Oral Intensity:
Reducing the Risk of
Non-Ventilator-Associated Hospital
Acquired Pneumonia (NV-HAP)
Trudy Robertson CNS Fr...
Acknowledgments
 Fraser Health Department of Evaluation
and Research Services (FH DERS)
 Team “Oral Intensity” and staff...
Disclosures
 Seed grant funding from the FH DERS to
conduct this point of care research (FHREB
# 2011-088)
 Unrestricted...
How This Research All
Began
 Clinical observation on the RCH
Neurosurgical Unit
 Looked into the literature
 Point of C...
RCH Neurosurgery Unit
 32 beds, 4 bed neuro observation room
(NOA)
 5 neurosurgeons, trauma service
 Case mix: Post-ope...
Current Oral Hygiene
Standards
 Current standard: nurse discretion “prn”
 Current practice: varies, nurse-to-nurse
 Whe...
Literature review
 Neuroscience literature
 Nursing literature
 Critical care
 Residential, older adult

 Medical lit...
The Research
 Defined the research question
 Design the study
 Ethics Board application
 Consent by substitute decisio...
Purpose
 To test the efficacy of a enhanced,
prevention-based oral care protocol in
reducing NV-HAP in the care-dependent...
Design
 Comparative, quantitative study
 Key measure: NV-HAP rates between
subjects who received standard oral
care (SOC...
Methods
 Data collected for both groups for a 6
month period
 SOC group: retrospective chart review
 EOC group: eligibl...
NV-HAP
 Diagnosis criteria
 >48 hours post admission
 Positive chest x-ray for infiltrates, consolidation, etc
 And 2 ...
Methods:
Inclusion/Exclusion Criteria
Table 1. Inclusion/Exclusion Criteria
Inclusion criteria
•
•
•
•
•

Adult (>19 years...
Methods: Retrospective
Group
 Charts were pulled according to
 Unit
 Primary diagnosis neurologic
 Time period

 300 ...
Methods: Prospective Group
 Screening upon admission to unit
 Approached TSDM of eligible subjects
 Upon consent, subje...
Study Protocol
Universal handwashing
Elevation of head of the bed
Teeth brushing twice a day
Scheduled inspection, cleanin...
Methods: Oral Care Protocol
Table 2. Oral Care Protocol Worksheet

Patient Name

Date: March 7, 2012

Minimum HOB 300 for ...
Data Collection: Both
Groups
 Demographic information
 Data collected weekly
 Incidences of NV-HAP
 Mode of nutrition
...
Findings: Demographic
Data
Table 3. Summary of Demographics and Medical Status
SOC Group
Retrospective Data (2010)

EOC Gr...
Findings: Case Mix

Figure 1. Neurological diagnosis: SOC group

Figure 2. Neurological diagnosis: EOC group

4% 14%
4%
8%...
Findings

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

Figure 3. ...
Findings: NV-HAP
 Presence of tracheostomy *
 With trach: 28%






Without: 13.8%

Teeth versus dentures**
Length o...
Implications: Patient
An enhanced oral care protocol:
 Improves health outcomes by decreasing:
 The risk of infections, ...
Implications: Nursing
Practice
 Important to assess the risk factors for NV-HAP
 Important to implement preventative car...
Implications: Systems
 Need for improved continuity in care
throughout the care continuum, across settings,
sites, sector...
Limitations
 Study limited to 1 unit, 1 institution
 First clinical nursing research study on this unit
 Small sample s...
Future Studies
 Explore further the relationship between NVHAP and other factors e.g. tracheostomy
 Study enhanced oral ...
Publication
 Publication: Canadian Journal of

Neuroscience Nursing, 35(2), 10-17.

 CANN Codman Award for Excellence in...
Translating Research into
Practice
 Nurse sensitive adverse event reduction initiaitive
 Oral care protocol, procedure, ...
In Closing
 Basics of nursing practice continue to
be fundamental to patient outcomes
 An ounce of prevention is still w...
Contact Information

Thank You !

