Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster Randomized Study.

BACKGROUND: Nonventilator hospital-acquired pneumonia (NV-HAP) presents a serious and largely preventable threat to patient safety in U.S. hospitals. There is an emerging body of evidence on the effectiveness of oral care in preventing NV-HAP. PURPOSE: The primary aim of this study was to determine the effectiveness of a universal, standardized oral care protocol in preventing NV-HAP in the acute care setting. The primary outcome measure was NV-HAP incidence per 1,000 patient-days. METHODS: This 12-month study was conducted on four units at an 800-bed tertiary medical center. Patients on one medical and one surgical unit were randomly assigned to receive enhanced oral care (intervention units); patients on another medical and another surgical unit received usual oral care (control units). RESULTS: Total enrollment was 8,709. For the medical control versus intervention units, oral care frequency increased from a mean of 0.95 to 2.25 times per day, and there was a significant 85% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 7.1 times higher on the medical control versus intervention units, a significant finding. For the surgical control versus intervention units, oral care frequency increased from a mean of 1.18 to 2.02 times per day, with a 56% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 1.6 times higher on the surgical control versus intervention units, although this result did not reach significance. CONCLUSIONS: These findings add to the growing body of evidence that daily oral care as a means of primary source control may have a role in NV-HAP prevention. The implementation of effective strategies to ensure that such care is consistently provided warrants further study. It's not yet known what degree and frequency of oral care are required to effect favorable changes in the oral microbiome during acute care hospitalization.

Effective mouth care for older people living in nursing homes.

Oral health for older people living in nursing homes has long been an area of interest and concern, with suboptimal oral health often having significant effects on their general health, well-being and quality of life. This article outlines the reasons why oral health can deteriorate in nursing home residents and the potential effects of this, and provides information about relevant national guidance. The article also details practical recommendations for nursing home staff on improving residents' oral hygiene, including undertaking oral health assessments, delivering mouth care and accessing dental services.

[The Triangular Relationship Among Swallowing Disorders, Aspiration Pneumonia, and Poor Oral Hygiene].

Persons with dysphagia have difficulties chewing and swallowing food because of functional, structural, or psychological reasons. Dysphagia may cause choking or the inhalation of food into the trachea and lungs. Patients with dysphagia often induce the coughing reflex when drinking water and brushing teeth and tend to suffer from gum bleeding. As a result, their caregivers tend to reduce the frequency of or discontinue teeth brushing, which promotes the spread of periodontal disease, dental caries, and oropharyngeal secretions colonizing in the oral cavity or throat. When a patient suffers a choking attack or aspiration, bacteria is inhaled into the trachea and lungs, causing aspiration pneumonia. Furthermore, patients with choking issues are often be fitted with nasogastric tubes to facilitate the delivery of nutrients and water. Long-term use of nasogastric tubes also significantly increases the risk of aspiration pneumonia. Adjusting eating posture, improving food texture, conducting swallowing rehabilitation, providing training, and practicing proper oral care are an effective approach to preventing the onset of chewing and swallowing disorders and aspiration pneumonia.

Improving oral care for hospitalised patients: choosing appropriate products.

BACKGROUND: Oral care is a fundamental part of nursing but it is often performed as a routine task, often based on historic practice, and lacks an evidence base. A variety of oral care products are used in practice. AIM: To discover evidence of effective oral care products for use in hospitalised patients. DESIGN: A systematic literature review was undertaken. METHODS: A review of articles was conducted using CINAHL, PubMed, the Cochrane Database and Google Scholar between 2007 and 2019. All articles were compared and contrasted and some excluded due to the quality of the evidence. DISCUSSION: The literature review identified a number of oral care problems and investigated a range of products. RESULTS: The main finding was that there is a need for a definitive, evidence-based oral care guideline on the products suitable for different oral care conditions, including dysphagia, xerostomia, mucositis, and for patients wearing dentures.

Introducing an oral care assessment tool with advanced cleaning products into a high-risk clinical setting.

