Oral health and oral care in patients in a surgical context: A quantitative study comparing patients' and nurses' assessments

AIMS

To investigate fundamental care delivery regarding oral care in a surgical context, and to compare patients' self-reported oral health with registered nurse assessments.

DESIGN

A descriptive and comparative study, with a consecutive selection.

METHODS

A patient oral health rating tool, including questions about performed oral care, was distributed to patients (n = 50), at four surgical wards in Sweden. The response rate was 72%. Oral health status was assessed by a registered nurse using the Revised Oral Assessment Guide (ROAG), and a comparison between patient and registered nurse assessment was performed by calculating Cohen's kappa coefficient and percentage agreement.

RESULTS

Patients (38%) reported severe oral symptoms, mostly dry lips and not an adequate amount of saliva, and 80% were not offered help with oral care. ROAG assessments revealed that 74% had problems with oral health. Almost half of the patients (48%) needed assistance with oral care but only 10% received help. Registered nurses assessed the patient's oral health as worse than the patient's self-assessment did.

CONCLUSION

There are deficiencies in fundamental care delivery regarding oral care in a surgical care context. Oral health assessments need to be performed by registered nurses. Routines for systematic oral assessments and for oral care need to be implemented by nurse managers to ensure that patients' fundamental care needs are fulfilled.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Oral health assessments need to be performed regularly by registered nurses since it is insufficient that patients self-assess their oral health. Nurse managers need to provide and implement routines for nurse assessments and oral care in surgical care contexts.

IMPACT

There are deficiencies in patients' oral health and oral care, and registered nurses need to perform oral health assessments. Nurse managers need to implement routines for registered nurse assessments and oral care.

PATIENT CONTRIBUTION

Patients admitted to a surgical ward were included in the study after being screened for inclusion criteria. After participants signed informed consent, they filled in a questionnaire about oral health and oral care, and a registered nurse performed an oral health assessment.

REPORTING METHOD

This study was carried out according to the STROBE checklist.

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.

[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.

Oral health for adults in care homes

Essential facts It is estimated that more than 400,000 adults live in UK care homes, 80% of whom have dementia. More than half of older people in care homes have tooth decay compared with 40% of over 75s and 33% of over 85s who do not live in care homes. Care home residents are more likely to have fewer natural teeth, and those with teeth are less likely to have enough teeth to eat comfortably and socialise without embarrassment.

Assessment of Chemotherapy-Induced Oral Complications in Children With Cancer

Objective: To assess children with cancer for oral complications using the oral assessment guide (OAG) and ascertain the efficacy of an oral hygiene care regimen in children undergoing chemotherapy and at 1 to 2 weeks postchemotherapy administration.Methods: Thirty pediatric cancer patients with either leukemia or lymphoma were randomly selected from 3 medical centers. A quasi-experimental design was used to evaluate the difference between pre- and post-oral hygiene care. Descriptive and inferential statistical techniques were used to analyze the data. The interrater agreement between the nurse and the dentist was calculated using a Kappa score. A paired t test was to examine the difference between preand post-oral hygiene care regimen.Results: The OAG scores ranged from 8 to 24. The higher the score, the more severe the oral complications. Ninety-six percent of the participants had a score [. greaterequal] 9, on the pre-test, 26. 7% had an OAG score [. greaterequal] 12. Oral complications included ulcerated mucous membranes, dry lips, deeper or raspy voice, and oral debris. No scores were [. greaterequal] 12 on the OAG following the posttest. The oral hygiene care regimen significantly improved oral assessment among patients (P <. 05).Conclusions: The authors postulate that the OAG and oral hygiene care regimen may be clinically useful in improving oral assessment and hygiene in children with cancer during and after chemotherapy, thus decreasing associated infection and enhancing patient comfort.

Oral Health and Hospital-Acquired Pneumonia in Elderly Patients: A Review of the Literature

The U.S. spends an average of $6.5 billion each year to treat patients who suffer from pneumonia. Pneumonia currently has the highest morbidity and mortality rates of all nosocomial infections, is hypothesized to account for 15% of all hospital-acquired illnesses and is responsible for 13 to 48% of all nursing home-associated illnesses. For years, researchers have tried to develop methods to prevent pneumonia because of its detrimental effects on the body, but only in the last decade have they been able to uncover possible methods to do so. Inadequate oral hygiene care is one of the ways that elderly patients contract hospital-acquired pneumonia (HAP). Proper oral disease prevention could possibly be considered the standard of care in long-term stay facilities to reduce and prevent elderly patients from contracting HAP. The purpose of this literature review is to explore the relationship between oral health care practices and HAP.

Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting

Oral care is a crucial routine for patients with dysphagia that, when completed routinely, can prevent the development of aspiration pneumonia. There is no standardised protocol for oral care within government hospitals in South Africa. This study aimed to investigate the outcome of an oral care protocol. Participants were patients with oropharyngeal dysphagia, with either stroke or traumatic brain injury as the underlying medical pathology, and nurses. All participants were recruited from one tertiary level government hospital in Gauteng, South Africa. 139 nurses participated in the study and received training on the oral care protocol. There were two groups of participants with oropharyngeal dysphagia. Group one (study group, n = 23) was recruited by consecutive sampling, received regular oral care and were not restricted from drinking water; however, all other liquids were restricted. Group two (comparison group, n = 23) was recruited via a retrospective record review, received inconsistent oral care and were placed on thickened liquids or liquid restricted diets. Results showed that a regimen of regular oral care and free water provision when combined with dysphagia intervention did prevent aspiration pneumonia in patients with oropharyngeal dysphagia. The article highlights two key findings: that regular and routine oral care is manageable within an acute government hospital context and a strict routine of oral care can reduce aspiration pneumonia in patients with oropharyngeal dysphagia. An implication from these findings is confirmation that teamwork in acute care settings in developing contexts must be prioritised to improve dysphagia management and patient prognosis.

Knowledge, Perceived Ability and Practice Behaviors Regarding Oral Health among Pediatric Hematology and Oncology Nurses

PURPOSE

Oral complications are common in children undergoing head and neck radiation and chemotherapy. The purpose of this study is to examine the knowledge, perceived ability and practice behaviors of pediatric oncology and hematology nurses in assisting with the various oral health care needs of pediatric oncology patients and to identify pediatric oncology nurses' previous training/education, practice types and other demographic characteristics that are related to their oral health competencies.

METHODS

A survey of a convenience sample of Pediatric Oncology and Hematology Nurses was conducted during the Association of Pediatric Oncology and Hematology Nurses' (APHON) 36(th) Annual Conference and Exhibit. Descriptive analysis and the exploratory factor analyses were performed using SAS version 9.2 (SAS Institute, Inc., Cary, NC).

RESULTS

Among the 300 surveys that were distributed, 235 surveys were completed (78% response rate) by pediatric oncology or hematology nurses who provide direct patient care in the U.S. Approximately 75% reported receiving less than 3 hours of oral health related education/training. Sixty percent did not have a clinical requirement regarding the assessment of the teeth and gums during their nursing school education. Bivariate analyses indicated that nurses who had clinical requirements regarding oral health assessment during nursing education/training presented greater overall oral health competencies including having greater confidence in examining oral complications than those who did not.

CONCLUSION

Pediatric oncology nurses' knowledge, perceived ability and practice in assisting patient's oral hygiene care, preventing and managing oral complications vary by topic and might reflect their educational preparedness. This study may provide valuable information pertaining to the need and opportunity for interprofessional oral health care education and collaboration with nursing and dental professionals, in order to increase access to comprehensive oral care for pediatric cancer patients.

[Nursing staff's knowledge and attitudes concerning preventive oral hygiene in palliative care]

Preventive mouth care is essential for the well-being of palliative care patients, though it is not performed enough outside units devoted to these patients. Our study aimed at getting a better knowledge of carers' attitudes and knowledge regarding this basic care. A validated questionnaire was sent anonymously to nurses and nursing aides working in the medical units of ten hospitals in Brittany. Of the 2,467 questionnaires sent, 54% were validated for use. The years of experience have little influence on nursing staff's answers. One in twenty does not think that preventive mouth care is part of his/her duties. This care is considered unpleasant, and difficult, by 11% and 22% of nurses, and 13.5% and 20.5% of nursing aides, respectively. A lack of knowledge is openly expressed with regards to oral diseases and dental prostheses. More than one in four cannot say if he/she knows the functions of the mouth, or he/she can identify a healthy mouth. These results show the scope for improvement as well as the priorities. They will be used as baseline for our future program assessment.

[The oral health of patients in psychiatric institutions and related comorbidities]

The oral health of inpatients who are treated for mental illness is very degraded compared with general population. We observe a significant caries index, disorders of salivary secretion and periodontal disease. The comorbidities associated such as smoking, metabolic disorders and the lack of oral hygiene explain partially this situation. A bad oral state can have grave consequences on overall health.A good oral health is an integral part of somatic care of patients hospitalized in psychiatry.

