Bacterial Growth in Secretions and on Suctioning Equipment of Orally Intubated Patients: A Pilot Study

Oral Care in Critically Ill Infants and the Potential Effect on Infant Health: An Integrative Review

BACKGROUND

Critically ill infants admitted to the neonatal intensive care unit are at risk for ventilator-associated pneumonia and abnormal oral colonization. Adherence to evidence-based guidelines for oral care in critically ill adults is associated with improved short- and long-term health outcomes. However, oral care guidelines for critically ill infants admitted to the neonatal intensive care unit have not been established, possibly increasing their risk of ventilator-associated pneumonia and other health complications.

OBJECTIVE

To describe and summarize the evidence regarding oral care for critically ill infants admitted to the neonatal intensive care unit and to identify gaps needing further investigation.

METHODS

The MEDLINE (through PubMed) and CINAHL databases were searched for observational studies and randomized controlled trials investigating the effect of oral care on oral colonization, ventilator-associated pneumonia, and health outcomes of infants in the neonatal intensive care unit.

RESULTS

This review of 5 studies yielded evidence that oral care may promote a more commensal oral and endotracheal tube aspirate microbiome. It may also reduce the risk of ventilator-associated pneumonia and length of stay in the neonatal intensive care unit. However, the paucity of research regarding oral care in this population and differences in oral care procedures, elements used, and timing greatly limit any possible conclusions.

CONCLUSIONS

Oral care in critically ill infants may be especially important because of their suppressed immunity and physiological immaturity. Further appropriately powered studies that control for potential covariates, monitor for adverse events, and use recommended definitions of ventilator-associated pneumonia are needed to make clinical recommendations.

Expanding germ-organ theory: Understanding non-communicable diseases through enterobacterial translocation

Diverse microbial communities colonize different habitats of the human body, including gut, oral cavity, nasal cavity and tissues. These microbial communities are known as human microbiome, plays a vital role in maintaining the health. However, changes in the composition and functions of human microbiome can result in chronic low-grade inflammation, which can damage the epithelial cells and allows pathogens and their toxic metabolites to translocate into other organs such as the liver, heart, and kidneys, causing metabolic inflammation. This dysbiosis of human microbiome has been directly linked to the onset of several non-communicable diseases. Recent metabolomics studies have revealed that pathogens produce several uraemic toxins. These metabolites can serve as inter-kingdom signals, entering the circulatory system and altering host metabolism, thereby aggravating a variety of diseases. Interestingly, Enterobacteriaceae, a critical member of Proteobacteria, has been commonly associated with several non-communicable diseases, and the abundance of this family has been positively correlated with uraemic toxin production. Hence, this review provides a comprehensive overview of Enterobacterial translocation and their metabolites role in non-communicable diseases. This understanding may lead to the identification of novel biomarkers for each metabolic disease as well as the development of novel therapeutic drugs.

Adverse effects of non-intubated airway suctioning: a clinical data-based study

AIMS AND OBJECTIVES

The purpose of this study was to investigate the adverse effects of non-intubated suctioning.

BACKGROUND

Airway hygiene aims to maintain a patent airway to ensure adequate ventilation. Nasopharyngeal, oropharyngeal or nasotracheal suctioning may be used in patients who require airway suctioning but do not have an artificial airway. However, no studies till date provide insight into the adverse effects of non-intubated airway suctioning.

DESIGN

A clinical data-based retrospective design.

METHOD

Using institutional and clinical databases of three university hospitals in 2008-2016, we conducted a study with a propensity score matching method of 3,326 hospitalised patients who had undergone suction therapy with or without a tracheotomy. Conditional logistic regression analyses were performed to investigate the link between suctioning and the probabilities of adverse effects. STROBE checklist was used to report the current study.

RESULTS

Patients who required nasopharyngeal, oropharyngeal or nasotracheal suctioning had a higher risk of gastrointestinal ulcers than tracheotomised patients (adjusted OR 1.99; 95% CI, 1.24-3.20). Patients who received non-intubated suction had a higher risk of developing pneumonia (adjusted OR 1.59; 95% CI, 1.26-2.00), and the risk of aspiration pneumonia was three times higher than tracheotomised patients (adjusted OR 3.04; 95% CI, 1.40-6.60).

CONCLUSIONS

Non-intubated patients who require suctioning for airway clearing are more susceptible to gastrointestinal ulcers, pneumonia and aspiration pneumonia. The findings would facilitate in alerting healthcare professionals to this group of patients. However, more clinical research is needed to elucidate the mechanisms of adverse effects in non-intubated patients who require suctioning.

RELEVANCE TO CLINICAL PRACTICE

The adverse effects of suctioning can easily be overlooked in debilitated patients with no intubation. Professionals must be aware of the discomfort and risks that patients may experience.

Frequency of ventilator circuit changes to prevent ventilator-associated pneumonia in neonates and children-A systematic review and meta-analysis

OBJECTIVE

To assess the effect of different frequencies of ventilator circuit changes in neonates and children through a systematic review and meta-analysis.

INTERVENTIONS

(1) "No routine change of ventilator circuit (unless visibly soiled)" versus "routine change at any fixed interval"; (2) routine change of circuit at "less frequent" versus "more frequent" intervals.

OUTCOMES

Primary outcomes were VAP rate (number of VAP episodes per 1000 ventilator-days) and all-cause mortality before discharge.

METHODS

MEDLINE, CENTRAL, EMBASE, and CINAHL were systematically searched from inception till November 3, 2020. Two authors assessed trial eligibility and risk of bias, and independently extracted data. Data were synthesized using fixed effects model. GRADE was used to assess certainty of evidence (CoE).

RESULTS

We identified six studies enrolling 768 participants evaluating circuit changes at two fixed intervals. Meta-analysis of studies on circuit changes "once in less than 7 days" versus "once weekly" showed no difference in VAP rate (risk ratio: 0.83 [0.38-1.81]; one randomized controlled trial (RCT) and 0.94 [0.49-1.81]; two before-after studies) or mortality before discharge (0.67 [0.34-1.3]; one RCT and 1.01 [0.63-1.64]; two before-after studies). CoE was very low. Less frequent circuit changes reduced health-care costs. No study evaluating "circuit changes only when visibly soiled" versus "circuit changes at a fixed interval" was identified.

