Pneumonia is responsible for about 23% of all healthcare-associated infections in the UK (National Institute for Health and Care Excellence (NICE), (2016). Non-ventilator hospital-acquired pneumonia (NV-HAP) is associated with increased patient morbidity, mortality, length of stay and transfer to an intensive care unit (Westendorp et al, 2011; Davis and Finley, 2012; Quinn et al, 2014; Mitchell et al, 2019). Consequently, NV-HAP imposes a significant economic and clinical burden on the NHS. A meta-analysis found that overall 10% of stroke patients develop pneumonia (95% confidence interval [CI] 9-10%), rising to 28% (95% CI 18-38%) in ICUs. Pneumonia was associated with a more than threefold increase in mortality (odds ratio [OR] 3.62; 95% CI 2.80-4.68) (Westendorp et al, 2011). However, despite its clinical and economic importance, the incidence of NV-HAP seems to be under-reported and poorly studied (Mitchell et al, 2019).
Poor oral hygiene is an important risk factor for the development of pneumonia (Scannapieco et al, 2003; Davis and Finley, 2012). About 700 bacterial species have been isolated from the human oral cavity (Gao et al, 2018) (not all of them harmful) and a UK study of 50 patients, followed for 14 days after a stroke, isolated 103 bacterial species in their mouths, with 15 patients experiencing at least one oral or systemic infection (Boaden et al, 2017). Although no patterns linked to the infection or the oral cavity emerged, given the bacterial diversity, the numbers of patients in this study may have been too small to discern a relationship.
Poor dental hygiene allows the accumulation of dental plaque and, in turn, the development of periodontal diseases. Plaque accumulation can also allow respiratory pathogens to colonise the oral cavity. Plaque can form a reservoir of the pathogens that cause NV-HAP (Scannapieco et al, 2003; American Association of Critical-Care Nurses, 2017; Mitchell et al, 2019). Good nursing care to prevent NV-HAP, therefore, involves reducing the number of pathogens in the patient's mouth and ensuring that the oral cavity remains healthy (Mitchell et al, 2019). A meta-analysis by Mitchell et al (2019) identified 15 studies of interventions to reduce NV-HAP, nine of which focused on oral care. The remainder covered physical activity (eg passive movements), dysphagia screening and management, and prophylactic antibiotics.
At the time of the study, inpatient oral care across the authors' hospital was inconsistent. In theory, it included cleaning patients' teeth using a basic toothbrush and swabs, disinfecting dentures, and rinsing patients' mouths with mouthwash; however, in practice oral care was ad hoc and the necessary equipment was not always available.
Anecdotal reports from the acute stroke ward suggested that poor oral hygiene was often visually apparent and several health professionals noted that patients had marked halitosis. Discussions with the multidisciplinary team (MDT) revealed that the speech and language therapists thought that oral care took up a disproportionate amount of their time, which could be better spent screening for aphasia, dysphagia, dysphonia and other post-stroke complications. Patients and relatives also indicated that oral care was not adequate. A review of practice identified a lack of consistency in the products used for oral care, which was potentially unsafe.
After considering the evidence provided by various manufacturers, Kew Ward at the Chelsea and Westminster NHS Foundation Trust, London, decided to assess whether use of the Stryker q4 QCare kit offered any benefits (Figure 1).
The authors prepared a business case to develop and implement a quality improvement initiative with the aim of delivering consistent, high-quality management across the spectrum of ‘nil-by-mouth’ patients—those assessed as high risk, or category C (see Table 1)—managed in the ward, from patients expected to recover to those needing end-of-life care. After a competitive Dragon's Den-style process and based on a pilot project, the Trust agreed to fund the quality improvement project to establish whether the introduction of a 24-hour oral care kit and an oral care assessment tool (Table 1 and Table 2) would better meet patients' needs.
GCS=Glasgow Coma Scale; NBM=nil by mouth
Methods
Setting and objectives
The study was conducted on the Trust's 28-bed acute stroke unit (Kew Ward). The objectives were as follows:
Intervention
The introduction of the care improvement initiative ensured that oral care was provided to all patients, with those identified as being at high risk (category C) receiving care using the Stryker care kit.
All patients considered at high risk (n=30 pre-implementation and n=10 post-implementation of the improvement initiative) (eg nil by mouth or severe dysphagia or dependency, according to the oral care assessment tool), received care using the Stryker q4° QCare kit (reference 6934-BP). The kit comprises:
Product representatives provided formal education and training that covered the use of the oral care assessment tool, aspects of oral care and risk-stratified interventions (Table 1 and Table 2). The kit was available 24 hours a day by the patient's bedside.
Table 3 describes the oral procedure followed and the components included in the kit.
