Oral Care to Prevent VAP and NV-HAP: Where Art Thou?

Oral Care to PreventVAP and NV-HAP

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Health care-associated infections (HAIs) are the leading cause of preventable harm in the US today. Patients experience pain, additional complications, increased length of stay, increased health care cost, and possibly death due to these infections. HAIs have direct medical costs of at least $28.4 billion annually, according to the 2022 National and State Healthcare-Associated Infections Progress Report, and potentially an additional $12.4 billion beyond the direct medical costs due to early death and lost productivity.¹

When asked, most health care providers would list HAIs such as central line-associated bloodstream infections or catheter-associated urinary tract infections as necessary. However, pneumonia is the number one HAI.² In a point prevalence study including 199 hospitals across 10 states, pneumonia was the number 1 HAI, accounting for 25.8% of all HAIs.Non-ventilator hospital-acquired pneumonia (NV-HAP) accounted for 65% of these pneumonia cases, whereas 35% were attributed to ventilator-associated pneumonia (VAP).² It is important to note that costs due to pneumonia are not included in the staggering HAI medical costs identified in the study above because hospitals are not required to report NV-HAP or VAP to the CDC’s National Healthcare Safety Network (NHSN).

In recent national guidelines published in Infection Control & Hospital Epidemiology, oral care is listed as an essential practice for preventing both VAP and NV-HAP.³ Critical care nurses have long known and supported the evidence that oral care is essential to routine, daily interventions for mechanically ventilated patients. However, oral care is frequently missed as a key treatment or intervention to prevent NV-HAP.^4,5 NV-HAP is a severe complication and occurs more frequently than VAP (65% vs 35%), has high morbidity and mortality (15-30%), and is a costly HAI.^2,6 In addition, hospital-onset sepsis is a complication of NV-HAP.7,8 In essence, patients are experiencing severe, hospital-acquired complications due to missing essential nursing care.

So why is oral care missed, dismissed, omitted, or not considered a critical intervention in caring for non-ventilated patients? There are several reasons. First, there needs to be more awareness regarding the importance and impact of NV-HAP. It needs to be more widely addressed in formal health care education and is often not a topic of in-servicing or continuing education in the hospital setting. In a recent survey of 179 Australian nurses on oral care practices and NV-HAP, Tehan et al described practices, barriers and facilitators, knowledge, and educational preferences of nurses performing oral care.⁹ From a listing of 6 interventions, oral care was reported to be moderately important or very important by 75% of nurses, while other interventions such as hand hygiene, mobilization, and dysphagia management were rated higher.⁹ Seventy-four percent of the nurses agreed or strongly agreed that they needed more information on research-proven oral care standards.⁹

Information on the importance and prevention of NV-HAP is needed both in formal education and in the clinical setting. Importantly, education on oral care and the prevention of NV-HAP goes beyond nursing and nursing-associated positions and needs to include physicians, advanced practice providers, respiratory therapists, speech-language pathologists, and anyone involved in direct patient care. Additionally, patients and families must be remembered when highlighting the importance of oral care. Understanding the “why” is key to driving an oral care initiative and fostering engagement and motivation.

Beyond education, what are some of the other barriers to oral care? Inadequate oral care supplies and equipment are a problem. In the survey by Tehan et al, 63% of the respondents either agreed/strongly agreed that they needed better supplies and equipment.⁹ Meanwhile, only 62% agreed/strongly agreed that the toothbrushes provided were suitable.⁹ The American Dental Association has endorsed a protocol for comprehensive oral care, including the required supplies and frequency of oral care, depending upon the patient population.¹⁰ This protocol should be part of every hospital’s procedure for oral care. Lastly, access to oral care supplies can also be a barrier. In the same survey, only 58% of nurses agreed/strongly agreed that supplies were readily available.⁹ All necessary oral care supplies or an oral care kit must be readily available at the bedside.

