Background
Admission of patients into the intensive care unit (ICU) is a common health practice worldwide. In the US alone, over 5 million people were admitted to the ICU (Suljevic et al., 2020). Patients in the ICU are provided with specialized care that requires close monitoring of medications and equipment. Because most of the patients are unconscious due to either sedating medications or severe disease, they require close monitoring to stabilize all body systems to improve outcomes. As a result, ICU patients require life-saving invasive procedures aimed at stabilization. Among the common procedures include central lines, urinary catheters, endotracheal intubation, tracheostomy, feeding tubes, and cardiac monitors (Suljevic et al., 2020). Ironically, despite these procedures being paramount in saving lives, they contribute to infections and other complications that are major contributors to death. For instance, catheters are associated with catheter-associated urinary tract infections (CAUTIs); central lines cause central line-associated bloodstream infection, while mechanical ventilators are associated with mechanical ventilators (VAP).
The presence of VAP or either of the infections in ICU patients complicates their clinical outcomes while increasing the risk of mortality and morbidity and increasing the cost of care. Therefore, preventing the incidence of such infections remains a priority issue in health care. Some of the nurse-led evidence-based practice preventive measures include encouraging early ambulation, hourly turning, installation of orotracheal as opposed to nasotracheal tubes, spontaneous breathing trials, sedation, head elevation, staff education, infection surveillance, and prophylaxis for stress ulcers and venous thromboembolism (Xu et al., 2019). These methods have helped in reducing the incidents of VAP but are not sufficient. The need to improve patient outcomes has led to various pieces of research using chlorohexidine (CHG) mouthwash to evaluate its effectiveness in preventing VAP while improving patient outcomes. There have been mixed findings from evidence. Most studies have proposed using CHG to prevent VAP and other infections, while some show contradictory results. Therefore, in my quest to understand the subject matter, I decided to undertake this project to find more evidence that will help in improving patient outcomes. This paper will address the following: problem statement, PICOT statement, the purpose of the change proposal, literature search strategy, literature evaluation, and barriers to implementation, as well as how to overcome them.
Clinical Problem Statement
By definition, VAP is a lower respiratory tract disorder that develops within 48 hours or more of being on mechanical ventilation in a patient who originally did not have the condition. VAP is among the most common nosocomial infections in ICU, accounting for 9 to 27% of all infections in the ICU. It is the second commonest hospital-acquired infection (HAI) after CAUTIs (Xu et al., 2019). Because up to 300,000 patients admitted to the ICU require mechanical ventilation to support breathing and necessitate gaseous exchange, up to 20% of all VAP associated with mechanical ventilators is the major risk factor (Suljevic et al., 2020). The ventilators act as a breach in the natural immunity that allows bacteria and other micro-organisms to access the lower respiratory tract and multiply to cause VAP. In addition, intubation compromises the integrity of the trachea and oropharynx, allowing oral and gastric secretions to access the respiratory tract, leading to irritation that further increases the risk of VAP. The incidences of VAP increase with the duration of ventilation, with an estimated rate of 3% in the first days, 2% per day between days 6 and 10, and 1% per day after day 10 (Suljevic et al., 2020). Notably, an infection caused by Pseudomonas contributes to crude mortality of 27 to 67% with VAP, which is higher than all other bacteria except for actinobacteria (Xu et al., 2019). In addition to mechanical ventilation, other risk factors combine to increase the risk, such as advanced age, immobilization, supine position, immunosuppression, and increased ICU stay.
Various microorganisms are implicated in the pathophysiology of VAP. Both gram-positive and gram-negative bacteria can colonize the lower respiratory tract, multiply, and cause pneumonia (Kohbodi et al., 2022). Comparing the timing of infection, early-onset VAP is associated with drug-sensitive bacteria, while late-onset VAP is associated with drug-resistant bacteria. Drug resistance pneumonia is difficult to treat and impairs patient outcomes. Furthermore, VAP increases the risk of mortality and morbidity for those who survive
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