ORAL CARE PRACTICES CRITICALLY ILL ADULTS FOR ORALLY INTUBATED. Pulmonary Critical Care

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1 Pulmonary Critical Care ORAL CARE PRACTICES FOR ORALLY INTUBATED CRITICALLY ILL ADULTS By Laura L. Feider, RN, PhD, Pamela Mitchell, RN, PhD, and Elizabeth Bridges, RN, PhD, CCNS American Association of Critical-Care Nurses doi:./ajcc Background Ventilator-associated pneumonia is a major threat to patients receiving mechanical ventilation in hospitals. Oral care is a nursing intervention that may help prevent ventilatorassociated pneumonia. Objectives To describe oral care practices performed by critical care nurses for orally intubated critically ill patients and compare these practices with recommendations for oral care in the AACN Procedure Manual for Critical Care and the guidelines from the Centers for Disease Control and Prevention. Methods A descriptive, cross-sectional design with a -item Web-based survey was used to describe oral care practices reported by randomly selected members of the American Association of Critical-Care Nurses. Results Oral care was performed every (%) or (%) hours, usually with foam swabs (9%). Oral care was reported as a high priority (%). Nurses with years or more of critical care experience performed oral care more often (P =.) than did less experienced nurses. Nurses with a bachelor s degree in nursing used foam swabs (P =.), suctioned the mouth before the endotracheal tube (P =.), and suctioned after oral care (P <.) more often than other nurses. Nurses whose units had an oral care policy (%) reported that the policy indicated using a toothbrush (%), using toothpaste (%), brushing with a foam swab (9%), using chlorhexidine gluconate oral rinse (9%), suctioning the oral cavity (%), and assessing the oral cavity (%). Oral care practices and policies differed for all those items. Conclusions Survey results indicate that discrepancies exist between reported practices and policies. Oral care policies appear to be present, but not well used. (American Journal of Critical Care. ;9:-) AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No.

2 Ventilator-associated pneumonia (VAP) is a major threat to patients who are receiving mechanical ventilation. Oral care is a nursing intervention that decreases the incidence of VAP. Oral care policies and practices vary from state to state, hospital to hospital, and even within intensive care units. In addition, protocols guiding oral care may be inconsistent, impractical, difficult to follow, or lacking altogether. - Evidence supporting the type, mode, frequency, and duration of oral care is limited. The primary goal of oral care is to promote oral hygiene and thereby decrease colonization of the oropharynx and dental plaque by bacteria and aspiration of colonized saliva. However, oral care is often neglected in critically ill patients or performed inadequately when a patient s mouth is swabbed only for comfort.,, Despite numerous guidelines designed to prevent VAP, empirical evidence supporting the various aspects of the protocols is limited. For example, results of studies, suggest that toothbrushes are the tool of choice for effective oral care to decrease dental plaque reservoirs. The ability of the toothbrush to remove plaque is consistently better and more clinically useful than foam swabs. - Grap et al found that toothbrushing was not routinely performed and that sponge toothettes were used more often than toothbrushes were used for patients receiving mechanical ventilation. Antimicrobial chlorhexidine gluconate has been tested as a potential strategy for preventing VAP in several studies. - When our study was done, no published studies had demonstrated a definitive link between chlorhexidine use and decreased VAP rates for critically ill patients. Recent studies - show a reduction in VAP rates when chlorhexidine is used, but the role of chlorhexidine in preventing VAP in critically ill patients remains unclear. Despite the numerous evidence-based guidelines for preventing VAP, no oral care guidelines that include the type, mode, frequency, and duration of About the Authors Laura L. Feider is a lieutenant colonel in the Army Nurse Corps at Madigan Army Medical Center in Tacoma, Washington. Pamela Mitchell is a professor and Elizabeth Bridges is an associate professor at the University of Washington in Seattle. Corresponding author: Laura L. Feider, RN, PhD, Lieutenant Colonel, Army Nurse Corps, Nursing Research Service (MCHJ-CN-NR), Madigan Army Medical Center, Tacoma, WA 9- ( laura.feider@us.army.mil). oral care practices for orally intubated critically ill adults have been nationally recognized. However, the AACN Procedure Manual for Critical Care does include a chapter on endotracheal tube and oral care. Additionally, few studies have addressed comprehensive or individual oral care practices for preventing VAP in patients receiving mechanical ventilation. Five surveys on oral care practices in critical care have been described in published reports.,,,,9 The sample populations were limited to regions of the United States or hospital, or the studies reported limited or no psychometric measures. A more recent European oral care survey showed that 9 ICUs provide oral care largely with mouthwash and less with manual toothbrushes. Further, either limited or no psychometric measures were reported. No studies have been reported that compared the recent recommendations from the AACN Procedure Manual for Critical Care and the Centers for Disease Control and Prevention (CDC) with actual reported practices in oral care. Study Purpose The purpose of this research was to describe oral care practices performed by critical care nurses for orally intubated critically ill patients and to compare these practices with the recommendations for oral care in the AACN Procedure Manual for Critical Care and the CDC guidelines. Methods Design and Sample A descriptive, cross-sectional design with a Web-based survey was used to describe oral care practices reported by critical care nurses. The sampling target included any registered nurse who was a member (-) of the American Association of Critical-Care Nurses (AACN) and was working in an adult critical care unit in the United States. A random sample of names meeting these inclusion criteria was obtained from the -member AACN database. Data Collection After getting approval from the University of Washington s human subjects committee, we mailed AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No.

