Final

PICOT: In mechanically ventilated patients in the ICU (P), does an oral care protocol using chlorhexidine mouthwash (I) compared to routine oral care (C) reduce the incidence of ventilator-associated pneumonia (O) over six months (T)?

We are not going to touch other parts of our paper. We are just adding this part to that paper and writing conclusion for whole paper.

Clinical implications summarize what you will need to do, or what you think needs to happen, based on the literature you have reviewed and critiqued. This is also where you will identify any gaps in the literature that you think need to be studied further. 

You will then develop an implementation plan for your project. Remember, this paper is built on previous sections of the project that you have already submitted so you will include your background and literature review. Make sure that you review the instructor's feedback and edit your previous sections based on that feedback. 

This is your final paper, so put all of the previous sections into this one paper for a final draft. 

 

Clinical Implications and Implementation Plan (100 points)

 

Purpose/Objective of this assignment: To recommend changes to practice based on the literature and grading of the evidence, assess potential barriers to using the change in practice, and develop an evaluation plan.

Assignment Requirements: Write a  2 to3 page section,  is to be added to the literature review, applying the  key findings  for recommendations in changes to nursing practice, with proper citations, to answer the PICOT question.

· Develop a logical transition from the Literature Review to this section, including the PICOT question.

· Briefly identify the key findings about the clinical problem as applicable to nursing practice.

· Discuss the clinical implications of these findings. What is the supporting evidence regarding practice change? Support recommendations for practice change with clear arguments, using rationale/support for the changes based on the literature review findings.

· Develop a plan for making the change in practice in a clinical setting.

· Identify the data to be collected for evaluation and when it will occur.

· Identify the comparison group.

· Identify how you will collect data and what statistical test you will complete with the data (review stats, must be an appropriate test)

· Discuss  relevant barriers  related to successful implementation of the evidence-based change,  and how you will manage them.

· Identify any relevant  ethical considerations  related to the clinical problem, the research reviewed (methodology, participants’ human rights, etc.), and the implementation of the change

· Briefly discuss gaps in the literature regarding the clinical problem and make recommendations for further research.

· Paper will utilize all appropriate APA 7th Ed guidelines for intro, conclusion, citations, references, document organization, formatting, academic language, and grammar.  First person is not appropriate in this paper.

· Include a Summary/Conclusion for  entire project.

· Some suggestions:

· 1. When you note you'll train or educate the staff, how would you do this? Via a required teaching session? A staff meeting?

· 2. For ethical considerations, think about principles of autonomy, justice, beneficence, and nonmaleficence. Also discuss specific populations that are more vulnerable if your population includes children, the elderly, those with mental health disorders- populations more at risk for medical abuse and that need further protection. All research and EBP implementation has some ethical considerations to think about.

· 3. Identify your variables- what is your dependent and independent variable for your project?

· 4. What are the appropriate statistical tests to use to show your outcomes? 

· 5. Think about the data collection- how will you collect it and discard of it? How will you maintain patient privacy?

· 6. What barriers would you anticipate? Financial? Staff compliance?

· 7. Remember you will NOT be completing an RCT- you are doing a pre and post intervention comparison. So you'll discuss how you'd collect data pre implementation and compare it to that post intervention. with EBP, it would be unethical to withhold a practice determined as best practice from a group. 

· 8. When you discuss your inclusion criteria, also make sure to include the exclusion criteria (often opposite your inclusion criteria). 

·  

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The Impact of Using Chlorhexidine Mouthwash Compared to Routine Oral Care for Reducing the Incidence of Ventilator-Associated Pneumonia:

A Literature Review

Shabnam Mashinchi

Azusa Pacific University

Scientific writing

Professor Elizabeth Spooner

November 23, 2023

The Impact of Using Chlorhexidine Mouthwash Compared to Routine Oral Care for Reducing the Incidence of Ventilator-Associated Pneumonia:

A Literature Review

Ventilator-associated pneumonia (VAP) is a serious complication among patients

receiving mechanical ventilation in the intensive care unit (ICU). Singh et al. (2022) and Pinto et

al. (2021) define it as pneumonia that arises later than 48 hours after intubation and mechanical

ventilation. VAP is a significant clinical problem that millions of patients suffer from every year

all over the world (Singh et al., 2022). The World Health Organization ascertains that VAP is not only the second most common hospital-acquired infection but also the principal reason behind mortality among infections (WHO, 2022). VAP poses morbidity and mortality risks, extended periods of mechanical ventilation and hospitalization, increased antibiotic consumption and resistance, and high healthcare expenditure (Karimi et al., 2023). The paper compares two studies by addressing research questions, methodologies, sample traits, findings, recommendations, and threats to reliability and validity.

