trust policy for oral hygiene: inpatients · oral hygiene should be the concern of the whole...

Trust Policy for Oral Hygiene: Inpatients

Document Control

Author/Contact Speech and Language Therapy, Dental Hospital, Academic Palliative and End of Life Care Department, Dietetics, Intensive Therapy, Pharmacy

Document File Path EQMS 8580

Document impact assessed

Yes

Date: 14th March 2018

Version 3.0

Status Approved

Publication Date Date: 13TH December 2018

Review Date 13th November 2020

Approved by Assistant Chief Nurse Date 13th November 2018

Ratified by Clinical Policy and Practice Group

Date 19th July 2018

Distribution: Royal Liverpool and Broadgreen University Hospitals NHS Trust Policy Website Please note that the Policy Website version of this document is the only version that is maintained. Any printed copies must therefore be viewed as “uncontrolled” and as such, may not necessarily contain the latest updates and amendments.

Royal Liverpool and Broadgreen University Hospitals Trust

EQMS 8580 V3 Oral Hygiene Policy 2

Table of Contents

Page

1.0 Introduction 3

2.0 Objective 3

3.0 Scope of Policy 3

4.0 Policy 4

4.1 Introduction 4

4.2 Resources and equipment for Mouth Care 4

4.3 Mouth Care Screen 6

4.3.1 Defining risk 6

4.4 Dysphagia (swallowing difficulties) 7

4.5 Mouth Care Assessment 7

4.6 Mouth Care Plan (both with and without dysphagia) 8

4.6.1 Healthy Mouth 8

4.6.2 Coated Mouth 9

4.6.3 Dry Mouth 9

4.6.4 Sore or ulcerated mouth 10

4.6.5 Oral Thrush 11

4.6.6 Denture Care 12

4.7 Palliative and End of Life Care 13

4.8 Intensive Care 14

4.9 Non-compliant / challenging patients 14

5.0 Roles and Responsibilities 14

5.1 Nursing staff and Health Care Assistants (HCA) 14

5.2 Ward Manager 14

5.3 Matron 15

5.4 Medical Team 15

5.5 Academic Palliative and End of Life Care Department 15

5.6 Speech and Language Therapy (SALT) 15

5.7 Learning Disabilities Team 15

5.8 Liverpool University Dental Hospital 16

5.9 Clinical Policy and Practice Sub-committee 16

6.0 Associated documents and references 16

7.0 Training and Resources 18

8.0 Monitoring and Audit 18

9.0 Equality and Diversity 18

9.1 Recording and Monitoring of Equality & Diversity 19

Appendices 19

1 Glossary of Terms 20

2 Mouth Care Assessment and Screen 21

3 Mouth Care Guideline for Intensive Care (Nursing Guidance) 24

4 Copy of information for ITU bedside information folder 27

5 Summary advice from Liverpool Dental Hospital 29

6 Document history/version control 30



1.0 Introduction This Policy sets out evidence based guidance and standards on oral hygiene (known as ‘mouth care’) for all hospital staff involved in patient care. It provides guidance on the management of routine oral hygiene for all patients, including those with a dry, sore, ulcerated and/or coated mouth/tongue and the management of dentures. It guides staff in providing mouth care for patients who have dysphagia (swallowing difficulties) and highlights the importance of mouth care for those who are Nil By Mouth (NBM). These patients will are likely to have further difficulty, as the ‘oral tissues are more prone to disease and discomfort than those who receive their nutrition orally’ (Griffiths et al, 2010). The policy also incorporates best practice for patients who are approaching the end of their life or are thought to be dying. Oral hygiene should be the concern of the whole multidisciplinary team. It is regarded as an essential aspect of care for all patients. Good oral hygiene is important for eating and drinking, communication, prevention of infection, general facial appearance and expression, and reducing risk of aspiration. Promoting and supporting patients with regular mouth care by leaving them with a clean and refreshed mouth can improve the individual’s overall comfort, health and wellbeing (Locker et al, 2002; Huskinson, 2009, Public Health England 2017). There is increasing evidence to link poor oral health to systemic diseases including cardiovascular disease, diabetes and hospital acquired pneumonia (Winning et al, 2015) poor nutritional intake, longer hospital stays, increased care costs (Terezakis et al, 2011) pain, infection and in some cases, life-threatening illness (Malkin, 2009). 2.0 Objective

The aim of this policy is to provide guidance and standards for hospital staff responsible for providing or assisting patients with mouth care to maintain or improve oral health. This policy will provide an evidence based overview of oral hygiene to guide hospital staff to undertake assessment of the mouth and deliver effective mouth care, which is completed twice daily, or more frequently if required and recorded in the patient’s hospital record as per the Department of Health’s Guidelines ‘Delivering better oral health: an evidence-based toolkit for prevention’ (DoH 2017). 3.0 Scope of Policy

This policy applies to all grades of staff caring for adult inpatients in the Royal Liverpool and Broadgreen University Hospitals NHS Trust including, Nurses and Healthcare Assistants, Doctors, Speech and Language Therapists (SALT), Occupational Therapists, Physiotherapists, Dieticians, and Pharmacists. It is the responsibility of the Registered Nurse to assess, plan, implement and evaluate care as part of the initial and on-going nursing assessment. Relatives and carers of the patient may also wish to be involved with this aspect of care and should be supported in this.



4.0 Policy

4.1 Introduction

Oral hygiene, or mouth care, is the care given to the oral mucosa, lips, teeth, palate, tongue and gums in order to promote comfort and prevent or treat disease. For staff to provide good daily mouth care, they require the:

1. Knowledge of the importance of mouth care and good oral health, and the links to general health and well-being

2. Skills gained through training on how to carry out an assessment of the mouth and how to provide mouth care

3. Resources and equipment 4. Support where necessary from other members of the multidisciplinary team.

4.2 Resources and equipment for Mouth Care

To carry out mouth care assessments and mouth care, hospitals should have a supply of the following:

Pen torch A light source can assist in assessment of the mouth. Without a light source, areas, particularly the palate, can be missed when giving oral hygiene.

