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A Nurse-Driven Oral Care Protocol to Reduce Hospital-Acquired Pneumonia

Warren, Chastity, DNP, MSN/Ed, RN, CCRN-K; Medei, Mary Kathryn, BSN, RN, CMSRN; Wood, Brooke, BSN, RN, CMSRN; Schutte, Debra, PhD, RN

AJN The American Journal of Nursing: February 2019 - Volume 119 - Issue 2 - p 44–51
doi: 10.1097/01.NAJ.0000553204.21342.01
Cultivating Quality

Purpose: The purpose of this evidence-based quality improvement (QI) project was to implement an oral care protocol in the adult in-patient care areas of a level 1 trauma hospital and to evaluate its impact on the incidence of hospital-acquired pneumonia (HAP).

Methods: A standardized, evidence-based oral care protocol was implemented depending on the level of care required by each ventilated, at-risk, or short-term care patient. The QI project included the introduction of a new suction toothbrush kit for at-risk patients and, for short-term patients, a new short-term oral care kit that featured a more ergonomically appropriate toothbrush, a baking soda toothpaste, and an alcohol-free antiseptic mouthwash; the project also supported the continued use of the then current suction toothbrush kit for patients receiving mechanical ventilation. We examined medical records retrospectively and used International Classification of Diseases (ICD) 9 and ICD 10 codes for pneumonia not present on admission to determine the incidence of HAP, including nonventilator hospital-acquired pneumonia (NV-HAP) and ventilator-associated pneumonia (VAP), in two seven-month periods: the baseline and intervention periods. Both periods were in the same seven calendar months of two different years to control for seasonal differences in pneumonia rates. Documentation of oral care interventions were compared with oral care supply use reports to measure protocol adherence in the intervention group.

Results: There were 202 patients in the baseline group and 215 in the intervention group. A χ2 analysis of NV-HAP incidence showed a statistically significant decrease in occurrences of NV-HAP from 52 in the baseline group to 26 in the intervention group (χ2 = 12.8, df = 1, P < 0.001). The number of patient deaths from NV-HAP also differed significantly between groups, with 20 in the baseline group and four in the intervention group (χ2 = 4.33, df = 1, P = 0.037). NV-HAP incidence per 1,000 discharges was calculated at 2.84 in the baseline group and 1.41 in the intervention group. Among patients on a ventilator, there were 56 ventilatorassociated events (VAEs) with 12 cases of VAP in the baseline group and 49 VAEs and three cases of VAP in the intervention group. Infection rates in the baseline group were calculated as 12.53 VAEs per 1,000 ventilator days and 2.87 cases of VAP per 1,000 ventilator days. The intervention group yielded a VAE rate of 14.29 per 1,000 ventilator days and a VAP rate of 1.26 per 1,000 ventilator days. Overall, nurses' adherence to the new oral care protocol ranged from 36% to 100% per month, with an average adherence to protocol of 76% as evidenced by oral care documentation and supply use.

Implications: Nurses improved pneumonia outcomes by providing oral health interventions to all adult patients admitted to the hospital, which reduced overall hospital costs, length of stay, and patient mortality.

The authors describe a quality improvement initiative to implement an oral care protocol in the adult in-patient care areas of a level 1 trauma hospital and evaluate its impact on the incidence of hospital-acquired pneumonia.

Chastity Warren is an assistant professor at the Michigan State University College of Nursing and a clinical nurse specialist in critical care at Sparrow Health System, Lansing, MI, where Mary Kathryn Medei and Brooke Wood are RNs in the surgical specialties department. Debra Schutte is an associate professor at the Wayne State University College of Nursing in Detroit and a nurse research consultant in the nursing education and practice department at Sparrow Health System. The following funding sources contributed to the completion of this project: the Sparrow Hospital Department of Nursing Evidence-Based Practice Fellowship Program, Sparrow Foundation Sue Tadgerson Nursing Research Fund, and Delta Dental Foundation, an affiliate of Delta Dental of Michigan, Ohio, and Indiana, which provided an unrestricted educational grant. Contact author: Chastity Warren, The authors have disclosed no potential conflicts of interest, financial or otherwise.

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