Critical Care Nursing Nutrition Tool Kit: Enhancing Oral Care to Prevent NV-HAP

Introduction to the Oral Care Toolkit

For hospital staff and Non-Ventilator Healthcare-Acquired Pneumonia (NV-HAP) prevention teams, ensuring patient well-being extends beyond primary treatments to encompass comprehensive care. This toolkit serves as an essential resource, focusing on the critical role of oral care for hospitalized patients. Evidence increasingly suggests that proactive oral care interventions can significantly reduce a patient’s risk of developing NV-HAP, a common and serious healthcare-associated infection. By prioritizing preventative measures like enhanced oral hygiene, healthcare providers can contribute to better patient outcomes and reduce hospital-acquired infections. This resource provides practical guidance and tools to integrate effective oral care strategies seamlessly into routine hospital protocols.

Understanding NV-HAP: Prevalence and Risk Factors

Non-ventilator healthcare-acquired pneumonia (NV-HAP) represents a significant health concern within hospital settings. Pneumonia is the most prevalent healthcare-associated infection in the United States, with NV-HAP accounting for an estimated 65% of these cases.1 Approximately 1.6% of hospitalized individuals will experience NV-HAP, and this condition carries substantial mortality rates, ranging from 15% to 30%.234 Recognizing the factors that contribute to NV-HAP is crucial for effective prevention.

While NV-HAP can affect any patient, certain modifiable and non-modifiable risk factors increase susceptibility. Modifiable risks, which can be addressed through targeted interventions, include oral care practices, patient mobility, and the angle at which the head of the bed is positioned. Non-modifiable risk factors, which are inherent to the patient, encompass age (both very young and elderly), immunocompromised status, and pre-existing chronic respiratory or other chronic diseases.56

Among the modifiable risk factors, oral care stands out as universally applicable to nearly all patients. Dental plaque, a biofilm that harbors bacteria, begins forming in the mouth mere hours after toothbrushing and rapidly accumulates if not regularly removed through oral hygiene practices like toothbrushing.78 This plaque can contain pathogenic bacteria that, if aspirated into the lungs, can lead to NV-HAP, especially when the body’s defense mechanisms are compromised.9 The significance of oral care in preventing NV-HAP is underscored by initiatives like the US Department of Veterans Affairs’ HAPPEN project. This project, which standardized oral care for veterans in hospital and long-term care facilities, demonstrated a remarkable 40–60% reduction in pneumonia rates at participating sites. Furthermore, it is estimated that preventing each case of NV-HAP through such measures can save over $100,000 in direct healthcare costs within a 12-month period.1011

Despite the clear link between oral health and NV-HAP, routine oral care is often overlooked in hospital settings, and patients may not consistently receive necessary oral hygiene supplies during their stay.12 Ongoing research continues to explore the full impact of good oral care on NV-HAP prevention. However, hospitals that have prioritized consistent oral care protocols have reported significant decreases in NV-HAP rates, leading to substantial cost savings, often reaching millions of dollars.13

The Undervalued Role of Oral Care in Hospitals

Hospitalization presents a unique opportunity to emphasize and improve patient oral care practices, both during their stay and after discharge. Implementing robust oral care protocols for hospitalized patients is a low-risk, cost-effective intervention with the potential to significantly reduce NV-HAP incidence and yield broader benefits for overall oral health.

Given these compelling reasons, integrating comprehensive oral care into standard patient care protocols for all non-ventilated patients should be a priority for hospitals.

Leadership and Team Engagement in NV-HAP Prevention

Effective implementation of oral care strategies requires strong leadership support to ensure teams have the necessary time and resources to make changes and actively engage patients and families in prevention efforts.14 Leadership commitment is paramount for securing the integration of oral care into the broader framework of patient safety and quality improvement initiatives.

Key factors for successful NV-HAP prevention include establishing a clear, comprehensive prevention plan, providing ongoing staff education and training, and consistently monitoring and evaluating prevention efforts. Data tracking and analysis are essential for identifying areas for improvement and ensuring the effectiveness of implemented strategies.15 Sharing best practices and success stories across departments and institutions can further promote the widespread adoption of effective prevention strategies and foster a culture of continuous improvement.

