Bibliography and resources supporting the essential use of oral care and providing a means to overcome communication barriers for all patients on non-invasive ventilation (NIV)

Guidelines and recommendations for patients on NIV:

American Thoracic Society Guidelines for the Management of Adults with Hospital-Acquired, Ventilator-Associated, and Healthcare-Associated Pneumonia

This official statement of the American Thoracic Society and the Infectious Diseases Society of America was approved by the ATS Board of Directors, December 2004 and the IDSA Guideline Committee, October 2004

Recommendation: 

Modulation of oropharyngeal colonization, by combinations of oral antibiotics, with or without systemic therapy, or by
selective decontamination of the digestive tract (SDD) is also effective in significantly reducing the frequency of HAP.
Although selective decontamination of the digestive tract reduces HAP, routine prophylactic use of antibiotics should be discouraged. Modulation of oropharyngeal colonization by the use of oral chlorhexidine has prevented ICU-acquired HAP
in selected patient populations such as those undergoing coronary bypass grafting, but its routine use is not recommended until more data becomes available.

 

Reference: Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar 26;53(RR-3):1-36. PMID: 15048056.

Guidelines for Preventing Health-Care-Associated Pneumonia, 2003
Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee

Guideline: 

3.  Prevention or modulation of oropharyngeal colonization

a.    Oropharyngeal cleaning and decontamination with an antiseptic agent: develop and implement a comprehensive

       oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute-care settings or

       residents in long-term care facilities who are at high risk for healthcare associated pneumonia.


Reference: Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar 26;53(RR-3):1-36. PMID: 15048056.

Regulatory Review:

Department of Health and Human Services (DHHS) State Operations Manual: Healthcare Financing Provider Certification: Transmittal 17

Mandates: 

“In providing this information, the hospital must be sensitive to the communication needs of its patients. As part of its
provider agreement, the hospital agrees to comply with Civil Rights laws that assure that it will provide interpretation for
certain individuals who speak languages other than English, use alternative communication techniques or aides for those who are deaf or blind, or take other steps as needed to effectively communicate with the patient. These civil rights laws and regulations also apply to the provision of this information.” Individuals who need assistive devices (e.g., magnifying glass, braille, sign language), or have a communications challenge, such as deafness, low vision, blindness, or not being proficient
in English, are at risk of not being informed of their rights.” 


“The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, 

and being able to request or refuse treatment.” 


Reference: Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. Title 42, Chapter IV, Subpart Conditions of participation: Patient Rights, §482.13.

The Joint Commission: Patient Rights

Details on the Patient’s Right to be Involved In Their Care

  • Hospitals must include the patient (or their legal representative) in the development, implementation, and modification
    of his/her plan of care. Hospitals must respect each patient’s wishes and honor advance directives and medical durable power of attorneys.

  • Accrediting agencies will ask hospitals how it demonstrates patient involvement in the plan of care. Hospitals require that nurses document patient comments as part of the care planning process.

  • Patients have the right to request or refuse treatment

  • The nurse must advocate for the patient and take the patient’s wishes up the chain of command if there is an issue


Reference: Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. Title 42, Chapter IV, Subpart Conditions of participation: Patient Rights, §482.13.

Forum on Augmentative and Alternative Communication (AAC) in Acute Care 

Summary: A significant percentage of people who are hospitalized face a communication barrier, and patients who cannot communicate with caregivers are at a heightened risk of experiencing a preventable adverse event (AE). There has been a growing realization that augmentative and alternative communication (AAC) strategies and tools can be used to support the communication needs of children and adults who are hospitalized, regardless of their premorbid condition or the cause of their admission. It has been suggested that by addressing communication barriers, hospitals can not only reduce patient suffering but also achieve considerable savings (more than $6 billion) by reducing the costs associated with having to treat preventable AEs. The case has been made that hospital SLPs who provide AAC services can have a significant impact and that success comes from working collaboratively with  nursing and other health care professionals.

Reference: Hurtig RR. Forum on Augmentative and Alternative Communication in Acute Care. Perspect ASHA Spec Interest Groups. 2019;4(5):989-990. 

Oral care for patients on NIV and reduction of hospital-acquired pneumonia
case studies:

Oral Care in Critically Ill Patients Requiring Noninvasive Ventilation: An Evidence-Based Review 

Summary: No standard of oral care exists for patients requiring noninvasive ventilation.

