Oral care practices in stroke: findings from the UK and Australia

Implementing a Screen-Clean-Hydrate bundle of care for improving swallow screening, oral health, and hydration in acute stroke: Protocol for a Type 2 hybrid-effectiveness pre-post study

Stroke clinical guidelines recommend care processes that optimize patient outcomes and minimize hospital-acquired complications. However, audits and surveys illustrate that recommended care is not always consistently or thoroughly implemented. This paper outlines the methods for implementing and evaluating a new bundle of care. Screen-Clean-Hydrate bundles together recommendations from the Australian Clinical Guidelines for Stroke Management and supplements these with evidence-informed best practice from the literature for: swallow screening within 4 h of presentation to hospital (Screen); oral health assessment and delivery of oral care (Clean); and hydration assessment and management (Hydrate). The study is a pre-post Type 2 hybrid effectiveness/implementation design with an embedded process evaluation, which will be conducted in two acute stroke units in a capital city of Australia. The integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) framework will be used to guide study design, conduct, and evaluation. Clinical effectiveness will be measured by rates of hospital-acquired complications and proxy measures of cost (length of stay, procedure costs) for 60 patient participants pre- and postimplementation. Implementation outcomes will focus on acceptability, feasibility, uptake and fidelity, and identification of barriers and enablers to implementation through staff interviews, medical record audits, and researcher field notes. Due to its design as a hybrid effectiveness/implementation study, once completed, the study will provide information on both intervention and implementation effectiveness, including details of successful and unsuccessful multidisciplinary implementation strategies. This will inform a larger multisite effectiveness/implementation trial for future upscale, leading to improved compliance with stroke guidelines and therefore stroke outcomes.

Hydration and nutrition care practices in stroke: findings from the UK and Australia

BACKGROUND

Dehydration and malnutrition are common in hospitalised patients following stroke leading to poor outcomes including increased mortality. Little is known about hydration and nutrition care practices in hospital to avoid dehydration or malnutrition, and how these practices vary in different countries. This study sought to capture how the hydration and nutrition needs of patients' post-stroke are assessed and managed in the United Kingdom (UK) and Australia (AUS).

AIM

To examine and compare current in-hospital hydration and nutrition care practice for patients with stroke in the UK and Australia.

METHODS

A cross-sectional survey was conducted between April and November 2019. Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing post-stroke inpatient acute care or rehabilitation. Non-respondents were contacted up to five times.

RESULTS

We received 150/174 (86%) completed surveys from hospitals in the UK, and 120/162 (74%) in Australia. Of the 270 responding hospitals, 96% reported undertaking assessment of hydration status during an admission, with nurses most likely to complete assessments (85%). The most common methods of admission assessment were visual assessment of the patient (UK 62%; AUS 58%), weight (UK 52%; AUS 52%), and body mass index (UK 47%; AUS 42%). Almost all (99%) sites reported that nutrition status was assessed at some point during admission, and these were mainly completed by nurses (91%). Use of standardised nutrition screening tools were more common in the UK (91%) than Australia (60%). Similar proportions of hydration management decisions were made by physicians (UK 84%; AUS 83%), and nutrition management decisions by dietitians (UK 98%; AUS 97%).

CONCLUSION

Despite broadly similar hydration and nutrition care practices after stroke in the UK and Australia, some variability was identified. Although nutrition assessment was more often informed by structured screening tools, the routine assessment of hydration was generally not. Nurses were responsible for assessment and monitoring, while dietitians and physicians undertook decision-making regarding management. Hydration care could be improved through the development of standardised assessment tools. This study highlights the need for increased implementation and use of evidence-based protocols in stroke hydration and nutrition care to improve patient outcomes.

