Reducing VAP/HAP Risk Factors

Maintaining oral hygiene has been proven to help reduce healthcare-acquired pneumonias (HAPs), including ventilator-associated pneumonia (VAP) and aspiration pneumonia.1,2,3 In fact, the CDC now requires acute care hospitals to “develop and implement a comprehensive oral hygiene program” for patients at risk for healthcare-associated pneumonia.4

The CDC is not the only professional organization to recommend a comprehensive oral care protocol. The IHI Protecting 5 Million Lives from Harm campaign recommends a comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse.5

The APIC Guide to the Elimination of Ventilator-Associated Pneumonia even outlines an example mouth care and documentation form that includes brushing teeth q12°, providing oral care every 2 to 4 hours with antiseptic, applying mouth moisturizer to oral mucosa and lips, and suctioning orally as needed.6

Through the use of clinical evidence, education, and implementation tools, this section will help you build and implement a comprehensive and evidence based oral hygiene program for your facility. These unique tools will help you assess current clinical practice, educate staff, customize and implement an evidence-based protocol, complete a performance improvement plan, and track progress, from infection rates, to staff compliance, to cost.

REFERENCE: 1. Schleder B, Stott K, Lloyd RC, J Advocate Health Care, 2002;4(1):27-30. 2. Vollman K, Garcia R, Miller L, AACN News. Aug 2005;22(8):12-6. 3. Yoneyama T, et al., J Am Geriatrics Society. 2002;50(3):434-8. 4. Tablan OC, et al., Guidelines for Preventing Health-Care-Associated Pneumonia, 2003. CDC, MMWR. 26 Mar 2004;53(RR03);1-36. 5 Million Lives Campaign. Getting Started Kit: Prevent Ventilator-Associated Pneumonia How-to Guide. Cambridge, MA. Institute for Healthcare Improvement; 2010. 6.APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia, pp. 38, 40.

Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study
Garcia R, Jendresky L, Colbert L, Bailey A, Zaman M, Majumder M
AJCC
View abstract 

The effect of a comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia
Schleder B, Stott K, Lloyd RC
Journal of Advocate Health Care, Spr/Sum 2002;4(1):27-30.
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Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia
Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS
Chest. Dec 2005;128(6):3854-3862.
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A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions.
Garcia R
American Journal of Infection Control. Nov 2005;33(9):527-41.
View abstract 

Bacterial growth in secretions and on suctioning equipment of orally intubated patients: a pilot study
Sole ML, Poalillo FE, Byers JF, Ludy JE
American Journal of Critical Care. Mar 2002;11(2):141-9.
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Comparative microbial analysis of oral antiseptics
Nisengard R, DDS, PhD, Distinguished Teaching Professor, Periodontics and Microbiology, Department of Periodontics and Endodontics, School of Dental Medicine, State University of New York at Buffalo.
Study Objective: To evaluate the in vitro antiseptic properties of Sage Antiseptic Oral Rinse, Cepacol mouthwash/gargle and Biotene mouthwash
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Clinical evaluation of the effect of a hydrogen peroxide mouth rinse, Toothette Plus® Swab containing sodium bicarbonate, and a water-based mouth moisturizer on oral health in medically compromised patients
Carl W, Daly C, Andreana S, Ciancio S, Cohen RE, Nisengard RJ
Periodontal Insights. Mar 1999.
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Improving oral care in patients receiving mechanical ventilation
Cutler CJ
American Journal of Critical Care. Sep 2005;14(5):389-94.
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Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis
Pineda LA, Saliba RG, Solh AA
Critical Care. 20 Feb 2006;10(1):R35.
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Frequency of oral care and positioning of patients in critical care: a replication study
Hanneman SK, Gusick GM
American Journal of Critical Care. Sep 2005;14(5):378-86.
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Oral care interventions in critical care: frequency and documentation
Grap MJ, Munro CL, Ashtiani B, Bryant S
American Journal of Critical Care. Mar 2003;12(2):113-8; discussion 119.
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Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders
El-Solh AA, Pietrantoni C, Bhat A, Okada M, Zambon J, Aquilina A, Berbary E
Chest. Nov 2004;126:1575-1582.
View abstract 