Background

According to Karimi et al. (2023), ventilator-associated pneumonia (VAP) is a common issue for patients receiving mechanical ventilation due to exposure to bacteria like Pseudomonas aeruginosa and Staphylococcus aureus. Further issues occur due to gram-negative bacteria like “Enterobacter species, Escherichia coli, Klebsiella pneumoniae, Proteus species, Serratia marcescens, and Acinetobacter species” (Karimi et al., 2023). Detection of such bacteria early while a patient receives mechanical ventilation is required to eliminate the occurrence of VAP. The occurrence of VAP is usually within 48 hours of a patient getting admitted, which results in the need for immediate healthcare management involving the patient. If patients do not respond immediately to treatment, the result is mechanical ventilation, which takes a longer time, and when the patients get exposed to more bacteria, the result is susceptibility to infections if healthcare providers do not perform proper measures (Lev et al., 2015). Worse outcomes in patients' lives occur when they visit healthcare environments to gain improvement in their well-being when they start experiencing infections during ICU treatment.

A complete practice change is for providers to start using oral care protocols immediately after a patient starts receiving MV so that they do not risk infection. Patients in the ICU are a vulnerable population whose management requires advanced processes to facilitate the provision of care that addresses various types of bacteria. Providing appropriate resources to patients in the ICU, like healthcare equipment, healthcare providers, and healthcare facilities, requires management to use ethical considerations to ensure impartial treatment for all persons involved. The United States (U.S.) healthcare system has been subjected to many operational methods concerning health reforms to serve patients in the ICU. Challenges are common when administering VAP since patients in ICU are not aware of the care provided to them and thus rely on providers to eliminate the occurrence of new infections apart from the issues they get treated for.

The use of Chlorhexidine for oral care has been found to be effective when administering care so that VAP would be eliminated. Without proper use of oral care methods, there can be barriers affecting nurses who attempt to engage with patients, misunderstandings, lack of direct care techniques, time-consuming health assessment processes, and a general barrier to approaching patients’ health needs. Since patients in ICU are usually in conditions where they cannot communicate, interaction with their next of kin requires better handling while explaining healthcare management options about treatment options VAP (Zimmerman et al., 2020). Reducing pneumonia incidence is imperative and can use contingency measures like avoiding deliberately withholding information about healthcare because patients in ICU may have a limited understanding of the concepts discussed.

Healthcare providers might not adequately understand patients' situations in connection to their symptoms if they do not perform advanced oral care that ensures patients receive a conducive environment for healthcare. Improving the accuracy of the care that patients will receive is valid for solving VAP and is possible by offering oral care operations so that patients' information can be adequately explained to nurses or physicians. The literature review in this paper provides a suitable evaluation for the PICOT question: In mechanically ventilated patients in the ICU (P), does an oral care protocol using chlorhexidine mouthwash (I) compared to routine oral care (C) reduce the incidence of ventilator-associated pneumonia (O) over six months (T)?

Literature Review

This section includes a comprehensive literature review of various articles that include research on how using chlorhexidine mouthwash is an effective method of routine oral care for reducing the incidence of ventilator-associated pneumonia. The section consists of methodology, sampling, research findings, study limitations, and clinical practice guidelines. All these sections shall be constructed to ensure an accurate discussion of the paper’s topic.

Methodology

The studies used in this literature require integrated different types of research designs. Pinto et al. (2021) performed a systematic review and meta-analysis as a quantitative study that was level I and of high quality. Some articles completed randomized control trials (RCT) level I and of high quality (Lev et al., 2015; Singh et al., 2022; Vyas et al., 2020). Zimmerman et al. (2020) performed an experimental, qualitative study that is a level I study and of high quality, and lastly, a study by Jahanshir et al. (2023) was done as a comparative, randomized, triple-blind clinical trial that is level I and of high quality. Each of the studies involved a unique method of assessing the study population.

Each of the studies analyzed the negative health environment caused by VAP, which required adequate addressing and improvement in management by using Chlorhexidine in oral care. The RCT by Singh et al. (2022), Vyas et al. (2020), and Jahanshir et al. (2023) integrated a different control and intervention whereby each group was provided with one type of method for improving the patients’ VAP. The RCT by Singh et al. (2022) involved a control group that was provided with Chlorhexidine wash only and a study group that was provided with oral care along with routine oral hygiene. The RCT performed by Vyas et al. (2020) involved administering Chlorhexidine by diluting commercially available Chlorhexidine for the intervention group and using commercially available Chlorhexidine without diluting it for the control group.

The RCT performed by Singh et al. (2022) selected random patients, and the persons in charge of the tests were not aware of the types of patients selected. The study further used a control group that was provided with standard oral care methods, which were four, and an intervention group involved care that was administered using standard oral care methods in addition to chlorhexidine gluconate and six other oral care methods. Concealment of persons involved in the RCT was performed to facilitate confidential assessment of health changes administered to the persons involved. The RCT method was applied by Jahanshir et al. (2023) since the intervention group was provided with clove extract mouthwash, while the control group involved the standard chlorhexidine mouthwash.

