Outcomes of an Oral Care Protocol in Postmechanically Ventilated Patients.

BACKGROUND: Oral care is standard practice to prevent hospital-associated infections while patients are intubated and in the intensive care unit. Following extubation and transfer, infections remain an important risk for patients, but less attention is paid to oral care. Few studies have assessed the impact of oral care in recently extubated acutely ill patients. AIMS: To develop an evidence-based oral care protocol for hospitalized patients and determine the impact of this protocol on health outcomes in recently extubated patients. METHODS: In this randomized controlled trial, subjects were randomized to usual care or an intervention protocol that included tooth brushing, tongue scraping, flossing, mouth rinsing, and lip care. Major outcome measures were the revised THROAT (R-THROAT; oral cavity assessment) and overall prevalence of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus on oral cultures. RESULTS: Seventy-four subjects were randomized. As measured by the R-THROAT, oral cavity health improved over time in both groups, but the intervention group demonstrated significantly more improvement than the control group (R-THROAT score improved by 1.97 intervention vs. 0.87 control; p = .04). Two categories, tongue and mouth comfort, demonstrated the most significant improvement. There was no difference in MSSA/MRSA colonization between the groups at the conclusion of the study. Overall, subjects in the intervention group were more satisfied with their protocol than subjects in the usual care group. LINKING EVIDENCE TO ACTION: This study offers an important evaluation of an oral care protocol after extubation. Results demonstrated improvement in the oral cavity assessment with the designed oral care protocol. Patients expressed a preference for the intervention protocol, which included a battery-operated toothbrush, higher-quality toothpaste and mouth rinse, tongue scraper, floss, and lip balm. The implementation of an oral care protocol specifically addressing patients in the immediate postintubation is essential.

Evaluation of the safety and efficacy of a nursing-driven midazolam protocol for the management of procedural pain associated with burn injuries.

Burn pain is one of the most excruciating types of pain and can be difficult to manage. Benzodiazepines may be effective in reducing pain by minimizing anxiety associated with dressing changes. This study aimed to evaluate the safety and efficacy of adjunctive midazolam during dressing changes in patients with uncontrolled pain using opioid monotherapy or significant anxiety associated with dressing changes. A retrospective cohort analysis comparing patients who received midazolam during dressing changes with control patients was performed. Each midazolam patient was matched with up to two control patients who did not receive midazolam on the basis of age, sex, TBSA burned, and grafting requirement. The primary endpoint was the oral morphine equivalents required during admission after initiation of midazolam. Thirty-six patients were included for evaluation (14 midazolam and 22 control patients). Baseline characteristics were similar between the two groups, although patients in the midazolam group had higher pain scores and oral morphine equivalent requirements at baseline. When adjusted for baseline pain, day postburn, age, sex, and grafting status, total oral morphine equivalents and mean pain scores during admission were similar between the groups. One midazolam patient experienced oxygen desaturation with midazolam, but did not require flumazenil for reversal. The use of midazolam during burn dressing changes in patients with poorly controlled pain and/or anxiety was not associated with reduced requirements for oral morphine equivalents or lower pain scores during admission. Further research into the role of benzodiazepines in burn pain management is warranted.