Oral HygieneOral HygieneEvidence Based Standards of CareEvidence Based Standards of Care

For The Dysphagic PatientFor The Dysphagic Patient

Stephen Fraser, Stephen Fraser, Speech-Language PathologistSpeech-Language Pathologist

Dept . of Communication DisordersDept . of Communication DisordersSt. Joseph’s HealthcareSt. Joseph’s Healthcare

Hamilton, OntarioHamilton, Ontario

Today's PresentationToday's Presentation

• Background information.• Current oral care practices in healthcare.• Implementation methods.• The Oral Care Standards.• Research at St. Josephs.

Components to Developing Standards of Care

Literature Review Consultation with other hospitals regarding

their standards Consultation with appropriate departments

(e.g.., pharmacy)

Why should hospitals care soWhy should hospitals care somuch about the oral cavity ?much about the oral cavity ?

Most bacterial nosocomial pneumonia are caused by aspiration of bacteria colonizing the oropharynx or upper GI tract of the patient.

Centres for Disease Control (1997)Centres for Disease Control (1997)

Nosocomial pneumonia accounts for 10-15% of all hospital acquired infections.20-50% of all infected patients will die as a result of the infection

J.Can.Dent.Assoc.(2002)J.Can.Dent.Assoc.(2002)

• Bacterial colonization of the oropharynx is an important risk factor for VAP. Muro (2004) American journal of critical care.

• Pathogens responsible for aspiration pneumonia were colonized in the dental plaque of patients.

Scannapieco (1992) Critical Care Medicine

Why is Speech-Language Pathology Why is Speech-Language Pathology Addressing the issue of Oral Care?Addressing the issue of Oral Care?

Susan Langmore, Dysphagia (1998)Susan Langmore, Dysphagia (1998)Susan Langmore, Dysphagia (2002) Susan Langmore, Dysphagia (2002)

How Does Aspiration Pneumonia How Does Aspiration Pneumonia

(including VAP) Occur?(including VAP) Occur?

ASPIRATION+

GRAM - BACTERIA

+OVERWHELM

IMMUNE SYSTEM

MUST HAVE ALL 3

When does Colonization occur?When does Colonization occur?

Within 48 hours of admission to hospital the oropharyngeal flora of critically ill patients changes from

the usual gram + streptococci and dental pathogens to

gram – organisms including Pathogens that cause VAP and Aspiration Pneumonia

American Journal of Critical Care (2004)

How do we stop this change in oral How do we stop this change in oral pharyngeal flora?pharyngeal flora?

Mechanical Interventions (tooth brushing) Use of pharmacological anti-microbial

agents (ex. Chlorhexidene) Combination Effect

American Journal of Critical Care ( 2004)

Oral Care ResearchOral Care ResearchTreatment with oral hygiene alone, reduced occurrence of pneumonia in older adults in nursing homes by 30%

Yoneyama et.al. Yoneyama et.al. (2002(2002))

Currently Reported Currently Reported Oral Care PracticesOral Care Practices

Protocols for oral care measures are generally intended to improve patient comfort, rather than removal of microbes.

AACN,Clinical Issues (1998)AACN,Clinical Issues (1998)

Oral care procedures are not based on research evidence but on tradition, anecdotal evidence and subjective assessments.

Nursing Standard (2001)Nursing Standard (2001)

In a comprehensive review of evidence-based practice related to strategies to prevent Aspiration Pneumonia in ventilator dependent patients, Hixon et.al. noted that even though oral hygiene is considered standard nursing care, it is often neglected in critically ill patients or performed by quickly swabbing the mouth. AACN , Clinical Issues (1998) AACN , Clinical Issues (1998)

Current OralCurrent Oral Care Care Practices Continued… Practices Continued…

Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care.

SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF. Journal of Advanced Nursing (1996)Journal of Advanced Nursing (1996)Nursing Times (1996)Nursing Times (1996)

However,

The foamstick is still the tool ofchoice, for most critical care nurses.

Critical Care Nursing Critical Care Nursing (1995)(1995)

Two Models of ImplementationTwo Models of Implementation(see Winter 2007 Communique Article)(see Winter 2007 Communique Article)

Firstly, poster presentation on Evidence Based Practice Day. Firstly, poster presentation on Evidence Based Practice Day. Invited units to implement Oral Care InitiativesInvited units to implement Oral Care Initiatives

ICU

• Standard Already Created. Told to change anything but the key points(Win Win Situation)

• Worked with Nurse Manager andNurse Educator

• Multiple in-services • Chose objective research measure

Acute Care(Including Stroke Unit)

• Standard Already Created. Told to

change anything but the key points(Win Win Situation)

• Worked with nurse educator• Single in-service• Chose subjective measurement

Standards of Practice for Providing Oral Care to The Dysphagic Patient

ICU Standard

Applicable to ICU adult inpatients who are NPO, including ventilated patients.

RN provides oral care. Oral assessment twice daily. Document status of oral cavity in CareVue

( ex. Tooth colour, gum condition, odours). Notify physician with any changes in oral cavity (ex.

Breakage of teeth, abscesses). Use mouth swabs for moisture relief only.

