Four years ago, when Karen Giuliano was admitted to a Boston hospital for hip replacement surgery, she received a pink box of toiletries: tissues, soap, deodorant, toothpaste, and, hands down, the worst toothbrush I’ve ever had. saw in his life.
“I could not believe it. He had a toothbrush with no bristles,” she said. “It was just a toothpick.”
For most patients, a useless hospital toothbrush would be a minor issue. But for Giuliano, a professor of nursing at the University of Massachusetts-Amherst, it was a reminder of an “ignored problem” in US hospitals: the dire consequences of not brushing your teeth.
Among patients who have not been placed on a ventilator, failure to brush their teeth, themselves or their nurses, is believed to be the main cause of hundreds of thousands of cases of pneumonia each year. Pneumonia is among the most common infections that occur in health care settings, with most cases being non-ventilator hospital-acquired pneumonia (NVHAP), a condition that kills up to 30% of people infected, Giuliano said. and other experts.
But unlike many infections that occur inside hospitals, the federal government does not require hospitals to report cases of NVHAP. As a result, few hospitals understand the origin of the disease, track its onset or actively work to prevent it, experts said.
Many cases of NVHAP could be prevented if hospital staff brushed the teeth of bedridden patients better, according to a growing body of peer-reviewed research articles. Instead, many hospitals typically skip toothbrushing to prioritize other tasks and just provide cheap, ineffective toothbrushes, often without realizing the consequences, said Dian Baker, a Sacramento State nursing professor who has spent more than a decade studying NVHAP.
“I’ll tell you, the vast majority of the tens of thousands of nurses in hospitals today have no idea that pneumonia comes from germs in the mouth,” Baker said.
Pneumonia occurs when germs trigger an infection in the lungs. Although NVHAP accounts for the majority of health care-associated cases, it has not historically received the same attention as ventilator-associated pneumonia, which is easier to identify and study because it occurs among a small subset of patients.
A risk to virtually all hospital patients, NVHAP is often caused by bacteria from the mouth that accumulate in the foamy biofilm of unbrushed teeth and are aspirated into the lungs.
Patients face a higher risk if they remain lying down or immobile for long periods, so NVHAP can also be prevented by elevating their heads and getting them out of bed more often.
According to the National Organization for NV-HAP Prevention, founded in 2020, this pneumonia infects about 1 in 100 hospitalized patients and kills 15% to 30% of them. For those who survive, this illness often extends their hospital stay by up to 15 days, and makes it much more likely that they will need to be readmitted within a month of discharge, or transferred to an intensive care unit.
John McCleary, 83, of Millinocket, Maine, contracted a probable case of NVHAP in 2008 after he broke his ankle in a fall and spent 12 days in hospital rehab, said his daughter, Kathy Day, a retired nurse and Patient Safety Action Network advocate.
McCleary recovered from the fracture, but not from the pneumonia. Two days after returning home, his lung infection prompted him to be rushed to the hospital, where he suffered sepsis and spent weeks in treatment before moving to an isolation unit at a nursing home.
He died weeks later, emaciated, largely deaf, unable to eat, and “too weak to drink water through a straw,” his daughter said. After contracting pneumonia, he never walked again.
“It was an amazing assault on her body, from her being here visiting me the week before her fall, to her death just a few months later,” Day said. “And it was all avoidable.”
While experts describe NVHAP as a largely ignored threat, that appears to be changing.
Last year, a group of researchers, including Giuliano and Baker, as well as officials from the Centers for Disease Control and Prevention (CDC), the Veterans Health Administration, and the Joint Commission, published an investigative article as a “ call to action” in hopes of launching “a national healthcare conversation on NVHAP prevention.”
The Joint Commission, a nonprofit organization whose accreditation can make or break hospitals, is considering expanding infection control standards to include more ailments, such as NVHAP, said Sylvia Garcia-Houchins, its chief prevention officer. and infection control.
Separately this year, ECRI, a nonprofit organization focused on health care safety, identified NVHAP as one of its top patient safety concerns.
James Davis, an infection expert at ECRI, said the prevalence of NVHAP, while already alarming, is likely “underestimated” and has gotten worse as hospitals filled with patients during the coronavirus pandemic.
“We only know what is being reported,” Davis said. “Could this be the tip of the iceberg? In my opinion, I would say, probably.”
To better measure the condition, some researchers are calling for a standardized surveillance definition of NVHAP, which could eventually open the door for the federal government to mandate case reporting or incentivize prevention. With increasing urgency, researchers are pressing 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 there are thousands who have yet to get on board.
“We’re not asking for a $300,000 big team,” Baker said. “The two things that show the best evidence for preventing this harm are things that should be done in standard care anyway: brushing teeth and moving patients.”
That evidence comes from a series of studies showing that those two strategies can lead to strong reductions in infection rates.
In California, a Kaiser Permanente study of 21 hospitals used reprioritization of oral care and getting patients out of bed to reduce hospital-acquired pneumonia rates by about 70%. At Sutter Medical Center in Sacramento, better dental care reduced NVHAP cases by an annual average of 35%.
At Orlando Regional Medical Center in Florida, a medical unit and a surgical unit where patients received enhanced oral care reduced NVHAP rates by 85% and 56%, respectively, compared to similar units receiving normal care. Similar studies are underway at two Illinois hospitals.
And the most compelling results come from a veterans hospital in Salem, Virginia, where a 2016 oral care pilot program reduced NVHAP rates by 92%, saving an estimated 13 lives in just 19 months. The program, the HAPPEN Initiative, has been expanded at the Veterans Health Administration, and experts say it could serve as a model for hospitals nationwide.
Michelle Lucatorto, a nursing officer who runs HAPPEN, said the program trains nurses to brush patients’ teeth more effectively, and educates patients and their families about the link between oral care and prevention of tooth decay. NVHAP. While it may seem like brushing your teeth requires no training, Lucatorto compared it to how the coronavirus revealed many Americans were doing a mediocre job of another routine hygiene practice: washing their hands.
“Sometimes we look for the most complicated intervention,” he said. “We are always looking for that new bypass surgery or some new technical equipment. And sometimes I think we fail to see the simple things we can do in our practice to save lives.”
KHN (Kaiser Health News) is the newsroom of KFF (Kaiser Family Foundation), which produces in-depth health journalism. It is one of three major programs of KFF, a nonprofit organization that analyzes the nation’s health and public health issues.