Small, soft headed toothbrush

If a patient does not have their own toothbrush on admission to hospital, a soft/medium toothbrush should be provided dependant on patient’s needs. Patients or relatives should be encouraged to bring in the patient’s own toothbrush. A small headed toothbrush is more effective for reaching all parts of the mouth. They can be ordered from April 2018 via supply chain using cost code ILE2307. It can also be used for patients with a sore mouth, ulceration or mucositis (inflammation of the lining of the mouth).

A toothbrush is the only effective way to remove dental plaque from teeth. Toothpaste Wards should have a supply of normal toothpaste (1350-1500ppm Fluoride). . For patients with dysphagia, a smear of non-foaming (Sodium Lauryl Sulphate free/ SLS free) fluoride toothpaste is recommended. This can be ordered via supply chain, using cost code ILA923. A pea sized amount can be used with any patient. Patients should be encouraged to spit out any excess toothpaste if possible, and not rinse their mouths after brushing.



Soft yellow paraffin* Please note, within our Trust soft yellow paraffin should not be used for patients on oxygen therapy, as per the advice of the Oxygen Assessment Service and National Patient Safety Agency. An alternative, non-paraffin based product such as Aquagel, or the Oralieve Dry Mouth Gel listed below, should be used instead. *Please note that ITU have separate guidance on this, please see appendix 3 for more information. Dry mouth products such as Oralieve Dry Mouth Gel

A dry mouth is a very common problem for a hospitalised patient. Dry mouth gels can be very useful in lubricating the mouth to alleviate symptoms, and prior to eating and toothbrushing. Wards should have a stock of dry mouth gels, such as Oralieve Avoid using excessive amounts of gel as this can accumulate in the mouth and become coated in oral debris. Please note that Oralieve gel contains milk, egg and gelatine proteins and may not be suitable for allergy sufferers or some patients who would not wish to use animal products. A number of alternative gels or salivary replacement rinses/sprays are available, see https://www.sps.nhs.uk/wp-content/uploads/2015/07/NW-QA190.8-Saliva-substitutes-.pdf for national guidance. These can also be prescribed by doctors and are listed in the BNF as Artificial Salivas.

Denture pots with lids When dentures are not in the mouth, they should be put in a labelled and dated denture pot with a lid. Dentures should be kept in a safe place. If dentures are ill-fitting this should be clearly documented as this can place the patient at risk of aspiration/choking. Section 10 advises on denture care. **Picture redacted – Section 40(2) Bite Blocks Bite blocks are used for gently propping the mouth open to help with tooth brushing. These may be particularly useful for patients with dementia or patients who find it difficult to open their mouth. The hard foam block is for the patient to bite down on, with a tongue depressor for the staff member to hold and guide. Available on NHS Supplies: Item number: FPA056

https://www.sps.nhs.uk/wp-content/uploads/2015/07/NW-QA190.8-Saliva-substitutes-.pdf





Saline solution

On occasion when it is not clinically possible to perform oral hygiene using a toothbrush, saline solution can be used with gauze to clean a patient’s mouth, particularly the gums and tongue. Mouth care tablets have been used in the past for this purpose, but it has been found that saline solution is just as effective. Pour the saline into a sterile pot and dip the gauze into the solution. Wring excess fluid and wipe gauze on lips, gums, tongue and roof of mouth. Note on foam swabs for oral care Following a Medical Device Alert from the Medicines and Healthcare Regulations Agency (MRHA), foam swabs are banned from use for mouth care on general wards, due to the increased risk of choking. Foam swabs can only be used in the Intensive and High Dependency Units (ITU/HDU) 4.3 Mouth Care Screen

The Mouth Care Screen forms part of a three-part Mouth Care Pack. All patients should have a Mouth Care Screen conducted within 24 hours of admission to hospital as per hospital guidelines, (and then weekly) to assess the levels of support required with mouth care. Mouthcare assessment should be recorded at least twice daily in the patient’s record of care. There is a printed version of this document (Appendix 1) and an electronic version available on PENS entitled Mouth Care Screen, under Nursing Documents. Completion of this form will classify the patient into 3 risk categories:

Independent Partially dependent Dependent If it is identified that the patient is Medium or High Risk (fully or partially dependent) then a full Mouth Care assessment must be completed weekly. PENS will guide the nurse to open a Mouth Care Assessment form, (also available on paper). If a patient requires a Mouth Care Plan, this can be located on PENS (form entitled Mouth Care).



4.3.1 Defining risk Low risk (independent) [coded green]: patients who are independent with regards to caring for their own mouth and have no underlying condition which would increase likelihood of having problems with their mouth: For patients assessed as low risk, the Mouth Care Screen should be repeated weekly. Medium risk (partially dependent) [coded yellow] or high risk (fully dependent) [coded red]: may include patients with the following conditions or situations:

