Date of Doctor of Nursing Practice Project Completion

Spring 2026

Faculty Advisor

Susan ,Alderman

Abstract

Purpose 
To increase night-shift adult ICU nurse compliance with standardized oral care documentation by at least 20% as a core ventilator-associated pneumonia (VAP) prevention process.
Background
VAP is a preventable healthcare-associated infection associated with increased morbidity, mortality, ICU length of stay, and costs. Oral-care documentation is often inconsistent because of competing priorities and workflow barriers.
Methodology
Guided by the Knowledge-to-Action framework, this QI project used three PDSA cycles after a September 2025 baseline in a 16-bed ICU. Interventions included 1:1 simulation, EPIC prompts, and bedside coaching; manual audits addressed EPIC misclassification. Trends and run charts analyzed 183 records; surveys assessed knowledge/barriers (pre n=43; post n=37)
Results
Documentation adherence improved from 33% at baseline (26/79) to 48% in Cycle 1 (16/33), peaked at 64% in Cycle 2 (14/22), and remained above baseline at 55% in Cycle 3 (27/49). Correct identification of the 12-hour brushing frequency increased from 20.9% pre-intervention to 81.1% post-intervention.
Implications
This workflow-integrated approach improved documentation reliability despite high acuity and competing priorities. Sustainability requires maintaining EPIC workflow prompts, integrating expectations into onboarding and ongoing competency process, and correcting automated audit-reporting logic to reduce manual audit burden. Adoption by additional nurses and spread to other shifts is feasible with clear documentation definitions and periodic feedback.

Keywords

quality improvement, ventilator-associated pneumonia, oral care, intensive care unit, nursing compliance

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Nursing Commons

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