Improving Oral Hygiene to Reduce Non-Ventilator-Associated Hospital Acquired Pneumonia (NV-HAP) in Acute, Care-Dependent Patients

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Oral Intensity: Reducing the Risk of

Non-Ventilator-Associated Hospital Acquired Pneumonia (NV-HAP)

Trudy Robertson CNS Fraser Health Neurosurgery&

Dulcie Carter BSc MMedSci, RSLP RCH

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T. Robertson & D. Carter August 2013

Acknowledgments

Fraser Health Department of Evaluation and Research Services (FH DERS)

Team “Oral Intensity” and staff of the Neurosurgical Unit, Royal Columbian Hospital in New Westminster, BC, Canada

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Disclosures

Seed grant funding from the FH DERS to conduct this point of care research (FHREB # 2011-088) Unrestricted modest donation of oral care

supplies was received from SAGE® Products Inc. during the study period

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How This Research All Began

Clinical observation on the RCH Neurosurgical Unit Looked into the literature Point of Care Research Challenge

coincided with a call to action “Team Oral Intensity”

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RCH Neurosurgery Unit

32 beds, 4 bed neuro observation room (NOA) 5 neurosurgeons, trauma service Case mix: Post-operative brain surgery,

TBI, complex spine, intracranial bleed Staff mix- RNs, LPNs, CA, rehab team Limited resources

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Current Oral Hygiene Standards

Current standard: nurse discretion “prn” Current practice: varies, nurse-to-nurse Where are the gaps? Nursing knowledge Variation in practice Nursing workload Lack of formal protocol

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Literature review

Neuroscience literature Nursing literature Critical care Residential, older adult

Medical literature AMMI Canada Guidelines – HAP including

VAP Dysphagia literature Dental literature

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The Research

Defined the research question Design the study Ethics Board application Consent by substitute decision maker BC Privacy Office

Development of tools, staff education

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Purpose

To test the efficacy of a enhanced, prevention-based oral care protocol in reducing NV-HAP in the care-dependent neurosurgical population outside the critical care environment Hypothesis: an enhanced oral care

protocol would decrease the incidence of HAP

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Design

Comparative, quantitative study Key measure: NV-HAP rates between

subjects who received standard oral care (SOC; retrospective group) and those who received an enhanced, prevention-based, oral hygiene protocol (EOC; prospective group) Identified other variables of interest

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Methods

Data collected for both groups for a 6 month period SOC group: retrospective chart review EOC group: eligible neurosurgical patients

who received the enhanced protocol Diagnostic criteria for hospital acquired

pneumonia were determined* Inclusion/exclusion criteria developed Data collection tools were developed

*AMMI Canada Guidelines: Clinical practice guidelines for hospital acquired pneumonia and ventilator associated pneumoniain adults. Can J Infect Dis Med Microbiol Vol 19 No 1 January/February 2008

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NV-HAP

Diagnosis criteria >48 hours post admission Positive chest x-ray for infiltrates, consolidation, etc And 2 of the following 3 criteria

Presence of fever Positive sputum culture Elevated serum WBC count

Did not rely on physician documentation or health records coding of HAP

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Methods: Inclusion/Exclusion Criteria

Table 1. Inclusion/Exclusion Criteria

Inclusion criteria Exclusion criteria

Adult (>19 years) Admitted to RCH neuroscience

unit Primary diagnosis is neurological

(brain injury/insult) Non-intubated Dependent for oral care and

unable to direct their own oral care

<19 years Off service patients Intubated, on Bipap or Cpap

(respiratory assistive devices) Palliative Capable of directing their own oral

care Unable to receive oral care due to: oral

tubes, nasal/oral airways, wired jaws, or behaviours such as resistiveness, combativeness, non-compliance, etc.

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Methods: Retrospective Group

Charts were pulled according to Unit Primary diagnosis neurologic Time period

300 charts were identified Care dependency confirmed ICU/HAU days excluded

52 met the inclusion criteria

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Methods: Prospective Group

Screening upon admission to unit Approached TSDM of eligible subjects Upon consent, subject was enrolled in

study, EOC protocol commenced Consented: n=34 Excluded: 2 Withdrawal: 1 (7 days on study)

32 included in analysis

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Study Protocol

Universal handwashing Elevation of head of the bed Teeth brushing twice a day Scheduled inspection, cleaning,

moisturizing mouth, lips every 2-4 hours Oral and tracheostomy suctioning Standardization of oral care supplies,

equipment*Informed by Bopp, 2006; De Riso et al, 1996; Fields, 2008; Grap et al., 2003; Safdar et al, 2005; Shorr & Kollef, 2005.

