Evidence map›Paper›PMID 34609548›Full record

Trial reportIntensive care medicine2021

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.

Craig M Dale, Louise Rose, Sarah Carbone, Ruxandra Pinto, Orla M Smith, Lisa Burry, Eddy Fan, Andre Carlos Kajdacsy-Balla Amaral, Victoria A McCredie, Damon C Scales and 1 more

3 registry-linked trialsOpen access · bronzeAbstract readMulticenter StudyRandomized Controlled Trial
PubMed Full text at PMC Publisher
In one paragraph

Trial report in Intensive care medicine, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 3 registered trials, which are not on this map. Cited by 39 papers, 3 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
39citing papers in PubMed, 3 pooled it
9.8field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT03382730 nacompletednot on this map

A Multi-centered Stepped Wedge Cluster Randomized Controlled Trial of the De-adoption of Oral Chlorhexidine Prophylaxis and Implementation of an Oral Care Bundle for Ventilated Critically Ill Patients

TypeinterventionalSponsorUniversity of TorontoRan2017 to 2020Enrolled3,260ConditionsMortality, Oral Health, Dryness, Mouth, Pain, OrofacialArmsChlorhexidine Mouth Rinse, Chlorhexidine Mouth Rinse De-Adoption
NCT06258603 nacompletednot on this map

The Effect of Oral Care Bundle Application on Salivary pH (Power of Hydrogen), Dry Mouth and Ventilator-associated Pneumonia in Intubated Patients

TypeinterventionalSponsorNigde Omer Halisdemir UniversityRan2019 to 2023Enrolled35ConditionsPneumonia, Mechanical Ventilation Complication, Salivation, Dry MouthArmsoral care bundle, clinical oral care
NCT07129733 nanot yet recruitingnot on this mapstarted 2025, after this paper: background citation

Oral Care Layered Enhancement for Improved Oral Hygiene in Intensive Care Units: A Stepped-Wedge Cluster Randomized Clinical Trial

TypeinterventionalSponsorHospital do CoracaoRan2025 to 2026Enrolled4,800ConditionsMechanical Ventilation, Infection Prevention, Oral Care, Oral Hygiene, Oral HealthArmsOral hygiene bundle
3 · Its place in the literature

Who cites it

39 citing papers in PubMed, 3 syntheses or guidelines pooled it, 84 citations in OpenAlex.

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  15. Update on infection prevention in the ICU.Current opinion in critical care · 2025
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4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

11 authors at 4 institutions in 2 countries.

Craig M DaleLawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.ORCID http://orcid.org/0000-0002-5042-0332
Louise RoseFlorence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, Room 1.1.3, London, SE1 8WA, UK.ORCID http://orcid.org/0000-0003-1700-3972
Sarah CarboneLawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.
Ruxandra PintoDepartment of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.ORCID http://orcid.org/0000-0003-3712-4624
Orla M SmithLawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.
Lisa BurryInterdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.ORCID http://orcid.org/0000-0002-6545-3890
Eddy FanInterdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.ORCID http://orcid.org/0000-0002-1210-9914
Andre Carlos Kajdacsy-Balla AmaralSunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
Victoria A McCredieInterdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.ORCID http://orcid.org/0000-0002-1590-2846
Damon C ScalesSunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.ORCID http://orcid.org/0000-0001-7101-3958
Brian H CuthbertsonSunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. Brian.Cuthbertson@sunnybrook.ca.ORCID http://orcid.org/0000-0003-4174-9424
Sunnybrook Health Science Centre · CAUniversity of Toronto · CAKing's College London · GBMount Sinai Hospital · CA

Funding

Canadian Lung Association 188404Network for Canadian Oral Health and Research (NCOHR) 201097
6 · The paper itself

Abstract

purposeOral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients.

methodsA stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors.

resultsA total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (- 0.96; 95% CI - 1.75 to - 0.17; P = 0.02) improved in the intervention period.

conclusionAmong mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health.

Indexed as

Patient Care BundlesPneumonia, Ventilator-AssociatedChlorhexidineHumansIntensive Care UnitsRespiration, ArtificialChlorhexidineChlorhexidineCritical careDe-adoptionOral healthRandomized controlled trialRespiration, artificial

Identifiers

PMID34609548
PMCPMC8490143
OpenAlexW3203014088

What OpenQuestion holds

Textmetadata
Read underepoch 390

Registered trials

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.