Oral care education in the prevention of ventilator-associated pneumonia: quality patient outcomes in the intensive care unit

Interventions to promote oral care regimen adherence in the critical care setting: A systematic review

BACKGROUND

Oral care is a fundamental nurse-led intervention in the critical care setting that provides patient comfort and prevents adverse outcomes in critically ill patients. To date, there has been minimal focus on nurse-focused interventions to improve adherence to oral care regimens in the adult intensive care unit setting.

OBJECTIVES

The objectives of this study were to (i) identify types and characteristics of interventions to improve oral care adherence amongst critical care nurses and intervention core components, (ii) evaluate the effectiveness of interventions to improve adherence of oral care regimens, and (iii) identify the types of outcome measures used to assess oral care regimen adherence.

DESIGN

This is a systematic review in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

Key bibliographic databases and platforms, including Scopus, Cochrane, MEDLINE, CINAHL, Embase, PsycINFO, ProQuest, and Web of Science, were searched for studies published before July 2020. The Joanna Briggs Institute's quality appraisal tool was used to assess risk of bias in included studies.

RESULTS

A total of 21 original research studies were identified, of which 18 studies used multifaceted interventions. In accordance with the Joanna Briggs Institute's quality appraisal tools, four of the 20 quasi-experimental studies were rated as high quality. The one randomised control trial was of moderate quality. Outcome measures included oral care adherence behaviours, oral care knowledge, self-reported adherence, and documentation. Improved effectiveness in oral care adherence was reported in 20 studies.

CONCLUSIONS

Review findings confirm interventions to change behaviours improve oral care adherence. The most effective interventional approach could not be determined owing to heterogeneity in intervention design and outcome measures. Oral care in the intensive care unit is a vital, nurse-led activity that reduces the risk of hospital-acquired infection. It is recommended that future research adopt implementation science methods to ensure stakeholder engagement and feasibility.

SYSTEMATIC REVIEW REGISTRATION NUMBER

This review was submitted and subsequently registered on PROSPERO, the International Perspective Register of Systematic Reviews PROSPERO 2019 CRD42019123142.

What nursing sensitive outcomes have been studied to-date among patients cared for in intensive care units? Findings from a scoping review

BACKGROUND

Although many studies have considered mortality and adverse effects as outcomes sensitive to nursing practice, it seems that other outcomes of nursing care in intensive care units have been explored less commonly.

OBJECTIVES

To describe the state-of-science in research in the field of nursing sensitive outcomes in intensive care units and to synthesize outcomes that have been documented to date as being influenced by nursing care.

DESIGN

A scoping review study based on the framework proposed by Arksey and O'Malley, further refined by the Levac and Joanna Briggs Institute was performed in 2019.

DATA SOURCES

The Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Google Scholar electronic databases were searched. In addition, the reference list of included articles was screened.

REVIEW METHODS

Two researchers independently identified publications on the basis of the following criteria: (a) articles that reported nursing sensitive outcomes on critically-ill adult patients admitted to the intensive care unit, (b) as primary and secondary studies, (c) written in English, and (d) without any time frame limitation.

RESULTS

Of the 4,231 records, 112 fully met the inclusion criteria and were included. Publications were mainly authored in the US and Canada (n = 44, 39.2%), and the majority (n = 62, 55.3%) had an observational design. A total of 233 nursing sensitive outcomes emerged, categorized in 35 outcomes, with, on average, two per study included. The most often measured outcomes were pressure ulcers (20 studies) and ventilator-associated pneumonias (19 studies); the less studied outcomes were quality of life, secretion clearance, patient-ventilator dysynchrony, and post-extubation dysphagia. When categorizing outcomes, the ones concerning safety (n = 77, 33.1%) were represented the most, followed by those concerning the clinical (n = 72, 30.9%), functional (n = 70, 30.0%), and perceptual (n = 14, 6.0%) domains. The interdependent outcomes linked to multi-professional interventions (e.g., ventilator-associated pneumonias) were the most frequently studied nursing sensitive outcomes (n = 20, 57.1%), while independent outcomes resulting from autonomous interventions performed by nurses were less often studied (n = 8, 22.9%).

CONCLUSIONS

From a clinical point of view, a large heterogeneity of outcomes influenced by nursing care emerged. However, identified outcomes have been studied with different approaches and metrics, so that future efforts will need to establish homogeneous conceptual and operative definitions. Moreover, increasing efforts in establishing perceptual outcomes, or those close to the fundamentals of nursing care, are suggested in order to better depict the contribution of critical care nurses in the field.

Nurses' perception and attitudes towards oral care practices for mechanically ventilated patients

OBJECTIVES

To explore the perception and attitudes of intensive care unit (ICU) nurses towards oral care practice for mechanically ventilated (MV) patients.

METHOD

A descriptive cross-sectional design was used in this study. A convenience sample of 96 ICU nurses completed a questionnaire on their perception and  attitudes towards oral care. The study setting was 3 representative Jordanian hospitals in Al-Karak and the capital, Amman, over a 6-month period between February and September 2016.

RESULTS

Ninety-six nurses participated in the study. The response rate was 76.8%. The results revealed that 65% only follow a specific oral care protocol. Nurses did not adhere to minimal standards. Although nurses' attitude towards oral care was strongly positive, 68% of them perceived it as an unpleasant task and 29% agreed that they had insufficient training; 78% agreed to learn more about the best way to perform oral care. Standard descriptive statistics were calculated for all baseline information (sociodemographic characteristics). Binary variables were expressed as proportions, and normally distributed continuous variables as means and standard deviations.

