Pneumonia
Conditions
Keywords
oral hygiene, tracheostomy, deglutition disorders, enteral nutrition, brain injury, coma
Brief summary
Hypothesis: The investigators hypothesize that the current oral protocol is sub-optimal and an enhanced protocol will decrease the incidence of hospital acquired pneumonia (HAP)in the acute, non-intubated, care-dependent, neurologically impaired, adult patient.
Detailed description
Overview Problem: Hospital-acquired pneumonia (HAP) is the second most common nosocomial infection and is a significant cause of morbidity and mortality. In the surgical population, HAP is associated with a 55% increase in length of stay and increased costs of approximately $31,000.00 per case. Neurologically impaired patients (those with brain injury causing alterations in mental status, immobility, impaired swallowing and cough, and increased risk of aspiration) are particularly vulnerable to HAP. HAP negatively impacts patient comfort and satisfaction, increases costs associated with diagnostic tests and treatments, increases risk for sepsis, and potential for higher level of care. It is estimated 95% of care-dependent patients on the Royal Columbian Hospital (RCH) neuroscience unit acquire HAP during their stay. Gap: Research studies have shown improving oral hygiene in critical care, neuroscience intensive care units and cardiac surgery reduces the incidence of HAP. However, in the acutely ill neuroscience population outside critical care areas, this relationship has not been determined. Current oral care protocols, products and practitioner practice on medical/surgical units such as the RCH neuroscience unit do not consider recent evidence or recent increases in patient acuity and complexity. Goal: The goal of this study is to test the efficacy of an improved, evidence-based oral care protocol in reducing HAP in this population on the medical/surgical neuroscience unit at RCH. Research question: Does implementing an enhanced oral care protocol reduce rates of HAP in the acute, non-intubated, care-dependent, neurologically impaired, adult patient on a neuroscience unit? Objective: To measure and compare the incidence of HAP among medical/surgical patients who had the current standard of oral care with those receiving an improved, preventative-based, oral hygiene protocol including regular teeth brushing, mouth and tongue inspection, swabbing and moisturizing, elevation of head of the bed (HOB), changing of suction equipment, and universal precautions. Relevance: This study may identify the importance of standardizing oral hygiene protocols to the evidence, and heighten awareness among care providers in the prevention of HAP. If proven successful, the oral care protocol could be considered for implementation on acute units outside the RCH neuro unit.
Interventions
OTHEREnhanced oral care protocol
* Changing mouth suction equipment every 24 hours * Mouth assessment every 2-4 hours * Cleansing mouth with toothbrush every 12 hours * Cleansing oral mucosa with oral rinse solution every 2-4 hours * Moisturize mouth/lips with swab and standard mouth moisturizer every 4 hours * Suction mouth and throat as needed * Head of the bed elevated to a minimum of 30° during oral care
Sponsors
Fraser Health
Study design
Allocation
NON_RANDOMIZED
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
19 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adult (\> 19 years) * Admitted to RCH neuroscience unit * Primary diagnosis is neurological (brain injury/insult) * Non-intubated * Dependent for oral care and unable to direct their own oral care
Exclusion criteria
* \< 19 years * Off service patients * Intubated, on bilevel positive airway pressure or continuous positive airway pressure devices, (respiratory assistive devices) * Palliative * Capable of directing their own oral care * Unable to receive oral care due to: oral tubes, nasal/oral airways, wired jaws, or behaviours such as resistiveness, combativeness, non-compliance, etc.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Hospital Acquired Pneumonia Occurrences | 10 months | Hospital acquired pneumonia is acquired greater than 48 hours after admission and is diagnosed by a positive chest x-ray plus 2 of the following 3 symptoms: presence of fever, elevated serum white blood cells count, and positive sputum specimen. |
Countries
Canada
Participant flow
Recruitment details
The retrospective study group included care-dependent adults with a primary diagnosis of neurological injury/insult (n=51) meeting the inclusion criteria. Enrolled subjects in the prospective study received the experimental protocol (n=32).
Participants by arm
| Arm | Count |
|---|---|
| Oral Care Treatment Group Subjects were neurologically impaired, dependent adults who met inclusion criteria. Subjects were identified upon admission to the in-patient unit during the study period. | 32 |
| Retrospective Study Group Subjects were neurologically impaired, dependent adults who met inclusion criteria. Subjects were identified through a retrospective chart review for the same in-patient unit. | 51 |
| Total | 83 |
Baseline characteristics
| Characteristic | Oral Care Treatment Group | Retrospective Study Group | Total |
|---|---|---|---|
| Age, Customized Age >=19 | 32 participants | 51 participants | 83 participants |
| Region of Enrollment Canada | 32 participants | 51 participants | 83 participants |
| Sex: Female, Male Female | 9 Participants | 24 Participants | 33 Participants |
| Sex: Female, Male Male | 23 Participants | 27 Participants | 50 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 32 | 0 / 51 |
| serious Total, serious adverse events | 2 / 32 | 13 / 51 |
Outcome results
Primary
Hospital Acquired Pneumonia Occurrences
Hospital acquired pneumonia is acquired greater than 48 hours after admission and is diagnosed by a positive chest x-ray plus 2 of the following 3 symptoms: presence of fever, elevated serum white blood cells count, and positive sputum specimen.
Time frame: 10 months
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Oral Care Treatment Group | Hospital Acquired Pneumonia Occurrences | 2 participants |
| Retrospective Study Group | Hospital Acquired Pneumonia Occurrences | 13 participants |