Reducing VAP/HAP Risk Factors

Maintaining oral hygiene has been proven to help reduce healthcare-acquired pneumonias (HAPs), including ventilator-associated pneumonia (VAP) and aspiration pneumonia.1,2,3 In fact, the CDC now requires acute care hospitals to “develop and implement a comprehensive oral hygiene program” for patients at risk for healthcare-associated pneumonia.4

The CDC is not the only professional organization to recommend a comprehensive oral care protocol. Safer Healthcare Now! has upgraded the VAP Bundle to include oral decontamination with Chlorhexidine and revised the VAP Bundle to include general recommendations for oral care.5

The APIC Guide to the Elimination of Ventilator-Associated Pneumonia even outlines an example mouth care and documentation form that includes brushing teeth q12°, providing oral care every 2 to 4 hours with antiseptic, applying mouth moisturizer to oral mucosa and lips, and suctioning orally as needed.6

Through the use of clinical evidence, education, and implementation tools, this section will help you build and implement a comprehensive and evidence based oral hygiene program for your facility. These unique tools will help you assess current clinical practice, educate staff, customize and implement an evidence-based protocol, complete a performance improvement plan, and track progress, from infection rates, to staff compliance, to cost.

REFERENCE: 1. Schleder B, Stott K, Lloyd RC, J Advocate Health Care, 2002;4(1):27-30. 2. Vollman K, Garcia R, Miller L, AACN News. Aug 2005;22(8):12-6. 3. Yoneyama T, et al., J Am Geriatrics Society. 2002;50(3):434-8. 4. Tablan OC, et al., Guidelines for Preventing Health-Care-Associated Pneumonia, 2003. CDC, MMWR. 26 Mar 2004;53(RR03);1-36. 5. Safer Healthcare Now! Prevent Ventilator Associated Pneumonia Getting Started Kit, June 2012. 6. APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia, pp. 38, 40.

Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study
Garcia R, Jendresky L, Colbert L, Bailey A, Zaman M, Majumder M
AJCC
View abstract 

The effect of a comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia
Schleder B, Stott K, Lloyd RC
Journal of Advocate Health Care, Spr/Sum 2002;4(1):27-30.
Download study (PDF)
Download poster (PDF)

A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions.
Garcia R
American Journal of Infection Control. Nov 2005;33(9):527-41.
View abstract 

Bacterial growth in secretions and on suctioning equipment of orally intubated patients: a pilot study
Sole ML, Poalillo FE, Byers JF, Ludy JE
American Journal of Critical Care. Mar 2002;11(2):141-9.
View abstract 
View authorized summary (PDF)

Oral care interventions in critical care: frequency and documentation
Grap MJ, Munro CL, Ashtiani B, Bryant S
American Journal of Critical Care. Mar 2003;12(2):113-8; discussion 119.
View abstract 
View authorized summary (.pdf*)

Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders
El-Solh AA, Pietrantoni C, Bhat A, Okada M, Zambon J, Aquilina A, Berbary E
Chest. Nov 2004;126:1575-1582.
View abstract 

NV-HAP Posters

Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP) in the ICU: Incidence and Prevention
Quinn B, Baker D, Parise C
Poster Presented at AACN-NTI (Amer Assoc of Critical Care Nurses/National Teaching Institute), 2013
Download poster (PDF)
Aspiration Pneumonia: Aspiration Precaution Bundle
Johnson L, Maddox P, Rockhold T
Poster presented at AMSN’s 18th Annual Convention, September 2009
Download poster (PDF)

VAP Posters

Screen Shot 2015-08-19 at 2.20.19 PM Oral care of the mechanically ventilated patient: you can make a difference in five minutes
Schleder B, Lloyd R, Stott K
Poster Presented at State of Illinois Critical Care Conference, Mar 2002.
Download poster (PDF)
A Comprehensive Oral Care Program Reduces Rates of Ventilator-Associated Pneumonia in Intensive Care Unit Patients
Hutchins K, Karras G, MD, Erwin J, Sullivan K
Poster presented at 2008 APIC Annual Conference: June 15-19, 2008
Download poster (PDF)
Download handout (PDF)
Sustained Reduction in Ventilator-Associated Pneumonia (VAP) Using a Two-Hospital, Multidisciplinary Approach that Includes Oral Care and Regular Staff Education
Lipke V, Carman B
Poster presented at 2008 APIC Annual Conference: June 15-19, 2008
Download poster (PDF)
Download handout (PDF)
Prevention of Hospital-Associated Pneumonia Using a Comprehensive Oral Hygiene Protocol
Jean Orr C, Mitchell, M
Poster presented at 2008 APIC Annual Conference: June 15-19, 2008
Download poster (PDF)
Download handout (PDF)

 

A healthcare provider must always rely on his or her own professional clinical judgement when deciding whether to use a particular product when treating a particular patient. Sage Products does not dispense medical advice and recommends that healthcare providers be trained in the use of any particular product before using it in surgery.
The information presented is intended to demonstrate the breadth of Sage Products’ product offerings. A healthcare provider must always refer to the package insert, product label, and/or instructions for use before using any of Sage Products’ product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Sage Products representative if you have questions about the availability of Sage Products’ products in your area.

