Fortifying the

Host Defense:

The Power of Oral

Care

Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN

Clinical Nurse Specialist / Educator / Consultant

ADVANCING NURSING LLC

Northville, Michigan

www.vollman.com © Vollman 2010

Disclaimer

• These slides are copyrighted by

Kathleen Vollman

• Use of these slides without the written

permission of Kathleen Vollman is

illegal

Quality & Safety Drivers Institute for Medicine

• IOM report• Transforming the work culture

Evidence based practice movement

Quality organizations• IHI/VHA:100,000 lives campaign /5 million lives campaign• Clean Care is Safer Care/WHO • Japan Council for Quality Health Care

Regulatory agencies:• Japan April 2007: Medical Service Law (Infection control

has become a legal obligation)• Certification for Infection control nurses through JNA

• Public Transparency

Professional Nursing: Back to the Basics

Economics

Driving Forces for Change

• Scientific Driver– Evidence-based practice movement

• Economic & Social Drivers – IOM/Medical error

– Leap Frog group

– Institute for HealthCare Improvement/VHA• 100,000 lives campaign

• 5,000,000 lives campaign

– Joint Commission

• Professional Driver: Back to the basics

Vollman KM. Crit Care Nurs Clin N Am, 2006; 18:453-467

Basic

Care

Science

Florence Nightingale …

An expert in nursing’s autonomous scope of practice

• Surveillance & monitoring of patient conditions for early detection of problems

• Preventing complications

―I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all of these at the least expense of vital power to the patient‖

Notes on Nursing (1860/1969 p. 8)

Florence Nightingale on:

The distinction between disease and illness―If a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault NOT OF THE DISEASE, BUT OF THE NURSING.‖

(emphasis added) Notes on Nursing (1860/1969, pg 8)

―… so deep-rooted and universal is the conviction that to give medicine is to be doing something or RATHER EVERYTHING; to give air, warmth, cleanliness, etc., is to do nothing.‖

(emphasis added) Notes on Nursing, (1860/1969, pg. 9)

Science Needs to Drive the Practice

Change..Otherwise It’s Like Shooting

in the Dark

• The target is out of focus, less accurate and

more shots are necessary to make a hit

• Science narrows the focus, sets the sight and

hits the target.

CLINICAL

RESEARCH

ROUTINE

PRACTICE

Host Defense

• External barriers to

prevent infection:– acidic pH

– normal flora

– cilia

– bactericidal secretions

– skin

• Interventions that

alter the host

defense:– central line

– antibiotics

– ET/NGT

– failure to feed

– minimal positioning

– sedation

– outdated wound care© Vollman 2001

Fortifying Host

Defense

Implement

Interventional Patient Hygiene

Interventional Patient Hygiene

• Hygiene…the science and practice

of the establishment and

maintenance of health

• Interventional Patient

Hygiene….nursing action plan

directly focused on fortifying the

patients host defense through

proactive use of evidence based

hygiene care strategies

Incontinence Associated

Dermatitis Prevention

Program

Attitude

&

Accountability

Factors Impacting the

ability to Achieve Quality

Nursing Outcomes

at the Point of Care

NSO

Components of Successful Long

Lasting Change

ValueVollman KM.

Australian Crit

Care, 2009;22(4):

152-154

Hospital Acquired Pneumonia (HAP) and

Ventilator-Associated Pneumonia(VAP)

• VAP crude mortality approximately 10-40%.

• HAP crude mortality 15-18%

• Pooled mean ranges from 2.3 to 12.3 per 1000 ventilator days

• HAP rates 5-15 per 1000 patient days

• Associated cost $30,000-$40,000 per VAP

• Increase LOS up to 4-14 days

• Annual cost $2 billion dollars.

Edwards JR, et al. Am J of Infect Control, 2007;35:290-301

Kollef MH, et al. Chest, 2005:128:3854-3862

Collard HR. Ann Intern Med. 2003;138:494-501

Rello J. Chest. 2002;12:2115-2121

ATS Guidelines for HealthCare Acquired Pneumonia 2006

Coffin SE, et al. Infection Control & Hosp Epid, 2008;29(1):S31-S40

Risk Factor Categories for

Nosocomial Pneumonia

• Factors that increase

bacterial burden or

colonization

• Factors that increase risk of

aspiration

Factors that Increase Bacterial

Burden or Colonization

• Extreme age, severe underlying condition/ immunosuppression

• Administration of antibiotics

• Agents which raise the gastric pH

• Withholding gastric feeding

• Mechanical ventilation

• Lack of oral care

• Poor infection control practices

• Contaminated respiratory equipment/contaminated condensate

• Saline administration

• Immobility

That’s not the way

we do it here!!!

