Oral assessment and oral care are proving more important than anyone ever thought. Researchers have linked oral pathogens to hospital-acquired infections. And each year, as many as 100,000 Americans die from hospital-acquired infections.
Among the most vulnerable are geriatric, disabled, oncology, and critically ill patients. To improve outcomes in intensive care unit (ICU) patients, our interdisciplinary team developed a new approach to oral care based on evidence from a multisite study conducted by The National Institutes of Health.
Obstacles to oral care
Providing basic oral care is a part of nursing practice, but we identified certain obstacles that nurses face. At best, they receive only limited information. During clinical rotations, little or no time is allotted to oral assessment and care, and nursing textbooks provide scant
information. Your patient may need “meticulous oral care,” but you’ll be hard pressed to find clear, consistent, universal guidelines on how to deliver it.
Ineffective oral-care tools in hospitals present another obstacle. In our study, “The effect of a systemic oral-care program on reducing exposure to oropharyngeal pathogens in the critically ill patients,” three of four hospitals didn’t have basic oral provisions available to nurses. The most widely distributed tool was the foam swab, which has been proven ineffective for plaque and debris removal and may not even protect patients from oral mucosa degradation.
The third obstacle results from competing priorities in an environment shaped by the nursing shortage. New graduates and seasoned nurses agree that oral hygiene is simply a low priority.
To address these problems and improve patient outcomes, medical, nursing, and dental professionals collaborated to introduce new strategies and tools. Together, we developed, implemented, and evaluated new oral-care measures in the ICU. Our study measured the effectiveness of treatment, staff education, and care delivery. Our educational strategies placed an emphasis on changing established behaviors to enhance patient care.
An easy-to-use assessment tool
Oral assessment provides baseline data, identifies the regression or progression of oral complications, drives the frequency of care, and identifies the need for professional dental intervention. Many assessment tools are available for different patient populations.
The Oral Assessment Guide, a commonly used tool, has been modified over the years to meet the needs of patient populations, such as pediatric oncology patients and geriatric rehabilitation patients. The Oral Hygiene Assessment Tool is designed for residential care and cognitively impaired patients. Our protocol uses a modified version of Beck’s Oral Assessment Scale. It allows nurses to quickly and easily assess the oral cavity with minimal tissue manipulation. (See Using the modified Beck’s oral assessment tool in PDF by clicking download now button.)
Using the new protocol
The protocol we developed for giving oral care to ICU patients is safe and comfortable, improves tissue integrity, and removes pathogenic bacteria. To try it, first evaluate the patient’s condition: A sedated, intubated patient presents challenges quite different from those of a combative, confused patient. Review the patient’s history to determine if you can safely use alcohol-free chlorhexidine gluconate.
If the patient’s lips are dry, apply a lubricant before opening the mouth to avoid pain and tissue tearing. For limited mouth opening, use a mouth prop, such as the handle of a large denture brush. Then, using the modified Beck’s oral assessment tool, inspect the oral cavity with a penlight. Document your findings. Remember, oral assessment drives the frequency of care, which should be given at least every 12 hours.
Using a soft pediatric toothbrush has several advantages: easy handling, good access inside a partially closed mouth, and minimal discomfort to friable tissues. You don’t need toothpaste. Dip the toothbrush into chlorhexidine. About 100 to 200 mcg per immersion will moisten the toothbrush and deliver the antibacterial benefit. You’ll need four immersions to clean the mouth. To reduce the risk of aspiration, use bedside suctioning. To wipe debris from the toothbrush, use gauze.
The tongue provides an excellent substrate for bacterial growth. When possible, lightly grasp the tongue and brush from the back forward. Don’t brush the tongue if the patient is intubated. If you’re concerned about inadvertent mouth closing or biting, use a mouth prop on the side opposite the one you’re treating. When you complete the debridement, rinse the toothbrush and allow it to air dry.
Then, use one spray (about 160 mcg) of chlorhexidine at the entrance of the mouth to coat all structures, including the endotracheal tube if the patient has one. If you’ve dipped the toothbrush four times and used one spray, the total dose of chlorhexidine will be about 1 mL per session. The current recommendation is to use a 15-mL swish twice daily for a total daily dose of 30 mL. Thus, our protocol allows you to safely increase the frequency of care, as needed.
Teaching aids for all
We developed these resources for both staff and patients:
• A DVD divided into short segments, demonstrating aspects of assessment and care. The DVD is available in a common space with unlimited accessibility.
• A pocket flip-chart containing a detailed algorithm of care and photographs showing various degrees of oral conditions. The pocket primer was well received by staff and patients. Many took them home.
• A large-print poster summarizing the steps to oral care, placed over the patient’s bed for easy viewing.
If your facility allows, have a dental hygienist available for oral-care rounds. Consult with a staff dentist or dental hygienist often. A multidisciplinary staff forum provides an opportunity for supplemental expert instruction and advice for difficult patient situations and complications. And encourage staff nurses to monitor the quality of their oral-care measures and note observable benefits.
Grim stats, better outcomes
In the United States, hospital-acquired infections cause between 45,000 and 100,000 deaths a year. But an evidence-based protocol created by a multidisciplinary team may just help us all improve those grim statistics.
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Visit www.AmericanNurseToday.com/journal for a complete list of selected references.
Sherri L. Gollins is a Dental Hygienist and a Protocol Specialist, and Jan Yates is Clinical Nurse Scientist at the National Institutes of Health in Bethesda, Maryland.