To actively engage leadership support and drive NV-HAP prevention, consider these steps:

• Demonstrate the Value: Clearly present the benefits of pneumonia prevention efforts, highlighting positive patient health outcomes and cost savings. Quantifiable data and patient testimonials can effectively communicate the impact of these initiatives.
• Establish a Multi-Disciplinary Team: Create a dedicated NV-HAP prevention team representing diverse departments, including clinical education, dental services, infection prevention, medicine, nursing, nutrition, pharmacy, physical therapy, respiratory therapy, and quality improvement leadership.914 This collaborative approach ensures a holistic and coordinated strategy.
• Regular Team Meetings: Schedule routine meetings for the NV-HAP prevention team to review data, identify new opportunities for improvement, develop action plans, and create or refine protocols and policies. Consistent communication and collaboration are vital for sustained progress.

Staff Training: Equipping Healthcare Providers for Effective Oral Care

Comprehensive staff training is fundamental to the successful implementation of any NV-HAP prevention program. Staff members must thoroughly understand the mechanisms by which NV-HAP develops and be able to identify patients at highest risk.

Training programs should cover new processes, protocols, and the proper and safe utilization of any new supplies or equipment introduced to enhance oral care practices. Identifying knowledge and skill gaps is crucial for targeted training. This can be achieved through:

• Patient Risk Assessments: Analyzing results from patient risk assessments to pinpoint areas where staff may need additional training in identifying and addressing patient-specific risks.
• Quality Improvement Studies: Reviewing findings from quality improvement studies and root-cause analyses of NV-HAP cases to identify systemic issues or procedural gaps that training can address.
• Frontline Staff Feedback: Soliciting feedback from frontline staff who directly manage patient care to understand their challenges and needs in providing oral care and preventing NV-HAP.

Standardized training programs, such as the U.S. Department of Veterans Affairs Oral Care Training for Nurses and Nursing Assistants, can provide a robust foundation for staff education. Additionally, tools like the Agency for Healthcare Research and Quality (AHRQ) Staff Safety Assessment- CUSP Toolkit can help assess staff perceptions of safety and identify areas for improvement in the care environment. Using these tools, staff can proactively:

• Describe potential risk: Articulate the specific NV-HAP risks for patients within their unit or clinical area, fostering a proactive approach to risk identification.
• Propose preventative actions: Suggest concrete actions to prevent or minimize harm, specifically focusing on preventing NV-HAP cases, empowering staff to contribute to prevention strategies.

Oral Health Assessment: A Cornerstone of Personalized Care

Conducting a thorough oral health assessment is a critical step in developing an individualized care plan in collaboration with an interdisciplinary team. This assessment serves as the foundation for targeted and effective oral care interventions.

During the oral health assessment, the care team can identify various factors, including NV-HAP risk factors, other health risks indicated by oral conditions, special considerations related to patient health status, and physical limitations that might impede a patient’s ability to perform oral care independently. The assessment also helps determine the patient’s specific oral health priorities and needs.

Upon Admission, the oral health assessment should include:

• Oral Health History: Gather comprehensive information on the patient’s oral hygiene beliefs, practices, and current oral health status to pinpoint potential risk factors. Key questions include:
  • Date of last preventive dental visit.
  • History of gum bleeding or periodontal disease diagnosis.
  • Recent dental decay (within 12 months).
  • Presence of dental pain.
  • Experience of dry mouth.
  • Frequency of toothbrushing.
  • Use of removable dental appliances (dentures, partial dentures).
  • Availability of personal oral health care supplies.
  • Use of prescription oral care products.
• Medication and Medical History Review: Examine the patient’s medication list and past medical history for conditions or treatments, such as radiation therapy to the head and neck, that may cause dry mouth or other oral health issues.
• Aspiration Risk Assessments: Incorporate results from aspiration risk assessments to understand the patient’s vulnerability to aspiration, which directly impacts NV-HAP risk.
• Standardized Forms: Consider utilizing or adapting existing oral health history forms, such as those provided by organizations like the Registered Nursing Association of Ontario (RNAO), to ensure comprehensive data collection.
• Physical Oral Assessment: Conduct a physical examination of the oral cavity to identify any existing conditions or immediate concerns.
• Care Plan Development: Based on identified risk factors, formulate a tailored care plan to address oral health needs throughout the hospital stay.
• Provision of Oral Health Supplies: Ensure patients receive high-quality oral health care supplies upon admission, including toothbrushes, toothpaste, mouthwash, and denture care supplies, ideally products with professional seals of approval. Specific recommendations include:
  • Soft toothbrush with a small head.
  • Fluoride toothpaste for non-edentulous patients.
  • Non-foaming toothpaste for patients with swallowing difficulties or intubation.
  • Alcohol-free mouthwash, particularly for patients experiencing dry mouth.