Oral Hygiene in Patients with Stroke: A Best Practice Implementation Project Protocol

Oral hygiene has been shown to reduce adverse events and promote the quality of life of patients with stroke. However, a stroke can result in the impairment of physical, sensory, and cognitive abilities, and comprise self-care. Although nurses recognize its benefits, there are areas for improvement in the implementation of the best evidence-based recommendations. The aim is to promote compliance with the best evidence-based recommendations on oral hygiene in patients with stroke. This project will follow the JBI Evidence Implementation approach. The JBI Practical Application of Clinical Evidence System (JBI PACES) and the Getting Research into Practice (GRiP) audit and feedback tool will be used. The implementation process will be divided into three phases: (i) establishing a project team and undertaking the baseline audit; (ii) providing feedback to the healthcare team, identifying barriers to the implementation of best practices, and co-designing and implementing strategies using GRIP, and (iii) undertaking a follow-up audit to assess the outcomes and plan for sustainability. So, the successful adoption of the best evidence-based recommendations on oral hygiene in patients with stroke will reduce the adverse events related to poor oral care and may improve patients' quality of care. This implementation project has great transferability potential to other contexts.

Patterns and predictors of dental hospitalizations in patients with acquired brain injury from pre-injury to acute and post-acute injury

BACKGROUND

Acquired brain injury (ABI) can cause long-term disability and functional impairment.

OBJECTIVE

This study aims to determine the prevalence of dental hospitalizations in an ABI cohort across different phases of injury and identify factors associated with such hospitalizations.

METHODS

The cohort comprises patients with ABI (n = 683), traumatic (n = 282) and non-traumatic (n = 401) who were admitted to a neurorehabilitation service in Western Australia between 1991 and 2016. De-identified patient data were linked to the Hospital Morbidity Data Collection. The incidence of dental hospitalizations was calculated per 1,000 person-years (PY), and associated factors were investigated using multilevel mixed-effects logistic regression.

RESULTS

Dental hospitalizations significantly increased from pre-injury (3.35/1,000PY) to acute injury (302.65, Δ+299.3) and remained elevated in the post-acute phase (23.98, Δ+20.63). Dental caries had the highest incidence rate among all diagnoses in the pre-injury and post-acute phases (0.68 and 8.93, respectively), followed by gingivitis and periodontal diseases (3.60) in the post-acute phase. Tooth extractions were performed more often than restorative and preventive treatment in the pre-and post-injury phase, p < 0.001. Dental hospitalizations were associated with the type of ABI, age at injury, remoteness, and history of pre-injury hospitalization.

CONCLUSION

Implementing comprehensive preventive dental care can reduce potentially preventable dental hospitalization among ABI patients.

Oral health status and its associated factors among post-stroke inpatients: a cross-sectional study in Hungary

Background

Post-stroke inpatients are at risk of poor oral health for a number of reasons. The aim of this study was to assess the oral health status of post-stroke patients and also to explore the factors that may influence it.

Methods

This cross-sectional study was organised at National Institute for Medical Rehabilitation in Hungary. Altogether 410 post-stroke patients were enrolled in the survey. Personal medical history and functional assessment was obtained from the final medical reports of the patients. The clinical examination and data collection were conducted according to the World Health Organization (2013) criteria. Socio-demographic background and behaviours related to oral health were assessed using a questionnaire. The dental status was explained by the number of Decayed, Missing and Filled Teeth (DMFT). The association of socio-demographic factors, stroke and functional assessment with oral health status and behaviour was evaluated. Chi-square test, Fisher’s exact test, Welch test, Mann–Whitney U test, Kruskal–Wallis test, ANOVA model and correlation analysis were used to analyse our data. The level of significance was set at p < 0.05.

Results

Mean age of stroke patients was 59.21(Standard Deviation [SD] 14.74) years. Mean DMFT score was 20.13 (8.08), including 3.28 (4.24) decayed teeth, 15.02 (10.29) missing teeth and 1.83 (2.94) filled teeth score. Factors that influenced the oral health status were gender, age, occupational status, level of education, type and risk factors for stroke. Significant correlation was found between the Functional Independence Measure and oral health-related behaviours with patients brushing their teeth once a month showing the lowest value.

Conclusion

According to the results, low socio-demographic and economic status, low level of education and the Functional Independence Measure score, unemployment, the combination of risk factors for stroke and residual dysfunctions are associated with poor oral health status. The data indicate that a series of changes are needed, for special attention and care in oral health for patients who have had a stroke. Based on the findings of this research, a new model of prevention and care can be developed, with an interdisciplinary collaboration, to promote the quality of life of these individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02259-2.