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Vol. 23, No. 8, AUGUST 2006

Practice Alert:

The goal of the AACN Practice Alerts is to help nurses and other healthcare practitioners carry their bold voices to the bedside to directly impact patient care. Practice Alerts are directives from AACN that are supported by authoritative evidence to ensure excellence in practice and a safe and humane work environment.

Expected Practice:
• Develop and implement a comprehensive oral hygiene program for patients in critical care and acute care settings who are at high risk for healthcare-associated pneumonia.
—Brush teeth, gums and tongue at least twice a day using a soft pediatric or adult toothbrush
—In addition to brushing, provide oral moisturizing to oral mucosa and lips every 2 to 4 hours.
—Use an oral chorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for adult patients who undergo cardiac surgery.

Supporting Evidence:
• Colonization of the oropharynx is a critical factor in the development of nosocomial pneumonia.1-3 Growth of potentially pathogenic bacteria in dental plaque provides a nidus of infection for microorganisms that have been shown to be responsible for the development of ventilator-associated pneumonia (VAP).2-4 Dental plaque provides a microhabitat for organisms, and provides opportunity for adherence either to the tooth surface or to other microorganisms. These microorganisms in the mouth translocate and colonize the lung, which can result in VAP.3,5 Dental plaque can be removed by brushing. (Level V)
—Whereas there are no data associated with critically ill patients, the American Dental Association recommends that healthy people brush teeth twice daily to remove plaque from all tooth surfaces.6 (Level VI)
—The use of an oral care protocol (brushing with a pediatric toothbrush, mouthwash, and moisturizing gel) reduced oral inflammation and improved oral health.7 (Level IV)
• Chlorhexidine oral rinse reduced respiratory infections in cardiac surgery patients who received chlorhexidine before intubation as well as postoperatively8 and reduced nosocomial pneumonia in patients who were intubated for more than 24 hours.9 However, when chlorhexidine was tested in a more varied ICU population, no difference was observed in VAP, mortality, or length of stay. Although oropharyngeal colonization by VAP pathogens was reduced with chlorhexidine, its efficacy was insufficient to reduce the incidence of respiratory infections.10 A recent meta-analysis of chlorhexidine trials found that use of chlorhexidine did not result in significant reduction in the incidence of nosocomial pneumonia, nor in alteration of the mortality rate.11 The CDC [Centers for Disease Control and Prevention] guidelines recommend use of chlorhexidine only during the perioperative period for adult patients undergoing cardiac surgery; routine use in other critically ill populations is not recommended.12 (Level V)
• Several studies have tested intervention bundles that included oral care as one of the interventions.13-14 Whereas these studies demonstrated that bundled interventions decreased nosocomial respiratory infections, the contribution of oral care to the results could not be determined. (Level IV)
• To date, no data have been published from large, well-controlled clinical trials of oral care interventions in critical care patients other than chlorhexidine studies. There are limited clinical reports of infection rates before and after changes in oral care procedures but these reports have not been published in refereed journals. Whereas some reports have shown a positive effect, the role of oral care in reducing nosocomial pneumonia is not clearly established by such projects, and it is possible that other changes in care occurred in the units and affected the results.

What You Should Do:
• Ensure that your unit has written practice documents such as a policy, procedure or standard of care that describes the oral care procedure.
• Document frequency of oral care differentiating between comprehensive oral care (including brushing) and oral cavity moisturizing.
• Include the oral care procedure as part of unit orientation to ensure consistency of care.

AACN Grading Level of Evidence:
Level I: Manufacturer’s recommendations only
Level II: Theory based, no research data to support recommendations:
Recommendations from expert consensus group may exist
Level III: Laboratory data, no clinical data to support recommendations
Level IV: Limited clinical studies to support recommendations
Level V: Clinical studies in more than one or two patient populations and situations to support recommendations
Level VI: Clinical studies in a variety of patient populations and situations to support recommendations.

1. Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care. 2004;13:25-33.
2. Fourrier F, Duvivier B, Boutigny H, Rourrel-Delvallez M, Chopin C. Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Crit Care Med. 1998;26:301-308.
3. Garrouste OM, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients: a prospective study based on genomic DNA analysis. Am J Respir Crit Care Med. 1997;156:1647-1655.
4. Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med. 1992;20:740-745.
5. El-Solh AA, Pietrantoni C, Bhat A, et al. Colonization of dental plaque: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Am J Respir Crit Care Med. 2004;126:1575-1582.
6. American Dental Association. Oral Health Topics: Cleaning your teeth and gums (oral hygiene). Accessed June 27, 2006.
7. Fitch JA, Munro CL, Glass CA, Pellegrini JM. Oral care in the adult intensive care unit. Am J Crit Care. 1999;8:314-318.
8. DeRiso AJ, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Am J Respir Crit Care Med. 1996;109:1556-1561.
9. Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care. 2002;11:567-570.
10. Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med. 2005;33:1728-1735.
11. Pineda LA, Saliba RG, El Solh AA. Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care. 2006;10:R35.
12. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, and the CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing healthcare-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.
13. Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30:2407-2412.
14. Simmons-Trau D, Cenek P, Counterman J, Hockenbury D, Litwiller L. Reducing VAP with 6 Sigma. Nurs Manage. 2004;35:41-45.

Debra K. Moser, DNSc, RN, FAAN, is the recipient of the 2007 AACN Distinguished Research Lecture award. Moser’s research focuses on the interaction between cognitive/psychological/ behavioral factors and physical outcomes in critically ill patients with cardiac disease. She was first to demonstrate the physiologic, clinical and psychological benefits of cognitive, biobehavioral intervention—biofeedback/relaxation—in patients with advanced heart failure.

Since 1989, Moser’s research has been instrumental in demonstrating that nursing education and counseling intervention improves re-hospitalization rates, costs and quality of life in heart failure patients with both preserved and no-preserved systolic function. Her work has directly impacted the care of patients with heart failure and acute myocardial infarction and has contributed to changes in the practice. In addition, she and her colleagues have conducted more than 25 landmark studies on every aspect of anxiety in critically ill patients.

Currently, Moser is testing non-pharmacological interventions that bring a unique and needed nursing perspective to the treatment of patients with heart failure. Her work is a major step toward an integrated, interdisciplinary approach that includes critical care nursing perspectives as an essential part of caring for these patients. A renowned speaker and writer, Moser gives lectures nationally and internationally and is widely published in interdisciplinary journals (122 peer-reviewed articles at last count) on topics related to her research.

Part of AACN’s Circle of Excellence recognition program, the Distinguished Research Lecture Award honors a nationally known researcher who has made significant contributions to acute and critical care research; is known for publications, presentations and mentorship relevant to acute and critical care; and is viewed as a consultant in his or her area of expertise.

Nominations for 2008 Lecture
Dec.1, 2006, is the deadline to apply for the 2008 AACN Distinguished Research Lecture Award. The recipient will present the Distinguished Research Lecture at NTI 2008 in Chicago, Ill.

The lecturer receives an honorarium of $1,000, an additional $1,000 toward NTI expenses and a crystal replica of the AACN vision icon. Distinguished Research Lecture award winners are selected based on several criteria: a continued body of research, publications, mentorship in research relevant to acute and critical care, and significant contributions made to acute and critical care research. The award is sponsored by Philips Medical Systems. Those interested in applying may e-mail research@aacn.org.

Practice Resource Network


We are instituting a new intensive insulin protocol for critically ill patients in our combined medical/surgical ICU. Our goal is to have a fingerstick glucose level between 80 and 100 mg/dL. This level seems low, and we are worried about our patients becoming hypoglycemic. Do you have any information to assist us as we develop these protocols?


The number of hospitalized patients with diabetes is unknown but is estimated between 12% and 25%.1 As a comorbidity, diabetes may result in devastating outcomes for hospitalized patients. Patients with elevated glucose levels fall into 3 categories:
• Medical history of diabetes – pre-existing condition, known diabetic
• Unrecognized diabetes (fasting blood glucose level 126 mg/dL or higher OR random blood glucose level 200 mg/dL or higher during hospitalization) that is confirmed after discharge from the hospital
• Hospital-related hyperglycemia with the same levels as above but the glucose level returns to normal after discharge from the hospital.1