Dementia

Nil by mouth

Learning disabilities/autistic spectrum* Frail elderly

Palliative or end of life care

Severe mental health conditions

Receiving chemotherapy

Uncontrolled diabetes

Intensive or high dependency care

Sedation

Immuno-compromised

Oxygen use

Receiving head and/or neck radiotherapy

Delirium

Stroke Mobility Problems / physical disabilities

Patients should be asked about any existing problems with their mouth including pain and dry mouth. All patients who are considered High (red) or Medium (yellow) risk should have a Mouth Care Assessment completed weekly and all mouth care should be recorded daily on the recording sheet (on PENS or on paper) *Please note that there is a specialist Learning Disabilities Service within our Trust. All patients admitted with a Learning Disability must be referred to this service via ICE. If you have any queries, you can contact the Learning Disabilities team on 0151 706 4602. Every person with a learning disability should have an oral care plan (BSDH, 2012). Section 15 provides further information on how the Learning Disabilities team can support mouth care with this high risk client group. 4.4 Dysphagia Of the categories above, dysphagia can be a common co-morbidity. Dysphagia (swallowing difficulties) has numerous causes and is most commonly seen in elderly patients. The reduced oral clearance in such patients negatively impacts their oral health. A study by Poisson et al. (2014) found that dysphagia was related to oral candidiasis (thrush), dependency for mouth care and reduced saliva production. If patients have severe dysphagia, they may be advised to remain Nil By Mouth (NBM). It is particularly important that these patients are given comprehensive mouth care. When cleaning the mouth of a patient at risk of dysphagia, extra care should be taken to reduce the risk of a patient aspirating toothpaste or any debris that may be present in



the oral cavity. The Mouth Care guidance throughout gives detail on how best to manage oral care in patients with and without dysphagia. The Speech and Language Therapy (SALT) team can assist with particularly complex patients. Some simple instructions that are likely to be beneficial for all patients with dysphagia include good positioning i.e. upright, or as upright as possible, with their head tilted forward to prevent aspiration pneumonia. Nursing staff should be aware of and follow any special guidance from the SALT team relating to oral care for very high risk patients. There is also a summary guidance poster on each ward (Appendix 3). 4.5 Mouth Care Assessment This detailed assessment should be completed for all patients who are considered High (red) or Medium (yellow) Risk following the Mouth Care Screen (See Appendix 1). This should be completed by a Registered Nurse or a staff member who has completed mouth care training. The assessment considers different parts of the mouth (lips, tongue, teeth and gums, cheeks, palate and under tongue, dentures and mouth cleanliness) and assigns a low, medium or high risk rating. It then recommends any actions necessary.

The curtains should be drawn to ensure privacy and dignity

Use the recommended equipment highlighted in Section 6

Wash hands before and after procedure

Wear disposable gloves to reduce the risk of cross infection (and a disposable apron if preferred). Relatives and carers should be encouraged to do the same.

Staff should begin with assessing the lips and then systematically the tongue, palate, cheeks, gums, teeth and dryness of the mouth.

Begin with an external assessment of the lips for cracks and sores. A torch allows for better visibility.

If the patient has dentures, these should be removed from the mouth before assessing the rest of the mouth.

All actions and outcomes must be documented in the patient’s Mouth Care Plan on PENS or on their Daily Recording Sheet.

There is a section to record any referrals for medical or dental advice. 4.6 Mouth Care Plan

Following assessment a Mouth Care Plan should be developed. This will be based on the actions suggested in the Mouth Care Assessment (Appendix 1). 4.6.1 Healthy Mouth Following the Mouth Care Assessment, if the form indicates no action to be taken, the patient should still be encouraged and supported with regular, twice daily mouth care.

Signs and Symptoms



The mouth should be moist, clean and free from odour, pain or discomfort. The tongue should be moist and clean. Lips should be smooth and moist. The teeth and gum margins should be free from a build-up of plaque or food debris. Saliva should be watery and clear. Routine oral hygiene for a patient without dysphagia

Clean tongue, teeth and gums with water or a saline solution and a small headed toothbrush.

Brush teeth at least twice a day using fluoride toothpaste (1350-1500ppm). Spit out excess but do not rinse immediately after brushing the teeth

Oral hydration may be maintained using water, saliva stimulants, gels [such as Oralieve and saliva replacement rinses/sprays. These need to be chosen depending on the individual patient.

Lips can be moistened with non-paraffin based product i.e. aquagel/ Oralieve dry mouth gel

If the patient needs assistance with tooth brushing: Assistance may include:

Helping the patient to walk to a sink to brush their teeth

Supply of a disposable bowl to brush teeth at the bedside

Providing equipment to brush teeth regularly

Helping the patient to brush their teeth if they are having any difficulty doing so themselves. It can be helpful to use a small headed toothbrush holding toothbrush at a 45 degree angle to the gum margin, sweeping in the downward direction. Systematically clean all surfaces of the teeth. Do not rinse.

Routine oral hygiene for a patient with dysphagia For patients who have been assessed by Speech and Language Therapy (SALT) as having dysphagia or are “Nil By Mouth” (NBM), it is important that tooth brushing is still carried out daily. Position the patient as upright as possible and do not use water on the toothbrush. A smear (a very small amount) of non-foaming Sodium Lauryl Sulphite free (SLS free) toothpaste can be used. The SALT team may recommend that suction is used for high-risk patients. 4.6.2 Coated Mouth /Tongue

Signs and symptoms

Adherent, white, brown or black coating on tongue.

Dried saliva or mucus may have coated the teeth and gums.

Mouth maybe dry. Causes



A coated mouth may be caused by dehydration, poor oral care, smoking. Often worse if NBM.

A coated tongue alone is not indicative of oral Candidiasis (thrush). Management for a patient without dysphagia

Routine oral hygiene as above.

Clean tongue with water using a soft toothbrush.

4 times daily using a small, soft headed toothbrush.

Consider care for dry mouth (see below) –saliva replacements maybe indicated Management for a patient with dysphagia

Oralieve dry mouth gel 4 times daily using a small, soft headed toothbrush (liaise with SALT if any concerns)

Clean mouth as per healthy mouth with a smear of toothpaste 4.6.3 Dry Mouth Signs and symptoms

Dryness of the oral mucous membranes and lips. Fissuring of tongue may be visible.

No evidence of saliva in the floor of the mouth. Oral debris and dried saliva accumulate.

Difficulty swallowing or chewing, Impaired taste. Difficulty with speech if severe.

Causes A dry mouth may be caused by dehydration, oxygen therapy, side effects from medication, damage to salivary glands, diabetes, reduced ability in managing own oral care, mouth breathing, or if the patient is approaching the end of their life or thought to be dying. Management for a patient without dysphagia

Routine oral hygiene as above.

