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Using oral care to prevent nonventilator hospital-acquired pneumonia

By: Barbara Quinn, MSN, CNS, RN, and Dian Baker, PhD, APRN-BC, PNP

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May Grossman, age 57, is admitted for elective surgery to reverse a colostomy from a previous surgical procedure. Her health has been good except for occasional diverticulitis bouts. She takes care of her three grandchildren several times a week.

Mrs. Grossman tolerates the surgery well until postop day 2, when she complains of shortness of breath. You measure her temperature at 101.4° F (38.5° C). A workup reveals an elevated white blood cell (WBC) count; a chest X-ray shows a left lower lobe in­filtrate.

The physician initiates antibiotics and respiratory treatments, but Mrs. Grossman continues to
deteriorate. She is transferred to the intensive care unit with a diagno­-sis of hospital-acquired pneumonia (HAP).

Nurses on medical-surgical and intensive care units (ICUs) are familiar with scenarios like this: A healthy person enters the hospital but deteriorates suddenly from HAP.

Since 2008, Medicare payment policy and the National Healthcare Safety Network (NHSN) have focused hospitals’ efforts on reducing HAP and other hospital-acquired infections (HAIs) by mandating prevention policies and monitoring of device-associated infections, such as central-line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and ventilator-associated pneumonia (VAP). Over the last 10 years, incidence of device-associated infections has dropped significantly.

But the three most common device-associated infections account for only about 25% of HAIs. What’s more, VAP represents only 38% of total HAP cases. Hospitals are striving to meet NHSN requirements; yet monitoring and interventions to prevent nonventilator HAP (NV-HAP) aren’t required. As a result, cases like Mrs. Grossman’s go unnoticed for their potential to inform basic nursing care and HAI prevention.

This article discusses the causes and impact of unaddressed NV-HAP and explains why we need to return to basic nursing and oral care to prevent this illness.

Understanding NV-HAP

HAIs are infections not present on admission, with signs and symptoms arising at least 48 hours after admission. In NV-HAP, pneumonia isn’t related to mechanical ventilation or VAP. (In our scenario, Mrs. Grossman acquired pneumonia after surgery and wasn’t on a ventilator.)

NV-HAP is one of the most common HAIs in the United States—more common than CAUTIs and CLABSIs. It occurs on every type of unit, including maternity, pediatrics, and low-risk surgery units. Although it carries the same mortality as VAP, its incidence is higher; thus, associated costs and deaths are higher. Also, NV-HAP patients are at greater risk for readmission within 30 days than patients without HAIs. Given the personal and economic burden of NV-HAP, nurses should lead their hospitals in monitoring and implementing effective NV-HAP prevention programs.

NV-HAP pathogenesis and prevention

During a hospital stay, significant changes occur in a patient’s microbial flora and ability to maintain basic hygiene functions, such as daily oral care. Three key factors predisposed Mrs. Grossman to HAP—changes in oral microbes, micro­aspiration (subclinical aspiration of small droplets), and a weakened host.

Studies show that within 48 hours of admission, critically ill patients experience changes in oral bacterial colonization, including more virulent gram-negative organisms. Moreover, even healthy adults microaspirate while sleeping, from such causes as supine positioning and drugs that suppress the central nervous system. Microaspirations typically don’t lead to disease. But in hospital patients, microaspirations combined with decreased mobility and changes in the oral flora create an ideal environment for microbes to flourish in the pulmonary tract.

Also, hospitalization itself can weaken a patient’s natural defenses and typically disrupts daily care patterns. Patients may lack the energy or desire to perform basic care, such as effective oral hygiene, unless caregivers encourage it and teach them about its importance. This happened with Mrs. Grossman; she was exhausted after surgery and no oral care was recorded.

Preventing HAP

Pneumonia risk can be reduced through basic care measures, including early and frequent mobilization, assessing the patient’s aspiration risk, elevating the head of the bed, and promoting lung expansion. However, except for ICU patients on mechanical ventilators, the link between basic oral care and pneumonia prevention hasn’t been well studied.

Because the 20 billion microbes in our mouths replicate every 4 to 6 hours and patients microaspirate these microbes, reducing oral microbes is crucial to HAP prevention. In one study, researchers found that oral care went undocumented in the 24 hours before NV-HAP diagnosis 73% of the time. This means missed nursing care may have contributed to NV-HAP caused by increased microbial load and oral flora changes. In our hospital, some nurses stated they avoided oral care for patients with known aspiration risk for fear they’d aspirate.

Nurses have been surveyed to analyze their understanding of the importance of oral care and knowledge of standards for oral care practices. The surveys found that although nurses understand that oral care increases patients’ comfort, they may not appreciate the pneumonia risk linked to missed oral care, especially in nonintubated patients. Thus, nurses should receive enhanced education on the importance of oral care, the need for increased access to effective oral-care supplies, and clear protocols that specify the required frequency of oral care and its documentation. (See Preventing hospital-acquired pneumonia.)