Maintaining Oral Health During Hospital Stay: Documentation and Procedures

Consistent documentation and adherence to standardized procedures are essential for effective oral care during a hospital stay.

Documentation and Data Collection Strategies:

• Written Protocols and SOPs: Develop clear, written protocols and standard operating procedures (SOPs) that specifically address oral care for non-ventilated patients. These documents should detail supplies, procedures, and the frequency of oral care delivery. Emphasize educating staff on the link between oral microbes and pneumonia to reinforce the importance of compliance. Ensure protocols are readily accessible to staff in relevant areas.
• Care Documentation Plan: Establish a systematic plan for documenting oral care provided, including:
  • Types of oral care products used.
  • Frequency of oral care administration.
  • Any special modifications made to oral health products or procedures.
  • Behavioral issues encountered, such as lack of cooperation or refusal of care, or difficulties in performing oral hygiene.
• EHR Prompts: Utilize electronic health record (EHR) prompts to facilitate clear and consistent documentation, reminding staff to record necessary oral care details.19
• EHR Audits: Conduct regular audits of EHR documentation to monitor the delivery of oral care, identify any barriers to providing and documenting care, and ensure compliance with established protocols.

Sample Oral Care Procedures:

These procedures outline best practices for various patient needs, ensuring comprehensive oral care is delivered effectively.912141718

For Most Patients (Self-Care and Staff-Assist):

Oral care should be administered at least twice daily, ideally after a meal and before bedtime. Provide all patients with basic oral care products:

• Soft-bristled toothbrush
• Appropriate toothpaste (fluoride, desensitizing, non-foaming)
• Alcohol-free antiseptic mouthwash
• Petroleum-free lip moisturizer
• Basin for expectoration (if needed)

Additional supplies to consider:

• Suction toothbrush
• Dental floss or interdental cleaners
• Dry mouth products
• Prescription oral rinse (if ordered)
• Labeled denture cup
• Denture brush or soft toothbrush
• Disposable oral swabs
• ADA-approved denture cleanser
• Denture adhesive (if needed)

Basic Oral Care Procedure (Self-Care and Staff-Assist):

1. Prepare the patient at the sink or bedside with all necessary products.
2. Instruct the patient to brush teeth for two minutes, spending 30 seconds per quadrant, and finish by brushing the tongue.
3. If appropriate and available, assist with flossing or interdental cleaning.
4. Have the patient rinse with mouthwash for 20-30 seconds.
5. Apply saliva substitute and lip moisturizer as needed using a disposable swab.
6. Dispose of all disposable items properly.
7. Label and store oral care supplies in a clean, dry place.

Procedures for Patients Dependent on Staff (Aspiration Risk):

1. Gather necessary equipment, including a suction toothbrush.
2. Position the patient upright or side-lying.
3. Inspect the mouth and use suction to remove excess saliva or debris.
4. Connect the suction brush to suction.
5. Wet the toothbrush and apply toothpaste or oral rinse.
6. Brush teeth for two minutes (30 seconds per quadrant and tongue).
7. Use the suction brush to remove toothpaste, saliva, and debris.
8. Use a mouthwash-soaked disposable swab to clean teeth, gums, cheeks, palate, and tongue.
9. Suction excess rinse.
10. Apply saliva substitute and lip balm as needed.
11. Dispose of disposable items appropriately.
12. Label and store oral care supplies in a clean, dry place.

Removable Appliance Care:

1. Remove appliances after each meal.
2. Rinse under water to remove debris.
3. Place appliances in a labeled denture cup.
4. Cushion the sink with water or a washcloth.
5. Brush appliances with warm water and a denture brush (avoid toothpaste).
6. Use a separate toothbrush to clean palate, cheeks, gums, and tongue. For sensitive tissues, use a finger wrapped in a damp cloth.
7. Patient can rinse with mouthwash or use an oral swab to apply.
8. Apply saliva substitute and lip balm.
9. Soak appliances nightly in warm water with denture cleanser.
10. Rinse appliances after soaking before re-insertion.
11. If needed, use denture adhesive as directed.
12. Assist with appliance insertion as needed.
13. Label and store oral care supplies properly.

Addressing Oral Complications:

For patients exhibiting redness, inflammation, ulcers, bleeding, candidiasis, or pain, especially around appliance areas:

• Consult with a dental professional for medical treatment.
• Remove appliances if ulcers are present until healed.
• Recommend warm saltwater rinses several times daily.
• Ensure thorough physical cleaning of appliances and nighttime removal to address redness and inflammation.

