Discussion Guide for the Rathbun Article

Oral health is vital for the overall well-being of hospitalized patients but is not routinely prioritized. Poor oral hygiene can result in hospital-acquired pneumonia (HAP). Research indicates that structured oral care protocols can significantly reduce pneumonia rates, particularly among patients not receiving mechanical ventilation, highlighting the importance of regular oral hygiene. Older adults, especially those in skilled nursing facilities (SNFs), are at a higher risk of developing HAP due to weakened immune systems, dependence on external dental devices, and preexisting health conditions that hinder their ability to care for themselves. Given the high prevalence of respiratory pathogens among older adults, investigating the oral microbiome in hospitalized seniors could lead to essential nursing interventions to enhance oral health and lower infection risks.The investigators (1) compared the oral microbiomes of older adults not receiving mechanical ventilation between those admitted from home and those admitted from a SNF and (2) assessed changes in patients’ oral microbiome during hospitalization to identify factors influencing oral health and potential nursing interventions.This prospective observational study was done at a Florida academic medical center from May 2021 to August 2022. The researchers recruited hospitalized adults aged 65 and older, admitted to 3 progressive care units from home or a SNF within the past 72 hours, who tested negative for COVID-19. Patients with community-acquired pneumonia, those requiring mechanical ventilation or hospice care, and individuals undergoing immunosuppression therapy were excluded. At enrollment, the Oral Health Assessment Tool (OHAT) was completed and salivary specimens were collected for microbiome DNA analysis. These procedures were repeated on hospital days 3, 5, and 7 to observe changes in oral health and microbiome composition. The investigators assessed microbial diversity using the Shannon Index and compared differences between groups (home vs SNF) using the Bray-Curtis dissimilarity index, adjusting for confounding variables such as sex, comorbidity severity, frailty, and OHAT scores.The investigators analyzed data from 46 participants: 15 admitted from SNFs and 31 from home. At enrollment, patients admitted from SNFs exhibited poorer oral health, a less diverse oral microbiota, higher prevalences of low-abundance (<1%) bacterial genera linked to oral disease (eg, Acinetobacter, Bacteroides, Mycoplasma), and greater microbial dissimilarity compared with those admitted from home. Oral health declined with time in the 28 patients who completed the study. The dominant bacterial genera remained relatively stable in the 20 patients admitted from home but decreased in the 8 admitted from SNFs. Further, the prevalence of low-abundance bacterial genera increased by twice as much in those admitted from SNFs.Older adults in SNFs show poorer oral health, decreased microbial diversity, and more harmful bacteria than those admitted from home. These problems persist and often worsen during hospitalization, underscoring the urgent need for organized oral care interventions to prevent microbial imbalances and improve patient outcomes. Future studies should explore clinician barriers and determine which strategies yield the most promising effects on enhancing microbial diversity and patient outcomes in practical, cost-effective ways.Kimberly Rathbun, PhD, RN, developed an early interest in oral health research while completing her undergraduate honors thesis at the University of Central Florida (UCF). She found that “oral care was completed less frequently in nonventilated hospitalized patients,” and standardized guidelines were limited. Once Dr Rathbun became a bedside nurse, she “saw firsthand the barriers patients experienced to completing oral care,” which drove her to pursue a PhD in nursing research to influence systemic change. As a graduate research assistant at UCF, she expanded her expertise in genetics and genomics, later attending the National Institute of Nursing Research Summer Genetics Institute, which provided the foundation for her dissertation.Forming the basis for this study, Dr Rathbun’s dissertation work was both rewarding and challenging. Conducting clinical research during the COVID-19 pandemic required adaptability: “We did not anticipate a limited pool of eligible patients from a skilled nursing facility to recruit,” she notes, which led the team to expand recruitment efforts. Despite these hurdles, participant engagement was strong. Another unexpected finding of this research was the relationship of poor oral health and microbial diversity with cognitive impairment. “This was not something we initially set out to investigate, but it became a significant focus as the data emerged.” This discovery has shaped her ongoing work, influencing her postdoctoral research at Moffitt Cancer Center.This study underscores the critical role of oral health in preventing hospital-acquired infections, particularly in vulnerable older adults. Dr Rathbun explains, “Many participants in our study had limited oral care during hospitalization, which may have contributed to the changes noted.” Thus, her work signals the need for institutional changes to integrate oral health into broader patient safety initiatives, such as ensuring uninterrupted access to oral care supplies, implementing educational initiatives for staff, and providing adequate staffing. Without these measures, patients remain at increased risk for preventable conditions such as nonventilator hospital-acquired pneumonia. The study also reinforces that nurses are key in advocating for standardized oral care protocols to improve overall health outcomes and reduce complications associated with poor oral hygiene.This feature briefly describes the personal journey and background story of the EBR article’s lead investigator, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Kimberly Rathbun, PhD, RN, transitioned from bedside nursing to postdoctoral research. Her expertise in nursing, research, and genetics enables her to translate basic research into practical interventions. She shares, “My experience and background as a registered nurse have given me the unique ability to bridge the gap between basic science and clinical practice to address clinically relevant problems.” Her success in this study stems from strategic team-building and interprofessional collaboration. She advises early-career researchers to “have an open mind and search for individuals who have a complementary program of research to your own.” Additionally, she encourages fledgling researchers to “take the initiative in reaching out to colleagues to see if there are any research opportunities you may join, or to discuss a potential research question you are interested in addressing.” Dr Rathbun also emphasizes the importance of adaptability in clinical research, particularly when navigating unexpected challenges. “Adaptability is an important trait to learn in clinical research that strengthens you as an investigator.” Her work exemplifies how dedication, collaboration, and strategic thinking can drive impactful advancements in health care research.