Chlorhexidine Use in VAP Cases Capstone Project

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Klompas M., Speck, K., Howell M.D., Greene, L.R., & Berenholtz, S.M. (2014). Reappraisal of routine oral care with chlorohexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA internal medicine, 174 (5), 751-761.

This article deals with the routine oral care of patients using chlorhexidine gluconate as standard care when they receive mechanical ventilation during their hospital stay. Their aim is to assess the overall impact routine oral care has in conjunction with chlorhexidine in regards to patient-centered outcomes for patients receiving the aforementioned mechanical ventilation. They chose randomized clinical trials that compared a placebo to chlorhexidine and chose only sixteen studies out of the 171 citations they explored because the 3,630 patients observed in the selected studies met criteria.

The results showed chlorhexidine provide patients with a lesser occurrence of infection than with placebo, although pneumonia risk was around the same for both. Although chlorhexidine reduced the risk of nosocomial infection, it did not reduce the risk of ventilator-associated pneumonia. Although the review appeared thorough with only a few studies chosen out of the 171, it still lacked details that would help highlight the effectiveness of chlorhexidine in regards to reduction in nosocomial infection.

2. Babcock, H., Zack, J.E., Garrison, T., Trovillion, E., Jones, M., Fraser, V.J., & Kollef, M.H. (2004). An educational Intervention to reduce Ventilator-associated pneumonia in an integrated Health System Chest, 125 (6), 2224-2231.

The first thing observed and appreciated about this article is the objective of the study was mentioned early. The study objectives were to determine if educational initiatives could lessen the rates of ventilator-related pneumonia within regional healthcare systems. In order to perform the study, they observed two teaching and community hospitals within a health system that is integrated. The time frame for observation of patients admitted was three and a half years from January 1999 to June 2002.

They mention that educational programs allow for emphasis on proper practices for prevention of ventilator-related pneumonia. They used posters and fact sheets in order to reinforce the practices all throughout the respiratory care and ICU departments. The fault found in the study is they did not use enough supplemental literature to show why educational programs are beneficial. However, the 46% reduction in cases seen throughout the 3.5 years highlights the positive effect educational programs can have on infection prevention.

3. Tablan, O.C., Anderson, L.J.M Besser , R., Bridges., C., & Hajjeh, R. (2004). Guidelines for preventing healthcare associated pneumonia, 2003. MMWR, 53 (RR-3), 1-36.

This is a guide of sorts that helps explains key terms, abbreviations and backgrounds on various types of disease and infection. While this is a helpful guideline for understanding the names and conditions associated with such infections, it is outdated and does not rely on information from current literature. It also does not provide adequate study information highlighting and correct practices that could decrease the rate of health-care-associated infections. The summary at the beginning was useful in getting a general idea of what can be expected, but overall, it is outdated.

4. Zhang, T., Tang, S,. & Fu, L. (2014). The effectiveness of different concentrations of chlorohexidine for prevention of ventilator-associated pneumonia; a meta-analysis. Journal Nursing, 23 (11/12), 1461-1475. doi:10.1111/jocn.12312

The objectives and aims were stated in the beginning of the study. These are to assess the effectiveness of using chlorhexidine in a health care setting to prevent or lessen occurrence of ventilator-associated pneumonia as well as exploring the desired concentration of such a medicine (chlorhexidine) for the positive outcome. In essence, they wanted to see if oral care measures had a positive impact in infection reduction. The background portion felt repetitive and should have included investigation into other medicines used at varying concentrations and its success in treating infection. The design of the study was a meta-analysis.

They searched and gathered information on randomized controlled trials and selected eighteen trials. They found the majority of the selected trials proved 2% concentration of chlorhexidine can prevent ventilator-related pneumonia. They even devised a range for effectiveness of chlorhexidine, which was from 0-12%. The fact that they included the mortality rates in ICU directly related to ventilator-associated pneumonia was a great way to add importance to the use of chlorhexidine and shined a spotlight on oral care.

5. Munro, C.L., Grap,. Grap,. M.J., Jones, D.J., McClish, D.K., & Sessler, C.N. (2009). CHLOROHEXIDINE TOOTHBRUSHING, AND PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA IN CRITICALLY ILL ADULTS.

