Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs

REDUCE missed oral healthcare: The outcomes of and learnings from an implementation project in an acute geriatric unit

Oral healthcare is one of the most missed aspects of fundamental care. Failure to provide reliable and effective daily oral healthcare for older patients can lead to hospital-acquired pneumonias, longer hospital stays, increased health costs, and poor patient experience. The objective of this study was to codesign, implement, and evaluate an oral healthcare intervention for older adults in a geriatric unit. This mixed methods implementation project combined the hospital's quality improvement processes with the i-PARIHS knowledge translation framework. Multilevel facilitation guided the development of multidisciplinary implementation strategies, which were co-designed, tailored, and implemented at the ward and organizational level, targeting: awareness/engagement; clinical guideline development; building workforce capacity; access to appropriate products; patient awareness and support; utilization of multidisciplinary/dental referral pathways; and systematizing oral healthcare documentation. Gaps between evidence-based and current oral healthcare practice were identified through audits of practice and interviews with patients. Interviews and surveys with staff evaluated the feasibility and acceptability of the oral healthcare intervention and the success of implementation strategies. At the conclusion of the project, awareness, attitudes, and capacity of staff had increased, however, we could not demonstrate change in multidisciplinary oral healthcare practices or improvements for individual patients. Despite mixed success, the project informed discussions about including oral healthcare as a national healthcare standard for the acute care sector in Australia. Attempts to address oral healthcare may have started locally, but its impact was through policy change, which will empower health practitioners and managers to support practice change more widely.

Relationship of oral bacterial number with medical hospitalization costs in analysis of Diagnosis Procedure Combination database from single institution in Japan

Oral bacteria are known to be associated with perioperative complications during hospitalization. However, no presented reports have clarified the relationship of oral bacterial number with medical costs for inpatients. The Diagnosis Procedure Combination (DPC) database system used in Japan provides clinical information regarding acute hospital patients. The present study was conducted to determine the association of oral bacterial numbers in individual patients treated at a single institution with length of hospital stay and medical costs using DPC data. A total of 2369 patients referred by the medical department to the dental department at Hiroshima University Hospital were divided into the low (n = 2060) and high (n = 309) oral bacterial number groups. Length of hospital stay and medical costs were compared between the groups, as well as the associations of number of oral bacteria with Charlson comorbidity index (CCI)-related diseases in regard to mortality and disease severity. There was no significant difference in hospital stay length between the low (24.3 ± 24.2 days) and high (22.8 ± 20.1 days) oral bacterial number groups. On the other hand, the daily hospital medical cost in the high group was significantly greater (US$1456.2 ± 1505.7 vs. US$1185.7 ± 1128.6, P < 0.001). Additionally, there was no significant difference in CCI score between the groups, whereas the daily hospital medical costs for patients in the high group treated for cardiovascular disease or malignant tumors were greater than in the low number group (P < 0.05). Multivariate regression analysis was also performed, which showed that oral bacterial number, age, gender, BMI, cardiovascular disease, diabetes, malignant tumor, and hospital stay length were independently associated with daily hospitalization costs. Monitoring and oral care treatment to lower the number of oral bacteria in patients affected by cardiovascular disease or cancer may contribute to reduce hospitalization costs.

Identifying patients at increased risk of non-ventilator-associated pneumonia on admission to hospital: a pragmatic prognostic screening tool to trigger preventative action

BACKGROUND

Non-ventilator healthcare-associated pneumonia (NV-HAP) is an important healthcare-associated infection. This study tested the feasibility of using routine admission data to identify those patients at high risk of NV-HAP who could benefit from targeted, preventive interventions.

METHODS

Patients aged ≥64 years who developed NV-HAP five days or more after admission to elderly-care wards, were identified by retrospective case note review together with matched controls. Data on potential predictors of NV-HAP were captured from admission records. Multi-variate analysis was used to build a prognostic screening tool (PRHAPs); acceptability and feasibility of the tool was evaluated.

RESULTS

A total of 382 cases/381 control patients were included in the analysis. Ten predictors were included in the final model; nine increased the risk of NV-HAP (OR between 1.68 and 2.42) and one (independent mobility) was protective (OR 0.48; 95% CI 0.30-0.75). The model correctly predicted 68% of the patients with and without NV-HAP; sensitivity 77%; specificity 61%. The PRHAPs tool risk score was 60% or more if two predictors were present and over 70% if three were present. An expert consensus group supported incorporating the PRHAPs tool into electronic logic systems as an efficient mechanism to identify patients at risk of NV-HAP and target preventative strategies.

