Oral Care Education in the Prevention of Ventilator-Associated Pneumonia: Quality Patient Outcomes in the Intensive Care Unit

Joyce Zurmehly, PhD, DNP , RN, NEA-BC

abstract
Background: Ventilator-associated pneumonia (VAP) is associated with high morbidity and mortality rates in mechanically ventilated patients in the United States. Routine oral care has been shown to have a direct effect on reducing VAP rates. Methods: Intensive care unit registered nurses attended educational sessions about oral care and also used online education modules. Nursing care involving 180 intubated patients was observed, and changes were noted in practices related to oral care. Results: After the education intervention, the frequency of oral care increased significantly (p = .001) to tooth brushing every 4 hours and swabbing every 12 hours with 0.12% chlorhexidine solution. The evidencebased practice education intervention decreased VAP rates by 62.5%. Conclusion: Significant reductions in VAP rates may be achieved through improved education and implementation of oral care protocols with 0.12% chlorhexidine solution. J Contin Educ Nurs 2013;44(2):67-75.

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educing the rate of hospital-acquired pneumonia continues to be a patient safety challenge in health care. Pneumonia accounts for 47% of all hospital-acquired infections, second only to urinary tract infections (Augustyn, 2007). Ventilator-associated pneumonia (VAP) occurs as a result of pulmonary inflammation after intubation. The mechanical process of intubation compromises the natural barrier between the oropharynx and the trachea, facilitating the entry of bacteria into the lungs (Berry, Davidson, Masters, Rolls, & Ollerton, 2011).
The Journal of Continuing Education in Nursing · Vol 44, No 2, 2013

The risk of pneumonia increases 6 to 21 times for patients receiving mechanical ventilation (Pruitt & Jacobs, 2006) and is often encountered within high-tech, high-touch environments, such as the intensive care unit (ICU). Critically ill patients have been identified as those primarily affected by VAP, with an incidence rate as high as 90% (O’Keefe-McCarthy, Santiago, & Lau, 2008). The National Healthcare Safety Network reported the incidence rate for VAP within the ICU as 2.1 to 11.0 cases per 1,000 patient days in adults undergoing mechanical ventilation (Centers for Disease Control and Prevention [CDC], 2009). The presence of VAP is linked to increased patient mortality, morbidity, and length of stay, as well as increased patient and hospital costs (Berry, Davidson, Masters, & Rolls, 2007; Hawe, Ellis, Cairns, & Longmate, 2009). In a study reported by Eagye, Nicolau, and Kuti (2009), patients with VAP typically amassed medical costs ranging from $98,426 to $183,275, more than $40,000 over the average health care costs of ICU patients without VAP. These costs have been attributed to increased ventilator days and increased length of stay. According to Bingham, Ashley, De Jong, and Swift (2010), the United States alone spends $6.5 billion for the treatment of VAP each year. Many patients with VAP are admitted to an ICU with harmful bacteria already in their system. The CDC (2009) reported that 63% of patients admitted to an ICU
Dr. Zurmehly is Associate Professor, Wright State University, Chillicothe, Ohio. The author has disclosed no potential conflicts of interest, financial or otherwise. E-mail: jzurmehly@gmail.com. Received: March 11, 2012; Accepted: November 1, 2012; Posted: December 10, 2012. doi:10.3928/00220124-20121203-16

