1 Interprofessional Collaboration and Expansion of an Oral Care Intervention to Reduce the Risk of Hospital Acquired Pneumonia Among Older Veterans Shannon Munro, PhD, APRN, BC, NP; Owais Farooqi, DDS, MDS; Shikha Vasudeva, MD Department of Veterans Affairs Medical Center, Salem, Virginia Contact: Shannon.munro@va.gov
Acknowledgments 2 • The opinions expressed herein are those of the authors and do not necessarily reflect those of the U.S. Government or any of its agencies. • This material is the result of work supported with Office of Strategic Integration, Veterans Engineering Resource Center, and VA Diffusion of Excellence Initiative funding and the use of facilities at the Department of Veterans Affairs Medical Center in Salem, Virginia.
3 Objectives In this session the learner will be able to: • Identify how daily oral care helps prevent non- ventilator associated hospital acquired pneumonia • Utilize the national VA oral care implementation toolkit to facilitate dissemination.
Scope of the problem 4 • 60% of hospital acquired pneumonia occurs among non-ventilated patients • Average cost of $40,000 per case • Mortality rates for NV-HAP range from 18-30% • 50% of sepsis cases initiate as pneumonia • Only 34.5% of Veterans who develop NV-HAP return home after admission • NV-HAP occurs among all types of patients on all types of hospital units
Most hospital acquired pneumonia 5 starts in the mouth Dental plaque bacteria replicate 5 times every 24 hours. Biofilm images supplied by: DG Allison & IW Sutherland http://archive.bio.ed.ac.uk/jdeacon/microbes/biofilm.htm
Missed nursing care is a risk factor 6 Elevated HOB Mobility Missed Achieved Oral Care IS/C&DB 0% 20% 40% 60% 80% 100% Kalisch, B. (2013). Am J Med Qual.- consistent with Salem VA findings
7 Literature: Oral care and 7 pneumonia prevention Study Type Method Outcomes Yoneyama (2002) Oral care RCT; control group vs. oral Experimental: brushed teeth Decrease in pna, febrile reduced pna, JNL AM GER care group after each meal, dental days, death from pna; SOC hygienist visit 1X/week improved ADLs, cognitive function Watando (2004) Daily oral RCT Experimental: brushed teeth Improved cough reflex care in elderly, CHEST, after each meal X 30 days (p<0.05) 126:1066-1070 Akutsu 2010 Preop dental RCT, 86 esophageal cancer Experimental: Brushed teeth Decrease post op pna from brushing reduced risk of pts divided into control & 5X/day prior to surgery 32% to 9% (p=0.013) post op pna, SURGERY, 497. experimental groups Quinn, Baker, Munro (2014) Quasi-experimental, Universal oral care protocol Decreased NV-HAP by 37% JNL NSG SCHOL retrospective, pre/post for all pts, increased in first 12 months. frequency 3X/day Kaneoka (2015) Prev. of Systematic Review & Meta Oral care to prevent NV-HAP RR for NV-HAP (P=.02) HCAP with oral care, INF CTL Analysis: 5 RCTs RR for fatal pna (P=.002) HOSP EPID PNA=pneumonia, ADL= activities of daily living, NV-HAP nonventilator associated hospital acquired pneumonia, HCAP= health care associated pneumonia; RCT= randomized controlled trial
Number of Cases 0 1 2 3 4 5 6 7 2014 Jan 2014 Feb 2018 $2.84M and 13 lives saved, October 2016-April NV-HAP down 90% from baseline, estimated 2014 Mar Salem VAMC CLC units control chart for NV-HAP, 50 beds combined 2014 Apr 2014 May 2014 Jun 2014 Jul 2014 Aug 2014 Sept 2014 Oct 2014 Nov 2014 Dec 2016 Oct 2016 Nov 2016 Dec 2017 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2018 Jan 2018 Feb Mean UCL 2018 Mar LCL 2018 Apr 8
NV-HAP down 100% from baseline, estimated 9 $144,000 saved, October 2017-March 2018 3.5 UCL 3 2.5 Number of Cases 2 1.5 1 Mean 0.5 LCL 0 2016 Jan 2016 Feb 2016 Mar 2016 Apr 2016 May 2016 June 2016 July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2017 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2018 Jan 2018 Feb 2018 Mar Salem VAMC medical surgical units (4H & 4J) control chart for NV-HAP, 44 beds combined
NV-HAP down 100% from baseline, estimated 10 $480,000 and 2 lives saved, February-July 2017 4.5 UCL 4 3.5 3 Number of Cases 2.5 Mean 2 1.5 1 0.5 LCL 0 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Houston VAMC CCU and 3D SDU control chart for NV-HAP, 45 beds combined
VA national implementation toolkit 11
Next steps 12 • Evaluate current practices including input from interdisciplinary team • Simplify standard operating procedures. • Assure oral care supplies are readily available. • Share evidence: educate patient, family, & staff. • Actively monitor & celebrate progress and successes.
Questions? 13 Contact: Shannon.munro@va.gov
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