Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)

Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)


Mechanical ventilation is a life-saving measure utilized when the respiratory status of a critically ill patient has become compromised.  Ventilator-Associated Pneumonia (VAP) is a complication of mechanical ventilation.  This paper will discuss oral care practices and their aid in the prevention of Ventilator-Associated Pneumonia.  This is examined using three research studies discussing the effects of oral care practices in the prevention of Ventilator-Associated Pneumonia.   Findings will provide information regarding oral care practices among nurses and if such practices reduce the incidence of Ventilator Associated Pneumonia.


Oral Care Practices and the Prevention of Ventilator-Associated Pneumonia

“Ventilator-associated pneumonia (VAP) is defined as pneumonia in patients receiving mechanical ventilation that was neither present nor developing at the time of intubation” (Munro, Grip, Jones, McLeish, & Sesser, 2009, p.429). According to Munro et al (2009), VAP is associated with increased mortality, hospital length of stay, and health care costs.  Among ventilated patients prevalence rates of VAP are consistently in the 10% to 20% range and mortality rates in the intensive care unit (ICU) are two to three times greater in patients with VAP.  Estimates of healthcare costs for individuals with VAP ranges from $11, 897 to $150,000.  Oral health can be compromised by critical illness, mechanical ventilation, and is influenced by nursing care (Munro, Grip, Keswick, McKinney, Sesser, & Hummel, 2006).

Working in the critical care unit, I frequently care for ventilated patients.  In our unit, we incorporate the use of the VAP bundle to improve patient outcomes and to prevent VAP.  This bundle includes using Sage Oral Care Kits and Chlorhexidine, as well as elevating the head of the bed thirty degrees or more, using oral gastric tubes over nasogastric tubes, deep vein thrombosis (DVT) prophylaxis, peptic ulcer disease (PUD) prophylaxis and daily sedation awakening (sedation vacation).  In addition many of the critical care physicians use a subglottic evacuation endotracheal tube when intubating patients.

According to Munro et al (2009), many risk factors for VAP have been identified.  Major ones include poor hand washing by staff, supine positioning of patients without backrest elevation, previous antibiotic therapy, presence of a nasogastric tube, and gastric alkalization.  The interventions include elevating the head of the bed 30 degrees or more, peptic ulcer disease (PUD) prophylaxis, deep vein thrombosis (DVT) prophylaxis, daily sedation awakening, and the assessment of readiness to extubate.

Another risk factor for VAP, according to Munro et al (2009) is the colonization of the oropharynx by potential pathogens.  These pathogens include Staphylococcus aureus, Streptococcus pneumonia, or gram-negative rods.  “The major route for acquiring endemic VAP is oropharyngeal colonization by endogenous flora or by pathogens acquired exogenously from the intensive care unit environment…” (Garcia et al, 2009, p. 524).

In this first research study, illustrated by Garcia et al (2009), patients at least 18 years old were admitted between January 1, 2001, and December 31, 2004, to a 10-bed medical intensive care unit (MICU).  These patients were eligible for the study if they were intubated for more than 48 hours. Patients in the study were followed up for VAP occurrence until they were weaned off mechanical ventilation in the MICU, for 48 hours after their transfer, or until they died.  The standards of care for all patients during the 48-month study period included changes in the ventilator circuit every 7 days, replacement of the heat moisture exchange every 24 hours,  a closed suctioning system, head of bed 30 degrees of more, peptic ulcer disease prophylaxis, and an active weaning protocol.  Oral Chlorhexidine was not used in this study.

During the intervention phase between January 1, 2003 and December 31, 2004, a comprehensive oral and dental care system was implemented (Garcia et al, 2009).  This system reduces secretions that accumulate in the oral cavity after the introduction of the endotracheal tube and reduce plaque on the surface of the teeth.  The protocol for the system included oropharyngeal suctioning every 6 hours, oral cleaning of the tissue and gums every 4 hours or as needed, and tooth brushing twice a day.  The outcome measures were as follows:  During the intervention, VAP rates decreased by 33.3%.  Both duration of mechanical ventilation and length of stay decreased after implementation of an oral care regimen.

