Mobility Minute: Dian Baker on mobility and oral care’s role in pneumonia prevention
Today we speak with Dian Baker (Ph.D., RN, APRN-BC).
Dian has been a thought leader in pneumonia prevention in the hospital, and her work has highlighted hospital-acquired pneumonia, the #1 hospital-acquired infection, as an underrepresented problem in hospitals across the country. During our conversation, we talk about the importance of mobility when it comes to preventing pneumonia in the hospital and some of the simple steps that bedside caregivers can take in order to improve outcomes.
“Given all the new information, we understand the critical importance of mobility in the hospital. Up as often as possible, up as early as possible, and maintaining activity is one of the most essential things nurses can do.”
-Dian Baker Ph.D., RN, APRN-BC
Listen to the full podcast here.
Note: Podcast transcript below is a condensed version of the conversation generated using a combination of speech recognition software and human transcribers, and may contain errors. Please check the corresponding audio before quoting in print.
Hi Dian - Thanks for joining us today. I want to start by talking a little bit about preventative measures in general such as routine oral care and mobility and how these help prevent adverse events.
There are several parts to a nurse's daily job in the acute care setting that interface with the prevention of secondary complications. We consider these aspects of fundamental care to be essential nursing procedures and interventions. And perhaps amongst the most important of those is mobility.
Mobility is tied to improving outcomes in several different areas, including prevention of non-ventilated, hospital-acquired pneumonia, gastric mobility, prevention of deep vein thrombosis, overall health, less muscle disintegration, maintaining a patient's strength and well-being. The other important intervention that nurses do on a daily basis to help prevent non-ventilator hospital-acquired pneumonia is preventing the oral microbiome from building up germs by daily oral care.
So the connection between mobility and fundamental care and other types of fundamental care, such as oral care all work together to protect patients in hospitals from non-ventilator, hospital-acquired pneumonia.
So you say, protect patients, which I find really interesting. What are some of the physiological benefits of mobility that directly affect hospital-acquired pneumonia prevention?
There are several physiological processes that help us prevent pneumonia. So in our lungs, full expansion helps us prevent pneumonia. Having good ciliary action, the little hairs that kind of keep brushing up dirt and things forward, help us prevent pneumonia.
General mobility helps us prevent pneumonia because it allows for greater lung expansion. It moves the fluids around in the lung and encourages us to deep breathe and cough, which we all do several times a day. I would say it's all part of lung hygiene. Lung hygiene and the ability to perform those necessary functions are directly tied to your mobility.
Even just sitting up. Everyone knows when they get up in the morning, the first thing you do is just take a nice big breath of air, you expand your lungs, you kind of get them ready for the day. Very often you might cough a little bit and just wake them up and get them going and the more that you do that, the healthier your lungs are going to be less likely you are to get pneumonia.
I listened to a previous podcast that you have done where you reference the great divide in terms of oral care’s relationship with the rest of the body. Can you talk a little bit about that?
Yes, we actually study the mouth, and who takes care of the mouth belongs to a whole different profession and that's the dental profession. And so when patients come into the hospital were often not thinking about looking in their mouths, assessing their mouth, making sure that oral hygiene is maintained because it's been psychologically and professionally separated from us, which has created a great divide.
And therefore when patients are in the acute care setting, little to no priority is given to the absolute physiological health reasons to maintain the oral microbiome and to prevent germs from growing in the mouth. We tend to think of it as a nicety, not a necessity for the patient's well-being.
And that great divide continues today, although there have been several groups that are moving toward what we call oral-systemic health and trying to reunite this great divide and to get us more focused on thinking of oral care is actually a therapeutic intervention, much in the same way we would think of mobility as a therapeutic intervention.
Right. So do you see a similar divide when it comes to the importance of mobility and uh the execution of mobility in the hospital?
Yes, very much so. We think that mobility is something we can do when it's convenient and that what does it hurt if somebody's in bed for a few days and that's an incorrect assumption on the part of all of us.