CONCLUSION

There is no evidence to suggest that ventilator circuits can be safely left unchanged until visibly soiled in neonates and children. Extending circuit changes interval to "once weekly" may not increase VAP rate (CoE-very low) and reduces healthcare costs.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units

BACKGROUND

Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection.

AIM

To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients.

DESIGN

A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion.

METHODS

The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable.

RESULTS

The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use.

CONCLUSION

Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort.

RELEVANCE TO CLINICAL PRACTICE

Effective oral care is integral to safe patient care in critical care.

No-Touch Automated Disinfection System for Decontamination of Surfaces in Hospitals

Background: Hospital-acquired infections (HAIs) remain a common problem, which suggests that standard decontamination procedures are insufficient. Thus, new methods of decontamination are needed in hospitals. Methods: We assessed the effectiveness of a no-touch automated disinfection (NTD) system in the decontamination of 50 surfaces in 10 hospital rooms. Contamination of surfaces was assessed with a microbiological assay and an ATP bioluminescence assay. Unacceptable contamination was defined as > 100 colony forming units/100 cm² in the microbiological assay, and as ≥ 250 relative light units in the ATP assay. Results: When measured with the microbiological assay, 11 of 50 surfaces had unacceptable contamination before NTD, and none of the surfaces had unacceptable contamination after NTD (p < 0.001). On the ATP bioluminescence assay, NTD decreased the number of surfaces with unacceptable contamination from 28 to 13, but this effect was non-significant (p = 0.176). On the microbiological assay taken before NTD, the greatest contamination exceeded the acceptable level by more than 11-fold (lamp holder, 1150 CFU/100 cm²). On the ATP bioluminescence assay taken before NTD, the greatest contamination exceeded the acceptable level by more than 43-fold (Ambu bag, 10,874 RLU). Conclusion: NTD effectively reduced microbiological contamination in all hospital rooms. However, when measured with the ATP bioluminescence assay, the reduction of contamination was not significant.

Monitoring the effectiveness of daily cleaning practices in an intensive care unit (ICU) setting using an adenosine triphosphate (ATP) bioluminescence assay

BACKGROUND

The degree to which daily intensive care unit (ICU) cleaning practices impacts bacterial burden is controversial. The study aimed to assess the utility of using adenosine triphosphate (ATP) bioluminescence assays for monitoring effectiveness of daily cleaning in ICU environments.

METHODS

We sampled 364 total samples from 57 patient rooms and 18 common areas in 3 medical ICUs over 12 weeks, before and after routine daily cleaning. Endpoints were ATP levels (relative light units, RLU) and bacterial bioburden (colony forming units, CFU).

RESULTS

High-touch surfaces in ICU patient rooms and common areas were contaminated before and after cleaning. Routine cleaning significantly reduced bacterial burden in patient rooms (0.14 log₁₀ CFU reduction, P = .008; 0.21 log₁₀ RLU reduction, P < .001) and in ICU common areas (1.18 log₁₀ CFU reduction, P < .001; 0.72 log₁₀ RLU reduction, P < .001). Among sites with colony counts >20 CFUs, the proportion of sites with ATP readings >250 RLU was significantly higher than those with ATP readings ≤250 RLU (90.0% vs 10.0%, P < .05).

CONCLUSION

Routine cleaning significantly reduced bacterial burden on ICU environment surfaces. Although not an alternative to culture methods, ATP assays may be a useful technique to provide rapid feedback on surface cleanliness in ICU settings.

Analysis of the Preventative Influence of an Oral Hygiene Protocol on Ventilator-Associated Pneumonia

AbstractVentilator-associated pneumonia (VAP) is the most commonly reported nosocomial infection among intensive care unit (ICU) patients. This study aimed to evaluate the influence of an oral hygiene protocol on VAP incidence among mechanically-ventilated (MV) ICU patients. The dentate patients admitted without VAP to the hospital’s adult ICU requiring mechanical ventilation for ≥48 hours during a 4-month period in two consecutive years (2015 – Control group and 2016 – Experimental group) were included in this investigation. The oral hygiene protocol was implemented daily, once a day, in the morning hours, using a disposable brush with suction and ultrasoft bristles and 3 g of 0.12% chlorhexidine gel. Hospital-related respiratory infection data, including VAP diagnoses and microbiological analyses, were collected from the monthly health epidemiological notification bulletins issued by the hospital. T tests were applied to compare variables before versus after implementation of the oral hygiene protocol with a significance criterion of P < .05. 43.94% reduction in VAP rate after the protocol implementation was observed. Implementation of the protocol was associated with a significant reduction of Enterobacter spp infections and no cases of VAP related to the main etiological agents of the disease (i.e., S. aureus and C. albicans) were identified. It can be concluded that an oral hygiene protocol performed with a suction brush and 0.12% chlorhexidine gel can serve as an effective prophylaxis against VAP in patients under mechanical ventilation.Keywords: Intensive Care Units. Disease Prevention. Oral Hygiene.ResumoA pneumonia associada à ventilação (PAV) é a infecção nosocomial mais comumente relatada em pacientes de Unidade de Terapia Intensiva (UTI). Este estudo teve como objetivo avaliar a influência de um protocolo de higiene bucal na incidência de PAV entre pacientes sob ventilação mecânica (VM). Os pacientes dentados internados na UTI adulta do hospital sem PAV e que necessitaram de ventilação mecânica por ≥ 48 horas durante um período de 4 meses em dois anos consecutivos (2015 - grupo Controle e 2016 - grupo Experimental) foram incluídos nesta investigação. O protocolo de higiene bucal foi implementado diariamente, uma vez ao dia, nas primeiras horas da manhã, utilizando-se escova descartável com cerdas de sucção e ultramacia e 3 g de gel de clorexidina a 0,12%. Dados de infecção respiratória relacionada ao hospital, incluindo diagnósticos de PAV e análises microbiológicas, foram coletados dos boletins mensais de notificação epidemiológica de saúde emitidos pelo hospital. Testes t foram aplicados para comparar as variáveis antes e após a implementação do protocolo de higiene bucal com um critério de significância de P <0,05. Observamos uma redução de 43,94% na taxa de PAV após a implementação do protocolo. A implementação do protocolo foi associada à uma redução significativa das infecções por Enterobacter spp e não foram identificados casos de PAV relacionados aos principais agentes etiológicos da doença (isto é, S. aureus e C. albicans). Pode-se concluir que u protocolo de higiene bucal realizado com escova de sucção e gel de clorexidina a 0,12% pode servir como uma profilaxia efetiva contra a PAV em pacientes sob ventilação mecânica.Palavras-chave: Unidade de Terapia Intensiva. Prevenção de Doenças. Higiene Bucal.