Trudy Robertson, Clinical Nurse Specialist: Neurosurgery
Trudy.Robertson@fraserhealth.ca...
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Improving Oral Hygiene to Reduce Non-Ventilator-Associated Hospital Acquired Pneumonia (NV-HAP) in Acute, Care-Dependent Patients

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This presentation was delivered in session D2 of Quality Forum 2014 by:

Trudy Robertson
Clinical Nurse Specialist, Neurosurgery
Fraser Health

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

  1. 1. 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 1
  2. 2. 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 T. Robertson & D. Carter August 2013 2
  3. 3. 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 T. Robertson & D. Carter August 2013 3
  4. 4. 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” T. Robertson & D. Carter August 2013 4
  5. 5. 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 T. Robertson & D. Carter August 2013 5
  6. 6. 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 T. Robertson & D. Carter August 2013 6
  7. 7. Literature review  Neuroscience literature  Nursing literature  Critical care  Residential, older adult  Medical literature  AMMI Canada Guidelines – HAP including VAP  Dysphagia literature  Dental literature T. Robertson & D. Carter August 2013 7
  8. 8. 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 T. Robertson & D. Carter August 2013 8
  9. 9. 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 T. Robertson & D. Carter August 2013 9
  10. 10. 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 T. Robertson & D. Carter August 2013 10
  11. 11. 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 pneumonia T. Robertson & D. Carter August 2013 in adults. Can J Infect Dis Med Microbiol Vol 19 No 1 January/February 2008 11
  12. 12. 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 T. Robertson & D. Carter August 2013 12
  13. 13. Methods: Inclusion/Exclusion Criteria Table 1. Inclusion/Exclusion Criteria Inclusion 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 Exclusion criteria • • • • • • <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. T. Robertson & D. Carter August 2013 13
  14. 14. 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 T. Robertson & D. Carter August 2013 14
  15. 15. 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 T. Robertson & D. Carter August 2013 15
  16. 16. 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. T. Robertson & D. Carter August 2013 16
  17. 17. Methods: Oral Care Protocol Table 2. Oral Care Protocol Worksheet Patient Name 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 T. Robertson & D. Carter August 2013 17
  18. 18. Data Collection: Both Groups  Demographic information  Data collected weekly  Incidences of NV-HAP  Mode of nutrition  Presence of:  Tracheostomy  Teeth versus dentures  Dysphagia T. Robertson & D. Carter August 2013 18
  19. 19. Findings: Demographic Data Table 3. Summary of Demographics and Medical Status SOC Group Retrospective Data (2010) EOC Group (2012) Prospective Data (2012) 51 32 27:24 23:9 Age (average) 57 Range: 19-88 years 61 Range: 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) Number of participants M:F ratio T. Robertson & D. Carter August 2013 *Not comparable variables 19
  20. 20. Findings: Case Mix Figure 1. Neurological diagnosis: SOC group Figure 2. Neurological diagnosis: EOC group 4% 14% 4% 8% 9% 3% ICH tumour 22% 63% 70% TBI 3% hydrocephalus other TBI ICH tumour hydrocephalus other T. Robertson & D. Carter August 2013 20
  21. 21. Findings  A statistically significant decrease in the rate of HAP occurred in the prospective group (p<0.05) Figure 3. HAP rate between groups 120 100 80 60 40 20 0 SOC group % HAP EOC group % no HAP T. Robertson & D. Carter August 2013 21
  22. 22. 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 T. Robertson & D. Carter August 2013 22
  23. 23. 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 T. Robertson & D. Carter August 2013 23
  24. 24. 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 im portant T. Robertson & D. Carter August 2013 24
  25. 25. Implications: Systems  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 T. Robertson & D. Carter August 2013 25
  26. 26. 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 T. Robertson & D. Carter August 2013 26
  27. 27. Future Studies  Explore further the relationship between NVHAP 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 T. Robertson & D. Carter August 2013 27
  28. 28. Publication  Publication: Canadian Journal of Neuroscience Nursing, 35(2), 10-17.  CANN Codman Award for Excellence in Neuroscience Nursing Research  Nominee for the WFNN Agnes Marshall Award for best poster, Sept, 2013,Gifu, Japan T. Robertson & D. Carter August 2013 28
  29. 29. Translating Research into Practice  Nurse sensitive adverse event reduction initiaitive  Oral care protocol, procedure, and care record implementation  Spread to admitted care-dependent patients in acute care within Fraser Health  On-line education module (in-progress)  Independent patient protocol (in discussion)  Incorporate oral care into other care areas  Pre-operative preparation e.g. SDC  Peri-operative areas  ED, Cardiac, Rehab T. Robertson & D. Carter August 2013 29
  30. 30. 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 T. Robertson & D. Carter August 2013 30
  31. 31. Contact Information Thank You ! Trudy Robertson, Clinical Nurse Specialist: Neurosurgery Trudy.Robertson@fraserhealth.ca Dulcie Carter, Registered Speech Language Pathologist Dulcie.Carter@fraserhealth.ca T. Robertson & D. Carter August 2013 31
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