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Saunders. Therefore. Ruppert. 2003). the rates of VAP were tracked through hospital infection control surveillance. and practice performance improved 34% compared with the traditional instructor-led group. One strategy for providing education and training is the use of technology-enhanced instruction. In 2007. 2009. educational interventions to reduce VAP effectively decreased the incidence by 57. evidencebased education and training is needed to maximize clinical application. (2004) found a decrease in the rate of VAP cases from 8. Zack et al. 2004). however. specific. These care bundles have been promoted as a means of improving patient outcomes by grouping evidence-based interventions together with quality care (Tolentino-Delosreyes. Morgan. Several studies further indicated that many nurses believe that oral care is simply a “comfort measure” that is beneficial only for the patient’s state of mind (Berry et al. aid in reducing the incidence of VAP. After an educational intervention. 2007). Several studies have shown that implementation of educational interventions for registered nurses (RNs) and ICU staff can effectively reduce the occurrence of VAP (Halm & Armola. Kleinpell.. Beavis. Munro.6% during a 12-month period. it is recognized that effective interventions are not always consistently practiced.. In 2009. The study also showed that 76% of ventilated patients had the same bacteria colonizing both the mouth and the lungs (Zack et al. the Institute of Healthcare Improvement (IHI) launched its 5-Million Lives campaign. The IHI has identified the prevention of VAP as one of its top priorities for improving health care outcomes and quality. after reviewing the Scotland studies that showed improved outcomes. 2007. For a year. (2009) reported a significant improve68 ment (p = . the IHI added the same daily oral care regimen to the ventilator care bundles given to ICUs in hospitals throughout the United States. 2009. In a study by Zack et al. At the study hospital. Babcock et al. Sona et al.. the oral care policy in an ICU was compared with the actual practice of oral care by critical care nurses. however.75 to 4. 2008). computer-based instruction with evidence-based modules further supports the Institute of Medicine’s report.have preexisting oral colonization with a pathogen. Cason. Besser.04) after the implementation of a low-cost oral care protocol within ICUs. The Copyright © SLACK Incorporated . what steps are being taken to prevent the spread and severity of this infection in the ICU? In response to this growing concern. 2009).5 million in health care costs. The optimal approach to reducing the incidence of VAP is still unclear. Westwell.” even though polices were in place. knowledge improved 21%.000 to $4. Feider et al.000 patient ventilator days. Garcia et al. 2009. thereby reducing deaths (American Association of Critical Care Nurses. Nurses are the main caregivers in hospital ICUs. Tablan. Anderson. the IHI reviewed studies performed in hospitals throughout Scotland. Ross and Crumpler investigated the differences in VAP rates before and after completion of an oral care education module within an ICU. In addition.. 2007). Results showed a 50% decrease in cases of VAP after the educational intervention. In one study by Feider. 2010). These studies included a daily oral care regimen of 0.. time savings over staff attendance at in-service sessions. an important deterrent to VAP is proper oral care (Halm & Armola. many studies have focused on oral care and oral care education as a strategy to aid prevention (Bellissimo-Rodrigues et al. With VAP so prevalent. (2010) recommended highlighting a “practice alert” for oral care with critically ill patients as an aid to reducing the number of cases of VAP.. This includes informatics and evidence-based practices (Hundert et al. (2002). Roh and Park (2010) performed a metaanalysis evaluating the effectiveness of computerbased education compared with traditional teaching methods. Ross & Crumpler. discrepancies were found within practice patterns. 2002). As a result.. In May 2010. Oral care policies were present. 2009. Tyner. Bloom and Hough (2003) evaluated nurses’ satisfaction with online learning and found that 75% of learners were satisfied with overall instruction. 2009. learning attitude improved 17%. & Sessler. and Pickering (2012) concluded that the benefits of using online learning modules included flexible delivery. 2002). Bridges. such as oral care education. 2007. Mitchell. & Shiao. which recommended integrating core competencies into health education. Health Professions Education: A Bridge to Quality. & Hajjeh. & Broome. Although these interventions are known to reduce the incidence of VAP. IHI. Jones. This successful intervention resulted in a savings of $425.75 cases. 2010. In the computer-educated group. 2009. and Bridges (2010). consistent implementation of lessons learned from the interventions remains a challenge. The VAP rate was defined by the National Healthcare Safety Network as the number of infections per 1. Grap.12% chlorhexidine solution for ventilator patients. and cost efficiency. yet the effectiveness of nursing oral care interventions on patient outcomes is limited. According to Kleinpell (2009). 2009.000 ventilator days (CDC. Although evidence-based interventions. McClish. The nurses were reported as “lacking in clarification of the best practice of care. Sona et al.74 per 1. surveillance showed that the VAP rate for the study hospital was 10.