Practices in Oral Care

• Culture cup, ½

H2O2, ½ sterile

H2O…little bit of

mouthwash

• Lemon glycerine

swabs

• Toothette with water

&/or mouthwash

• No oral care

Lemon & Glycerin Swabs• Harmful

• Hastens drying of mucosa by depleting the saliva reserve caused by over-stimulation of salivary glands by lemon juice

• Citric acid has no moisturizing capabilities

• Irritates oral mucosa & decalcifies teeth

• Glycerin is a trihydric alcohol that absorbs water causing drying

Foss-Durant Am et al. Clin Nurs Res. 1997;6(1):90-104

Krishnasamy M. Eur J Cancer Care. 1995;4(4):173-177.

Regnard C et al. Br Med J. 1997;315(7114):1002-1005.

Van Drimmelen JR et al. Nurs Res 1969;18:327-332

Epidemiological & Risk Factor

Categories for Institutional Pneumonia

Residents >75 years old at 6x higher risk

33 out of 1000 nursing home residents require hospitalization for pneumonia per year vs. 1.14 out of 1000 elderly living in the community per year

Leading cause of death in nursing home residents

Annual cost of nursing home acquired pneumonia exceeds $8 billion dollars

Factors that increase bacterial burden or colonization

Factors that increase risk of aspiration

Terpenning M. et al. JAGS 2002;50:584-585

Murder RR. Am J Med 1998;105:319-330.

Oral Care Practices: Large Multi-site Study

2000 vs. 2005

Sole M.L. Am J of Crit Care. 2003;12(3):220-230

Cason Cl, et al. Am J of Crit Care. 2007;16(1):28-36

Oral Care Practices are Changing

Oropharyngeal Colonization

• 89 critically ill patients

• Examined microbial colonization of the oropharynx

through out ICU stay

• Used pulse field gel electrophoresis to compare

chromosomal DNA

Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156:1647-1655

Methodology:

Results:• Diagnosed 31 VAPs

• 28 of 31 VAP’s the causative organism was

identical via DNA analysis

Oropharyngeal Colonization

• 49 elderly nursing home residents admitted to the

hospital

• Examined baseline dental plaque scores &

microorganism within dental plaque

• Used pulse field gel electrophoresis to compare

chromosomal DNA

El-Solh AA. Chest. 2004;126:1575-1582

Methodology:

Results:

• 14/49 adults developed pneumonia

• 10 of 14 pneumonias, the causative organism was

identical via DNA analysis

Bacterial Growth In Oral Secretions & Suctioning

Equipment in Orally Intubated Patients

Results• 24 hours/all patients had oral pathogens

• 67% had sputum cultures positive for pathogens

• Suctioning devices were colonized with similar pathogens in the mouth

• 94% of tonsil suction devices were colonized within 24 hours

Sole ML et. al. AJCC. 2002;11(2):141-149

Methodology

• 20 patients intubated orally for >24 hours

requiring mechanical ventilation

• Specimens (sputum & oral) obtained at baseline

& equipment changes

STAMP Study:

ET/Oral Care & Suctioning Practices

• Only 48% of institutions studied included oral care as

part of a policy/procedure

• Only 37% had a policy for oral suctioning

• 82% use of a single suction canister and tubing for both

closed ET tube suctioning and oral suctioning.

• 59% of institutions changed suction tubing as needed

• 89% yankauer use with no policy for rinsing, changing or

storing.