Nursing oral suction intervention to reduce aspiration and ventilator events (NO-ASPIRATE): A randomized clinical trial

AIM

The primary aim of this study is to compare an oropharyngeal suction intervention versus usual care on microaspiration in intubated patients. Secondary aims are to evaluate the intervention on ventilator-associated condition rates, time to occurrence and compare tracheal-oral α-amylase ratios between groups.

DESIGN

Prospective randomized clinical trial.

METHODS

The study received funding from the National Institutes of Health in February 2014 and Institutional Review Board approval in July 2013. Over 4 years, a convenience sample of 600 orally intubated, ventilated adult patients will be enrolled within 24 hr of intubation. The target sample is 400 participants randomized to the two groups. The intervention involves enhanced suctioning of the mouth and oropharynx every 4 hr, while the usual care group receives a sham suctioning. The research team will deliver usual oral care to all patients every 4 hr and collect oral and tracheal specimens every 12 hr, to quantify α-amylase levels to detect aspiration of oral secretions. Study completers must be enrolled at least 36 hr (baseline and three paired samples). Outcomes include α-amylase levels, percent of positive specimens, ventilator-associated conditions, length of stay, ventilator hours, and discharge disposition.

DISCUSSION

Enrolment has closed, and data analysis has begun. Subgroup analyses emerged, contributing to future research knowledge.

IMPACT

Standardized interventions have reduced but do not address all risk factors associated with ventilator-associated conditions. This study provides the potential to reduce microaspiration and associated sequelae in critically ill, intubated patients.

The Quality of Sputum Specimens as a Predictor of Isolated Bacteria From Patients With Lower Respiratory Tract Infections at a Tertiary Referral Hospital, Denpasar, Bali-Indonesia

Sputum quality is crucial in finding infectious bacteria that will be used to guide definitive antibiotic therapy. Errors in reporting isolated bacteria will affect the rate of patients' morbidity, mortality, and increase patient care costs. This study aims to find out the relationship between sputum quality and isolated bacteria at a Tertiary Referral Hospital, Denpasar, Bali-Indonesia. The study was conducted for 6 months in the Sanglah Hospital Clinical Microbiology laboratory. There were 726 sputum specimens examined and categorized based on Murray Washington criteria. After Gram examination, all specimens were inoculated on aerobic culture media. We classified 41.4% of poor-quality sputum specimens, and non-pathogenic bacteria were isolated from 70.2% of that specimen dominated by Streptococcus mitis (42.53%). Whereas, isolated pathogens were obtained from 54.4% of good-quality sputum specimens dominated by Klebsiella pneumonia (30.86%). Statistical analyses showed that there is a relationship between isolated bacteria and the sputum quality (OR = 3.844; p < 0.001). Good-quality sputum is 3.8 times more likely to isolate pathogenic bacteria than poor-quality sputum. In the Pearson Chi-Square test, the likelihood of isolating pathogenic bacteria from good-quality specimens was significant too (p < 0.001). The results of this study indicate that poor-quality sputum specimens are still found. Therefore, the capacity of good sputum collection must be improved. Supervision of the application of standard sputum culture operational procedures must be more rigorously carried out.

Changes in endotracheal tube intracuff pressure and air leak pressure over time in anesthetized Beagle dogs

OBJECTIVE

To evaluate endotracheal tube intracuff pressure (P_cuff) changes over time and the effect of these changes on air leak pressure (P_leak).

STUDY DESIGN

Prospective experimental study.

ANIMALS

A group of nine healthy adult Beagle dogs.

METHODS

In part I, in vitro measurements of P_cuff were recorded for 1 hour in eight endotracheal tubes subjected to four treatments: room temperature without lubricant (RT0L), room temperature with lubricant (RTWL), body temperature without lubricant (BT0L), and body temperature with lubricant (BTWL). In part II, nine dogs were endotracheally intubated and P_leak was evaluated at P_cuff of 25 mmHg. Subsequently, P_cuff was reset to 25 mmHg (baseline) and P_cuff measurements were recorded every 5 minutes for 1 hour. Subsequently, a second P_leak measurement was recorded at the current P_cuff. The data were analyzed using Wilcoxon signed-rank test, repeated measures anova and Mann-Whitney U test.

RESULTS

In part I, P_cuff differed significantly between the RT0L and RTWL treatments at 5-60 minutes, and between the BT0L and BTWL treatments at 5-35, 55 and 60 minutes (p < 0.05). In part II, compared with baseline pressures, mean P_cuff decreased to <18 mmHg at 10 minutes and significant decreases were recorded at 15-60 minutes (P_cuff range: 10.0 ± 4.9 to 13.4 ± 6.3 mmHg, mean ± standard deviation). Significant differences were observed between the first and second P_leak measurements (p = 0.034). P_leak decreased in six of nine dogs, was not changed in two dogs and increased in one dog.

CONCLUSIONS AND CLINICAL RELEVANCE

Significant decreases in P_cuff over time were measured. P_leak may decrease during anesthesia and increase the risk for silent pulmonary aspiration. The results indicate the need for testing P_cuff more than once, especially at 10 minutes after the onset of anesthesia.