Current nursing practices were evaluated against the CDC recommendations for prevention of hospital-acquired infections. this rate was approximately 50% above the state and national averages.12% chlorhexidine gluconate (CHG) oral rinse solution within a 12-bed ICU setting. and no personal or patient information was disclosed. The VAP prevention program was developed during the month of September by integrating the verified effective aspects of previous studies of intervention programs into a multidimensional program. An evidence-based practice approach was used. outlining current nursing practices to improve oral care in accordance with CDC guidelines. Procedure With ICU nurses as the target. Participants were assured that their responses would be confidential and would not be released to their employer. The study began with an extensive literature review to determine the state of the science related to the oral care practices of ICU nurses caring for critically ill patients. 2009).. Data were reported to the hospital in aggregate. and their awareness and performance in VAP prevention was measured. The study included all RNs implementing oral care education by using the 0. staff education. The recommendation for oral care was inte69 . The researcher investigated literature on VAP management and analyzed the infection occurrence rate of the study institution’s ICU and its guidelines for infection management. a VAP program was developed using evidence-based clinical guidelines. The study focused on oral care. OBJective The study evaluated the effectiveness of a nursing quality education improvement program on oral care practice in reducing the incidence of VAP within the ICU. Intervention This evidence-based practice project was conducted to transform evidence into practice by effectively using a unit-level education intervention.12% CHG oral rinse solution. The recommendations included nursing interventions. Based on the study findings. specifically.49 cases and 5. and the American Association for Respiratory Care evidencebased clinical practice guidelines (2011) were analyzed.state and national rates were 6. An evidence-based education intervention on oral care was instituted. Of these. Therefore. brushing the teeth of patients undergoing mechanical ventilation at least three times a day and oral swabbing every 12 hours with 0. Patient data were gathered from existing electronic medical records (EMRs). practice changes were identified and implemented. Patients who had used a mechanical ventilator for more than 48 hours but did not have VAP at the time of admittance to the ICU were included in the study. The The Journal of Continuing Education in Nursing · Vol 44. Specifically. METHODS This study used a quasi-experimental design to evaluate the effectiveness of an evidence-based practice education program. and its effect was measured with a pretestposttest design that used a convenience sample. 2001). Findings from the American Association of Critical Care Nurses (2010)..12% CHG swabbing solution. THeoReticaL FRaMeWoRK The theoretical framework used for this study was the Iowa model of evidence-based practice to promote quality care. 2013 VAP occurrence rate for 180 mechanically ventilated ICU patients was also calculated. with the goal of improving oral care among ICU patients in the critical care setting. respectively (CDC. Respondents were further informed that their participation was totally voluntary and would not influence their employment. this study implemented a VAP prevention education program for all 60 nurses providing direct patient care in a 12-bed hospital ICU. The standard for inclusion of nurses was more than 3 months of work experience in the ICU. The model can be used to identify areas where evidencebased practice should be implemented to keep procedures current within a changing health care environment (Titler et al. A matched pre. incorporating the nursing intervention of oral care with 0. the hospital’s policy review committee implemented a new oral care protocol for mechanically ventilated patients.and posteducation intervention patient sample was collected during a 6-month period. a convenience sample of 44 nurses was selected. The review board determined this study to be exempt from institutional review board full review because the RNs were voluntarily registering for the program. No 2. 2001). Nurses transferring into or out of the ICU during the study and patients admitted to the ICU after being connected to a mechanical ventilator were excluded from the study. After a review of evidence-based practice material and guidelines. with the goal of improving patient outcomes while providing an opportunity for bedside nurses to make a significant contribution to quality care (Titler et al.50 cases. and ongoing patient surveillance. The effect of the intervention on the incidence of VAP in the unit was also evaluated. the IHI (2010). The model was chosen for this study because it promotes the integration of evidence into practice.