• 71% store yankauer in original package

Sole M.L. AJCC. 2003;12(3):220-230

Significant Independent Predictors of Aspiration Pneumonia

Dependant for feeding

Dependant for oral care

Number of decayed teeth

Tube feeding

Multiple medical diagnoses

Number of medications

Dry mouth

Smoking

Langmore SE. et al. Dysphagia 1998;13:69-81

Role of Salivary Flow

• Provides mechanical removal of plaque and microorganisms

• Innate & specific immune components (IgA, cortisol, lactoferrin)

• Patients receiving mechanical ventilation have dry mouth which in turn contributes to accumulation of plaque & reduced distribution of salivary immune factors

Munro CL & Grap MJ. AJCC. 2004;13:25-34

Frequency of Oral Care

and Suctioning

• Process of giving oral care rather than specific agent has a greater influence on the general condition of the mouth.

• 2 to 4 hour interval tends to show a greater improvement in oral health.

• If oral care is omitted for a period of 4 to 6 hours the previous benefits are lost.

Ginsberg MK. Am J of Nurs. 1961;61:67-69

DeWalt EM. Nurs Research. 1975;24(2):104-108

Drimmelen and Rollins. Nurs Research. 1969;18:27-332

O’Reilly M. Australian Critical Care. 2003;16(3):101:110

Brush

CHX rinse alone

CHX rinse in Combination

Swab/Clean/Moisturize

Suction

All of the above

BRUSH & SWAB• 77% more clean approximal sites with

brushing

• 44% more clean crevice sites with brushing

• Benefit of brushing is directly correlated with

technique

• Foam swabs could not remove plaque from

sheltered areas on or between teeth

Pearson LS. et. al. J of Adv Nursing. 2002;39(5):480-489

Toothbrush; grade D, Swabs; unresolved, Use of flexible

suction catheter post oral cleansing; Grade D (Berry AM et al.

AJCC, 2007;16:552-563)

Oral Care Reduces Pneumonia In

Nursing Homes

11 nursing homes in Japan over 2 year period

417 enrolled / 366 residents analyzed (death from other causes)

184 received oral care program/182 did not

Tooth brushing after each meal (teeth or dentures) & 1x weekly review by dentist/or hygienist

Methodology

Results

No Oral Oral Care p value

Febrile 29% 15% p<.01

Pneumonia 19% 11% p<.05

Death 16% 7% p<.01

MMSE Increase p<.05

Yoneyama et al. JAGS. 2002;50:430-433

Oral Care Reduces Pneumonia In

Nursing Homes Residents

• Improves

swallowing and

cough reflex

sensitivities

Watando A. et al. Chest, 2004; 126:1066–1070)

Proposed Oral Care Plan

Independent

Weekly assessment

Encouragement to

perform tooth

brushing

/denture cleaning

minimum x2 daily

Dependant on Oral Care

Ability to expectorate Unable to expectorate

Assist with brushing

teeth/clearing out

debris & /or cleaning

dentures using with

1.5% H2O2 after each

meal/night &

moisturize following

cleaning

Brush teeth (dentures)

/clear debris using

suction toothbrush am &

pm with 1.5% H2O2

followed by moisturizing

Assist oral cleansing

(dentures)/clear debris

after lunch & dinner

using a suction swab

with 1.5% H2O2 followed

by moisturizing denture

cleaning

The Right Cleaning Solution

1.5% H2 O2

• >3% may cause harm .

• <1% no benefit in plaque removal.

• Must be diluted properly, not with normal

saline.

• 3x a day mouth rinse with 1.5% H2 02

revealed no mucosal damage, improved

plaque scores and overall gingival health.

Gomes BC et.al. Clin Prev Dentistry. 1984; 6:21-25

Boyd RL. et. al. J Clin Periodentol.1989; 16:557-563

West TL et. al. Journal of Peridontol. 1983; 54(6):339

Tombes MA et. al. Nursing Research. 1993; 42(6):332-337

Beck S. Cancer Nursing. 1979; 2:185-189.

Safety and Efficacy of 1.5% H2O2

and Baking Soda Dentifrice

• Methodology

– 60 day single blind study.

– 150 subjects randomly assigned to 1 of 5 groups

– Brushed 3x daily.

– Buccal smears done on 7 patients from each group

– Measured stain index, plaque index and gingival index

Shibly O. Et al. J Clin Dent 1997;8:145-149

Safety and Efficacy of 1.5% H2O2

and Baking Soda Dentifrice

• Results – No pathologic or anti-plastic changes

– No disruption to normal flora.

