Four years ago, when Karen Giuliano went to a Boston hospital for hip replacement surgery, she was given a pale-pink bucket of cosmetics for patients at many hospitals. Tissue inside, bar soap, deodorant, toothpaste and undoubtedly, it was the worst toothbrush he had ever seen.
“I couldn’t believe it. I got a toothbrush that had no bristles, “he said.” It certainly didn’t go through the bristle machine. It was just a stick. “
For most patients, a useless hospital toothbrush will be a mild inconvenience. But to Giuliano, a nursing professor at Amherst University in Massachusetts, it was a reminder of a wide “blind spot” in a U.S. hospital: the stunning consequences of not brushing teeth.
Hospital patients not brushing their teeth, or not brushing their own teeth, are considered a major cause of several thousand pneumonia a year in patients who are not kept on a ventilator. Pneumonia is the most common infection that occurs in healthcare facilities and in most cases non-ventilator hospital-acquired pneumonia, or NVHAP, which kills up to 30% of those infected, says Giuliano and other experts.
But unlike many infections that injure within the hospital, the federal government is not required to report to the hospital’s NVHAP. As a result, some hospitals understand the source of the illness, track its presence, or work actively to prevent it, experts say.
Many cases of NVHAP can be avoided if hospital staff brush the teeth of bedridden patients more responsibly, according to a growing body of peer-reviewed research papers. Instead, many hospitals often avoid brushing their teeth to prioritize other tasks and provide only cheap, ineffective toothbrushes, often unaware of the results, says Diane Baker, a Sacramento State nursing professor who has spent more than a decade studying NVHAP.
“I’ll tell you that most of the thousands of nurses in hospitals today have no idea that pneumonia comes from oral germs,” Baker said.
Pneumonia occurs when a bacterium infects the lungs. Although NVHAP is responsible for most cases associated with healthcare, historically it has not received the same attention as ventilator-associated pneumonia, which is easier to detect and study because it occurs in a narrow subset of patients.
NVHAP, a risk for virtually all hospital patients, is often caused by bacteria from the mouth that accumulate in unbrushed teeth and enter the lungs. Patients are at greater risk if they are lying flat or inactive for long periods of time, so NVHAP can be prevented by raising their heads and getting them out of bed more often.
According to the National Organization for NV-HAP Prevention, which was established in 2020, this pneumonia infects 1 in every 100 hospital patients and 15% to 30% of them die. For those who survive, the illness often extends their hospital stay to 15 days and makes them much more likely to be re-admitted within a month or transferred to an intensive care unit.
John McCleary, 83, of Bangor, Maine, contracted NVHAP in 2008 when he fell and broke his ankle and spent 12 days in a hospital rehabilitation, his daughter, Kathy Day, a retired nurse and advocate, told the Patient Safety Action Network.
McCleary recovered from a fracture but not from pneumonia. Two days after he returned home, he was rushed to hospital with an infection in his lungs, where he went into sepsis and spent a few weeks in treatment before moving to an isolated unit in a nursing home.
He died a few weeks later, furious, very deaf, unable to eat, and often “too weak to get water with straw,” his daughter said. He no longer walked after suffering from pneumonia.
“It was an amazing attack on her body, she met me here a week before her fall, until just a few months after her death,” Day said. “And the whole thing was avoidable.”
Although experts have described NVHAP as a widely ignored threat, this seems to be changing.
Last year, a team of researchers – including Giuliano and Baker, and officials from the Center for Disease Control and Prevention, the Veterans Health Administration and the Joint Commission – called for a “National Healthcare Conversation on NVHAP Prevention” in hopes of publishing a “call-to-action” research paper.
The Joint Commission, a non-profit organization whose accreditation can build or dismantle hospitals, is considering expanding infection control standards to include more illnesses, including NVHAP, said Sylvia Garcia-Houchins, director of infection prevention and control.
Separately, ECRI, a nonprofit focusing on healthcare safety, identified NVHAP as one of the top patient safety concerns this year.
James Davis, an ECRI infection specialist, says the prevalence of NVHAP, although already worrying, has probably worsened as hospitals have swelled with patients during the coronavirus epidemic.
“We only know what is being reported,” Davis said. “Could this be the tip of the iceberg? I’d say, in my opinion, probably.”
To better measure the situation, some researchers have called for a standardized surveillance definition of NVHAP, which could open the door for the federal government to make case reporting mandatory or encourage prevention in a timely manner. With the growing urgency, researchers are pressuring hospitals not to wait for the federal government to act against NVHAP.
Baker said he has talked to hundreds of hospitals about how to prevent NVHAP, but thousands more have yet to accept the cause.
“We’re not asking for some big, $ 300,000 piece of equipment,” Baker said. “The two things that show the best evidence of this damage prevention are the things that should be in standard care anyway – brushing teeth and making patients mobile.”
This evidence comes from the isolation of studies that show that these two strategies can lead to a sharp decrease in the rate of infection.
In California, a study of 21 Kaiser Permanent Hospitals was used to reapply oral care and reduce the rate of hospital-acquired pneumonia by getting patients out of bed by about 70%. At Sutter Medical Center in Sacramento, Good Oral Care reduced NVHAP cases by an average of 35% annually.
At the Orlando Regional Medical Center in Florida, a medical unit and a surgical unit where patients received enhanced oral care, NVHAP rates decreased by 85% and 56%, respectively, compared to similar units receiving normal care. Similar research is underway at two hospitals in Illinois.
And the most impressive results come from a veteran hospital in Salem, Virginia, where a 2016 oral care pilot program reduced the rate of NVHAP by 92% – saving an estimated 13 lives in just 19 months. The program, the Happen Initiative, has been expanded across the Veterans Health Administration, and experts say it could serve as a model for all U.S. hospitals.
Michelle Lucarto, a nursing officer who leads Happen, said the program trains nurses to brush patients’ teeth most effectively and educates patients and families about the link between oral care and NVHAP prevention. While training to brush teeth may not seem necessary, Lucatorto revealed how the coronavirus revealed that many Americans are doing a poor job of doing another regular health practice: comparing their hands to washing.
“Sometimes we search for the most complex interventions,” he said. “We are always looking for that new bypass surgery or some new technological equipment. And sometimes I think we fail to see the simple things we can do in our practice to save people’s lives. “
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