Data Analysis Data were analyzed with the Statistical Package for the Social Sciences. percentile. gender. Demographic data for all RNs were collected at the beginning of the study. A diagnosis of VAP was made if the patient had a new. Most RNs in the ICU had an associate’s degree (66%) in nursing. as well as two nursing school professors. IL). The test consisted of 10 questions on the content of the module. 2010). and total hospital experience. discharge to another facility. The majority of RNs who worked in the ICU were female (98%) compared with male (2%). chest x-ray. All tests were two-tailed. evaluated the program. The ICU manager. diagnosis category. Patient Selection After a review of the EMR. with a p value of less than . purulent tracheal aspiration. along with the results of the posttest and the VAP rates of patients.0 (SPSS Inc. persistent. 44 RNs completed the educational program. RESULTS Overall. A code number was used to record test results. risk factors. version 16. leukopenia. Ventilator-Associated Pneumonia Prevention Program The VAP prevention program was implemented from October to December. and components of comorbidity. Daily assessment surveillance data included time of observation. a professional online teaching module was used as the educational tool. patients who met the inclusion criteria were enrolled in the study. The sample and outcome variables of the patient’s general characteristics and related disease were verified using the chi-square test on frequency. Online pre. age. white blood cell count. study materials were also available in an educational tool kit. To support evidence-based practice. with any potential staff identifiers removed. and a master’s degree (7%). or sudden death. time of observation. Department of Health and Human Services. The module took an average of 30 minutes to complete. followed by a bachelor of science degree (27%). To compare the difference in nurses’ awareness and performance of VAP prevention before and after the intervention. a respiratory therapist. examination scores were downloaded from the server database onto a staff education competency database specifically designed for this study. data were analyzed with repeated measures analysis of variance. and most (69%) had 6 years or more of critical care nursing experience. leukocytosis. and homogeneity.grated into the prevention program for nurses in the ICU. The tool kit materials included one complete study module booklet and oral care packets containing a toothbrush and swabbing supplies for any RN to use. Acute Physiology and Chronic Health Evaluation IV (APACHE IV) score. date of intubation. study code number. or positive culture findings. Chicago. strategies to reduce VAP. Demographic data showed a range in participants’ age. All of the surveillance variables were used to identify suspected cases of VAP.and posttests to assess participants’ understanding of the content and educational objectives were administered immediately before and after delivery of the module educational content. Each patient was evaluated daily through the EMR for ongoing assessment of pneumonia symptoms as well as the frequency of oral care. and four experts in the field confirmed its validity. approximately 4 years younger than the national average (U. Patient state characteristics included days of ventilation. After the educational intervention. The online education module included best practice techniques.S. chest x-ray report. an educator. temperature. 70 date of admission. The focus of the education initiative was a self-study module and a 10-item questionnaire. or progressive infiltrate on a chest x-ray. study code number. A 10-item VAP questionnaire with an evidence-based protocol was developed. and the hospital’s infection control nurse. intubation in the past 24 hours. and matching question formats were used. The program was initiated with a number of different strategies. Questions were designed to best examine whether optimum comprehension and synthesis of information was achieved. with information on topics related to VAP: epidemiology and scope of the problem. true-or-false. years of experience in critical care. educational level. The data were compiled and analyzed. date of birth. Rates of VAP were compared with chi-square analysis. emphasizing a specific nursing intervention or oral care procedure. and prevention. The EMR included an initial assessment completed on the day of ICU admission or the first day of mechanical ventilation. and sputum culture and sensitivity results. In addition to online availability. Copyright © SLACK Incorporated . definitions.. Health Resources and Services Administration. The 44 RNs in the sample were notified of its availability via weekly e-mails until the module was completed. Patients were excluded from the study for any of the following reasons: extubation. Most of the RNs (68%) had at least 8 years of hospital experience. Multiple-choice. The following data were recorded from the patient EMR: enrollment date. in combination with at least three of the following: fever. with an average age of 44 years.05 being significant.

60% were male. Overall. No scores of less than 90% were reported on the posttest. Posttest analysis showed a statistically significant (p < . Improved practice of oral care every 4 hours after education.84 (SD = 0. and mean APACHE IV score was 67.78) 30 (34. Of these. 95% (SD = 7. Directly after the education intervention. the mean level of education had increased to 9. with oral care administered consistently at 2-hour (28%) and 4-hour intervals (60%) (Table 2).0 SD 0.63.9 years (SD = 17. 2013 Figure.12% CHG swabbing solution.06% +21.97).44) Before the VAP education program. the clinical characteristics of the preand postintervention groups did not differ significantly 71 . In terms of changes in practice patterns.001 N (%) 44 (51. Postintervention documentation showed an improvement.67) 6 (7. The nurses were reported to be providing statistically significant (F = 13.69) 57 (60.009).26) Results (Change) -49. showing a positive shift in overall compliance with tooth brushing at least three times a day and oral swabbing every 12 hours with 0. Significance defined as p < .93) were noted as providing oral care. p < .18% p < . The measurement and monitoring components of the study also included evaluation of patient VAP rates during a period extending from 3 months before to 3 months after the intervention. whereas after the intervention. whereas the rest (5%) scored 90%. Postintervention (n = 95) N (%) 2 (2. mean age was 57. the mean total score on oral care was 8.68). No 2.0 10.46) of the nurses were practicing oral care procedures properly before the intervention.00) 10 (10.02% +52.05) oral care.84 Median 8.001 TABLE 2 FREQUENCY OF ORAL CARE DOCUMENTATION Preintervention (n = 85) Variable—Oral Care Not documented Every 2 hours Every 4 hours > Every 4 hours Note.541.58 (SD = 25. 80% of the audited records showed an increase in documented oral care.001). p = .45 out of a possible 10 (SD = 0.05. The changes in the test scores indicate that the 30-minute education module increased RNs’ knowledge of VAP and oral care with 0.12% CHG (t test.TABLE 1 INTENSIVE CARE UNIT NURSING TEST SCORES TWO-SAMPLE T TEST Variable Oral care Oral care Group Pre Post N 44 44 Mean 8.001). p < .22% -24.001 < . Most of the RNs (95%) had a perfect score on the posttest.05) 26 (27. This finding represents a significant improvement compared with pre-education compliance (Figure).45 9.05) difference in the total oral care educational level after the oral care intervention (F = 0. Preintervention oral care was documented at an interval of greater than every 4 hours (34%) or not at all (51%). a total of 180 mechanically ventilated patients were enrolled in the study.5). The Journal of Continuing Education in Nursing · Vol 44.11) 5 (6.37 p .001 < . after the education sessions.001 < . examination of patient EMRs showed that the frequency of oral care increased significantly (p = .37). Patients were most likely to be admitted to the ICU with preexisting pulmonary disease. Comparison of RNs’ scores on the pretest and posttest is shown in Table 1.97 0. The results showed that 44% (SD = 7. During the 6-month period. Therefore.

