Integrating Oral Care into a Process for Prevention of Pneumonia in Patients with Artificial Airways

ISSUE: In intensive care settings, effective oral care may be a lower priority due to the demand for more critical nursing skills. However, the impact for infections involving the respiratory tract, particularly for patients with artificial airways, can be significant. Bacterial colonization and the risk of introducing pathogens along the conduit of an endotracheal tube are significant risk factors for ventilator associated pneumonia. PROJECT: In May 2004, a task force consisting of Infection Control, Medical Pulmonary Intensive Care (MICU) and Surgical Trauma Intensive Care (STICU) nurses was charged with developing a process for effective oral care. Concurrently, the Infection Control department monitored ventilator associated pneumonia (VAP) rates. A product based on interval oral care was selected. A six-month trial was mandated by the hospital Value Analysis Committee. The task force designed a program with 4 components: hand hygiene, oral care, mobility and elevation of head of bed. The initiative was called “Our Goal is HOME,” an acronym from the components. Educational storyboards, data collection tools, written policy and procedure were developed, implemented and feedback provided. RESULTS: VAP rate in the STICU was reduced from 19 for Jan-Mar 2004 to a rate of 10 for Jan-Mar 2005. Jan-Dec 2004 had 31 VAPS, while Jan-Nov 2005 has seen 11 VAPs. As part of a quality improvement intitiative for this unit, this demonstrates a 65% reduction. This unit has continued to decrease VAPs, achieving a 5.4 rate. A cost of $560,000 has been avoided based on a published estimate of $40,000 per VAP. In MICU Jan-Mar 2004 the rate was 4.4, compared to 3.5 in Jan-Mar 2005. Jan-Dec 2004 had 5 VAPs, while Jan-Nov 2005 counted 2 VAPs with a cost avoidance of $120,000. Positive feedback from families and healthcare workers has been significant. LESSONS LEARNED: Daily and weekly data collection on intervention compliance was tedious and complicated. As a participant in the IHI Initiative for VAP prevention, monitoring components of the vent bundle has been added to our electonic pateint record. Oral care is included in our bundle components. Issues arose regarding disposal or reuse of pieces of the oral care kit left over at discharge or death. Discarding the product seems wasteful, however potential transmission of pathogens is a concern. A supply management process needs improvement. VAP rates were significantly impacted by a focused process for improving hand hygiene, oral care, mobility and head of bed elevation. Monitoring oral care regimen by use of a timed delivery system was the easiest component to monitor and the most significant process change of the study period.