D219 Oral Care of a Hospitalized Patient and the Risk of Pneumonia

Impact of the Problem on the Patient

Hospital-acquired pneumonia (HAP) is a common yet largely preventable complication affecting individuals admitted to acute care facilities. Hospitalization often disrupts patients’ usual daily routines, including independent hygiene practices, regular physical activity, and balanced nutritional intake. These disruptions, combined with physiological stress from illness, surgery, or advanced age, can weaken immune defenses and significantly increase susceptibility to respiratory infections such as pneumonia.

When HAP develops, patients frequently require escalated levels of care, including broad-spectrum intravenous antibiotics, supplemental oxygen, diagnostic imaging, and prolonged clinical monitoring. These interventions often lead to extended lengths of stay and increased risk for secondary complications such as sepsis, functional decline, and delayed wound healing. Many affected patients are unable to return directly home after discharge and instead require placement in rehabilitation or long-term care facilities, resulting in reduced independence and diminished quality of life.

The impact of HAP extends beyond physical health and includes notable psychological consequences. Patients may experience heightened anxiety, depressive symptoms, frustration, and reduced engagement in recovery activities. These emotional responses are particularly pronounced among older adults and postoperative patients, where fear of complications can hinder participation in mobility and self-care. Evidence-based preventive strategies, such as structured oral hygiene practices and early ambulation, play a vital role in reducing infection risk while supporting both physical recovery and emotional well-being.

Impact of the Problem on the Organization

Hospital-acquired pneumonia also poses substantial challenges for healthcare organizations. Regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS) identify HAP as a largely preventable hospital-acquired condition, and costs associated with its treatment are often non-reimbursable. As a result, hospitals incur significant financial losses related to prolonged hospitalizations, increased medication use, diagnostic testing, and reduced patient throughput.

Operationally, HAP increases demands on nursing staff, respiratory therapists, and interdisciplinary teams. Managing pneumonia requires intensive monitoring, frequent medication administration, and additional documentation, which can strain staffing resources and contribute to workload fatigue. These pressures may detract from other essential patient care activities and negatively influence staff efficiency and morale.

From a quality and performance standpoint, elevated HAP rates adversely affect hospital quality metrics, accreditation outcomes, and public reporting scores. Poor performance in these areas can undermine organizational reputation and patient trust. Consequently, healthcare institutions have a strong incentive to adopt evidence-based interventions, such as standardized oral care protocols, that enhance patient safety, optimize resource utilization, and align with national quality and safety benchmarks.

Identification of the PICO Components

Evidence-Based Practice Question

For hospitalized patients, does the implementation of a scheduled oral care protocol reduce the incidence of hospital-acquired pneumonia when compared with the absence of a standardized oral care regimen?

This evidence-based practice (EBP) question examines whether consistent oral hygiene interventions can effectively lower rates of non-ventilator hospital-acquired pneumonia (NV-HAP) among inpatient populations. The intent is to evaluate oral care not merely as a comfort measure, but as a critical infection prevention strategy capable of improving patient outcomes and reducing healthcare-associated complications.

Research Article

Title

Impact of an Oral Care Intervention among Medical-Surgical Patients

Background and Introduction

The selected research study evaluates the effect of implementing a structured oral care protocol on the incidence of non-ventilator hospital-acquired pneumonia in a community hospital setting. The authors emphasize that non-intubated patients, particularly those with limited mobility or compromised immune function, are often overlooked in pneumonia prevention efforts. Standardizing oral hygiene practices is presented as a foundational and cost-effective intervention to reduce infection risk.

Methodology

A quantitative, quasi-experimental design was used to compare NV-HAP rates before and after implementation of the oral care intervention. Data collection adhered to Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) surveillance criteria. An interdisciplinary oral care task force conducted a gap analysis of existing practices and introduced standardized oral care supplies, staff education sessions, and enhanced documentation workflows to support consistent practice.

Level of Evidence

The study was conducted over a two-year period in a 208-bed community hospital and is classified as Level III evidence under the Johns Hopkins Evidence-Based Practice (JHEBP) Model. Although not randomized, the real-world clinical setting and oversight by a nurse scientist strengthen the credibility and applicability of the findings.

