Date of Graduation


Document Type


Degree Name

Bachelor of Science in Nursing

Degree Level





Smith-Blair, Nan

Committee Member/Reader

McNeill, Charleen

Committee Member/Second Reader

Holloway, Ginger



Purpose: Nonventilator-associated hospital acquired pneumonia is a nosocomial infection that has not been heavily researched. With hospital-acquired pneumonia accounting for some of the most frequent nosocomial infections in the United States, it is important to determine ways to decrease rates of infection. The purpose of this study was to determine the rate of nonventilator-associated pneumonia in a hospital patient population, to determine charting compliance of nurses, and to determine whether there was a need for a new oral care protocol.

Design: A retrospective electronic record review was performed to determine the rate of nonventilator- associated hospital acquired pneumonia, the charting compliance of the staff, and the need for a new oral care protocol.

Methods: All patient information was coded and de-identified according to the Health Insurance Portability and Accountability Act (HIPAA). Each electronic medical record reviewed was given a random case number. All data was stored on a password-protected computer. Once the charts were reviewed, there was no way to match the patient to the extracted information. All information was reported in the aggregate form so no individuals could be identified by Demographic data on patients (e.g., age, ethnicity, admitting diagnosis, comorbidities) was extracted. The rate of NV-HAP was calculated along with percentages of charting compliance on documentation of the type of oral care and frequency of oral care. A Chi Square test and Cramer’s V test were used to test a correlation between oral care and specific units. Percentages of oral care documentation per floor of the hospital were obtained.

Results: Both the Chi Square test and the Cramer’s V test confirmed that there was a statistically significant (p value: 0.005) correlation between oral care documentation and units of the hospital. The oral care documentation percentages ranged from 11.5% to 55.9%. The first floor had the lowest percentage of documentation and the third floor had the highest percentage of documentation. The infection rate was 0.02%

Conclusions: There did not appear to be a need for an oral care protocol on the basis of infection rate. The infection rate was well below the national average of 15%. The poor documentation rates, however, did suggest that there should be an oral care protocol on the basis of increasing documentation compliance. The lack of consistency of documentation from unit to unit reflected the lack of an established structure and protocol for documentation.

Included in

Nursing Commons