Survey on oral hygiene measures for intubated patients in Swiss intensive care units

Five to ten percent of all hospitalized patients are treated in intensive care units. The risk of nosocomial infections is inherent in the latter, especially in cases of intubation. In this context, impaired oral hygiene may play a pivotal role. Therefore, the purpose of this survey among representative Swiss intensive care units was to assess the standards and measures taken in this patient collective with reduced oral hygiene. To this end, a questionnaire was sent to 25 institutions which represented all A- and University hospitals in Switzerland as well as all accredited intensive care units in the canton of Zurich according to the register of the Swiss Society of Intensive Medicine. Intensive care units from pediatric departments were excluded. Twenty-one questionnaires were received and evaluated (84%). Only one quarter of all respondents reported having protocols available for preventing ventilation-associated pneumonia (VAP). Systemic antibiotic regimens were never performed. Ninety percent reported cleaning the patients' teeth mechanically with a toothbrush. Sixty-seven percent used chlorhexidine as a disinfectant (81% in liquid form). Seventy-five percent of the responding hospitals performed routine oral cleaning procedures three times a day (90% immediately after intubation). In summary, oral prophylaxis was neither standardized nor consistently implemented in the evaluated Swiss intensive care units of the responding hospitals. Only a small proportion had protocols available for preventing VAP, which is in accordance with similar surveys conducted in the US and Europe. Additional and improved measures have to be determined to confirm or optimize prophylactic oral strategies and to create standards and guidelines for this at-risk patient collective.

More than just a simple swish and spit: implementation of oral care best practice in clinical neurosciences

Suboptimal oral care is well documented in the literature and is linked to increased nosocomial pneumonia rates and prolonged hospitalization, negatively affecting patients' quality of life (Terezakis et al. 2011). A standardized approach to oral care can change these adverse outcomes. This project used best practice guidelines and evidence in the literature to guide the development of oral care best practice within an acute care inpatient unit. Based on the work of the interprofessional Clinical Neurological Sciences (CNS) Continuous Quality Improvement (CQI) Council at London Health Sciences Centre-University Hospital (LHSC-UH), an oral care policy and bedside assessment tool were implemented in line with Stroke Best Practice Recommendations (Heart and Stroke Foundation of Canada 2010). A validated, reliable and feasible oral health assessment tool (OHAT) was selected for implementation, and is now completed on every patient within 24 hours of admission to the CNS inpatient unit. Favourable outcomes to date include improved accessibility of oral health supplies, including regular and suction toothbrushes, toothpaste and bite blocks. Post-implementation audits indicate increased frequency and quality of oral care. This review provides a synopsis of how oral care best practice was implemented in an acute care neurology/neurosurgery setting.

Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-dependent, neurologically impaired patients

INTRODUCTION

The purpose of this point-of-care study was to test the efficacy of a prevention-based oral care protocol in reducing non-ventilator-associated hospital-acquired pneumonia in a neurosurgical population outside the critical care environment. The researchers hypothesized that an enhanced oral care protocol would decrease the incidence of pneumonia.

METHODS

This quasi-experimental, comparative study took place on an acute neurosurgical unit at a tertiary care trauma hospital in Western Canada. Subjects were non-intubated, care-dependent adults with a primary diagnosis of neurologic injury/insult, and at high risk for pneumonia. The prospective study group comprised 34 subjects; two subjects were excluded from the study analysis. The retrospective study group comprised 51 subjects. Data were collected for both groups for a six-month period. Retrospective data were collected through chart review. The prospective group were eligible neurosurgical patients who received the enhanced oral care protocol. Data collection tools were developed and diagnostic criteria for hospital-acquired pneumonia were determined. The pneumonia rates between subjects who received standard oral care (retrospective group) and those who received an enhanced, prevention-based, oral care protocol (prospective group) were compared.

RESULTS

A statistically significant decrease in the pneumonia rate occurred in the prospective group (p < 0.05).

DISCUSSION

An enhanced oral care protocol was beneficial in reducing the incidence of non-ventilator-associated hospital-acquired pneumonia.

IMPLICATIONS

Nurses play a vital role in preventing hospital-acquired pneumonia. Foundational nursing practices, such as regular oral hygiene, are important aspects of care in preventing nosocomial infections and related costs, optimizing health, and promoting quality care.

Nurses' knowledge of the provision of oral care for patients with dysphagia

There has been little research on the provision and adaptation of oral care for patients with dysphagia in nursing homes. This study collected data via a questionnaire specifically on the knowledge of oral hygiene and the current oral care practices for patients with dysphagia. Fifty-three registered nurses (RNs) completed the questionnaires. The results of the questionnaire indicated that although RNs gave more oral care daily to their patients with dysphagia than to their patients without dysphagia, they had limited knowledge of drugs that affect oral care and of medical conditions associated with poor oral hygiene. Of particular concern was the limited knowledge of the link between dysphagia, oral hygiene and pneumonia and that some of the current oral care practices may be putting patients who have dysphagia at increased risk of developing pneumonia. These results are discussed in light of previous research on the topic and recommendations are made with regards to oral care training.

