Chlorhexidine Gluconate Solution for VAP Prevention in ICU Patients

This research proposal aims to establish the effectiveness of Chlorhexidine Gluconate Solution in preventing Ventilator-Associated Pneumonia (VAP) in intubated ICU patients. The study will use a quasi-experimental design with a study group using Chlorhexidine Gluconate Solution and a control group using alternative dental hygiene. The primary outcome is improved oral health status and prevention of VAP in the study group.

Research Proposal 1
Introduction of Chlorhexidine Gluconate Solution for Mouth Cares in order to reduce the
Incidence of Ventilator-Associated Pneumonia in an Adult Intensive Care Unit
Name of Author
Name of the class (Course)
Tutor’s Name
School Name
City School is Located
Date

Research Proposal 2
Details
To establish the effects of Chlorhexidine Gluconate Solution in oral hygiene among
intensive care unit patients, fifty adults obtained from both sexes with endotracheal tube as well
as mechanical ventilation were presumed to be eligible for participating in the study. The
patients to be considered had to be intubated for at least 48 hours with the use of nasogastric tube
while having only one intubation attempt, no oral or facial trauma, or evidence showing VAP.
The study would go into showing how important oral hygiene is among patients in intensive care
units through the use of Chlorhexidine Gluconate Solution. According to research, it has been
established that Ventilator-associated Pneumonia (VAP) is one of the commonly acquired
infection in ICU wards and it is often associated with poor oral hygiene (Amanullah & Posner,
2015). Chlorhexidine Gluconate Solution is one of the top solutions that has been recommended
for use in this regard. This research proposal will go into exploring this subject further and find
out how effective Chlorhexidine Gluconate Solution is in the prevention of VAP in adult
intensive care units. The research design that would be applied is quasi-experimental in that there
will be two groups: the study group and the control group. The study group will use
Chlorhexidine Gluconate Solution while the control group will not, and the result compared to
give recommendations as required by the proposal design.
Overview
Ventilator-associated Pneumonia (VAP) is among one of the most common hospital-
acquired infections inside the intensive care units and is often associated with high morbidity and
significant cost of care. For many years, the epidemiology, pathophysiology, treatment as well as
prevention of VAP has been studied, but there has never been any clear prevention strategy
(Keyt et al., 2014 pg. 8). VAP is the occurrence of pneumonia in patients who are in the ICU

Research Proposal 3
receiving mechanical ventilation for more than 48 hours after endotracheal intubation (Kalanuria
et al., 2014). VAP in ICUs has many effects, some of which include: prolonged treatment with
mechanical ventilation, increased length of hospital stay, increased care costs and high mortality
rates (Hillier et al., 2013). Looking at the Australian Intensive care units, it has been estimated
that the incidence of VAP can occur roughly at 6.2 per every 1000 days of treatment using
mechanical ventilation. Based on estimates, VAP can occur in up to 28% of the ventilated
patients with each incidence of VAP attracting an increased cost of about $20,000 to $40,000
(Elliott et al. 2015). According to research, multiple interventions could be used and
recommended to reduce ventilator-associated pneumonia such as sedation holiday for the
mechanically ventilated patients, semi-recumbent position as well as regular oral care (Zhang et
al. 2017).
To reduce the risk of ventilator-associated pneumonia for the intubated patients in the
ICU, some measures have to be taken such as the provision of good oral hygiene, the use of
either a mouth rinse gel, toothbrush, solution or a combination of frequent suctions of the
sections (Ullman, 2009 pg. 51). VAP tends to arise when there is a bacterial invasion in the
pulmonary parenchyma for the patients receiving, mechanical ventilation (Pobo et al., 2010 pg.
21). VAP has become the foremost validation of why it is crucial for the patients in the ICU units
to get an oral cleaning (Kelly, 2014 pg. 20). Evidence has shown that inadequate mouth care for
the intubated patients could facilitate the aspiration of bacteria in the oropharyngeal secretions
and thus the cause of VAP (Dale, 2013 pg. 191). For this reason, the essential strategy for
reducing the risk of VAP is to improve oral health. Some of the techniques suggested for this
include removal of dental plaques as well as oral pathogens, the use of antiseptic solutions and
cuff pressure control, suctioning and lastly elevating the patient’s head of the of the bed by about

