Whether Oral Hygeine in Ventilated Patients can Reduce Ventilator Associated Pnuemonia - Literature review Example

Strategy for Literature Search: Evidence Based Practice Clinical Problem WHETHER ORAL HYGEINE IN VENTILATED PATIENTS CAN REDUCE VENTILATOR ASSOCIATEDPNUEMONIA (VAP) Introduction In the intensive or critical care units, the nurses play important roles in managing the patients. The management of these patients quite often needs placing them under mechanical ventilation for respiratory support. While mechanical ventilation is a life-saving measure, prolonged mechanical ventilation has its own drawbacks. The main reason the patients on ventilator needs to be monitored and managed with dexterity is ventilator associated pneumonia (VAP), which adds to the morbidity and mortality statistics associated with ventilator management and hence this condition needs to be prevented (Fagon et al., 1996). VAP is the most serious complication of critical illness, and this occurs not due to the illness per se, but due to management of the patient, and in that sense, although slightly an over expression, this may be termed as an iatrogenic condition that merits strict monitoring and care in order to prevent it. On the whole, hospital-acquired pneumonia occurring in patients after 48 hours of admission, who were admitted with no preexisting pneumonia and placed on a ventilator is known as ventilator associated pneumonia (Girou et al., 1998). Background This is an important safety issue in patients with critically illness for which they receive mechanical ventilation. Nursing is a very important aspect of care in patients on ventilator since adequate, competent, and effective nursing care can prevent both mortality and morbidity associated with VAP (Tokars et al., 2004). In patients with VAP, it has been reported that there is 20% to 55% mortality. Moreover, with the onset of VAP, there has been a reported increase in hospital stay which in itself may have morbid complications. Therefore, the occurrence of VAP is a dreaded complication, specially when it is caused by a multi-drug resistant pathogen accounting for 76% of mortality when it occurs (Torres et al., 2001). To meet the competency standards of practice and to remain accountable in practice are very important aspects of nursing care. The main reason the patients on ventilator needs to be monitored and managed with dexterity is ventilator associated pneumonia (VAP), which adds to the morbidity and mortality statistics associated with ventilator management and hence this condition needs to be prevented. As has been indicated by Misset et al. (2004), VAP is the most serious complication of critical illness, and this occurs not due to the illness per se, but due to management of the patient. (Misset et al., 2004) The magnitude of the problem will be more relevant from the fact that this accounts for almost half the intensive care unit infections in Europe (Vincent et al., 1995). Practice Issues These facts indicate that there are indeed relevant practice issues involved in the management, care, and monitoring of the patients on mechanical ventilation. Among many reasons, VAP is the most serious complications of critical illness, many of which are preventable by appropriate care. Incidence of VAP is highest in the first week of ventilation, and among the survivors, the VAP increases the duration of ventilation with increased conditional risk and increased attributable mortality among the survivors (Cook et al., 1998). The matter of hope is that in most cases institutional critical care conforms to the requirement of quality nursing care through guidelines of practice. These set of guidelines relevant to prevention of VAP are set of multidisciplinary patient care practices, known as ventilator bundle. These apart from providing the guideline of nursing care also serve as a method to standardise management of patients receiving mechanical ventilation. From the utility point of view, these parameters have three objectives, namely, ability to wean and extubate sooner, to reduce aspiration, which is the main mechanism of the pneumonia; and to maintain a cleaner hypopharynx and oropharynx, the locus of the source of the infection (Cook et al., 1998). These feasible, safe, and cost-effective measures which can be implemented by the nurses in the practice area include elevation of the head of the bed to 30 degrees to 40 degrees where medically permissible, constant removal of subglottic secretions, maintenance of the ventilator circuit every 48 hours, and washing the hands before and after contact with the patient. Some studies also include blood sugar prophylaxis and deep vein thrombosis prevention protocols in this bundle approach (Drakulovic et al., 1999). However, there is no recommendation about the oral care and maintenance of oropharyngeal hygiene which are usually delivered by the nurses (Cook & Ellrodt 1996). Evidence Based Practice The nursing competency standards recommend evidence based practice that involves the establishment of best practice guidelines through review of literature in a systematic manner to rate level of evidence and implementing the recommendations or findings from them in practice (Hatcher et al., 2005). No ventilator bundle recommendation include strategies for nursing oral care for the patients on a ventilator despite some literature indicating reduced rates of respiratory infection with rigorous oral hygiene. Some studies have established the efficacy of brushing of teeth, use of chlorhexidine oral rinse before intubation, the efficacy of mouth decontamination in reduction of frequency of tracheobronchial colonisation, successful eradication of oropharyngeal bacterial population through topical prophylaxis, and efficacy of these maneuvers in reduction of tracheal microbial colonisation, there is still lack of understanding that nurse-administered oral care to the patients on a mechanical ventilator could be an effective and feasible care approach that can be deployed by the nurses in critical care with no cost implications (Tolentino-DelosReyes et al., 2007). Moreover, this approach is substantiated by the finding that oral aspiration is a factor contributing to VAP. Recent literature indicates association between aspiration and development of pneumonia. However, literature also indicates paucity of practice guidelines