Consider reversible causes i.e. dehydration, diabetic control or medications.

In discussion with the medical team, review the need for oxygen or switch to humidified oxygen (as prescribed).

Patients may benefit from non-foaming SLS free toothpaste (as SLS can dry the mouth out further).

Moistening agents to tongue, palate, lips and soft tissues, such as Oralieve dry mouth gel every 2 hours using a small, soft headed toothbrush or gauze.

Saliva stimulants – sugar free chewing gum if appropriate, Salivix Pastilles or SST tablets Saliva replacements need to be chosen dependant on the individual patient.

Frequent sips of water and during meals.

Avoid dry food that may be difficult or uncomfortable to eat or swallow

Also consider



Ice chips to suck (if safe to do so) Management for a patient with dysphagia

Ensure regular fluids via alternative means i.e. Intra venous fluids or via a nasogastric tube.

Dry Mouth Gel e.g. Oralieve x 4 times daily using a small, soft headed toothbrush.

Non-paraffin based product for lips i.e. aquagel/ Oralieve gel

SLS free toothpaste with suctioning as required

Regular oral care using gauze dipped in saline or soft toothbrush (no excess fluid) 4.6.4 Sore or Ulcerated Mouth

Signs and symptoms

Swelling, ulcers, redness of oral mucosa and soreness.

Eating and drinking painful and difficult - nutrition can be affected if condition persists.

A single, persistent ulcer with firm, raised margins should raise suspicion of an oral cancer.

Causes A sore or ulcerated mouth can be caused by underlying systemic diseases, haematinic deficiencies /side effects of medication or treatment and infections, ill-fitting dentures or sharp teeth. Patient may have a history of recurrent mouth ulcers (aphthae). Possible - squamous cell carcinoma requires urgent specialist opinion. Management for a patient without dysphagia

Check for and manage any underlying cause or potential trauma

Treat oral candidiasis on basis of clinical presentation (see below).

If a solitary ulcer is present with no obvious cause – refer urgently for assessment (Appendix 5).

Patients with persistent, widespread or undiagnosed oral ulceration require a specialist opinion (Appendix 5)

Maintain oral hygiene (see above)

If toothbrushing is too painful-consider chlorhexidine 0.2 % mouthwash or spray (reduces plaque formation and secondary infection in oral ulceration).

Provide symptomatic relief as per Trust formulary: Topical Analgesia:



o Benzydamine Oral Rinse 0.15% solution: 15 mL every 1.5 – 3 hours as required (usually for not more than 7 days). If stinging occurs, dilute with an equal volume of water. May also benefit from rinsing mouth with saline.

OR

o Benzydamine Oral Spray (Difflam spray): 4 – 8 puffs onto affected area every 2 – 3 hours as required (do not swallow in large amounts) or Benzydamine oral rinse 0.15% solution alcohol free 15ml (can dilute with an equal volume of water if stinging occurs)

o Systemic Analgesia: As prescribed by the Doctor, adhering to the analgesic

ladder, Topical analgesia is often sufficient.

Management for a patient with dysphagia

As for patients without dysphagia but do not use oral rinses

o Soak gauze in Benzydamine Oral Rinse 0.15% solution (alcohol free mouth wash): 15 mL, remove excess fluid and gently wipe over coated surfaces, teeth and gums.

4.6.5 Oral Candidiasis :Thrush (fungal infection)

Signs and symptoms Creamy white plaques that rub off easily. The underlying mucosa maybe red. Corners of mouth are often cracked and sore [angular cheilitis]. Causes Oral thrush can be caused by medication (particularly steroids and antibiotics), immunosuppression, diabetes, oxygen therapy, dehydration and poor oral / denture hygiene. Management for a patient without dysphagia

Consider underlying cause and manage

Routine oral and denture hygiene

Dentures can be soaked in 0.2% chlorhexidine mouthwash solution overnight (see below).

Topical treatments: Check BNF for up to date prescribing guidelines.

Nystatin Oral Suspension (avoid diet and fluids for 30 minutes after application. Avoid concurrent use with Chlorhexidine.

Miconazole Oral Gel – Continue use for 48 hours after oral thrush has resolved. Systemic treatment: Check BNF for up to date prescribing guidelines.

Fluconazole capsules



Fluconazole oral suspension

Advise change in toothbrush at start of treatment and then again at the end to reduce risk of re- infection.

Management for a patient with dysphagia

Check BNF for up to date prescribing guidelines. (Consult with SALT team)

Fluconazole oral suspension: check BNF online for prescribing guidelines. o Can be given via NG or PEG tube

Nystatin: Carefully drip 1ml onto front of tongue whilst head in upright position.

Miconazole gel and Fluconazole both raise the INR in patients on Warfarin so monitor INR and adjust Warfarin if these are prescribed. 4.6.6 Denture Care

It is vital that dentures are kept safe whilst the patient is in hospital. The loss or breakage of dentures can have a detrimental effect on health and general wellbeing. A patient may experience difficulty with speech, nutritional needs and develop low self-esteem. If dentures are lost or broken a Datix Incident Form must be completed as per Trust policy.

Dentures can be made of metal or acrylic parts.

Complete top and bottom set of dentures; replaces all of the teeth and the adjacent gums.

Partial dentures; bridges the space between missing tooth/teeth Good denture care can reduce the risk of patients developing oral candidiasis (Thrush). Denture care for patients without dysphagia

Remove dentures when cleaning or assessing mouth and at night.

Dentures should be cleaned with a toothbrush or denture brush using either liquid soap or toothpaste at least twice a day

After washing, if not immediately going back in the patient’s mouth, dentures should be stored in a labelled denture pot in cold water

A new denture pot should be supplied every day

Patients who have dentures still require their mouths cleaning routinely as detailed above.