3 a survey packet to the random sample of AACN members. The survey packet included an informational cover letter with the Internet address for the Webbased survey. This letter invited potential participants to voluntarily access the study survey via the Internet and complete the survey. Two weeks after the initial mailing, a follow-up postcard was sent to each participant as a reminder to complete the survey. As an incentive, AACN memberships and a AACN National Teaching Institute conference registration fee were raffled in a lottery for participants. Completing the Web-based survey signified the respondent s consent to use the data for the study. Confidentiality of the responses was ensured by using individual custom identification codes. Table Survey sections Section No. of items Content Demographics, professional work experience, characteristics of intensive care unit Unit-level incidence rate for ventilatorassociated pneumonia Frequency and duration of oral care tasks, including toothbrushing with toothpaste, foam swabbing, chlorhexidine gluconate oral rinse, and oral secretion management Priority of oral care Oral care assessment activities and frequencies Existing oral care policies for orally intubated or patients receiving mechanical ventilation Open-ended comment Instrument A -item Web-based survey was used to collect data (Table ). The details of development and testing for reliability and validity are described elsewhere. Survey items were derived from published reports on oral care practices, which included toothbrushing, swabbing, use of chlorhexidine, and management of oral secretions. The items were designed to elucidate information on the type and frequency of each specific task for oral care. Three national experts on oral care evaluated potential items and overall content for face and content validity. Their ratings were summarized by using a content validity index (9.%) and kappa values (.-.). After face and content validity had been established, test-retest reliability (r =.-.9) was evaluated by critical care staff nurses who repeated the survey at a -week interval. The final survey consisted of items. Descriptive statistics (frequency distribution, central tendency, and variability) and Pearson χ tests were used to describe and compare findings. Results A total of of the randomly selected AACN members completed the survey between November,, and January,. A total of surveys (.%) were used in the analysis. Six surveys could not be recovered because of a server entry error. Demographic Characteristics Sample participants had a mean (SD) of. (9.) years of nursing experience and.9 (9.) years of critical care nursing experience. Eighty-six percent (n = 9) were clinical staff nurses. Sixty-one percent (n = ) reported a baccalaureate degree (BSN) as the highest degree earned and % (n=) were CCRN certified. The largest percentage of the sample (%, n = ) reported working in combined intensive care/coronary care units (ICU/CCUs). Demographic characteristics of the sample are presented in Table. The sample demographic data were compared descriptively with demographic data on the AACN membership. The study sample was similar to the overall AACN population in years practicing nursing, highest degree level achieved, certification status, type of ICU, hospital size, and hospital affiliation. The study sample had slightly more nurses with BSNs (% vs %), more clinical staff nurses (% vs %), and more nurses who worked in the combined ICU/CCU (% vs %) than the AACN population. The fact that nurses working in critical care inpatient units were the target population for the survey may explain why the study sample had a higher proportion of clinical staff nurses (%) than did the AACN population (%). VAP Incidence Rates and Priority Level of Oral Care Eighty percent of the nurses (n=) reported not knowing the VAP incidence rate for their institution. Of the % (n = ) who knew their VAP incidence rate, the reported mean VAP incidence rate was./ ventilator days. Forty-seven percent (n = ) of the respondents rated oral care as a high priority, and % of respondents (n = ) reported having adequate time to provide oral care at least every hours. Oral Care Frequency, Tools, and Duration Results indicated that % (n=) of the nurses provided oral care every hours and % every Thirty percent of nurses reported brushing patients teeth with a toothbrush and toothpaste twice a day. AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No.