Research Proposal 4
35 to 45 degrees (Pobo et al., 2010 pg. 15). One practical solution that could be used for oral
hygiene is Chlorhexidine Gluconate Solution. Several studies have indicated that the use of
Chlorhexidine Gluconate Solution to be an effective way of preventing VAP (Mohammed &
Gamal, 2017). The use of this solution is safe, cost-effective, feasible, and easy to apply while
having minimal side effects. For that reason, the solution is in many circumstances considered to
be a crucial part of the ventilation care bundle (Par et al., 2014). For the hospitals to attain high
standards levels, they need to look at the current practices to help them in improving the patient's
outcome. As such, it can be recommended that the project proposal would be beneficial to the
patient as well as the facility (Gupta et al., 2016).
Aim
To expand on the knowledge that exists on the effectiveness of Chlorhexidine Gluconate
Solution in the prevention of VAP. The study, therefore, aims to examine the effects of the
solution on oral health status as well as the occurrence of ventilator-associated-pneumonia in
intubated ICU patients.
Objectives
To evaluate the effects of Chlorhexidine Gluconate Solution on ICU patients.
To use the solution for mechanically ventilated patients and compare them to a control ICU
patient group using alternative dental hygiene to establish how effective the Chlorhexidine
Gluconate Solution could be in the prevention of ventilator-associated pneumonia.
To collect and analyze data from previous research and comparing it to the research to expand
knowledge in establishing the effectiveness of Chlorhexidine Gluconate Solution in the
prevention of VAP

Research Proposal 5
Primary Outcome
Based on research that has already been conducted on this subject, it has been established
that oral hygiene is one of the most fundamental things to do to prevent the occurrence of
ventilator-associated pneumonia in patients inside the ICU wings of hospitals. Best practice for
conducting oral hygiene could include various solutions and steps as pointed out earlier.
However, for this research, the chlorhexidine gluconate solution would be explored in the
prevention of VAP. The primary outcome of this research is that oral health of the control group
is expected to deteriorate, but improved oral health status is expected for patients using
chlorhexidine gluconate solution to show its effectiveness in preventing VAP in intubated ICU
patients.
Background and Justification of the need for the proposal
Ventilator-associated pneumonia is a severe condition that attracts high health care costs,
increased risks of developing complex illnesses as well as associated with high morbidity rates in
the hospitals. Over the decades, it was established that patients that are ICU beds receiving
intubation are at high risk of acquiring VAP and therefore methods have to be established to find
out ways through which this could be prevented. VAP has a significant impact on the lives of the
patients, and therefore there is a need for exploring this subject further to establish proper ways
of dealing with the condition once and for all. According to recently published articles on this
subject, the occurrences of ventilator-associated pneumonia could be reduced significantly
through the implementation of structured, evidence-based guidelines for mouth care (Chipps et
al., 2016). These articles suggest that the improvement of oral hygiene is a vital part of reducing
the chances of acquiring VAP for these patients. This research had to be conducted, therefore, to

Research Proposal 6
establish the most appropriate way of maintaining oral hygiene for the patients in the ICU to
prevent VAP apart from the traditional routine oral care.
There is a need for exploring on this subject further because more people need to
understand VAP, the causes and the ways to prevent the disease as best as possible. Also, it is
essential to know more about chlorhexidine gluconate solution and why it is the best bet for the
prevention of VAP in intubated ICU patients (WebMD, 2018). According to a survey, about
60% to 70% of the intensive care units in both the U.S and Europe use chlorhexidine gluconate
solution at least only once a day to perform oral hygiene in intubated adult patients (Klompas et
al., 2014). Many hospitals in developed nations have commenced the use of chlorhexidine
gluconate solution in oral hygiene of their mechanically ventilated patients (Vollman, 2017). It is
essential to note that there are many alternative solutions and ways of ensuring oral hygiene for
these patients but out of the broad range, there was a reason why chlorhexidine gluconate
solution was opted to be the best bet in the fight against VAP and these reasons will be explored
further in the course of this proposal (Institute for Healthcare Improvement, 2012 pg. 10).
Setting and Participants
The research study is to be conducted at an ICU section of an Australian medical facility.
Fifty adults obtained from both sexes with endotracheal tube as well as mechanical ventilation
will be used for the study. The patients to be considered had to be intubated for at least 48 hours
with the use of nasogastric tube while having only one intubation attempt, no oral or facial
trauma, or evidence showing VAP.
Data collection methods and analysis

