Effectiveness of a Mouth Care Program Provided by Nursing Home Staff vs Standard Care on Reducing Pneumonia Incidence

Abstract

IMPORTANCE Pneumonia affects more than 250 000 nursing home (NH) residents annually. A strategy to reduce pneumonia is to provide daily mouth care, especially to residents with dementia. OBJECTIVE To evaluate the effectiveness of Mouth Care Without a Battle, a program that increases staff knowledge and attitudes regarding oral hygiene, changes mouth care, and improves oral hygiene, in reducing the incidence of pneumonia among NH residents. DESIGN, SETTING, AND PARTICIPANTS This pragmatic cluster randomized trial observing 2152 NH residents for up to 2 years was conducted from September 2014 to May 2017. Data collectors were masked to study group. The study included 14 NHs from regions of North Carolina that evidenced proportionately high rehospitalization rates for pneumonia and long-term care residents. Nursing homes were pair matched and randomly assigned to intervention or control groups. INTERVENTION Mouth Care Without a Battle is a standardized program that teaches that mouth care is health care, provides instruction on individualized techniques and products for mouth care, and trains caregivers to provide care to residents who are resistant and in special situations. The control condition was standard mouth care. MAIN OUTCOMES AND MEASURES Pneumonia incidence (primary) and hospitalization and mortality (secondary), obtained from medical records. RESULTS Overall, the study enrolled 2152 residents (mean [SD] age, 79.4 [12.4] years; 1281 [66.2%] women; 1180 [62.2%] white residents). Participants included 1219 residents (56.6%) in 7 intervention NHs and 933 residents (43.4%) in 7 control NHs. During the 2-year study period, the incidence rate of pneumonia per 1000 resident-days was 0.67 and 0.72 in the intervention and control NHs, respectively. Neither the primary (unadjusted) nor secondary (covariate-adjusted) analyses found a significant reduction in pneumonia due to Mouth Care Without a Battle during 2 years (unadjusted incidence rate ratio, 0.90; upper bound of 1-sided 95% CI, 1.24; P = .27; adjusted incidence rate ratio, 0.92; upper bound of 1-sided 95% CI, 1.27; P = .30). In the second year, the rate of pneumonia was nonsignificantly higher in intervention NHs. Adjusted post hoc analyses limited to the first year found a significant reduction in pneumonia incidence in intervention NHs (IRR, 0.69; upper bound of 1-sided 95% CI, 0.94; P = .03). CONCLUSIONS AND RELEVANCE This matched-pairs cluster randomized trial of a mouth care program compared with standard care was not effective in reducing pneumonia incidence at 2 years, although reduction was found during the first year. The lack of significant results in the second year (continued) Key Points Question Can nursing home staff reduce pneumonia by providing mouth care to residents? Findings In this pragmatic cluster randomized trial including 2152 residents from 14 paired nursing homes during 2 years, there was no statistically significant difference in the primary outcome of pneumonia incidence during 2 years. Adjusted post hoc analyses indicated a stat...

Impact of an Oral Hygiene Intervention in People with and without Dementia on Oral Health Parameters—Results from the Oral Health, Bite Force, and Dementia (OrBiD) Pilot Study

“…Studies point out the limited evidence for the effectiveness of the oral health education of caregivers to improve oral health in people with dementia [ 22 , 23 ]. For example, the implementation of a standardized oral care program (teaching, instruction on the use of individualized oral care concepts, and the training of caregivers to perform oral hygiene in patients with refusal behavior) did not lead to a long-term reduction in the incidence of pneumonia [ 40 ]. Otherwise, a situational learning perspective [ 36 ], the usage of a comprehensive, practically oriented program [ 41 ], or the use of oral and written instructions concerning oral and denture hygiene [ 42 ] can support both caregivers and residents in achieving adequate oral and denture hygiene.…”

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

“…[294][295][296][297] Two large, cluster randomized trials conducted in nursing homes did not show a benefit, but their generalizability to acute-care hospitals is unknown. 298,299 Most randomized trials in acute-care hospitals have focused on ICU patients, most of whom were on mechanical ventilation, making it difficult to discern their effect on NV-HAP. 300,301 a.…”

Pragmatic Trials and Improving Long-Term Care: Recommendations From a National Institutes of Health Conference

“…18,47,48 For example, the Pragmatic Trial of Video Education in Nursing Homes (PROVEN) evidenced low fidelity because the videos were not integrated into work flow, and Mouth Care Without a Battle was successful over 1 year but not over 2 years because sustainability was challenging. 27,42 In sharing information related to implementation, future success is more likely. 61 Next Steps for Pragmatic Trials in Long-Term Care and Achieving Widespread Change…”