Construction Of The Oral Care Procedure In Intubated Patients Receiving Mechanical Ventilation Through The Mouth And Its Empirical Study

Objective:Using evidence-based nursing(EBN)theories and methodologies,we designed an oral care procedure for patients receiving mechanical ventilation(MV)through the mouth,and evaluated its effect on clinical application.By developing and implementing programs,we helped nurses become evidence-based practitioners who would personalize oral care interventions for patients with MV.Through these efforts,we could improve the oral health for MV patients and reduce the incidence of complications including oral infection and ventilator-associated pneumonia(VAP),providing recommendations for improving the quality of oral care of patients with MV.We would explore the use of modern biotechnology clinical nursing research and provided new opportunities for improving clinical care.Methods:1.Using EBN and clinical trials research methods,we provided high-quality evidence and practical basis for MV patients with oral care programs.We looked over intubated patient-related oral care guidelines and systematic reviews,assess their quality using the AGREE system and the OQAQ standard,and summarized high quality evidence for intubated patients.We conducted a systematic evaluation for the detection of oropharyngeal bacterial colonization,analyzed the accuracy and effectiveness of current procedures for detecting oral bacterial colonization,and compared the results of a range of detection approaches as previously reported.Based on the systematic evaluation for the detection of bacterial colonization in MV patients,we performed 16 Sr DNA gene sequencing to analyze the composition of bacterial population from the lower respiratory tract and oropharyngeal secretions of VAP patients,compared routine bacterial culture with positive result,and assessed the accuracy of two analysis methods.2.According to the high quality evidence and practice of oral care for MV patients,we would propose the oral care procedure for MV patients after the panel discussion by ICU nurses and expert consulting.3.An empirical study of MV patients with oral care.Three weeks before the clinical application for MV patients with oral care,nurses who participated in research study received the training and evaluation of oral care knowledge and skills.Using the methodology of the non-randomized controlled trial,we enrolled the MV patients who met the inclusion criteriafor the study from a 3A-level hospital in Jiangsu Province from July to October in 2015.MV Patients enrolled during July-August into control group received routine care according to the procedure for intubated patient with oral care described in "Clinical Nursing Practice Guidelines(2011 Edition)",while intervention patients enrolled during September-October received the individual oral care procedure.The two groups of patients were compared based on a broad range of indicators including patient's halitosis,plaque index,oropharyngeal infection,VAP incidence,total tracheal intubation time,length of stay in the ICU,and total hospital cost.SPSS17.0 statistical software was used for data processing and analysis.Results:1.We set the inclusion criteria and found 6 guidelines,10 systematic reviews and 7Meta analyses on the MV patients with oral care from the databases,such as NGC.We applied AGREE system to assess the quality of the guidelines,and used the OQAQ standard to evaluate the systematic reviews and Meta analyses.We summarized a total of 28 high quality evidences in 6 areas including the assessment of oral care,the methods and tools of oral care,oral care solution,the frequency of oral care,oral medications and oral care evaluation.By entering the words of oral bacterial colonization and detection methods' as the search term,we retrieved up to 177 papers from a series of databases.Excluding 97 papers,we read the abstracts and full texts of 80 papers.Then we ruled out 72 papers and carefully compared the results described in 7 papers.It concluded that 16 SrDNA sequencing is an ideal method for the detection of oral bacterial colonization.We applied 16 Sr DNA gene sequencing to identify bacterial populations in the lower respiratory tract and oropharyngeal secretions.The data indicated that two bacteria of Prevotella and Proteus were detected by 16 Sr DNA gene sequencing,while not routine bacterial culture.Both assays showed the presence of seven bacteria,in which Streptococcus,Klebsiella,Acinetobacter,Corynebacterium,Pseudomonas,Staphylococcus and Neisseriahad a significant higher detection rate using16 Sr DNA gene sequencing(P<0.05 and P<0.01).2.2.Based on the high quality and practical evidence,ICU nurse team had a discussion and proposed the oral care procedures for MV patients.After expert consulting,we conducted the evaluation,screening and revision and reached the final oral care procedure for MV patients.The entire procedure consisted of three elements–oral care assessment system,oral care intervention system,and oral care operational processes for MV patients.The three key factors in oral care assessment system were oral functional status,oral bacteria colonizationand plaque.On the basis of evidence-based research,we chose 4 objective quantitative assessments of oral care tools–a modified Beck Oral Assessment Scale(BOAS),the WHO clinical staging of oral ulcer,Plaque Index,and PH test strips.16 SrDNA gene sequencing was used as a detection technique of oral bacterial colonization.The oral intervention strategies for MV patients were presented in flowchart form.One flow chart was about the oral care intervention system before or after the oral microbial test of MV patients.The other flow chart of oral care operational processes included four technical operational procedures–wiping,rinsing-wiping,rinsing-brushing,and subglottic attract.3.We evaluated the nurse training on the oral care procedure for MV patients,and found that nurses who participated in research study made significant improvements in understanding oral care knowledge and skills prior to the clinical implementation.By looking into the effect of oral care procedure,we showed that this procedure could significantly improve the effectiveness and quality of care in MV patients.After oral care,the occurrence rate of halitosis,mouth ulcers and VAP were 12.5%,8.33%,and 8.3%,respectively.Oral functional status 6.52±1.968,oral PH value 6.76±0.45.The total tracheal intubation time was125.50±47.805 hours and the length of stay in the ICU was 9.42±3.6317 days.While in the control group,the occurrence rate of halitosis,mouth ulcers and VAP were 33.3%,21.57%,and 29.4%,respectively.Oral functional status 9.29±2.648,oral PH value 6.22±0.88.The total tracheal intubation time was 153.92±43.508 hours and the length of stay in the ICU was12.04±4.9191 days.Compared to control,all seven sets of parameters from the intervention group were lower,and the difference was statistically significant(P<0.05).Compared to control group,the distribution of Streptococcus,Neisseria,Corynebacterium,Acinetobacter,Pseudomonas,Klebsiella,and Prevotella in significantly decreased in oropharynx(P<0.05).There was no significant difference in the total hospital cost of between the intervention group and the control group(P>0.05).Conclusion:Through the evidence-based research of oral care for MV patients,the systematic evaluation and experimental investigation of oral bacterial colonization detection technology,the panel discussion by ICU nurses and expert consulting,we provided an optimized oral care procedure.Nurses who received the training made significant improvements in understanding oral care knowledge and skills.Implementation of the oral care procedure could significantly reduce the incidence of oral infection,plaque index and lung infection,shorten total trachealintubation time and ICU hospitalization time,and achieve an improved quality of oral care for MV patients.It is concluded that our empirical study confirms the importance of the development and implementation of clinical practice in MV patients with oral care.