Research Proposal 7
To conduct this study with this groups, some factors had to be considered to establish the best
data collection methods. These include:
i) Administrative concerns
To be able to conduct this research, it was essential for the research team to seek for permission
to conduct the study on the patients selected. This would be done through the stating of the aim
and objectives of the research which is not only beneficial to the research team but also to the
center in which chlorhexidine gluconate solution is used for the ICU mechanical ventilated
patients.
ii) Content as well as face validity
This was the second method where the related literature was reviewed as well as tested for
validity by a jury that consisted of seven experts from the medical-surgical nursing,
anesthesiologist, nursing educators, statistician and bacteriologist fields. Their opinions are
essential to ensuring that the result that is obtained from the study are accurate and that the
recommendations made are practical in healthcare settings.
iii) Human rights and Ethical Considerations
The reason for ethical and human rights consideration is due to the fact that through the
anonymity of the patients to participate in the research, confidentially was restored and thus the
patients are expected to benefit from the research in terms of improving the oral health care to
prevent the occurrences of VAP or reduce arisen cases (Oshodi & Bench, 2013). For the
unconscious, care had to be taken to ensure that there are no incidences of chocking through the
fluid used. Finally, formal consent from the conscious patients was obtained from them and that
of the unconscious obtained from their significant others and immediate family for consideration.

Research Proposal 8
iv) Pilot study
A pilot study was conducted on at least 10% of the group to test feasibility as well as the
applicability of tools and resources used for the research and establish any gaps that have been
left by previous research on the subject.
Data Collection Method to be used.
After looking at the various factors to be considered in conducting the research. It was
established that qualitative data collection methods are the most appropriate for the study. This is
because these methods play a crucial role in impact evaluation through the provision of
information which is useful in understanding the processes that are behind the observed results as
well as assess the changes in the perception individual’s well-being. For this case, the qualitative
methods to be used include observation methods, document reviews as well as in-depth interview
to establish the importance of using chlorhexidine gluconate solution in oral hygiene of the
mechanically ventilated patients to prevent Ventilated-associated pneumonia occurring.
Project Implementation and Change Theory Application
For a change to be introduced in the health care system, it is essential to understand a
change theory model for assessment, implementation, and management. In terms of change
theory to conform to, the project seeks to incorporate the Kurt Lewin’s change theory. The
model is based on three steps which include unfreeze, change and refreeze as shown in the figure
below.

Research Proposal 9
Figure 1 Kurt Lewin Change Model.
1. Unfreezing Stage
In this stage, there is a rationale for change. The process involves finding suitable
methods of making it possible for individuals to let go of the old ways and pattern of doing
things which is counterproductive and adopt more productive strategies. Unfreezing is
therefore essential in overcoming the strains that come with individual resistance to change
and group conformity (Connelly, 2016). In this stage, the problems are diagnosed and the
resources assessed as well as forces that cause resistance to change assessed. It is in this stage
that considerations are established to use chlorhexidine gluconate solution as a method of
preventing VAP. The effects of the solution are to be studied among two groups to establish
the change in their response towards VAP prevention. In this stage, however, change is not to
be introduced immediately, but a sense of psychological safety is brought about by the

Research Proposal 10
thought of modification. The solution is not to be administered in this stage but ways
discussed through which it can be administered to bring about change.
2. The moving stage
This stage involves the process of change in thoughts, behavior, or feelings in some way
that is more productive or liberating. Once the people involved in the process are open-
minded enough, then it is possible for change to begin (Mitchell, 2013). In the process,
people react to change and thus move toward a new beginning. It is for this reason that a
detailed action plan has to be devised to engage individuals to implement the so needed
change. The change process has to be viewed as a type of investment in a person both in
terms of time as well as the allocation of resources (Morrison, 2014). This stage is focused
towards eliciting actual shifts in behavior. In our case study, the focus group is given
chlorhexidine gluconate solution during the oral hygiene process as a change towards using
this as the primary solution to preventing VAP. The moving stage ensures that the focus
group is administered with chlorhexidine gluconate solution while the control group uses the
routine oral hygiene checkups by the nurses. The process helps in establishing whether the
change imposed is sustainable for preventing VAP which is established from the outcome of
the research conducted between the two groups.
3. The Refreezing stage.
A particular change will only result if its full effect is made permanent. This means that
immediately change has been established, efforts should be made to ensure that cementing is
done to make the change permanent (Daniel Lock Consulting, 2017). In this stage, people are
given the chance of thriving in the new amendments and taking full advantage of the

