Improving ICU Outcomes through Oral Care Interventions

1. Improving ICU Outcomes through Oral Care Interventions Cindy L. Munro RN, ANP-BC, PhD, FAAN, FAANP, FAAAS NYU Langone Medical Center 21stAnnual Nursing Research Conference Keynote Address June 14, 2017

3. Why Does ORAL HEALth matter?

4. Systemic Health Oral Health

5. Systemic Health Oral Health • Respiratory • pneumonia • Cardiovascular • atherosclerosis • endocarditis • Bacteremia • Endocrine • diabetes mellitus control • Reproductive • preterm birth • Quality of life • Xerostomia (dry mouth) • increased cavity risk • Gingival disease • hyperplasia • gingivitis • Periodontal disease

6. Why is oral health important in acute care? • Growth of potential pathogens in dental plaque • by 48 hours in ICU (Johanson, 1988; Abele-Horn, 1997; Munro, 2006) • Ventilator associated pneumonia (VAP) • Introduction of organisms with intubation • Circumventing immune protection mechanisms • Translocation of organisms from oropharynx to lung (Schwartz, 1978; Scannapieco, 1992; Torres, 1993; Garrouste-Orgeas, 1997; Fourrier, 1998; Cardenosa-Cendrero, 1999; Munro, 2002) • Inflammation/Infection • Comfort

7. Dental plaque accumulationwith usual nursing care • Dental plaque covered greater than 50% of tooth surfaces from day 1 to day 7. Jones DJ, Munro CL, Grap MJ. Intensive and Critical Care Nursing.2011.

10. Oral health over time: POE study Munro, Grap, et al, AJCC, 2006, 15(5), 453-60 Plaque score (P<.001) and CPIS (P < .01) increased over time, while salivary flow and salivary volume decreased (P<.01) Lower salivary volume was associated with higher day 4 CPIS (P=.02).

11. Ventilator Associated Pneumoniain the 1990’s • Leading cause of nosocomial infection death • Associated with increased • length of mechanical ventilation • length of stay • mortality • COST

13. VAP as a quality indicator • Centers for Disease Control and Prevention, Joint Commission, National Institute of Medicine all view VAP rate as measure of quality • Centers for Medicare and Medicaid Services considered including VAP as preventable condition • Withdrawn in face of substantial opposition

14. Clinical Pulmonary Infection ScorePugin, 1991 0 6 12

15. .5 .5 .5 1.0 1.0 1.0 1.5 1.5 1.5 2.0 2.0 2.0 2.5 2.5 2.5 3.0 3.0 3.0 3.5 3.5 3.5 4.0 4.0 4.0 4.5 4.5 4.5 CPIS1 CPIS1 CPIS1 Interaction of Plaque, APACHE II, and Day 1 CPIS in Predicting Day 4 CPIS Lowest Plaque Tercile (Cleanest teeth) Middle Plaque Tercile Highest Plaque Tercile (Most plaque) Munro et al., AJCC, 2006

16. Goals and strategies

17. Goals of oral care interventions • Prevent the accumulation of dental plaque, and associated bacteria • Stimulate local oral immunity • Gingival health • Comfort

18. Two strategies for oral care Pharmacologic • Killing of organisms by application of antimicrobial agent Mechanical • Physical removal of dental plaque and associated organisms

19. Two strategies for oral care Pharmacologic • Killing of organisms by application of antimicrobial agent • Risks • Aspiration? • Systemic effects? • Antibiotic resistance? • Overgrowth? Mechanical • Physical removal of dental plaque and associated organisms • Risks • Aspiration? • Bacteremia?

20. Pharmacologic strategies

21. The Focus has been on VAP… Reduced VAP Reduction in Oral Organisms Pharmacologic Interventions

22. Early Studies: Topical Antibiotics • PolymyxinB sulfate, neomycin sulfate, and vancomycin hydrochloride (PNV) (Pugin, 1991) • reduction in VAP and colonization • Tobramycin (Abele-Horn, 1997) • reduction in VAP by gram negative pathogens • overgrowth of S. aureus in oropharynx

23. CHX and VAP CHX oral rinse; tested in cardiac surgery pts DeRiso, 1996; Houston, 2002 • CHX oral gel; reduced dental plaque, but no effect on nosocomial infections • Fourrier, 2005

24. CDC 2003 recommendations • Prevention or modulation of oropharyngeal colonization • Chlorhexidine • No recommendation can be made for routine use of an oral chlorhexidine rinse for prevention of health care associated pneumonia in all postoperative or critically ill patients and/or other patients at high risk for pneumonia (Unresolved issue) • Use an oral chlorhexidine gluconate (0.012%) rinse during the perioperative period on adult patients who undergo cardiac surgery (level II)