Given all the new information, we understand the critical importance of mobility in the hospital. Up as often as possible, up as early as possible, and maintaining activity is one of the most essential things nurses can do.
Nurses just like the rest of us are constrained by time and even more so in many cases. How do you see oral care and mobility become either prioritized or deprioritized, and what leads to that?
Well, first and foremost, nurses need to be educated about the importance of oral care. Again, seeing it as a therapeutic intervention rather than something nice or simply a comfort care. The same thing with mobility, it's not the last thing you're going to do if you can get around to it, it should be the first thing that you should do.
The constraint of time requires sometimes reorganizing the team and how the team works together. It involves getting patients and families involved in their care, and it involves education for the patients and families. Quite often for the patient care technicians or nurses aides that are also caring for the patient and working with other team members that have a role in mobility such as a physical therapist. By working all together, realigning our priorities, we will find a way.
I have a great example of that from Kaiser Permanente in northern California where they put mobility as a priority on the unit. They rearranged their workflow, they got patients up out of bed first thing you know before a lot of other activities took place because it became prioritized. They knocked back their NV-HAP rates significantly, also reduced their antibiotic usage for patients, all of which are very positive outcomes. All directly related to priority with mobility.
Yes, that's a great example of how successful mobility initiatives can be in the hospital. So thank you for sharing that. And I find it interesting because we know that there are all these benefits for mobilizing patients, but there has to be a reason why patients aren't being mobilized in the first place. As a nursing educator yourself, do you see a fear of falls being instilled in young nurses? And how does that contribute to immobility?
Yes, I think I think there are several barriers that allow us to have mobility is less of a priority. Certainly one is time, right? And we talked about teamwork and the importance of that. The other is the emphasis on fall prevention. You cannot go into a hospital today and not see warning signs about falls, patients wearing yellow socks, and signs above the bed.
All those things would send a pretty direct message to any nurse in the field and especially new nurses into practice. (Nurses find themselves saying) “Oh, the most important thing I have to do here is to make sure my patient doesn't fall and it feels like getting them up and out of bed would increase that risk.”
But it doesn't. We know from numerous studies that mobility programs do not increase fall risk and in fact, there is fairly suggestive evidence that it does exactly the opposite.
Maintaining the patient's strength, getting them up, setting up good communication techniques so patients get assistance when they need to get out of bed are all things that not only prevent falls, but you get all the advantages of mobility with it.
Exactly and not just the fear falls, but also the unknown of whether a patient is ready to mobilize or not. You can ask them questions and try to feel out the situation and based on the physical therapy consult, you have a lot of factors there. When it comes down to it, you want the patient to be ready to mobilize. So how do you know that?
Good assessment technique, communicating clearly with the patient and the family, using a standardized mobility readiness framework, assessing the patient frequently every four hours, and then minimizing those things and activities that take away from mobility time.
So for example, a patient can be off to therapeutic things like going to X-ray or having tests and procedures, or they gotta wait for the lab person to come in. Reorganizing the day and putting mobility as a priority will also help with all of that. So you're kind of knocking down those barriers and you know, if you will excuses.
Right. Because if there is clarity around that mobility status and readiness to mobilize, then you can take a lot of the question marks out of it. I wanted to also talk a little bit about family member engagement. I know you mentioned that briefly, Can you talk a little bit more about the importance of family member engagement in all of this?
Most family members want something to do. They’ve come to the hospital to visit their loved one for exactly that reason. They're there to be comfort, support, and help. By engaging them in a partnership and asking them what they would like to do what they're comfortable doing and then taking the time to teach them.
I can remember one time working with a family, a patient had just come out of surgery. It was a very large surgery that had been over six hours and the wife was there and (the patient) was very drowsy. It was time for his oral care and he just didn't want to do it. He didn't want to sit up in bed - didn't want to move. He just felt so down and out, and I'm talking with his wife about how to talk through those feelings and emotions. And then her offer of I'm here to help you. I will help you brush your teeth.
As the nurse, I was able to show her the technique to use a suction toothbrush. And then we went through the passive range of motion for all of his limbs and talked about the importance of turning in position and building up his strength. All the while doing reflective listening and teaching with both the wife and the husband.
