Determining how nurses living with their families decide to work in a COVID-19 intensive care unit: grounded theory study

Background: Ventilator-associated pneumonia (VAP) and post-extubation dysphagia (PED) are common complications in mechanically ventilated patients. Oral care, although recommended to prevent VAP, has limited evidence regarding its effectiveness in preventing PED, particularly during the intubation period.
Objective: To develop and evaluate a nurse-led, assessment-based oral care protocol that is free from chlorhexidine (CHX) and adjusts moisturizing frequency based on the patient's oral health status
Design: Quasi-experimental study
Setting: Emergency ICU of a university hospital.
Participants: Intubated adults (≥18 years; control n=50, intervention n=50).
Methods: The protocol integrated tooth brushing with Oral Health Assessment Tool (OHAT)-guided moisturizing, with intensified care implemented when any OHAT item scored 2. Primary outcomes included OHAT scores, oral moisture, and oral bacterial counts, which were measured over the first three days in the ICU. Secondary outcomes encompassed ventilator duration, ICU length of stay, VAP (IVAC), PED, and ICU mortality. Analyses employed the Mann–Whitney U test, Fisher’s exact test, logistic regression, and Kaplan–Meier survival analysis.
Results: Baseline characteristics were generally comparable between the groups. On day 3, the intervention group demonstrated significantly improved oral health compared with the control (OHAT scores, 1.88 vs. 5.20; moisture levels, 20.4 vs. 6.6; bacterial counts, 36.3 vs. 83.0, respectively; all p < .001). The duration of ventilation was shorter in the intervention group than in the control (5.0 days versus 9.5 days, respectively; p < .001), as was the length of ICU stay (8.0 days versus 11.0 days, respectively; p = .006). The incidence of PED was markedly reduced (4% versus 46%; adjusted odds ratio = 0.044, 95% confidence interval 0.009–0.209; number needed to treat = 3, p < .001). VAP occurred in 10% of the control group and in none of the intervention group; however, statistical significance was not achieved due to the limited number of events. Protocol adherence was 97.8%, with no adverse events reported.
Conclusions: The protocol was effective in preserving oral health, substantially reduced PED, and decreased the duration of mechanical ventilation and the length of ICU stay for critically ill, intubated patients. The implementation utilized cost-effective, commercially available materials and demonstrated high adherence rates, indicating that the protocol is both feasible and scalable. These findings highlight the significant role of critical care nursing in improving patient-centered outcomes through systematic, assessment-based oral care.