Issue link: https://beckershealthcare.uberflip.com/i/430838
20 Executive Briefing: Non-ventilator hospital-acquired pneumonia Ms. Robertson knows the effects that non-ventilator HAP can have on patients and nurses first-hand. "As a nurse, clinically we noticed an ongoing problem in the patient population with pneumonia rates while they were in the hospital," she says. "I had lost too many patients to pneumonia. I felt as a clinical nurse specialist that we needed to do something." That experience, paired with the literature and studies, motivat- ed Ms. Robertson and her colleague Dulcie Carter, a registered speech language pathologist, to study the issue in order to de- velop interventions that could be targeted to reduce the incidence of non-ventilator HAP. What can be done? Since the problem of non-ventilator HAP has only been uncov- ered in the last few years, clinicians and researchers have just begun to develop the empirical base of evidence needed to pre- vent the problem. As a result of this inquiry, two main factors have emerged as effective ways to prevent this problem. Target specific risk factors with comprehensive oral care "There is a strong linkage between the level of oral contaminants and pneumonia," Ms. Robertson said. When there are elevated levels of bacteria in the mouth, it is more likely for bacteria to be aspirated into the patient's lungs, which can then cause pneu- monia. Hospitalized patients with neurological conditions or who have difficulty swallowing are at an even higher risk. Since there is a relationship between oral care and non-ventila- tor HAP, several researchers, including Ms. Robertson, looked at their own oral care processes and experimented with vari- ous methods and frequencies in order to measure the effects on pneumonia rates. In Ms. Robertson's 2012 study, "Oral intensity: Reducing non- ventilator-associated hospital-acquired pneumonia in care-de- pendent, neurologically impaired patients," an enhanced oral care protocol was implemented for a group of non-intubated, care-de- pendent adults with a neurologic injury — in other words, a group highly susceptible to pneumonia. First, Ms. Robertson and Ms. Carter looked into what nurses had been doing for oral care, and found training and implementa- tion of optimal oral care was inconsistent. "Prior to initiating our research, we did not have a written, clear protocol for nurses to follow" for providing oral hygiene, Ms. Robertson says. "There were no specifics on how to adequately clean a patient's mouth with the products available," which resulted in wide variation in practice. Next, a clear protocol was put into place. The protocol involved placing oral care kits at every patient's bedside, which includ- ed toothbrushes, swabs and hydrogen peroxide solution. The cleaning protocol was provided on nursing worksheets and a standard for documentation of oral care was developed. The protocol included an assessment of the mouth every two to four hours, tooth brushing every 12 hours, cleaning and suctioning of the oral mucosa every two to four hours and moisturizing every four hours. After the six-month study, the HAP rate of the group of patients who received enhanced oral care were compared to retrospective pneumonia rates from a group who received stan- dard care. The researchers found the baseline retrospective group had a 25.5 percent rate of non-ventilator HAP, while the enhanced oral care group had a 6.3 percent rate of non-ventilator HAP, which constituted a statistically significant drop in pneumonia rates. Studies from other institutions have had similar findings. For ex- ample, a 2014 study in the Journal of Nursing Scholarship, titled "Basic Nursing Care to Prevent Nonventilator Hospital Acquired Pneumonia," that involved implementing a new oral care proto- col for all adult non-ventilator patient four times per day saw the number of non-ventilator HAP cases drop by 37 percent over the study's 12-month period. The new protocol was also attributed to a reduction in mortality and had a return on investment of $1.6 million in avoided costs. Change nurse practice Many of the studies on the importance of implementing oral care protocols cite the importance of nurse buy-in to successfully im- plementing the changes. "Nurses play a vital role in preventing hospital-acquired pneumonia," the conclusion of Ms. Robertson's study in the Canadian Journal of Neuroscience Nursing states. "Foundational nursing practices, such as regular oral hygiene, are important aspects of care in preventing nosocomial infections and related costs, optimizing health and promoting quality care." "Center the discussion around that oral care isn't just for comfort anymore — it can prevent a pneumonia event." — Trudy Robertson RN, MSN, clinical nurse specialist with Fraser Health Neurosurgery in New Westminster, British Columbia The problem of non-ventilator HAP has only been uncovered in the last few years, and clinicians and researchers have just begun to develop the empirical base of evidence needed to prevent it.