4 Table Demographic characteristics of the study sample compared with overall membership of the American Association of Critical-Care Nurses (AACN) Demographic Years practiced nursing Mean (SD) Minimum Maximum Years worked in ICUs Mean (SD) Minimum Maximum Total No. of beds in ICU Mean (SD) Minimum Maximum Highest degree Diploma Associate s Bachelor s Master s Doctorate Current position Clinical staff nurse Nurse manager Clinical nurse specialist Nurse practitioner Clinical educator Certification status (n = ) CCRN certification None Type of ICU Combined ICU/coronary care unit Coronary care unit Cardiovascular/surgical ICU Surgical Trauma Medical Neurological/neurosurgical Surgical trauma Burn Teaching hospital (n = ) Yes No No. of beds (n = ) > Unknown Study sample (N = ). (9.)..9 (9).. (.) No. (%) 9 () () () () () 9 () () () () () () () () () () () () () () 9 () () () () () (9) 9 () () () 9 () () () 9 () AACN population (9.) (.) % < continued hours (n = ). The most common tools used were foam swabs (n=, 9%) and a manual toothbrush (n =, %). Table summarizes the oral care frequency, tool frequency, and duration of tool use. Oral Care Products, Secretion Management, and Oral Cavity Assessments Chlorhexidine gluconate oral rinse solutions were used by % (n = ) of the nurses. Forty-six percent (n=) of nurses combined toothbrushing, toothpaste, and chlorhexidine oral rinses. The sequence of chlorhexidine use should be at least hours before manually brushing the teeth to ensure that the chlorhexidine does not deactivate. oral care products used by critical care nurses included moisturizers (n =, %), hydrogen peroxide (n =, %), normal saline (n =, %), and lemon glycerin swabs (n =, 9%). The oral cavity was suctioned after oral care was completed (n =, 9%), before the endotracheal tube cuff was deflated (n=, 9%), after suctioning of the endotracheal tube (n=, %), before performing oral care (n=99, %), after repositioning the patient (n = 9, %), and before suctioning of the endotracheal tube (n =, %). During oral cavity assessments, the respondents reported checking for the following: bleeding (n=, 9%), oral-mucosal tears, ulcerations, abrasions, or cracks (n =, %), dry mouth (n = 9, %), tissue color (n = 9, %), redness (n =, %), and swelling (n =, 9%; Table ). The most common frequency reported for assessing the oral cavity was every hours (n=, 9%). Most nurses (n =, 9%) reported not using a standard oral assessment tool to assess the oral cavity. Experience, Education, and Certification Status Critical care nurses who had been practicing nursing for. years or more (n=) reported significantly more frequent oral care (9% vs %, P=.) and use of foam swabs (9% vs 9%, P=.). No significant associations were found between suctioning practices and years of work experience in critical care. Oral care practices were analyzed by nurses educational level: baccalaureate, associate s degree, and diploma. Baccalaureate-prepared nurses reported more frequent use of foam swabs (% vs %; P =.) and more frequent performance of oral suctioning before endotracheal tube suction (% vs %; P=.) and after oral care (% vs %; P <.) than the other nurses reported. Oral care practices were analyzed for nurses with and without CCRN certification. Nurses with the CCRN certification (n =, %) most frequently AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No.