Does objective measurement of tracheal tube cuff pressures minimise adverse effects and maintain accurate cuff pressures? A systematic review and meta-analysis

Correct inflation pressures of the tracheal cuff are recommended to ensure adequate ventilation and prevent aspiration and adverse events. However there are conflicting views on which measurement to employ. The aim of this review was to examine whether adjustment of cuff pressure guided by objective measurement, compared with subjective measurement or observation of the pressure value alone, was able to prevent patient-related adverse effects and maintain accurate cuff pressures. A search of PubMed, Web of Science, Embase, CINAHL and ScienceDirect was conducted using keywords 'cuff pressure' and 'measure*' and related synonyms. Included studies were randomised or pseudo-randomised controlled trials investigating mechanically ventilated patients both in the intensive care unit and during surgery. Outcomes included adverse effects and the comparison of pressure measurements. Pooled analyses were performed to calculate risk ratios, effect sizes and 95% confidence intervals. Meta-analysis found preliminary evidence that adjustment of cuff pressure guided by objective measurement as compared with subjective measurement or observation of the pressure value alone, has benefit in preventing adverse effects. These included cough at two hours (odds ratio [OR] 0.42, confidence interval [CI] 0.23 to 0.79, P=0.007), hoarseness at 24 hours (OR 0.49, CI 0.31 to 0.76, P <0.002), sore throat (OR 0.73, CI 0.54 to 0.97, P <0.03), lesions of the trachea and incidences of silent aspiration (P=0.001), as well as maintaining accurate cuff pressures (Hedges' g 1.61, CI 2.69 to 0.53, P=0.003). Subjective measurement to guide adjustment or observation of the pressure value alone may lead to patient-related adverse effects and inaccuracies. It is recommended that an objective form of measurement be used.

Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate

BACKGROUND

Ventilator-associated pneumonia (VAP) in neonates can be reduced by implementing preventive care practices. Implementation of a group, or bundle, of evidence-based practices that improve processes of care has been shown to be cost-effective and to have better outcomes than implementation of individual single practices.

PURPOSE

The purpose of this article is to describe a safe, effective, and efficient neonatal VAP prevention protocol developed for caregivers in the neonatal intensive care unit (NICU). Improved understanding of VAP causes, effects of care practices, and rationale for interventions can help reduce VAP risk to neonatal patients.

METHOD

In order to improve care practices to affect VAP rates, initial and annual education occurred on improved protocol components after surveying staff practices and auditing documentation compliance.

FINDINGS/RESULTS

In 2009, a tertiary care level III NICU in the Midwestern United States had 14 VAP cases. Lacking evidence-based VAP prevention practices for neonates, effective adult strategies were modified to meet the complex needs of the ventilated neonate. A protocol was developed over time and resulted in an annual decrease in VAP until rates were zero for 20 consecutive months from October 2012 to May 2014.

IMPLICATIONS FOR PRACTICE

This article describes a VAP prevention protocol developed to address care practices surrounding hand hygiene, intubation, feeding, suctioning, positioning, oral care, and respiratory equipment in the NICU.

IMPLICATIONS FOR RESEARCH

Implementation of this VAP prevention protocol in other facilities with appropriate monitoring and tracking would provide broader support for standardization of care. Individual components of this VAP protocol could be studied to strengthen the inclusion of each; however, bundled interventions are often considered stronger when implemented as a whole.

Exposure to reprocessed single-use tracheal suction catheter and ventilator-associated pneumonia risk: A preliminary, single unit-based, matched case-control study

PURPOSE

The reuse of reprocessed single-use suction catheter for suctioning an amount of tracheal secretion among orally intubated, mechanically ventilated patients, who are at risk of acquiring ventilator-associated pneumonia (VAP), has not been thoroughly investigated. This study aimed to examine the association between the repetitive use of reprocessed single-use suction catheter and VAP development.

MATERIALS AND METHODS

A preliminary, single unit-based investigation was designed as matched case-control study to extract data from hospital's existing 5-year VAP report and inpatients' clinical records. Cases were defined as patients, who developed VAP between December 2009 and October 2014. Controls were defined as patients, who had no evidence of VAP during study period. Six hundred eight controls were frequency matched to 152 cases in 4:1 ratio. Chart-extracted clinical data were stratified and included for conditional logistic regression analysis.

RESULTS

Analysis showed a significant association between reprocessed single-use tracheal suction catheter exposure and VAP development [odds ratio (OR), 3.64; 95% confidence interval (CI), 2.47-5.35]. A statistically significant increase in VAP risk was found in male intubated patients (OR, 5.33; 95% CI, 1.22-23.3), who are older than 60 years (OR, 8.08; 95% CI, 1.47-44.3), had severe Glasgow Coma Scale scores (OR, 8.27; 95% CI, 1.83-37.3), and received mechanical ventilatory support for more than 96 hours (OR, 9.67; 95% CI, 1.98-47.1). In addition, a statistically significant increase in VAP risk was seen in intensive care unit, where reprocessed tracheal suction catheter changes were routinely provided (OR, 16.0; 95% CI, 2.40-106.7) and unsatisfactory hand hygiene percentage compliance was observed (OR, 8.40; 95% CI, 1.60-44.1). Ventilator-associated pneumonia proportion analysis revealed a higher number of unknown exogenous VAP among exposed cases compared to nonexposed case patients (32.2% vs 13.8%; OR, 2.31; 95% CI, 1.31-4.05; P < .005) that were mechanically ventilated for more than 96 hours (62.5% vs 25.7%; OR, 3.62; 95% CI, 2.40-5.46; P < .0001).

CONCLUSIONS

This current study suggests that exposure to reprocessed single-use tracheal suction catheter may predispose orally intubated, mechanically ventilated patients in developing VAP. Further research studies are recommended to validate these findings.

IMPLICATIONS FOR CLINICAL NURSING PRACTICE

The estimated VAP risk of this traditional-based practice is essential to provide strong basis for infection control measures to reduce, if not totally eliminate, VAP.