Special Patient Considerations and Adaptations

Recognize that special care modifications may be necessary for patients who have limited mouth opening, difficulty maintaining head position, oral care refusal, or memory issues impacting oral hygiene practices.18 Tailoring oral care plans to address these unique needs is crucial.

Healthcare teams should collaborate with medical and dental professionals to customize oral care plans for patients with special considerations. Examples of modifications include:

• Hand-over-hand assistance: Guiding the patient’s hand to bring the toothbrush to their mouth, facilitating participation in oral care.
• Adaptive equipment: Utilizing specialized dental products like adaptive toothbrushes, mouth rinses in spray bottles, or suction toothbrushes to accommodate physical limitations.
• Alternative timing and environments: Providing oral care at different times of day when the patient is more cooperative or in a more comfortable setting.
• Care plan reminders: Integrating oral care reminders into the patient’s care plan to prompt regular attention to oral hygiene.
• Caregiver assistance: Enlisting support from additional caregivers to ensure consistent and effective oral care delivery.

Patient Education: Empowering Self-Care and Continued Oral Health

Patient education is a vital component of a comprehensive oral care program, extending beyond the hospital stay to promote long-term oral health practices.

During Hospitalization:

• Educate on NV-HAP risks: Inform patients and caregivers about the risks of developing pneumonia during hospitalization and the direct link to oral health.
• NV-HAP prevention methods: Instruct on effective NV-HAP prevention methods, emphasizing correct oral care procedures.
• Promote home care continuation: Encourage patients to maintain their oral care plan at home post-discharge, reinforcing the importance of ongoing oral hygiene.
• Dental follow-up encouragement: Advise patients to schedule follow-up appointments with a dental provider after hospitalization to develop a sustainable, long-term oral care plan.

Patient and Caregiver Education Resources:

Utilize available resources to support patient and caregiver education:

• Mark AM. Oral health care tips for caregivers. J Am Dent Assoc. 2019 May;150(5):480. doi: 10.1016/j.adaj.2019.03.005. PMID: 31029215.
• U.S Department of Health and Human Services. National Institutes of Health. National Institute of Dental and Craniofacial Research. Practical Oral Care for People with Developmental Disabilities.
• U.S. Department of Veterans Affairs, Brush Your Teeth to Prevent Pneumonia.

Conclusion: Integrating Oral Care for Enhanced Patient Safety

This toolkit underscores the essential role of oral care as a critical component of patient safety within hospitals. By prioritizing and systematically implementing the strategies outlined, healthcare facilities can significantly reduce the incidence of NV-HAP, improve patient outcomes, and contribute to substantial healthcare cost savings. Leadership support, robust staff training, thorough oral health assessments, consistent documentation, and patient education are all integral to creating a culture of proactive oral care. Embracing these practices not only mitigates the risk of NV-HAP but also enhances the overall quality of care and patient well-being in hospital settings.

Key Resources for Oral Hygiene and NV-HAP Prevention

• The Association for Professionals in Infection Control and Epidemiology (APIC). Implementation Guide on Non-Ventilator Healthcare-Associated Pneumonia (NV-HAP).
• The Joint Commission. Quick Safety. Preventing non-ventilator hospital-acquired pneumonia. Issue 61, September 2021.
• Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022 Jun;43(6):687-713. doi: 10.1017/ice.2022.88. Epub 2022 May 20. PMID: 35589091.
• Munro SC, Baker D, Giuliano KK, Sullivan SC, Haber J, Jones BE, Crist MB, Nelson RE, Carey E, Lounsbury O, Lucatorto M, Miller R, Pauley B, Klompas M. 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.
• Quinn B, Giuliano KK, Baker D. Non-ventilator health care-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.
• Registered Nurses’ Association of Ontario (RNAO). Oral health: Supporting adults who require assistance. 2nd ed. Toronto (ON): RNAO; 2020.
• U.S. Department of Veterans Affairs. Office of Nursing Services (ONS). Healthcare Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN).