Garcia et al (2009) found the 48-month study yielded 4 important findings:

  • Risk and incidence of VAP are significantly reduced by the implementation of a multifaceted protocol that includes daily oral assessment combined with procedures and tools specifically designated for bacterial reduction in the oral cavity, subglottic space, and on teeth, and conducted on a daily schedule; (2) infection avoidance can be sustained for considerable periods; (3) despite the establishment of other evidence-based interventions such as elevation of the head of the bed and prophylaxis of stress ulcers, VAP rates of zero did not occur until the new protocol was instituted; (4) a comprehensive oral-dental program has profound effects of reducing the duration of mechanical ventilation (from 7.2 days to 5.1 days) (p.529).

In this study, it would have been beneficial to see the results on random patients.   The types of patients admitted to the intensive care unit can vary and there can be extenuating circumstances such as an emergent intubation.  Overall though, the findings of this study support that an oral care regiment reduces and prevents VAP.

The second research study shows insight in the prevention of VAP using Chlorhexidine and tooth brushing.  In this research study, Munro et al (2009) tested the effect of each individual intervention using Chlorhexidine alone and tooth brushing alone. Chlorhexidine is a broad spectrum antibacterial agent that is used in healthy populations to control dental plaque and prevent gingivitis.  Patients were older than 18 years in medical, surgical/trauma/ and neuroscience ICU’s.  Patients receiving mechanical ventilation were enrolled within 24 hours of intubation and those with preexisting pneumonia were excluded.  “Patients were randomly assigned to 1 to 4 treatments:  a 0.12% solution of Chlorhexidine 5 ml by oral swab twice daily, tooth brushing 3 times a day, combination care (tooth brushing 3 times a day and Chlorhexidine every 12 hours), or control (usual care)”  (Munro et al, 2009, p.430).  According to Munro et al (2009), every patient’s mouth was divided into four quadrants (right upper, right lower, left upper, left lower), and each quadrant was brushed in a defined pattern.  This pattern included every quadrant and tooth brushed for 5 strokes on lingual, buccal, and biting services.  Chlorhexidine was applied in a defined pattern by using a green Toothette swab to evenly coat each tooth, tongue and palette.

Munro et al (2009) found that Chlorhexidine oral swabbing was effective in reducing early VAP.  Tooth brushing did not reduce the incidence of VAP and the combination of Chlorhexidine and tooth brushing did not provide any additional benefit.  I found this study to be beneficial in supporting the use of Chlorhexidine in an oral care regiment.  At my place of employment in the intensive care units, the facilitation of Chlorhexidine is incorporated with the VAP Bundle.

The third research study includes research on oral comfort and hygiene measures.  This article focuses on the impact of nursing care and the prevention of VAP.  At the time of this article no comprehensive guidelines existed that defined the method and frequency of oral care.  Practices varied from site to site.  “The disparity between what nurses think they do and what is actually documented raises questions about the reliability and the consistency of practice” (Cutler & Davis, 2006, p.390).  Cutler and Davis (2006) found that healthcare settings with specific protocols and procedures facilitated consistency and quality care through standardization.  In this study, observations were made in 8 ICUs, with varying patient diagnoses.  None of the study sites had an oral cleansing protocol that defined frequency and the tools for oral care on patients receiving mechanical ventilation.  According to Cutler and Davis (2006), nurses and respiratory personnel were educated and trained to follow a standardized oral cleansing regimen for all patients receiving mechanical ventilation.  During this period, 24-hour oral kits were mounted on the wall near the patient’s bedside.  Observation of nurses and respiratory staff was conducted.  The observers noted the frequency, tasks, and tools used for oral care.  Also, they recorded the types of oral care cleanser used.  The results concluded that with education to the staff, every aspect of oral care performance increased and VAP decreased significantly among patients (Cutler & Davis, 2006).

I agree with this article in that education among staff helped patients have better outcomes.  In my own professional practice, the nurses and respiratory staff have been educated on effective oral care.  Every month, we have critical care classes that discuss evidence based practice in preventing VAP and other respiratory issues.  These classes stress education in prevention and effective nursing care to provide better outcomes for patients.  Also, the critical care units have an outcomes specialist who provides us with statistics and keeps the nurses up to date on their progress.

After reviewing the three research articles, I found that they support the ideas of the nursing theorist Betty Neuman.  Oral care practices and their role in the prevention of VAP reflect her model of prevention as the primary nursing intervention (“Nursing Theories”, 2010).    Her vision of prevention includes health promotion and maintenance of wellness. Her nursing theory focuses on a “comprehensive flexible holistic and system based perspective for nursing” (“Nursing Theories”, 2010).  Neuman theorized that “prevention focuses on keeping stressors and the stress response from having a detrimental effect on the body” (“Nursing Theories”, 2010).   In addition, Neuman’ theory consists of concentric lines of defense, protecting individuals from negative external and internal variables.  When a patient is mechanically ventilated, their body is put through multiple stressors and oral care interventions are imperative for the prevention of VAP.  Using Neuman’s model system along with nursing interventions can help eliminate the episodic events of VAP, promoting better patient outcomes.