A drastic difference in the study by Jahanshir et al. (2023) illustrated how this study did not use many oral care methods, yet the studies by Karimi et al. (2023) and Vyas et al. (2020) used more than 5 oral care methods. The study by Lev et al. (2015) conducted a controlled study that promoted an accurate review of treatment methods using Chlorhexidine. In the study group of these researchers, oral care involved many techniques, but Chlorhexidine was not used, while the control group used standard oral care methods. The study by Zimmerman et al. (2020) analyzed different medical records of patients who had been provided with mouth care while receiving care. The study by Pinto et al. (2020) used a systematic review and meta-analysis of records from different databases where data concerning patients who received VAP had been stored. Such a technique validated access to unique information as it was possible to access information from unique types of studies.

Sampling

The study's sample analysis by Zimmerman et al. (2020) indicated that information from databases containing different articles relied upon sources. A total of 89 articles were used from the databases to aid in forming the argument supporting the use of Chlorhexidine. Zimmerman et al. (2020) involved 2152 patients in nursing homes,

The study by Lev et al. (2015) was 90 patients in the ICU. The collection of suitable patients was done, one those already admitted to the ICU. Grouping the patients was done using a study group that received care that was routine oral hygiene, while the control group received care that was oral hygiene and use of chlorhexidine gluconate. The study was a randomized one, and grouping the patients was done randomly as long as they were already admitted.

Jahanshir et al. (2023) involved 168 ICU patients. Grouping the patient was done into a control and intervention group. The group was small and was randomized. An intervention group was handled with clove extract mouthwash at 6.66% concentration, while the control group received Chlorhexidine 0.2% twice a day for 5 days.

Karimi et al. (2023) involved 200 intubated patients who were recruited initially for the study. Grouping the patients was done as one group, the intervention group received oral healthcare using evidence-based oral health protocol while the other group, the control group, received routine oral healthcare. The group was small and involved a randomized grouping process. Organizing the patients was done randomly to ensure the control and intervention groups involved different people.

Pinto et al. (2021) involved 1,276 patients who were not studied physically, but their information was accessed from credible peer-reviewed articles. The group was big and involved a post-type of study. The patients were 506 females and 770 males within the age group of 45 and 63 years. Grouping the patients' data was done based on their admittance to the hospital due to "coronary diseases, diabetes, respiratory diseases, neurological diseases, and neoplasms".

Vyas et al. (2020) involved 140 patients in the ICU. For grouping the patients, a study group received care that was routine oral hygiene, while the control group received care that was oral hygiene and the use of chlorhexidine gluconate. The study was a randomized one, and grouping the patients was done randomly as long as they were already admitted.

Singh et al. (2022) involved 220 ICU patients. The existence of different sample sizes allowed the studies to integrate a comprehensive review of the effect of using Chlorhexidine in reducing the occurrence of VAP.

Research Findings

All of the studies show a reduction in infection with VAP if the patients received routine oral care, then adding Chlorhexidine as a critical component of oral care. For instance, Lev et al. (2015) discovered that 33.3% of patients in a control group experienced VAP, while only 8.9% of patients in the study group developed VAP. The study thus illustrates how oral care using Chlorhexidine still did not fully protect patients from VAP. Comparing this to the RCT study done by Singh et al. (2022) indicated how the use of chlorhexidine wash with other oral care methods reduced the occurrence of VAP in patients. Support for the use of Chlorhexidine is possible further in other studies conducted since there is a gradual improvement in health management operations when oral care methods get implemented in diverse methods while using conventional and new methods of care.

Study Limitations

Analysis of limitations in all the studies indicates that they involved constricted sample sizes, which caused the details discovered not to be suitable for a large sample size. Admission of patients into the ICU was also not communicated suitably since there were patients whose history did not get explained, resulting in the limited capability of understanding how the data would be used to generalize to a larger population that needs to be managed VAP. Another limitation was the consistency of performing oral care on patients since some studies explained that care was performed around three times a day while others performed it less or more. There is thus difficulty when attempting to generalize the information of effectiveness while using Chlorhexidine as a critical component of oral care. None of the studies was based on a specific ethnicity. A limitation exists in terms of population since all the studies involved patients who were above 18 years meaning the data cannot be generalized to all types of patients in the ICU.