Rinse mouth and dentures with water after meals

Do not leave dentures to dry out as this may cause them to warp.

Dentures should be removed at night and stored in pot , containing water

A saliva substitute may be required before replacing dentures in the mouth Saliva substitutes need to be chosen dependant on the individual patient.

If a patient has oral candidiasis [thrush] their dentures should be cleaned and soaked in Chlorhexidine (0.2%) Mouthwash Solution for 15 minutes twice daily.



Denture care for patients with dysphagia

Remove dentures and clean as above, following guidance from section 4.4.1 in

how to clean the mouth of a patient with dysphagia

4.7 Routine oral hygiene and treatment for a patient who is approaching the end

of their life or thought to be dying

The principles of oral hygiene for any patient who is approaching the end of their life or thought to be dying and in the last hours and days of life, are essentially the same as for any other patient and aimed at keeping the mouth moist and clean. The major difference is that the patient is unlikely to be able to take active measures to care for their own oral hygiene. Wherever possible, these patients should be encouraged and supported to eat and drink for as long as possible, if safe to do so. These patients may also experience dysphagia. Coughing and aspiration can be distressing so staff should ensure it is safe for the patient to continue to eat or drink. Liaise with SALT where appropriate. It is essential that oral hygiene is provided by staff and supported by a relative or carer if they feel able to and wish to help with oral care. While it is important that relatives or carers are given the opportunity to help provide care, others find it distressing and difficult. It is therefore important that relatives or carers do not feel pressurised into providing oral hygiene. Professional carers remain accountable and have a duty of care to always provide adequate instruction, supervision and support for this task. Oral hygiene is essential for the maintenance of patient comfort, to maintain dignity and respect and to support the patient to retain an ability to talk with those closest to him or her. Relatives and carers may wish to be very close or to kiss the patient’s face; therefore it is imperative that the patient’s mouth is kept as clean and fresh as possible. This can be achieved by providing:

Regular oral hygiene, (i.e. at least at two hourly intervals) as per policy above.

Giving the patient the opportunity to have a mouth moisture boost in whichever form the patient prefers, e.g. sips of water, ice cubes, ice lollies, if safe to do so.

Moistening agents to tongue, palate, lips and soft tissues, such as Oralieve dry mouth gel every 2 hours using a small, soft headed toothbrush or gauze.

Lips can be moistened with non-paraffin based product ie aquagel/ Oralieve dry mouth gel

4.8 Oral care in the Intensive or High Dependency Unit

Patients in the Intensive or High Dependency Unit have very specific needs. Organisms can colonize in the mouths of critically ill patients which are more virulent, compared to organisms in the mouths of healthy individuals. Plaque formation increases when salivary flow is reduced. In patients with altered consciousness levels / those who are Nil By Mouth or dysphagic, there is a potential risk of aspiration as oral secretions can pool in the oropharynx and then leak past the Endotracheal Tube increasing the risk of Ventilator Associated Pneumonia. 4.9 Non-compliant patients



Patients (regardless of age, physical or mental health) may refuse or resist mouth care (NICE, 2018). To promote mouth care, explain of the importance of oral hygiene and the risks associated with non-compliance, encourage patient participation and independence as much as possible, utilise the support of other staff members and create a positive and calm environment. If requiring further support, please liaise with the specialist teams listed below. If the patient continues to refuse mouth care, it is important to document this in their medical notes. Return later to the patient to offer again. It may be appropriate to provide mouth care whilst family members are present if this aids compliance. 5.0 Roles and Responsibilities

5.1 Nursing Staff and Health Care Assistants

It is the responsibility of the Registered Nurse to assess, plan, implement and evaluate care using the tools provided and detailed above. This should happen within 24 hours of admission and on-going throughout the patient’s stay. Nurses, Health Care Assistants and Student Nurses may deliver or assist with oral hygiene to patients following appropriate mouth care training. The Nursing and Midwifery Council’s Code (Professional standards of practice and behaviour for nurses and midwives 2015) states that there must be a current and appropriate plan of care for all patients. The plan must incorporate on-going evaluation and reassessment of care, and provide evidence that relevant observations and interventions have been communicated to appropriate members of the multidisciplinary or medical teams. Staff are advised to seek training and support from the Speech and Language Therapy Team (SALT) and the Academic Palliative and End of Life Care Team as appropriate, to maintain their skills in this area. 5.2 Ward Manager The Ward Manager must ensure that the policy is adhered to at all times. It is the responsibility of Ward Manager to ensure that all staff are trained in oral hygiene and any challenges are reported via the Perfect Ward Meeting. They must ensure that any adverse events or challenges are reported via the Trust Datix system to highlight areas where improvement is needed. 5.3 Matron

It is the responsibility of the Matron to demonstrate assurance (within the clinical area) that the policy is being adhered to via audit and other available information. any challenges are reported via the Perfect Ward Meeting. They must ensure that any adverse events or challenges are reported via the Trust Datix system to highlight areas where improvement is needed. 5.4 Medical Team

Doctors are responsible for the on-going care of their patients. This may involve oral examination as part of a general examination to rule out oral causes of ill health (for

http://www.nmc.org.uk/standards/code/



example oral ulceration). Doctors will be responsible for prescribing any medications required to treat any of the conditions listed above (such as thrush and severe dry mouth). 5.5 The Academic Palliative and End of Life Care Team The Doctors and Nurses on the Academic Hospital Specialist Palliative Care Team will advise the clinical teams on the symptom management of any patient with palliative care needs, not just limited to those thought to be imminently dying. This may also include advice on artificial hydration and oral care. They can assist the treating teams with sensitive and difficult conversations with relatives and carers. They provide regular education sessions to the multidisciplinary teams on all aspects of care in the context of life limiting illness, including the importance of providing exceptional oral care at this time. 5.6 Speech and Language Therapy (SALT)

