Prevention of Ventilator Associated Pneumonia through Chlorhexidine Gluconate Oral Care

NURS2006 ASSIGNMENT 3
Clinical Practice Improvement Project Report
Student Name, FAN and ID:
Type your assignment into the white spaces in the template and the rows will
expand as much as you need them to.ie Alex Smith smit0000 ID 1234567
Project Title:
Prevention of ventilator associated pneumonia (VAP) in Mobury intensive care units (ICUs)
through chlorhexidine gluconate (CHX) oral care
Project Aim:
The aim of the project is to reduce the VAP in Mobury ICUs by 50% in 5 months through
prevention by chlorhexidine gluconate oral care
VAP is a common hospital acquired infection (HAI) that occurs when bacteria is being aspirated
into the lungs after 48 hours of intubation (Hunter 2012). VAP is one of the HAI that is leading
cause of death in ICUs and its prevention is important for improved outcomes in its reduction. This
condition of VAP occurs due to little are provided to the patients in ICU under assisted ventilation
and gradually, progress to lungs and bacteria accumulation within oral region that matures to
VAP. This infection is often fatal; however, it can be managed. Prevention can largely address VAP
condition to occur through proper oral care and hygiene. CHX has been used for the prevention of
colonization of bacteria from travelling into lungs leading to VAP (Charles et al. 2014).
Relevance of Clinical Governance to your project
Clinical Governance is a defined system that work through National Health Service (NHS)
organizations who are accountable for continuously improving the quality of healthcare services
and safeguarding the high standards of care through creation of an environment in which clinical
care can excel and flourish (Specchia et al. 2015). Seven pillars or areas of activity are present in
clinical governance ensuring that high quality healthcare services are provided to service users.
This includes service user, public involvement and carer, clinical audit, risk management, staffing
management, education and training, clinical effectiveness and information. Among all these, the
most relevant pillar for the project is the risk management. The nurses need to implement the
approach of CHX oral care to reduce the risk of HAI and prevent VAP that is associated with it. This
clinical governance pillar defines the reduction and prevention of VAP that can be linked to this

project, as nurses need to perform hygiene and oral care in ventilator-assisted patients in ICU and
provide evidence based intervention strategies to prevent VAP (Davoodi et al. 2014). CHX bathing
will enable to prevent bacteria to colonize and enter lungs in ventilator assisted ICU patients and
in turn reduce the incident of VAP in this particular setting.
Evidence that the issue / problem is worth solving:
The second most common nosocomial infection is pneumonia in critically ill patients that affects
27% of them or 86% pneumonias associated with mechanical ventilation termed VAP (Bassi et al.
2014). It accounts for 60% of deaths from HAIs having mortality rate of 33% and greatly increases
the patient time in ICU by 3 to 6 days (Barbier et al. 2013). VAP is s global issue estimating to
generate increased costs and pose burden on the healthcare system on a whole. The hospital days
are increased with an average of 12 days due to this hospital acquired lower respiratory tract
infection and pose additional costs per patient. National Infection Surveillance System (NNIS) by
Centres for Disease Control and Prevention (CDC) reported that patients who receive continuous
mechanical ventilation have highest risk of developing VAP as compared to patients who were not
receiving mechanical ventilation (Bouadma, Wolff and Lucet 2012).
The quality of care delivered to ICU patients is pertinent in the health outcomes or in
acquiring infections. Criticaally ill patients who are intubated in ICUs through endotracheal route
are temporarily or permanently ventilated if prevention measures are not adopted stringently.
Elliott et al. (2015) stated that a study conducted across 14 ICUs in Australia revealed that VAP
rates were 28% and therefore, prevention strategies are important to be implemented. VAP is a
serious risk influenced by immune function, severity of illness, duration of invasive ventilation or
physiological reserves. VAP incidence is a serious challenge for healthcare settings increasing the
duration of hospital stays, higher costs of treatment and high mortality rates. This depicts that
reduction and prevention of VAP need implementation of strategies and tested interventions that
improve patient safety and reduction of untoward outcomes. In ICUs, oral care importance is well
documented for VAP prevention for ensuring patient safety and better health outcomes. CHX is a
prescribed solution for oral care that is licensed, administered in critical healthcare settings along
with routine hygiene practices for the prevention of VAP among critically ill patients in ICUs. CHX is
a broad-spectrum anti-bacterial solution, it kills plaque and prevent bacterial colonization in lungs
that migrate from mouth during aspiration that a ventilated patient is risked for (Özçaka et al.
2012).
Key Stakeholders:
The key stakeholders for this project could be board of directors, project coordinator, nurses or

