American Journal of Infection Control
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Key Words: A quality improvement project developed between 2 intensive care units using a quasiexperimental pre-
Quality improvement and postintervention comparison between nonstandardized placement of oral care equipment in patient
Compliance rooms and standardized placement of equipment in patient rooms. Daily assessments of equipment use
Mechanical ventilation
were compared for the control (14 days) and the intervention (15 days) periods to identify a difference
in the amount of equipment used by nurses. A significant increase in equipment use by nurses was ob-
served after implementation of the intervention. Standardized design and supply of equipment in patient
rooms may help to influence desired nursing behavior related to oral care for ventilated patients.
© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.
Although meticulous oral care for ventilated patients has been METHODS AND ANALYSIS
associated with decreased incidence of ventilator-associated
pneumonia, effective oral care practices among nurses remain The quality improvement project developed between 2 14-bed
inconsistent,1-3 institutional guidelines often lack the instruction re- intensive care units serving neurosurgery and medicine popula-
quired to become standard bedside practice,4 and the implementation tions was a quasiexperimental comparison between current use of
of multiple interventions to improve outcomes for ventilated pa- oral care equipment and postintervention use of oral care equip-
tients results in an inability to isolate the effects of various ment. At the onset of the project, bedside nurses identified that oral
interventions.2,5 After identifying oral care as a challenge to nursing care practices were inconsistent among staff and hindered by short-
practice via a unit assessment, researchers used a survey to iden- ages of appropriate oral care equipment. Available tools were
tify barriers to clinical interventions that included a lack of adequate analyzed and barriers were discussed with key stakeholders, in-
tools and consistency in practice. Following gestalt psychology, which cluding nurses, nurse managers, medical materials specialists,
states that individuals interpret their surroundings by gravitating respiratory therapists, and nurse technicians. Preparation for the in-
toward that which is simple and regular,6 researchers followed the tervention included the assurance of adequate supplies within the
example set by Cure, Van Enk, and Tiong,7 which identified that the hospital and permission to modify each patient room for the in-
most effective placement of hand sanitizer dispensers were in con- tervention. The tool chosen for daily auditing consisted of hospital-
spicuous and easy-to-reach locations. For this project, a comparison issued oral care kits each consisting of 9 components that were
was made measuring the frequency of oral care equipment use before designed to be used in a 24-hour period. Components were made
standardization with frequency of use after standardization. to be used throughout the day based on nursing judgment of patient
needs and consisted of 1 suction device, 2 toothbrush packs with
hydrogen peroxide solution, 4 suction swab packs with alcohol-
free mouthwash, and 2 deep suction catheters. Analysis of each
period consisted of daily audits between 5:00 a.m. and 7:00 p.m.
to evaluate the number of components used during the previous
* Address correspondence to Trevor Lacovara Diaz, MSN, RN, CNL, 2H Neurosurgical 24 hours. Patient labels were dated and placed on kits to ensure
Intensive Care Unit, MedStar Washington Hospital Center, 110 Irving St, NW,
Washington, DC 20010.
that use could be accurately monitored during both periods.
E-mail address: trevor.diaz@gmail.com (T.L. Diaz). During the control period, kit assessment was performed
Conflicts of interest: None to report. based on current nursing behavior, which was characterized by
0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2016.12.008
ARTICLE IN PRESS
2 T.L. Diaz et al. / American Journal of Infection Control ■■ (2017) ■■-■■
nonstandardized placement of oral care kits at different locations in control and intervention periods, nurses may have influenced results,
patient rooms and an insufficient supply of kits. For 14 days, daily as evidenced by conversations that revealed how some nurses would
audits of component use from kits took place to evaluate the fre- add components to their kits so that they would not run out of tools,
quency of baseline oral care performance by nurses. add secondary kits to rooms due to personal preference or inabil-
Between the control period and intervention period a day was ity to identify the presence of a previously placed kit, or would forego
taken to ensure sufficient supplies of kits in both units and to place oral care in favor of prioritizing more critical interventions. In each
wall mounts as designed by the kit manufacturer at a standard- scenario where an instance required evaluation for exclusion or con-
ized location in each patient room; that is, at the head of each patient founding data, the nurse was approached and questioned regarding
bed near the ventilator.8 Additionally, an informal education session the use of kit components. Further influence on the results of this
was provided to nurses present in both intensive care units regard- study includes the dual role of researchers employed as clinicians
ing the change in practice. Education included information about on their respective units during audits; bias was unaccounted for
the uniform placement and supply of oral care kits but did not but avoided when possible when making daily unit staff assign-
include information related to ventilator-associated pneumonia pre- ments. Oral care kits were frequently left over from one patient to
vention to reduce the likelihood of confounding factors.2 For the start the next and were monitored for exclusion criteria; the implica-
of the intervention period on the following day, each room with a tions for improving infection control practices cannot be understated.
ventilated patient was equipped with a fully stocked kit on the ap-
propriate wall mount. LIMITATIONS
The intervention period included daily audits of component use
from kits for 15 days to identify frequency of equipment use by Limitations of this study include the use of equipment as an in-
nurses. During each audit, missing kit components were restocked direct measure of oral care and the inability to directly measure
to their original 9 component contents or replaced in the event of patient outcomes, methodologic criticisms attributable to a before-
an empty kit. In the event that a patient was newly intubated before and-after analysis, variable nursing preference for nonkit equipment,
an audit, a new kit was placed for evaluation during the subse- nursing resistance related to kit use when coupled with sched-
quent audit. uled oral care medications, and the inability to perform a long-
term audit due to a manufacturer’s notice of a regional shortage of
RESULTS 24-hour kits that occurred at the end of the study.
Daily audit data were aggregated during the control period and CONCLUSIONS
intervention period to construct an unpaired t test that would eval-
uate instances of component use from oral care kits by nurses. For More kit components were used after the intervention was in-
this project, an instance was defined as a day that a ventilated patient stituted in comparison to the control period. Implications for future
met criteria for inclusion in the study. Exclusion criteria for any in- research include effective documentation for the performance of oral
stance were defined as the occurrence of intubation, extubation, care as part of all plans of care for ventilated patients and devel-
admission, discharge, transfer, or death within 24 hours of any audit. opment of institutional guidelines that define the placement and
In addition to these criteria, data for tracheostomy patients were supply of oral care tools. Further investigation should seek to account
not included in this study due to additional variances in oral care for the Hawthorne effect when performing audits and continued ap-
practice; verbal reports received from nurses included the belief that plication of the intervention to multiple critical-care populations
patients being weaned to a 24-hour period of oxygen delivery via at various institutions.
tracheostomy mask may experience distress when receiving oral care
and were therefore not given oral care as frequently. During daily References
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Multiple factors may contribute to variances in oral care, in- 7. Cure L, Van Enk R, Tiong E. A systematic approach for the location of hand sanitizer
cluding nursing practice, education, and resource availability, and dispensers in hospitals. Health Care Manag Sci 2013;17:245. doi:10.1007/s10729
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