Fortifying the Host Defense:

Transcription

1 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 Vollman 2010

2 Disclaimer These slides are copyrighted by Kathleen Vollman Use of these slides without the written permission of Kathleen Vollman is illegal

3 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

4 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:

5 Science Basic Care

6 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)

7 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)

8 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

9 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 Vollman care 2001

10 Fortifying Host Defense Implement Interventional Patient Hygiene

11 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

12 Components of Successful Long Lasting Change Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Vollman KM. Australian Crit Care, 2009;22(4): Value Attitude & Accountability NSO

13 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: Kollef MH, et al. Chest, 2005:128: Collard HR. Ann Intern Med. 2003;138: Rello J. Chest. 2002;12: ATS Guidelines for HealthCare Acquired Pneumonia 2006 Coffin SE, et al. Infection Control & Hosp Epid, 2008;29(1):S31-S40

14 Risk Factor Categories for Nosocomial Pneumonia Factors that increase bacterial burden or colonization Factors that increase risk of aspiration

15 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/contamina ted condensate Saline administration Immobility

16 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 That s not the way we do it here!!!

17 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): Krishnasamy M. Eur J Cancer Care. 1995;4(4): Regnard C et al. Br Med J. 1997;315(7114): Van Drimmelen JR et al. Nurs Res 1969;18:

18 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 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: Murder RR. Am J Med 1998;105:

19 Sole M.L. Am J of Crit Care. 2003;12(3): Cason Cl, et al. Am J of Crit Care. 2007;16(1):28-36 Oral Care Practices: Large Multi-site Study 2000 vs Oral Care Practices are Changing

20 Oropharyngeal Colonization Methodology: 89 critically ill patients Examined microbial colonization of the oropharynx through out ICU stay Used pulse field gel electrophoresis to compare chromosomal DNA Results: Diagnosed 31 VAPs 28 of 31 VAP s the causative organism was identical via DNA analysis Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156:

21 Oropharyngeal Colonization Methodology: 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 Results: 14/49 adults developed pneumonia 10 of 14 pneumonias, the causative organism was identical via DNA analysis El-Solh AA. Chest. 2004;126:

22 Bacterial Growth In Oral Secretions & Suctioning Equipment in Orally Intubated Patients Methodology 20 patients intubated orally for >24 hours requiring mechanical ventilation Specimens (sputum & oral) obtained at baseline & equipment changes 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):

23 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):

24 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

25 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

26 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): Drimmelen and Rollins. Nurs Research. 1969;18: O Reilly M. Australian Critical Care. 2003;16(3):101:110

27 Brush CHX rinse alone CHX rinse in Combination Swab/Clean/Moisturize Suction All of the above

28 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): Toothbrush; grade D, Swabs; unresolved, Use of flexible suction catheter post oral cleansing; Grade D (Berry AM et al. AJCC, 2007;16: )

29 Oral Care Reduces Pneumonia In Nursing Homes Methodology 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 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:

30 Oral Care Reduces Pneumonia In Nursing Homes Residents Improves swallowing and cough reflex sensitivities Watando A. et al. Chest, 2004; 126: )

31 Proposed Oral Care Plan Independent Dependant on Oral Care Weekly assessment Encouragement to perform tooth brushing /denture cleaning minimum x2 daily Ability to expectorate Assist with brushing teeth/clearing out debris & /or cleaning dentures using with 1.5% H 2 O 2 after each meal/night & moisturize following cleaning Unable to expectorate Brush teeth (dentures) /clear debris using suction toothbrush am & pm with 1.5% H 2 O 2 followed by moisturizing Assist oral cleansing (dentures)/clear debris after lunch & dinner using a suction swab with 1.5% H 2 O 2 followed by moisturizing denture cleaning

32 The Right Cleaning Solution 1.5% H 2 O 2 >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% H 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: West TL et. al. Journal of Peridontol. 1983; 54(6):339 Tombes MA et. al. Nursing Research. 1993; 42(6): Beck S. Cancer Nursing. 1979; 2:

33 Safety and Efficacy of 1.5% H 2 O 2 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:

34 Safety and Efficacy of 1.5% H 2 O 2 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:

35 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

36 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) (Senol G et al. Am J Infec Control, 2007;35:531-7) 2006: Sequin (povidone-iodine) 2006: Mori (povidone-iodine) 2008: Tantipong (CHG) 2009: Tanmay S (CHG) negative trial CHG & H 2 O 2 have good antibacterial effects against most isolated VAP pathogens in Vitro

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

38 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 Conclusion: Oropharynx SOD preferred Decontamination to (1904 pts) SDD & consider other oral antiseptics like CHX in Standard Care (1990 pts) environments with high levels Measured: of mortality resistance 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 study desmet AMGA, et al. N Engl J Med 2009;360:20-31

39 Comprehensive Oral Care Program

40 Comprehensive Oral Care Protocol: The Good Shepherd Study Methodology: Retrospective study 10 bed Med-Surg Protocol included: Covered Yankauer for nontraumatic oral suctioning, soft-suction toothbrush, Suction Oral Swab, use of a 1.5% H 2 O 2 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

41 Comprehensive Oral Care Protocol: The Good Shepherd Study Methodology: Retrospective study 10 bed Med-Surg Protocol included: Covered Yankauer for nontraumatic oral suctioning, soft-suction toothbrush, Suction Oral Reduction Swab, use in of VAP a 1.5% from H5.6 2 O 2 peroxide mouth rinse to for 2.2 cleansing, per 1000 subglottic catheter suction catheter used days 4x with daily, all dedicated other care oral suction line for infection factors control held and constant ease of use. Education provided and presence of clinical champion. Schleder B. et al. J Advocate Health 2002;4(1):27-30

42 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: ) 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): )

43 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= using the CPIC score at day 3 (Munro CL, et al. Am J Crit Care Sep;18(5): CHG & Comprehensive Oral care Dickinson S et al. SCCM Critical Connections, Feb 2008

44 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 Second study examining the same intervention suctioning prior to position change (11 additional demonstrated a reduction in VAP from 15.1 % (n=159) to suctions) 4.9% (n= 102) with oral suctioning prior to position change All other nursing care the same Results: Chao YF, et al. J of Clin Nursing 2008;18:22-28 VAP: 6.51 to 2.04 per 1000 ventilator days ( p<0.002 ) Vent days: vs (p <0.009) ICU LOS: vs (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;

45 Nurses Implementation of Guidelines Methodology: 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: 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 82% compliance with hand washing 75% appropriate glove wearing 50% HOB 33% subglottic suctioning 50% oral care 56% oral care protocols Cason CL et al. AJCC 2007;16(1): 28-38

46 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

47 TARGET ZERO!!!!!!!

48 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

49 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

50 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

51 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.

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