Trudy Robertson and Dulcie Carter Team Oral Intensity

Oral care protocol became standard at all 12 acute care surgical sites after Royal Columbian Hospital study showing its contribution to reduced rates of hospital-acquired pneumonia.

For patients who are staying overnight or longer-term in hospital, getting pneumonia while there can add 7 to 11 days to their stay on average and can cost the health care system up to $60,000 or more per patient for associated care. Symptoms include high fever and coughing. Patients can have difficulty breathing and some develop a full body infection in their bloodstream. The original condition for which patients are being treated often worsens, and Canadian studies have shown as many as 20 per cent of non-intensive care patients and as many as 33 per cent of neurologically impaired intensive care patients die from complications of hospital-acquired pneumonia.

Trudy Robertson, clinical nurse specialist, neurosurgery, and Dulcie Carter, registered speech language pathologist, work with stroke, traumatic brain injury and other neurologically impaired patients in acute care at Royal Columbian Hospital. In 2012, they were co-principal investigators of a six-month study of an oral care protocol their research team had designed. Jereme Bennett, Tina Moran and Sue Kadyschuk were also members of the team. The study involved 32 adult patients who depended on nursing care for basic hygiene.

“We compared data from this study group with data from a similar group of 51 patients two years earlier and found the odds of patients developing hospital-acquired pneumonia were more than five times higher with the patients who weren’t involved with the enhanced oral care protocol,” says Trudy. “By following a very structured schedule of mouth cleaning, suctioning and moisturizing, with checks every 2 to 4 hours, only two of our study group patients developed pneumonia compared to 13 of the earlier control group.”

The protocol has added benefits. “Any time a nurse has a regularly scheduled care activity, it promotes that nurse-patient interaction that we know is very important for helping the brain to heal,” says Trudy.

Dulcie adds, “When I’m doing oral care with patients, they can go from fairly drowsy to a lot more awake. They want to talk and interact.” She also notes, “The protocol includes moisturizers to relieve dryness, which is a lot more pleasant for general comfort.”

The executive director of Fraser Health’s Surgery program, who had approved the study, quickly approved the continuation of the protocol for care-dependent, acute care neurology patients, and very soon after approved next steps to adapt the protocol for use at all 12 acute care surgical sites across the region. “When you have support of senior leadership, it makes it a lot easier,” says Trudy.

Next steps included a requirement to work with Fraser Health’s Clinical Policy Office to receive feedback on the proposed regional protocol from various professional practice councils.

The research team was also required to work with the health authority’s Professional Practice department to expand the protocol. They partnered with a Professional Practice consultant who managed their strategy regionally. “What we called the Hospital-Acquired Pneumonia Prevention Initiative (HAPPI) team was created and tasked with turning the study protocol into a regional one,” says Trudy.

“Also helping to move the research into practice, we used clinical nurse educators in the roll-out at the surgical sites across the region,” says Dulcie. The roll-out took about a year, and since fall 2013, the researchers estimate tens of thousands of patients have benefited.

“We took the further step of publishing it in the Canadian Journal of Neuroscience Nursing to make the study available to a broad audience,” says Trudy. And both Trudy and Dulcie have made numerous presentations to B.C., national and international groups and associations.

“The study has been the springboard for additional quality improvement projects related to oral care within Fraser Health,” says Trudy who in early February 2017 finished a new study at Royal Columbian Hospital that was also carried out at Abbotsford Regional Hospital. “There are many places within the health care system that an oral care protocol could be adapted because pneumonia affects people at all points in the health care system and all ages.”

Following the 2012 study, Fraser Health began using rates of hospital-acquired pneumonia as one of its indicators of overall performance. As part of this, the health authority sets targets for reduced rates at individual sites and for the region as a whole. Oral care protocol is one of several evidence-based strategies used to help patients avoid pneumonia while in hospital. Because of the protocol’s success to date, it’s expected further expansion of it will help Fraser Health meet its performance targets.

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