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American Journal of Critical Care: An official Publication, American Association of Critical-Care Nurses, 18 (5), 428-438. http://doi.org/10.4037/ajcc2009792

This study observed roughly 269 patients with some having pneumonia as baseline and other without. Those with pneumonia at baseline experienced no difference when tooth brushing and chlorhexidine were introduced. From the pool of participants that did not have pneumonia at baseline, early intervention with chlorhexidine proved effective while tooth brushing had no effect by itself nor did it increase rate of prevention coupled with chlorhexidine. The study provided answers to questions such as if oral care that involves tooth brush is effective and if it adds to the efficacy of chlorhexidine. Overall, the study shows that chlorhexidine is in fact useful in preventing or reducing early ventilator-associated pneumonia when patients do not have pneumonia at baseline.

6. Snyders, O., Khondowe, O., & Bell, J. (2011). Oral chlorohexidine in the prevention of ventilator-associated pneumonia in critically ill adults in the ICU: A systematic review. Southern African Journal of Critical Care, 27 (2), 48-56.

The article uses electronic search engines in order to provide information on chlorhexidine and its use in preventing or reducing ventilator-associated pneumonia. They searched for one year and found eight studies that included effectiveness of chlorhexidine in comparison to power brushing, placebos, Listerine, normal saline, and bicarbonate isotonic serum. This article mentioned like the previous on the best concentration for treating VAP and that is 2%. It also mentioned that chlorhexidine alone provided the best reduction of risk of VAP by a remarkable 36%. This article provided information on and confirmed two things, that 2% concentration chlorhexidine is the ideal concentration to use and chlorhexidine alone reduces risk of VAP.

7. Belamurugan, E., Kanimozhi, A., & Kumari, G., (2012). Effectiveness of Chlorohexidine oral decontamination in reducing the incidence of ventilator associated pneumonia: A meta-analysis. British Journal of Medical Practitioners, 5(1).

This article provided background information in the importance of reducing VAP because of its prevalence and its ability to increase patient mortality, patient stays, and medical expenses. The literature review highlighted nine trials that demonstrated a major reduction in occurrence of VAP when patients received chlorhexidine treatment. The only thing that could have used improvement was the clarification as to why chlorhexidine does not help in reducing the general mortality rate among patients that are mechanically ventilated. Although people may fear antibiotic resistance when using antibacterial medicines like chlorhexidine, the reduction rate among patients with VAP proves that it is a successful intervention for prevention of VAP.

8. Sharma, S.K. & Kaur, J. (2012). Randomized Control Trial on Efficacy of Chlorohexidine Mouth Care in Prevention of Ventilator Associated Pneumonia (VAP). Nursing and Midwifery research, 8(2).

This study did two things, it showed the efficacy of using chlorhexidine to prevent VAP even in patients with longer periods of mechanical ventilation and it showed that 0.12% concentration of chlorhexidine was effective in preventing VAP. The only problems with the study is that it was only done for roughly 4 months and the study only involved 260 patients. However, it is very good news that concentrations lesser than 2% can still provide reduction in VAP even long-term as long as it is done twice daily.

9. Hiller, B., Wilson, C., Chamberlain, D., & King, L. (2013). Preventing ventilator-associated pneumonia through oral care, product selection, and application method; A literature review. AACN advanced critical care, 24 (1), 38-58.

This study failed to provide a concentration for chlorhexidine. However, it did suggest that use of chlorhexidine along with nurse education and assessment played significant roles in reducing occurrences of VAP. They also suggested that chlorhexidine was the preferred oral care product. However, no best practices were revealed including application techniques or optimization of VAP prevention.

10. Andrews, T., & Steen, C. (2013). A review of oral preventive strategies to reduce ventilator-associated pneumonia. Nursing in Critical Care, 18 (3), 116-122. doi:1111/nicc.12002

The article does not bring any new information in relation to chlorhexidine. It confirms that 2% concentration of chlorhexidine can be the most effective way of reducing the likelihood of VAP. However, it does identify a gap in research as most of the results gathered from the studies are from patients following cardiothoracic surgery. More research should focus on patients outside of that pool of surgery outcomes.

11. Robers, N., & Moule, P. (2011). Chlorohexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates. Nursing.....

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