As a critical care nurse, there are ways that I am able to implement VAP prevention.  By being a preceptor in my unit, I can share with new graduates the VAP bundle and the interventions used to prevent VAP.  Also by attending monthly respiratory classes, this will impact my practice by keeping me up to date on the current guidelines in VAP prevention.  In the future, I will focus on educating staff about VAP prevention and future practice and continue my research into effective oral care interventions to ensure better patient outcomes.

Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)









Cutler, C. N., & Davis, N. (2005). Improving oral care in patients receiving mechanical      ventilation. American Journal of Critical Care, 14(5), 389-394.

Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009)

Reducing ventilator-associated pneumonia through advanced oral-dental care:

A 48-month study.  American Journal of Critical Care 18(6), 523-531.

Munro, C.L., Grap, M.J., Elswick, R.K., McKinney, J., Sessler, C. N., & Hummell R. S. (2006).              Oral health Status and development of ventilator-associated pneumonia:  A descriptive

study. American Journal of Critical Care, 15(6), 453-460.

Munro, C. L., Grap, M. J., Jones, D. J., McClish, D. K., & Sessler, C. N. (2009).

Chlorhexidine, tooth brushing, and preventing ventilator-associated pneumonia

in critically ill adults. American Journal of Critical Care, 18(6), 428-437.

doi:  10.4037/ajcc2009792.

Nursing theories a companion to nursing theories and models. 2010, January 16.  Retrieved

from http://www.currentnursing.com/nursing_theory/nursing_theorists.html.






Appendix A

Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP) – Checklist for submitting papers







1. Page Numbers:  Did you number your pages using the automatic functions of your Word program? [p. 230 and example on p. 40)]
2. Running head: Does the Running head: have a small “h”? Is it on every page? Is it less than 50 spaces total? Is the title of the Running head in all caps? Is it 1/2” from the top of your title page? (Should be a few words from the title of your paper). [p. 229 and example on p. 40]
3. Abstract: Make sure your abstract begins on a new page. Is there a label of Abstract and it is centered at the top of the page?  Is it a single paragraph?  Is the paragraph flush with the margin without an indentation?  Is your abstract a summary of your entire paper? Is it written in the past tense?  Remember it is not an introduction to your paper. Someone should be able to read the abstract and know what to find in your paper. [p. 25 and example on p. 41]
4. Introduction: Did you repeat the title of your paper on your first page of content? Do not use ‘Introduction’ as a heading following the title. Do not bold your title.  The first paragraph clearly implies the introduction and no heading is needed. [p. 27 and example on p. 42]
5. Margins: Did you leave 1” on all sides? [p. 229]
6. Double-spacing: Did you double-space throughout? No triple or extra spaces between sections or paragraphs except in special circumstances. This includes the reference page. [p. 229 and example on p. 40-59]
7. Line Length and Alignment: Did you use the flush-left style, and leave the right margin uneven, or ragged? [p. 229]
8. Paragraphs and Indentation: Did you indent the first line of every paragraph?  See P. 229 for exceptions.
 Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
10. Typeface: Did you use Times Roman 12-point font throughout, even in your header? [p. 228]
 Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
11. Plagiarism: Cite all sources! If you say something that is not your original idea, it must be cited. DO NOT COPY THE EXAMPLE AND USE IT AS YOUR OWN!  You may be citing many times…this is what you are supposed to be doing!  Is there a citation for every paragraph? [p. 170]
12. Direct Quote: A direct quote is exact words taken from another. An example with citation would look like this:

“The variables that impact the etiology and the human response to various disease states will be explored” (Bell-Scriber, 2007, p.1).

Please note where the quotation marks are placed, where the final period is placed, no first name of author, and inclusion of page number, etc. Do all direct quotes look like this, except for block quotes? [p. 170-172]

13. Quotes Over 40 Words: Did you make block quotes out of any direct quotes that are 40 words or longer? Did you place the period after the text rather than after the citation? [p. 170-172]
14. Paraphrase: A paraphrase citation would look like this:

Patients respond to illnesses in various ways depending on a number of factors that will be explored (Bell-Scriber, 2007). Do all paraphrased citations look like this? [p. 171 and multiple examples in text on p. 40-59]

15. Headings: Did you check your headings for proper levels and format? [p. 62-63].
16. General Guidelines for References: Do not bold the word References!