CONCLUSION

The poor perception and attitudes of ICU nurses regarding oral care for MV patients require the urgent attention of clinical administrators. In-hospital training regarding oral care protocol could improve nurses' perception and attitudes.

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review

BACKGROUND

Intensive care unit nurses are critical for managing mechanical ventilation. Continuing education is essential in building and maintaining nurses' knowledge and skills, potentially improving patient outcomes.

AIMS

The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes.

METHODS

Five electronic databases were searched from 2001 to 2016 using keywords such as mechanical ventilation, nursing and education. Inclusion criteria were invasive mechanical ventilation continuing education programmes that involved nurses and measured patient outcomes. Primary outcomes were intensive care unit mortality and in-hospital mortality. Secondary outcomes included hospital and intensive care unit length of stay, length of intubation, failed weaning trials, re-intubation incidence, ventilation-associated pneumonia rate and lung-protective ventilator strategies. Studies were excluded if they excluded nurses, patients were ventilated for less than 24 h, the education content focused on protocol implementation or oral care exclusively or the outcomes were participant satisfaction. Quality was assessed by two reviewers using an education intervention critical appraisal worksheet and a risk of bias assessment tool. Data were extracted independently by two reviewers and analysed narratively due to heterogeneity.

RESULTS

Twelve studies met the inclusion criteria for full review: 11 pre- and post-intervention observational and 1 quasi-experimental design. Studies reported statistically significant reductions in hospital length of stay, length of intubation, ventilator-associated pneumonia rates, failed weaning trials and improvements in lung-protective ventilation compliance. Non-statistically significant results were reported for in-hospital and intensive care unit mortality, re-intubation and intensive care unit length of stay.

CONCLUSION

Limited evidence of the effectiveness of continuing education programmes on mechanical ventilation involving nurses in improving patient outcomes exists. Comprehensive continuing education is required.

RELEVANCE TO CLINICAL PRACTICE

Well-designed trials are required to confirm that comprehensive continuing education involving intensive care nurses about mechanical ventilation improves patient outcomes.

The impact of oral care on oral health status and prevention of ventilator-associated pneumonia in critically ill patients

BACKGROUND

Ventilator-associated pneumonia is one of the most common nosocomial infections which increase mortality rate and length stay of hospitalisation. Oral care would not only improve patient's oral health and well-being, but it can also reduce the incidence rate of ventilator-associated pneumonia.

OBJECTIVES

The objective of this study was to identify the impact of oral care practices on oral health status of patients in intensive care unit and the incidence rate of ventilator-associated pneumonia.

METHODS

This clinical trial recruited 100 participants who were randomly assigned to a control group (receiving oral care by nurses) and an intervention group (receiving systematic care by the researcher) during 2015-2016. Beck Oral Assessment Scale was used to determine the required number of times for receiving oral care with regard to patient's oral health in the intervention group. Each care included adjusting endotracheal tube cuff pressure, brushing with toothpaste, using antiseptics and moistening the lips. The oral cavity was examined using BOAS and Mucosal-Plaque Score, and Clinical Pulmonary Infection Score was used for detecting pneumonia.

RESULTS

The BOAS scoring showed significant differences between the two groups from the first to fifth day (P<0.001). The mucosal-plaque index was significantly different between the two groups from the third day to fifth day (P<0.001). The incidence rate of pneumonia on the third and fifth day was 10% (5) and 14% (7) in the control group, and 4% (2) and 10% (5) in the intervention group, respectively. The Fisher test did not show significant difference (P=0.538), however, the incidence rate in the intervention group reduced compared with the control group.

CONCLUSION

Although following a systematic oral care program could not significantly decrease the incidence of ventilator-associated pneumonia in critically ill patients compared to the conventional oral care practices, it significantly improved the oral health and mucosal-plaque index.

Analysis of ventilator-associated pneumonia infection route by genome macrorestriction-pulsed-field gel electrophoresis and its prevention with combined nursing strategies

The aim of the present study was to explore the infection route of ventilator-associated pneumonia (VAP) and assess the effectiveness of a combined nursing strategy to prevent VAP in intensive care units. Bacteria from the gastric juice and drainage from the hypolarynx and lower respiratory tracts of patients with VAP were analyzed using genome macrorestriction-pulsed-field gel electrophoresis (GM-PFGE). A total of 124 patients with tracheal intubation were placed in the intervention group and were treated with a combined nursing strategy, comprising mosapride (gastric motility stimulant) administration and semi-reclining positioning. A total of 112 intubated patients were placed in the control group and received routine nursing care. The incidence rate of VAP, days of ventilation and mortality rate of patients were compared between the two groups. The GM-PFGE fingerprinting results of three strains of Pseudomonas aeruginosa from the gastric juice, subglottic secretion drainage and drainage of the lower respiratory tract in patients with VAP were similar across groups. The number of days spent on a ventilator by patients in the intervention group (7.37±5.32 days) was lower compared with that by patients in the control group (12.34±4.98 days) (P<0.05). The incidence rate of VAP was reduced from 40.81 to 21.25% following intervention with the combined nursing strategy (P<0.05); furthermore, the mortality rate of intubated patients in the intervention group was 29.46%, a significant reduction compared with the 41.94% mortality rate observed in the control group (P<0.05). Gastroesophageal reflux (GER) was confirmed as one of the infection routes for VAP. The combined nursing strategy of gastric motility stimulant administration and the adoption of a semi-reclining position was effective in preventing VAP by reducing the occurrence of GER.