Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
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...
Upcoming SlideShare
Loading in …5
×

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

930 views

Published on

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

Trudy Robertson
Clinical Nurse Specialist, Neurosurgery
Fraser Health

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

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

×