Overcoming the problem of residual microbial contamination in dental suction units left by conventional disinfection using novel single component suction handpieces in combination with automated flood disinfection

OBJECTIVES

Decontaminating dental chair unit (DCU) suction systems in a convenient, safe and effective manner is problematic. This study aimed to identify and quantify the extent of the problems using 25 DCUs, methodically eliminate these problems and develop an efficient approach for reliable, effective, automated disinfection.

METHODS

DCU suction system residual contamination by environmental and human-derived bacteria was evaluated by microbiological culture following standard aspiration disinfection with a quaternary ammonium disinfectant or alternatively, a novel flooding approach to disinfection. Disinfection of multicomponent suction handpieces, assembled and disassembled, was also studied. A prototype manual and a novel automated Suction Tube Cleaning System (STCS) were developed and tested, as were novel single component suction handpieces.

RESULTS

Standard aspiration disinfection consistently failed to decontaminate DCU suction systems effectively. Semi-confluent bacterial growth (101-500 colony forming units (CFU) per culture plate) was recovered from up to 60% of suction filter housings and from up to 19% of high and 37% of low volume suction hoses. Manual and automated flood disinfection of DCU suction systems reduced this dramatically (ranges for filter cage and high and low volume hoses of 0-22, 0-16 and 0-14CFU/plate, respectively) (P<0.0001). Multicomponent suction handpieces could not be adequately disinfected without prior removal and disassembly. Novel single component handpieces, allowed their effective disinfection in situ using the STCS, which virtually eliminated contamination from the entire suction system.

CONCLUSION

Flood disinfection of DCU suction systems and single component handpieces radically improves disinfection efficacy and considerably reduces potential cross-infection and cross-contamination risks.

CLINICAL SIGNIFICANCE

DCU suction systems become heavily contaminated during use. Conventional disinfection does not adequately control this. Furthermore, multicomponent suction handpieces cannot be adequately disinfected without disassembly, which is costly in time, staff and resources. The automated STCS DCU suction disinfection system used with single component handpieces provides an effective solution.

The effect of different oral hygiene treatments on the occurrence of ventilator associated pneumonia (VAP) in ventilated patients

BACKGROUND

We compared the incidence of ventilator associated pneumonia (VAP) among patients treated with comprehensive oral care to those treated with conventional methods of oral care.

METHODS

We conducted a prospective, controlled study in an intensive care unit of 90 ventilated patients. Patients in the study group received a comprehensive oral hygiene treatment regimen that involved tooth brushing, suctioning, sodium bicarbonate, rinsing with an antiseptic solution containing 1.5% hydrogen peroxide and a mouth moisturiser. Patients in the control group received a more conventional treatment that included cleaning with a sponge and atraumatic clamp, and rinsing with a 0.2% solution of chlorhexidine gluconate.

RESULTS

Among the 90 patients admitted to the ICU, 8.9% of the study group developed VAP compared with 33.3% of the control group (p< 0.004). The development of VAP per 1,000 ventilation days was 10.2 in the study group, and 29.5 in the control group (p< 0.06). The mean number of ventilation days and the mean number of hospitalisation days were also lower in the study group.

CONCLUSIONS

In patients who are ventilated, a comprehensive oral hygiene treatment regimen that includes tooth brushing, suctioning and rinsing with an antiseptic is more effective in preventing VAP than more conventional protocols.

Portable suction unit failure in a rural EMS system

INTRODUCTION

Portable suction units used by EMS personnel are utilized infrequently and often are powered by batteries. Lack of use and inspection often results in failure of the device when it is needed. The purpose of this study was to examine the incidence of portable suction unit failure in a rural EMS system and to identify the reasons for failures.

METHODS

A convenience sample was obtained through both random inspections by the staff of a regional EMS council and data from twice monthly checks reported by respective EMS agencies following a standard protocol for each unit. A standard protocol was used, including checking the vacuum level on each suction unit and inspecting the tubing, canister, and battery. Each inspector assessed whether the unit was capable of achieving 300 mmHg of suction within four seconds. Also, the unit was inspected for any signs of misalignment or dry rot of the gasket, kinking of suction hose, damage to the suction canister, weak/dead battery, or defective pump. Findings were recorded.

RESULTS

Over a two-year period, 9,631 suction unit inspections were completed. There were 233 failures (2.4%) noted. The majority (126, 54.1%) were due to battery failure. Seventy-three units failed due to other reasons (not recorded, switch failure, battery not seated). Ten inspections failed due to incorrect assembly. Nineteen inspections failed due to defects with the suction canister. Five inspections failed due to kinked/disconnected suction tubing.

CONCLUSION

Only a relatively small percentage of inspections of suction units revealed failures (4.6% Advanced Life Support, 8.6% Basic Life Support) using the above-stated criteria. However, given the importance of airway management and potential complications associated with airway compromise, including aspiration pneumonia, hypoxia, and hemodynamic instability, this is of concern relative to the morbidity and mortality that could be related to airway failure. Due to the relative infrequency of use and the nature of portable suction units, the potential for lack of maintenance and deficiencies in routine inspection may impact the functional status of these devices in EMS agencies. Clearly, improved documentation of battery installation date, charging in accordance with manufacturer recommendations, and thorough inspection of the portable suction unit in its entirety will ensure readiness of these devices. Additionally, more rigorous documentation and analysis of inspections should be a focus of EMS agencies.

Use of nebulized antimicrobial agents in burned and mechanically ventilated patients with persistent Acinetobacter baumannii, Pseudomonas aeruginosa, or Enterobacteriacea

BACKGROUND

Nebulized antibiotics are used to locally treat colonizations of multi-resistant organisms. Prior systemic nephrotoxic antibiotic use with serum creatinine rises warranted an alternative therapy in 69 ventilator-dependent patients with persisting sputum cultures and need for ventilatory support.

MATERIALS AND METHODS

Following IRB approval, retrospective patient data were reviewed. Analysis included comparison of these 69 patients (71 treatments) to 142 Gram-negative infected burn patients matched for age and burn size.