The SALT team provide advice regarding the safety of oral intake for patients who are at risk of dysphagia (swallowing difficulties). These patients, as discussed in Section 7.0 are at an increased risk of poor oral hygiene, and can be considered high risk. The SALT team can advise on oral problems such as mobile teeth, poor oral hygiene and very dry mouths, as they routinely assess mouths as part of a dysphagia examination. SALT will provide recommendations regarding management of oral hygiene for these patients and will support and implement staff training to ensure competent mouth care is provided on wards. SALT will also implement the policy on the wards. 5.7 Learning Disabilities Team The Learning Disabilities team support patient with a learning disability throughout their stay in hospital; often from pre-admission to discharge. They provide training to help staff understand how to best care for people with a learning disability and suggest reasonable adjustments to maximise comfort and quality of care. People with Learning Disabilities are at high risk of poor oral hygiene secondary to problems with tongue thrusting, gagging or retching on brushing, reduction in oral sensitivity, problems with oral clearance and/or reduction or lack of co-operation (BSDH, 2012). The Learning Disabilities team will assist in assessing the need of the patient, and promoting the optimal environment to carry out oral hygiene with this population. 5.8 Liverpool University Dental Hospital For Urgent In-patient Dental Referral,

This service is restricted to patients with:

acute dental pain not relieved by simple analgesia

facial swellings without systemic upset or airway compromise

mobile teeth at risk of aspiration

5.9 The Clinical Policy and Practice Sub-Committee



Will review this policy and ratify as required. Please note at the time of release the NICE guidelines for Oral Hygiene in Hospital Settings was not published. This policy may be amended following new guidelines on release of this national publication.

6.0 Associated Documents and References

BNF (2015) British National Formulary. BMJ group and RPS publishing, London.

Bragg J. (2003) Oral Candidosis: how to treat a common problem Eur J Pall Care;

10(2): 54-56.

BSDH (2012) Clinical Guidelines and Integrated Care Pathways for the Oral Health Care of People with Learning Disabilities. http://www.wales.nhs.uk/documents/BSDH_Clinical_Guidelines_PwaLD_2012.pdf Department of Health (2017) Delivering better oral health: an evidence-based toolkit for prevention. London

Duffin, C. (2008) Brushing up on oral hygiene – nursing older people, 20 (2), 14-16.

Ellers J, Berger A, Peterson M (1998) Development, testing and application of the oral

assessment guide. Oncology Nursing Forum 15(3): p325-330

Fraise, A P and Bradley, T. (2009) Ayliffes control of healthcare – associated infection: a practical handbook, 5th edn. Hodder Arnold, London Griffiths, J., Jones, v., Leeman, I., Lewis, D., Patel, K., Wilson, K. (2010). Guidelines for

the development of local standards for dependents, dysphagic, critically and terminally

ill patients. British Society for Disability and Oral Health.

Huskinson, W. and Lloyd, H. (2009) Oral health in hospitalised patients: assessment

and hygiene. Nursing standard, 23 (36), 43-47.

Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press <http://www.medicinescomplete.com> [Accessed on 09/03/17]

Locker, D., Matear, D., Stephens, M., Jokovic, A. (2002) Oral health-related quality of

life of a population of medically compromised elderly people. Community Dental Health;

19 (2): 90-97.

Malkin, B. (2009) the importance of patients oral health and nurses role in assessing

and maintaining it. Nursing times, 105 (17), 19-23.

National Institute for Health and Care Excellence. April 2015. Clinical Knowledge Summaries: Palliative cancer care – oral (Last revised in April 2015), via http://cks.nice.org.uk/palliative-cancer-care-oral#!topicsummary [accessed June 2015] National Institute for Health and Care Excellence. (2018). Oral health for adults in care homes. https://www.nice.org.uk/guidance/ng48/resources/oral-health-for-adults-in-care-homes-1837459547845

http://www.medicinescomplete.com/

http://cks.nice.org.uk/palliative-cancer-care-oral#!topicsummary



Public Health England, (2017). Delivering better oral health: an evidence based toolkit for prevention. Third edition. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/605266/Delivering_better_oral_health.pdf [accessed Jan 2018]

Roberts J (2000) Developing an oral assessment and intervention tool for older people: 2. British Journal of Nursing. 9, 18 2033-2040). Royal Liverpool and University Hospitals NHS Trust (2013) Policy for prescribing supplemental oxygen EQMS83 Salamone K, Yacoub E, Mahoney AM, Edward K. 2013. Oral Care of Hospitalised Older Patients in the Acute Medical Setting. Nursing Research and Practice, via http://dx.doi.org/10.1155/2013/827670 (accessed June 2015)

Sweeney, P. (2005) Oral hygiene; in oral care in advanced disease (eds Davies A. and

Finlay I. Oxford University Press, Oxford, 23-35.

Terizakis, E., Needleman, I., Kumar, N., Moles, D., Agudo, E. (2011) The impact of

hospitalization on oral health; a systemic review. Journal of Clinical Periodontology; 38

(7): 628-638.

The Nursing and Midwifery Council (2015) The Code: professional standards of practice

and behaviour for nurses and midwives. NMC London.

Nursing and Midwifery Council (2004; updated March 2015) Standards for competence

for registered nurses. NMC London

Winning, L. & Linden, J (2015) Periodontitis and systemic disease. BDJ team 2.

British Medical Association (2005) Nurse Prescribers’ Formulary – for community

practitioners London: BMA.

Davies A, Finlay I. (2005) Oral Care in Advanced Disease. Oxford University Press

De Conno F, Cinzia Martini C, Sbanotto A, Ripamonti C & Ventafridda V: Mouth care in Hanks G, Cherny NI, Christakis NA, Fallon M, Kassa S, Portenoy RK (eds) (2010) Oxford Textbook of Palliative Medicine, Fourth Edition Oxford University Press: Oxford Dougherty, L., Lister, S. (2011) The Royal Marsden Hospital Manual of Clinical Nursing

Procedures. 8th Edition. Wiley – Blackwell.

