NEW YORK NURSE: May 2007
By Patrice Keegan, NP-C, CNS, RN, Research Nurse Practitioner for the Center for Integrated Health Center, Syracuse Veterans Administration Medical Center, NYSNA Nursing Research Fellow
Simple nursing interventions can have a big impact when they are based on evidence. In 2006, Weitzel, Robinson, and Holmes published a study aimed at reducing the risk of hospital-acquired pneumonia (HAP) by providing routine oral care to hospitalized patients unable to complete their own oral care. HAP accounts for 20-30% of mortality associated with these patients, making it a leading cause of death in comparison with other hospital-acquired infections. There is also the increased burden of the cost associated with increased lengths of stay.
The highest risk for HAP is in patients on mechanical ventilation. Recently, however, HAP has increased in frequency in non-ventilated patients. Sopena and Sabria (2005) found that 64% of their study subjects were on general medical floors. This study highlights that this increase in HAP is occurring hospital-wide and has implications for all nurses.
The most common cause of HAP is thought to be microaspiration of bacteria-colonizing oropharyngeal secretions and aspirations of secretions from the esophagus or elsewhere in the gastrointestinal tract. Hospitalized patients’ oropharynxes can become colonized with bacteria from the hospital environment. Other contributing factors include the dental plaques that form a film on teeth and gums, and provide a rich environment for bacteria to grow. Poor nutritional status, compromised immune systems, and recent use of antibiotics are other risk factors in developing HAP.
There is evidence that supports nursing interventions to prevent pneumonia in healthcare settings. Yoneyama and colleagues (2002) studied oral care and the incidence of pneumonia. A 33% reduction of HAP was seen in mechanically ventilated adults when there was head-of-bed elevation and oral care every two hours. Nursing home patients who received oral care after each meal had 15% fewer febrile days and lower incidence when compared to a control group. Oral care is not always seen as a prophylactic measure, however. Previous research done by Grap et al. (2003) comparing self-report to actual documentation demonstrated that oral care is given low priority by nurses in all settings. Nurses averaged performing oral care just 1.2 times per day.
Researchers conducted this study in a 36-bed general intermediate unit of a teaching hospital to examine the impact of oral care protocols. Patients of the same sex, age, and risk factors that were admitted prior to the standardization of oral protocols were compared to patients admitted after the implementation of oral care protocols. The control group included 132 patients and 124 patients received the oral care protocol. The subjects were divided into three risk groups: ventilated patients and those with artificial airways, high-risk patients, and low-risk patients. Prior to the start of the study staff nurses received education on the incidence of HAP, the impact on the family, the nurse’s role in prevention, and the oral protocol to be followed.
This study demonstrates that oral care protocols play an important role in reducing HAP in all risk categories. In patients receiving the intervention, incidence of HAP decreased from 7.6% to 2.4% delivering an estimated savings of $29,369. Reduction in pathogens and improvement in swallowing and coughing reflex are some of the benefits of improved oral care and are thought to account for the decease in HAP. An unexpected secondary benefit was that patients enjoyed their food more and nutritional intake improved.
Grap, M.J., Munro, C., Ashtiani, B., Bryant, S. (2003). Oral care interventions in critical care: Frequency and documentation. American Journal of Critical Care, 12(2), 113-118.
Sopena, N., & Sabria, M. (2005). Multicenter study of hospital acquired pneumonia in non-ICU Patients. Chest, 127(1), 213-219.
Weitzel, T., Robinson, S., & Holmes, J. (2006). Preventing nosocomial pneumonia: Routine oral care reduced the risk of infection at one facility. American Journal of Nursing, 106(9), 72a-72e.
Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., Ihara, S. (2002). Oral care reduces pneumonia in older adults in nursing homes. Journal of the American Geriatric Society, 50(3), 430-433.
In patients with teeth:
In patients without teeth:
*Oral care provided every four hours.
In patients with teeth:
In the patient without teeth:
*Those with nasal or gastric tubes, continuously receiving nothing by mouth, on oxygen therapy, having a pulmonary diagnosis, receiving chemotherapy, having neuromuscular impairment with difficulty swallowing, or the immunocompromised. Oral care was given before breakfast, lunch, and at bedtime.
In patients with teeth:
In patients without teeth:
*Oral care is provided before breakfast and at bedtime.