[Enhancing nurse implementation of oral healthcare in an intensive care unit]

BACKGROUND

Oral health professionals identified inadequate levels of patient oral health in our intensive care unit (ICU). A post-review analysis of collected data and field observation notes concluded that this problem resulted from several factors including: (1) Failure of ICU nurses to follow mouth care standards; (2) lack of oral injury care procedures; (3) lack of oral injury consultation procedures; (4) lack of oral care monitoring; (5) substandard oral care assistive devices.

PURPOSE

The authors designed this project to raise general nursing staff knowledge of oral hygiene standards and increase the ability of nurses to implement proper oral healthcare.

RESOLUTION

After discussions with oral health professionals and reviewing articles in the literature, the authors implemented Critical Patient Oral Care Standards and Oral Injury Consultation Procedures and purchased new assistive care devices. The authors also conducted regular on-the-job training sessions for hospital staff that were reinforced by regular monitoring.

RESULTS

Training significantly increased nursing staff recognition of oral health care. Oral health care test scores rose from an initial average of 16% correct to a final average of 90% correct. Accurate implementation of oral health care in the ICU rose from an initial 19.69% to 78.66% of cases.

CONCLUSION

This project significantly enhanced the accuracy and appropriateness of nurse oral health care delivery and quality health care promotion in the ICU.

Review of the evidence to support oral hygiene in stroke patients

Maintaining good oral hygiene in patients who have had a stroke is an essential part of care. This literature review highlights the poor provision of such care in acute medical and rehabilitation settings. It reveals a lack of evidence for current practices and suggests that research may be helpful in defining which nursing interventions are most effective.

Oral hygiene care in the pediatric intensive care unit: practice recommendations

Oral hygiene significantly affects children's well being. It is an integral part of intensive and critical care nursing because intubated and ventilated children in the Pediatric Intensive Care Unit (PICU) are dependent on the health care team to tend to their everyday basic needs. Fourteen articles were identified as being relevant to pediatric oral care in the PICU. These articles were subsequently appraised, and an oral hygiene in the PICU guideline was developed. Research highlighted the relationship between poor oral hygiene in the intensive care unit (ICU) and an increase in dental plaque accumulation, bacterial colonization of the oropharynx, and higher nosocomial infection rates, particularly ventilator-associated pneumonia. Research and a local, informal audit found the provision of oral hygiene care to PICU children varied widely and was often inadequate. Children in the PICU need their mouths regularly assessed and cleaned. Maintaining consistent, regular, and standardized oral hygiene practices in the PICU will also set an example for children and their families, encouraging and teaching them about the life-long importance of oral hygiene.

[Oral care practice and procedures in intubated patients: an observational study]

BACKGROUND

Effective oral care improves patient comfort and prevents oral infection. While common in general nursing practice, administering oral care to intubated patients is particularly challenging.

PURPOSE

This study investigated practices and factors associated with oral care of intubated patients in intensive care units (ICUs).

METHODS

This study used a cross-sectional design and recruited nurses using purposive sampling. Data were collected with a structured observational checklist between January and April 2008 at a medical center in northern Taiwan. Observational data reflected oral care procedures performed by thirty-one ICU nurses on intubated patients in six ICUs.

RESULTS

Cotton and foam swabs were found to be the main oral care cleaning instruments used with intubated patients, with dilute mouthwash the primary cleaning solution. Nearly three-quarters (72.4%) of participants were found to employ proper oral care procedures. Participants selected different cleaning equipment, cleaning solutions, cleaning solution usage methods and oral endotracheal tube securement methods based on differing conditions. ICU nurse age was positively associated oral care completeness. The level of oral care completeness achieved by participants in medical ICUs was significantly higher those assigned to surgical ICUs.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Study findings showed that ICU nurses did not follow procedures and steps recommended by current evidence-based practice (e.g., brushing the teeth and gums; positioning patients in a side or semi- / high-fowlers position when providing oral care to intubated patients). ICUs must establish policies and procedures for oral care of intubated patients that reflect patient characteristics. Furthermore, ICUs should provide oral care related on-the-job training and education in order to improve the quality of oral care administered to critical care patients.

Developing and implementing an oral care policy and assessment tool

Oral hygiene is an essential aspect of nursing care. Poor oral care results in patients experiencing pain and discomfort, puts individuals at risk of nutritional deficiency and infection, and has an adverse effect on quality of life. This article describes how an oral care policy and assessment tool were updated to ensure the implementation of evidence-based practice at one hospital in the Republic of Ireland.

The importance of patients' oral health and nurses'role in assessing and maintaining it

Oral hygiene is undervalued in terms of its effects on patient health and nutrition. Effective oral care reduces infection and promotes health. This article explores the evidence for appropriate assessment of oral health and provides guidance for effective oral care.

Hard to swallow: understanding dysphagia

Review what causes this potentially dangerous disorder and how to help patients who struggle with it.