Development Of Clinical Practice Guideline For Oral Care On Critically Ill Patients With Endotracheal Intubation

Background Endotracheal intubation is widely used in ICU patients, and ventilator-associated pneumonia (VAP) is a common and serious complication in mechanically ventilated critically ill patients. Various oral care interventions are demonstrated to be effective on reducing the incidence of VAP. The evidence-based clinical practice guideline (CPG) for oral care on critically ill patients with endotracheal intubation has not yet been established till now at home and abroad, resulting in the disjunction of the theory and clinical practice. It's urgent to apply the principle of evidence-based nursing on finding best evidence to develop CPG that could effectively guide the oral care practice for intubated patients in domestic critical care units.Objective This study aimed to explore the status quo of clinical oral care pactice for critically ill patients with endotracheal intubation, to investigate the existing problems and influencing factors, to appraise and synthesize evidence related to oral care, to develop evidence-based "Clinical practice guideline for oral care on critically ill patients with endotracheal intubation" and best practice information sheet (BPIS) and to preliminarily probe into its applicability. Then the CPG for oral care on Critically ill patients with endotracheal intubation was reviewed.Methods A survey for ICU nurses and in-depth interviews of key informants were conducted to explore the current oral practice for intubated patient in ICUs. Systematic review and meta-analysis was performed to synthesize evidence. The related evidence-based resources, clinical care operation specifications and hospital infection standard operating procedure (SOP) were also gathered. All above were synthesized and the clinical practice guideline for oral care on critically ill patients with endotracheal intubation was established. The frontline ICU nurses were chosen to probe into the applicability of this CPG, and then the clinical practice guideline for oral care on critically ill patients with endotracheal intubation was reviewed by experts according to the Appraisal of Guidelines Research&Evaluation System. Results1. The oral care practice status was showed through a questionnaire survey of195ICU front-line nurses and semi-structured in-depth interviews of10ICU nursing managers. The present ICU oral care operation specifications were obsolete and non-targeted, along with low degree of awareness, and the status quo of oral care implemention was in confusion. The knowledge and attitude of ICU nurses, oral care appliances, departments'attention, staffing and workload became dominant factors that affected the current oral care implemention for intubated patients. The next step should take full account of the current situation and existing problems and integrate evidence at home and abroad, to develop the localized CPG for oral care on critically ill patients with endotracheal intubation.2. Through comprehensive search of various databases and critical quality appraisal of all retrieved studies,32randomized controlled trials and6quasi-experimental studies were finally included. Information was integrated into three aspects of different oral care methods, solution and frequency, and effects of chlorhexidine and oral rinse were evaluated through various outcomes by meta-analysis, providing strong evidence for the next step of CPG development.3.17evidence-based researches related to oral care for critically ill patients with endotracheal intubation were retrieved from databases and websites, and10clinical oral care operation procedures and hospital infection SOP were collected and integrated from10different ICUs of7tertiary hospitals in Shanghai. All the resources were deeply digged and analyzed for the establishment of an evidence-based CPG.4. The results above, including cross-sectional study, qualitative interviews, systematic review and analysis of related resources, were all consolidated and synthesized, then a draft of clinical practice guideline and BPIS for oral care on critically ill patients with endotracheal intubation were developed, which mainly covered pre-nursing assessment of patients' mouths and selection of oral care solution, methods/appliances and frequency, a total of17recommendations.5.20ICU first-line nurses and ICU nursing managers were selected, from the general ICU and neurosurgery ICU of a tertiary hospital in Shanghai, and a small-scale investigation was performed to probe into the applicability of the clinical practice guideline for oral care on critically ill patients with endotracheal intubation. ICU nurses thought highly of its applicability and effectiveness, and also pointed out that problems might exist in hardware nursing-care equipment and human resources when applying part of the recommendations. The results of this investigation could provide the basis for the next step of experts' review.6. The CPG draft was reviewed by3experts according to the Appraisal of Guidelines Research&Evaluation System and the results of applicability investigation. The evaluation experts fully affirmed the rigor, independence and clarity of the CPG, and gave impartial appraisal and recommendations on clinical application and maneuverability of the CPG.Conclusion1. Oral care practice nowadays on critically ill patients with endotracheal intubation lacks scientific and effective standards, so evidence-based clinical practice guideline should be established, and great attention should be paid to cultivating ICU nurses' cognition and attitude, and improving oral care appliances.2. The clinical practice guideline for oral care on critically ill patients with endotracheal intubation is an evidence-based CPG based on domestic ICU status quo, best evidence, evidence-based resources and professionals' clinical expertise.