Regarding toothbrushes, an interesting observational study published in Clinical Nurse Specialist by DeJuilio et al. reported results of 136 acute care hospitals to determine the prevalences of microbial growth on toothbrushes found in patient rooms from 2018 to 2022.¹¹ A total of 5340 patient rooms were surveyed.¹¹ Of these rooms, 46% did not have a toothbrush available or had not used the available toothbrush (still in package and toothpaste not opened).¹¹ This highlights a supply issue for oral care and a need for more understanding of its importance. Of the used toothbrushes sampled for microbial colonization, 48% had at least one organism, and 14% were positive for 3 or more organisms, which included gram-negative, vancomycin-resistant Enterococcus, methicillin-resistant Staphylococcus aureus, Enterococcus, and Staphylococcus aureus.11 These results document the lack of available toothbrushes and the evident risk of microbial exposure on used toothbrushes. To address the risk of microbial colonization on toothbrushes, hospitals should assess replacing toothbrushes more frequently.

Lastly, nursing staff have identified an additional barrier to providing oral care: having sufficient time. Tehan et al. reported that only 59% of nurses agree or strongly agree with having sufficient time to provide oral care.⁹ Oral care needs to be identified as a high-priority intervention or treatment in the daily care of patients versus a task or a comfort measure.

It is important to reflect on questions regarding NV-HAP and oral care that need to be answered—What is the level of knowledge about NV-HAP and oral care in your organization? Is your organization doing surveillance of NV-HAP? Are guideline-compliant oral care supplies available at the bedside, and are they used appropriately? NV-HAP is a harmful complication that can be prevented. It is time to step up, prioritize, and implement an oral care protocol to help prevent NV-HAP.

References:

1. Office of Policy, Performance, and Evaluation. Health Topics – Health care-associated Infections (HAI). CDC. Accessed October 2, 2024. https://www.cdc.gov/policy/polaris/healthtopics/hai/index.html#:~:text=HAIs%20are%20infections%20resulting%20from,early%20deaths%20and%20lost%20productivity.

2. Magill SS, O'Leary E, Janelle SJ, et al. Emerging Infections Program Hospital Prevalence Survey Team. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med. 2018 Nov 1;379(18):1732-1744. doi: 10.1056/NEJMoa1801550. PMID: 30380384; PMCID: PMC7978499.

3. Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infection Control & Hospital Epidemiology. 2022;43(6):687-713. doi:10.1017/ice.2022.88

4. Quinn B, Baker DL, Cohen S, Stewart JL, Lima CA, Parise C. Basic nursing care to prevent nonventilator hospital-acquired pneumonia. J Nurs Scholarsh. 2014 Jan;46(1):11-9. doi: 10.1111/jnu.12050. Epub 2013 Sep 30. PMID: 24119253.

5. Munro S, Baker D. Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs. Appl Nurs Res. 2018 Dec;44:48-53. doi: 10.1016/j.apnr.2018.09.004. Epub 2018 Sep 19. PMID: 30389059.

6. Munro SC, Baker D, Giuliano KK, et al. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol. 2021 Aug;42(8):991-996. doi: 10.1017/ice.2021.239. Epub 2021 Jun 9. PMID: 34103108; PMCID: PMC10947501.

7. Giuliano KK, Baker D. Sepsis in the Context of Nonventilator Hospital-Acquired Pneumonia. Am J Crit Care. 2020 Jan 1;29(1):9-14. doi: 10.4037/ajcc2020402. PMID: 31968079

8. Carey E, Chen HP, Baker D, et al. The Association Between Non-ventilator Associated Hospital Acquired Pneumonia and Patient Outcomes Among U.S. Veterans. Am J Infect Control. 2022; 50(12):1339-1345. doi: 10.1016/j.ajic.2022.02.023

9. Tehan PE, Browne K, Matterson G, et al. Oral care practices and hospital-acquired pneumonia prevention: A national survey of Australian nurses. Infect Dis Health. 2024 May 8:S2468-0451(24)00028-2. doi: 10.1016/j.idh.2024.04.006. Epub ahead of print. PMID: 38724299.

10. Quinn B, Giuliano KK, Baker D. Non-ventilator healthcare-associated pneumonia (NV-HAP): Best practices for prevention of NV-HAP. Am J Infect Control. 2020 May;48(5S):A23-A27. doi: 10.1016/j.ajic.2020.03.006. PMID: 32331561.

11. DeJuilio P, Powers J, Soltis LM, Brooks JA. Multisite Evaluation of Toothbrushes and Microbial Growth in the Hospital Setting. Clin Nurse Spec. 2023 Mar-Apr 01;37(2):83-89. doi: 10.1097/NUR.0000000000000733. PMID: 36799704; PMCID: PMC9969552.