Poor oral hygiene is an important risk factor for the development of non-ventilator hospital-associated pneumonia (NV-HAP), which imposes a significant burden on the NHS. This study aimed to establish whether the use of a 24-hour oral care kit and an oral care assessment tool can meet the needs of patients on an acute stroke unit. In comparison with the same period the preceding year, the introduction of the oral care kit and assessment tool improved compliance with oral care by more than 4 times; the overall costs of antibiotics to treat NV-HAP patients fell by 79%, with the number of doses falling by 70%, and the mortality rate decreased from 27% to 20%. According to a survey of multidisciplinary team (MDT) members keeping oral care tools available at the point of use saved time, and the oral health of patients on the unit improved after the introduction of the oral care kit and assessment tool. Almost all MDT members would recommend the use of the kit over previous interventions.

Implementing and Evaluating the Impact of a Nurse-Led Oral Care Initiative.

BACKGROUND: Nursing interventions in oral hygiene have been shown to be important for health promotion and illness prevention. This medical center advanced a registered nurse (RN)-led oral health initiative to introduce and standardize oral care practices. PROBLEM: To examine the impact of the oral health initiative, we conducted an evaluation of documentation trends among RNs and the effect of the initiative on patients' oral health during hospitalization. APPROACH: We used a single-group pretest-posttest design and drew a sample of all inpatients who were admitted to the medical center from October 1 through December 31, 2017. OUTCOMES: Of the 13 303 patients admitted, the empirical evidence demonstrates 99.5% compliance in documentation at admission and discharge. Among 13 237 patients, there was improvement in patients' oral health during hospitalization (-0.03, P < .001), especially those initially assessed with moderate or severe dysfunction. CONCLUSIONS: The oral health initiative standardized assessment and care practices that have improved outcomes in patients' oral hygiene.

Factors influencing oral care in intubated intensive care patients.

BACKGROUND: The practice of oral care in intensive care settings remains inconsistent among intubated patients, yet these patients are at high risk of developing ventilator-associated pneumonia. Therefore, it is important to adopt safe professional behaviour based on clinical practice guidelines. This study was based on Ajzen's (1985) theory of planned behavior, a conceptual framework that allows a better understanding of how internal and external factors influence behaviour adoption. AIMS AND OBJECTIVES: To study influential factors in how nurses practice oral care with intubated clients in intensive care settings, referring to the theory of planned behavior (TPB) constructs. DESIGN: A cross-sectional descriptive correlational design was conducted through a provincial postal survey in Quebec, Canada. METHODS: A questionnaire was completed by 375 nurses working in intensive care units (ICUs). RESULTS: Perceived behavioural control and attitude were the most important determinants in the level of intention to engage in oral care. Knowledge, available human and material resources, and number of years of experience in critical care nursing also seemed to be significant influencing factors. CONCLUSIONS: This study improved our understanding of the factors influencing the practice of oral care in intubated patients in the ICU, relying on TPB as an explanatory framework. It would be important to continue to study this professional behaviour and to work in collaboration with health care facilities to promote the importance of oral care as an imperative for the safety and quality of health care. RELEVANCE TO CLINICAL PRACTICE: The results of this study represent a solid foundation for advancing continuing education programmes and intensive care orientation programmes tailored to the needs of nurses.

Exploring nursing and allied health perspectives of quality oral care after stroke: A qualitative study.

