Toothette Q-Care q2 o Oral Cleansing and Suctioning System from Sage Products

A patient on a ventilator is in a boatload of trouble already. The last thing he needs is some insidious little bug creeping toward his lungs with pneumonia in mind. But it happens often and easily. And why wouldn’t it? Bacteria thrive in dental plaque and oropharyngeal secretions. The ventilator tube provides the ideal avenue for migrating bugs. The pathway is convenient, it’s direct, and it can be deadly. There are other ways it can happen: A patient could inhale aerosolized bacteria. Or aspirate his gastric juices. Or the bacteria could be carried in by blood from another site. That’s all it takes for the hateful little bugs to get a foothold.

Cost of nosocomial pneumonia
The Centers for Disease Control and Prevention (CDC)’s1 "Guidelines for Preventing Health-Care–Associated Pneumonia, 2003" noted that "pneumonia has accounted for approximately 15% of all hospital-associated (HA) infections and 27% and 24% of all infections acquired in the medical intensive-care unit (ICU) and coronary care unit, respectively."

A study by Wenzel et al,2 cited in a report for the CDC by LaScola,3 noted that ". . . pneumonia is the most common cause of nosocomial infection in intensive-care units. . . . This pneumonia is associated with high death rates."

The pneumonia guideline adds: "The primary risk factor for the development of HA bacterial pneumonia is mechanical ventilation. . . . Patients receiving continuous mechanical ventilation had 6 to 21 times the risk of developing HA pneumonia compared with patients who were not receiving mechanical ventilation."1

The cost of pneumonia, particularly ventilator-associated pneumonia (VAP), is high. It’s high in morbidity and mortality and high in consumption of resources. The pneumonia guideline noted that ". . . HA pneumonia can prolong ICU stay by an average of 4.3-6.1 days and hospitalization by 4 to 9 days. An estimate of the direct cost of excess hospital stay due to VAP is $40,000 per patient."1

Pity the poor patient; he pays the greatest price. Under the circumstances, preventing VAP may be the best thing that could happen to him. However, preventing VAP benefits the healthcare facility, too. The bottom line? It saves cold, hard cash. At $40,000 per infection, preventing even a few cases of VAP could translate into astounding savings for an institution.

The role of oral- healthcare in VAP
Any condition that extracts such a great price in human suffering and from hospitals’ resources deserves serious attention. As with any nosocomial infection, eradication is unrealistic, but there are steps that can be taken to reduce risk factors associated with VAP.

Barbara Skiba, RN, BSN, Senior Products Development Manager, Sage Products, Cary, IL, explained how VAP can happen: "Bacteria colonize in the mouth and nose. Because the patient is on a ventilator, and the ventilator is doing the breathing, he has no control over his secretions; therefore the bacteria slowly migrate into the patient’s lungs, causing VAP." It’s no small wonder that the CDC recommends healthcare personnel establish an oral-healthcare program.1

Skiba continued, "Sage’s Toothette Q-Care Suction System can help to decrease risk factors for VAP. If we decrease the bacteria, we’ve decreased the risk factor. Our product does an excellent job of providing a way for the nurses to do good, comprehensive oral care for the intubated patients," said Skiba.

The concept of oral care to reduce bacteria in intubated patients’ mouths is simple and logical, but it hasn’t always gotten the attention it merited. "Sometimes it takes people a little longer to take simple things seriously. Handwashing is another example of that," observed Skiba.

With healthcare personnel always short on time, what does it take to convince them that

 an oral care program is worth their time? Skiba explained, "They’ve done all those other things" [e.g., raising the head of the bed, observing hand washing and gloving, taking the patient off the ventilator when possible, using orotracheal rather than nasotracheal tubes] recommended for reducing risk factors for VAP. It’s after they’ve instituted a comprehensive oral-care program that "they really see the reduction [in VAP] take off. Look at the case study of Colorado Springs Memorial.4 They did all kinds of things, and then the oral-care protocol really reduced their VAP rates."

"We made oral care very easy to do," said Skiba. "We were the first company that added a suction port to our oral-care products. As for the latest, each kit includes everything needed for the patient for 24 hours. The hospital can choose whether they want to do an every 2-, 4-, or 8-hour protocol." The product is hung on the wall by the nightshift, and then any healthcare worker on any shift can see at a glance what needs to be done for the ventilated patient’s mouth care.

The routine is to brush the patient’s teeth morning and evening, with swabs in between every 2 hours or as needed. Included is a solution to put on the toothbrush or swab for cleansing the teeth. The suction device is built right into the toothbrush and swab, so there’s no need to wield multiple tools. The Yankauer is covered with a plastic sheath to help prevent cross-contamination.