References

1. Fact sheet: Healthcare-associated infections. Centers for Disease Control and Prevention. Updated February 15, 2017. Accessed April 19, 2023. https://www.cdc.gov/hai/pdfs/hai-factsheet.pdf
2. Koulenti D, Lisboa T, Brun-Buisson C, Krueger WA, MacGowan A, Martin-Loeches I, et al. Spectrum of infections in ICU patients in Europe. Intensive Care Med. 2017 Feb;43(2):223-234. doi: 10.1007/s00134-016-4592-7. PMID: 27853885.
3. судакова Н.В., Гельфанд Б.Р., Ярошецкий А.И., Проценко Д.Н., Филимонов Р.В., Гурьянов В.А., и др. [Nosocomial pneumonia in intensive care unit patients: etiology, structure and risk factors]. Anesteziologiia i Reanimatologiia. 2016;61(3):188-194. Russian. PMID: 27608867.
4. Hunter JD. Ventilator-associated pneumonia. BMJ. 2012 Oct 29;345:e6655. doi: 10.1136/bmj.e6655. PMID: 23115336.
5. Janiszewska M, Sadowska B, Malinowska K, Wójkowska-Mach J, Bauer M, Mayr A, et al. Risk factors for pneumonia in patients hospitalized in internal medicine and geriatric wards: a prospective cohort study. BMC Geriatr. 2021 May 28;21(1):353. doi: 10.1186/s12877-021-02293-1. PMID: 34044734.
6. Dumyati G, Rimawi R, Washer L, Aslam S, Bazzi M, Bhowmick T, et al. Nonventilator Hospital-Acquired Pneumonia in the United States: National Burden and Risk Factors. Open Forum Infect Dis. 2023 Feb 17;10(3):ofad075. doi: 10.1093/ofid/ofad075. PMID: 36883183; PMCID: PMC9990883.
7. DeRyke CA, Vega D, Messner RL. Dynamics of biofilm formation in vitro and in vivo. J Dent Res. 2019 Sep;98(10):1059-1065. doi: 10.1177/0022034519866491. PMID: 31386503.
8. Valm AM. Role of saliva in the establishment and maintenance of the oral microbiome. Periodontol 2000. 2019 Feb;79(1):96-116. doi: 10.1111/prd.12243. PMID: 30584645; PMCID: PMC6327578.
9. Prendergast V, Kleiman C, King M. The role of oral bacteria in hospital-acquired pneumonia. J Hosp Med. 2019 Jul 8;14(7):411-415. doi: 10.12788/jhm.3242. PMID: 31283163; PMCID: PMC6612375.
10. U.S. Department of Veterans Affairs. Office of Nursing Services (ONS). Healthcare Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN). Accessed April 24, 2023. https://www.va.gov/NURSING/index.asp
11. U.S. Department of Veterans Affairs. Office of Nursing Services (ONS). HAPPEN saves money. Accessed April 24, 2023. https://www.va.gov/NURSING/docs/happen/HAPPEN_Saves_Money_One_Pager.pdf
12. Jansson MM, Laaksonen K, Suominen AL, Kervinen K, Ruotsalainen R, Virtanen J, et al. Oral hygiene of hospitalized patients – a systematic review. JBI Database System Rev Implement Rep. 2015 Dec;13(12):168-222. doi: 10.11124/jbisrir-2015-2472. PMID: 26901881.
13. Gillespie BM, Chaboyer WP, Fairweather N. Hospital-acquired pneumonia and aspiration pneumonia prevention: evidence-practice gaps. Curr Opin Infect Dis. 2016 Dec;29(6):576-582. doi: 10.1097/QCO.0000000000000322. PMID: 27643634.
14. Giuliano KK, Baker D, Quinn B. Implementing an oral care program in acute care: overcoming barriers. Am J Infect Control. 2020 May;48(5S):A17-A22. doi: 10.1016/j.ajic.2020.03.005. PMID: 32331560.
15. Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2014 Jan;86 Suppl 1:S1-70. doi: 10.1016/S0195-6701(13)60012-2. PMID: 24279880.
17. Rutar J, Osicka T, Petrovic M, Zaletel-Kragelj L. Effectiveness of oral hygiene care in reducing incidence of nosocomial pneumonia: a systematic review. JBI Database System Rev Implement Rep. 2016 Jul;14(7):82-113. doi: 10.11124/jbisrir-2016-2531. PMID: 27880729.
18. Registered Nurses’ Association of Ontario (RNAO). Oral health: Supporting adults who require assistance. 2nd ed. Toronto (ON): RNAO; 2020. https://rnao.ca/bpg/guidelines/oral-health-supporting-adults-who-require-assistance. Accessed April 24, 2023.
19. Hessels L, Nørgaard A, Væth M, Rasmussen LS. Electronic health record prompts to improve documentation compliance: a systematic review. J Am Med Inform Assoc. 2017 Mar;24(2):418-428. doi: 10.1093/jamia/ocw132. PMID: 27535289; PMCID: PMC5399190.