Statement of Health Problem
Nosocomial pneumonia is a bacterial infection that mainly affects patients who are in critical care unit (CCU) because of intubation that promotes entry of oral pathogens into the lungs. In the United States, nosocomial pneumonia ranks second of all nosocomial infections that affect CCU patients. There are three sources of bacterial inoculation for nosocomial pneumonia viz. oral environment, gastric inoculation, and nasopharyngeal bacteria. CCU patients, under intubation, are more susceptible to nosocomial pneumonia because of poor oral health that allows proliferation of virulent pathogens, which move into the lungs through nasal and oral tubes that aid patients in breathing.
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Additionally, the pathogen strains occurring in the oral environment of CCU patients are more virulent than those found in healthy people are. Poor nutrition, compromised immune system, intubation injury, stress, and mucosal desiccation among others factor promote proliferation of bacteria in the oral cavity, which when aspirated into lungs, it causes nosocomial pneumonia (Bopp, Darby, Loftin, and Broscious, 2006, p.2). The current methods involving selective decontamination of the digestive tract with antibiotics poses the risk of these pathogens developing resistance. However, oral hygiene procedures that use antimicrobial agents have the potential of reducing nosocomial infections for intubated patients in CCU settings.
Intended Users of the Policy/Guideline/Practice
The results of the study by Bopp et al. show that oral hygiene for intubated patients administered twice daily using 0.12% chlorhexidine gluconate can significantly reduce cases of nosocomial pneumonia in CCU settings (2006, p. 4). Overall, intubated patients subjected to the standard protocol (oral hygiene with Listerine or hydrogen peroxide) experienced high cases of nosocomial pneumonia relative to patients under 0.12% chlorhexidine gluconate. The procedure is meant for nursing staff attending to patients in CCU at various hospital settings.
The experimental procedure involved intubated patients admitted at hospital CCU as subjects. These patients experience relatively high cases of nosocomial pneumonia than patients admitted in other units or departments. Additionally, poor oral hygiene and the oral tubes that aid breathing in intubated patients promote the entry and proliferation of bacteria in the lungs increasing the pneumonia risk. The procedure targets intubated patients with complex conditions at CCU units who are more prone to bacterial infection. Patients with complex and multiple conditions at CCU are the prime target population of this procedure.
The objective of Bopp et al. study was to explore the potential of daily oral care with 0.12% Chlorhexidine Gluconate protocol in reducing pneumonia risk in intubated patients under hospital CCU (2006, p. 3). The study aimed at collecting data to support this protocol relative to the standard protocol. The objective of the protocol was to reduce the rate of nosocomial pneumonia in patients with complex conditions and under intubation at CCU settings.
Proposed outcomes from recommendations or practice change
The results of the pilot study by Bopp et al. indicated that, almost a third of the patients subjected to the standard protocol, and discharged from the hospital CCU were diagnosed with nosocomial pneumonia (2006, p. 5). However, the experimental group subjected to two-daily 0.12% Chlorhexidine Gluconate oral care did not suffer from nosocomial pneumonia afterwards. Based on the findings, the researchers recommend the 0.12% Chlorhexidine Gluconate oral care, as an effective approach for the reduction of nosocomial pneumonia in patients admitted at CCU hospital settings. Additionally, the researchers recommend that future studies of the procedure (0.12 Chlorhexidine Gluconate oral care) be conducted across multiple hospital settings besides the CCU and involve a larger sample size to enhance the validity of the results.
They recommend that the inclusion criteria for future studies involve patients with less severe conditions to increase the number of participants and consequently enhance the validity and reliability of the results. Future research should also involve a coordinator based at the hospital departments or units under study to facilitate the selection of subjects. With regard to the procedure, the researchers recommend a further investigation into the application of the 0.12% chlorhexidine gluconate in before operations to reduce nosocomial pneumonia. The results of this study were inconclusive with regard to the specified mechanism by which the procedure resulted to a reduction in nosocomial pneumonia. They recommend a further research to establish whether the reduction was entirely due to chlorhexidine protocol, or the removal of mouth secretions and debris by the Oral Evacuator Brush used in the procedure.