List price for the Toothette system is $43.50 for the every 2-hour care program; $26.25 for every 4-hour care; and $12.25 for the every 8-hour care. Distributor margins, corporate account contracts, volume, and so forth determine real cost. Healthcare institutions might pay up to 25% less list price. If you think that the cost of the system and training personnel to use it sounds like a lot of money, compare it to $40,000 per nosocomial pneumonia.

Sage Q-Care Set-up

Case study
Lynchburg General Hospital, part of the Centra Health system, has used Sage oral-care products to reduce risk factors for VAP successfully. Mary Ann Tate, RN, MSN, CCRN, Critical Care Clinical Nurse Specialist, related their story: "In 2001, we started in the collaborative with the Institute for Health Care Improvement’s Idealized ICU and VHA Inc.’s Transformation of the ICU programs. We implemented some changes at that time, including the ventilator bundle. We saw that keeping the head of the patient’s bed raised >30º [to prevent gastric juices from being aspirated into the lungs] at all times resulted in some improvement in our VAP rate, but we still had VAP."

"We were already using Sage oral-care products. In 2003, we were made aware of Sage’s new mouth-care product, the Toothette Oral Care Suction System. I took it to the products committee, and it was approved. We felt that, since we already gathered the numbers for VAP, we could really see if it made a difference. We had several cases of VAP in the first part of that year; so, we decided to implement the new protocol. We rewrote the oral-care policy and educated staff, using inservicing and posters, and started using it between April and May."

How did staff respond to the change in routine? "The one unit, the medical intensive care unit (MICU), who had been involved in this change all along was more receptive," noted Tate. "You’re always going to get some resistance. Some of the other five critical care units were not as ready to use it every 2 hours. Their rates didn’t decrease as drastically as the MICU did. The other units decreased their VAP rate by about 50%."

"From May to December, we only had two cases of VAP. Those two patients had been in the unit for a very long time and were immunocompromised. They were outliers, because they had underlying illnesses and conditions that would cause them to be more susceptible to infection. They also had a lot longer length of stay, and of course longer stay would expose them to possibility of infection."

"We felt like we had decreased our rate by at least three infections here (in the MICU). We had six VAP cases in the previous year, 2002. Our infectious disease specialist estimated that we had saved probably three infections in the same period time, which saved about $120,000 at $40,000 per nosocomial VAP. Our rates continue to be low. Since January, in the MICU, we’ve only had one case. That patient also was immunocompromised, had come to us from another unit, and was already intubated."

"The packages that we use have morning, midday, and evening components. Patients’ teeth are brushed morning and evening. The toothbrush has a suction capability. You just apply the suction after you brush, suctioning through the toothbrush. In the afternoon, we use Sage’s individually packaged swabs with a built-in suction catheter. The package has a mouth-care product in it to clean the teeth, and you put it on the toothbrush or the swab. We supplement the package with Sage individual products for every 2 hours’ cleaning. They now have a product that you can get for every 2 hours or every 4 hours. We have looked at that, but we have not bought it yet."

Conclusion
Skiba notes, "Oral care has become a huge topic, because people are seeing results when they have applied an oral-care protocol along with all of those other measures to reduce risk factors."

Tate advised having a clinical specialist to take the lead in instituting an oral-care program and analyzing the data so as to prove the effectiveness of the program.

Tate added, "When you attend conferences, you see advances in products, and you see published data for positive outcomes in other healthcare institutions that have used the new products; then you try to align yourself with best practice to bring that product to your own institution. That’s what I try to do."

"People are seeing that the results of an oral-care program are very beneficial in terms of decreasing VAP," asserted Skiba. "As for nurses, being a nurse myself, if you know the hospital’s VAP rate is going down, you’re really going to believe that what you’re doing is helping patients."

That’s the real bottom line. HPN

REFERENCES
1. Centers for Disease Control and Prevention. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR 2004;53(RR03):1-36.
2. Wenzel RP. Hospital-acquired pneumonia: overview of the current state of the art for prevention and control. Eur J Clin Microbiol Infect Dis 1989;8:56-60.
3. La Scola B, Boyadjiev I, Greub G, Khamis A, Martin C, Raoult D. Amoeba-resisting bacteria and ventilator-associated pneumonia. Emerg Infect Dis [serial online] 2003 Jul [date cited]. Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no7/03-0065.htm.
4. Sage Products, Inc. Case studies: Memorial Hospital saves more than $j1.25 million through oral hygiene program. http://www.sageproducts.com/company/media2.asp?ArticleID=27.