in this area, although another study has revealed that nurses provide oral care to the patients on mechanical ventilation more frequently, there is still lack in documentation of the oral care process as evident by nurses' self-reported administration of oral care, which is not the case in deployment and documentation of ventilator bundle (Zack et al., 2002). This demonstrates lack of consensus about this approach, absence of a structured oral care protocol, lack in provision of appropriate oral hygiene tools, lack in comprehensiveness of nurse-administered oral care protocol as part of ventilator bundle or otherwise. There is a high probability from the literature reviews in this area that a methodologically rigorous review might be necessary to indicate, rate, synthesise, and implement evidence from research into practice. Therefore, I propose a systematic review of literature in this area of practice to find out evidence as to whether oral hygiene in the patients on mechanical ventilators can reduce incidence of VAP, and if that be so, the strength of evidence may indicate modification or change of practice in this area of nursing where oral care may be included in the ventilator bundle. These would definitely improve the care outcomes of the patients on ventilator in that there would be less morbidity for the patients, less mortality rates within the organisation, and due to decreased bed occupancy, there would be increased bed availability in the intensive care units. The decrease in the hospital stay will have financial implications both at the customer, local, and national levels (Lorente et al., 2007). Focus Question Does maintenance of oral hygiene in patients on mechanical ventilation in the intensive care units reduce the incidence of ventilator associated pneumonia Methodology of Literature Review To this end, the methodology of the literature review and the strategy were chalked out. A general discussion and theoretical framework of the search strategy is important to ascertain the rigour of the methodology which is linked to the strength and level of evidence. Methodology is important to fill in the intellectual vacuum that may be associated with a research question, and therefore, there is a need to pinpoint the context of a research within the existing knowledge base. Since there is a considerable body of existing literature depicting the studies in several areas of science and practice, while performing a literature review, it is pertinent and important to perform the review in a systematic and logical manner. A mapping and precise documentation of the systematic process ensure and indicate that the researcher had employed a comprehensive and systematic plan to undertake the review. This would also ensure reproducibility of the review, if some reader desires to perform it. A literature review that is approached systematically is very different from one that is approached in a haphazard manner (Evans, 2002). A thorough and comprehensive search strategy will help to ensure that key literature and texts on the focus topic are identified. Without a thorough search strategy, searching will be random and disorganised, and the reader of the review will not be confident that all the relevant research papers relating to the topic have been identified. A strong methodological rigor ensures repeatability of the system of retrieval of information, and thus, an audit trail is necessarily important in systemic review of literature (Evans, 2003). The focus question must be followed closely throughout the review and obtain only that information which is relevant to the research question in the search for literature. All literature must address the focus question of the review. Thus a strategy needs to be developed for managing the literature so it can be identified quickly which literature is directly related to the question. This would need development of exclusion and inclusion criteria for the review (Finfgeld, 2003). Today's practice has been termed evidence based due to availability of studies or researches on various aspects of practice. Consequently, it is not only an academic requirement or requirements for accomplishing practice standards. The first step to glean information from research is to perform a literature review, and this skill, therefore, is necessary to improve practice. Literature reviews can serve a number of important functions in the research process-as well as important functions for nurses seeking to develop an evidence-based practice (Fink, 2005). A critical assessment and appraisal of available and relevant literature can orientate the researcher and the reader to the focus question and areas of enquiry, putting the question into perspective. This enhances personal knowledge since these reviews in a methodical manner can indicate a possible future research to contribute to the existing base of knowledge. Determination of any gaps or inconsistencies may indicate the need for replicating a study through relevant theoretical or conceptual framework, and even if not that, it can update the personal knowledge of the practitioners leading to delivery of standard practice (Greenhalgh and Peacock, 2005). The focus question sets the criteria for the three chosen aspects of this literature review. The first is a brief overview of the oral care. The second is cause-effect relationship of oral care and reduced incidence of VAP. The third is the evidence from practice whether these reduce the incidence of VAP when used alone or in combination with the ventilator bundle in mechanically ventilated critical care patients. Based on these, the inclusion criteria were established as follows Client group: All adults with no gender or race restrictions imposed who are mechanically ventilated. Date Restrictions: The most up-to-date information was sought 2003 - 2009 as full text primary research articles. Geographical Locations As this is a nursing issue in the UK, restrictions applied for British nursing literature. Nursing Studies dealing with nursing intervention in the form of ventilator bundle application and oral care in patients on mechanical ventilation without VAP Table 1: Basic inclusion criteria Strategy for Literature Review It is important to know that all questions involving practice issues cannot be answered since there is a paucity of methodologically rigorous