Oral Care Protocol Combined with Ventilator Bundle Reduces VAP Rates

Figure 2: VAP Prevention Audit Form

Phase I: Before Surgery

On the morning of surgery, the patients brushed their teeth with the 0.12 percent CHG solution with alcohol (15 mL prepackaged solution) and used the solution to brush their teeth and swab their mouths with the provided swab, rinsed, and expectorated.

Phase II: Ventilated Patient

Patients began the oral care protocol immediately postoperatively during intubation. The oral cavity was swabbed with 1.5 percent peroxide mouthwash and moisturizer was applied inside the mouth and to the lips to protect the mucous membranes every two hours and as needed. Oral care consisted of brushing the teeth and swabbing the mouth with 0.12 percent CHG with alcohol every 12 hours while intubated. The brush or swab was connected to suction and rotated around the oral cavity to remove plaque and secretions during the cleansing process. Three types of suctioning were implemented in between episodes of oral care protocol. Suction of the oral cavity occurred with a Yankauer catheter, while continuous suctioning around the endotracheal tube occurred by subglottic suction. Suctioning inside of the endotracheal tube occurred through an in-line catheter. Care was taken to ensure minimal breakage of the patient’s suction lines occurred, and suction lines were dedicated specifically and maintained separately for each of the three types of suctioning.

Phase III: Post-extubation

The patients received oral care after extubation by swabbing and brushing teeth with the 0.12 percent CHG with alcohol rinse. Suction was done as needed, or the patient rinsed and expectorated. This process was repeated every 12 hours for 48 hours after extubation. The staff was educated to ensure documentation and consistent use of the protocol. Group education on VAP was conducted by an infection control nurse. Education on the bundle protocol was carried out by the unit educational staff and by a clinical support representative from the manufacturer of the oral care system. Instruction and reinforcement before and during the ventilator bundle intervention were provided during rounds by the nurse manager and the nurse educator. Laminated posters of the oral care protocol were displayed for the staff. Staff conducted informal daily audits by counting the number of oral care systems used in order to ensure that the oral care was provided every two hours. Staff provided peer review and encouragement to each other to maintain compliance with the new protocol. Feedback was also provided in monthly staff meetings, during which time VAP rates were reported. VAP rates were also posted on the “Nursing Report Card” to encourage nurse ownership of the outcomes through performance improvement, peer accountability, goal-setting, and celebrating improvements. Nurses’ pride in the project and outcomes rose, as they participated in preparing data and gave presentations at clinical and research conferences.