Clinical Practice Guideline

A clinical practice guideline developed by Hess et al. (2003) is the care of the ventilator circuit by ensuring patients who are at risk of experiencing ventilator-associated pneumonia receive interventions. As stated in the recommended measures, ensuring good-will treatment of the ventilator circuits is crucial in combating VAP. Another recommendation focuses on how passive humidification can be better than active humidification when it comes to reduction in VAP rate. Nevertheless, the decision to apply a passive humidifier requires more than infection control, such as the resistance, dead space volume, and risk of airway obstruction. Finally, recommendation number four notes the need to change passive humidifiers every day, arguing that it is not necessary and that they can be used safely between 24-7 days, depending on the case at hand.

There can be benefits of the closed-suction system in avoiding suctioning-related complications, and contamination is discussed as well. This evidence implies that the use of closed suctioning instead of open suctioning can potentially help in reducing VAP risk. These results highlight the need for thorough ventilator circuit practice with attention paid to using a humidifier replacing a passive humidifier and suction catheter properly. Following this advice helps reduce infection rates, improves patient safety, and supports a better overall picture of mechanical ventilation in ICU practice.

Conclusion

In conclusion, oral care using Chlorhexidine is a valid method for improving the well-being of patients when the practices involved get handled in advanced methods to prevent exposure of ICU patients to bacteria. A reliable health management structure can be attained when reducing the risk of VAP using oral care that is structured to integrate advanced practices, consistency, and the proper substances for patients' conditions.

References

Hess, D. R., Kallstrom, T. J., Mottram, C. D., Myers, T. R., Sorenson, H. M., & Vines, D. L. (2003). Care of the Ventilator Circuit and Its Relation to Ventilator-Associated Pneumonia. Respiratory Care, 48(9), 869–879.

Jahanshir, M., Nobahar, M., Ghorbani, R., & Malek, F. (2023). Effect of clove mouthwash on the incidence of ventilator-associated pneumonia in Intensive Care Unit Patients: A comparative randomized triple-blind clinical trial. Clinical Oral Investigations, 27(7), 3589–3600. https://doi.org/10.1007/s00784-023-04972-w.

Karimi, S., Kolyaei, E., Karimi, P., & Rahmani, K. (2023). Effectiveness of supervised implementation of an oral health care protocol on ventilator-associated pneumonia patients in intensive care units: A double-blind multicenter randomized controlled trial. Infection Prevention in Practice, 5(3), 100295. https://doi.org/10.1016/j.infpip.2023.100295.

Lev, A., Aied, A. S., & Arshed, S. (2014). The effect of different oral hygiene treatments on the occurrence of ventilator-associated pneumonia (VAP) in ventilated patients. Journal of Infection Prevention, 16(2), 76–81. https://doi.org/10.1177/1757177414560252.

Pinto, A. C. da S., Silva, B. M. da, Santiago-Junior, J. F., & Sales-Peres, S. H. de C. (2021). Efficiency of different protocols for oral hygiene combined with the use of Chlorhexidine in the prevention of ventilator-associated pneumonia. Jornal Brasileiro de Pneumologia: Publicacao Oficial Da Sociedade Brasileira de Pneumologia E Tisilogia, 47(1), e20190286. https://doi.org/10.36416/1806-3756/e20190286.

Rak, K. J., Ashcraft, L. E., Kuza, C. C., Fleck, J. C., DePaoli, L. C., Angus, D. C., Barnato, A. E., Castle, N. G., Hershey, T. B., & Kahn, J. M. (2020). Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study. American Journal of Respiratory and Critical Care Medicine, 201(7), 823–831. https://doi.org/10.1164/rccm.201910-2006oc.

Singh, P., Arshad, Z., Srivastava, V. K., Singh, G. P., & Gangwar, R. S. (2022). Efficacy of Oral Care Protocols in the Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Patients. Cureus, 14(4). https://doi.org/10.7759/cureus.23750.

Vyas, N., Mathur, P., Jhawar, S., Prabhune, A., & Vimal, P. (n.d.). Effectiveness of Oral Hygiene with Chlorhexidine Mouthwash with 0.12% and 0.2% Concentration on Incidence of Ventilator Associated Pneumonia (VAP) in Intubated Patients – A Parallel arm Double Blind Randomized Controlled Trial. Annals of International Medical and Dental Research, 7(3), 6–13. https://doi.org/10.21276/aimdr.2021.7.3.AN2

WHO (World Health Organization). (2022). WHO launches first ever global report on infection prevention and control. https://www.who.int/news/item/06-05-2022-who-launches-first-ever-global-report-on-infection-prevention-and-control.

Zimmerman, S., Sloane, P. D., Ward, K., Wretman, C. J., Stearns, S. C., Poole, P., & Preisser, J. S. (2020). Effectiveness of a mouth care program provided by Nursing Home Staff vs standard care on reducing pneumonia incidence. JAMA Network Open, 3(6). https://doi.org/10.1001/jamanetworkopen.2020.4321