Supplies 1 SAGE package containing 2 toothbrushes

and perox-a-mint solution 2-4 toothettes Chlorhexidene 0.12% oral rinse Disposable medical cups Suction source Yankauer suction handle

ProcedurePart A - Brushing

1. Wash hands and put on gloves 2. Obtain 1 pkg. Sage – 6572 – c3. Attach suction to toothbrush, moisten brush and

apply perox-a-mint solution4. Brush patient’s teeth, gums, tongue, palate and

inside cheeks5. Apply suction to cleansed areas6. Rinse brush in water and repeat step 4-57. Soak dentures in denture solution

ProcedurePart B – Chlorhexidene 0.12%1. Check patient chart for allergies to chlorhexidene2. Obtain doctor’s order for chlorhexidene3. Place 15ml of chlorhexidene in medication cup4. Soak toothette in chlorhexidene5. Rub teeth, tongue, gums, and sides of mouth in

circular motion6. Suction oral cavity and do not rinse7. Apply oral moisturizer to lips

Procedure

Document use of chlorhexidine in patient’s cMAR and CareVue

Use moistened toothettes every 2 hours following brushing routine

Moisten toothettes with water or water and 1.5% hydrogen peroxide

Practice Alerts

DO NOT add mouthwash or any medication to chlorhexidine solution

DO NOT administer Nystatin within 2 hours of chlorhexidine use, as it renders Nystatin ineffective

Acute CareStandard

Applicable to adult inpatients who are NPO, or are unable to have thin fluids.

Oral assessment OD. Oral care prior to AM meal and post PM meal. If NPO, oral care once on AM and PM shift If NPO, moist swab every 2 hours for moisture relief. DOES

NOT CONSTITUTE ORAL CARE. Patient in semi/high fowlers unless contraindicated. SLP makes recommendation as part of assessment.

Supplies

1 PLAK VAC oral evacuator brush. Toothpaste Suction source Yankauer suction handle

OR Chlorhexidene 0.12% oral rinse Mouthswab

Toothpaste – Why not?

Canadian Dental Association (CDA) regarding oral problems that would restrict a person from using toothpaste to clean their mouth. Other than allergy to a component, CDA is not aware of any specific contraindications for any particular patient group. Kindly note, that individual patients should consult with their dentist for specific advice about oral care products in any given situation.

Toothpaste – Why not?

Trademark medical – no contraindication regarding foaming in the suction line(None found at St. Josephs)

Informal Interview of SLP’s- some do not use toothpaste, but no evidence based reasons have yet been obtained

Procedure - Brushing Wash hands and put on gloves Obtain PLAC VAC BRUSH Attach suction to toothbrush, moisten toothbrush and

apply baking soda Brush patient’s teeth, gums, tongue, palate

and inside cheeks Apply suction to cleansed areas Rinse brush in water, repeat step 4-5 Soak dentures in denture solution

Alternate Procedure Chlorhexidene 0.12%1. Place 15ml of chlorhexidene in medication

cup2. Soak toothette in chlorhexidene3. Rub teeth, tongue, gums, and sides of

mouth in circular motion4. Suction oral cavity and do not rinse5. Apply oral moisturizer to lips

Procedure

Continue with routine until patient is receiving thin fluids.

Use moistened toothettes (with water) every 2 hours following oral care

ICU Research

2.0 VAP Bundle Compliance

0%

50%

100%

Month

Percen

tage

Actual Goal

1.0 VAP Rate in ICU per 1000 Ventilator Days

0

10

20

30

40

50

60

Month

VAP

Rat

e pe

r 100

0 Ve

ntila

tor D

ays

Actual Goal

1. Vent Circuit Changed2. HOB>30'3. Oral Care Education Started

Oral Care q12h Implemented Oral Care

Increased to q6h

Questions?Questions?

References

• Gaynor, E. (2001). A Rational for Oral Care. Nursing Standard 15(43): 33-36• Grap, M.J. (2003). Oral Care Interventions in Critical Care: Frequency and Documentation. American journal of

Critical Care, 12(2): 113-119 • Langmore, S.E. et al. (1998) Predictors of Aspiration Pneumonia; How important is Dysphagia? Dysphagia 13:

69-81• Langmore, S.E. et al. (2002) Predictors of Aspiration Pneumonia in Nursing Home Residents. Dysphagia 17: 298-

307• Marik, P. & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. Chest. 124(1):328-336.• McNeil. H. E. (2000). Biting back at poor oral hygiene. Intensive and Critical Care Nursing, 16: 367-372• Mojon, P. (2002) Oral health and respiratory infection. Journal of the Canadian Dental Association. 68(6):340-345.• Mojon, P. & Bourbeau, J. (2003). Respiratory infection: How important is oral health? Current Opinion in

Pulmonary Medicine. 9:166-170.• Okuda, K et al. (1998, Feb). The efficacy of antimicrobial mouth rinses in oral health care. The Bulletin of Tokyo

Dental College. 39(1):7-14• Perry, A.G. et. Al., Clinical Nursing Skills Techniques, Fifth edition (2002) • Shay, K. (2000) Denture Hygiene: A review and update. The Journal of Contemporary Dental Practice. 1(2):1-8.• Terpenning, M. et al. (2001). Aspiration pneumonia: Dental and oral risk factors in an older veteran population.

JAGS. 49:57-563.• Terpenning, M. & Shay, K. (2002). Oral Health is cost-effective to maintain but costly to ignore. Editorial in JAGS,

50:584-585.• Trieger, N. (2004), Oral Care in the Intensive Care Unit, American journal of Critical Care, 13(1): 24-33• Yoneyama, T et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. JAGS. 50:430-433.