Foam swabs should be used with care. It is important to follow advice issued by the Medicines and Healthcare products Regulatory Agency (MHRA, 2012), which published an alert that the foam heads of oral swabs may detach from the stick during use, presenting a choking hazard. When using swabs, the MHRA recommendations state:
Data collection started in June 2018 and continued until the end of September 2018. A retrospective analysis was performed for the same time span in 2017. A staff survey collected users' views about the Stryker q4° QCare kit before and after the product was introduced and made available at the point of use (ie by the patient's bedside).
Results
In 2018/2019, 590 patients (mean age 73 years) were managed on the ward compared with 464 patients (mean age 74 years) in 2017/2018. Over the periods examined the total number of patients in the ward was as follows: June to September 2017, n=144; June to September 2018, n=180. In the pre-implementation group 30 (of 144) patients were assessed as category C and in the post-implementation group 10 (of 180) were assessed as category C.
Following introduction of the kit, compliance with good oral care increased by more than 4 times (20% versus 82%) compared with the same period in 2017/2018 (Table 4). Total antibiotic costs for managing NV-HAP declined by 79% (£189 versus £118 per patient, or a 38% drop) and the number of antibiotic doses for treating NV-HAP fell by 70% (n=749 versus n=222). There were fewer NV-HAP related deaths (8/30, 27%, versus 2/10, 20%) (Table 4).
| Pre-implementation (June–September 2017) | Post-implementation (June–September 2018) | |
|---|---|---|
| Total number of patients on the ward | n=144 | n=180 |
| Cases of NV-HAP (category C patients) | n=30 | n=10 |
| NV-HAP deaths | 8/30 (27%) | 2/10 (20%) |
Before the introduction of the kit, about one quarter of the MDT thought they did not have the tools to provide comprehensive oral care. A similar proportion disagreed or strongly disagreed that current practice in oral care was good. The results of pre-implementation and post-implementation surveys of the MDT on the ward (Table 5 and Table 6) showed that all those who responded thought that the risk-stratified interventions had improved oral hygiene for patients.
| Question | Strongly agree | Agree | Not answered | Disagree | Strongly disagree |
|---|---|---|---|---|---|
| I understand my unit's oral cleansing and suctioning protocol | 37% | 59% | 0% | 1% | 3% |
| It is important to use proven evidence-based oral care products | 67% | 33% | 0% | 0% | 0% |
| I understand the importance of brushing teeth to remove dental plaque | 80% | 20% | 0% | 0% | 0% |
| I feel that current practice is good | 28% | 45% | 1% | 20% | 6% |
| I have all the tools I require to perform comprehensive oral care | 23% | 49% | 0% | 22% | 6% |
| I feel confident performing oral care on nil-by-mouth patients | 32% | 58% | 0% | 9% | 1% |
| I know what to document and where to document that I have performed oral care | 32% | 52% | 0% | 14% | 1% |
| I feel that I have enough time to perform regular comprehensive oral care for my patients | 25% | 49% | 3% | 17% | 6% |
| Question | Strongly agree | Agree | Not answered | Disagree | Strongly disagree |
|---|---|---|---|---|---|
| I understand the importance of comprehensive oral care for my nil-by-mouth and category C* patients | 96% | 4% | 0% | 0% | 0% |
| One-piece thumb-port tools make it easier to control suction strength | 58% | 31% | 4% | 8% | 0% |
| Sage's suction toothbrush with nylon bristles provides better cleansing action than toothbrushes with fewer bristles or plastic bristles | 58% | 35% | 4% | 4% | 0% |
| Toothette® oral care mouth moisturiser effectively moisturises the lips and oral tissues | 62% | 38% | 0% | 0% | 0% |
| By keeping oral care tools available at the point of use, Q∙Care saves time and eliminates steps | 81% | 19% | 0% | 0% | 0% |
| The sequential packaging of Q∙Care makes it easier to comply with my unit's oral care protocol | 69% | 27% | 0% | 4% | 0% |
| I feel the oral health of the patients on the ward has improved | 62% | 38% | 0% | 0% | 0% |
| The Q·Care system's premixed cleansing solution saves time | 64% | 32% | 4% | 0% | 0% |
| Compared with previous interventions, the Q∙Care system makes it easier to comply with my unit's oral care protocol | 62% | 31% | 4% | 4% | 0% |
| The timings when I need to perform oral care are easy to comply with | 36% | 60% | 4% | 0% | 0% |
| I would recommend the Q∙Care oral cleansing and suctioning system over previous interventions | 58% | 35% | 4% | 4% | 0% |
Discussion
Poor dental hygiene and the resulting accumulation of plaque can allow respiratory pathogens to colonise the oral cavity, which seems to increase the risk of developing NV-HAP (Scannapieco et al, 2003). In this study, following the introduction of an oral care kit and assessment tool, compliance with oral care increased more than 4 times (20% versus 82%). The results were striking, in that there was a 70% drop in antibiotic doses to treat patients with NV-HAP and the overall antibiotic costs of managing NV-HAP declined by almost 80%. The increased use of the oral care kit and, consequently, patients' better oral health, was associated with a lower proportion of NV-HAP-related deaths compared with the same period in the preceding year. Members of the MDT agreed that keeping oral care tools available at the point of use saves time by eliminating the need to collect all the components of the equipment necessary separately, and that the oral health of patients on the unit has improved. Almost all staff would recommend the kit over previous interventions.
