NR 439 Week 7 Oral Care Pneumonia Practice Change Example

Twice-Daily Toothbrushing to Prevent Pneumonia in Patients Who Are Not Ventilated: A Practice Change Proposal

Student Name

College of Nursing, Chamberlain University

NR 439: RN Evidence-Based Practice

Instructor Name

Month Day, Year

Twice-Daily Toothbrushing to Prevent Pneumonia in Patients Who Are Not Ventilated: A Practice Change Proposal

The Recommended Change

This proposal recommends that every adult inpatient on a composite 34-bed medical unit who is not on a ventilator receive toothbrushing with a soft brush and toothpaste twice a day, plus denture care where it applies, delivered or supervised by nursing staff and documented as a scheduled task in the electronic health record rather than as an optional hygiene item. Patients who can brush independently would be set up with supplies at the bedside and prompted; patients who cannot would have their teeth brushed by a nursing assistant or nurse.

The problem the change targets is nonventilator hospital-acquired pneumonia, an infection that receives far less attention than ventilator-associated pneumonia even though national data suggest it is now at least as common (Giuliano et al., 2018). On this unit, oral care is charted for fewer than half of dependent patients on a typical day, toothbrushes are not stocked in patient rooms, and pneumonia that develops after admission is usually treated without anyone asking whether it could have been prevented.

The Evidence, Condensed

The case for the change rests on a mechanism that is well established and on intervention studies that are encouraging but not definitive. The mechanism is aspiration of oral bacteria: plaque on unbrushed teeth becomes colonized with respiratory pathogens within days of admission, and older or sicker patients aspirate small amounts of oral secretions routinely. National surveillance by Baker and Quinn (2018) found nonventilator pneumonia across hospitals of every size, with the highest burden on medical and surgical units rather than in intensive care, which places the problem squarely on units like this one.

The intervention evidence comes mainly from quality improvement studies. Quinn et al. (2014) introduced a standardized oral care protocol with new supplies and staff education across a large medical center and reported a 38.9% reduction in nonventilator pneumonia over the following year. The study had no concurrent control group, so other changes during the same year could account for part of the drop, and the certainty is correspondingly moderate at best. What matters for this proposal is that the direction is consistent with the mechanism, the intervention carries almost no risk, and the cost is limited to supplies and staff time. The evidence supports adopting the change with local measurement rather than treating the outcome as guaranteed.

The case for acting now rather than waiting for a randomized trial rests on the balance of benefit and harm. Brushing teeth does not injure patients, requires no order, and uses supplies that cost less than a single dose of most intravenous antibiotics. If the protocol prevented even one pneumonia on this unit in a year, it would have repaid its cost many times over.

Who Does Something Differently

Nursing assistants would carry most of the change, since they already deliver hygiene care; they would brush teeth for dependent patients at 0800 and 2000 and set up independent patients with supplies. Registered nurses would assess each patient on admission for the ability to perform oral care, assign the right level of help, and check that care was documented at the end of each shift. Speech-language pathology would be consulted for patients with dysphagia who need suction toothbrushes. Supply chain staff would stock each room with a soft toothbrush, fluoride toothpaste and denture supplies at admission. The unit educator would teach the protocol at two short huddles on each shift, and infection prevention would report the unit's nonventilator pneumonia rate monthly.

Barriers and Facilitators on This Unit

Three barriers are specific to this unit. The first is time at 0800, when nursing assistants are also collecting vital signs and setting up breakfast trays; brushing at 0800 competes directly with that work, so the protocol would allow brushing any time before 1000 rather than at a fixed minute. The second is supply: toothbrushes are currently kept in a central supply room and are issued only on request, so the change fails on the first day unless supplies reach the room on admission. The third is belief; many staff regard oral care as comfort care rather than infection prevention, and it is the first task dropped on a short-staffed shift.

Two facilitators work in the change's favor. The unit already has a scheduled task list in the electronic health record for turning and vital signs, so adding oral care there makes it visible without a new system. The unit also has a nursing assistant who has asked to serve as a champion and who is respected by colleagues on both shifts. Rogers (2003) notes that innovations spread faster when they are simple, visible and compatible with existing work, and this change fits all three once supplies and scheduling are solved.

The Nurse's Role in This Change

A bedside nurse can start this change without new authority. Oral care is within nursing practice and needs no provider order, so a staff nurse can raise the problem at a unit practice council meeting, bring the evidence, propose the protocol and volunteer to run the pilot. The standards published by the American Nurses Association (2021) name the use of evidence to guide practice and the responsibility to question practices that no longer serve patients as standards of professional performance for every registered nurse, not only for leaders. In this proposal the nurse's role is threefold: to assess each patient's ability to perform oral care and assign help, to hold the unit accountable for documentation at shift handoff, and to teach patients and families why brushing matters in the hospital, since patients who understand the reason are more likely to ask for it.

How Anyone Would Know It Worked

Two measures would be watched for six months against the previous twelve. The process measure is the percentage of patients with oral care documented twice in each 24 hours, checked by a weekly audit of ten charts, with a target of 80%. The outcome measure is nonventilator hospital-acquired pneumonia per 1,000 patient days, reported monthly by infection prevention using the same case definition before and after the change. Because pneumonia on a single unit is uncommon, the outcome will move slowly, and the proposal should be judged first on whether oral care is actually delivered; a falling rate without improved documentation would suggest something other than the protocol was responsible.

A balancing measure belongs in the plan as well. If nursing assistants spend an extra ten to fifteen minutes each morning on oral care, something else may slip, and the item most likely to slip is the timing of morning vital signs. The unit would therefore track the percentage of 0800 vital signs documented by 0900 during the same six months. If that figure falls, the protocol would be adjusted, for example by moving brushing for independent patients to the evening bath, rather than abandoned. Reporting the balancing measure alongside the outcome also answers the question staff are most likely to ask at the first huddle, which is what they are expected to stop doing to make room for this.

References

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.).

Baker, D., & Quinn, B. (2018). Hospital acquired pneumonia prevention initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. American Journal of Infection Control, 46(1), 2-7. https://doi.org/10.1016/j.ajic.2017.08.036

Giuliano, K. K., Baker, D., & Quinn, B. (2018). The epidemiology of nonventilator hospital-acquired pneumonia in the United States. American Journal of Infection Control, 46(3), 322-327. https://doi.org/10.1016/j.ajic.2017.09.005

Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic nursing care to prevent nonventilator hospital-acquired pneumonia. Journal of Nursing Scholarship, 46(1), 11-19. https://doi.org/10.1111/jnu.12050

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.