– All groups showed a significant reduction in the gingival index

– Slight increase in stain index across all groups

– Sage products can be used daily without concern for oral irritation, mucosal sloughing or a change in normal oral flora with a significant improvement in gingival health.

Shibly O. Et al. J Clin Dent 1997;8:145-149

Brushing Removes Plaque

• Methodology:

– 34 volunteers.

– Double-blind crossover study.

– Examine the amount and % of

plaque removed with a single

brushing with 3 solutions

(Sodium Bicarb, Crest,

Cologate).

• Results:

– Significantly higher % of plaque

removed with one minute brush

using Sodium Bicarb.

Mankodi et al. J Clin Dent. 1998; 9(3):57-60

Recent Trials Reduction in VAP or

Colonization with CHG or Povidone-iodine

• 2004: Grap (CHG via swab)

• 2005: Fourier (CHG) (negative trial)

• 2006: Koeman (CHG or CHG/colistin)

• 2006: Munro (CHG via swab &

toothbrusing)

• 2006: Sequin (povidone-iodine)

• 2006: Mori (povidone-iodine)

• 2008: Tantipong (CHG)

• 2009: Tanmay S (CHG) negative trial

CHG & H2O2 have good antibacterial effects

against most isolated VAP pathogens in Vitro(Senol G et al. Am J Infec Control, 2007;35:531-7)

Chan EY, et al. BMJ, 2007;334:889

Oral Decontamination for the Prevention of

Pneumonia in Mechanically Ventilated Patients:

Systematic Review and Meta Analysis

Meta Analysis• 298 articles screened

• 11randomized controlled

trials used

• 3242 patients

• 4 trials (1098 pts) no

significant difference with

oral antibiotics

• 7 trials (2144 pts) Oral

application of antiseptics

significantly reduced VAP

rates

• No decrease in Mortality,

mechanical ventilation or

LOS

Compendium:

Preventing VAP’s

Perform regular oral care

with antiseptic solution (1 A)

Coffin SE, et al. Infect Control Hosp

Epidemiol 2008;29:S31-41

Decontamination Gut & Oropharynx

• Cross over study with cluster design in 13 ICU’s

• Expected duration of MV > 48hrs

• Each ICU 3 regimens:

– Selective Digestive Decontamination (2045 pts)

– Selective Oropharynx Decontamination (1904

pts)

– Standard Care (1990 pts)

• Measured: mortality at 28 days, antibiotic resistance

Results: – ARR in mortality of 3.5 & 2.9% at 28 days for SDD & SOD

– Cost of SDD $12 vs. $1 for SOD

– Resistance only tracked for length of the studydeSmet AMGA, et al. N Engl J Med 2009;360:20-31

Conclusion: SOD preferred to

SDD & consider other oral

antiseptics like CHX in

environments with high levels

of resistance

Comprehensive Oral Care

Program

Comprehensive Oral Care Protocol: The

Good Shepherd Study

Methodology:• Retrospective study 10 bed Med-Surg

• Protocol included: Covered Yankauer for non-traumatic oral suctioning, soft-suction toothbrush, Suction Oral Swab, use of a 1.5% H2O2 peroxide mouth rinse for cleansing, subglottic suction catheter used 4x daily, dedicated oral suction line for infection control and ease of use.

• Education provided and presence of clinical champion.

Schleder B. et al. J Advocate Health 2002;4(1):27-30

Comprehensive Oral Care Protocol: The

Good Shepherd Study

Methodology:• Retrospective study 10 bed Med-Surg• Protocol included: Covered Yankauer for non-

traumatic oral suctioning, soft-suction toothbrush, Suction Oral Swab, use of a 1.5% H2O2 peroxide mouth rinse for cleansing, subglottic suction catheter used 4x daily, dedicated oral suction line for infection control and ease of use.

• Education provided and presence of clinical champion.