25. 3 Early Meta-analyses of CHX in ICU • Pineda et al., Critical Care, 2006 • N=4 RCTs • “The results of this meta-analysis suggest that the incidence of nosocomial pneumonia and rate of mortality are not reduced by administration of the oral antiseptic agent chlorhexidine.” • Chlebicki & Safdar, Critical Care Medicine, 2007 • N= 7 RCTs • “…topical chlorhexidine is beneficial in preventing VAP; the benefit is most marked in cardiac surgery patients.” “There was no mortality benefit…” • Chan et al., British Medical Journal, 2007 • 11 RCTs of oral decontamination using antibiotics (n=4) or antiseptics (n=7) • Both antibiotics and antiseptics reduced VAP risk • No reduction in overall mortality, length of mechanical ventilation, ICU LOS • Unblinded trials yielded larger treatment effects • Trials of surgical or trauma patients yielded larger treatment effects than medical or mixed critically ill patients.

26. Oral Care Intervention in Mechanically Ventilated Adults. NIH R01 NR07652 ClinicalTrials.gov NCT00234598

27. The SToPP Study: Strategies ToPrevent Pneumonia Development of VAP Oral Care Interventions Dental Plaque Oral Immunity Oral Microbial Flora CPIS 12 6 0

28. RCT 2X2 Factorial Design • Chlorhexidine (CHX) 0.12% twice a day • Tooth brushing three times a day

29. SToPP Study VAP Results

30. SToPP Study VAP Results

32. Changes in Practice • IHI Ventilator Bundle • Elevation of the Head of the Bed • Daily “Sedation Vacations”; Assessment of Readiness to Extubate • Peptic Ulcer Disease Prophylaxis • Deep Venous Thrombosis Prophylaxis • Oral care with CHX (added 2010!) • SToPP study cited as evidence

33. Early, single CHX dose: RCT • 145 mechanically ventilated trauma subjects randomly assigned to 2 groups within 24 hrs of intubation • 1) intervention -- 5 mL Chlorhexidine (CHX) • 2) control group -- usual care • Changes in CPIS from admission to 48 hrs and to 72 hrs Funded by the TSNRP MDA-905-03-1-TS02; MJ Grap COL/AN/Ret, PI Grap MJ, Munro CL, Hamilton VA, Elswick RK Jr, Sessler CN, Ward KR.. Heart and Lung. 2011

34. Chlorhexidine Intervention Oropharyngeal organisms present before intubation Decreased contamination of ET tube during intubation Decreased Risk of VAP Next step…SToPP2! • Application of chlorhexidine BEFORE intubation (in patients other than cardiac surgery) Munro CL, Grap MJ, Elswick RK, Sessler C. Oral Care Intervention in Mechanically Ventilated Adults. Funded by NIH R01 NR07652, ClinicalTrials.gov NCT00893763.

35. SToPP2 Results • PreintubationCHX did not provide additional benefit to daily CHX Munro et al., Chest. 2015

36. SToPP2 Results • ETT colonization rates were equivalent between groups Munro et al., Chest. 2015

37. Ventilator Associated Pneumoniain the 2010’s • Drastically reduced incidence • New CDC surveillance definitions • VAE (ventilator-associated events) • VAC (ventilator-associated condition) • IVAC (infection-related ventilator-associated complication) • VAP (ventilator-associated pneumonia) • No use of chest radiographs in surveillance • Implications for CPIS • VAC identified only after 3 days of stability or improvement • VAP for internal reporting purposes

38. Tooth brushing

40. Toothbrushing and VAP 2009-2011

41. But… • Back to toothbrushing! • Determining the best brushing interval • Balancing risk and benefit

42. If tooth brushing does not reduce VAP, is there any reason to do it??

43. If tooth brushing does not reduce VAP, is there any reason to do it?? YES!

44. If tooth brushing does not reduce VAP, is there any reason to do it?? YES! Dental plaque Gingival health Inflammation Patient comfort

46. SToPP Study Dental Plaque Results • CHX: no effect on amount of dental plaque (p=0.9397) • Tooth brushing: significant reduction in dental plaque (p=0.0411) • No interaction effect between tooth brushing and CHX.

47. Assuming one tooth brushing for each patient for each day of ICU care in the US,

48. Assuming one tooth brushing for each patient for each day of ICU care in the US, tooth brushing is performed at least 18 million times annually in the ICU.

49. Assuming one tooth brushing for each patient for each day of ICU care in the US, tooth brushing is performed at least 18 million times annually in the ICU. BUT we have NO evidence to guide frequency of tooth brushing in the ICU!

50. Frequency of Oral Care Intervention Study: FOCIS • Back to tooth brushing! • Determining the best brushing interval • Balancing risk and benefit • RCT, registered as NCT02289131 • Funded by R01 NR07652 (2nd competing renewal)