BACKGROUND: Maintaining good oral health remains a challenge among those hospitalised after stroke. Stroke nurses and allied health clinicians have a potential role in providing oral care, but no studies in Australia to date have explored their perceptions and needs. AIMS: To explore the perspectives of nursing and allied health stroke clinicians regarding oral care for stroke patients across acute care and stroke rehabilitation settings. METHODS: This study followed an exploratory qualitative design, using a constructivist approach. Participants from two metropolitan public hospitals were purposively recruited to participate in focus groups. Data was thematically analysed. RESULTS: Twenty-one clinicians participated. Clinicians' knowledge and practices relating to oral healthcare for stroke patients were inadequate. Most staff felt they did not have adequate knowledge, resources and training to administer oral care in this setting and proposed enhancing education of stroke clinicians, patients and informal caregivers, as well as improving quality point of care resources. There was overall support for the integrated dental care after stroke model of care. DISCUSSION: This study revealed many gaps in current care and highlighted areas for improvement. Patients and their caregivers needed to be actively engaged as partners to improve oral healthcare within acute and rehabilitation stroke settings. CONCLUSION: This study provided insight into nurses' and allied health stroke clinicians' current knowledge and practices of oral care in various stroke settings. The findings from this study will inform development of a model of care to train stroke nurses in providing oral care.

A context analysis on how oral care is delivered in hospitalised patients: A mixed-methods study.

AIMS AND OBJECTIVES: To analyse oral care delivery in one hospital through exploring experiences from both nurses' and patients' perspectives and examining patients' oral health. BACKGROUND: Oral health problems are associated with undernutrition and other general health outcomes. Although oral care belongs to the essentials of nursing, it is often neglected. Improving oral health may require behaviour change of both nurses and patients. Defining tailored strategies need a clear view on the context. DESIGN: A context analysis in one hospital using a convergent parallel mixed-methods design was reported following the EQUATOR guidelines using two checklists: COnsolidated criteria for REporting Qualitative research (qualitative research) and STROBE (observational research). METHODS: Semi-structured interviews were conducted with 19 nurses and 11 patients. The topic list was based on the Integrated Change Model. Prospective oral examination was performed among 91 surgical patients using the Oral Health Assessment Tool (OHAT). RESULTS: Nurses acknowledged that they did not prioritise oral care in daily practice. Furthermore, they lacked knowledge and skills to identify and provide care for oral problems. Nurses mentioned helpful resources to perform oral care, like standardised language and instruments. However, they had no access to or were unaware of them. Patients admitted that they did not prioritise oral care due to their sickness during hospitalisation, were unaware of the importance of oral care, but felt responsible for their oral care. The most prominent oral problems identified with the OHAT were unclean mouths (n = 75, 82%), unhealthy gum and tissues (n = 55, 60%) and dry mouth (n = 42, 46%). CONCLUSIONS: This context analysis identified inadequate oral care due to lack of positive attitude and knowledge in both nurses and patients, skills for nurses, and resources. RELEVANCE TO CLINICAL PRACTICE: The behavioural factors indicate strategies for development of a multicomponent intervention to improve oral care in this hospital, nutritional status and general health outcomes.

Oral care practices in non-mechanically ventilated intensive care unit patients: An integrative review.

AIMS AND OBJECTIVES: To explore current oral care practices in nonmechanically ventilated ICU patients. BACKGROUND: Oral hygiene is an important aspect of nursing care in hospitalised populations. Oral care is a disease preventive and cost-effective measure for patients, particularly in ICU patients. Numerous studies support the value of oral care practices in mechanically ventilated ICU patients. Due to evidence supporting the benefits of oral care in nonmechanically ventilated patients, it would be beneficial to examine the literature for oral care practices in this population. METHODOLOGY: Literature searches of the following databases were performed: CINAHL Plus, MEDLINE, PsychInfo, Academic Search Premier, Cochrane Database of Systematic Reviews, and Web of Science. Three peer-reviewed articles were included in the review after inclusion criteria were applied. Findings were appraised, organised conceptually and synthesised using Torraco (2016b) as a guiding framework. Evidence was appraised using the Johns Hopkins Nursing Evidence-based Practice Rating Scale. PRISMA reporting guidelines were followed, when applicable. RESULTS: Findings support the existing gap in the literature of oral hygiene practices in nonmechanically ventilated ICU patients. Themes included the type of oral care products used, frequencies of oral care, documented oral care practices and personnel that performed the care. STUDY IMPLICATIONS: This integrative review identified an important gap in the literature for oral care practices in nonmechanically ventilated ICU patient populations. Further research on current oral care practices and development of evidence-based guidelines for this population are recommended. RELEVANCE TO CLINICAL PRACTICE: Nurses should provide oral care to all hospitalised patients and follow oral care guidelines specific to their population, if available.

