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Review of the Literature

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Ames, N. J. (2011). Evidence to support tooth brushing in critically ill patients. American Journal of Critical Care, 20 (3): 242-50.

Article Summary:

The author explores the relationship between oral health and terminal illness. According to Anes, tooth brushing should be a basic care practice among terminally ill patients. The focus was on the impacts of oral microbiome and respiratory pathogens that causes respiratory infections.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The study is based on case studies, whereby the author explores the effectiveness of tooth brushing. The study summarizes various cases that explore the effectiveness of tooth brushing among critically ill patients, particularly those under mechanical ventilation. The study established that oral microbiome promotes respiratory pathogens. Results published in the article can be applied in evidence-based practice.

Berry, A. M., Davidson, P. M., Masters, J., & Rolls, K. (2007). Systematic literature review of the oral hygiene practices for intensive care patients receiving mechanical ventilation. American journal of critical care, 16(6), 552-562.

Article Summary:

This article appraises other peer-reviewed literature with the intention of establishing the best available evidence. The author evaluated 55 articles, which included 20 observational studies, 11 controlled trials, 24 descriptive reports. Keywords used to retrieve the literature included oral hygiene practices, oral hygiene, oral care, mechanical ventilation, and critical care, intensive care.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The study found insignificant evidence from randomized clinical trials for evidence based practice. Since the study population included terminally ill patients, some participants were extebated to establish the link between oral health and respiratory infection. This is the most outstanding element of this research. Unfortunately, the article does not account for accessibility to oral health among intebated patients.

Cason, C.L., Tyner, T., Saunders, S., & Broome, L. (2007). Nurses' implementation of guidelines for ventilator-associated pneumonia from the Centers for Disease Control and Prevention. American Journal of Critical Care, 16 (1): 28-38.

Article Summary:

The study intended to “identify the gap between what is known and what nurses report as their care practices” (Cason, Tyner, Saunders, & Broome, 2007, p. 31). The authors hoped to develop well thought guidelines for evaluation and improvement of the healthcare system. The study was conducted through “cross-sectional survey of nurses who attended either the 2005 American Associated of Critical-Care Nurses National Teaching Institute (NTI) or selected training programs offered by Barbara Clark Mims Associates (BCMA)” (Cason et al., p. 31).

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The study population included intensive care nurses with patients under mechanical ventilation. The researchers identified the following independent variables presence or absence of a hospital protocol, gender, age, critical care certification, and care experience in years, academic qualification hospital size. The study established that “18% of nurses reported not always washing their hands between patients and 23% reported not using gloves when providing oral care” (Cason et al., p. 35). The main limitation of the study is that the credibility of the surveys utilized in the study cannot be assessed. Lastly, the article is based on self-reported and estimated results.

Chao, Y., Chen, Y., Wang, K., Lee, R., & Tsai, H. (2009). Removal of oral secretion prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: A clinical controlled trial study. Journal of Clinical Nursing, 18(1), 22-28.

Article Summary:

The study wanted to establish the role of oral secretions in reducing ventilator associated pneumonia (Chao, Chen, Wang, Lee, & Tsai, 2009, p. 22). The research established that, “removal of oral secretions prior to position change can reduce the incidence of ventilator associated-pneumonia for adult ICU patients” (Chao et. al., 2009, p. 22).

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

Study population included adults (above 18 years) who had been in artificial ventilation for over 24 hours. Study results proved that removal of oral secretion prior to the ventilation exercise reduced cases of ventilator-associated pneumonia. The main strength of the article is that it uses certified test results and hence applicable in evidence based practice.

Cutler, C.J., & Davis, N. (2005). Improving oral care in patients receiving mechanical ventilation. American Journal of Critical Care, 14 (5): 389-94.

Article Summary:

The study was meant to develop guidelines for critical care nurses to differentiate between hospital-acquired pneumonia (HAP) and ventilator –associated pneumonia (VAP). The study population was identified from terminally ill patients who were at risk of developing HAP and/or VAP. The guidelines were also meant to distinguish various diagnostic and evaluation techniques. The guidelines summarizes relevant topic in oral health and prevention of VAP. The study advocates for continued use of oral antiseptic in reducing VAP. 

