Oral Hygiene Oral Hygiene Evidence Based Standards of Evidence Based Standards of Care Care For The Dysphagic Patient For The Dysphagic Patient Stephen Fraser, Stephen Fraser, Speech-Language Pathologist Speech-Language Pathologist Dept . of Communication Disorders Dept . of Communication Disorders St. Joseph’s Healthcare St. Joseph’s Healthcare Hamilton, Ontario Hamilton, Ontario
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Oral HygieneOral HygieneEvidence Based Standards of CareEvidence Based Standards of Care
For The Dysphagic PatientFor The Dysphagic Patient
Stephen Fraser, Stephen Fraser, Speech-Language PathologistSpeech-Language Pathologist
Dept . of Communication DisordersDept . of Communication DisordersSt. Joseph’s HealthcareSt. Joseph’s Healthcare
Hamilton, OntarioHamilton, Ontario
Today's PresentationToday's Presentation
• Background information.• Current oral care practices in healthcare.• Implementation methods.• The Oral Care Standards.• Research at St. Josephs.
Components to Developing Standards of Care
Literature Review Consultation with other hospitals regarding
their standards Consultation with appropriate departments
(e.g.., pharmacy)
Why should hospitals care soWhy should hospitals care somuch about the oral cavity ?much about the oral cavity ?
Most bacterial nosocomial pneumonia are caused by aspiration of bacteria colonizing the oropharynx or upper GI tract of the patient.
Centres for Disease Control (1997)Centres for Disease Control (1997)
Nosocomial pneumonia accounts for 10-15% of all hospital acquired infections.20-50% of all infected patients will die as a result of the infection
J.Can.Dent.Assoc.(2002)J.Can.Dent.Assoc.(2002)
• Bacterial colonization of the oropharynx is an important risk factor for VAP. Muro (2004) American journal of critical care.
• Pathogens responsible for aspiration pneumonia were colonized in the dental plaque of patients.
Oral care procedures are not based on research evidence but on tradition, anecdotal evidence and subjective assessments.
Nursing Standard (2001)Nursing Standard (2001)
In a comprehensive review of evidence-based practice related to strategies to prevent Aspiration Pneumonia in ventilator dependent patients, Hixon et.al. noted that even though oral hygiene is considered standard nursing care, it is often neglected in critically ill patients or performed by quickly swabbing the mouth. AACN , Clinical Issues (1998) AACN , Clinical Issues (1998)
Current OralCurrent Oral Care Care Practices Continued… Practices Continued…
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care.
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF. Journal of Advanced Nursing (1996)Journal of Advanced Nursing (1996)Nursing Times (1996)Nursing Times (1996)
However,
The foamstick is still the tool ofchoice, for most critical care nurses.
Critical Care Nursing Critical Care Nursing (1995)(1995)
Two Models of ImplementationTwo Models of Implementation(see Winter 2007 Communique Article)(see Winter 2007 Communique Article)
Firstly, poster presentation on Evidence Based Practice Day. Firstly, poster presentation on Evidence Based Practice Day. Invited units to implement Oral Care InitiativesInvited units to implement Oral Care Initiatives
ICU
• Standard Already Created. Told to change anything but the key points(Win Win Situation)
• Worked with Nurse Manager andNurse Educator
• Multiple in-services • Chose objective research measure
Acute Care(Including Stroke Unit)
• Standard Already Created. Told to
change anything but the key points(Win Win Situation)
• Worked with nurse educator• Single in-service• Chose subjective measurement
Standards of Practice for Providing Oral Care to The Dysphagic Patient
ICU Standard
Applicable to ICU adult inpatients who are NPO, including ventilated patients.
RN provides oral care. Oral assessment twice daily. Document status of oral cavity in CareVue
( ex. Tooth colour, gum condition, odours). Notify physician with any changes in oral cavity (ex.
Breakage of teeth, abscesses). Use mouth swabs for moisture relief only.
ProcedurePart B – Chlorhexidene 0.12%1. Check patient chart for allergies to chlorhexidene2. Obtain doctor’s order for chlorhexidene3. Place 15ml of chlorhexidene in medication cup4. Soak toothette in chlorhexidene5. Rub teeth, tongue, gums, and sides of mouth in
circular motion6. Suction oral cavity and do not rinse7. Apply oral moisturizer to lips
Procedure
Document use of chlorhexidine in patient’s cMAR and CareVue
Use moistened toothettes every 2 hours following brushing routine
Moisten toothettes with water or water and 1.5% hydrogen peroxide
Practice Alerts
DO NOT add mouthwash or any medication to chlorhexidine solution
DO NOT administer Nystatin within 2 hours of chlorhexidine use, as it renders Nystatin ineffective
Acute CareStandard
Applicable to adult inpatients who are NPO, or are unable to have thin fluids.