Since the late 1990s, several studies have looked at the effectiveness of maintaining tight glucose control in hospitalized patients. The DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) study was one of the first. This study showed an improved long-term prognosis in diabetic patients following an acute MI when tight control of glucose was maintained.2 In 2001 a large randomized controlled study (Leuven Study) by van den Berghe et al demonstrated that maintaining tight glycemic control using an intensive insulin infusion protocol improved clinical outcomes in patients who were admitted to a surgical ICU. This study showed that by maintaining a blood glucose level between 80 and 110 mg/dL, ICU mortality was reduced by 42%. Additionally, van den Berghe and colleagues found a reduction in bloodstream infections, acute renal failure, the need for prolonged ventilatory support, and the duration of the ICU stay.3 In 2003, Furnary et al published findings that demonstrated that blood glucose levels lower than 150 mg/dL decreased mortality in postoperative open heart surgery patients. Other findings indicated that glucose levels lower than 175 mg/dL significantly reduced the incidence of infection, and glucose levels less than 125 mg/dL decreased the incidence of postoperative atrial fibrillation.4 In February 2006, van den Berghe et al published findings on a study indicating intensive insulin therapy significantly reduced morbidity in medical ICU patients.5 In February 2006, the American Association of Clinical Endocrinologists and the American Diabetes Association published a position paper advocating keeping blood glucose levels as close to 110 mg/dl as possible for critically ill patients. Their recommendations include developing tight glycemic control protocols not only in the ICU but in other areas of the hospital as well.1 The Institute for Healthcare Improvement has identified the implementation of an effective glucose control program as an effective intervention for improving the care of ICU patients.6

In van den Berghe’s initial study, hypoglycemia occurred in 5.2% of patients receiving intensive insulin therapy. A plan for treating hypoglycemia should be established for each patient, and each episode should be tracked for quality improvement.5

With such overwhelming evidence to support the use of intensive insulin therapies in the ICU several items should be considered. Characteristics of ideal protocols┬║:
• Easily ordered (requires a physician signature only)
• Effective (brings glucose level quickly to goal levels)
• Safe (presents minimal risk of hypoglycemia)
• Easily implemented
• Able to be used on a hospital-wide basis

Components of intravenous insulin therapy include:1
• Regular insulin in concentrations of 1 unit/mL or 0.5 unit/mL
• Infusion controller adjustable in 0.1 unit/mL doses
• Accurate hourly bedside glucose monitoring (every 2 hours if patients are stable)
• Potassium levels should be monitored and potassium administered if necessary

Developing an intensive insulin therapy protocol is best achieved through a multidisciplinary team with administrative support. Nurses, pharmacists, physicians, diabetes educators, and clinical nurse specialists are essential members of the team.

Other things to consider when implementing a new protocol:
• Are there enough glucose meters and IV pumps to meet the demands of your patient population?
• How will patients on total parenteral nutrition or enteral feedings be managed?
• How and when will patients transition from continuous IV insulin to subcutaneous insulin?
• How is the protocol affected for patients on multiple vasoactive infusions or those receiving steroid therapy?

To get started, several well accepted protocols are available in the literature and on the Internet. You can find more information at:
• Institute for Healthcare Improvement, www.ihi.org
• American Diabetes Association, www.diabetes.org
• American Association of Clinical Endocrinologists, www.aace.com
• Atlanta Diabetes Association, www.adaendo.com—a clearinghouse of presentations and information on a variety of protocols and studies
• www.glycemiccontrol.net—a clearinghouse for information that includes links to published protocols such as the Yale and Portland protocols7
• www.glucommander.com—information about the Glucommander computer device and protocol7
• www.providence.org/portlandprotocol - a clearinghouse by the Providence Heart and Vascular Institute, which includes the Portland protocol and other resources7

1. American Diabetes Association. Standards of medical care in diabetes—2006. Diabetes Care. 2006;29(suppl):S1-S42.
2. Bode BW, Braithwaite SS, Steed RD, et al. IV insulin infusion therapy: indications, thresholds and target range glucose, protocols and methodology transition to subcutaneous insulin. Atlanta Diabetes Association Web site. Available at: http://www.adaendo.com/bode.htm.
Accessed June 24, 2006.
3. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Eng J Med. 2001;345:1359-1367.
4. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1007-1021.
5. van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Eng J Med. 2006;354:449-461.
6. Implement effective glucose control. Institute for Healthcare Improvement Web site. Available at: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementEffectiveGlucoseControl.htm. Accessed June 24, 2006.
7. Smith SD. Not too high, not too low. Minn Med [serial online]. September 2005;88. Available at: http://www.mmaonline.net/publications/MNMed2005/September/Quality.htm. Accessed June 24, 2006.

Do you have a practice-related question? Call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or e-mail practice@aacn.org.