Feider, L.L., Mitchell, P., & Bridges, E. (2010). Oral care practices for orally intubated critically ill adults. American Journal of Critical Care, 19 (2): 175-83.

Article Summary:

The article seeks to illustrate oral care practices carried out by critical care nurses for orally intubated terminally ill patients. The researcher also wanted to check the compliance of these practice with oral care health recommendations published in the CDC guidelines and AACN Procedure Manual for Critical Care18 (Feider, Mitchell, & Bridges, 2010, p.176).

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The researchers utilized descriptive cross-sectional techniques alongside Web-based surveys on demographics and oral care assessments. Study sample was drawn randomly from American Association of Critical-Care Nurses (AACN) members. The study showed existence of inconsistency between reported and practiced oral healthcare. The study also showed disparity of performance between experienced and less experienced caring nurse. Indeed, the study utilizes credible information and provides sufficient details. Research results can be utilized to measure the effectiveness of foam swabs.

Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing ventilator-associated pneumonia through advanced oral-dental care. American Journal of Critical Care, 18 (6): 523-32.

Article Summary:

The study seeks to establish the “effect of implementing a comprehensive oral and dental care system and protocol on the rate of ventilator-associated pneumonia” (Garcia et al., 2009, p.523). Study population comprised of students from affiliated universities and patients under artificial ventilation for over 48 hours.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

Study variables included LOS, protocol compliance among staff, VAP rate and ventilation duration. The study established that the implementation of oral care protocol to decrease bacterial colonization and ventilator-associated pneumonia. The study utilized non-randomized design and, therefore, its results and recommendation can be applied in evidence-based practice.   

Grap, M.J. (2009). Not-so-trivial pursuit: Mechanical ventilation risk reduction. American Journal of Critical Care, 18 (4): 299-309.

Article Summary:

The study reviews programs intended to reduce the risks associated with mechanical ventilation. In particular the study analyze “risks related to airway management practices, prevention of ventilator-associated pneumonia (VAP, particularly via positioning and oral care interventions), and sedation issues” (Grap, 2009 p. 300). Airway management practices have significant impacts on the outcomes of intensive care patients particular those that are under mechanical ventilation. Types of sanctions, duration, and number of process determine the quality of the process.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The study population included 100 caring nurses selected from intensive care units around the country. The study concluded that reducing risks associated with mechanical ventilation in terminally ill patients is a complex issue that requires an interdisciplinary approach.

Munro, C., Grap, M., Jones, D., McClish, D., & Sessler, C. (2009). Chlorhexidine, tooth brushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care, 18(5), 428-438.

Article Summary:

The study intended “to test the effects of tooth brushing and/or chlorhexidine in reducing the risk for VAP in adult ICU patients receiving mechanical ventilation” (Munro et al., 2009, p.429). Study population included 547 patients under mechanical ventilation. The patients were selected from trauma ICUs at Virginia Commonwealth University Medical Center. Independent variables for the study included chlorhexidine gluconate (taken from oral swab twice a day), tooth brushing (three times a day), and chlorhexidine-enhanced tooth brushing (every 12 hours).

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The study utilized a 2x2 factorial experimental design. Data for the study was collected from Clinical Pulmonary Infection Score (CPIS) for each of the following quantities; temperature, WBC counts, chest radiograph results, tracheal secretions, oxygenation. Although the study utilizes incredible techniques, extubation or uncontainable attrition due to death lowers its validity.

O'Keefe-McCarthy, S. (2006). Evidence-based nursing strategies to prevent ventilator-acquired pneumonia. Dynamics, 17 (1): 8-11.

Article Summary:

Patients under mechanical ventilation are at risk of acquiring ventilator-associated pneumonia. Critical care nurses assisting intubated patients need to adopt measures to prevent VAP within their protocol. The article analyzes risk factors under –the current VAP prevention strategies.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

Participants of the research were drawn from student population of universities that are affiliated to care centers around the country. The researcher sought to establish the level of awareness among practicing student in regards to oral health among critically ill patients. In conclusion, the article advocates for the implementation evidence-based oral care protocols in clinical practices to counter VAP prevalence.