CONCLUSIONS

This prognostic screening (PRHAPs) tool, applied to data routinely collected when a patient is admitted to hospital, could enable staff to identify patients at greatest risk of NV-HAP, target scarce resources in implementing a prevention care bundle, and reduce the use of antimicrobial agents.

Intervention to reduce the incidence of non-ventilator-associated hospital-acquired pneumonia: A pilot study

BACKGROUND

Our aim was to evaluate the effectiveness of an intervention to reduce the incidence of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) and determine compliance with preventive measures.

METHODS

This was a quasi-experimental before-after study involving patients in the 53-bed Internal Medicine ward in a university hospital in Spain. The preventive measures included hand hygiene, dysphagia detection, head-of-bed elevation, withdrawal of sedatives in the event of confusion, oral care, and sterile or bottled water use. A prospective post-intervention study of the incidence of NV-HAP was carried out from February 2017 to January 2018 and compared with baseline incidence (May 2014 to April 2015). Compliance with preventive measures was analyzed with 3-point-prevalence studies (December 2015, October 2016, and June 2017).

RESULTS

The rate of NV-HAP decreased from 0.45 cases (95% confidence interval 0.24-0.77) in the pre-intervention period to 0.18 cases per 1,000 patient-days (95% confidence interval 0.07-0.39) in the post-intervention period (P = .07). Compliance with most preventive measures improved after intervention and remained stable over time.

CONCLUSIONS

The strategy improved the adherence to most of the preventive measures, with a decrease in the incidence of NV-HAP. Efforts to enhance adherence to such fundamental preventive measures are critical to lowering the incidence of NV-HAP.

Development and psychometric testing of the attitude and confidence with oral healthcare among nursing students (ACORN) scale

AIM

To develop and test the psychometric properties of the attitude and confidence with oral healthcare among nursing students (ACORN) scale.

BACKGROUND

Delivering oral healthcare is an essential component of care, which is often overlooked and omitted. A nurse's attitude or confidence may influence how oral healthcare is prioritised. To date, there are no scales that assess both attitude and confidence for nurses when undertaking oral healthcare and thus the ACORN scale was developed.

METHODS

The 24-item scale was developed following a three-stage process, which included concept identification and item construction, pilot testing, factorial and discriminant validity and reliability testing. The survey was distributed to nursing students to assess their attitude and confidence in providing oral healthcare. This study has been registered with the Registry of Efficacy and Effectiveness Studies (12940.1v1).

RESULTS

Using a before and after intervention survey design, the psychometric properties of the ACORN scale were examined with data collected from two student groups. Exploratory Factor Analysis yielded a two-factor structure, which was verified using Confirmatory Factor Analysis. Importantly, aggregated scale scores were able to detect differences in attitude and confidence following oral healthcare education (4.95 versus 5.66, p < 0.01). The Cronbach's alpha for the 24-item scale was 0.94.

CONCLUSION

The ACORN scale is a valid and reliable tool that can be used to assess differences in attitude and confidence of students following oral health education. Further research is recommended to test the utility of this scale using other educational interventions with different groups of healthcare providers.

Electronic surveillance criteria for non-ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity

OBJECTIVE

Surveillance of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses.

METHODS

We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans' Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa).

RESULTS

Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP.

CONCLUSIONS

Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.

A mixed-methods evaluation of the national implementation of the Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) initiative

OBJECTIVE

To describe healthcare provider, veteran, and organizational barriers to, challenges to, and facilitators of implementation of the oral care Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) initiative to prevent non-ventilator-associated hospital-acquired pneumonia (NV-HAP).

DESIGN

Concurrent mixed methods. Qualitative interviews of staff and patients were conducted in addition to a larger survey of VA employees regarding implementation.

SETTING

Medical surgical or extended care units in 6 high-complexity (01a-c) VA hospitals.

PARTICIPANTS

Between January 2020 and February 2021, we interviewed 7 staff and 7 veterans, and we received survey responses from 91 staff.

INTERVENTION

Provide education, support, and oral care supplies to prevent NV-HAP.