Oral assessment OD. Oral care prior to AM meal and post PM meal. If NPO, oral care once on AM and PM shift If NPO, moist swab every 2 hours for moisture relief. DOES
NOT CONSTITUTE ORAL CARE. Patient in semi/high fowlers unless contraindicated. SLP makes recommendation as part of assessment.
Canadian Dental Association (CDA) regarding oral problems that would restrict a person from using toothpaste to clean their mouth. Other than allergy to a component, CDA is not aware of any specific contraindications for any particular patient group. Kindly note, that individual patients should consult with their dentist for specific advice about oral care products in any given situation.
Toothpaste – Why not?
Trademark medical – no contraindication regarding foaming in the suction line(None found at St. Josephs)
Informal Interview of SLP’s- some do not use toothpaste, but no evidence based reasons have yet been obtained
Procedure - Brushing Wash hands and put on gloves Obtain PLAC VAC BRUSH Attach suction to toothbrush, moisten toothbrush and
apply baking soda Brush patient’s teeth, gums, tongue, palate
and inside cheeks Apply suction to cleansed areas Rinse brush in water, repeat step 4-5 Soak dentures in denture solution
Alternate Procedure Chlorhexidene 0.12%1. Place 15ml of chlorhexidene in medication
cup2. Soak toothette in chlorhexidene3. Rub teeth, tongue, gums, and sides of
mouth in circular motion4. Suction oral cavity and do not rinse5. Apply oral moisturizer to lips
Procedure
Continue with routine until patient is receiving thin fluids.
Use moistened toothettes (with water) every 2 hours following oral care
ICU Research
2.0 VAP Bundle Compliance
0%
50%
100%
Month
Percen
tage
Actual Goal
1.0 VAP Rate in ICU per 1000 Ventilator Days
0
10
20
30
40
50
60
Month
VAP
Rat
e pe
r 100
0 Ve
ntila
tor D
ays
Actual Goal
1. Vent Circuit Changed2. HOB>30'3. Oral Care Education Started
Oral Care q12h Implemented Oral Care
Increased to q6h
Questions?Questions?
References
• Gaynor, E. (2001). A Rational for Oral Care. Nursing Standard 15(43): 33-36• Grap, M.J. (2003). Oral Care Interventions in Critical Care: Frequency and Documentation. American journal of
Critical Care, 12(2): 113-119 • Langmore, S.E. et al. (1998) Predictors of Aspiration Pneumonia; How important is Dysphagia? Dysphagia 13:
69-81• Langmore, S.E. et al. (2002) Predictors of Aspiration Pneumonia in Nursing Home Residents. Dysphagia 17: 298-
307• Marik, P. & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. Chest. 124(1):328-336.• McNeil. H. E. (2000). Biting back at poor oral hygiene. Intensive and Critical Care Nursing, 16: 367-372• Mojon, P. (2002) Oral health and respiratory infection. Journal of the Canadian Dental Association. 68(6):340-345.• Mojon, P. & Bourbeau, J. (2003). Respiratory infection: How important is oral health? Current Opinion in
Pulmonary Medicine. 9:166-170.• Okuda, K et al. (1998, Feb). The efficacy of antimicrobial mouth rinses in oral health care. The Bulletin of Tokyo
Dental College. 39(1):7-14• Perry, A.G. et. Al., Clinical Nursing Skills Techniques, Fifth edition (2002) • Shay, K. (2000) Denture Hygiene: A review and update. The Journal of Contemporary Dental Practice. 1(2):1-8.• Terpenning, M. et al. (2001). Aspiration pneumonia: Dental and oral risk factors in an older veteran population.
JAGS. 49:57-563.• Terpenning, M. & Shay, K. (2002). Oral Health is cost-effective to maintain but costly to ignore. Editorial in JAGS,
50:584-585.• Trieger, N. (2004), Oral Care in the Intensive Care Unit, American journal of Critical Care, 13(1): 24-33• Yoneyama, T et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. JAGS. 50:430-433.