RESULTS

Mean pooled age and burn wound percent for the 71 triplicates (n=211 patients) were 55.6±18.3 years and 27.4±22.3% burns. Fifty-seven of 69 (83%) patients had inhalation injuries and 54 of 69 (78%) patients survived. Nebulizations averaged 6.8±3.3 days (range 3-12 days). Serum creatinine rose in 2 patients receiving colistimethate nebulizations, known to cause nephrotoxicity following nebulization. Triplicate comparisons via ANOVA noted prolonged ventilatory support (F=13.39; p≪0.05) and length of stay (F=6.11; p≪0.5). Variance was attributed to the sicker nebulized patients. Twenty-four inhalation injury-only triplicates further confirmed that nebulized patient subgroup was more ill.

CONCLUSION

Short duration antibiotic nebulization may allow higher intra-tracheal antibiotic concentrations and may facilitate weaning from the ventilator by reducing bacterial bioburden.

Oropharyngeal secretion volume in intubated patients: the importance of oral suctioning

BACKGROUND

Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown.

OBJECTIVES

To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning.

METHODS

A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals.

RESULTS

Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05).

CONCLUSIONS

A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.

Pursuing excellence: development of an oral hygiene protocol for mechanically ventilated patients

Oral hygiene in seriously ill patients is a nursing responsibility. Oral hygiene regimens in conjunction with standardized ventilator-associated pneumonia "bundles" reduce the incidence of pneumonia, length of stay, and associated costs in critical care. Following strict adherence to the recommended ventilator-associated pneumonia bundle, the ventilator-associated pneumonia rate at the Northeast Baptist Hospital intensive care units has remained 0% for 36 months. Oral care in this patient population, however, has remained vague based on ritual and nurse preference. This article describes the development of an oral care protocol based on best evidence, providing a rationale for standardization of oral hygiene and the plan for surveillance and updating.

An exploration of factors affecting Hong Kong ICU nurses in providing oral care

AIM AND OBJECTIVES

This paper aims to explore the factors that affect Hong Kong intensive care unit nurses in providing oral care.

BACKGROUND

The literature shows that evidence-based oral care prevents ventilator-associated pneumonia. Nevertheless, not all intensive care unit nurses provide such care. Although several studies have been undertaken to identify factors that affecting the provision of oral care, none of these studies looked at the situation in Hong Kong.

DESIGN

An exploratory qualitative design was adopted, with audio-taped interviews.

METHODS

A convenience sample of 10 registered nurses with 3-14 years of intensive care unit working experience was recruited from the intensive care unit of one regional hospital in Hong Kong. Transcribed interviews were analysed by means of content analysis.

RESULTS

The participants' descriptions of their oral care practices covered oral health assessment, cleansing the oral cavity and care of the surrounding areas. Findings revealed the following significant factors that influenced intensive care unit nurses in providing oral care: their perceptions of the purpose of oral care; their fears about providing it; the priority of oral care; and inadequate support for oral care.

CONCLUSIONS

The findings indicate that nurses' oral care practices were not evidence based. Factors that affected the provision of oral care were consistent with those found in previous studies.

RELEVANCE TO CLINICAL PRACTICE

Study findings indicate that present oral care training should be revised. The findings also highlight the influence of ward culture on nurses' priorities in providing oral care. Appropriate materials, adequate staffing levels and the establishment of an evidence-based oral care protocol may facilitate the provision of oral care in the intensive care unit.

The effects of different oral care protocols on mucosal change in orally intubated patients from an intensive care unit

AIM

To compare the effectiveness of three different oral care protocols in intubated patients.

BACKGROUND

Although oral care is important to improve the oral mucosa integrity in intubated patients, there are few evidence-based nursing protocols to deal with this problem in critical care units.

DESIGN

A quasi-experimental design was employed for this study.

METHODS

Eighty-one orally intubated patients recruited from the intensive care unit of a medical centre in northern Taiwan were employed in this study. Patients were divided into three treatment groups: a control group (n = 27), green tea group (n = 29) and boiled water group (n = 25). Oral mucosal status was monitored using a rating scale for 14 days. All data were analysed by the sas software (version 8.2; SAS Institute, Cary, NC, USA) using descriptive statistics, the Kruskal-Wallis H test and generalised estimating equation regression models.

RESULTS

Severity of mucosal change was significantly less on six subscales (labial mucosa, tongue mucosa, gingival colour, gingivitis, salivary status and amount of dental plaque) in the boiled water group than the control group (p < 0·05). In addition, severity was significantly less on two subscales (salivary status and amount of dental plaque) in the green tea group than the control group (p < 0·05).

CONCLUSIONS

Both boiled water and green tea oral care protocols may improve mucosal status of orally intubated patients. Mucosal status was significantly more improved by oral care with boiled water than by oral care with green tea.

RELEVANCE TO CLINICAL PRACTICE

Because oral care plays an important role in improving mucosal status, nurses are urged to find new effective oral care methods to further reduce the occurrence of oropharyngeal colonisation and ventilator-associated pneumonia in intubated patients.

Strategies to prevent ventilator-associated pneumonia in neonates

Ventilator-associated pneumonia (VAP) is one of the leading causes of preventable morbidity and mortality in neonatal intensive care units. This review examines the epidemiology and pathogenesis of VAP in neonates as well as the dilemmas faced by caregivers to diagnose and prevent VAP.

How I learned my ABCs: Action, back to basics, collaboration, discovery

BACKGROUND

Research is essential to generate the scientific evidence for critical care nursing practice, but it is challenging to conduct research in the busy critical care environment. The challenges are even greater in a setting with limited resources for research and where nurses have not typically conducted independent clinical studies.

OBJECTIVES

To detail a successful research trajectory for studying the ABCs of patient care in the critically ill: airway, breathing, and circulation.

METHODS

After initial studies on circulation were conducted, the research was narrowed to focus on airway management. Airway management may be a key factor in preventing ventilator-associated pneumonia because aspiration of colonized oral, gastric, and tracheal secretions is the primary cause of ventilator-associated pneumonia. Multiple descriptive, pilot, and interventional studies have been conducted; findings from each have contributed to future studies.