Professional organizations are now recognizing comprehensive oral care as key to addressing VAP and HAP:

 

SAFER HEALTHCARE NOW! (SHN)1

“In summary VAP is a common problem in Canadian ICUs, which is associated with poor outcomes, in vulnerable critically ill patient populations. There are evidence-based practices that can reduce the incidence of VAP; implementation of these practices have been effective in reducing VAP and its associated sequelae. Although it is often argued that in the Canadian Healthcare system money is not saved by improving efficiency (because each discharged patient is replaced by a new patient with comparable overall costs), our incentive to reduce VAP should be directed towards liberating wasted ICU and hospital days, thus improving ICU access for other patients in need.”

Oral Care and Decontamination with Chlorhexidine
“Oropharyngeal colonization as well as colonization of dental plaque have been identified as risk factors for VAP as there is high concordance between the bacteria isolated from the oropharyngeal cavity or the dental plaque and those recovered from tracheal aspirates.”

 

AACN

Procedure Manual for Critical Care — Oral Care Interventions, 2005,

“Assess oral cavity and lips every 8 hours, and perform oral care every 2 to 4 hours and as needed.† With oral care, assess for buildup of plaque on teeth or potential infection related to oral abscess.”

“Perform oral hygiene, using pediatric or adult (soft) toothbrush, at least twice a day. Gently brush patient’s teeth to clean and remove plaque from teeth.”†

“In addition to brushing twice daily, use oral swabs with a 1.5% hydrogen peroxide solution to clean mouth every 2 to 4 hours.”†
“With each cleansing, apply a mouth moisturizer to the oral mucosa and lips to keep tissue moist.”†

“Suction oral cavity/pharynx frequently.”††

“Antiseptic oral rinses (chlorhexidine, cetylpyridinium chloride (CPC), added after brushing or done in conjunction with comprehensive oral care did achieve elimination of VAP. (Level B)”

 

Institute for Healthcare Improvement (IHI)

Prevent Ventilator-Associated Pneumonia – How-to Guide

    Ventilator Bundle:
  • Elevation of the Head of the Bed
  • Daily “Sedation Vacations” and Assessment of Readiness to Extubate
  • Peptic Ulcer Disease Prophylaxis
  • Deep Venous Thrombosis Prophylaxis
  • Daily Oral Care with Chlorhexidine

 

CDC

Guidelines for Preventing Healthcare–Associated Pneumonia, 2003

CDC, MMWR. March 26, 2004;53(RR03);1-36.
Download Oral Hygiene Excerpt (PDF)
View full text

 

APIC

2009 Guide to the Elimination of Ventilator-Associated Pneumonia2

    Key prevention strategies:
  • Perform routine antiseptic mouth care
    Example mouth care and documentation form includes the following:
  • Brush teeth q12°
  • Provide oral care every 2 to 4 hours with antiseptic
  • Apply mouth moisturizer to oral mucosa and lips
  • Suction orally as necessary

 

Society for Healthcare Epidemiology of America (SHEA)3

A Compendium of Strategies to Prevent Healthcare- Associated Infections in Acute Care Hospitals

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals
“Perform regular antiseptic oral care in accordance with product guidelines”4,5

 

REFERENCES: 1. Safer Healthcare Now! How-To Guide: Prevent Ventilator Associated Pneumonia Getting Started Kit, pp 10, 22, June 2012. 2. APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia, pp. 38, 40. 3. SHEA, Oct 2008,Vol. 29, Supplement 1, S31. 4. Among other interventions 5. Category IA: Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. †. Level IV: Limited clinical studies to support recommendations.

 

A healthcare provider must always rely on his or her own professional clinical judgement when deciding whether to use a particular product when treating a particular patient. Sage Products does not dispense medical advice and recommends that healthcare providers be trained in the use of any particular product before using it in surgery.
The information presented is intended to demonstrate the breadth of Sage Products’ product offerings. A healthcare provider must always refer to the package insert, product label, and/or instructions for use before using any of Sage Products’ product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Sage Products representative if you have questions about the availability of Sage Products’ products in your area.

Hospital-Acquired Pneumonia in Nonventilated Patients: The Next Frontier
Klompas M
Infection Control & Hospital Epidemiology / Volume 37 / Issue 07 / July 2016, pp 825-826
View abstract

Reduction of Microbialcolonization in the oropharynx and dental plaque reduces ventilator-associated pneumonia
Garcia R, Jendresky L, Colbert L
Brookdale University Medical Center (BUMC), Brooklyn, NY
Download (PDF)

Oral Care Practices for Orally Intubated Critically Ill Adults
Feider L, Mitchell P, Bridges E
American Journal of Critical Care. 2010;19: 175-183
View abstract

Treasured chests: reducing VAP in the ICU
Carter CL
Alliance Magazine. Apr 2004:14-16.
Download (PDF)