Oral Hygiene Care in Patients With Advanced Disease: An Essential Measure to Improve Oral Cavity Conditions and Symptom Management.

BACKGROUND: Oral problems are frequent in palliative care and can cause disabling symptoms such as orofacial pain, dysgeusia, and xerostomia. Even if oral care is an essential aspect of nursing, it is often not considered as a priority, especially when various complex patients' needs have to be managed. OBJECTIVE: The aim of this study was to describe oral conditions and evaluate the impact of standard oral care on symptom control and patient's perceived comfort in a sample of terminally ill patients. METHOD: A prospective cohort study was carried out among 415 patients who were admitted to hospice. Patients were recruited before undergoing standard assisted procedure for oral hygiene care. Oral cavity condition, symptoms, and comfort were assessed at the recruitment (T0) and after 3 days (T2). RESULTS: Seventy-five eligible patients were recruited. The Oral Assessment Guide score was significantly decreased after oral standard care (P value <.0001). The average time spent by nursing staff for oral hygiene care was 5.3 minutes. Dysgeusia and xerostomia were significantly decreased after oral standard care (P = .02 and P = .03). Patients reported a high level of comfort (86.6%) after the procedures for oral hygiene care. CONCLUSION: Patients admitted to hospice had frequent alterations in oral cavity with partial loss of its functions that can compromise their quality of life. Standard procedures for oral hygiene care are simple and fast to perform, and they may improve oral cavity conditions, symptoms control, and patients' comfort.

[Cost-Effective, Easy-to-Implement, but Still-Neglected Oral Hygiene].

In rapidly aging societies, it is commonly found that the limited number of remaining teeth in elders results in chewing difficulties that cause health problems and malnutrition. Surprisingly, even the latest high-tech oral medical care achieves health maintenance results that are inferior to those regularly achieved by healthy natural teeth. Oral health issues are particularly serious in rural areas. The literature supports a close association between oral hygiene and general health. Because oral microorganisms are known to cause infections and inflammation reactions, people with poor oral hygiene often have high incidences of periodontal disease and tooth loss and an even higher prevalence of cardiometabolic-related chronic diseases, poorer life quality, and higher mortality than their peers with better oral hygiene (Ma et al., 2017; Tsai et al., 2015; World Health Organization, 2018). Although promoting oral hygiene may be done on a minimal budget and with high efficacy, many people retain improper oral-hygiene concepts and behaviors. For instance, many do not recognize the relationship between real teeth and general health, brush their teeth for inadequate durations, and/or apply improper methods. Furthermore, many do not make use of the regular dental cleaning resources available through the National Health Insurance program, leading to poor oral hygiene care outcomes such as tooth decay in school-age children, periodontal disease and tooth loss in adulthood, and the current average of fewer than 20 real teeth in adults 65~80 years of age. All of these poor oral-hygiene realities lead to Taiwan falling far short of WHO oral-health-related goals. Based on the perspective of prevention and health promotion, this column presents the important role of the nursing profession in improving the quality of oral hygiene care through the three critical phases of life: school age, active adulthood, and elderly adulthood. We look to advance national oral hygiene in Taiwan to a standard exceeding that of the World Health Organization in order to demonstrate the practical benefit of Taiwan's two-decade-long National Health Insurance system.

A Nurse-Driven Oral Care Protocol to Reduce Hospital-Acquired Pneumonia.