5 reported a toothbrushing duration between and 9 seconds. CCRNs had a significantly longer toothbrushing duration than did non-ccrns (χ =., P =.) and reported suctioning after oral care more often (χ =.9, P <.). Oral Care Policies Compared With Reported Practices A majority (n =, %) of critical care nurses were not aware of the chapter on endotracheal tube and oral care in the AACN Procedure Manual for Critical Care. Two hundred fifty nurses (%) reported having an ICU oral care policy for orally intubated critically ill patients. The ICU oral care policies addressed using a toothbrush (n =, %), using toothpaste (n =, %), brushing with a foam swab (n =, 9%), using chlorhexidine gluconate oral rinse (n =, 9%), suctioning the oral cavity (n = 9, %), and assessing the oral cavity (n =, %). When asked about the frequency of use for each oral care tool recommended in the ICU oral care policy, the most commonly reported policy recommendations were as follows: using a toothbrush every hours (n = 9, %), using toothpaste when using a toothbrush (n =, %), brushing with a foam swab every hours (n =, 9%) or every hours (n =, %), using toothpaste and a foam swab every hours (n =, %) or every hours (n =, %), suctioning the oral cavity every hours (n =, 9%), and assessing the oral cavity every hours (n =, %). Reported practices were compared with the practices advocated in the AACN Procedure Manual for Critical Care and the CDC guidelines. Differences were noted for swabbing the oral cavity every to hours and assessing the oral cavity every hours. Twenty-seven percent of respondents reported that they swabbed the oral cavity more often than was recommended in the oral care policy. Fifty-seven percent reported that their oral care policy called for assessment of the oral cavity every hours, and only % of respondents reported assessing the oral cavity every hours. Table summarizes reported oral care practices and oral care policy recommendations. Discussion No gold standard exists for oral care for critically ill patients who are orally intubated. The AACN Procedure Manual for Critical Care and the Table continued Demographic Hospital affiliation College/university Community (profit) Community (nonprofit) County Federal Health maintenance organization/ managed care Military/government Public State Private industry Region of United States Northeast Mid-Atlantic Southeast Midwest Southwest West Northwest No. (%) of study sample (N = ) (9) () 9 () () () () 9 () () (<) () () () (9) () () () () () Abbreviations: ICU, intensive care unit;, not applicable. CDC guidelines provide recommendations for oral care; however, the level of evidence supporting these recommendations is generally low. Therefore, we were not surprised to see a gap in actual practices compared with policies because of the variations among different organizations policies. For those nurses (%) who indicated that their unit had an oral care policy for orally intubated patients, using a toothbrush, using toothpaste with a toothbrush, brushing with a foam swab, using chlorhexidine oral rinse solution, suctioning the oral cavity, and assessing the oral cavity were stated in their ICU policy. The AACN guidelines recommend brushing the teeth twice a day, swabbing the mouth every to hours, and suctioning the oral cavity frequently. The large number of nurses (, %) who did not know their ICU s VAP incidence rate was not surprising. Many facilities keep this information confidential and do not report this metric, as it may influence the type of patients who seek care. For those nurses who reported knowing their VAP incidence rate, it is encouraging to see the mean VAP rate was (SD.) cases per thousand ventilator days. National VAP rates are highest in trauma ICUs (%), surgical ICUs (%), CCUs (9.%), and medical ICUs (.%). % of AACN population 9 < AACN guidelines recommend brushing the teeth twice a day and swabbing the mouth every to hours. AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No. 9

6 Table Oral care frequency, tool frequency, and duration of tool use Frequency Survey item (N = ) % Oral care frequency Every h Every h Every h Every h Every h Tool frequency Manual toothbrush (reported by ) Never <Once a shift Every h Every h Every h Every h Pediatric toothbrush (reported by ) Never <Once a shift Every h Every h Every h Every h Toothpaste (reported by 99) Never <Once a shift Every h Every h Every h Every h Foam swabs/toothettes (reported by ) Never <Once a shift Every h Every h Every h Every h Duration of tool use Manual toothbrush s s s s s 9 s Unknown Do not use this tool Pediatric toothbrush s s s s s 9 s Unknown Do not use this tool < < 9 Ninety-two percent of nurses reported providing oral care every or hours, which is consistent with the recommended practice in the AACN procedure manual for swabbing the mouth. However, interpretation of these results is difficult given the general nature of the term oral care. In, further definition of oral care was included in an AACN Practice Alert that defined comprehensive oral care as brushing with a toothbrush and toothpaste twice a day as opposed to oral care with foam swabs every or hours. When this more concise definition is used, only % of nurses who responded to this survey reported brushing with a toothbrush and toothpaste twice a day, in contrast to the 9% who used a foam swab every to hours. In this survey, the most common mechanical