Four years ago, when Karen Giuliano went to Boston Hospital for hip replacement surgery, she was given a pale pink bucket of toiletries issued to patients at several hospitals. Inside were wipes, soap, deodorant, toothpaste and, without a doubt, the worst toothbrush ever.
“I couldn’t believe it. I got a toothbrush without bristles,” she said. “She must not have gone through the bristle machine. It was just a stick.”
For most patients, a useless hospital toothbrush will be a minor inconvenience. But Giuliano, a professor of nursing at the University of Massachusetts Amherst, was a reminder of the prevalence of the “blind spot” in US hospitals: the staggering consequences of not brushing teeth.
Hospital patients who do not brush their teeth, or do not brush themselves, are believed to be the main cause of millions of thousands of cases of pneumonia annually in patients who are not placed on a ventilator. Giuliano and other experts said pneumonia is among the most common infections that occur in health care facilities, and most cases are hospital-acquired pneumonia without a ventilator, or NVHAP, which kills up to 30% of those infected.
But unlike many hospital infections, the federal government does not require hospitals to report cases of NVHAP. As a result, experts said, few hospitals understand the origin of the disease, trace its occurrence or are actively working to prevent it.
Many cases of NVHAP could be avoided if hospital staff faithfully cleaned the teeth of bedridden patients, according to a growing body of peer-reviewed research papers. Instead, many hospitals often skip brushing to prioritize other tasks and only provide cheap, ineffective toothbrushes, often unaware of the consequences, said Sacramento State Nursing Professor Diane Baker, who has spent more than a decade studying NVHAP.
“I will tell you today that the vast majority of the tens of thousands of nurses in hospitals have no idea that pneumonia comes from germs in the mouth,” Becker said.
Pneumonia occurs when germs cause an infection in the lungs. Although NVHAP accounts for most of these 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 narrow subset of patients.
A hazard to nearly all hospital patients, NVHAP is often caused by bacteria from the mouth that collect in the thin biofilm on unbrushed teeth and are inhaled into the lungs. Patients are at greater risk if they lie flat or remain immobile for extended periods, so NVHAP can also be prevented by raising their head and getting them out of bed more often.
According to the National Organization for the Prevention of NV-HAP, founded in 2020, this pneumonia affects about 1 in 100 hospitalized patients and kills 15% to 30% of them. For those who survive, the disease often prolongs their hospital stay by up to 15 days and increases the likelihood that they will be readmitted within a month or transferred to the intensive care unit.
John McCleary, 83, of Bangor, Maine, contracted a probable case of NVHAP in 2008 after he fractured his ankle in a fall and spent 12 days in hospital rehab, said his daughter, Cathy Day, a retired nurse and attorney with Network Patient safety work.
McCleary recovered from the fracture but not from pneumonia. Two days after he returned home, an infection in his lungs caused him to quickly be hospitalized, where he developed sepsis and spent weeks in treatment before moving to the isolation unit in a nursing home.
His daughter said he died weeks later, largely emaciated and deaf, unable to eat, and often “too weak to get water through a straw.” After contracting pneumonia, he never walked again.
“It was an amazing attack on his body, from him being here to visit me the week before he fell, to his death just a few months later,” Day said. “It was all avoidable.”
While experts describe NVHAP as a largely ignored threat, this 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, the Veterans Health Administration, and the Joint Commission — published a research paper urging action in hopes of launching a “national healthcare conversation on prevention.” from NVHAP.”
Silvia Garcia Huchins, director of Infection Prevention and Control, said the Joint Commission, a nonprofit whose accreditation can make or break hospitals, is considering expanding infection control standards to include more diseases, including NVHAP.
Separately, ECRI, a nonprofit organization focused on healthcare safety, this year identified NVHAP as one of the top patient safety concerns.
James Davis, an ECRI infection expert, said the prevalence of NVHAP, while already alarming, is likely to be “underestimated” and possibly exacerbated as hospitals swell with patients during the coronavirus pandemic.
“We only know what has been reported,” Davis said. “Could this be the tip of the iceberg? I would say, in my opinion, probably.”
To better measure the condition, some researchers are calling for a standardized surveillance definition for NVHAP, which could open the door in time 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 she’s spoken with hundreds of hospitals about how to prevent NVHAP, but thousands more haven’t yet embraced the cause.
“We’re not asking for $300,000 in big gear,” Becker said. “The two things that show the best evidence of preventing this damage are the things that should happen in standard care anyway – brushing teeth and moving patients.”
This evidence comes from a handful of studies that show that these two strategies can lead to a drastic reduction in infection rates.
In California, a study in 21 Kaiser Permanente hospitals used reprioritizing oral care and getting patients out of bed to reduce rates of hospital-acquired pneumonia by about 70%. At Sutter Medical Center in Sacramento, Better Oral Care reduced NVHAP cases at an annual rate 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, when compared to comparable units that received normal care. A similar study is underway in two hospitals in Illinois.
The most compelling results came from a veterans hospital in Salem, Virginia, where a 2016 pilot oral care program cut NVHAP rates by 92% — saving an estimated 13 lives in just 19 months. The program, the HAPPEN Initiative, has been expanded across the Department of Veterans Health, and experts say it could be a model for all American hospitals.
Michele Lucatorto, the chief nursing officer who leads HAPPEN, said the program is training nurses to clean patients’ teeth more effectively and educating patients and families about the link between oral care and NVHAP prevention. While brushing may not seem like training, Lucatorto has drawn comparisons with how the coronavirus has revealed many Americans do a poor job of another routine hygiene practice: washing their hands.
“Sometimes we look for the most complex intervention,” she said. “We are always looking for that new bypass surgery, or some new technical equipment. And sometimes I think we fail to look at the simple things that we can do in our practice to save lives.”
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