SPECIAL SESSION: Improving Oral Health in Critically Ill Adults

Description/Overview: This symposium describes an exemplar of a successful research trajectory focused on improving outcomes for critically ill, mechanically ventilated adults through establishing best practices in oral care. Dr. Munro, who is a 2016 International Nurse Researcher Hall of Fame inductee, will review the series of research studies she has conducted which have informed evidence-based guidelines for oral care in the critically ill. Oral health is directly linked to systemic illness, including risk of ventilator-associated pneumonia (VAP). Descriptive and observational studies of critically ill adults established the importance of dental plaque in development of VAP and examined existing nursing practices in oral care. Subsequent NIH-sponsored intervention studies to test oral care protocols in critically ill adults have built upon that foundation. The first randomized clinical trial tested the effects of tooth brushing and chlorhexidine in reducing risk of VAP in critically ill adults, and showed that VAP was reduced by topical application of chlorhexidine initiated after intubation, although tooth brushing did not reduce VAP. The study had a rapid and dramatic effect on clinical practice, and was cited by the Institute for Healthcare Improvement (IHI) as evidence for the inclusion of daily oral care with chlorhexidine in the May 2010 update of recommendations for the care of mechanically ventilated patients (the ventilator bundle). Chlorhexidine is now standard of care for mechanically ventilated adults. Because the effects of chlorhexidine after intubation were so beneficial, a second NIH-funded randomized clinical trial investigated the impact of chlorhexidine applied before intubation compared to post-intubation. Applying chlorhexidine before intubation did not provide additional VAP risk reduction compared to starting chlorhexidine application after intubation. The current NIH-funded randomized clinical trial seeks to determine the optimal frequency of tooth brushing for critically ill, mechanically ventilated patients to maximize oral health benefits (such as reduced oral inflammation and dental plaque removal) while minimizing systemic risks (including ventilator-associated events, bacteremia, and sepsis). The importance of collaboration and mentoring in building nursing science will be discussed. Future directions for research will also be explored.