 

Reference: Johnny JD, Drury Z, Ly T, Scholine J. Oral Care in Critically Ill Patients Requiring Noninvasive Ventilation: An Evidence-Based Review. Crit Care Nurse. 2021 Aug 1;41(4):66-70. 

Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster
Randomized Study

Summary: Hospital-acquired pneumonia (HAP) is now the most common type of hospital-acquired infection in the United States, accounting for 26% of all such infections, according to the most recent point prevalence survey conducted by the Centers for Disease Control and Prevention (CDC). It is also the most common hospital acquired infection in Europe. Of
the HAP cases in the CDC survey, fully 65% were found to be nonventilator hospital-acquired pneumonia (NVHAP).

Researchers have found an important relationship between the oral microbiota and HAP. Within 48 hours of hospitalization, changes occur in the oral microbiota that are associated with more virulent pneumonia-causing organisms. Respiratory pathogens such as Staphylococcus aureus, Klebsiella pneumoniae, Enterobacter cloacae, and Pseudomonas aeruginosa colonize the dental plaque and can be aspirated, introducing these organisms into the lungs, even in healthy adults.

 

Studies indicate that patients are up to six times more likely to develop HAP if the mouth is persistently colonized by such pathogens. Several studies have shown that improved cleaning of the oral biofilm provides primary source control of HAP pathogens and reduces HAP incidence.

 

The purpose of this study was to determine the effectiveness of a universal, standardized oral care protocol in preventing NV-HAP in the acute care setting.

 

Oral care frequency increased from a mean of 0.95 to 2.25 times per day, and there was a significant 85% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 7.1 times higher on the medical control versus intervention units. These findings add to the growing body of evidence that daily oral care as a means of primary source control may have a role in NV-HAP prevention.

Reference: Giuliano KK, Penoyer D, Middleton A, Baker D. Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster Randomized Study. Am J Nurs. 2021 Jun 1;121(6):24-33.

 

Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of Nonventilator Hospital-Acquired Pneumonia in
the United States

Summary: 1,300 NV-HAP patients acquired NV-HAP (rate, 0.12-2.28 per 1,000 patient days) across the 21 hospitals
that completed the data collection. Most NV-HAP infections (70.8%) were acquired outside of intensive care units
(ICUs); 18.8% required transfer into the ICU.

Reference: Baker D, Quinn B. Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018 Jan;46(1):2-7. 

 

Implementation and Dissemination of a Department of Veterans Affairs Oral Care Initiative to Prevent Hospital-Acquired Pneumonia Among Nonventilated Patients
Summary: The incidence rate of non-ventilator-associated hospital-acquired pneumonia decreased from 105 cases to
8.3 cases per 1000 patient-days (by 92%) in the initial VA pilot, yielding an estimated cost avoidance of $2.84 million
and 13 lives saved in 19 months post implementation.
 

Reference: Munro S, Haile-Mariam A, Greenwell C, Demirci S, Farooqi O. Original Research: Implementation and Dissemination of a Department of Veterans Affairs Oral Care Initiative to Prevent Hospital-Acquired Pneumonia Among Nonventilated Patients Nurs Adm Q Oct/Dec 2018;42(4):363-372

Nurse-Driven Oral Care Protocol to Reduce Hospital-Acquired Pneumonia
Summary: A standardized, evidence-based oral care protocol was implemented depending on the level of care required by each ventilated, at-risk, or short-term care patient. NV-HAP incidence per 1,000 discharges was calculated at 2.84 in the baseline group and 1.41 in the intervention group.

Reference: Warren C, Medei MK, Wood B, Schutte D. A Nurse-Driven Oral Care Protocol to Reduce Hospital-Acquired Pneumonia. Am J Nurs. 2019 Feb;119(2):44-51. 

 

Basic Nursing Care to Prevent Nonventilator Hospital-Acquired Pneumonia
Summary: After oral care protocol were initiated, the rate of NV-HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%). The overall number of cases of NV-HAP was reduced by 37% during the 12-month intervention period. The avoidance of NV-HAP cases resulted in an estimated 8 lives saved, $1.72 million cost avoided, and 500 extra hospital days averted. The extra cost for therapeutic oral care equipment was $117,600 during the 12-month intervention period. Cost savings resulting from avoided NV-HAP was $1.72 million. Return on investment for the organization was $1.6 million in avoided costs.

