In health care, there are cases when solutions aimed at saving people’s lives “backfire” with undesired consequences. In turn, it endangers human lives the medical staff is trying to save. These consequences are known as associated risks. One of such controversial medical cases is mechanical ventilation. Mechanical ventilation is called to assist patients in breathing – one of the basic functions of the human body without which living is biologically impossible. However, instead of helping the lungs perform their function, mechanical ventilation puts the patients exposed to it for 48 hours or more at risk of acquiring ventilator-associated pneumonia (VAP).
The problem: The mechanisms of the VAP development are still discussed. However, many scholars agree on the following model as the most credible and medically viable. It is assumed that the pathogenesis of VAP starts with the development of pathogenic bacteria and colonization in the mouth cavity. These microorganisms are then aspirated by the patient and may cause pneumonia. Nasogastric tubes are regarded as a contributing risk factor increasing the degree of bacterial colonization and facilitating entry of pathogenic bacteria to the lower respiratory tract (Pineda, Saliba, & Sohl, 2006). According to the specialists, “Oropharyngeal colonization with potentially pathogenic microorganisms… is pivotal in the pathogenesis of VAP” (Koeman et al., 2006, p. 1348). Pineda, Saliba and Sohl (2006) state that their laboratory tests confirmed the association between pathogens colonizing dental plaques and those responsible for the development of VAP in mechanically ventilated patients. Thus, in addressing VAP in mechanically ventilated patients, health professionals should address the source of the problem, i.e. decrease the oral bacterial load.
Evidence: A question may arise whether the abovementioned problem deserves medical attention and the efforts needed for changing the existing routine procedures and adjacent policies. The answer to this question can be found in numerous reports. VAP is considered to be a global problem which results in an increased length of hospital stay, healthcare costs, and mortality. More than a half of all mechanically ventilated patients develop pneumonia after 120 hours of exposure to mechanical ventilation (Sharma & Kaur, 2012, p. 175). The overall rate of VAP is eight to twenty-eight percent in patients receiving mechanical ventilation, with a crude mortality rate up to fifty percent (Balamurugan, Kanimozhi, & Kumari, 2012; Gu, Gong, Pan, Ni, & Liu, 2012). Obviously, this seemingly rare, minor problem is, in fact, a big issue worth attention and a subsequent shift in evaluation perspectives as well as medical practices used.
The current policy of addressing the issue of VAP in mechanically ventilated patients is called traditional. Its effectiveness is frequently doubted, especially within the framework of the ongoing medical and scientific debate of the last decade which is occurring around the problem of VAP prevention and its strategies. The available strategies include the application of antibiotics, tooth brushing, elevating the head of bed greater than 30 degrees, the use of iodine mouth swabs, silver coated endotracheal tubes, Bactroban nasal ointment, etc. Of these strategies, antibiotics and tooth brushing tend to be the most commonly used. Nevertheless, each of the two approaches can be doubted in terms of efficiency. For example, tooth brushing – a standard of hygiene - has recently been proved ineffective in VAP prevention (Gu et al., 2012). As for oral decontamination with antibiotics, this approach is proved to be effective in reducing the incidences of VAP. However, the negative and undesired side effect of this type of proactive treatment is potential selection of antibiotic-resistant pathogens. Thus, continuous prophylactic use of antibiotics is proved to enhance the risk of induction and selection of resistant pathogens. Moreover, the use of antibiotics is costly. According to the data, the majority of antibiotic use in ICUs is prescribed for treatment of respiratory tract infections. As of 2006, the estimated costs attributable to VAP were $11,897 in America alone (Koeman et al., 2006).
The suggested alternative intervention technique consists in oral decontamination with Chlorhexidine. Chlorhexidine is a cationic chlorophenyl bis-biguanide antiseptic agent which has the ability to bind to oral tissues and release antiseptic properties slowly, therefore, having a long period of antibacterial action (Snyders, Khondowe, & Bell, 2011). As for the complementary benefits, Tantipong et al. (2008) reported that the use of Chlorhexidine (2%) was cost-effective and cost-saving. The estimated cost of Chlorhexidine is ten times less than the cost of antibiotics needed for the treatment of VAP. In terms of side-effects associated with the Chlorhexidine use, the majority of studies do not report any. The report by Tantipong et al. (2008) does indicate the side-effects in a form of irritation of the oral mucosa (in 10% of patients) associated with the use of 2% Chlorhexidine oral rinse solution. However, these effects are mild, reversible and attributed to the peculiarities of the procedure. It was found that the intensity of physical intervention, i.e. the intensity of rubbing and pressure applied during the procedure of oral decontamination with 2% solution applied with gauze, resulted in a corresponding degree of irritation. The more pressure was applied, the severer were the reactions in patients’ mucosa.