Therefore.1219 0. This study was conducted for 3 months before and 3 months after the intervention. Overall ventilator days were significantly decreased in the postintervention group (p < .000 ventilator patient days.55).0440* 0.3267 0.. APACHE IV = Acute Physiology and Chronic Health Evaluation IV. Eayge et al.0652 -0.0212 0. coma. Subsequently.6463 Coefficient p (1/1. 2011. although limitations were present. Table 3 shows pairwise correlation analysis conducted between individual independent variables of patient characteristics and VAP. During the postintervention period. even a small number of occurrences can significantly affect the infection rate. or 2. Although a trend was seen toward higher acute physiology and APACHE IV scores.0357 -0. 2007.1879 .9856 . occurrence rates may vary widely. in acuity during the collection periods (p = . Another limitation of this project Copyright © SLACK Incorporated Note. Further limitations of this project.0014* .003) was noted in VAP rates 72 . However.4745 . When there is a small target group evaluated within a short study period. it was not possible to determine whether oral care alone specifically influenced VAP.TABLE 3 PAIRWISE CORRELATION OF VENTILATORASSOCIATED PNEUMONIA AND INDEPENDENT VARIABLES Variable Independent variable Patient trait characteristics Age Gender APACHE IV score Medical diagnosis Coma COPD CVA Degenerative neurological disease Immunosuppression Renal Patient state characteristics Days of ventilation Autonomous nursing intervention Oral care not documented Oral care every 2 hours Oral care every 4 hours Oral care > every 4 hours Outcome Ventilator days.1737 0.1374 .1304 0.0161* .5334 0. 5 had VAP..5% compared with the preintervention period.5) than those in the preintervention group (6. Limitations Because of the epidemiology of nosocomial infections such as VAP.0000* 0. *Significance defined as p < . Berry et al. Furthermore.0264* .1041 .69). and cerebrovascular accident. which is an important and proven strategy to reduce the incidence of VAP that includes oral care. 2009). ICU = intensive care unit. COPD = chronic obstructive pulmonary disease. the infection rate was 1. only one episode of VAP occurred during a total of 421 ventilator days among 854 total patient days.8 per 1. the researcher randomly selected EMR reviews.5%) occurred postintervention. CVA = cerebrovascular accident. a decrease of 62. This is equivalent to an infection rate of 4.65 days preintervention versus postintervention.05.1075 . including a specific medical diagnosis.0163 -0. During the preintervention period. it alone may not prevent VAP.0061* 0. Patients who underwent mechanical ventilation for at least 24 hours were included in this study. To minimize the increase in performance as a result of the Hawthorne effect. which was an insufficient period relative to previous studies (Augustyn.8128 .0803 .4716 . a total of four episodes of VAP occurred during 471 ventilator days among 832 total patient days. 4 of 95 cases (2.0488 0.0014 0. several patient trait characteristics were significantly correlated with the development of VAP. The postintervention mean number of ventilator days was 3.01). patients in the postintervention group had fewer days on the ventilator (3.7690 . At the bivariate level. Another limitation of this study was the nonevaluation of all IHI bundle outcomes other than those associated with pneumonia and oral care. total ICU length of stay 0.21). Of the 180 patients in the ICU.26 (SD = 1. analysis suggested that oral care with tooth brushing at least three times per day and oral swabbing every 12 hours with 0. may have led to more conscientious oral care. After the education was completed.1413 0. making statistical judgments difficult. The pre-education mean number of ventilator days for all patients was 4.12% CHG swabbing solution was significantly correlated with a decreased incidence of VAP.7% of the total sample of 180 patients.4).000).0143 . during the postintervention period.1129 0.91 (SD = 1.0000* . Although the IHI recommends the VAP bundle.000 ventilator days.7186 . for a difference of -1. a statically significant difference (p < .3451 . this study showed that a statistically significant difference was attainable through educational interventions. including RNs’ awareness of being evaluated before and after the education sessions.2%) occurred preintervention and 1 of 85 cases (0.8 patients per 1.

