Stopping infection in its tracks: Best practices in oral care
It is difficult to establish the true rates of ventilator-associated pneumonia (VAP), but very important to do so. VAP is a major cause of increased time on ventilators, more critical illnesses, and death. It is also expensive, increasing the direct medical costs(1) healthcare organizations bear.
The problem: VAP among ventilated patients
Surveillance definitions for VAP are nonspecific and subjective. In the past, 10% to 20%(2) of ventilated patients have experienced VAP. Those rates drop in more recent reports, but it isn’t clear(3) that the drop is the result of better care, given that surveillance criteria varies and is often subjective. Clinical surveys suggest(4) that current rates of VAP among ventilated patients still hover at around 5% to 15%(2).
Even more important than establishing rates of ventilator-associated events (VAE), such as VAP, is preventing it, and the connection between VAE prevention and good oral hygiene is well-established.(5) VAE develops from bacterial infection of the lungs, and it can appear within 48 to 96 hours (8) of intubation. In ICUs treating adult patients, the risk of infection grows with time spent on mechanical ventilation, and mean VAE rates per 1,000 ventilator days range from zero to six(9).
The service gap: the need for oral care versus the reality
Although the mouth is the home of various flora and microbes in all patients(10,11). For ventilated patients, the mouth thus becomes a refuge for plaque, pathogens, and other opportunistic organisms that may be able to form resistance to many antibiotics(12). Routine oral care helps remove these microorganisms, lowering their chances of colonizing the lungs and becoming VAE after being inhaled(12).
Recent research(7) shows that there is a disparity between how often critical care personnel state they provide oral care to ventilated patients and how often they record such care in the record. This appears to confirm that the problem is ongoing, and that there is a genuine need to adopt data-driven best practices to standardize a higher and more reliable level of oral care in ICUs.
It is essential for ICU teams and other frontline healthcare providers to prioritize infection control and maintain best oral hygiene practices to prevent VAE and its associated illnesses and fatalities. Data-driven best practices for oral care may allow healthcare providers to protect ventilated patients with a higher level of confidence.
Best practices for oral care of ventilated patients
There are a number of oral care best practices that healthcare organizations can institute that improve the outlook of ventilated patients and reduce their risk of VAE. According to an article in the American Journal of Nursing (AJN), best practices for prevention of VAP in adult patients include(9):
- Protective equipment.Providers should wash hands with gentle friction for 20 seconds with antiseptic soap and warm water, or rub a palmful of alcohol-based hand sanitizer over all hand surfaces with gentle friction until dry. Use gloves. When there are oral secretions or isolation precautions are in effect, consider using additional protective equipment, such as a face shield and gown.
- Regular assessment.Assess the mouth every eight hours using an assessment tool that the facility has determined is reliable and valid. Train healthcare staff on how to use tool and to assess all internal and external structures of the mouth. Practitioners recommend assessing the mouth for bleeding, inflammation, odor, overgrowth of plaque or yeast, saliva production, and ulceration.
- Suction secretions.Before providing oral care, suction the mouth using a flexible suction catheter to remove excess secretions. Use different catheters for subglottic and oral suctioning. The ideal frequency of suctioning can vary, but will typically take place every two to four hours and more frequently as needed to prevent oral bacteria from invading the lower respiratory tract.
- Brush with antiseptic.Use an antiseptic mouth rinse such as chlorhexidine to brush the patient’s teeth for three to four minutes. Brush consistently and no less than twice daily. Practitioners recommend elevating the head of a patient’s bed to 30 degrees or more unless specifically contraindicated and using a soft pediatric toothbrush or suction toothbrush to minimize mucosal irritation and discomfort while accessing hard-to-reach areas.
- Rinse all surfaces in the mouth with a soft sponge, a suction sponge, a sprayer, a swab, or a transfer pipette and an alcohol-free mouth rinse or sterile water. This should allow you to remove any remaining mucus, debris, or saliva that might be aspirated, and any excess antiseptic. The AJN recommends using no more than 15 mL of rinse to reduce risk of aspiration.
- Suction secretions again.AJN recommends first delivering oxygen at 100% for one minute. Insert suction catheter until you feel resistance, and apply intermittent suction as you withdraw the suction catheter. Make a maximum of two passes and suction for 15 seconds at most to remove subglottic secretions. Apply oxygen again when finished and do not instill saline.
- In between brushing sessions and at least every two to four hours, practitioners recommend moisturizing the oral mucosa and lips with a water-based moisturizer and a separate swab for each oral mucosa and lips. This way you avoid patient discomfort, and keep hydrated the cracked areas that allow bacteria to enter the body.
- Check pressure.After each brushing and suctioning, change the position of the tube and ensure endotracheal tube cuff pressure is between 20 and 30 cm H2O using a manometer. Insufficient pressure carries risk of microaspiration of secretions carrying bacteria, and too much pressure can damage the trachea. Assessing pressure with gentle palpation is unreliable. Frequently changing the tube’s position helps prevent the oral mucosa from breaking down.
- Finish and document.Discard brushes and swabs. Clean reusable tools and store in clean, dated container that allows some airflow. Remove protective equipment and clean hands as in the first step. Document oral care in record.
Better oral care helps stop infection in its tracks
Although VAEs are costly and a major cause of more critical illnesses, increased time on ventilators, and death, and the connection between VAE prevention and good oral hygiene is well-established, oral care practices in ICU are not always consistent. Maintaining best oral hygiene practices is the proven way to prevent VAE and the risks that come with it.
- https://www.ncbi.nlm.nih.gov/pubmed/16215368 Clinical and economic consequences of ventilator-assisted pneumonia: A systematic review
- https://www.jstor.org/stable/10.1086/677144 Strategies to prevent VAP in acute care hospitals
- https://www.cdc.gov/nhsn/pdfs/datastat/2010nhsnreport.pdf National Healthcare Safety Network (NHSN) Report, Data Summary for 2009, Device-associated Module
- International study of the prevalence and outcomes of infection in intensive care units
- https://www.ncbi.nlm.nih.gov/pubmed/21885453 Effects of systematic oral care in critically ill patients: a multicenter study
- https://www.ncbi.nlm.nih.gov/pubmed/11934711 Ventilator-assisted pneumonia
- http://ajcc.aacnjournals.org/content/12/2/113.long Oral care interventions in critical care: Frequency and documentation
- http://ccn.aacnjournals.org/content/27/4/32.full VAP: risk factors and prevention
- https://www.nursingcenter.com/cearticle?an=00000446-201310000-00022&Journal_ID=54030&Issue_ID=1606223 Mouth care to reduce VAP
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1287824/ Defining the Normal Bacterial Flora of the Oral Cavity
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768665/ The Oral Microbiota: Living With a Permanent Guest
- https://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Oral-Care-During-Mechanical-Ventilation—Critical-for-VAP-Prevention.aspx Oral Care During Mechanical Ventilation – Critical for VAP Prevention