HAPPI team

Based on these findings and to help prevent HAP and other adverse events, our interprofessional group at Sutter Medical Center in Sacramento, California, began a HAP prevention initiative (HAPPI) in 2012. This nurse-led oral-care initiative has reduced NV-HAP incidence by 60% and saved the hospital more than $2 million over 1 year.

The HAPPI team includes staff from nursing, rehabilitation services, nutrition services, infection control, respiratory therapy, material supplies, and administration, in addition to physicians. The team meets monthly to plan, implement, and monitor the NV-HAP prevention program.

Initial steps included a gap analysis, which compared best practices and published guidelines with current nursing practices. Gaps revealed by the analysis helped determine what changes to make in nursing practice. (See What the gap analysis found.) The HAPPI team addressed each barrier to an effective oral-care program; interprofessional collaboration helped overcome these barriers.

Addressing lack of supplies

Gap analysis showed our nurses lacked the right supplies to perform effective oral care.

  • The small, stiff toothbrushes our hospital (and many others) used didn’t meet American Dental Association (ADA) recommendations for soft-bristled toothbrushes and were inadequate for oral care.
  • Units weren’t stocked with alcohol-free antiseptic mouthwash, petroleum-free lip moisturizers, or sodium bicarbonate toothpaste that can remove dental plaque.
  • Basic denture cleansers and adhesives were missing from supply shelves.
  • Suction toothbrushes and other oral-care supplies weren’t readily available for patients at risk for aspiration.

Besides bringing our oral-care supplies up to ADA standards (including suction toothbrush kits similar to those used for ventilated ICU patients), we decided to provide easy-to-use, ready-to-go, complete oral-care supplies and to restock regularly.

Updating our oral-care protocol

The Centers for Disease Control and Prevention’s 2003 Guidelines for the Prevention of HAP state that all patients should receive comprehensive oral care. Gap analysis showed our hospital had an oral-care protocol only for ventilated ICU patients.

To remedy this, we updated the protocol to cover all patients. It now specifies what supplies to use, what procedures to follow, and how frequently to perform oral care. Although we couldn’t find research on optimal frequency of oral care for med-surg patients, we determined it should be done four times daily, based on how quickly oral bacteria replicate (five times per 24 hours). The new protocol was put in easy-to-read table format, enlarged, and posted in supply rooms for easy access. (See Oral-care protocol.)

Documenting oral care

As with any other patient-care process, oral care should be documented. But our documentation system lacked a place to record the type and frequency of oral care provided. So we enlisted staff to redesign the documentation of basic nursing care in the medical record. The redesign was piloted and refined repeatedly until staff were satisfied.

Documenting oral care also was essential for monitoring our quality-improvement project and determining the impact of oral care on NV-HAP rates. To reinforce the importance of oral care, we conducted unit audits to monitor oral-care delivery, related issues, and barriers to providing adequate oral care on HAPPI units.


We completed an oral-care knowledge and attitude survey before the oral-care intervention to determine the staff’s educational needs. Results were telling: The majority of our nursing staff didn’t know we had an oral-care protocol and few nurses were aware of the link between oral microbes and pneumonia. (We recommend including nurses’ aides in surveys and comprehensive education sessions in hospitals where they provide basic oral care.)

We then developed an oral-care education program in collaboration with the local dental society (which served as an expert resource). The program covered HAP causes and prevention, our new oral-care protocol, and demonstration of our new oral-care equipment, which empowered staff to deliver this valuable basic intervention.

We also developed a patient and family education program, which included a poster and flyers detailing the importance of oral care during hospitalization. We placed the posters in elevators and hallways and used the flyers in one-on-one education sessions with patients and family members.

Audits and monitoring to sustain quality improvements

Collecting and sharing relevant data can help motivate staff, change behavior, and sustain improvement. Before HAPPI, we’d measured and reported a baseline average for two measures—NV-HAP (an outcome measure) and how often oral care was documented for patients (a process measure). Baseline data enabled us to measure improvement. By collecting and reporting on both types of measures, we were able to connect nursing practice with patient outcomes. This was meaningful to staff and helped engage them in ongoing improvement efforts.

Each month, we measured oral-care frequency by sampling 10 patients on each unit and counting the number of oral-care episodes they’d had in the previous 24-hour period. Also, each month we identified the number of NV-HAP cases per unit and the hospital’s NV-HAP rate. Every quarter, we analyzed data and put it into graphs for each unit. We were able to show staff that as oral-care frequency increased, NV-HAP cases decreased. The reports included case studies of patients who’d acquired NV-HAP. These stories spoke to the hearts of staff (“These are our patients”) and spurred them to seek continued improvement.