there is a need for further education on oral care for intubated patients. This study was conducted to support evidence that proper oral care practices can significantly reduce the incidence of VAP in patients in the ICU. 1 The Institute of Health Care Improvement has identified the prevention of ventilator-associated pneumonia (VAP) as one of its top priorities for improving health care outcomes and quality. Educating nurses and providing them with opportunities to show competency in their care increases the likelihood of enhanced patient outcomes. the intervention of oral care appeared to be effective. DISCUSSION The occurrence of VAP increases the duration of mechanical ventilation. Munro et al. 2007. 2013 key points Ventilator-Associated Pneumonia Zurmehly. As this study found. Clearly. identifying and embracing the factors that facilitate best practices is critical. J. Low rates of VAP are likely the result of many coordinated The Journal of Continuing Education in Nursing · Vol 44. Oral Care Education in the Prevention of Ventilator-Associated Pneumonia: Quality Patient Outcomes in the Intensive Care Unit. the overall length of stay in the ICU. No 2. and the length of the hospital stay (Berry et al. can be improved with an active educational intervention and can lead to significant changes in outcome measurement. The Journal of Continuing Education in Nursing. critical care nurses often perform oral hygiene according to their individual preferences. Therefore. Therefore. the goals of the project were successfully met. To facilitate evidence-based practice with the aim of achieving better patient outcomes. Considerable efforts have been made to incorporate VAP prevention into routine care in many ICUs. (2013).000 ventilator days. the process of translating evidencebased guidelines into day-to-day practice varies. These results show that an intensive 30-minute targeted education intervention can influence RNs’ knowledge and clinical practice. Providing education to RNs and evaluating whether there is proper implementation of the lessons learned can dramatically decrease VAP rates. After the nurses completed the education. 2007). this study chose an intervention method that would be more likely to ensure long-term effects. 2010). 44(2). Ross & Crumpler. However. nurses’ compliance with oral care increased after education sessions based on best practice. The findings indicated that. Hawe et al. The results suggest that oral care with 0. In this study. their knowledge increased and their use of evidence-based oral care practice improved.. 67-75. Kleinpell. reflecting increased levels of compliance and awareness among RNs of the validity of evidence-based. thereby reducing deaths. For patients who are critically ill within the ICU setting. 2009. it appears that educational sessions with pretest and posttest evaluations followed by evaluation of patient outcomes provide the most consistent predictor of adherence to the oral care guidelines. only short-term change occurred and lasted approximately 1 week (Feider et al.. 2009. including oral care. Thus. Orientation of these nurses must include oral care practices and the opportunity for the nurses to work with the equipment before working on the unit. Education programs should be more widely employed for infection control in the intensive care setting and can lead to a sustainable decrease in cost and patient morbidity attributed to hospital-acquired infections. the reported effect may continue for several weeks to several years (Ross & Crumpler. VAP continues to be a significant clinical problem. This education should encompass all nurses who work in ICUs and should focus on oral care as a preventive measure for VAP instead of a task that only increases the patient’s comfort.was the absence of a control group that could be used to compare findings and evaluate the reliability of the test questions. In this study. This training is especially important for nurses who are new to the critical care environment. when formal education is provided. This study has further implications for the education of ICU nurses. nurses who provided tooth brushing 73 . A 30-minute education session improved knowledge and use of VAP prevention strategies.. 2 3 4 efforts.12% CHG solution significantly contributed to reducing the patient’s risk of VAP. as shown by the significant improvement in the nurses’ test scores and the patient infection rate per 1. Positive changes were noted in RNs’ oral care practices during patient care. 2009.. with formal education. Implementation of the VAP bundle. 2009). The actual oral care used and noted in patients’ EMR improved significantly. Without evidence-based guidelines. along with feedback. 2007). However. educating nurses on how to use the oral care equipment and how to perform appropriate oral care for the intubated patient resulted in decreased VAP rates. The findings of this study support earlier studies of educational outcomes with VAP (Halm & Armola. when only informal training was provided. According to previous studies. quality patient care.

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