RESULTS

Barriers to HAPPEN implementation and tracking at the pilot sites included maintaining oral care supplies and completion of oral care documentation. Facilitators for HAPPEN implementation included development of supportive formal and informal nurse leaders, staff engagement, and shared beliefs in the importance of care quality and infection prevention. Nurses worked together as a team to provide consistent oral care. Oral care was viewed as an essential infection control practice (not just "a task") and was considered part of the "culture" and "mission" in caring for veterans.

CONCLUSIONS

Nurse leaders and direct-care staff were engaged throughout HAPPEN implementation, and most reported feeling supported and well prepared as they walked through the steps. Veterans reported positive experiences and increased knowledge about prevention of pneumonia. Lessons learned included building a community of practice and sharing expertise, which led to the successful replication of the HAPPEN initiative nationwide, improving patient safety and care quality and influencing health policy.

The association between non-ventilator associated hospital acquired pneumonia and patient outcomes among U.S. Veterans

BACKGROUND

Non-ventilator associated hospital acquired pneumonia (NV-HAP) affects approximately 1 in 100 hospitalized patients yet risk-adjusted outcomes associated with developing NV-HAP are unknown.

METHODS

Retrospective cohort study with propensity score matched populations (NV-HAP vs no NV-HAP), using ICD-10 codes for bacterial pneumonia not present on admission. Outcomes included the patient level probability of NV-HAP developing among acute care non-transfer admissions in 133 Veterans Affairs hospitals and subsequent mortality, length of stay, inpatient sepsis, and 12-month costs.

RESULTS

NV-HAP occurred in 0.6% of Veteran admissions. Among admissions that developed NV-HAP, the mean length of stay of 26.3 days (6.72 days among non-NV-HAP), 30-day mortality was 18.4% (4.5% among non-NV-HAP), 1-year mortality was 47.8% (21.4% among non-NV-HAP), and total median 12-month direct medical costs were $138,136.32 ($64,357.21 among non-NV-HAP). Inpatient sepsis occurred in approximately 20% of NV-HAP admissions (0.7% among non-NV-HAP). Data available at admission was insufficient to identify high and low risk patient groups.

CONCLUSIONS

NV-HAP is associated with severely worse patient outcomes and increased costs of care up to 12 months post-episode. Since population risk stratification is not feasible, prevention efforts should be directed at the full population of hospitalized Veterans.

The Impact of Improved Oral Care Methods on the Oral Health of Patients Undergoing Transoral Mechanical Ventilation

Objective

To explore the effects of improved oral care on the number of oropharyngeal bacteria and the incidence of ventilator-associated pneumonia in patients undergoing mechanical ventilation through oral endotracheal intubation by improving conventional oral care methods and operating procedures and to evaluate the quality of improved oral care and effect.

Methods

A total of 100 cases of mechanically ventilated patients with oral endotracheal intubation who met the inclusion criteria were randomly divided into the observation group and control group with 50 cases each. The control group took routine oral care, that is, scrubbing 3 times per day, and the oral care solution was selected as physiological brine. The observation group improved the conventional oral care method, namely, oral scrubbing before intubation, brushing and washing after intubation, 3 times per day, and 0.1% povidone-iodine in oral care solution. Analysis and comparison of the oral bacterial flora, oral cleanliness, and incidence of ventilator-associated pneumonia, mechanical ventilation time, ICU hospitalization time, and mortality rate of the two groups of patients were analyzed and compared. The relevant data were collected and processed for statistical processing.

Results

The oral bacterial flora of the two groups of patients before oral care after mechanical ventilation after oral tracheal intubation was compared, and there was no significant statistical difference (P > 0.05). After nursing, the oral bacterial flora of the observation group at 8 h, 16 h, and 24 h after intubation was significantly lower than that of the control group. Statistics showed that the difference was statistically significant (P < 0.05). After nursing, the number of patients with oral cleanliness in the observation group was significantly higher than that of the control group, while the incidence of ventilator-associated pneumonia in the observation group was 8% significantly lower than that of the control group 14%. Statistics show that this difference is statistically significant (P < 0.05). After nursing, the observation group's oral cleanliness score, mechanical ventilation time, ICU hospitalization time, and GCS score were better than those of the control group. Statistics showed that the difference was statistically significant (P < 0.05). The mortality of the observation group was significantly lower than that of the control group, which was not statistically significant (P > 0.05).