Formula: Presumably, Chlorhexidine should be in a form of a 0.1-2% solution or gel. The consensus on the concentration and formula of Chlorhexidine is still not reached which leaves the medical staff with a variety of applicable variants. In core, they do not differ considerably. Nevertheless, the estimated effectiveness of the suggested and tested formulas shows a slight gradation from less to more effective. Sharma and Kaur (2012) suggest the formula of the 0.12% Chlorhexidine gluconate. It is prepared by using 3 ml Chlorhexidine gluconate 20% added to 200 ml of normal saline (0.9% NaCl); separately 5 ml essence of peppermint was mixed with 5 ml 95% ethanol, and then 15 ml glycerin. The solutions are then mixed and brought to 500 ml with normal saline. The solution can be applied via a rinse-saturated oral foam applicator (Sharma & Kaur, 2012, pp. 171-172). The optional variant is ready-to-use pharmacologically produced Chlorhexidine in solution or gel. For the 2% Chlorhexidine solution, Tantiponng et al. (2008) recommend the amount of 15 ml per procedure for one patient. The solution can be applied with gauze. The technique of application for gel Chlorhexidine product is suggested in Keoman et al. (2006). Approximately 0.5 g of Chlorhexidine 2% in petroleum jelly should be put on a gloved fingertip and administered to the buccal cavity. The remnants of medication are removed with the gauze moistened with saline (NaCl 0.9%) (Koeman et al., 2006).
Target population: The risk group embraces all patients needing mechanical ventilation for 48 hours or more, inter alia, cardiac-surgery patients and general ICU patients. This initiative will focus on adult, ill or critically ill patients, or patients in unstable condition, of any sex and race, situated in critical care, inter alia, ICUs (in particular, cardiac-surgery patients and general ICU patients) and undergoing mechanical ventilation for 48 hours or more.
Areas of application: The treated areas should include teeth, the floor of the mouth and tongue dorsum, and the oral soft tissues including buccal mucosa, vestibule, and gingival (Sharma & Kaur, 2012).
Duration and frequency: The recommended duration of the procedure for the formula of the 0.12% Chlorhexidine gluconate is one minute after which the excess rinse should be suctioned out (Sharma & Kaur, 2012). The procedure should be applied on an everyday basis, two or three times a day during the time of the patient’s exposure to the process of mechanical ventilation and, generally, until removal of the nasogastric or endotracheal tubes, or discharge from ICU (Koeman et al., 2006). Considering the findings in Tantipong et al. (2008), the medical personnel should be advised to clean the oropharyngeal mucosa gently (if gauze is used).
Rationale: Chlorhexidine is proved to have a broad range of activity against grampositive microorganisms and remarkably little resistance development rate combined with high effectiveness in preventing VAP. These characteristics make Chlorhexidine a preferable alternative to hazardous antibiotics-based oral decontamination or relatively ineffective tooth brushing (Koeman et al., 2006). After the issue of the problem validity is addressed, it is important to proceed from the questions of “why” and “what” to the question of “who” and “how.” This brings one to the issue of implementation logistics and resources.
According to Couchman, Wetzig, Coyer and Wheeler (2007), “The care of the mechanically ventilated patient is at the core of a nurse’s clinical practice in the Intensive Care Unit” (p. 4). In patients undergoing mechanical ventilation, the link between hygiene and life or death is direct so that erroneous or inadequate hygienic practices may lead to serious deterioration of the patients’ health condition or even death. Intensive and critical care nursing is a challenging environment with multiple issues. Some of these issues can and should be solved with the available, relatively simple, proved-to-be cost-efficient and safe methods. The current issue of focus is VAP prevention in mechanically ventilated ICU patients, and the professionals empowered to solve it are, in fact, nurses themselves.