studies. Although there are quite a few meta-analyses available, meta-analyses have their drawbacks. On the contrary, primary research directly dealing with the issue only in the form of randomized controlled trials was less in number. This indicated the need for a strategy based on key word generation in order to find out as many primary research articles as possible based on variety of key words which will elaborate the concept of the focus question. However, since these topics may be somewhat out of focus, there was a need to develop both inclusion and exclusion criteria, so the research question may be addressed by the literature in the best possible manner. The developed criteria would be guided by the wording of the focus question. It was decided that primary research on the topic would be looked for, since primary research provides research findings from a study and is reported first hand. Primary research is most often published in journals and the most up-to-date resources are available in journal articles rather than in textbooks (Greenhalgh and Taylor, 1997). Inclusion Criteria Inclusion criteria for each article reviewed were answers to the following questions. 1. Valid research article 2. Covered topic, ventilator associated pneumonia, ventilator bundle, mechanical ventilation, nursing care in the critical care unit, oral hygiene and care, controlled trial. 3. Outcome study of oral care on pneumonia and ventilator associated pneumonia. 4. Article publication within 10 years 5. English language If the answers to all these questions were "yes", these articles would be included in the literature review. Those which were review, conversation, editorial, poster presentation, or letters to the editor were excluded. Resources The university library would expectedly be an important source of information. The university database had extensive database of full-text medical and nursing journals, which can serve as references. The campus library had access to databases, which revealed numerous studies on this specified area of nursing practice. To build a scientific basis of evidence, a comprehensive literature search was undertaken and then evaluated critically. For the purpose of the review of literature, to support the rationale, need, and continuation of the project, this author conducted a literature search across databases. Those accessed for information included: CINHAL, Medline and Pubmed along with the Google Scholar internet search engine. Moreover MEDLINE, EMBASE, and CINAHL and Cochrane databases were searched to identify relevant literature on prevention of VAP in the patients who are cared for by the nurses in the critical care units. These sites were accessed through online registration in the respective websites (Polit and Beck, 2005). Nursing Standards and Nursing Times also served as a source for some articles. Since there were very less randomised controlled trials, the focus question was modified to locate studies that would examine whether there is any relationship between oral hygiene and ventilator associated pneumonia. From the literatures located with the initial focus question, the evidence was in favour of using oral care as a strategy to prevent VAP, since it was correlated that in most cases, the causative organisms in VAP were from the oral cavity. However, most of these studies included small sample size, and the design did not include enough methodological rigour to reach definitive and conclusive evidence, so it could be recommended that oral care as a nursing strategy to be included in the ventilator bundle (Blamoun et al., 2009). Moreover, there were hardly any studies where nurse administered oral care regimen had been used as a part of the ventilator bundle or simultaneously with ventilator bundle practice. There would be thus many confounding factors in these studies, where the study design needs to incorporate adjustments to determine the effect size of the oral care. This was not evident in the studies located, and despite literature demonstrating enough causative correlation to understand the likelihood of effectiveness of oral nursing care in preventing VAP (Boles et al., 2007). Moreover, in order to frame a nursing guideline as a part of the ventilator bundle or as a separate entity, evidence also needs to compare and trial different regimens, so a definite care regimen can be advised. Evidence was not of enough power to suggest a definite oral care regimen, most studies took up empirical regimens (Elatrous et al., 1996). This suggested a need to reframe the focus question, and thus a PICO question format was used to ascertain the key words for addressing the reformatted question. P: Population: Adult population, intensive or critical care, intubated, mechanical ventilation, pneumonia. I: Intervention: Oral hygiene, oral care, oral application C: Comparison: Different regimens of oral care, oral hygiene regimens O: Reduction of VAP incidence. The search for relevant literature began with identification of the key words. These words were coined from the rationale and the focus question of this particular research. Then through application of Boolean logic, some combinations of key words were decided to be searched (Horsburgh, 2003). The initial search was conducted on the abstracts of the prospective articles, and if an article could be narrowed down with presence of the combination key word terminology, a detailed search was undertaken on that article (Horton, 1995). The articles that appeared in the reference of these articles were also located and searched to see whether they match the inclusion criteria mentioned above. All of these resulted in access to many articles, and for a more focused search was conducted through combination of key words with use of Boolean adjuncts "and", "or", or "not." The literature search included opinion papers, systemic reviews and meta-analysis, original research articles including randomized clinical trials, qualitative and quantitative data reports, which kept the rationale and the focus question at the centre. Once the studies and papers were defined in this manner, the most appropriate ones were selected based on the aim of this review (Rochon et al., 2005), which was to elicit the best available current evidence to enable best evidence-based practice of the nurses in this area. The key words included