Targeting Ventilator-Associated Pneumonia
The Source. Mar 2007;59-61.
View full text (PDF)

Best-practice interventions: How can you prevent ventilator-associated pneumonia?
Pruitt B, Jacobs M
Nursing 2006. Feb 2006;36(2):36-41;quiz 41-2.
View full text (Log in required)

Preventing aspiration pneumonia in at-risk residents
Logsdon BK
Nursing Homes Long Term Care Management, Aug 2004.
View full text

Reducing the risk of ventilator-associated pneumonia
Brooks T
Infection Control Today. May 2004.
View full text

New Oral Care Routine Eliminates VAP at Florida Hospital
Harris C (Ed.)
ICP Report. Jan 2004;9(1)14-16.
Download (PDF)

Aspiration pneumonitis and aspiration pneumonia
Marik PE
New England Journal of Medicine. 1 Mar 2001;344(9):665-71.
View full text

A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions.
Garcia R
American Journal of Infection Control. Nov 2005;33(9):527-41.
View abstract

 

A healthcare provider must always rely on his or her own professional clinical judgement when deciding whether to use a particular product when treating a particular patient. Sage Products does not dispense medical advice and recommends that healthcare providers be trained in the use of any particular product before using it in surgery.
The information presented is intended to demonstrate the breadth of Sage Products’ product offerings. A healthcare provider must always refer to the package insert, product label, and/or instructions for use before using any of Sage Products’ product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Sage Products representative if you have questions about the availability of Sage Products’ products in your area.

Oral Care Program Helps Overlake Hospital Reduce VAP by 81 Percent, Saving $1.4 Million
Bellevue, WA
View full text (PDF)

HealthEast Eliminates VAP, Saving $360,000 in VAP-Related Costs – Oral Care Key to Success
St. Paul, MN
View full text (PDF)

Oral Care Program Helps Eisenhower Medical Center Cut VAP Rates In Half
Rancho Mirage, CA
View full text (PDF)

Provena Saint Joseph Steps up Compliance and Zaps Major Hospital-Acquired Infection
Mokena, IL
View full text (PDF)

Alamance Regional Medical Center Eliminates Ventilator-Associated Pneumonia
Burlington, N.C.
View full text (DOC)

Sherman Hospital Saves $1.6 Million on VAP-Related Costs
Elgin, IL
View full text (PDF)

Villages Regional Hospital Significantly Reduces VAP Rates Through Clinical Interventions, Including Oral Care
Lady Lake, FL
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Blount Memorial Reduces VAP Rates
Maryville, TN
View full text (PDF)

West Jefferson Medical Center Eliminates VAP Cases Through Comprehensive Oral Care Program, Saving More than $750,000
Marrero, LA
View full text (PDF)

Porter Valparaiso Hospital Campus Virtually Eliminates VAP Rates
Valparaiso, IN
View full text (PDF)

United Regional Uses Oral Care Protocol to Reduce VAP, Hospital Saves Close to $400,000
Wichita Falls, TX
View full text (PDF)

Centra Health Reduces Ventilator-Associated Pneumonia Rates
Lynchburg, VA
View full text (PDF)

Unity Health System Saves $360,000, Reduces VAP Rates Through Oral Care
Rochester, NY
View full text (PDF)

WakeMed Reduces Risk for Ventilator-Associated Pneumonia
Raleigh, NC
View full text (PDF)

Memorial Hospital Saves More Than $1.25 Million Through Oral Hygiene Program
Colorado Springs, CO
View full text (PDF)

Vanderbilt University Medical Center Improves VAP Rates In SICU through Oral Care
Nashville, TN
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St. Luke’s Regional Medical Center Eliminates VAP Rates
Boise, ID
View full text (PDF)

Coral Springs Reduces Ventilator-Associated Pneumonia
Coral Springs, FL
View full text (PDF)

 

A healthcare provider must always rely on his or her own professional clinical judgement when deciding whether to use a particular product when treating a particular patient. Sage Products does not dispense medical advice and recommends that healthcare providers be trained in the use of any particular product before using it in surgery.
The information presented is intended to demonstrate the breadth of Sage Products’ product offerings. A healthcare provider must always refer to the package insert, product label, and/or instructions for use before using any of Sage Products’ product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Sage Products representative if you have questions about the availability of Sage Products’ products in your area.

Comprehensive Oral Care Comparison (PDF)
Customizable Protocol (doc)

Lanyard Assessment Form

Order Lanyard Assessment Cards

Evaluation Forms

Clinical Practice Assessment

Product Evaluation Form

Sample Performance Improvement Plan
Track the impact of Routine Oral Care and Closed End Suction on VAP rates at your facility with this customizable template.

Customize (Microsoft® Word Document)Download (PDF)

Sample Process Improvement Plan
Assess staff knowledge and opinions about oral care practices in your facility. This template includes a section to list your facility’s desired oral care objectives, your protocol, and an area to record results from the Clinical Evaluation Form.

Establish your facility’s objectives for oral care. Then enter them into the left hand column of the Process Improvement Plan template.

Customize (Microsoft® Word Document)Download (PDF)