The results in this study are similar to those reported by other quasi-experimental studies. For example, a retrospective study undertaken in the USA found that the incidence of NV-HAP decreased by 49% with enhanced oral care compared with standard care (P<0.0001; OR 0.51; 95% CI 0.38-0.70) (Davis and Finley, 2012). A prospective Canadian study in neurologically impaired patients also reported that enhanced oral care significantly reduced the NV-HAP rate from 25.5% in those receiving standard care to 6.3% (P<0.05) (Robertson and Carter, 2013). Another US study (Quinn et al, 2014) found that improved oral care protocols were associated with a 38.8% reduction in the NV-HAP rate from 0.49 to 0.3 per 100 patient days. The number of NV-HAP cases declined by 37% during the 12-month study.
The two MDT surveys undertaken in the authors' ward showed that the risk-stratified interventions improved the level of oral hygiene for patients. Having an oral care kit available at the bedside is likely to have contributed to improved compliance by raising awareness that oral care should be performed. The use of suction devices, alongside the solutions (antiseptic mouthwash, hydrogen peroxide and Stryker's mouth moisturiser) greatly improved the oral health of patients, exemplified in the reduction in NV-HAP. However, the study had relatively low numbers in both patient groups (pre-implementation, n=30/188; post-implementation, n=10/140) and we are continuing to collect data as part of the audit cycle.
We plan to undertake audits to ensure that we maintain a high standard of care and ensure, for example, that new staff members have adequate training in providing oral care and using the equipment correctly. Practical and classroom training is carried out by trained members of staff and by Stryker reps on the use of the kits, and education about how poor oral care can contribute to NV-HAP. The ward has also developed a competency sheet to allow healthcare assistants (HCAs) to be educated on using the products and being signed off as competent.
Anecdotally, the benefits offered by the quality improvement initiative were apparent immediately to the MDT, and to patients and relatives. Nurses and HCAs noted a visible and olfactory improvement in oral hygiene. Other members of the MDT also noticed a difference and were able to spend more time on their core objectives, rather than mouth care. For example, before the introduction of the products, due to poor oral care, the speech and language therapists often spent a large proportion of their sessions providing mouth care. Patients and carers noted the improvement in oral hygiene and they reported an improved interest in food and drink, including that the food tasted and smelt better.
A clear, evidence-based policy, with a standardised assessment of oral hygiene, was an important driver for success. The protocol stressed that all nurses and HCAs should be equipped with the skills to assess the oral hygiene of every patient to determine their needs and provide appropriate mouth care. Moreover, the quality improvement initiative reflected certain core objectives of the Trust and NHS, such as optimising the patient experience and antimicrobial stewardship, which NICE (2015) defines as ‘an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness'. In addition, the initiative had the potential to improve efficiency by, for example, reducing the risk of infections and the associated prolongation of inpatient care.
Education was another important driver for success to ensure that everyone appreciated the risks associated with poor oral hygiene and the need to improve oral care. This ensured that the quality improvement initiative was implemented by all staff across different shifts. Some colleagues needed to upskill and develop a competency in suction.
Following the positive results of the initiative, we introduced the quality improvement initiative across the whole trust, supported by a ‘mouth care awareness week’ to ensure that all colleagues appreciated the importance of good oral hygiene. Moreover, after we presented the results at a local stroke meeting for northwest London, there has been interest in applying the policy across the region.
The initiative has also brought some less tangible benefits. For example, the initiative offered the opportunity to be involved in nurse-led research and raised the profile of our unit and the individual members, which facilitates our professional development. Supported by the Trust's charity CW+ we have been encouraged to further innovate in our practice by applying for funding for further projects, such as using fall sensors and an alarm system to improve patients' continence. Following the success of the initiative we have gained funding for a quality improvement initiative in continence management. The project is planned to start in 2020 once the equipment has been purchased and training has started. Our experience has also encouraged other teams to assess the opportunity for quality improvement initiatives in their clinical settings.
The oral care kit and assessment tool meet the needs of patients on an acute stroke unit, considerably improving patients' oral hygiene, helping to reduce cases of NV-HAP and associated antibiotic use and mortality. The Stryker q4° Q∙Care kit is fit for purpose as a suitable intervention to help prevent NV-HAP.