Research Proposal 11
alteration. In this case, when chlorhexidine gluconate solution is adopted as the best bet for
oral hygiene to prevent VAP, the refreezing stage has been reached (Shirley, 2013).
Comparing the results of the two groups, it can be established that the use of chlorhexidine
gluconate solution is the best way of dealing with ventilator-associated pneumonia. In that
case, the solution could be adopted as a permanent way of conducting oral hygiene for
intubated patients in the ICU.
Benefits, potential difficulties and possible solutions.
The benefit of using chlorhexidine gluconate solution is that it helps in preventing the
colonization of gastrointestinal tracts as well as the upper airway. During mechanical ventilation,
bacteria is bound to colonize this area and could cause serious health complications for the
patient. For this reason, the use of a suitable solution as an oral hygiene procedure is essential to
prevent such from happening and thus the benefit of chlorhexidine gluconate solution (Akimkin
et al., 2017 pg. 8). Some potential difficulty that could be encountered in the application of this
solution is the high cost that the procedure attracts compared to the standard oral hygiene care
given to patients. The solution to this is to encourage more people and explain to them the
importance of using chlorhexidine gluconate solution as opposed to other alternatives
Potential costs of carrying out the project and Conclusion.
Some of the resources that are required for this research were books, visual aids,
computer as well as consultative resources. Since the books are available online, and a computer
accessible, the visual aids could be prepared easily and thus attract no charges. The only charges
to be incurred could include the cost of transportation and consultative charges which are
estimated not to go beyond $200. Conducting such a study would prove beneficial for the

Research Proposal 12
hospital facility as it would be in a position to provide better care for their ICU patients as well
help in showcase the positive effect of using the solution in preventing VAP incidences in
intensive care units in Australia and the rest of the world. Based on the research conducted, it can
be concluded that the chlorhexidine gluconate solution is the best oral hygiene procedure for
preventing ventilator-associated pneumonia in ICU patients.

Research Proposal 13
Appendix
1. Questionnaire for staff compliance and knowledge pre and post implementation
a. How well do you know about the effects of mechanical ventilations in ICU patients?
b. Have you been in a position where you were directly involved with a patient suffering
from VAP?
c. If yes, what did you do in these circumstances? If no, what would you suggest be done?
d. Apart from chlorhexidine gluconate solution, do you know any other viable solution
effective for preventing VAP?
e. On conducting this study, what do you expect to benefit from it?
f. After the study, do you see yourself using chlorhexidine gluconate solution to prevent
VAP in these patients? Kindly state your reason.
2. Safety and Quality survey report pre and post implementation
a. Pre-Implementation
Before conducting the study, it is essential to get the consent of the people that are
involved. In this case, from the 50 individuals that are to participate. In addition, all
mechanically ventilated patients that are conscious must be taken through the process
and told about the benefits of the project. Lastly, all tools and personnel used for the
study should evaluated to ensure quality outcome.
b. Post Implementation
After the implementation of the study, it is essential to use quality data collection
methods and the right personnel for translating the information. All necessary
information for drafting the conclusion and recommendations must be scrutinized and
assessed to ensure accuracy

Research Proposal 14
3. Poster Card (Attached)
4. Presentation (Attached)
5. Gantt Chart (Attached)

Research Proposal 15
References
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10.1136/bmjopen-2015-008924.

Research Proposal 16
Gupta, A., Singh, T., & Saxsena, A. (2016, March). Role of Oral Care to prevent VAP in
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Respiratory & Critical Care Medicine, vol.38, no. 3, pp. 381-390.

Research Proposal 17
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Research Proposal 18
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