RESULTS

Other ABCs were critical to this research success: action, back to basics, collaboration, and discovery. It is important for researchers to be self-motivated and to take initiative to develop skills and resources for conducting clinical studies. Several guiding principles help to promote success in research: (1) generate research ideas grounded in observation and clinical practice, (2) collaborate with others, and (3) establish affiliations and partnerships. Discovery occurs in many ways: new findings to guide practice and research, resources to conduct the study, and self-discovery.

CONCLUSIONS

Nursing research is not easy. However, determination and resources help nursing researchers achieve success.

Impact of polyurethane on variations in tracheal cuff pressure in critically ill patients: a prospective observational study

OBJECTIVE

To determine the impact of polyurethane (PU) on variations in cuff pressure (P (cuff)) in intubated critically ill patients.

METHODS

Prospective observational before-after study performed in a ten-bed ICU. Cuff pressure was continuously recorded for 24 h in 76 intubated patients, including 26 with polyvinyl chloride (PVC), 22 with cylindrical polyurethane (CPU), and 28 with tapered polyurethane (TPU)-cuffed tracheal tubes. P (cuff) was manually adjusted every 8 h by nurses and was maintained around 25 cmH(2)O. Time spent with cuff underinflation and overinflation was continuously measured. In addition, pepsin, a proxy for microaspiration of gastric contents, was quantitatively measured in tracheal secretions at the end of recording period.

RESULTS

A total of 1,824 h of continuous recording of cuff pressure was analyzed. Patient characteristics were similar in the three groups. No significant difference was found in percentage of time spent with underinflation (mean +/- SD, 26 +/- 22, 28 +/- 12, 30 +/- 13% in PVC, CPU, and TPU groups, respectively) and overinflation [median (IQR), 7 (2-14), 6 (3-14), 11% (5-20)] among the three groups. However, a significant difference was found in the coefficient of variation of P (cuff) (mean +/- SD, 82 +/- 48, 92 +/- 47, 135 +/- 67, p = 0.002). While the coefficient of P (cuff) variation was significantly (p < 0.017) higher in the TPU compared to CPU and PVC groups, no significant difference was found between the CPU and PVC groups. The pepsin level was significantly different among the three groups (408 +/- 282, 217 +/- 159, 178 +/- 126 ng/ml; p < 0.001). In fact, the pepsin level was significantly lower in the CPU and TPU groups compared with the PVC group.

CONCLUSION

PU does not impact variations in P (cuff) in critically ill patients.

Oral care practices for orally intubated critically ill adults

BACKGROUND

Ventilator-associated pneumonia is a major threat to patients receiving mechanical ventilation in hospitals. Oral care is a nursing intervention that may help prevent ventilator-associated pneumonia.

OBJECTIVES

To describe oral care practices performed by critical care nurses for orally intubated critically ill patients and compare these practices with recommendations for oral care in the 2005 AACN Procedure Manual for Critical Care and the guidelines from the Centers for Disease Control and Prevention.

METHODS

A descriptive, cross-sectional design with a 31-item Web-based survey was used to describe oral care practices reported by 347 randomly selected members of the American Association of Critical-Care Nurses.

RESULTS

Oral care was performed every 2 (50%) or 4 (42%) hours, usually with foam swabs (97%). Oral care was reported as a high priority (47%). Nurses with 7 years or more of critical care experience performed oral care more often (P=.008) than did less experienced nurses. Nurses with a bachelor's degree in nursing used foam swabs (P=.001), suctioned the mouth before the endotracheal tube (P=.02), and suctioned after oral care (P<.001) more often than other nurses. Nurses whose units had an oral care policy (72%) reported that the policy indicated using a toothbrush (63%), using toothpaste (40%), brushing with a foam swab (90%), using chlorhexidine gluconate oral rinse (49%), suctioning the oral cavity (84%), and assessing the oral cavity (73%). Oral care practices and policies differed for all those items.

CONCLUSIONS

Survey results indicate that discrepancies exist between reported practices and policies. Oral care policies appear to be present, but not well used.

When ventilator-associated pneumonias haunt your NICU--one unit's story

IN THE NEW MILLENNIUM, LEVEL III NICUs are increasingly caring for low birth weight (LBW) and extremely low birth weight (ELBW) infants. This subpopulation represents a most fragile and vulnerable group that is subject to numerous complications. An ever-important concern is the development of health care– associated infections. This article focuses on the occurrence and prevention of ventilator-associated pneumonia, better known as VAP, which is an infection of the lung occurring in patients who are being mechanically ventilated at the onset of the infection or have been mechanically ventilated within 48 hours of its onset.1

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

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.

Ventilator-associated pneumonia: prevention is better than cure

BACKGROUND

The prevention of ventilator Assisted Pneumonia (VAP), a hospital acquired infection, among intensive care patients is a major clinical challenge. It is a condition that is associated with high rates of morbidity, mortality, length of stay and hospital costs.

AIM

The aim of this paper is to critically review the available literature and identify current evidence based nursing and medical interventions to support practitioners in preventing VAP in their patients.

METHODS

A literature search using keywords, including 'ventilator-associated pneumonia' were entered into a search engine. A number of highly pertinent papers relevant to the aims of the review were identified, however only a small sample came from nursing journals. Only those papers, which discussed specific strategies for managing VAP were selected for analysis and inclusion in this review.

DISCUSSION

We identified a number of practical and evidence based strategies that nurses can incorporate into their practice to prevent VAP and to reduce its incidence. In addition, the introduction of newer techniques, advances in equipment and use of multidisciplinary care bundles can further support and improve the quality and delivery of safe patient care.

CONCLUSION

Targeted strategies aimed at preventing VAP, should be implemented to improve patient outcome and reduce length of intensive care unit stay and costs. Front-line critical care nurses need to understand the factors which place their patients at risk of developing VAP and, institute evidence-based interventions that will compromise the patients' survival and recovery.

Ventilator-associated pneumonia in neonatal and pediatric intensive care unit patients

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.

Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU

The health care culture must change. Florence Nightingale wrote [8] "deep-rooted and universal is the conviction that to give a medicine is to be doing something, or rather everything and to give air, warmth, cleanliness etc. is to do nothing." Hygiene care practices and mobility activities are fundamental and independent care components in the nursing profession. When implemented using available evidence, they can significantly improve patient outcomes. It is time to claim and demonstrate the importance of consistent delivery of the fundamentals of basic nursing care. Interventional patient hygiene is an effective framework to ensure the the basics of nursing care are consistently applied to improve patient outcomes.

Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis

BACKGROUND

Closed suction systems (CSS) are increasingly replacing open suction systems (OSS) to perform endotracheal toilet in mechanically ventilated intensive care unit patients. Yet effectiveness regarding patient safety and costs of these systems has not been carefully analyzed.

OBJECTIVE

To review effectiveness of CSS and OSS, with respect to patient outcome, bacterial contamination, and costs in adult intensive care unit patients.

DATA SOURCE

Search of MEDLINE, CINAHL, EMBASE, and Cochrane databases and a manual review of article bibliographies.

STUDY SELECTION

Randomized controlled trials comparing CSS and OSS in adult intensive care unit patients were retrieved.

DATA EXTRACTION/SYNTHESIS

Assessment of abstracts and study quality was performed by two reviewers. Data were combined in meta-analyses by random effect models. Fifteen trials were identified. No significant differences were found in incidences of ventilator-associated pneumonia (eight studies, 1,272 patients) and mortality (four studies, 1,062 patients). No conclusions could be drawn with respect to arterial oxygen saturation (five studies, 109 patients), arterial oxygen tension (two studies, 19 patients), and secretion removal (two studies, 37 patients). Compared with OSS, endotracheal suctioning with CSS significantly reduced changes in heart rate (four studies, 85 patients; weighted mean difference, -6.33; 95% confidence interval, -10.80 to -1.87) and changes in mean arterial pressure (three studies, 59 patients; standardized mean difference, -0.43; 95% confidence interval, -0.87 to 0.00) but increased colonization (two studies, 126 patients; relative risk, 1.51; 95% confidence interval, 1.12-2.04). CSS seems to be more expensive than OSS.

CONCLUSIONS

Based on the results of this meta-analysis, there is no evidence to prefer CSS more than OSS.

Nurses’ Implementation of Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease Control and Prevention

• 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.

Tailoring the Institute for Health Care Improvement 100,000 Lives Campaign to pediatric settings: the example of ventilator-associated pneumonia

In December 2004, the Institute for Healthcare Improvement launched a campaign to save 100,000 lives by implementing evidence-based interventions in six areas, five of which are relevant to children. Working collaboratively, the Child Health Corporation of America, National Associate of Children's Hospitals and Related Institutions, and National Initiative for Children's Health Care Quality provided a series of Web-enabled seminars on how the campaign initiatives might be adapted for pediatric settings. Ventilator-associated pneumonia (VAP) is an example of how interventions based on evidence in adult settings may need to be tailored in pediatric settings. The authors describe how assessing and implementing parts of the VAP bundle led to reduction in VAP in two children's hospitals.

Improving Oral Care in Patients Receiving Mechanical Ventilation

• Background Comprehensive oral care is an evidence-based prevention strategy to reduce the risk of ventilator-associated pneumonia in patients receiving mechanical ventilation. Until recently, no comprehensive guidelines or standards existed to define necessary tasks, methods, and frequency of oral care to provide patients with optimal results.

• Objectives To observe current practice of, define best practice for, and measure compliance with standardized comprehensive oral care.

• Methods This observational study was part of a larger research study performed at 5 acute care hospitals. Time blocks of 4 hours were randomized over 8 intensive care units and the 7 days of the week. Baseline data were collected before implementation of multifaceted education on an oral-cleansing protocol; interventional data were collected afterward.

• Results Oral care practices were observed for 253 patients. During the baseline period, oral cleansing was primarily via suction swabs. Toothbrushing and moisturizing of the oral tissues were not observed. Only 32% of the patients had suctioning to manage oral secretions. During the interventional period, 33% of patients had their teeth brushed, 65% had swab cleansing, and 63% had a moisturizer applied to the oral mucosal tissues. A total of 61% had management of oral secretions; 38% had oropharyngeal suctioning via a special catheter.

• Conclusions Implementation of an evidence-based oral cleansing protocol improved the care of patients receiving mechanical ventilation. Multifaceted education and implementation strategies motivated staff to increase oral care practices.

The role of oral microbial colonization in ventilator-associated pneumonia

The present article reviews the association between microbial colonization of the oral cavity and the lungs in critically ill patients that develop ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) setting. The risk factors and microorganisms associated with VAP are presented. The role of oral colonization of VAP-associated pathogens (VAP-AP) in the development of VAP is examined. We explore the potential factors involved in oral colonization of VAP-AP, which are atypical bacteria for the oral cavity. Strategies for the prevention or moderation of oral colonization of VAP-AP have had limited success. We need a deeper understanding of the pathophysiology of VAP in order to reduce the morbidity, mortality, and cost from this common complication in ICU medicine and surgery.

Preventing ventilator-associated pneumonia: evidence-based care

Ventilator-associated pneumonia is a common complication of mechanical ventilation with significant morbidity and mortality. This article summarizes the data related to specific risk factors associated with ventilator associated pneumonia (patient position, oral health, airway management, and gastrointestinal factors) and provides recommendations for practice based on the present evidence.

Mechanical Ventilation

Mechanical ventilation is the second most frequently performed therapeutic intervention after treatment for cardiac arrhythmias in intensive care units today. Countless lives have been saved with its use despite being associated with a greater than 30% in-hospital mortality rate. As life expectancies increase and people with chronic illnesses survive longer, artificial support with mechanical ventilation is also expected to rise. In one survey, over half of senior internal medicine residents reported their training on mechanical ventilation as inadequate, whereas the majority of critical care nurses reported having received no formal education on its use. Technological advances resulting in the availability of sleeker ventilators with graphic waveform displays and new modes of ventilation have challenged the bedside clinicians to incorporate this new data along with evidenced-based research into their daily practice. A review of current thoughts on mechanical ventilation and weaning is presented.