It wasn't long afterward, he was sitting up and brushing his own teeth. He had good passive range of motion when he wasn't able to get out of bed. So he was prepared for when he could get out of bed. And those types of engagements with the family are one of the beautiful joys of nursing.
When did your research on the effects of pneumonia in the hospital begin? It seems as though you've really prioritized spreading awareness about the importance of pneumonia prevention and doing a lot of research to help continue that conversation on a nationwide scale. Can you talk a little bit about that?
Several things happened about the same time in my career about 10 years ago, and I was invited to partner with two different hospital systems in northern California. And at that time the CDC had just put out very strong advisories that hospitals had to be held accountable for hospital-acquired infections. But in looking over the data, what the hospitals found was that their number one hospital-acquired infection wasn't on the list that was being required by the CDC. And that number one hospital-acquired infection was non-ventilator hospital-acquired pneumonia. It felt, at that time, like a huge ‘aha.’ There's this hidden infection, hospitals aren't aware of it, no one is doing anything about it specifically, and it's not being required to be monitored like the other ones. And yet it's the number one or number two hospital-acquired infection in every hospital we looked at.
Ultimately we did a national study with 21 hospitals across the country and found the same thing. It was like opening Pandora's box and our group decided that we were going to persist study and pursue this until we have the opportunity to bring to national attention this problem.
It's now the 11th year into this journey, and I'm proud to say that one of my colleagues Dr. Shannon Munro with the Veteran’s hospital system is leading a national effort called ‘No HAP’, which has partnerships from the CDC, AHRQ, The Joint Commission, American Hospital Association, American Dental Association, and multiple academic institutes. Groups have partnered together to get this on the national radar. So it's been a long but rewarding journey. And I think we're not too far away from every hospital having to talk about oral care and mobility as a priority in terms of nursing care to prevent pneumonia.
Well, we thank you for the work that you've put in and that you've been able to uncover some of these key issues in the hospital. If you could, for our listeners - detail the difference between non-ventilator-acquired pneumonia and ventilator-acquired pneumonia. And talk a little bit about how the two are differentiated in the hospital.
So great question. And a lot of people do ask about the distinction. In fact - when we first started talking about non-ventilator hospital-acquired pneumonia, people were confused. They just kept assuming that we were talking about ventilator because that was so much the priority for everyone. And it became a priority because the CDC issued that requirement that hospitals had to and must monitor and pay attention to hospital-acquired infections. But as I mentioned before, NV-HAP was not on that list.
First of all - hospital-acquired means something that you get after you've been in the hospital for 48 hours. For non-ventilator - it means that there's never been that device or that tube put down into the lungs, which greatly increases the risk of pneumonia.
It makes sense - you're taking a tube through that germy mouth and putting it into the lungs. It's easy to see why ventilator-acquired pneumonia could occur. But the thought that patients were getting pneumonia not being on a ventilator wasn't really well established or very well studied, especially among non surgical patients. And so our difference is calling attention to the information from our study that non-ventilator hospital-acquired pneumonia occurs on every unit in the hospital, including maternity.
There is a risk for all age groups and all patients to some extent. Certainly some patients are more at risk than others. Elderly, frail, oncology patients, but they're not the sole risk. In our study, 50% of the patients were under 65 and so it's it was like this hidden alert. So just trying to create that general awareness and seeing people to distinguish between envy. HaP and ventilator acquired pneumonia I think is an important one. It's not just the ventilator that creates risk.
Well, Diane, I want to thank you for your time today. We appreciate your expertise on pneumonia in the hospital and willingness to share with our listeners some of the impacts that preventative measures such as mobility and oral care can have on improving pneumonia outcomes in the hospital. So thank you very much.
Thank you for this opportunity.
ABOUT THE AUTHOR
DREW MARTIN
Drew works as marketing manager and takes care of digital and content marketing efforts for Recovery Force Health. He enjoys learning about and discussing newer medical technologies and adopting them into everyday marketing practices.