As I have learnt from the previous research on the subject of health care modernization, nurses are envisioned to become much more meaningful unit in the mechanism of care delivery as well as decision-making overall. As Norlander (2011) said, the system of health care will soon transform into “nurse-led and nurse-managed health care” (p. 2). The proof that nurses are transforming into a more empowered force – into managers, coordinators, and leaders – is undeniable and already present. This implementation plan was developed by me, a nurse who works in the ICU and knows the problem from the inside. It will be implemented by me and my colleagues. The reasons to claim that the proposed practice is easy to incorporate into the existing medical practices are as follows. The preparation formula is relatively simple. The change can be integrated into the current organizational structure, culture, and workflow at any moment. The practice requires the basic knowledge already available to the nursing personnel. Apart from and in addition to the proposed practice, all participating wards should continue employing their usual care protocols. It means that no considerable changes are to be introduced that could hinder the routine schedule of procedures. In essence, the traditional practices of oral decontamination will be substituted by Chlorhexidine-based antiseptic protocol. Since the method of oral decontamination with Chlorhexidine is combinatory, it can be used in addition to, inter alia, raising the head of the bed to 45 degrees and tooth brushing. The latter is proved to be ineffective in VAP prevention, but still remains the basic hygienic procedure to be carried.
In terms of funds, the initiative is not burdensome. The suggested antiseptic is cost-efficient per se and can be cost-saving for the institution which uses it. Printing of educational materials is not needed. Gathering and analyzing data before, during, and following implementation is not needed, either. All background analysis in regard to techniques and outcomes was already provided in the numerous studies the findings from which are refined and provided in this project. The success of the procedure is guaranteed by precision in following the suggested instructions.
Finally, the educational materials needed for successful implementation may not require more than one PowerPoint presentation presented on a one-time meeting for all nursing staff of the hospital. Some of the studies which were used as theoretical materials for this project, such as the study by Tantipong et al. (2008), involved the nurses training as a part of the study methodology. The experiments proved that minimum efforts were needed on behalf of personnel to implement the strategy successfully and effectively. I am sure my fellow staff will support me and this plan. As for the leadership, the fund introspective should be the kernel appeal to make the higher echelons willing to assist in the implementation of this initiative.
- Balamurugan, E., Kanimozhi, A., & Kumari, G. (2012). Effectiveness of Chlorhexidine oral decontamination in reducing the incidence of ventilator associated pneumonia: A meta-analysis. British Journal of Medical Practitioners, 5(1), A512.
- Couchman, B. A., Wetzig, S. M., Coyer, F. M., & Wheeler, M. K. (2007). Nursing care of the mechanically ventilated patient: What does the evidence say? Part one. Intensive and Critical Care Nursing, 23, 4-14.
- Gu, W.-J., Gong, Y.-Z., Pan, L., Ni, Y.-X., & Liu, J.-C. (2012). Impact of oral care with versus without toothbrushing on the prevention of ventilator associated pneumonia: A systematic review and meta-analysis of randomized controlled trials. Critical Care, 16, R190. Retrieved from http://ccforum.com/content/16/5/R190.
- Koeman, M., Van der Ven, A. J., Hak, E., Joore, H. C., Kaasjager, K., de Smet, A. G., … Bonten, M. J. (2006). Oral decontamination with Chlorhexidine reduces the incidence of ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 173, 1348-1355.
- Norlander, L. (2011). Transformational models of nursing across different care settings. The Future of Nursing: Leading Change, Advancing Health. Retrieved from http://www.thefutureofnursing.org/sites/default/files/Future%20of%20Nursing%20Report_0.pdf
- Pineda, L. A., Saliba, R. G., & Sohl, A. A. (2006). Effect of oral decontamination with Chlorhexidine on the incidence of nosocomial pneumonia: A meta-analysis. Critical Care 2006, 10, R35. doi:10.1186/cc4837.
- Sharma, S. B., & Kaur, J. (2012). Randomized control trial on efficacy of Chlorhexidine mouth care in prevention of ventilator associated pneumonia (VAP). Nursing and Midwifery Research Journal, 8(2), 169-178.
- Snyders, O., Khondowe, O., & Bell, J. (2011). Oral chlorhexidine in the prevention of ventilator-associated pneumonia in critically ill adults in the ICU: A systematic review. Southern African Journal of Critical Care, 27(2), 48-56.
- Tantipong, H., Morkchareonpong, C., Jaiyindee, S., & Thamlikitkul, V. (2008). Randomized controlled trial and meta-analysis of oral decontamination with 2% Chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infection Control and Hospital Epidemiology, 29(2), 131-136.