Interventions/Practices being addressed
The nosocomial pneumonia is caused by pathogen of the nasopharyngeal, the oral environment, and the gastric pathogens. In CCU patients, these organisms gain entry into the body from the CCU environment through the nasal and oral tubes that aid patient breathing causing pneumonia. To prevent this, a number of procedures are used: for instance, decontamination with antimicrobial agents, rigorous hand washing by the nursing staff, semi-Fowler patient positioning, and extubation. The research addresses oral hygiene as another strategy of reducing nosocomial pneumonia. In particular, the two-daily 0.12% chlorhexidine gluconate based oral hygiene of intubated patients is investigated as having potential benefits over the standard Listerine or hydrogen peroxide based protocol.
Another major focus of the research involved the efficacy of the chlorhexidine protocol in reducing nosocomial pneumonia by comparing it with the standard protocol. Not all the subjects under the chlorhexidine protocol suffered nosocomial pneumonia infection after discharge from CCU. However, a third of the control group suffered pneumonia after discharge from CUU. This indicates that, the chlorhexidine protocol is more effective compared to the standard protocol or other decontamination procedures in reducing nosocomial pneumonia. This study intended to inform the nursing staff about the importance of chlorhexidine oral hygiene care on CCU patients as an effective pneumonia reduction strategy.
Description of the evidence collection method
The sample for this study comprised of intubed patients in CCU settings. All participants were of Caucasian descent with the majority of the subjects being female (n=3). Many of the subjects were 50 or older, an age group more vulnerable to pneumonia. Overall, the average age of the control group was higher than that of the experimental group. The study was conducted within a span of 7 months with each patient into the CCU eligible for participation. However, this was subject to ethical considerations, legal issues, and informed consent.
After admission, further screening was conducted to evaluate the associated risks and the subjects’ decision to participate in the study. The inclusion criteria involved patients, not under metronidazole medication, is non-allergic to chlorhexidine gluconate, has no history of heart disease, rheumatic fever, endocaeditis, joint problems, or cardiomyopathy. Eligible patients were also required to be healthy, not suffering from diabetes, hemophilia, erythematosus, and sickle cell anemia. They were also required not to have been under intubation in CCU settings before. Twenty patients met these requirements and subsequently participated in the study. Subsequently, the subjects were placed into two groups: the control and experimental group. The experimental group underwent twice-daily chlorhexidine protocol during the intubation duration. On the other hand, the patients in the control group were subjected to the standard care during their intubation period. The experimental group received the 0.12% chlorhexidine oral care twice daily while the control group received the standard care six times daily. The results were collected after discharge of patients from intubation.
Summary of the study
The aim of the research was to evaluate the effectiveness of the 0.12% chlorhexidine gluconate in reducing the rates of nosocomial pneumonia, relative in intubated patients, in hospital CCUs relative to the standard protocol. The methods for this pilot study involved identification and screening of the subjects (CUU patients) followed by randomized grouping into two categories: control and experimental groups. In duration of seven months, each group received a different treatment; the control group that comprised of three CCU patients received a standard protocol of hydrogen hydroxide based oral care while the experimental group received a twice-daily 0.12 % chlorhexidine gluconate oral care throughout their intubation period. This involved the use of an Oral Evacuator brush. The nursing staff performed both the standard and chlorhexidine protocols during each subject’s intubation period.
After discharge, the results indicated that of the two subjects of the experimental group neither developed pneumonia. However, one subject of the three subjects of the control group developed nosocomial pneumonia after discharge. From these results, the authors concluded that a 0.12% chlorhexidine gluconate administered twice daily has the potential of reducing the rates of nosocomial pneumonia. However, the small sample size used could not produce reliable and valid results.
The study design for Bopp et al. study involved a randomized two-group (control and experimental) research design (2006, p. 4). The independent variables for this study included the standard oral hygiene protocol administered six times a day to the control group, and the 0.12% chlorhexidine gluconate oral hygiene administered twice a day to the experimental group. The nursing staff administered these oral care protocols. The measurable outcome for this study was the rate of nosocomial pneumonia between the two groups as recorded in charts. The small sample size of five subjects necessitated a case study survey towards the final stages of the study, which involved a descriptive analysis of the patient data of the five subjects.
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Research Purpose, Research Question, and Hypothesis
The major purpose of this research study was to compare the effectiveness of a six-time daily standard oral hygiene, and the twice-daily 0.12% chlorhexidine gluconate oral care in reducing nosocomial pneumonia rates for patients in CCU. The research question for the study was; what is the efficacy of the 0.12% chlorhexidine gluconate oral care procedure, administered twice daily, in reducing the rates of nosocomial pneumonia among CCU patients compared to the standard oral hygiene protocol administered six times a day?