Work Groups Focus on Association Initiatives

National AACN work groups will convene later this month to continue work on association initiatives in specific subject areas. The group members were selected from the pool of volunteers who registered in AACN’s just-in-time Volunteer Profile Database online (www.aacn.org > About AACN > Volunteer Opportunities).

Following are the appointments as well as the board and staff liaisons for 2006-07.

Advanced Practice Work Group
Nancy L. Munro, RN, MN, MS, CCRN, ACNP, APRN (chair)
Laurie A. Baumgartner, RN, RNP, CNS, MS, MSN, CCRN-CSC, APRN, ACNP-C, RN-BC
Karen A. Cuipylo, RN, MS, CCRN, CCNS
Laura K. Kierol-Andrews, RN, PhD, ACNP, APRN, RN-BC
Sheila Melander, DSN, ScD, ACNP, APRN
Lauren Van Saders, RN, MS, MSN, CS, APRN, RN-BC
Paula A. Lusardi, RN, PhD, CCRN, CCNS (board liaison)
Linda J. Bell, RN, MSN (staff liaison)

Ethics Work Group
Debra Lynn-McHale Wiegand, RN, PhD, CCRN, CRN, FAAN (chair)
Joan B. Harvey, RN, MN, MS, CCRN
Peggy G. Kalowes, RN, MS, MSN, CNRN
Rosemary Lee, RN, MSN, CCRN, CCNS, CRN
Elizabeth A. Mann, RN, MN, MS, CCNS, CRN
Christine G. Westphal, RN, MS, MSN, CCRN, APRN, CRN, APRN-BC RN-BC
Lucia D. Wocial, RN, MSN, BA, PhD, CCNS
Roberta Kaplow, RN, PhD, CCRN, CCNS (board liaison)
Teresa A. Wavra, RN, MSN (staff liaison)

NTI Work Group
Kathleen M. Schatz, RN, MSN, APRN (chair)
Cheri S. Blevins, RN, BSN, CCRN
Karen K. Carlson, RN, MN, CCNS
Beth A. Glassford, RN, MS, CHE
Rizalina V. Mauricio, RN, MN, MS, CCRN, APRN, PNP
Barbara B. Pope, RN, MS, MSN, CCRN, CCNS
Kathryn E. Roberts, RN, RNP, MS, MSN, CCRN, CCNS, PNP
Paula A. Lusardi, RN, PhD, CCRN, CCNS (board liaison)
Bonnie L. Baker, RN, MHA (staff liaison)

Healthy Work Environment Standards Work Group
Connie Barden, RN, CNS, MN, CCRN, CCNS, CRN (chair)
Sonia M. Astle, RN, CNS, MS, CCRN, CCNS, CS, CRN
Nancy T. Blake, RN, MN, MS, CCRN, CNA
Sharon Bragg, RN, BSN, CCRN
Mary K. Jaco, RN, MS, MSN, CNA, CNAA
Lisa A. Manni, RN, MSN, CCRN
Mary Frances D. Pate, RN, CNS, DSN
Heather Russell, RN, MN, MHM
Faye Q. Sabado, RN, MS, MSN, CCRN, CRN
Janice M. Wojcik, RN, MS, CCRN, APRN, ACNP-C, APN, RN-BC (board liaison)
Dana K. Woods, MBA (staff liaison)

Research Work Group
Christine L. Schulman, RN, CNS, MS, CCRN (chair)
Annette M. Bourgault, RN, MS, MSN, CCNCc
Lisa A. Falcon, RN, BS, BSN, CCRN, CRN
Margo Anne Halm, RN, RNP, DSN, PhD, CCRN, RN-BC, FAHA
Linda L. Henry, RN, PhD, CCRN
Kathryn R. Small, RN, MS, CCRN, ACNP, CNP, CRN, NP
Mona P. Ternus, RN, CNS, MN, PhD, CCRN
Patricia Morton, RN, PhD, NP, FAAN (board liaison)
Justine L. Medina, RN, MS (staff liaison)

Public Policy Update

HHS Announces $15- Million Prevention Initiative for Seniors
The Department of Health and Human Services has announced a $15 million public-private collaborative to help seniors better manage chronic diseases, eat better, exercise more and avoid injuries such as falls.