Reference: Quinn B, Baker DL, Cohen S, Stewart JL, Lima CA, Parise C. Basic nursing care to prevent nonventilator hospital-acquired pneumonia. J Nurs Scholarsh. 2014 Jan;46(1):11-9. 

Communication with patients on NIV: 

Giving Voice: Nurse-Patient Communication in the Intensive Care Unit
Summary: Communication is the essence of the nurse-patient relationship. The critical care nurse’s role in facilitating
patient communication and enabling communication between patients and their families has never been more important
or poignant than during the COVID-19 pandemic. We have witnessed tremendous examples of resourceful, caring nurses
serving as the primary communication partner and support for isolated seriously ill patients during this pandemic .However, evidence-based tools and techniques for assisting awake, communication-impaired, seriously ill patients to communicate are
not yet systematically applied across all settings. Missed communication or misinterpretation of patients’ messages induces panic and fear in patients receiving mechanical ventilation and can have serious deleterious consequences. This lecture presents a 23-year program of research in developing and testing combination interventions (eg, training, tailored assessment, and tools) for best practice in facilitating patient communication during critical illness. Evidence from related nursing and inter professional research is also included. Guidance for unit-based assessment, tailoring, and implementation of evidence-based patient communication protocols also is provided.
Reference: Happ MB. Giving Voice: Nurse-Patient Communication in the Intensive Care Unit. Am J Crit Care. 2021 Jul 1;30(4):256-265. 

Giving Patients a Voice Among the Inpatient Orchestra: Communication Vulnerability in Noninvasive Ventilation Therapy
Summary: Communication vulnerability is defined as a struggle to share information in a particular environment. Potential obstacles to effective communication may include language barriers, voice, hearing, and vision impairments. Despite its promise  as an effective therapy for respiratory failure, NIV poses a significant risk of communication vulnerability. NIV face masks muffle vocalization and hinder speech intelligibility.  Impaired communication encumbers patient-caregiver and patient-clinician relationships,  contributes to delirium, and increases the risk for preventable adverse events. The Joint Commission mandates that hospitals provide auxiliary aids, services, or Augmentative and Alternative Communication (AAC) to address communication challenges for patients. Regardless of the surrounding environment, NIV creates communication vulnerabilities. The ideal AAC device would improve speech intelligibility while filtering background noise.  All ICUs should have a program to aid communication during assisted ventilation. For patients wearing NIV struggling to vocalize, a device as described by Wong et al may facilitate effective communication, improve patient satisfaction, and enhance patient voice among the “orchestra” of inpatient care.
Reference: Dubin R, Ackrivo J. Giving Patients a Voice Among the Inpatient Orchestra: Communication Vulnerability in Noninvasive Ventilation Therapy. Chest. 2021 Apr;159(4):1324-1325.

Impact of Patient Communication Problems on the Risk of Preventable Adverse Events in Acute Care Settings
Summary: Patients with communication problems appeared to be at highest risk for preventable adverse events. Of 217 adverse events, 63 (29%) were judged to be preventable, for an overall population rate of 2.7% (95% confidence interval [CI] 2.1%-3.4%). We found that patients with preventable adverse events were significantly more likely than those without such events to have a communication problem.

Reference: Bartlett G, Blais R, Tamblyn R, Clermont R, MacGbbon B. Impact of patient communication problems on the risk of preventable adverse events in acute care settings CMAJ 2008 Jun 3;178(12):1555-62.

 

Anxiety in Patients Receiving Non-Invasive Ventilation for Acute Respiratory Failure: Prevalence, Risk Factors
and Prognostic Impact

Summary: Among patients receiving NIV for an ARF, anxiety is frequent and potentially severe. Moderate to severe anxiety is associated with NIV failure and a trend toward higher mortality.

Reference: Demoule, L. Dangers, J.-P. Laforet, A. Kouatchet, S. Jaber, F. Meziani, S. Perbet, E. Azoulay, V. REVA, the European Research Network on Mechanical, and A.D.I.T.I. Grrr-OH, the Reasearch Group on Oncologic  and Haem. C104. CRITICAL CARE: BODY AND MIND IN AND OUT OF THE ICU - SEDATION, DELIRIUM, MOBILIZATION, AND LONG TERM FUNCTIONAL AND COGNITIVE OUTCOMES. May 1, 2018, A6020-A6020.