tool used was the foam swab (9%). This finding is consistent with previous studies in which the use of sponge toothettes was significantly greater in intubated patients than nonintubated patients., A manual toothbrush (%) was the second most common mechanical tool reported. The toothbrush findings contrast with previous studies that found toothbrushes and toothpaste to be unavailable in the supply system or less commonly used., Although the American Dental Association has no standards for the orally intubated patient, toothbrushing with toothpaste is recommended twice a day, and this practice is now included in the AACN s oral care protocol for practice. Routine use of chlorhexidine in all ICU patients is not recommended.,-,, Among the nurses who worked with cardiac surgery patients, % used chlorhexidine in a manner consistent with the CDC s recommendations. Recent studies - show a reduction in VAP rates when % chlorhexidine is used times a day. No studies to date have reported frequency of suctioning the oral cavity. Oral suctioning is indicated to prevent aspiration of oral care solutions and rinses during oral care.,-9 We found that % of nurses in our study reported suctioning the oral cavity every or hours to prevent buildup of oral secretions. This study confirms the findings of Binkley et al and Jones et al 9 that oral care is a moderate or high priority (%). A shift in priority of oral care from may indicate that evidence-based recommendations are being used in clinical practice due to the recent attention on oral care practices by AACN and the Institute for Healthcare Improvement, with its VAP Bundle campaign. Additionally, critical care nurses may now view oral care as an intervention that prevents hospital-acquired pneumonia in critically ill patients rather than only as a comfort-care measure. Further uptake of evidence-based oral care may

7 be enhanced by the dissemination of the AACN Practice Alert for oral care in the critically ill to all members of AACN. A recent meta-analysis suggests that oral care is significantly associated with reduced VAP rates. No standard tool has been accepted by critical care nurses to assess the oral cavity of intubated critically ill patients. Eilers et al developed and tested an oral assessment guide for oncology patients, and Barnason et al adapted this tool for the assessment of orally intubated patients. The AACN Procedure Manual for Critical Care recommends assessment of the oral cavity every hours. In our study, every hours was the most common frequency for oral assessment; however, 9% of participants reported not having a standardized oral assessment tool. Thus, it remains unclear what was actually assessed. Further work to clarify critical aspects of oral assessment in intubated patients is needed. We found that % of ICUs have an oral care policy that recommends using a toothbrush, suctioning the oral cavity, and assessing the oral cavity every hours. This study highlights the importance of comparing these policies with actual practice. For example, respondents indicated that they use foam swabs when performing oral care, which is similar to what has been reported in other studies., The respondents, however, indicated that their policies do not recommend use of foam swabs. The lack of a recommendation to use oral swabs may reflect evidence that foam swabs have minimal effect on oral health status or on decreasing oral colonization and thereby decreasing the VAP incidence rate.,- These results demonstrate a lack of uptake of evidence regarding optimal oral care. Only % of nurses reported that their ICU policy contained recommendations for using a toothbrush with toothpaste every hours. The absence of this recommendation is in contrast to the American Dental Association s oral hygiene recommendations for healthy adults. This finding was not a surprise, as many nurses find using a toothbrush to be time-consuming and cumbersome, and manipulation of the endotracheal tube limits access to the oral cavity and causes fear of potential dislodgement of the tube., Limitations The survey response rate of % was low, despite our use of the Dillman method of survey administration, but was within generally accepted return rates of mail-out surveys. Several explanations are possible for the low response rate. Some participants may not have been interested in the oral care topic, Table continued Frequency Survey item (N = ) % Foam swabs/toothettes s s s s s 9 s Unknown Do not use this tool 9 9 Table Oral cavity assessment, frequency and tools Frequency Survey item (N = ) % Assessing oral cavity Redness Swelling Dry mouth Oral mucosal tears, ulcers, abrasions, and cracks Lack of saliva Dental plaque Dental caries Oral mucosal or dental abscess Tissue color Bleeding Tenderness I do not assess the oral cavity Frequency of oral assessment Every h Every h Every h Every h Every h I do not assess the oral cavity Standard oral assessment tool Yes No some may not have liked the Web-based survey format, or perhaps they did not have the time available to take the survey. According to the director of the AACN list rental, a % to % response rate is the average for the AACN membership, and a small number of research requests are performed annually for clinical staff nurses. Clinical nurses may be less likely to respond to surveys than other groups < < AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No.