Conclusion

Oral care can effectively reduce the number of oropharyngeal bacteria in patients who are mechanically ventilated through orotracheal intubation and significantly reduce the incidence of ventilator-associated pneumonia.

Time to integrate oral health screening into medicine? A survey of primary care providers of older adults and an evidence-based rationale for integration

OBJECTIVE

Primary care providers were assessed regarding their training and interest to screen oral conditions in patients ≥55 years old.

BACKGROUND

Oral health (OH) is an essential component of overall health and can affect systemic health. Medical/dental integration in older adults is underdeveloped.

METHODS

A brief survey assessed primary care providers' self-reported skills, practices and barriers towards integrating OH screening into adult primary care. Data were collected using Survey Monkey® . Respondents were physicians and advanced practice providers (APPs) working at a large mid-western safety-net hospital. Descriptive statistics, T-tests and Chi-squared tests were reported.

RESULTS

Eighty-two of 202 participants (41%) completed the survey. Most respondents were female (75%). A majority were physicians (68%); the remainder APPs. All providers (100%) reported OH was important or extremely important to overall health. More physicians (93%) reported not being well-trained to address adult OH issues and perceived less medical-oral health integration in their practice (16%) compared to APPs (P < .05). Time was more of a barrier with APPs (74%), compared to physicians (51%), to integrate OH screening activities (P < .05). Most providers reported other barriers such as inadequate OH training and insurance coverage. Providers endorsed that OH should be assessed frequently (56%) including providing referrals to dentists (77%) and educating patients on oral-systemic issues (63%). More female than male providers endorsed dental referrals and educating patients (P < .05).

CONCLUSION

Primary care providers embraced greater medical/dental integration for older adults. Instituting OH activities appears to be supported. Future interventions that are feasible in primary care settings are examined.

Oral Microbes in Hospital-Acquired Pneumonia: Practice and Research Implications

BACKGROUND

Hospital-acquired pneumonia accounts for 25% of all health care-associated infections and is classified as either ventilator-associated or non-ventilator-associated pneumonia. Hospital-acquired pneumonia most frequently results from aspiration of oropharyngeal secretions into the lungs. Although preventive measures for ventilator-associated pneumonia are well established, few preventive measures exist for the nonventilator type.

OBJECTIVE

To (1) explore oral microbes associated with ventilator-associated and non-ventilator-associated pneumonia in acutely ill, adult hospitalized patients, and (2) provide evidence-based recommendations for measures to prevent pneumonia in hospitalized patients.

METHODS

A literature search was conducted using CINAHL, Academic Search Premier, Medline, and the Cochrane Library.

RESULTS

Ten studies were found that identified common oral microbes in ventilator-associated and non-ventilator-associated pneumonia, including Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, S aureus, and Streptococcus pneumoniae. Collectively, oral colonization with E coli, P aeruginosa, methicillin-resistant S aureus, and S aureus increased the risk of nonventilator pneumonia. Findings also suggested microaspiration of colonized oral microbes into the lungs. Non-ventilator-associated pneumonia had similar colonization rates of gram-positive and gram-negative bacteria, whereas ventilator-associated pneumonia had greater colonization with gram-negative bacteria. The literature did not indicate a standard of oral care effective in all patient populations.

DISCUSSION

Oral care is an effective intervention to prevent hospital-acquired pneumonia by reducing pathogenic oral microbial colonization. The impact of different methods and timing of oral care on oral microbes should be further explored, particularly in patients not receiving mechanical ventilation.

CONCLUSIONS

Findings reaffirm the importance of consistent oral care in hospitalized patients. In addition, practices should be different in patients receiving mechanical ventilation versus patients not receiving ventilation. Results may also provide knowledge to inform future preventive measures for pneumonia, particularly for nonventilator pneumonia.