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Methods: Oral Care Protocol

Table 2. Oral Care Protocol Worksheet

Date: March 7, 2012 Minimum HOB 300 for all Mouth Care

Intervention Write in Time of Care and Initial

Change mouth suction equipment every 24 hours

- - - - -

Mouth assessment every 2-4 hours

Cleanse mouth with toothbrush every 12 hours

- - - -

Cleanse oral mucosa with oral rinse solution every 2-4 hours

Moisturize mouth/lips with swab and standard

mouth moisturizer every 4 hours

Suction mouth and throat as needed

Patient Name

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Data Collection: Both Groups

Demographic information Data collected weekly Incidences of NV-HAP Mode of nutrition Presence of: Tracheostomy Teeth versus dentures Dysphagia

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Findings: Demographic Data

Table 3. Summary of Demographics and Medical Status

SOC Group Retrospective Data (2010)

EOC Group (2012)Prospective Data (2012)

Number of participants 51 32

M:F ratio 27:24 23:9

Age (average) 57Range: 19-88 years

61Range: 33-84 years

Tracheostomy 12 (24%) 13 (40%)

Dysphagia 42 (84%) 27 (84%)

HAP events 13 2

Average LOS* 23 days (on unit) 21 days (on study)

Median LOS* 15 days (on unit) 13.5 days (on study)

*Not comparable variables

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Findings: Case Mix

Figure 2. Neurological diagnosis: EOC group

3%9%3%

63%

22%

TBI ICH tumour hydrocephalus other

Figure 1. Neurological diagnosis: SOC group

4%4%8%

70%

14%

TBI ICH tumour hydrocephalus other

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Findings

A statistically significant decrease in the rate of HAP occurred in the prospective group (p<0.05)

Figure 3. HAP rate between groups

0

20

40

60

80

100

120

SOC group EOC group

% HAP % no HAP

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Findings: NV-HAP

Presence of tracheostomy * With trach: 28% Without: 13.8%

Teeth versus dentures** Length of stay*** Mode of nutrition Dysphagia

* p=0.134, 2 sided Fishers Exact test ** p=0.720, 1-sided Fishers exact test*** p=0.044, Mann-Whitney test

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Implications: Patient

An enhanced oral care protocol: Improves health outcomes by decreasing: The risk of infections, inflammatory processes, fever The need for diagnostic tests, treatments, medications,

procedures, NV-HAP complications Length of stay (readiness for rehabilitation)

Improves patient comfort, QOL, family satisfaction Improves overall satisfaction with care

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Implications: Nursing Practice

Important to assess the risk factors for NV-HAP Important to implement preventative care We need to examine nurses’ decision-making &

attitudes towards preventative-based care What are the barriers to prevention-based care? Dispelling myths about workload impact

It takes leadership to advance care practices, to foster a culture of inquiry, improving quality of care, leading change

We need to foster team-based approaches to care Foundational nursing care practices are still

important

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Need for improved continuity in care throughout the care continuum, across settings, sites, sectors

Improved quality of care Improved access to specialty beds Financial impact Decreases transfers to higher level of care Increase supply costs is offset by decreased rates of

NV-HAP Decreased LOS Decreased medical and diagnostic costs

Implications: Systems

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Limitations

Study limited to 1 unit, 1 institution First clinical nursing research study on this unit Small sample size limited analysis of some

variables Documentation limitations Nursing compliance 95%: 32 patients, combined total

of 676 days NV-HAP diagnosis by physicians Confirming care dependency was difficult in the

retrospective group

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Future Studies

Explore further the relationship between NV-HAP and other factors e.g. tracheostomy

Study enhanced oral care protocols in other populations e.g. acute medical patients

Explore nurses’ attitudes and barriers to performing oral care

Economic analysis on the financial impact of enhanced oral care Length of stay, medical and supply costs, nursing

workload

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Next Steps

Formalize an oral care protocol Spread protocol regionally to all care-

dependent in-patients in acute care within Fraser Health Published manuscript in the Canadian

Journal of Neuroscience Nursing Incorporate oral care into peri-operative

practices

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In Closing

Basics of nursing practice continue to be fundamental to patient outcomes An ounce of prevention is still worth a

pound of cure Changing nursing practice begins with

critical inquiry and seeking to understand and question why we do what we do

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Contact Information

Thank You !

Trudy Robertson, Clinical Nurse Specialist: [email protected]

Dulcie Carter, Registered Speech Language [email protected]

Health & Medicine

Improving Oral Hygiene to Reduce Non-Ventilator-Associated Hospital Acquired Pneumonia (NV-HAP) in Acute, Care-Dependent Patients