Data Analysis

Over a 28-month evaluation period, the intervention was associated with a 58% reduction in NV-HAP cases. Pneumonia diagnoses were confirmed through clinical evaluation and radiographic imaging. The NV-HAP rate was calculated using the standardized formula:

NV-HAP Rate = (Number of NV-HAP cases ÷ Total patient days) × 1,000

These findings demonstrate a clinically meaningful reduction in infection rates following consistent oral care implementation (Stepinski et al., 2022).

Ethical Considerations

Institutional Review Board (IRB) approval was obtained and renewed annually throughout the study period. Because the oral care protocol aligned with standard nursing care practices, informed consent was not required. The intervention posed minimal ethical risk and did not expose patients to harm beyond routine care expectations.

Quality Rating

Using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) appraisal tool, the study was rated as high quality. Results were clearly reported, outcomes were consistent across measurement periods, and the intervention was directly relevant to bedside nursing practice.

Analysis of Results and Alignment With the EBP Question

The study’s outcomes directly address the EBP question by demonstrating that a structured oral care regimen performed four times daily significantly reduces NV-HAP incidence. These findings reinforce the concept that oral hygiene is an essential component of infection prevention rather than an optional comfort intervention.

Non-Research Article

Title

Oral Health Status and the Etiology and Prevention of Non-Ventilator Hospital-Associated Pneumonia

Background and Introduction

This scholarly review explores the association between oral health and the development of non-ventilator hospital-acquired pneumonia. The authors describe how pathogenic bacteria colonizing the oral cavity can be aspirated into the lower respiratory tract, leading to infection. The article emphasizes oral hygiene as a critical preventive measure that disrupts bacterial growth and reduces pneumonia risk.

Type and Level of Evidence

The article is a comprehensive literature review synthesizing findings from multiple peer-reviewed studies, clinical trials, and institutional reports. According to the Johns Hopkins EBP Model, this represents Level V evidence, as it summarizes existing research to inform clinical practice recommendations.

Quality Rating

The review received a high-quality appraisal rating due to the consistency of findings across studies. The authors report that implementation of structured oral hygiene programs can reduce NV-HAP rates by approximately 37%, yielding substantial cost savings, fewer hospital days, and reduced mortality (Scannapieco et al., 2022).

Author Recommendations

The authors recommend several evidence-based preventive strategies, including:

• Maintaining appropriate head-of-bed elevation
• Ensuring pneumococcal and influenza vaccination
• Providing regular denture cleaning and storage
• Implementing standardized oral care protocols

They also advocate for future randomized controlled trials to further validate oral care interventions across diverse healthcare environments.

Recommended Practice Change

Both Stepinski et al. (2022) and Scannapieco et al. (2022) support the implementation of a standardized oral care protocol performed four times daily, ideally after meals and before bedtime. Evidence indicates that such interventions can reduce NV-HAP incidence by 37%–58%, resulting in improved patient outcomes and meaningful cost savings. Integrating oral care into routine nursing workflows strengthens infection prevention efforts and promotes safer discharge outcomes.

Key Stakeholders Involved in Implementation

Barriers to Implementation

Several challenges may limit successful adoption of standardized oral care protocols. These include high patient-to-nurse ratios, competing clinical priorities, limited awareness of the link between oral hygiene and pneumonia prevention, and resistance to changes in documentation or workflow processes.

Strategies to Overcome Barriers

To address these challenges, organizations can implement electronic medical record reminders, provide regular education and competency validation, and use audit-and-feedback mechanisms to reinforce adherence. Recognition programs and leadership support can further promote sustained compliance.

Indicators to Measure Outcomes

The primary outcome indicator is a reduction in NV-HAP cases per 1,000 patient days. Secondary indicators include decreased length of stay, reduced readmission rates, and lower antibiotic utilization. Continuous monitoring and data-driven feedback are essential to sustaining long-term improvements.

References

Scannapieco, F. A., Giuliano, K. K., & Baker, D. (2022). Oral health status and the etiology and prevention of non-ventilator hospital-associated pneumonia. Periodontology 2000, 89(1), 51–58. https://doi.org/10.1111/prd.12423

D219 Oral Care of a Hospitalized Patient and the Risk of Pneumonia

Stepinski, J., Rowe, S., & Robertson, R. (2022). Impact of an oral care intervention among medical-surgical patients. MEDSURG Nursing, 31(2), 91–