8 Table Oral care: reported practices compared with policy components Recommended practices a Brush teeth twice a day Swab every - h Suction the oral cavity and pharynx frequently Assess the oral cavity every h Use chlorhexidine gluconate oral rinse in cardiac surgical patients twice a day Reported practices (N = ) 9 () (9) 9 () No. (%) of responses () () b Policy components (N = ) 9 () 9 () (9) 9 (9) (9) a Recommended by the AACN Procedure Manual for Critical Care and the Centers for Disease Control and Prevention s guidelines for oral care. b For use of chlorhexidine, n =. Oral care may now be viewed as a means to prevent ventilatorassociated pneumonia rather than just as comfort care. of nurses. In contrast, those nurses who responded may have more of a vested interest in oral care practices, and therefore the results may be different than they would be if all nurses responded. Finally, the AACN membership may be oversurveyed by researchers. Nursing Implications VAP increases duration of mechanical ventilation, overall length of stay in the ICU, length of hospital stay, morbidity, and mortality.,,- Oral care is a nursing intervention that may decrease VAP incidence rates. This valid and reliable survey tool was created to describe oral care practices reported by critical care nurses. This is the first national survey of oral care practices among critical care nurses to use the AACN membership database. Additionally, we compared reported practices against recommended practices and against the AACN/CDC guidelines. Further research that captures comprehensive data on oral care frequency and duration and compares actual observed oral care practices with documented practices is needed. An evidence-based standard oral assessment tool for orally intubated critical care patients also is needed. In addition, implementing easy-to-use oral care policies and testing their effectiveness in decreasing VAP incidence rates requires further research. Finally, the most recent AACN Practice Alert recommends that critical care units have a written practice policy that describes oral care procedures, documents of oral care frequency and specifies comprehensive oral care including toothbrushing and oral cavity moisturizing, and includes a competency check for oral care procedures during unit orientation. Conclusions Oral care policies appear to be present but not well used. Overall, since the publication of the AACN Procedure Manual for Critical Care, the CDC s recommendations and the recent AACN Practice Alert, this study s findings are reflective of some improvements in the clinical practice of oral care procedures. Nurses, however, are not aware of published guidelines. Some oral care practice gaps are being addressed and changes implemented. A gap exists between national oral care standards, reported oral care practices, and unit-level oral care policies. Therefore, our study results suggest that current oral care practices do not match evidence-based recommendations. ACKNOWLEDGMENTS Thank you to the dissertation committee members who assisted with the research process: Dr Lori Loan and Dr Betty Gallucci. Thank you to Mary McCarthy, RN, PhD, CNSN, for her invaluable mentorship.the views expressed in the article are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense, or the US government. FINCIAL DISCLOSURES This research was funded by a grant from the University of Washington Hester McLaws Nurse Scholar Program. eletters Now that you ve read the article, create or contribute to an online discussion on this topic. Visit and click Respond to This Article in either the full-text or PDF view of the article. SEE ALSO For more about oral care for mechanically ventilated patients, visit the American Journal of Critical Care Web site, and read the article by Munro et al, Chlorhexidine, Toothbrushing, and Preventing Ventilator-Associated Pheumonia in Critically Ill Adults (September 9). REFERENCES. Centers for Disease Control. Guidelines for preventing healthcare-associated pneumonia. Morbid Mortal Weekly Rep. ;(RR-):-.. Cutler C, Davis N. Improving oral care in patients receiving mechanical ventilation. Am J Crit Care. ;():9-9.. Binkley C, Furr A, Carrico R, McCurren C. Survey of oral care practices in US intensive care units. Am J Infect Control. ;():-9.. Sole M, Byers J, Ludy J, Zhang Y, Banta C, Brummel K. A multisite survey of suctioning techniques and airway management practices. Am J Crit Care. ;:-.. Grap M, Munro C, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care. ;():-9.. Pearson L. A comparison of the ability of foam swabs and toothbrushes to remove dental plaque: implications for nursing practice. J Adv Nurs. 99;:-9. AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No.