NV-HAP Posters

Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP) in the ICU: Incidence and Prevention
Quinn B, Baker D, Parise C
Poster Presented at AACN-NTI (Amer Assoc of Critical Care Nurses/National Teaching Institute), 2013
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Clinical Attributes of Non-Ventilator Associated Hospital-Acquired Pneumonia (NV-HAP)
Quinn B
Poster presented at the Association for Professionals in Infection Control & Epidemiology (APIC), San Antonio, TX, June 2012
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Aspiration Pneumonia: Aspiration Precaution Bundle
Johnson L, Maddox P, Rockhold T
Poster presented at AMSN’s 18th Annual Convention, September 2009
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VAP Posters

Reduction of microbial colonization in the oropharynx and dental plaque reduces ventilator-associated pneumonia
Garcia R, Jendresky L, Colbert L
Poster Presented at APIC Conference, Jun 2004.
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Screen Shot 2015-08-19 at 2.20.19 PM Oral care of the mechanically ventilated patient: you can make a difference in five minutes
Schleder B, Lloyd R, Stott K
Poster Presented at State of Illinois Critical Care Conference, Mar 2002.
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A Comprehensive Oral Care Program Reduces Rates of Ventilator-Associated Pneumonia in Intensive Care Unit Patients
Hutchins K, Karras G, MD, Erwin J, Sullivan K
Poster presented at 2008 APIC Annual Conference: June 15-19, 2008
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Sustained Reduction in Ventilator-Associated Pneumonia (VAP) Using a Two-Hospital, Multidisciplinary Approach that Includes Oral Care and Regular Staff Education
Lipke V, Carman B
Poster presented at 2008 APIC Annual Conference: June 15-19, 2008
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Prevention of Hospital-Associated Pneumonia Using a Comprehensive Oral Hygiene Protocol
Jean Orr C, Mitchell, M
Poster presented at 2008 APIC Annual Conference: June 15-19, 2008
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Ventilator-Associated Pneumonia Prevention How Oral Care Helps Reduce VAP Rates
Bollinger A, Berry M, Brecht C, Conro K, Hunt K, Kuretski S, Patterson B
Poster Presented at AACN-NTI (Amer Assoc of Critical Care Nurses/National Teaching Institute), May 19-24, 2013 Orlando, FL
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Comprehensive Quality Improvement Program in Magnet Facility ICU Significantly Reduces Incidence of Ventilator-Associated Pneumonia (VAP)
Heck K
Poster presented at the 37th Annual APIC Educational Conference July 11-15, 2010
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Respiratory Infection Prevention for Ventilated and Tracheotomy Residents of a Long Term Care Facility
Harris M
Poster presented at the 2010 NADONA/LTC National Conference, June 12 -16, 2010
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Creative Change Management and Educational Strategies Ensure Compliance with VAP-Prevention Bundle and Adherence to NPSG #13 and Significantly Decreased VAP Rates in 2 Adult ICUs
DeJuilio P
55th AARC International Respiratory Congress December 5-8, 2009 San Antonio, TX
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Improved Patient Outcomes and Substantial Economic Savings From Quality Improvement Initiative for VAP Prevention
Hample C
HealthTrust University Conference, August 17-19, 2009
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Simple and Cost-Effective Strategies to Reduce the Occurrence of Ventilator-Associated Pneumonia
Killer H, Haines T
Poster presented at the 36th Annual APIC Educational Conference and International Meeting, June 7-11 2009
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Oral Care and Ventilator Bundle Reduces VAP
Bugg L, Downs L, Blakenship P
Presented at Institute for Healthcare Improvement (IHI), Nashville, TN December 2008
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IHI Bundles and Oral Care Reduces VAP and CRBSI
Belkoski D
Presented at Institute for Healthcare Improvement (IHI), Nashville, TN December 2008
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Compliance with VAP prevention bundle reduces VAP rate to 0
Button T, Southard T, Donaldson S
Presented at Institute for Healthcare Improvement (IHI), Nashville, TN December 2008
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Getting compliance: A respiratory therapy initiative to take ownership of oral care in critical care settings
Crouch L, Weber R
Presented at the AARC 51st International Respiratory Congress, San Antonio, Texas December 2005
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Annihilating ventilator-associated pneumonia with a respiratory therapy emphasis on oral care
Button T, Culmer D, Southard T, Donaldson S
Presented at the AARC 51st International Respiratory Congress, San Antonio, Texas December 2005
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Professional organizations are now recognizing comprehensive oral care as key to addressing VAP and HAP.

