Dental Hygienist Intervention to Prevent Ventilator-Associated Pneumonia in an Intensive Care Unit

Ventilator-associated pneumonia (VAP) is the leading cause of death from nosocomial infection with 1 in 5 affected patients dying.1 It increases the duration of hospitalization by 5 to 7 days and health care costs by approximately $40 000 per hospitalization.2 Ventilator-associated pneumonia is a pneumonia not present at the time of admission into the hospital, developing in a patient who has received mechanical ventilation for at least 48 hours.1 Although the development of VAP is multifactorial, evidence suggests there is an association between oral hygiene and the development of pneumonia—particularly the role of the bacterial biofilm present in the oral cavity that colonizes on tooth surfaces and oral mucosa and is at risk for aspiration into the lungs.3 Colonization of this oral bacterial biofilm is exacerbated with omitted or low-quality oral hygiene, allowing the bacteria to triple in the oral cavity within 3 to 6 hours.3 This leads to rapid deterioration of oral health in critically ill patients. In fact, authors of a recent study estimated that 91% of acute care patients in the hospital experience impaired oral health.4Patients who receive mechanical ventilation usually depend on nursing staff to have oral hygiene completed. Nursing staff understand the association between oral hygiene and incidence of VAP; however, oral hygiene is often neglected in critical care settings as it is conditionally a real or perceived lower priority task relative to other patient needs.5,6 In addition, because of the number of competing priorities in critical care, the quality of oral hygiene being performed may be compromised. For example, although the American Dental Association recommends brushing the oral cavity for 2 minutes, actual brushing time completed by nursing staff averages 30 to 60 seconds, if completed at all.3Within the critical care environment, many multidisciplinary specialists support hospitalized patients to improve patient outcomes (eg, respiratory therapists, physical therapists, occupational therapists). Emerging evidence may support a dental hygienist as a key member of a critical care multidisciplinary team. Dental hygienists are experts in oral health and well qualified to provide oral hygiene to hospitalized patients.The intervention implemented in this pilot was routine oral hygiene provided by dental hygienists (rather than nursing staff) in a cardiovascular surgical intensive care unit (ICU).Oral care documentation, incidence of VAP, ICU length of stay, hospital length of stay, and patient mortality were retrospectively evaluated. Before implementation, the Mayo Clinic Institutional Review Board granted a nonresearch determination for this project, and review was waived.To prepare the dental hygienists for the intensive care environment, they met with the ICU-based clinical nurse specialist for three 2-hour in-service sessions to become familiar with the environment, ICU-specific devices (eg, central venous catheters, endotracheal tube, ventilator), and available oral care supplies. Oral care regimen expectations were reviewed as well as safety considerations and collaboration approaches with the room nurses and ICU medical staff.This pilot was conducted with adult patients in a 12-bed cardiovascular surgical ICU in a large quaternary medical center in the Midwest. During October 2022, 1 dental hygienist was staffed on the unit Monday through Friday from 7 am to 4 pm. A standardized, evidence-based oral hygiene regimen was used. The dental hygienist provided oral hygiene every 2 hours to patients who received mechanical ventilation using a suction toothbrush or suction swab with alcohol-free antiseptic mouth rinse. Oral hygiene also included suctioning the oral cavity of excess secretions before oral hygiene, applying chlorhexidine or nystatin as directed by the ordering clinician and in collaboration with the room nurse, and moisturizing the lips and oral mucosa as needed. The dental hygienist completed a daily oral assessment using the Modified Eilers Oral Health Assessment. The dental hygienist documented the oral health assessment and oral hygiene provided in the electronic health record of each patient. Dental hygienists also reviewed the importance and expected steps of oral hygiene with bedside nurses, patients, and patient caregivers.To identify the impact of a dental hygienist as a member of the critical care multidisciplinary team, health care records were examined retrospectively for the 1-month pilot as well as the baseline period of the previous 9 months in the same year for oral care documentation, the International Classification of Diseases, Ninth Revision and Tenth Revision codes for pneumonia that is not present at the time of admission, and the median ICU and hospital length of stay.This pilot was not constructed using inferential statistics to demonstrate an association between the hygienist intervention and VAP. To power such a study would require nearly a year of intervention. However, during the dental hygienist intervention, a nonstatistically evaluated slight reduction in VAP incidence and median hospital and ICU lengths of stay occurred in the intervention unit. Additionally, documentation of oral care for patients who received mechanical ventilation improved by 3 percentage points, which may be clinically important given more than 400 opportunities for oral care completion in the month. This result was also a notable improvement given that the hygienists’ presence was restricted to weekday daytime hours. Relatedly, though not the focus of this article, documentation of oral care for patients who did not receive mechanical ventilation improved more substantially, by 10 percentage points (dental hygienists also provided oral hygiene to patients who did not receive mechanical ventilation during the pilot).Anecdotally, the quality of oral care provided by the dental hygienists was much higher than that of the nurses. Nurses were often noted to brush only the facial tooth surfaces, whereas hygienists brushed the facial/buccal, lingual, and occlusal surfaces and the tongue during oral hygiene. No reported patient safety events related to the hygienists’ interventions or presence occurred. Qualitatively, bedside nurses reported high levels of satisfaction with the hygienists’ presence.Although not the first report of dental professionals practicing in the hospital, this may be one of the first forays of dental hygienists into the critical care setting. Embedding dental hygienists is in line with an assessment by Barnes7 that an interprofessional collaboration with dental professionals may optimize the prevention of hospital-acquired pneumonia. Creating a multidisciplinary care team that includes dental hygienists to help prevent hospital-acquired pneumonia and reduce health care costs would allow nursing staff to focus their care on other critical services and improve patient outcomes.Through the course of this pilot, nurses frequently related their satisfaction with the hygienists’ contributions. One nurse stated, From the hygienists’ standpoint, the ICU provided a unique opportunity to use their education and experience to collaborate with medical colleagues to improve patient outcomes and the overall patient experience. The dental hygienists felt like valued members of the multidisciplinary team, caring for the oral health of those who were critically ill.The implementation team hopes to expand the pilot and construct it with sufficient power to infer any statistically significant associations between the dental hygienists’ interventions and VAP.