Schleder B. et al. J Advocate Health 2002;4(1):27-30

Reduction in VAP from 5.6 to 2.2 per 1000 catheter days with all other care factors held constant

Literature Review: Oral Care Impact of VAP

Comprehensive Oral Care:

• Reduction in VAP from 4.10 (2005) to (2.15) in 2006 with

addition of CPC & comprehensive oral care. Vent bundle &

rotational therapy already being performed

• Reduction in VAP from 12.0 to 8.0 (p=.060) with 80%

compliance, vent bundle already being preformed, 1538

patients randomized to control or study group, Additional

outcomes; vent days (p=.05), ICU LOS (p=.05) time

to VAP (p= <.001) & reduction in mortality (p=.05) (Garcia R

et al AJCC, 2009;18:523-534)

Comprehensive Oral Care & CHG:• Reduction in VAP to zero for 2 years, vent bundle, mobility,

oral care & CHG with comprehensive education preformed (Murray TM et al. AACN Advanced Critical Care. 2007;18(2):190-199)

Literature Review: Oral Care Impact of VAP

CHG vs. Tooth brushing vs. Usual Care• Receive one of 4 treatments :control/usual care, tooth brushing x3 daily,

CHG, CHG & tooth brushing • Results: CHX showed greatest reduction in VAP 24.4% vs. 52.4%

p=0.0093 using the CPIC score at day 3 (Munro CL, et al. Am J Crit Care. 2009

Sep;18(5):428-37

CHG & Comprehensive Oral care

Dickinson S et al. SCCM Critical Connections, Feb 2008

Oral Suctioning with Position Change• Prospective time sequenced non-randomized study

– 237 control (observation phase 9 months)

– 227 Interventional (7 months interventional)

– Difference in nursing protocol was oral

suctioning prior to position change (11 additional

suctions)

– All other nursing care the same

• Results: – VAP: 6.51 to 2.04 per 1000 ventilator days ( p<0.002 )

– Vent days: 28.8 + 17.2 vs. 20.2 + 4.0 (p <0.009)

– ICU LOS: 27.6 + 17 vs. 20.3 + 4.0 (p < 0.012)

– Suctioning before positional change only independent factor

responsible for VAP decrease (p=0.003)

Tsai, HH, et al. Am J of Med Sci, 2008;336;397-401

Second study examining the same intervention

demonstrated a reduction in VAP from 15.1 % (n=159) to

4.9% (n= 102) with oral suctioning prior to position change

Chao YF, et al. J of Clin Nursing 2008;18:22-28

Nurses Implementation of Guidelines

from the CDC

1200 nurses attending education seminars completed a 29

question survey about the type and frequency of care

provided (return rate of 81%)

Examine the extent to which nurses working in the ICU

implemented best practices in caring for mechanically

ventilated patients

Results: 82% compliance with hand washing

75% appropriate glove wearing

50% HOB

33% subglottic suctioning

50% oral care

56% oral care protocols

Methodology:

Cason CL et al. AJCC 2007;16(1): 28-38

Nurses in hospitals with oral care protocols reported

better compliance with HOB and hand washing & were

more likely to perform regular oral care & familiar with

their VAP rates than without nurses in hospitals without

an oral care protocol

Examining Your Oral Care Practices

• Are you brushing the teeth x 2 daily

• What is being used for suctioning the oral

cavity between brushing & cleaning?

• Is there a policy for cleaning and changing

oral care equipment?

• Is there a method for deep oral cleansing?

• Do you have an oral care policy &

procedure

TARGET ZERO!!!!!!!

Tips To Get Started

• Perform an initial assessment of the current

state of the union on hygiene care practices

within your environment that impact patient

safety

• Build the valuing of changing of those care

practices through sharing of the scientific

literature with your peers

• Select product lines that allows the nurse to

―do the right thing in an efficient manner‖

Tips To Get Started

• Develop processes that enhance efficiency and communication to help move evidence into practice.

• Implement Interventional Hygiene

• Measure the results (use standardized definitions to capture & compile data)

• Compare against the benchmarks

• Celebrate & reward your success and growth as a team

• Check on a quarterly basis continued compliance with the new program

CREATE A SAFE PATIENT

ENVIRONMENT

Everyday hospital

care activities increase

the patients risk of

INJURY & BACTERIAL

INVASION ……

Help reduce that risk by changing the

routine ways you provide care &

replace it with research…Implement

Interventional Hygiene

Forbid yourself to be deterred by

poor odds just because your mind

has calculated that the opposition

is too great.

If it were easy, everyone would do it.