caregivers.
Board of Directors: The recognized group who would jointly oversee the project and provide
permission for implementing the intervention
Project coordinator: Plan and coordinate the CHX oral care program and ensure the successful
implementation of the intervention along with budget maintenance.
Nurses: They will perform the CHX oral care among the critically ill patients in ICUs under
mechanical ventilation and document reduction rates
Caregivers: Assist in the implementation of the project by looking for risk, supporting and helping
nurses when required
CPI Tool:
A study conducted by Shi et al. (2013) illustrated that quality improvement plan through CHX oral
care can reduce the incidence and prevent VAP along with oral care and deep oral suctioning at
least twice a day. Therefore, Plan-Do-Study-Act (PDSA) tool will be used for the clinical practice
improvement in the ICU setting.
Plan: Literature review of evidence-based practice regarding CHX oral care targets the bacterial
colonisation in the lungs that can cause VAP in intubated patients. The statistics will be gathered
regarding the VAP infections in ICUs among mechanical ventilated patients, as it is the baseline
information required before the implementation of CHX oral care.
 We are going to implement a consistent 4 months CHX oral care targeting pneumonia
bacteria and prevent VAP infections in ICU setting among critically ill patients.
 We are hopeful that implementation of this intervention can prevent VAP conditions by
around 50% at the end of four months
Steps for execution
 Nurses need to understand the benefits of this intervention and related information that
reduce the incidence of VAP and its prevention in ICUs. Nurses should be educated about
the correct CHX oral care procedure through a handbook that gives description of the
steps in text and pictures involved in the oral care using CHX solution.
 The nurses and caregivers should be encouraged by the project coordinator assisted by
nurse leader to be engaged in the oral care at appropriate intervals. It is advised to
perform oral care sessions 6 times a day where two out of six oral care sessions should

include CHX performed every 12 hours.
 Application of training session for nurses for one week to meet the expectations of the
project and coordinator work to make adjustments for the successful implementation of
the proposed intervention
Do: In this step, the plan will be executed where the ICU oral care through CHX will be preformed.
The performing of subglottic suctioning, ensuring proper ETT cuff inflation and proper brushing
time for more than two minutes are steps involved in oral hygiene care. Brushes should be used if
required to remove soft debris and visible plaque by using soft brush that makes small circular
movements and clean gums, tongue and palate (Alhazzani et al. 2013).
 CHX oral care is performed by alcohol free solution with 10cc. Squirt 5cc on right side of
mouth between gum and cheeks assuring to get the lower and upper teeth, tongue, and
pharynx and from front to back. Toothette can also be used to reach gums or teeth
through swabbing and suction out pools in the mouth. This step should be repeated on the
left side of the mouth with remaining 55cc and look for if the patient requires nystatin, if
so, CHG should be given 12 hours apart from nystatin (Lorente et al. 2012).
 CHX oral washing should be performed at the zero hours and then again at 12 hours
(Kusahara, Peterlini and Pedreira 2012).
 There should be careful observation by the nurses with proper documentation and
recording of changes, progress achieved and get back on time. Nurses should also ensure
that they are well adhered to the program and nurse leader should help them to stay
motivated in the project (Blair and Smith 2012).
Study: There is the observation step where there will be careful monitoring of the intervention
being carried out. The current situation will be observed to look if the intervention is running
smoothly along with observed barriers and scope for improvement in the proposed project.
The reduction rates of VAP and prevention among critically ill patients in ICUs and observe their
willingness and performance of nurses while conducting CHX oral care.