Impact of Chlorhexidine Oral Care on Pneumonia Outcomes Following Neck of Femur Fracture: A Two-Cycle Prospective QI Audit

Introduction

Pneumonia is a common complication following neck of femur (NOF) fracture and is associated with increased morbidity, prolonged hospitalisation and mortality. Following a previous prospective audit identifying pneumonia as a major contributor to increased length of stay, chlorhexidine mouthwash was introduced into the electronic NOF admission prescribing bundle. This quality improvement project evaluated its impact on pneumonia-related outcomes.

Methodology
A two-cycle prospective quality improvement audit was undertaken. Cycle 1 included 65 consecutive patients admitted with NOF fractures. Following implementation of chlorhexidine mouthwash, a second prospective audit of 35 consecutive patients was performed by the same investigator using identical inclusion criteria and data collection methods. Data collected included demographics, pneumonia diagnosis, antibiotic use, length of stay (LOS), 30-day mortality and chlorhexidine compliance. Continuous variables were compared using the Mann–Whitney U test and categorical variables using Fisher's exact test.

Results
Baseline characteristics were comparable between cycles. Pneumonia incidence was similar following implementation of chlorhexidine (46.2% vs 48.6%, p=0.837), with no significant differences in overall LOS (median 13 vs 10.5 days, p=0.990) or 30-day mortality (6.2% vs 5.7%, p=1.000). Within Cycle 2, patients prescribed chlorhexidine had lower pneumonia incidence (42.9% vs 71.4%), shorter LOS (10.0 vs 16.5 days) and lower 30-day mortality (3.6% vs 14.3%), although these differences were not statistically significant. Across the pooled cohort, pneumonia was associated with significantly prolonged LOS (median 14 vs 9 days, p=0.0012), while mortality was similar (6.4% vs 5.7%, p=0.681).

Conclusion
Chlorhexidine mouthwash was successfully implemented within the NOF admission pathway but was not associated with statistically significant reductions in pneumonia, LOS or mortality. Outcomes consistently favoured chlorhexidine, suggesting a potential benefit that this audit was underpowered to detect. Pneumonia remained associated with significantly prolonged hospitalisation, supporting continued emphasis on preventative oral care and early management in patients with NOF fractures.