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Hydration and Nosocomial Pneumonia: Killing Two Birds with One Stone (a Toothbrush)
Clear and compelling evidence exists in the literature to suggest that nosocomial pneumonia is linked to poor oral care. In nursing homes and intensive care units, practicing good oral care has been demonstrated to reduce the risk of aspiration pneumonia (Furr, Binkley, McCurren, & Carrico, 2004). In an oral care program implemented in a 29-bed rehabilitation unit, lung status was improved in 77% of patients who were admitted with aspiration pneumonia. Key components of the forces of magnetism (American Nurses Credentialing Center, n.d.) were used to implement the program, including autonomy and interdisciplinary relationships. The rehabilitation unit also applied the theory proposed by Higgins and Howell, which promotes using champions to make important process changes (1990). This article reviews the steps one rehabilitation unit took to implement an oral care plan.
Although it is the goal of rehabilitation to improve patients’ level of independence, many patients have a variety of risks for complications from their acute illness that can potentially affect their ability to make gains in their functional independence. It is the responsibility of the rehabilitation nurse to promote healthy behavior while also reducing health risks that would deter patients from meeting their goals. It is important, therefore, to constantly watch for those factors that create the greatest risk to patients’ health. Some of the diagnoses common to rehabilitation—stroke, brain injury, high-level spinal cord injury, and Guillain-Barre—often lead to difficulty swallowing (i.e., dysphagia). Because of the high incidence of dysphagia in the rehabilitation population, many patients are at greater risk for aspiration pneumonia (Marik & Kaplan, 2003). In fact, the risk of aspiration may be as high as 40%–50% in stroke patients with dysphagia (Smithard, Smeeton, & Wolfe, 2007).
Although nosocomial pneumonia was recognized as a problem decades ago (Charache, Graybill, Marshall, Wallace, & Melvin, 1973), healthcare-related pneumonias are cited as the second most common nosocomial infection and a leading cause of nosocomial death with a mortality rate estimated between 20% and 33% of all hospitalized patients (Tablan et al., 1997). In addition, according to the Centers for Disease Control and Prevention (CDC), ventilator-associated pneumonia (VAP) accounts for 60% of all deaths resulting from nosocomial infections (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2003). Frequently, patients with dysphagia are prescribed diets with thickened liquids to reduce the risk of aspiration pneumonia. Unfortunately, evidence suggests that patients report dissatisfaction with this type of diet and are less likely to ask for additional thickened liquids during nonmeal times (Davis, 2007). In addition, when cornstarch- or pectin-based thickeners are used, some binding with water occurs, which increases patients’ risk for dehydration (Baker, 2008; CDC, 1997). Consequently, addressing one problem—risk for aspiration—can create others. Using thickened liquids to reduce the risk of aspiration can increase risk of dehydration because overall fluid intake is reduced or some thickeners bind with water. In this study, a 29-bed inpatient acute rehabilitation unit in a 407-bed acute care hospital sought to reduce the risk for both aspiration pneumonia and dehydration.
To reduce the risk for aspiration pneumonia, it was important to first properly identify the contributing factors. Within the past 10 years, the etiology of hospital-acquired pneumonias has become more apparent. In 1997, the CDC published a document stating “Most bacterial nosocomial pneumonias occur by aspiration of bacteria colonizing the oropharynx” (Tablan et al., 1997). In addition, it is clear that “colonization of the oropharynx is an important step in the pathogenesis of aspiration pneumonia” (Marik & Kaplan, 2003). So, despite the fear of aspiration of food particles, the greatest risk for aspiration pneumonia comes from bacteria growing in patients’ mouths. Fortunately, oral care has been shown to reduce the risk of VAP in patients on mechanical ventilation (Furr, Binkley, McCurren, & Carrico, 2004) and pneumonia in nursing home populations (Raghavendran, Mylotte, & Scannapieco, 2000).
