Regardless of mixed findings, the studies reveal that regular use of chlorhexidine in ventilatory patients, especially in the ICU is useful in the prevention of ventilator-acquired pneumonia. The condition is common among patients who use the ventilator because of their critical illness. Therefore, it is important to implement effective interventions to prevent the infection and related costs, such as extended hospitalization and the disease burden and cost. From the reviewed evidence, only Kusahara, Peterlini, & Pedreira (2012) failed to find evidence of the efficacy of the use of chlorhexidine in the prevention of VAP. However, the difference between the study and others involves the use of a sample of mechanically ventilated children instead of adults. The remaining studies revealed that the intervention helps, to a greater extent, to prevent the acquisition or progression of VAP in ventilatory patients, especially in the ICU.
Therefore, from the evidence, the proposed best practice is the regular use of chlorhexidine in ventilatory patients, especially in the ICU. The research shows that oral usage of chlorhexidine is closely related to the prevention of the incidence of VAP (Enwere, Elofson, Forbes, & Gerlach, 2016). According to the study, prophylactic chlorhexidine mouthwash can effectively prevent VAP if used as part of the routine treatment of ventilatory patients. The retrospective study compared two groups, one that received the intervention and the other that did not receive prophylaxis. The intervention group revealed a considerable reduction in the possibility of acquiring VAP and reduction in Pseudomonas infections. Furthermore, the results revealed a reduction in the cost of care associated with disease management using antibiotic. Evidently, the study shows the need for hospitals to implement regular use of the intervention to prevent VAP in ventilatory patients.
Similarly, positive results were evident in studies that used a systematic review of evidence from randomized controlled studies. In the studies by Buckley et al. (2013) and Snyders, Khondowe and Bell, (2011) evidence is available to affirm the regular use of chlorhexidine as an intervention in the prevention of VAP in ventilatory patients. According to Buckley et al. (2013), regardless of mixed findings in the reviewed studies, there is adequate evidence to show the effectiveness of the use of chlorhexidine in the prevention of VAP. Snyders, Khondowe, and Bell (2011) affirm the findings from eight RCTs that were reviewed in the study. Chlorhexidine has been proved beneficial in preventing VAP, which means that it should be regularly used in practice to reduce the prevalence of VAP and save patients from the negative effects of the infection.
The studies provide information about the correct implementation of the intervention in practice. Snyders, Khondowe, and Bell, (2011) used reliable and valid evidence to show that 2% chlorhexidine is the most effective in the prevention of ventilator-acquired pneumonia. Furthermore, the studies reveal the importance of including chlorhexidine as part of the regular VAP bundle to control the infection in the intensive care unit where patients use the ventilator as part of their treatment (Enwere, Elofson, Forbes, & Gerlach, 2016). Thus, the intervention should especially be used in areas where VAP is common among hospitalized patients to reduce the cost and burden of care for individual patients, their families, and healthcare organizations. Besides, nurses should learn about the importance and use of oral chlorhexidine as part of the treatment of ventilatory patients, especially in the ICU.
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Evaluation Table
Use this document to complete the evaluation table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical Appraisal of Research
| Full citation of selected article | Article #1 | Article #2 | Article #3 | Article #4 |
| Buckley, M. S., Dzierba, A. L., Smithburger, P. L., McAllen, K. J., Jordan, C. J., & Kane-Gill, S. L. (2013). Chlorhexidine for the prevention of ventilator-associated pneumonia in critically ill adults. Journal of Infection Prevention, 14(5), 162–169.