Roberts, N., & Moule, P. (2011). Chlorhexidine and tooth brushing as prevention strategies in reducing ventilator-associated pneumonia rates. Nursing in Critical Care, 16 (6): 295-302.

Article Summary:

The study sought to establish the impacts of CHX or CHX/COL decontamination on VAP development. The study utilized randomized surveys, which selected their participants from consecutive patients who had been under mechanized ventilation for periods exceeding 48 hours.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

Test medication was administered every six hours through the buccal cavity. Quantitative analysis of Oropharyngeal swabs was also conducted to determine gram-negative and positive pathogens. Study results showed a decline in VAP risk in the study population. With CHX or CHX/COL, oral sanitization reduces VAP proliferation.

Sedwick, M., Beth, L., Mary, R., Sara, J., & Nardi, J. (2012). Using evidence-based practice to prevent ventilator-associated pneumonia. Critical Care Nurse, 32 (4): 41-51.

Article Summary:

The article explores practices aimed at controlling ventilator-associated pneumonia. Ideally, the author intended to develop a care guide for nurses working in critical care units. The ventilator bundle was developed to incorporate hand washing and mouth care protocols.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The study established that compliance rates that were above 98% reduced the risk of ventilator-related pneumonia. Consequently, ventilator-associated pneumonia cases decreased from 9,47 to 1,9 cases for every 1000 ventilator-days. The rate would save approximately $1,5 million in medical bills. The research proposes strict adherence bundled practices for the prevention of ventilator-associated pneumonia. The article also proposes controlled protocols and use of electronic feedback mechanism.

Soh, K. L., Soh, K.G., Japar, S., Raman, R. A., Davidson, P.M. (2011). A cross-sectional study on nurses' oral care practice for mechanically ventilated patients in Malaysia. Journal of Clinical Nursing, 20 (5/6): 733-42.

Article Summary:

The study wanted to establish methods, strategies, and frequency of oral healthcare provided to Malaysian ICU patients under mechanical ventilation. The study also evaluates nurses’ attitude and knowledge of propagation of VAP. The study used a cross sectional design to conduct surveys and clinical observations. Trained nurses conducted observational studies over a three-week period.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

Study participants included trained nurses working in intensive care clinics. Among the 284 participants selected for the study, 90% had positive attitude towards providing oral care for terminally ill patients. The participant advocated or preferred cotton and forceps in oral cleaning to toothbrushes. The study identifies lack of adherence to evidence-based practice among practicing nurses. If implemented, results from the study will transform provision of oral health care among ICU patients.  

Vincent, J. L., Barros. S, S., & Cianferoni, S. (2010). Diagnosis, management, and Prevention of Ventilator associated pneumonia and update. Adis data information, 70(15), 1927-1940.

Article Summary:

The study provides a review of diagnostic and management techniques used to control VAP. According to the authors, modern diagnostic and management practices need to be reviewed.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

Through qualitative surveys, the researcher sought to establish the level of suspicion VAP proliferation among practicing nurses. If implemented, preventive and diagnostic techniques illustrated in the article will lower operation costs in intensive care centers. Consequently, the results would improve outcomes for ICU mechanically ventilated patients.

Yeung, K., & Chui, Y. (2010). An exploration of factors affecting Hong Kong ICU nurses in providing oral care. Journal of Clinical Nursing, 19(21/22), 3063-3072.

Article Summary:

The study evaluates the role of toothbrishing and use of tropical antimicrobials in the improvement of oral health among critically ill patients. Therefore, the study intended to establish the type and frequency of different oral care practices applied in ICUs.

Research Elements: Methods, Research Results, Strengths, Limitations, Importance:

The study utilized surveys from randomly selected ICU nurses in US hospitals. The study was qualitative and it sought to establish beliefs, knowledge, and attitude of intensive care nurses in relation to oral health. Among the 102 participants, 92% supported oral care as a measure against ventilator related pneumonia. Majority of the respondent (nurses), advocated for research proven oral care standards and practices. The main weakness in the study is that it utilized random samples and oral methods that do not correspond with modern oral care protocols

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