HHS’ Administration on Aging will provide grants to support evidence-based interventions in up to 12 states for three years, subject to available funding. Community-based aging services providers will work with health organizations and other partners to promote the programs. In addition, the Atlantic Philanthropies will provide up to $5 million in funding and technical support to up to five states with the potential to reach large numbers of older adults.

For more information, go to www.hhs.gov/news/press/2006pres/20060705.html.

Input Sought on Online Patient Safety Practices Resource
The Joint Commission International Center for Patient Safety is developing an online patient safety practices database with more than 500 links to national and international patient safety Web sites.

The site provides tips, tools and resources to address patient safety problems. The problem categories and topics have been culled from the Joint Commission’s Sentinel Event Database.

The commission is encouraging user feedback on the site’s content and functionality. Visitors are invited to submit comments as well as suggest additional links for consideration. A brief opinion survey is included at www.jcipatientsafety.org/show.asp?durki=11787.

JCAHO Issues Infection Control Standard on Influenza Vaccines
JCAHO has approved an infection control standard that requires accredited organizations to offer influenza vaccinations to staff, including volunteers, and licensed independent practitioners with close patient contact.

Saying that preventing the spread of the flu protects patients and saves lives, JCAHO noted that immunization of healthcare workers can play a vital role in stopping the transmission of this potentially fatal infection. Healthcare-associated transmission of influenza has been documented among many patient populations in a variety of clinical settings, and infections have been linked epidemiologically to unvaccinated healthcare workers. However, fewer than 40 percent of healthcare workers are immunized each year.

The JCAHO statement is available at www.jointcommission.org > Patient Safety > Infection Control. Search for Influenza and read the June 16 statement.

Citizens’ Group Proposes Standards for Health Reform
The Citizens’ Health Care Working Group, established by Congress to conduct public discussion about the nation’s health system, has released interim recommendations following feedback from 75 community meetings, online polls and letters.

The group said it should be public policy that all Americans have affordable healthcare and that a defined, core benefit package as well as protections against catastrophic costs should be available to everyone. In addition, the group said a majority of participants backed federal support for public-private networks aimed at caring for vulnerable populations and those living in underserved areas; more intense federal efforts to improve healthcare quality and efficiency; and increased access to palliative care and other end-of-life services.
Read the interim recommendations at www.citizenshealthcare.gov/.

For more information about these and other issues, visit the AACN Web site.


Oct. 1 is the deadline to apply for three AACN nursing research grants.

AACN Clinical Practice Grant
This $6,000 grant supports research focused on one or more AACN research priorities. Research conducted in fulfillment of an academic degree is acceptable.

AACN-Sigma Theta Tau Critical Care Grant
AACN and Sigma Theta Tau International cosponsor this $10,000 grant. The grant may be used to fund research for an academic degree. Principal investigators must be members of AACN and/or of Sigma Theta Tau International.

Evidence-based Clinical Practice Grant
This grant funds six awards of up to $1,000 each to stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice.

To find out about AACN’s research priorities and grant opportunities, visit the Research area of the AACN Web sites or e-mail research@aacn.org.

Is Your Unit a Beacon of Excellence?

The AACN Beacon Award for Critical Care Excellence shines national recognition on units that attain high standards for quality, exceptional care of patients, and healthy, humane and healing work environments.

The Web-based application process asks you to evaluate your critical care unit in six areas:

• Recruitment and retention
• Education, training and mentoring
• Evidence-based practices
• Patient outcomes
• Healing environments
• Leadership and organizational ethics

Applications, which may be submitted at any time, are evaluated on a quarterly basis. Awards are granted twice a year. The application fee is $1,000 per unit.

For more information, visit the AACN Web site.

Research and Creative Solutions Abstracts Invited for NTI 2007

AACN is inviting abstracts for presentation at the National Teaching Institute & Critical Care Exposition, May 19 through 24 in Atlanta, Ga.

Selected abstracts will be exhibited as either a poster or an oral presentation. Individuals whose abstracts are accepted will receive a $75 reduction in NTI registration fees.

Four research abstracts will also be selected to receive the Research Abstract Award. This award recognizes individuals whose abstracts reflect outstanding original research, replication research or research utilization. Each of the award recipients will present his or her findings at one of the research oral presentation sessions at NTI and will also receive an additional $1,000 toward NTI expenses.

Sept. 1, 2006, is the deadline to submit research abstracts.

The applications, guidelines and resources are available online at www.aacn.org > Research > NTI Abstracts.
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