Establishing Evidence-Based Practice
The current literature was reviewed to identify guidelines and support for changing practice to reduce the risk for aspiration pneumonia and dehydration among patients. According to the evidence, if a patient has teeth, a toothbrush must be used to remove the plaque that harbors the pathogens (Pearson & Hutton, 2002). Only dentate patients with very fragile oral mucosa or low platelet counts (i.e., <20,000 x 10 cells/mm3) should receive oral care with toothettes (Cancer Care Nova Scotia, 2006). Toothettes, which are foam basal swabs, may also be used on edentulous patients; however, their dentures must be brushed and soaked in a denture-cleaning product. The literature states that even patients who take nothing by mouth (NPO) need oral care and are at significant risk for aspiration pneumonia (Furie et al., 2005). Further research shows that oral care should be given a minimum of two times a day for all patients, and it is recommended up to four times a day for patients with neurological disorders (Cohn & Fulton, 2006). Because the nighttime hours allow for a prolonged period for bacteria and plaque to form, it is recommended that oral care be provided first thing in the morning (Knight, 2008). To simultaneously address the risk of dehydration, providing unthickened water safely to patients as long as oral care is completed first has proven to be successful (Panther, 2005). Although this water protocol research had been successfully conducted at another nearby rehabilitation hospital, the rehabilitation unit in this study took an extra precaution. In conjunction with representatives from speech therapy, nursing leaders decided that oral care needed to be improved to ensure the safe implementation of a water protocol without increasing the risk for pneumonia. The oral care program was simultaneously initiated with the hydration protocol.
Baseline data about the oral care of patients with dysphagia were gathered to determine whether they were practicing oral care before the program proceeded any further. Patients who were assigned to a feeding group because they exhibited clinical signs of aspiration (as noted by a speech therapy evaluation) were surveyed. The charge nurse randomly asked patients with dysphagia, who were not cognitively impaired, if they had received oral care. One speech therapist also checked patients’ oral cavities for visible signs of food particles and proper oral care. The surveys were conducted primarily in the mornings when patients were sitting upright in the dining room and after they should have received oral care. The nursing assistants were not notified in advance, and there was no pattern regarding the days during which the surveys and inspections were conducted. Based upon surveys and visual inspections, it was determined that 29% of the patients on the rehabilitation unit had oral care before breakfast. Furthermore, only 35% had oral care at least once daily based on the auditors’ inspections.
The data suggested it was necessary to improve oral care and create a project that would address both oral care and hydration. The nurse manager, charge nurse, director of speech therapy, and a speech pathologist met on several occasions to clearly define the purpose of the project, which was to initiate an evidence-based comprehensive oral care program that reduces the risk for aspiration pneumonia and provides for hydration in a rehabilitation population with clinical signs of dysphagia.
Targeting Obstacles for Oral Care and Hydration
The hospital in this study is seeking Magnet status, and two of the Forces of Magnetism—autonomy and interdisciplinary relationships—heavily influenced how the rehabilitation unit proceeded. To promote Magnetism, this project needed to foster autonomy by allowing the nurses and nursing assistants to identify obstacles and solutions. It was also important to encourage the use of interdisciplinary relationships by including representatives from physical therapy, occupational therapy, speech therapy, and nursing to be champions for this change. Higgins and Howell point out that teams of change champions are essential for process improvement (1990). Furthermore, Higgins and Howell define champions as “individuals who emerge to take creative ideas (which they may or may not have generated) and bring them to life. They make a decisive contribution to the innovation process by actively and enthusiastically promoting the innovation, building support, overcoming resistance, and ensuring that the innovation is implemented”(1990, p. 40).
The managers of each discipline identified and invited members who exemplified this definition of champion to participate in the Oral Care and Hydration Committee. The committee met to discuss obstacles to practicing oral care and to identify ways to overcome these barriers. This group agreed the leading barriers were insufficient knowledge about the importance of oral care and time to perform it. Furthermore, the literature supports the theory that a lack of knowledge, time constraints, and poor understanding of the importance of oral care are common barriers to providing adequate oral care in hospitalized patients (Cohn & Fulton, 2006; Preston, Kearns, Barber, & Gosney, 2006).
To overcome these barriers to oral care and hydration, multiple in-service sessions were initiated to educate staff about the evidence in the literature. The in-service sessions were led by a speech therapist who did extensive research on the best practices for oral care. The speech therapist trained staff members from physical therapy, occupational therapy, and speech therapy. She also trained nursing assistants and nurses in the oral care program. Because several nursing assistants were on the oral care committee, they were helpful in disseminating the information to their peers and acting as champions of the program. During the in-service sessions, staff members were given time to ask questions. A form was created by one of the speech therapists and a charge nurse to facilitate educating staff about oral care. The form included instructions for oral care as well as space for recommended times and frequency of oral care (Figure 1). The nursing assistants were expected to initial the form each time they gave oral care. This form acted as an audit tool that allowed educational needs to be readdressed. To address the issue of time constraints, a few nursing assistants were scheduled to arrive earlier in the morning to provide oral care to patients with dysphagia before breakfast. With patients’ consent and an order from their physiatrists or pulmonologists, patients who safely tolerated water, as determined by their speech pathologist, were permitted water between meals after oral care. Flow sheets followed the patients to all of their therapies to allow therapists, nurses, and nursing assistants to document when and how much water was being offered between meals.