: Purpose: The purpose of this evidence-based quality improvement (QI) project was to implement an oral care protocol in the adult in-patient care areas of a level 1 trauma hospital and to evaluate its impact on the incidence of hospital-acquired pneumonia (HAP). METHODS: A standardized, evidence-based oral care protocol was implemented depending on the level of care required by each ventilated, at-risk, or short-term care patient. The QI project included the introduction of a new suction toothbrush kit for at-risk patients and, for short-term patients, a new short-term oral care kit that featured a more ergonomically appropriate toothbrush, a baking soda toothpaste, and an alcohol-free antiseptic mouthwash; the project also supported the continued use of the then current suction toothbrush kit for patients receiving mechanical ventilation. We examined medical records retrospectively and used International Classification of Diseases (ICD) 9 and ICD 10 codes for pneumonia not present on admission to determine the incidence of HAP, including nonventilator hospital-acquired pneumonia (NV-HAP) and ventilator-associated pneumonia (VAP), in two seven-month periods: the baseline and intervention periods. Both periods were in the same seven calendar months of two different years to control for seasonal differences in pneumonia rates. Documentation of oral care interventions were compared with oral care supply use reports to measure protocol adherence in the intervention group. RESULTS: There were 202 patients in the baseline group and 215 in the intervention group. A χ(2) analysis of NV-HAP incidence showed a statistically significant decrease in occurrences of NV-HAP from 52 in the baseline group to 26 in the intervention group (χ(2) = 12.8, df = 1, P < 0.001). The number of patient deaths from NV-HAP also differed significantly between groups, with 20 in the baseline group and four in the intervention group (χ(2) = 4.33, df = 1, P = 0.037). NV-HAP incidence per 1,000 discharges was calculated at 2.84 in the baseline group and 1.41 in the intervention group. Among patients on a ventilator, there were 56 ventilatorassociated events (VAEs) with 12 cases of VAP in the baseline group and 49 VAEs and three cases of VAP in the intervention group. Infection rates in the baseline group were calculated as 12.53 VAEs per 1,000 ventilator days and 2.87 cases of VAP per 1,000 ventilator days. The intervention group yielded a VAE rate of 14.29 per 1,000 ventilator days and a VAP rate of 1.26 per 1,000 ventilator days. Overall, nurses' adherence to the new oral care protocol ranged from 36% to 100% per month, with an average adherence to protocol of 76% as evidenced by oral care documentation and supply use. IMPLICATIONS: Nurses improved pneumonia outcomes by providing oral health interventions to all adult patients admitted to the hospital, which reduced overall hospital costs, length of stay, and patient mortality.

Impact of an education program on the performance of nurses in providing oral care for mechanically ventilated children.

BACKGROUND: Mechanically ventilated children are prone to pneumonia due to immobilization and lack of laryngeal (cough) reflex and swallowing. Nurses are directly responsible for many clinical approaches used to prevent ventilator-associated pneumonia. OBJECTIVE: The research objective is to determine the effectiveness of the nurse education program on the performance of nurses in providing oral care for mechanically ventilated children. METHODS: This quasi-experimental pretest-posttest design was conducted on 100 nurses (50 in each of the control and intervention groups) in pediatric intensive care units (PICU) in Tehran, 2015. The research tools included a demographic form and three checklists for evaluation of performance according to the clinical practice guidelines for the oral health status of children in PICU. Before intervention, the performance of nurses in both groups was observed at three stages and three different shifts, using an observational checklist. After one month, their performance was observed again with the same checklist at three stages and three different shifts in the PICU. The training was done in four 40-50 minute sessions in a workshop with a 4-week follow-up. The Chi-square test, Fisher's exact test, paired t-test, independent t-test, and regression analysis comprised the tools used to analyze the data. FINDINGS: The mean performance scores of nurses before the education program in the intervention and control groups were 42.8 (±18.5) and 48.7 (±15.7), respectively. These scores improved to 68.6 (±31.4) and 48.6 (±15.4) four weeks after the intervention (p < 0.001). CONCLUSION: The performance of nurses in providing oral care for mechanically ventilated children improved after the intervention. It is recommended to implement this program for all nurses, regardless of their ward or specialty, based on the clinical practice guidelines. The periodic refreshing in-service training program should be provided to nurses in PICU in order to enhance their performance in providing oral care.