The research hypothesis for the study was; CCU patients who receive the 0.12% chlorhexidine gluconate oral care twice daily (i.e. the experimental group) will have a low likelihood of developing nosocomial pneumonia relative to the control group. However, the small sample size could not allow testing of this hypothesis.
Data Collection, Data Analysis, and Findings
The nursing staff participated in the administration of the oral hygiene procedures (twice-daily chlorhexidine protocol and the standard protocol) and collection of data from the two groups. The data collected primarily involved the adverse effects of the protocols to the study subjects and a record of the administration of the oral hygiene protocols. A principal investigator coordinated the administration of the oral hygiene procedures and the monitored the patient record kept by the nursing staff.
Given the small sample size in the study, a descriptive data analysis was used. This involved the use of measures of central tendency, percentages, and frequencies. Overall, 60% of the subjects were female while 40% were male. Majority of the subjects (60%) were 60 years and above. The study found out that the 0.12% chlorhexidine gluconate administered twice daily could reduce nosocomial pneumonia for CCU patients.
Strengths and Weaknesses of the Article
|Strength||The use of a stringent exclusionary criteria in recruiting the subjects|
|Explanation||The inclusion of patients intubated under CCU settings for longer periods ensured that they were exposed to bacteria colonization from the CCU environment. The prime objective of the study was to establish the effectiveness of the chlorhedixine protocol relative to the standard protocol in reducing pneumonia in patients admitted to CCU. Thus, the inclusion of patients with long intubation period was appropriate in this case.|
|Strength||The randomized two-group experimental design|
|Explanation||This alleviated bias in the selection of the subjects into either group. Additionally, it enhanced the descriptive analysis and data validity. To avoid subjectivity in experimental design, a randomized design is necessary.|
|Strength||The requirement for informed consent of the subjects participating in this research study|
|Explanation||In the study, the subjects had to provide an informed consent or get approval of a legal representative prior to participating in the research. In health research, involving human subjects, the trustworthiness and validity of the results requires consent of the participant (s) (Fortun, West, Chalkley, Shonde, & Hawkey, 2008, p. 626). The subjects must be made aware of the potential risks associated with the research relative to the benefits. In Bopp et al. study, the subjects had to give informed consent before participating in the research. Additionally, a legally authorised health representative was allowed to decide on behalf of the patient.|
|Strength||The data collection and analysis methods used|
|Explanation||The study involved the principal investigator and the nursing staff. The involvement of nurses in data collection and keeping the demographic data was particularly significant because of the optimal and individualized nature of nursing care. The nurses were at a better position to observe changes in patient condition than the physicians were.|
|Limitation||The study subjects comprised of 100% Caucasian CCU patients|
|Explanation||The two study groups; that is, control and experimental groups comprised of subjects of Caucasian background. This limited the scope of the study and thus affected the applicability of the procedure across the ethnic/racial groups.|
|Limitation||The use of a small sample size in the study|
|Explanation||Only five subjects took part in the case study. This affected the credibility and validity of the data collected. Consequently, the results were inconclusive owing to the limited sample size.|
|Limitation||Limitation The majority of the participants were of advanced age with a mean age of 73.2 years for the control group and 60 years for the experimental group.|
|Explanation||The involvement of older subjects presumably as the vulnerable group means that the conclusions/recommendations cannot apply to younger CCU patients.|
|Limitation||Lack of a clear mechanism by which the 0.12% chlorhexadine gluconate reduces nasocomial pneumonia|
|Explanation||Due to the limited sample size, no enough tests were performed to establish whether the reduction of the rates of pneumonia was due to the Oral Evacuator brush, or the 0.12% chlorhexadine gluconate oral care protocol|
Bopp, M., Darby, M., Loftin, K., & Broscious, S. (2006). Effects of Daily Oral Care with 0.12% Chlorhexidine Gluconate and a Standard Oral Care Protocol on the Development of Nosocomial Pneumonia in Intubated Patients: A Pilot Study. Journal of Dental Hygiene, 80(3), 1-11.
Fortun, P., West, J., Chalkley, L., Shonde, A. & Hawkey, C. (2008). Recall of informed Consent information by healthy volunteers in clinical trials. QJM: Monthly Journal Of the Association of Physician, 101(6), 625-629.