The Need for Oral Hygiene Care and Periodontal Status among Hospitalized Gastric Cancer Patients

Poor oral hygiene leads to the accumulation of dental plaque, thus contributing to the initiation of periodontal disease (PD). Local infections can lead to systemic inflammatory responses, which are essential mediators for the evolution of systemic conditions or cancer tumorigenesis. Often, patients hospitalized with life-threatening and incapacitating disorders such as gastric cancer (GC) might lose interest in keeping their mouth healthy. This study evaluates oral hygiene, periodontal status, and the need for oral care and medical personnel to assist in achieving it in patients hospitalized with GC. This study was carried out on 25 patients with a diagnosis of GC, divided into two groups (GP-14 patients from the Gastroenterology Department, and SP-11 patients from the 1st Department of Surgery). Patients were examined on the day of admission (T0), the day of the medical procedure of endoscopy or surgery (T1), and the day of discharge (T2), recording the number of absent teeth, dental plaque (PI), bleeding on probing (BOP), probing depths (PPD), frequency of toothbrushing, and if the oral hygiene had been self-performed or assisted. Data were subjected to statistical analysis. Our results showed that, in both the GP and the SP group, there were strong and statistically significant correlations between PI and BOP measured on the last day of hospitalization and the period of hospitalization after the medical procedure. Longer hospital stays and the presence of surgery were risk factors for changing toothbrushing frequency. Results also highlight the need for a dentist to diagnose and eventually treat periodontal disease before and after hospitalization, and for a trained nurse who should help take care of the patient's oral hygiene during hospitalization.

Oral health status and the etiology and prevention of nonventilator hospital-associated pneumonia

Nonventilator hospital-associated pneumonia has recently emerged as an important preventable hospital-associated infection, and is a leading cause of healthcare-associated infection. Substantial accumulated evidence links poor oral health with an increased risk of pneumonia, which can be caused by bacterial, viral, or fungal pathogens, each with their own distinct mechanisms of transmission and host susceptibility. These infections are frequently polymicrobial, and often include microbes from biofilms in the oral cavity. Evidence documenting the importance of oral care to prevent nonventilator hospital-associated pneumonia is continuing to emerge. Reduction of oral biofilm in these populations will reduce the numbers of potential respiratory pathogens in the oral secretions that can be aspirated, which in turn can reduce the risk for pneumonia. This review summarizes up-to-date information on the role of oral care in the prevention of nonventilator hospital-associated pneumonia.

Implementing Oral Care as a Nursing Intervention to Reduce Hospital-Acquired Pneumonia Across the United States Department of Veterans Affairs Healthcare System

Hospital-acquired pneumonia is a preventable complication. The primary source of pneumonia among hospitalized and long-term care residents is aspiration of bacteria present in the oral biofilm. Reducing the bacterial burden in the mouth through consistent oral care is associated with a reduction in the incidence of hospital-acquired pneumonia. Following a significant reduction in pneumonia among non-ventilated patients in the research pilots, the Veterans Health Administration deployed the evidence-based, nurse-led oral care intervention called Hospital Acquired Pneumonia Prevention by Engaging Nurses as quality improvement nationwide. In this article, nursing informatics experts on the team describe the design and implementation of process and outcome measures of Hospital-Acquired Pneumonia Prevention by Engaging Nurses and outline lessons learned. The team used standardized terms and observations embedded within the EHR documentation templates to measure the oral care intervention in acute care areas. They also developed a tracking system for hospital-acquired pneumonia cases among non-ventilated patients. In addition to improving patient safety and care quality, Hospital-Acquired Pneumonia Prevention by Engaging Nurses links evidence-based practice with nursing informatics principles to generate numerous opportunities to measure the value of nursing at the point of care. This initiative was reported using SQUIRE 2.0: Standards for QUality Improvement Reporting Excellence.

Non-ventilator associated hospital acquired pneumonia incidence and health outcomes among U.S. veterans from 2016-2020

Among 1,635,711 Veteran acute care admissions (FY2016-2020), the risk of non-ventilator associated hospital acquired pneumonia (NV-HAP) was 1.26 cases per 1,000 hospitalized days and decreased linearly over time with an uptick in cases in the last year coinciding with the onset of the covid-19 pandemic. Veterans who develop NV-HAP experience remarkably higher 30-day and 1-year mortality, longer length of stay, and higher rates of inpatient sepsis. Monitoring and prevention measures may substantially reduce negative outcomes.