Ellershaw JE, Sutcliffe JM, Saunders CM. (1995) Dehydration and the dying patient.

Journal of Pain & Symptom Management; 10(3), 192-197

Ellershaw JE, Wilkinson S. (2011) Care of the Dying A pathway to excellence 2nd edition

Oxford University Press.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/605266/Delivering_better_oral_health.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/605266/Delivering_better_oral_health.pdf

http://dx.doi.org/10.1155/2013/827670

http://www.nmc.org.uk/standards/code/

http://www.nmc.org.uk/standards/additional-standards/standards-for-competence-for-registered-nurses/

http://www.nmc.org.uk/standards/additional-standards/standards-for-competence-for-registered-nurses/



Joint Formulary Committee. British National Formulary 65. London: British Medical

Association and Royal Pharmaceutical Society of Great Britain, 2013.

Marlow, C. (2005) A guide to managing the pain of treatment-related oral mucositis.

International Journal of Palliative Nursing ; Vol 11 no 7 p 338-345.

Rydholm M, Strang P. (2002) Physical and psychosocial impact of xerostomia in

palliative care. Int J Palliat NurS; 8(7): 318-323.

7.0 Training and Resources A Mouth Care e-learning programme has been developed for completion by all nursing and HCA staff as part of their mandatory training. To complete this training, please liaise with the Learning and Development team on 0151 706 3747 or search for Oral Hygiene on the clinicalskills.net site. Health Care Assistants will also require practical training which will be given as part of their Induction Programme or as part of a training course. Registered Nurses will provide on-going patient assessment, support and advice education and training to Health Care Assistants, and relatives or carers. The Speech and Language Therapy Team and the Academic Palliative and End of Life Care Team can be contacted for any additional support and advice. 8.0 Monitoring and Audit Implementation of the policy will be supported and monitored by the Ward Managers. A review of the previous policy and its implementation was conducted by the SALT team in 2017 to ensure inclusion and representation of dysphagic and Nil By Mouth patients. The SALT team, alongside Ward Managers and Matrons will monitor compliance with the policy via local audit results and data from concerns and complaints via Datix. Any challenges will be reported via Perfect Ward. 9.0 Equality and Diversity The Trust is committed to an environment that promotes equality and embraces diversity in its performance as an employer and service provider. It will adhere to legal and performance requirements and will mainstream equality and diversity principles through its policies, procedures and processes. This policy should be implemented with due regard to this commitment. To ensure that the implementation of this policy does not have an adverse impact in response to the requirements of the Equality Act 2010 this policy has been screened for relevance during the policy development process and a full equality impact analysis conducted where necessary prior to consultation. The Trust will take remedial action when necessary to address any unexpected or unwarranted disparities and monitor practice to ensure that this policy is fairly implemented. This policy and procedure can be made available in alternative formats on request including large print, Braille, moon, audio, and different languages. To arrange this



please refer to the Trust translation and interpretation policy and the Accessible Publications Policy in the first instance. The Trust will endeavor to make reasonable adjustments to accommodate any employee/patient with particular equality and diversity requirements in implementing this policy and procedure. This may include accessibility of meeting/appointment venues, providing translation, arranging an interpreter to attend appointments/meetings, extending policy timeframes to enable translation to be undertaken, or assistance with formulating any written statements. 9.1 Recording and Monitoring of Equality and Diversity The Trust understands the business case for equality and diversity and will make sure that this is translated into practice. Accordingly, all policies and procedures will be monitored to ensure their effectiveness. Monitoring information will be collated, analysed and published on an annual basis as part Equality Delivery System. The monitoring will cover the nine protected characteristics and will meet statutory duties under the Equality Act 2010. Where adverse impact is identified through the monitoring process the Trust will investigate and take corrective action to mitigate and prevent any negative impact. The information collected for monitoring and reporting purposes will be treated as confidential and it will not be used for any other purpose. Appendices

Appendix 1: Glossary of terms

Appendix 2: Mouth Care Screen and Assessment Tool

Appendix 3: Mouth Care Guideline within Intensive Care (Nursing Guidance) summary

Appendix 4: Copy of information for ITU bedside Information Folder

Appendix 5: Guidelines from the Liverpool University Dental Hospital

Appendix 6: Mouth care product ordering poster Appendix 7: Document History/Version Control Appendix 1: Glossary of Terms

http://rq6eqms01/lcgqeqms/Administrator/LoadDocADM.asp?ID=130&Ext=True&CCID=1





- Dysphagia: a medical team used to describe difficulty swallowing food or fluids. In its most severe form, patients can be advised to remain Nil By Mouth

- Nil By Mouth (NBM): No oral intake

- Oral hygiene: or mouth care, is the care given to the oral mucosa, lips, teeth, palate, tongue and gums in order to promote comfort and prevent or treat disease.



Appendix 2: Mouth Care Screen and

Assessment Tool

Patient Name ____________________ RQ ____________________ DOB ____________________

Amended with permission from NHS England Mouth Care Matters Mouth Care Pack http://www.mouthcarematters.hee.nhs.uk/wp-content/uploads/2016/10/MCM_PACK_KB_V4_sp.pdf




Assessment Tool


DATIX IF LOST AND PATIENT TO SEE OWN DENTIST TO REPLACE ON DISCHARGE




Assessment Tool


Amended with permission from NHS England Mouth Care Matters Mouth Care Pack http://www.mouthcarematters.hee.nhs.uk/wp-content/uploads/2016/10/MCM_PACK_KB_V4_sp.pdf


25

Oral Care within the Critical Care Department: Nursing Guidance

REDACTED – Section 40(2)