Improving the oral health of older people in hospital.

OBJECTIVE: To determine whether an oral health therapist daily oral hygiene intervention, compared with the same routine performed by nurses with some dental support, can improve the oral health of older inpatients. METHODS: A prospective study was conducted at two tertiary referral hospitals with three phases: (i) pre-intervention (PI) usual oral care; (ii) oral health therapist intervention (OHTI); and (iii) nurse-led intervention (NI). Oral health was assessed with the Oral Health Assessment Tool. RESULTS: Three hundred and fifty nine patients participated across three phases (PI (n = 206); OHTI (n = 77); NI (n = 76)). In the intervention groups, there was a significant decrease in 'unhealthy' oral cleanliness at day 7, OHTI; 86 to 53% (P < 0.001), NI; 80 to 50% (P < 0.001) compared to PI; 78 to 72% (P > 0.14). Movement from 'unhealthy' oral cleanliness at day 1 to 'healthy' at day 7 was significantly higher in the OHTI (35%) and NI (37%) compared to PI (17%) (P < 0.001). CONCLUSION: With support, nurses can improve the oral health of older patients similarly to an oral health therapist.

Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs.

Consistently delivered, effective oral care targets bacterial multiplication reducing the risk of non-ventilator associated hospital acquired pneumonia (NV-HAP). AIM: Determine the effect of a twice daily oral care initiative on the incidence and cost of NV-HAP. METHODS: This single arm intervention study used pre/post population data to determine the effectiveness of a universal, standardized oral care protocol vs. usual care in preventing NV-HAP. This phase followed a retrospective study of 14,396 patient days (2002-2012) that determined the pre-intervention levels of nursing care provided, and the overall disease prevalence. RESULTS: The pilot incidence rate on the geriatric units decreased from 105 to 8.3 cases per 1,000 patient days (by 92%) in the first year. The intervention yielded an estimated cost avoidance of $2.84 million and 13 lives saved in 19 months post-implementation. Expansion of this study as quality improvement is in progress at 8 VA hospitals with plans for national VA deployment. CONCLUSIONS: While oral care may seem deceptively simple in terms of base care provision, hospital and nursing services struggle to provide effective oral care delivery with high-reliability. Barriers to oral care include: (1) the perception that oral care is an optional daily care activity for patient's comfort, (2) hospitals supply inadequate, poorly designed oral care materials, and (3) hospitals are not required to monitor the incidence of NV-HAP. The impact of consistently delivered oral care is substantial in terms of Veteran health, quality of life, and well-being in addition to considerable cost avoidance.

Iowa nursing facility oral hygiene (INFOH) intervention: A clinical and microbiological pilot randomized trial.

PURPOSE/AIM: The aim of this pilot study was to evaluate feasibility and gather initial data for a definitive study to test the clinical and microbiological effectiveness of a nursing facility (NF) customized oral hygiene protocol, intended to be delivered by dental hygienists and NF personnel. MATERIALS AND METHODS: A convenience sample of 8 Eastern Iowa NFs was recruited, and each NF was assigned to one of three intervention groups: (1) control (current oral hygiene practice), (2) educational program only, and (3) educational program plus 1% chlorhexidine varnish monthly application. Demographic information, systemic health data, patient centered data, oral health data, and microbiology samples were collected at baseline and after 6 months. RESULTS: Recruitment response rates were 21% for NFs and 23% for residents. A total of 81 residents were examined at baseline and of those, 49 were examined at 6 months (39.5% attrition). There were no statistically or clinically significant differences among the intervention groups at 6 months for any of the recorded clinical or microbiological outcomes. CONCLUSIONS: Recruitment and retention posed a significant challenge to this trial, even with a relatively short observation period. Results from this pilot study did not encourage further investigation of this customized oral hygiene protocol.