Improving Oral Care Adherence for NV-HAP Prevention

By: Olivia Lounsbury, Clinical Research Coordinator, Patient Safety Movement Foundation
Shannon Munro, PhD, APRN, NP-C, VA Diffusion of Excellence Initiative

Hospital-acquired pneumonia, whether device associated or not, is the number one hospital-acquired infection in the United States and a major threat to the safety of patients. Ventilator-associated pneumonia (VAP) contributes 300,000 cases annually at a cost of over $50,000 per patient; VAP and non-ventilator associated hospital acquired pneumonia (NV-HAP) have a combined incidence of 6-8.6 per 1,000 admissions in high-income settings (Howie, 2017).  NV-HAP represents over 60% of hospital-acquired pneumonia cases with a rate of 3.63 per 1,000 patient days and a mortality rate of 18% (Magill, et al. 2018; Giuliano, Baker & Quinn, 2018). 

While these numbers alone are shocking, it’s even worse to consider just how preventable both conditions are. It has been shown that hospital-acquired pneumonia can be decreased by 70% through inexpensive, easily integrated preventive measures such as oral care, respiratory exercises, and mobility (Baker & Quinn, 2018; Munro & Baker, 2018; Quinn, Baker & Giuliano, 2020). Preventing even 100 cases of NV-HAP is estimated to save $400 million, 700-900 hospital days, and the lives of 20-30 patients (Quinn, et al. 2013).

Most clinicians are aware that basic nursing care procedures reduce the risk of VAP and NV-HAP. These procedures include:

  •     Consistent oral care (e.g. toothbrushing, denture cleaning)
  •     Weaning and sedation vacation from ventilation
  •     Head of bed elevation
  •     Deep breathing and coughing exercises
  •     Early mobility
  •     Suctioning
  •     Hand hygiene

Prevention measures are relatively inexpensive but require time, prioritization, vigilance, and integration into routine care. The components that do require equipment, such as oral care, cost little to introduce into routine clinical workflow ($3-5 per patient).

So why is hospital acquired pneumonia such a significant cause of harm and death in hospitals?

It has been reported that only 29% of intensive care unit nurses feel adequately educated on oral care and 20% did not take care of patients’ mouths during their shifts (Javadinia, et al., 2014). Other studies have shown that up to 82% of patients who spend time in a healthcare facility do not receive oral care assistance during their stay (Kalisch & Xie, 2014; Kalisch, Landstrom, & Williams, 2009).

While it is easy to place the blame on the individual, let’s take a step back and recognize the overwhelming workload and personnel shortages, and lack of organizational prioritization on the preventive measure of oral care. A culture of safety, continuous improvement, and a model for sustainment are fundamental pillars in patient safety for any organization and without these components, preventive measures, such as oral care for ventilated and non-ventilated patients, fall through the cracks and expose the patient to significant risk.

Success in improving oral care adherence for ventilated and non-ventilated patients to prevent hospital acquired pneumonia (and its frequent complication: sepsis) is directly related to the degree of organizational prioritization and integration into the existing clinical workflow. If the new protocol does not move seamlessly into the existing clinical workflow, implementation will be ineffective, and adherence will be low. 

The National HAPPEN (Hospital-acquired Pneumonia Prevention by Engaging Nurses) Implementation team at the Veterans Administration (VA) has been successful in improving oral care adherence for non-ventilated patients and has spread to 70 VA hospitals across 246 medical surgical, pre-surgical, intensive care, long term care, blind rehabilitation, oncology, hospice and palliative care, spinal cord injury, and inpatient mental health units to date. Shannon Munro, PhD, APRN, NP-C, began studying the incidence of NV-HAP within the VA in 2012 and developed plans to make oral care a priority for hospitalized Veterans. With the support of the Diffusion of Excellence Initiative and VA leadership, HAPPEN launched in 2016. The HAPPEN team developed staff and patient education and created a toolkit to facilitate implementation and they provide ongoing guidance for transitioning to this strategy. In the initial pilots in 8 VA hospitals, NV-HAP was reduced by 51% on the long-term care units and by 62% on the medical surgical units. The implementing units have sustained this reduction in cases for over 2 years saving many lives and millions of health care dollars.

Recognizing the great divide between learning and actual performance, the team took a ground up approach to improve the consistency and quality of oral care provided to non-ventilated patients at the VA. The team looked to the nurses and nursing assistants to take ownership of the initiative and make changes on their units to improve the oral care provided for Veterans. The team begins with a gap analysis so they can determine the needs and best approach for each facility (e.g. facility wide launch or one unit at a time, needed supplies). Each facility is instructed to begin using the national oral care documentation template in the electronic health record (EHR) and monitor the care provided and documented through an automated health factor report which tracks the care provided. Random chart audits and spot checks with patients are encouraged to make sure the information being documented is accurate and high performing staff are recognized as champions of the initiative. Pre-COVID-19, preparing to launch HAPPEN would take 3-4 months on average. Implementing units have consistently seen improvement in NV-HAP rates within a short period of time, which helps reinforce the importance of prevention measures like oral care. 

The team believes the most important factors in being successful are staff buy in, local and national leadership support, and making sure the EHR accurately reflects practice. The VA led the first think tank meeting in January 2020 in Washington DC with VA Leadership (Diffusion of Excellence, Nursing, Dentistry, HSR&D), the CDC, the Joint Commission, FDA, ADA, HRSA, Patient Safety Movement Foundation, and private industry. The team is working with these national leaders in health care to develop a national research agenda, policy, and a unified implementation campaign. 

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