AACN Procedure Manual for Critical Care — Oral Care Interventions, 2005,
“Assess oral cavity and lips every 8 hours, and perform oral care every 2 to 4 hours and as needed.† With oral care, assess for buildup of plaque on teeth or potential infection related to oral abscess.”

“Perform oral hygiene, using pediatric or adult (soft) toothbrush, at least twice a day. Gently brush patient’s teeth to clean and remove plaque from teeth.”†

“In addition to brushing twice daily, use oral swabs with a 1.5% hydrogen peroxide solution to clean mouth every 2 to 4 hours.”†
“With each cleansing, apply a mouth moisturizer to the oral mucosa and lips to keep tissue moist.”†

“Suction oral cavity/pharynx frequently.”††

“Antiseptic oral rinses (chlorhexidine, cetylpyridinium chloride (CPC), added after brushing or done in conjunction with comprehensive oral care did achieve elimination of VAP. (Level B)”

Institute for Healthcare Improvement (IHI)
Prevent Ventilator-Associated Pneumonia – How-to Guide

    Ventilator Bundle:
  • Elevation of the Head of the Bed
  • Daily “Sedation Vacations” and Assessment of Readiness to Extubate
  • Peptic Ulcer Disease Prophylaxis
  • Deep Venous Thrombosis Prophylaxis
  • Daily Oral Care with Chlorhexidine

CDC Guidelines for Preventing Healthcare–Associated Pneumonia, 2003
CDC, MMWR. March 26, 2004;53(RR03);1-36.
Download Oral Hygiene Excerpt (PDF)
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APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia1

    Key prevention strategies:
  • Perform routine antiseptic mouth care
    Example mouth care and documentation form includes the following:
  • Brush teeth q12°
  • Provide oral care every 2 to 4 hours with antiseptic
  • Apply mouth moisturizer to oral mucosa and lips
  • Suction orally as necessary

Society for Healthcare Epidemiology of America (SHEA)2
A Compendium of Strategies to Prevent Healthcare- Associated Infections in Acute Care Hospitals
Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals
“Perform regular antiseptic oral care in accordance with product guidelines”3,4

REFERENCES: 1. APIC 2009 Guide to the Elimination of Ventilator-Associated Pneumonia, pp. 38, 40. 2. SHEA, Oct 2008,Vol. 29, Supplement 1, S31. 3. Among other interventions 4. Category IA: Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. 5. Scott JM, Vollman KM, Endotracheal tube and oral care. In DJ Lynn-McHale Wiegand and KK Carlson (Eds.) AACN Procedure Manual for Critical Care, Fifth Ed., pp. 28-33, Elsevier Saunders, St. Louis, MO. 6. In addition to other interventions. †. Level IV: Limited clinical studies to support recommendations.

