn Memorial
Hospital. [J Med Assoc Thai. 2005] PMID:16623043

    A survey of the oral care practices of intensive care nurses. [Intensive Crit
Care Nurs. 2004] PMID:15072774

    Prevention of ventilator-associated pneumonia: current practice in Canadian
intensive care units. [J Crit Care. 2002] PMID:12297991

18: Intensive Crit Care Nurs. 2004 Apr;20(2):69-76.

A survey of the oral care practices of intensive care nurses.

Jones H, Newton JT, Bower EJ.

Department of Oral Health Services Research & Dental Public Health, GKT Dental
Institute, Caldecot Road, London SE5 9RW, UK.

BACKGROUND: Intensive care unit (ICU) patients have complex oral care needs.
Inadequate oral care may predispose ICU patients to nosocomial infections. Recent
initiatives have sought to improve the quality and evidence base of ICU oral care
provision. OBJECTIVES: To describe the current priority given to oral care, the
knowledge and practice of oral needs assessment and oral care methods, and
adherence to the local ICU oral care protocol of ICU nurses working in one
hospital. METHOD: Self-administered questionnaire survey of all nurses working in
adult ICU ( n = 160 ). RESULTS: Replies were received from 103 (response rate
64.5%). On average, oral care was given a similar priority to other aspects of
personal care. 13.5% nurses rated oral care as a low priority. Whilst 98% nurses 
routinely performed an oral needs assessment, only 26% used a written assessment 
tool. Toothbrushes were used at least once a day by 85.5% nurses and
chlorhexidine products were routinely used by 50.5% nurses. The oral care
practices of most nurses matched the local ICU protocol. 23.5% nurses had
received no training in oral care and 58% nurses requested initial/further
training. CONCLUSIONS: Most oral care methods were appropriate, based on the
available evidence. A small minority of nurses gave oral care a low priority and 
were not using evidence-based oral care methods recommended in the local ICU
protocol. Encouraging the general use of oral needs assessment tools is a
priority, and further oral care training is required.


PMID: 15072774 [PubMed - indexed for MEDLINE]

Related Links

    The impact of an evidence-based practice education program on the role of oral
care in the prevention of ventilator-associated pneumonia. [Intensive Crit Care
Nurs. 2007] PMID:17204424

    An observational study on the open-system endotracheal suctioning practices of
critical care nurses. [J Clin Nurs. 2008] PMID:18205692

    Exploring the relationship between nursing protocols and nursing practice in an
Irish intensive care unit. [Int J Nurs Pract. 2005] PMID:15985092

    Oral care in the adult intensive care unit. [Am J Crit Care. 1999] PMID:10467468

    Oral care in cancer nursing: nurses' knowledge and education. [J Adv Nurs. 2007] 
PMID:17346322