A. Did you start the References on a new page? [p. 37]

B. Did you cut and paste references on your reference page? If so, check to make sure they are in correct APA format. Often they are not and must be adapted. Make sure all fonts are the same.

C. Is your reference list double spaced with hanging indents? [p. 37]



13. Did you follow the assignment rubric? Did you make headings that address each major section? (Required to point out where you addressed each section.)
14. Watch for run-on or long, cumbersome sentences. Read it out loud without pausing unless punctuation is present. If you become breathless or it doesn’t make sense, you need to rephrase or break the sentence into 2 or more smaller sentences. Did you do this?
15. Wordiness: check for the words “that”, and “the”. Don’t use the terms ‘I feel’ or ‘I think’.  If not necessary, did you omit? Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
16. Conversational tone: Don’t write as if you are talking to someone in a casual way. For example, “Well so I couldn’t believe nurses did such things!” or “I was in total shock over that.” Did you stay in a formal/professional tone?
17. Avoid contractions. i.e. don’t, can’t, won’t, etc. Did you spell these out?
18. Did you check to make sure there are no hyphens and broken words in the right margin?
19. Do not use “etc.” or “i.e.” in formal writing unless in parenthesis. Did you check for improper use of etc. & i.e.?
20. Stay in subject agreement. When referring to 1 nurse, don’t refer to the nurse as “they” or “them”. Also, in referring to a human, don’t refer to the person as “that”, but rather “who”. For example: The nurse that gave the injection….” Should be “The nurse who gave the injection…” Did you check for subject agreement? Likewise, don’t refer to “us”, “we”, “our”, within the paper…this is not about you and me. Be clear in identifying. For example don’t say “Our profession uses empirical data to support ….” . Instead say “The nursing profession uses empirical data…..
21. Did you check your sentences to make sure you did not end them with a preposition? For example, “I witnessed activities that I was not happy with.” Instead, “I witnessed activities with which I was not happy.”
22. Did you run a Spellcheck? Did you proofread in addition to running the Spellcheck? Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)
23. Did you have other people read your paper? Did they find any areas confusing?
24. Did you include a summary or conclusion heading and section to wrap up your paper?
25. Do not use “we” “us” “our” “you” “I” etc. in a formal paper! Did you remove these words?  Only use these if you are the subject of your paper.
26. Does your paper have sentence fragments? Do you have complete sentences?
27.  Did you check apostrophes for correct possessive use. Don’t use apostrophes unless it is showing possession and then be sure it is in the correct location.  The exception is with the word it.  It’s = it is.  Its is possessive.
28. Did you use proper punctuation, particularly commas?  If you are unsure of when to use them, please contact the writing center.


Signing below indicates you have proofread your paper for the errors in the checklist:

Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP) Grading Rubric

Name: _________________________________


Clear Introductory Description of Practice Concern/Interest: Describes reason for interest or concern and description of issue. 10 10
Practice Environment:

Provides clear description of practice area.

Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)

5 5
Causal Factors:  Personal Perspective and Description/Analysis of Possible Contributing or Causative Factors for the Concern 10 10
Defined Area of Research Search: Narrows down and defines a specific area for research review and provides a clear statement of same. 5 5


Research Findings: Shares the findings of a minimum of 3 original research studies from professional journals on the selected topic. Briefly describes the research approaches and findings of each.  


Critique of the Research: Attempts to point out any research limitations/credibility of the studies. 5 5
Implications For Practice: Identifies potential practice implications of research. This goes beyond implications included in the study itself, to include perceptions of implications for personal practice. 5 5
Critical Reflection: Identifies a nursing theory that this practice concern/research findings is an appropriate fit. Includes reflections on the significance/implications of integrating research into practice. Great job with theory 10 10
APA:  Attaches and adheres APA checklist and APA manual guidelines. Length appropriate (5-6 pages of typed content excluding the reference page, abstract, and title page).

Did someone proof read your Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)?

15 15
Writing: Development of a clear, logical, well-supported paper. Overall presentation: Grammar, punctuation, clean and legible. 15 15


Evidence Based Practice Essay Paper – Ventilator-Associated Pneumonia (VAP)