9 . Nelsey L. Mouthcare and the intubated patient: the aim of preventing infection. Intensive Care Nurs. 9;:-9.. Munro C, Grap M. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. ;():-. 9. Pearson L, Hutton J. A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. J Adv Nurs. ;9():-9.. Fitch FA, Munro CL, Glass CA, Pellegrini JM. Oral care in the adult intensive care unit. Am J Crit Care. 999;():-.. DeRiso A, Ladowski J, Dillon T, Justice J, Peterson A. Chlorhexidine gluconate.% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 99;9():-.. Houston S, Hougland P, Anderson J, LaRocco M, Kennedy V, Gentry LO. Effectiveness of.% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care. ; ():-.. Genuit T, Bochicchio G, Napolitano L, McCarter R, Roghman M. Prophylactic chlorhexidine oral rinse decreases ventilatorassociated pneumonia in surgical ICU patients. Surg Infect. ;():-.. Martin S, Larson E. Chemotherapy-handling practices of outpatient and office based oncology nurses. Oncol Nurs Forum. ;():-.. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with % chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol. ;9():-.. Chlebicki M, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med. ;():9-.. Koeman M, van der Ven A, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilatorassociated pneumonia. Am J Respir Crit Care Med. ;: -.. Scott J, Vollman K. Endotracheal tube and oral care. In: Lynn-McHale D, Carlson K, eds. AACN Procedural Manual for Critical Care. th ed. Philadelphia, PA: WB Saunders Co; :-. 9. Jones H, Newton J, Bowen EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Care Nurs. ;():9-.. Rello J, Koulenti D, Blot S, et al. Oral care practices in intensive care units: a survey of 9 European ICUs. Intensive Care Med. ;():-.. Feider LL, Mitchell P. Validity and reliability of an oral care practice survey for the orally intubated adult critically ill patient. Nurs Res. 9;():-.. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 99 through June. Am J Infect Control. ;:-9.. AACN practice alert: oral care in the critically ill. AACN Web site. - %CARE/$file/Oral%Care%in%the%Critically %Ill%-.pdf. Accessed December 9, 9.. Hanneman SK, Gusick GM. Frequency of oral care and positioning of patient in critical care: a replication study. Am J Crit Care. ;():-.. American Dental Association (ADA). Oral health topics: Cleaning your teeth and gums (oral hygiene). /public/topics/cleaning.asp. Accessed December 9, 9.. Grap M, Munro C, Elswick R, Sessler C, Ward K. Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study. Heart Lung. ;():-9.. Sole M, Poalillo F, Byers J, Ludy J. Bacterial growth in secretions and on suctioning equipment of orally intubated patients: a pilot study. Am J Crit Care. ;():-9.. Drakulovic M, Torres, A, Bauer T, Nicolas J, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a random trial. Lancet. 999;:-. 9. Grap M, Cantley M, Munro C, Corley M. Use of backrest elevation in critical care: a pilot study. Am J Crit Care. 999;():-.. Implement the ventilator bundle. Institute for Healthcare Improvement Web site. /CriticalCare/IntensiveCare/Changes/Implementthe VentilatorBundle.htm. Accessed December 9, 9.. Chan Y, Ruest AO, Meade M, Cook D. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. Br Med J. ;:9.. Eilers J, Berger A, Peterson M. Development, testing, and application of the oral assessment guide. Oncol Nurs Forum. 9;():-.. Barnason S, Graham J, Wild C, et al. Comparison of two endotracheal tube securement techniques on unplanned extubation, oral mucosa, and facial skin integrity. Heart Lung. 99;():9-.. Dillman D. Mail and Internet Surveys the Tailored Design Method. nd ed. New York: John Wiley & Sons, Incorporated;.. Tablan O, Anderson L, Besser R, Bridges C, Hajjeh R.. Guidelines for preventing health-care associated pneumonia. Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC). Accessed December 9, 9.. Rello J, Ollendorf D, Oster G, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. ;():-.. Craven D, Kunches L, Kilinsky V, Lichtenberg D, Make B, McCabe W. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis. 9;:9-9. To purchase electronic or print reprints, contact The InnoVision Group, Columbia, Aliso Viejo, CA 9. Phone, () 99- or (99) - (ext ); fax, (99) -9; , reprints@aacn.org. AJCC AMERICAN JOURL OF CRITICAL CARE, March, Volume 9, No.