Balancing reality in embedded research and evaluation: Low vs high embeddedness

Embedding research and evaluation into organizations is one way to generate “practice‐based” evidence needed to accelerate implementation of evidence‐based innovations within learning health systems. Organizations and researchers/evaluators vary greatly in how they structure and operationalize these collaborations. One key aspect is the degree of embeddedness: from low embeddedness where researchers/evaluators are located outside organizations (eg, outside evaluation consultants) to high embeddedness where researchers/evaluators are employed by organizations and thus more deeply involved in program evolution and operations. Pros and cons related to the degree of embeddedness (low vs high) must be balanced when developing these relationships. We reflect on this process within the context of an embedded, mixed‐methods evaluation of the Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program. Considerations that must be balanced include: (a) low vs high alignment of goals; (b) low vs high involvement in strategic planning; (c) observing what is happening vs being integrally involved with programmatic activities; (d) reporting findings at the project's end vs providing iterative findings and recommendations that contribute to program evolution; and (e) adhering to predetermined aims vs adapting aims in response to evolving partner needs.

A Perspective: Integrating Dental and Medical Research Improves Overall Health

The past decade has seen marked increases in research findings identifying oral-systemic links. Yet, much of dental research remains poorly integrated with mainstream biomedical research. The historic separation of dentistry from medicine has led to siloed approaches in education, research and practice, ultimately depriving patients, providers, and policy makers of findings that could benefit overall health and well-being. These omissions amount to lost opportunities for risk assessment, diagnosis, early intervention and prevention of disease, increasing cost and contributing to a fragmented and inefficient healthcare delivery system. This perspective provides examples where fostering interprofessional research collaborations has advanced scientific understanding and yielded clinical benefits. In contrast are examples where failure to include dental research findings has limited progress and led to adverse health outcomes. The impetus to overcome the dental-medical research divide gains further urgency today in light of the coronavirus pandemic where contributions that dental research can make to understanding the pathophysiology of the SARS-CoV-2 virus and in diagnosing and preventing infection are described. Eliminating the research divide will require collaborative and trans-disciplinary research to ensure incorporation of dental research findings in broad areas of biomedical research. Enhanced communication, including interoperable dental/medical electronic health records and educational efforts will be needed so that the public, health care providers, researchers, professional schools, organizations, and policymakers can fully utilize oral health scientific information to meet the overall health needs of the public.

Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster Randomized Study

BACKGROUND

Nonventilator hospital-acquired pneumonia (NV-HAP) presents a serious and largely preventable threat to patient safety in U.S. hospitals. There is an emerging body of evidence on the effectiveness of oral care in preventing NV-HAP.

PURPOSE

The primary aim of this study was to determine the effectiveness of a universal, standardized oral care protocol in preventing NV-HAP in the acute care setting. The primary outcome measure was NV-HAP incidence per 1,000 patient-days.

METHODS

This 12-month study was conducted on four units at an 800-bed tertiary medical center. Patients on one medical and one surgical unit were randomly assigned to receive enhanced oral care (intervention units); patients on another medical and another surgical unit received usual oral care (control units).

RESULTS

Total enrollment was 8,709. For the medical control versus intervention units, oral care frequency increased from a mean of 0.95 to 2.25 times per day, and there was a significant 85% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 7.1 times higher on the medical control versus intervention units, a significant finding. For the surgical control versus intervention units, oral care frequency increased from a mean of 1.18 to 2.02 times per day, with a 56% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 1.6 times higher on the surgical control versus intervention units, although this result did not reach significance.

CONCLUSIONS

These findings add to the growing body of evidence that daily oral care as a means of primary source control may have a role in NV-HAP prevention. The implementation of effective strategies to ensure that such care is consistently provided warrants further study. It's not yet known what degree and frequency of oral care are required to effect favorable changes in the oral microbiome during acute care hospitalization.

(Lack of) oral hygiene care for hospitalized elderly patients

OBJECTIVE

to analyze the oral hygiene care for hospitalized elderly patients provided by the nursing staff.

METHOD

this is a qualitative, exploratory-descriptive study carried out in a university hospital, with the participation of 35 professionals from the nursing staff. Data collection was carried out through semi-structured interviews, explored through thematic content analysis.

RESULTS

two categories emerged: The oral hygiene of hospitalized elderly patients as an extension of body care and Barriers in (lack of) care with the oral hygiene of hospitalized elderly patients, with two subcategories: The oral hygiene and dental prosthesis technique performed divergently; Care hampered by deficit of materials and human resources.

FINAL CONSIDERATIONS

this study showed weaknesses in the oral hygiene care of hospitalized elderly patients, promoting reflections on the practice informed in data and management actions, allowing recommendations of care standards for the nursing staff.

Incidence and Predictors of Nonventilator Hospital-Acquired Pneumonia in a Community Hospital

BACKGROUND

Nonventilator hospital-acquired pneumonia (NV-HAP) is a common hospital-acquired condition that is amenable to basic nursing care interventions.