|
Enwere, E. N., Elofson, K. A., Forbes, R. C., & Gerlach, A. T. (2016). Impact of chlorhexidine mouthwash prophylaxis on probable ventilator-associated pneumonia in a surgical intensive care unit. International Journal of Critical Illness & Injury Science, 6(1), 3–8 | Kusahara, D. M., Peterlini, M. A. S., & Pedreira, M. L. G. (2012). Oral care with 0.12% chlorhexidine for the prevention of ventilator-associated pneumonia in critically ill children: Randomised, controlled and double-blind trial. International Journal of Nursing Studies, 49(11), 1354–1363. | Snyders, O., Khondowe, O., & Bell, J. (2011). Oral chlorhexidine in the prevention of ventilator-associated pneumonia in critically ill adults in the ICU: A systematic review. Southern African Journal of Critical Care, 27(2), 48–56 | |
| Conceptual Framework
Describe the theoretical basis for the study
|
None is given
|
None is given | None is given | None is given |
| Design/Method Describe the design
and how the study was carried out
|
A systematic review of the controlled trials | A retrospective cohort study and data was collected using statistical tests. | Randomized controlled trial | A systematic review of the controlled trials |
| Sample/Setting
The number and characteristics of patients, the attrition rate, etc. |
A systematic review of the literature by using online databases. | 158 patients in a 44-bed SICU in a University Medical Center. | 96 mechanically ventilated children. The participants were assigned to two groups: chlorhexidine and control groups. | Eight randomized controlled trials investigating the efficacy of oral chlorhexidine |
| Major Variables Studied
List and define dependent and independent variables |
Chlorhexidine is the independent variable and intervention, while ventilator-associated pneumonia is the dependent variable | Dependent variable: ventilator acquired pneumonia occurring >48 hours following endotracheal intubation
Independent variable: chlorhexidine mouthwash (intervention in the prevention of chlorhexidine mouthwash AP). |
Independent variable: Oral chlorhexidine
Dependent variable: ventilator associated pneumonia in children |
Independent variable: Oral chlorhexidine
Dependent variable: ventilator associated pneumonia |
| Measurement
Identify primary statistics used to answer clinical questions |
None because the research used a systematic review of literature | Statistical Package for Social Sciences (SPSS) version 20 (IBM Armonk, NY | Descriptive statistical analysis | None because the research used a systematic review of literature |
| Data Analysis
Statistical or qualitative findings |
A systematic review of evidence from RCTs | Chi-square statistics and Fisher’s exact test | Chi-square Fisher’s exact test | A systematic review of evidence from RCTs |
| Findings and Recommendations
General findings and recommendations of the research |
Numerous clinical trials have evaluated the use of chlorhexidine in preventing VAP. The contrasting results from these studies warrant further research. | Patients using chlorhexidine mouthwash had a 69.1 percent reduction in infections of the track.
The results revealed a decrease in the cost of treatment using antibiotics. However, additional research is ncesary to establish the extent of the cost reduction. |
The study revealed that utilization of 0.12% chlorhexidine did not have a significant effect on VAP incidence in the participants.
|
There was a 36% higher chance of VAP in the control group compared with the chlorhexidine group (RR 0.64, 95% CI 0.44 – 0.91). |
| Appraisal
Describe the general worth of this research to practice. What are the strengths and limitations of study? What are the risks associated with implementation of the suggested practices or processes detailed in the research? What is the feasibility of use in your practice? |
The study is useful in further research because it provides quality evidence from previously conducted RCTs. Although the results are mixed on the efficacy of the intervention, the findings can be used in practice. | The study is consistent with previous ones that indicated the importance of chlorhexidine in the prevention of VAP. The statistical tests used confirm the validity, hence the strength of the study. The results can be used in practice. | The study rated well in terms of validity and reliability because of the use of statistical methods on a randomized controlled study. However, the findings can only be used in research because they failed to reveal a positive effect of the intervention. | The review revealed a positive effect of chlorhexidine in the prevention of VAP. It provides evidence from previous studies, which is reliable and valid. |
| General Notes/Comments | The article provides reliable data for use in further research and practice.
|
The article provides reliable and valid findings for use in the management of VAP. | The article failed to provide evidence for the use of the prevention of VAP in children | The review of literature offers reliable and valid findings for use in the management of VAP. |
Levels of Evidence Table
Use this document to complete the levels of evidence table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical Appraisal of Research
| Author and year of selected article | Article #1 | Article #2 | Article #3 | Article #4 |
| Buckley, Dzierba, Smithburger, McAllen, Jordan, & Kane-Gill (2013). | Enwere, Elofson, Forbes, & Gerlach (2016). | Kusahara, Peterlini, & Pedreira (2012). | Snyders, Khondowe & Bell, (2011). | |
| Study Design
Theoretical basis for the study
|
A systematic review of the controlled trials
|
A retrospective cohort study and data was collected using statistical tests. | Randomized controlled and double-blinded trial | A systematic review of the controlled trials
|
| Sample/Setting
The number and characteristics of patients |
A systematic review of the literature by using online databases. | 158 patients in a 44-bed SICU in a University Medical Center. | 96 mechanically ventilated children. The participants were assigned to two groups: chlorhexidine and control groups. | Eight randomized controlled trials investigating the efficacy of oral chlorhexidine |
| Evidence Level *
(I, II, or III)
|
Level 1 evidence because it is a systematic review of RCTs
|
Level IV evidence because it is a retrospective cohort study. | Level II evidence because it is a randomized controlled trial.