Measuring Results and Making Adjustments
During staff meetings, staff members were provided opportunities to give feedback about the success of the program and to suggest necessary changes. For example, when oral care was initially given to dysphagia patients at 6 am, many of them complained about being woken up an hour and a half before breakfast to receive oral care. Consequently, in consultation with the nursing assistants, the start time for oral care was changed to 6:30 am; there was a noted improvement in patient satisfaction and reduced complaints and refusals of oral care. In staff meetings, several nurses and nursing assistants noted that families did not understand why their loved ones could receive water but not other thin fluids. In response, the director of speech therapy created a pamphlet to help families understand why plain water was safe for their loved ones while other thin liquids were not. During audits of patients’ fluid intake, the charge nurse noted that patients on the hydration protocol were not receiving additional thin water. To promote water intake, reminder posters were placed on the unit that said “Got Water?” Therapy staff members complained that patients did not want to drink cool water from the tap; they preferred the ice water they could receive on the unit. Because there was no water fountain or cooler in the gym, pitchers were purchased and one of the occupational therapy aides was responsible for filling them daily with ice water. All of these adjustments contributed to greater interest in and adherence to the water protocol among patients, staff members, and families. Anecdotally, there was a decrease in patients refusing oral care and a reduction in the number of complaints from family members about their loved ones not receiving unthickened liquids aside from water. After implementing this project, inspections and audits showed that 100% of dysphagia patients received oral care at least once a day, with the majority receiving oral care 2–3 times per day.
Measuring the effect of oral care on the incidence of aspiration pneumonia was difficult because most of the patients with aspiration pneumonia were diagnosed before being admitted to the unit; however, committee leaders decided to assess how effective the program was in improving the lung status in patients previously diagnosed with aspiration pneumonia. Consequently, when closed charts were reviewed, patients who came to the unit recovering from aspiration pneumonia before the program was initiated showed improved lung status in only 33% of the cases (as evidenced by auscultation by their physician or by radiographic examination). After the program was initiated, patients who came to the unit recovering from aspiration pneumonia showed improved lung status in 77% of the cases. On average, it was found that patients on the hydration program received 100–200 cc more fluid per day than they did before the hydration program. Although it was difficult to find documented evidence of decreased incidences of dehydration before or after the initiation of the program, the authors believe that by increasing fluid intake—even by minor amounts—the risk for dehydration was decreased. In addition, patient satisfaction increased as patients were able to safely drink regular water. The Hydration and Oral Care Program has proven to be successful in addressing two potential risk factors in the rehabilitation population—aspiration pneumonia and dehydration—killing two “birds” with one toothbrush.
There is a story found in the Old Testament about a military commander, Naaman, who is afflicted with leprosy. He seeks to be healed by the prophet Elisha. Naaman sends his servant to bring Elisha back to heal him. Elisha responds to the servant that he should tell his master to wash seven times in the Jordan River. Naaman’s servant reports Elisha’s instructions to him. Naaman is insulted by this. His servant responds by telling Naaman, “My father, if the prophet had told you to do some great thing, would you not have done it? How much more, then, when he tells you, ‘Wash and be cleansed!’” (2 Kings 5:13 NIV). Eventually Naaman follows the instructions and is healed of his leprosy. The point is that medical practitioners are like Naaman. They seek some new technique for healing or curing disease while often ignoring the basics. Preventing aspiration pneumonia does not involve a complex or high-priced scientific breakthrough. It is as simple as using a toothbrush and practicing basic oral care. For each nursing unit, the obstacles are varied. The obstacles presented in this study may not exist in every unit. The program was successful because it used shared governance, change champions, and interdisciplinary teams to solve two significant risks to the population. It was the team of nurses, therapists, and nursing assistants working together who identified the obstacles, suggested the solutions, and implemented the changes.
About the Authors
James J. Farrell, MBA RN CRRN, is nurse manager of the rehabilitation unit at Baptist Hospital East in Louisville, KY. Address correspondence to him at email@example.com.
Sarah C. Petrik, MS CCC-SLP, is a speech language pathologist at Baptist Hospital East in Louisville, KY.
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