the safety and efficacy of chlorhexidine oral care. The results are surprising,” says Dr. Dale. Antimicrobial rinse has limited to no effect in preventing pneumonia among ICU patients.2 More concerning, there’s an excess mortality signal (i.e., more die than statistically expected) among patients exposed to the treatment. “We can’t quite explain the mortality signal, but certainly it gave us pause to think about whether or not we should continue with this treatment,” says Dr. Dale. Given the risks and the limited benefits of chlorhexidine oral care, Dr. Dale and his colleagues wanted to stop using the rinse in their ICUs. “However, we know that abrupt interruption of a long-standing practice can have unintended consequences,” he says, “so we opted to conduct a rigorous, de-adoption trial to study this process.” Dr. Dale and his colleagues conducted a stepped wedge cluster randomized controlled trial with an embedded process evaluation in 6 ICUs in the Toronto area. In each ICU, the staff stopped using chlorhexidine oral care and began using a standardized oral care bundle, including tooth brushing, moistening the mouth and deep suctioning. “To accomplish this, we conducted frontline staff education, including point-of-care training and monthly audit and feedback to support this practice change over the study period.” The study’s primary research aim was to measure the impact of chlorhexidine de-adoption on mortality in mechanically ventilated patients. The second goal was to measure the impact of chlorhexidine de-adoption and implementation of a standardized oral care bundle on time to infection, procedural oral pain and objective measures of oral health dysfunction. One goal was to measure the impact of chlorhexidine de‑adoption and implementation of a standardized oral care bundle on time to infection, procedural oral pain and objective measures of oral health dysfunction. “We found that swapping the two kinds of care did not change mortality, time to infection, time on the ventilator or procedural pain for our patients,” says Dr. Dale. “However, we did see improvement in oral health dysfunction scores after the rinse was de-adopted. In short, oral health improved.” The investigators also found an increase in oral care delivery during the trial. “Oneway to interpret the findings is that we did not see any advantage of chlorhexidine rinse over a standardized oral care bundle. Since tooth brushing should be happening anyway in hospitalized patients, this should really be the default form of oral care and pneumonia prophylaxis,” says Dr. Dale. The study has led to new guidelines for oral care in hospitals endorsed by multiple infection control bodies including the Centers for Disease Control and Prevention. “These guidelines move oral care from the background to the foreground,” says Dr. Dale. “This will impact every patient admitted to hospital, both on wards and in ICUs. Tooth brushing is now considered an essential practice, which will improve patient outcomes.” References: 1. Dale CM, Rose L, Carbone S, Pinto R, Smith OM, Burry L, et al. Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial. Intensive Care Med. 2021 Nov;47(11):1295-1302. 2. Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014 May;174(5):751-61. Watch a conversation with Dr. Dale on CDA Oasis: bit.ly/44QhGlW 26 | 2023 | Issue 5 Issues and People
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