We shared quarterly NV-HAP reports in many venues, including small unit-based staff meetings, quality council meetings, and hospital boardrooms. We used the data to celebrate oral-care improvements and NV-HAP decreases. We recognized and rewarded units that made and sustained improvements, in a way that was fun for both staff and management. For example, a volunteer dressed as the Tooth Fairy to present oral care staff development, and directors wore toothbrush and toothpaste costumes to present data to executives.

Making a difference in lives and costs

Our HAPPI program has made a difference in patients’ lives and hospital costs. When we compared data before and after implementation of our comprehensive oral-care program, we found a statistically significant difference in NV-HAP incidence—p < .0001; odds ratio = 0.51; 95% confidence interval = 0.38, 0.70.

Patients admitted during the intervention year were 49% less likely to acquire NV-HAP than those admitted the year before the intervention. This means we’d avoided 60 NV-HAP cases and saved more than $2.4 million by avoiding extra hospital days. With the $117,600 expenditure for our new, higher-quality oral-care supplies, the return on investment (ROI) was $2.28 million. Given the economic stress for all hospitals these days, this ROI for basic nursing care can’t be overlooked.

Evidence-based nursing care has an even more significant reach. Consider what happened to May Grossman.

NV-HAP added 7 days to May Grossman’s hospital stay. Instead of being discharged her to her home where her family could have cared for her, she was discharged to a skilled-care facility, where she stayed an additional month. She wasn’t able to resume her role as care provider to her grandchildren, and she lost part of her previous quality of life.

Today, with our new HAPPI program, she and her family would have received education on the importance of oral care, along with help and support to perform oral care four times daily. She could have avoided a prolonged hospital stay and retained her quality of life.

Nurses need to use current evidence to develop programs that emphasize the importance of basic oral care—not just for comfort but also as an essential life-saving measure. Implementing an oral-care program with every hospital patient is an indispensable part of the national effort to protect patients from HAIs.

Selected references

Avila M, Ojcius DM, Yilmaz O. The oral microbiota: Living with a permanent guest. DNA Cell Biol. 2009;28(8):405-11.

Ganz FD, Ofra R, Khalaila R, et al. Translation of oral care practice guidelines into clinical practice by intensive care unit nurses. J Nurs Scholarsh. 2013;45(4):355-62.

Kalisch BJ, Landstrom G, Williams RA. Missed nursing care: errors of omission. Nurs Outlook. 2009;57(1):3-9.

Kalsekar I, Amsden J, Kothari S, et al. Economic and utilization burden of hospital-acquired pneumonia (HAP): a systematic review and meta-analysis. Chest. 2010;138

Lee JS, Collar HR, Raghu G, et al. Does chronic microaspiration cause idiopathic pulmonary fibrosis? Am J Med. 2010;123(4):304-11.

Quinn B, Baker DL, Cohen S, Stewart JL, Lima CA, Parise C. Basic nursing care to prevent non-ventilator hospital-acquired pneumonia. J Nurs Scholarsh. 2014;46(1):11-9.

Barbara Quinn is a clinical nurse specialist with Integrated Quality Services at Sutter Medical Center in Sacramento, California. Dian L. Baker is a professor in the School of Nursing at California State University, Sacramento.

4 Comments. Leave new

  • 🙂

  • This article is amazing and i’m glad i got into it. I am a dentist and i live in Brazil. Actually i’m working in an ICU at a hospital in Rio and i did find out how oral care protocols are dismissed. It’s very difficult to bring the staff aware of the importance of oral care and its link with NV-HAP.
    It would be very important if we were better accepted as part of a multi professional team and how we can help ,not only on the education source but on the daily work. It is such a simple care….so important and it doesn’t take that long!
    I wonder when we will be able to act as a real team with only one purpose: the Patient!
    I want to thank the authors of this article and also for the protocols mentioned here .
    Is it possible to exchange experiences? I would love to implement and oral care program and share it with Hospitals.

  • Anne M. Devney
    June 14, 2017 10:44 pm

    This is just another example of how important the simple basic nursing care tasks are to patient outcomes! As the saying goes… It is so simple, no one does it…! And who pays the price?!? The patients under our care.

  • Amy L. Charette
    May 3, 2017 11:05 am

    This is fabulous research confirming the clinical impact of a contantly neglected part of patient care. Not to mention personal wellbeing. I recently had 2 elderly friends hospitalized and then sent to rehab. NO ONE assisted them with oral cares. When I visited and wanted to assist them there was no equipment. I had to ask for everything. and then bring them soft toothbushes and dental flossers. Between visits they continue to get no assistance.
    They both have developed pneumonias!


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