Hospital-Acquired Pneumonia in Nonventilated Patients: The Next Frontier
Klompas M
Infection Control & Hospital Epidemiology / Volume 37 / Issue 07 / July 2016, pp 825-826
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Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study
Garcia R
American Journal of Critical Care
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Is CMS overstepping its regulatory authority?
Evans G,
Hospital Infection Control & Prevention
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Reduction of Microbialcolonization in the oropharynx and dental plaque reduces ventilator-associated pneumonia
Garcia R, Jendresky L, Colbert L
Brookdale University Medical Center (BUMC), Brooklyn, NY
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Oral Care Practices for Orally Intubated Critically Ill Adults
Feider L, Mitchell P, Bridges E
American Journal of Critical Care. 2010;19: 175-183
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Treasured chests: reducing VAP in the ICU
Carter CL
Alliance Magazine. Apr 2004:14-16.
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Targeting Ventilator-Associated Pneumonia
The Source. Mar 2007;59-61.
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Best-practice interventions: How can you prevent ventilator-associated pneumonia?
Pruitt B, Jacobs M
Nursing 2006. Feb 2006;36(2):36-41;quiz 41-2.
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Preventing aspiration pneumonia in at-risk residents
Logsdon BK
Nursing Homes Long Term Care Management, Aug 2004.
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Reducing the risk of ventilator-associated pneumonia
Brooks T
Infection Control Today. May 2004.
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New Oral Care Routine Eliminates VAP at Florida Hospital
Harris C (Ed.)
ICP Report. Jan 2004;9(1)14-16.
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Aspiration pneumonitis and aspiration pneumonia
Marik PE
New England Journal of Medicine. 1 Mar 2001;344(9):665-71.
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A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions.
Garcia R
American Journal of Infection Control. Nov 2005;33(9):527-41.
View abstract

Oral Care Program Helps Overlake Hospital Reduce VAP by 81 Percent, Saving $1.4 Million
Bellevue, WA
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HealthEast Eliminates VAP, Saving $360,000 in VAP-Related Costs – Oral Care Key to Success
St. Paul, MN
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Oral Care Program Helps Eisenhower Medical Center Cut VAP Rates In Half
Rancho Mirage, CA
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Provena Saint Joseph Steps up Compliance and Zaps Major Hospital-Acquired Infection
Mokena, IL
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Alamance Regional Medical Center Eliminates Ventilator-Associated Pneumonia
Burlington, N.C.
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Sherman Hospital Saves $1.6 Million on VAP-Related Costs
Elgin, IL
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Villages Regional Hospital Significantly Reduces VAP Rates Through Clinical Interventions, Including Oral Care
Lady Lake, FL
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Blount Memorial Reduces VAP Rates
Maryville, TN
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West Jefferson Medical Center Eliminates VAP Cases Through Comprehensive Oral Care Program, Saving More than $750,000
Marrero, LA
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Porter Valparaiso Hospital Campus Virtually Eliminates VAP Rates
Valparaiso, IN
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United Regional Uses Oral Care Protocol to Reduce VAP, Hospital Saves Close to $400,000
Wichita Falls, TX
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Centra Health Reduces Ventilator-Associated Pneumonia Rates
Lynchburg, VA
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Unity Health System Saves $360,000, Reduces VAP Rates Through Oral Care
Rochester, NY
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WakeMed Reduces Risk for Ventilator-Associated Pneumonia
Raleigh, NC
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Memorial Hospital Saves More Than $1.25 Million Through Oral Hygiene Program
Colorado Springs, CO
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Vanderbilt University Medical Center Improves VAP Rates In SICU through Oral Care
Nashville, TN
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St. Luke’s Regional Medical Center Eliminates VAP Rates
Boise, ID
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Coral Springs Reduces Ventilator-Associated Pneumonia
Coral Springs, FL
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Comprehensive Oral Care Comparison (PDF)
Customizable Protocol (doc)
Customizable Protocol w/ CHG (doc)

Patient Education Card

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Lanyard Assessment Form

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Clinical Practice Assessment

Product Evaluation Form

Sample Performance Improvement Plan
Track the impact of Routine Oral Care and Closed End Suction on VAP rates at your facility with this customizable template.

Customize (Microsoft® Word Document)Download (PDF)

Sample Process Improvement Plan
Assess staff knowledge and opinions about oral care practices in your facility. This template includes a section to list your facility’s desired oral care objectives, your protocol, and an area to record results from the Clinical Evaluation Form.

Establish your facility’s objectives for oral care. Then enter them into the left hand column of the Process Improvement Plan template.

Customize (Microsoft® Word Document)Download (PDF)