|
level 1 evidence because it is a systematic review of RCTs |
| Outcomes
|
Many clinical trials have evaluated the use of chlorhexidine in preventing VAP. The contrasting results from these studies warrant further research | Patients who received chlorhexidine mouthwash demonstrated a 69.1% reduction in respiratory tract infections.
|
Patients using chlorhexidine mouthwash had a 69.1 percent reduction in infections of the track.
|
The study revealed a 36% higher possibility of VAP in the group that did not receive the treatment compared to the treatment group.
|
| General Notes/Comments | The article provides reliable data for use in further research and practice.
|
The article provides reliable and valid findings for use in the management of VAP. | The article failed to provide evidence for the use of the prevention of VAP in children. | The review of literature provides reliable and valid findings for use in the management of VAP. |
* Evidence Levels:
- Level I
Experimental, randomized controlled trial (RCT), systematic review RTCs with or without meta-analysis
- Level II
Quasi-experimental studies, a systematic review of a combination of RCTs and quasi-experimental studies, or quasi-experimental studies only, with or without meta-analysis
- Level III
Nonexperimental, a systematic review of RCTs, quasi-experimental with/without meta-analysis, a qualitative, qualitative systematic review with/without meta-synthesis
- Level IV
Respected authorities’ opinions, nationally recognized expert committee/consensus panel reports based on scientific evidence
- Level V
Literature reviews, quality improvement, program evaluation, financial evaluation, case reports, nationally recognized expert(s) opinion based on experiential evidence
Outcomes Synthesis Table
Use this document to complete the outcomes synthesis table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical Appraisal of Research
| Author and year of selected article | Article #1 | Article #2 | Article #3 | Article #4 |
|
Buckley, Dzierba, Smithburger, McAllen, Jordan, & Kane-Gill (2013).
|
Enwere, Elofson, Forbes, & Gerlach (2016). | Kusahara, Peterlini, & Pedreira (2012). | Snyders, Khondowe & Bell, (2011). | |
| Sample/Setting
The number and characteristics of patients |
A systematic review of the literature on RCTs using online databases. | 158 patients in a 44-bed SICU in a University Medical Center. | 96 mechanically ventilated children. The participants were assigned to two groups: chlorhexidine and control groups. | Eight randomized controlled trials investigating the efficacy of oral chlorhexidine |
| Outcomes
|
Numerous clinical trials have evaluated the use of chlorhexidine in preventing VAP. The contrasting results from these studies warrant further research. | Patients using chlorhexidine mouthwash had a 69.1 percent reduction in infections of the track.
|
The study revealed that utilization of 0.12% chlorhexidine did not have a significant effect on VAP incidence in the participants.
|
The study revealed a 36% higher possibility of VAP in the group that did not receive the treatment compared to the treatment group.
|
| Key Findings
|
The article provides mixed findings from the reviewed literature on the use of chlorhexidine in preventing VAP. | The results revealed a decrease in the cost of treatment using antibiotics. However, additional research is ncesary to establish the extent of the cost reduction. | The treatment did not have any significant impact on the prevention of VAP among chidren.
|
The article provides evidence on the effectiveness of chlorhexidine in the prevention of VAP |
| Appraisal and Study Quality
|
Regardless of the mixed results, the study is useful in research and practice because it involves a review of various findings. | The study used statistical tests to establish the effect of chlorhexidine mouthwash on VAP. Furthermore, the use of pre-post tests confirmed the quality of the study. | The design and data collection are indicative of a quality study. However, the results cannot be used in practice because of the lack of efficacy of the intervention. | The study is useful in research and practice because it involves a review of previous evidence on the efficacy of chlorhexidine in the prevention of VAP. |
| General Notes/Comments | The article provides reliable data for use in further research and practice.
|
The results of the study provide statistical evidence that can be used in other settings to prevent VAP. | The article failed to provide evidence for the use of the prevention of VAP in children. | The review of literature provides reliable and valid findings for use in the management of VAP. |
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