PURPOSE

The purpose of this study was to determine the incidence of NV-HAP in a California community hospital and to identify the patient and nursing care factors including missed nursing care associated with its development.

METHODS

A retrospective study identified possible NV-HAP cases with ICD-10 (International Classification of Diseases, Tenth Revision) codes and then validated cases using Centers for Disease Control and Prevention confirmatory criteria.

RESULTS

The incidence of NV-HAP in our hospital was 0.64 cases per 1000 patient-days. Patient factors most strongly associated with NV-HAP were age (each year of increased age was associated with a 4% increased likelihood of developing NV-HAP) (OR = 1.04-1.07) and the presence of underlying disease, which reduced odds of developing NV-HAP by 36% (OR = 0.36; 95% CI, 0.12-0.98). Head-of-bed elevation reduced by 26% the odds of developing NV-HAP (OR = 0.26; 95% CI, 0.07-0.08).

CONCLUSIONS

NV-HAP can be predicted and potentially prevented. Paradoxically, the presence of underlying disease was not positively associated with the development of NV-HAP in this study.

Challenging Precedent: Critical Care Nursing and Medical Product Innovation

In this presentation, I will share my unconventional journey, starting from my first job as a critical care staff nurse to my current role as tenure-track faculty at the University of Massachusetts Amherst, where I hold a joint position with the Institute for Applied Life Sciences and the College of Nursing. Throughout this journey, I have had many opportunities to participate in interdisciplinary clinical outcomes research and medical product development as a staff nurse, clinical nurse specialist, and project lead from the clinical, industry, and academic perspectives. While passionate about my central clinical research interests in technology innovation and its responsible use in critical and acute care, the foundation of my approach is dedicated to the values and lessons of my earliest experiences in critical care bedside nursing: supporting and preserving the dignity and humanity of person-centered patient care. Early in my career as a critical care nurse, I realized how vitally important a critical care nursing perspective could be in the design of technology for meeting the critical care needs of patients, nurses, and other professionals who provide this care. As the nation's largest group of health care professionals, nurses use more products than any other health care professional, and thus nurses have a uniquely practical and care-sensitive perspective on the development and design of medical products. Nurses, especially critical care nurses, are in a unique position to identify and address everyday health care issues, challenge assumptions and the status quo, address unrecognized and unarticulated needs, and ensure that clinical outcomes research serves as the foundation for validating the effectiveness of medical product innovation. My goal is to share lessons learned and to help participants to see the many different ways that critical care nursing knowledge can be used to improve patient care.

Electric brushes improve outcomes in caregiver-assisted oral hygiene

An effective means of maintaining oral health is imperative for the health of long-term-care patients. This article assesses oral hygiene using an electric toothbrush compared with a manual toothbrush.

Strategies to reduce non-ventilator-associated hospital-acquired pneumonia: A systematic review

BACKGROUND

Point prevalence studies identify that pneumonia is the most common healthcare associated infection. However, non-ventilator associated healthcare associated pneumonia (NV-HAP) is both underreported and understudied. Most research conducted to date, focuses on ventilator associated pneumonia. We conducted a systematic review, to provide the latest evidence for strategies to reduce NV-HAP and describe the methodological approaches used.

METHODS

We performed a systematic search to identify research exploring and evaluating NV-HAP preventive measures in hospitals and aged-care facilities. The electronic database Medline was searched, for peer-reviewed articles published between 1st January 1998 and 31st August 2018. An assessment of the study quality and risk of bias of included articles was conducted using the Newcastle-Ottawa Scale.

RESULTS

The literature search yielded 1551 articles, with 15 articles meeting the inclusion criteria. The majority of strategies for NV-HAP prevention focussed on oral care (n = 9). Three studies evaluated a form of physical activity, such as passive movements, two studies used dysphagia screening and management; and another study evaluated prophylactic antibiotics. Most studies (n = 12) were conducted in a hospital setting. Six of the fifteen studies were randomised controlled trials.

CONCLUSION

There was considerable heterogeneity in the included studies, including the type of intervention, study design, methods and definitions used to diagnose the NV-HAP. To date, interventions to reduce NV-HAP appear to be based broadly on the themes of improving oral care, increased mobility or movement and dysphagia management.