those mentioned in the PICO format above. The findings are presented below. Keywords Results Pneumonia 9595 Oral Hygiene 5279 Tooth brush 1966 Pneumonia & oral hygiene 24 Intubation & Adults 149972 Intubation , Adults & Oral Hygiene 2101 Pneumonia, Intubation & oral hygiene 2 Validity in research terminology refers to the accuracy of the data and the findings. It is also important to validate the concepts that are being evaluated in any particular study. Reliability is related to the proof of consistency and dependability of the data. This would also indicate generalizability of the findings irrespective of the time, place, and subject of the research. This researcher used the following programme to assess the quality of the studies (Russell and Gregory, 2003). The articles reviewed would fit the quality and credibility of the study. The status of peer review and standards of the authors and their qualification and experience also adds. Peer review is one of the methods of sympathetic critical review by colleagues, where the pros and cons of a research article is analysed in order to better the quality of the study. The accuracy and coherence of the content with the existing knowledge on the subject would also grade the study. In the appendix, the summary of the all the reviewed literature are placed in the evaluation grid, however it must be stated that this author's lack of knowledge on assessment of quantitative data had exerted some limitations on the appropriate assessment of the reviewed literature (Sandelowski et al., 1997). Reflection Literature reviews are becoming more and more important in health and social care. The growing importance of evidence-based practice within health and social care today has led to literature reviews becoming more and more relevant to current practice. While doing this literature review, I remember coming across a large number of articles (Jensen and Allen, 1996). While reflecting, I could see many articles did not meet the methodological parameters and the framework that was chosen for the review, and it was very easy to be swayed away from the focus questions (Knipschild, 1994). To be able to do that appropriately and to ensure remaining within the framework, I needed to take regular and detailed notes of even the irrelevant studies were needed to be taken (Law, 2004, 54-66). It must be admitted that even when some article was rejected, these provided a better insight of the topic of the review, and in general these helped to get some general depth of knowledge on the topic (Oxman, 1994). In the beginning, it was natural to start trusting in any information given in a particular literature. However, as this process progressed, it was found that it would be very important for this author to retrieve all available evidence on the topic and start reviewing them critically so that an overall picture of what is known about the topic is achieved (Littleton et al, 2004). Gradually, the awareness resulted that such literature reviews are not only course requirements, but these were often required as a preliminary introduction to the topic of enquiry that is carried out prior to a primary research study. Thus the purpose was clear, and it was to provide a critical account of the literature in a particular area, in order to demonstrate why a new research study is required (Mulrow et al., 1997). Therefore, this review was planned in such a manner that this review would demonstrate the understanding of both the research and of the methods previously used to investigate the area. Accessing databases mentioned above could have been a problem if university library would not have facilitated access of the above databases through Athens to enter and access Ovid online databases. As mentioned earlier, this researcher could manage access to these databases. The most robust articles chosen to be reviewed in this extended literature review with a nonbiased enhancement of extension of enquiry (Jones, 2004). The aim of this project is to critically evaluate an aspect of practice of nursing where strategies may be developed for change in practice. Moreover, conducting a literature review would contribute to development of analytic and critical evaluative skills through identification of strength, relevance, and limitations of the study in establishing its reliability and validity to the posed question (Montori et al., 2004). Although it has been acknowledged that there are no such standard questionnaires possible in order to evaluate any research, still these questions could throw some light into assessment of reliability, validity, and generalisability of each of these studies (Morse, 1999). Managing so much data is not easy, and therefore, to be able to manage these data easily and to be able to review them, extensive notes were needed to be taken, and these were tallied with the photocopies of the article. Sometimes there would be an apparent gap in the reasoning; however, on closer examination, which often would occur at a later time, it would be found that there was subtle reasoning that would substantiate the authors' perspectives. It was immediately known that it was not an easy task, and it needed practice. In this author's opinion, the most difficult part is to synthesize the findings in such a small space, and there was so much to cover (Mulrow, 1994). This problem was managed by deciding to take only the salient points in study and to summarise the findings. Overall, this had been a very enriching experience, and given a future opportunity; this author would first study my topic extensively and then agree to do a literature review. There are limitations in this literature review, since this cannot be claimed that all aspects of the evidence had been examined. Resources would sometimes be not available. Moreover a systemic review would produce better results if a method of statistical analysis could be incorporated in the methodology. Due to lack in statistical knowledge, the data culling and analysis became purely qualitative, which may fail to provide concrete evidence despite it being there. This is one of the limitations of this extended literature review; however, as would be apparent, despite these limitations, this review could result in suggestions for guideline for practice in this area of nursing. 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