July 2017

Introduction Ventilated patients can harbour respiratory pathogens increasing the risk of ventilated Associated Pneumonia. The Critically ill patient’s mouth can become colonized within 48 hours of admission to hospital with bacteria that tends to be more virulent then those found in healthy individuals mouths (Abidia, 2007; Turk et al, 2012). Ventilator associated pneumonia (VAP), occurs in up to 25% of ventilated patients (Zuckerman, 2016) increasing mortality, length of stay and cost (Hellyer et al, 2016). Aspiration of the infectious bacteria from the oral cavity will cause pneumonia (Scannapieco et al, 2014); therefore, placement of an endotracheal tube through the larynx and trachea can provide a route for bacteria to attach to the respiratory epithelium. Oral hygiene is an integral part of nursing and an inexpensive method of controlling oropharyngeal colonisation (Chan, 2005; Coker et al, 2013). This highlights the importance of effective mouth care in minimising VAP and should not be only a comfort measure. VAP is described as a pneumonia that develops 48 hours or more after intubation with an endotracheal tube or a tracheostomy tube, which was not present before intubation. HAP is defined as a pneumonia that occurs 48 hours or more after admission that was not incubating before admission. The use of oral Chlorhexidine is widespread and recommended in previous guidelines. The ICS does not recommend the use of oral chlorhexidine in non-cardiac surgery patients. Furthermore, the National Institute for Clinical Excellence (NICE) has recently withdrawn its

Guideline

Appendix 3: Oral Care within the Critical Care Department: Nursing Guidance


26

VAP prevention recommendations in light of this. The BMJ (2014) report oropharyngeal chlorhexidine was associated with an increased mortality in adult in general Intensive care units. Therefore, Chlorhexidine is no longer included in the recommends for the care of general intensive care patients (GPICS, 2015). Patient Inclusion Oral care is recommended for all patients admitted to Intensive care. Patient Exclusion/Considerations Patients with deranged clotting or a low platelet count are at a higher risk of bleeding; therefore, they should be discussed with the doctor. Medical advice should also be sought for patients with maxillofacial trauma or post oral surgery. Guidelines in providing mouth care to patients in Intensive Care & Preventing VAP: Having access to the oral cavity can be limited when patients are intubated with an endotracheal tube. This can cause a fear of displacement or dislodging the tube when providing oral care.

Patients should be nursed in a semi-recumbent position (head elevation 30°-45°)

Oxygen should be humidified to prevent the oral mucosa drying excessively causing

cracks and sores which allows bacteria to multiply.

Mechanically ventilated patients should have their tracheal cuff pressure maintained

above 20 cmH20. Checked and documented 4 hourly. The presence of an Endotracheal

Tube allows direct entry of bacteria into the pulmonary tract, impairs the cough reflex and

promotes excessive oral secretion production.

Oral secretions can be uncomfortable for patients to swallow and pose as a high risk of

aspiration or cause excessive dribbling. Oral suctioning should be performed with a

maximum pressure of 20kpa/150mmHg to minimise the risk of trauma to the oral tissues.

Tooth brushing should be performed 12 hourly using a soft bristled and toothpaste.

Toothpaste will dry and harden on the mucosa impeding effort to keep the mouth clean.

Sterile water (a minimum of 20ml) should be used to rinse the oral cavity, using a yankeur

for suctioning to avoid aspiration.

2-4 hourly mouth care with sterile H20 and green sponges.

Moistening of lips with yellow soft paraffin and movement of ET tube position 4 hourly to

prevent cracking, sores and pressure damage. Intact lips provide a natural barrier

therefore If skin is not intact this leads to potential pathogens invading the oral cavity

ET tapes should be clean and dry. They are to be changed at least 12 hourly to prevent

pressure/moisture damage. High risk patients should have them changed 6 hourly.

Documenting the position of ETT, tape changes and skin inspection.


27

Subglottic aspiration. A tracheal tube which has a subglottic secretion drainage port

should be considered for patients expected to be intubated >72 hours. Providing 1-2

hourly secretion aspirations.

References Abidia, R. F. (2007). Oral Care in the Intensive Care Unit: A Review. The Journal of Contemporary Dental Practice. 8 (1), 1-8 Chan, E. Y. (2005) sited in: Oral decontamination with chlorhexidine reduced ventilator

associated pneumonia in patients needing mechanical ventilation for ⩾48 hours http://ebn.bmj.com/content/10/1/19.full#cited-by Accessed 18/12/2016 Coker, E. Ploeg, J. Kaasalainen, S. & Fisher, A. (2013) A concept analysis of oral hygiene care in dependent older adults Journal Of Advanced Nursing, 69, 10, pp. 2360-2371, MEDLINE with Full Text, EBSCOhost, viewed 5 January 2017. Guidelines for the Provision of Intensive Care Services (GPICS). (2015) Edition 1. Hellyer, T.P. Ewan, V. Wilson, P. and Simpson, AJ. (2016). The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. http://journals.sagepub.com/doi/full/10.1177/1751143716644461. Last accessed 09/07/2017. Price, R. MacLennan, G. Glen, J. (2014). Slective digestive or oropharyngeal decontamination and topical oropharnygeal chlorhexidine for the prevention of death in general Intensive care: systematic review and network meta-analysis. The BMJ. 348:g2197 https://doi.org/10.1136/bmj.g2197. Accessed 08/07/2017 Scannapieco, F.A and Shay, K. (2014). Oral Health Disparities in Older Adults: Oral Bacteria, Inflammation, and Aspiration Pneumonia. Geriatric Dentistry. 58 (4), 771-782. http://dx.doi.org.liverpool.idm.oclc.org/10.1016/j.cden.2014.06.005. Accessed 05/01/2017 Turk, G. Kocacal, G.E. Eser, I. Khorshid, L. (2012). Oral Care Practices of Intensive Care Nurses: A descriptive Study. International Journal of Nursing Practice. 18, 347-353. Zuckerman, L.M (2016). Oral Chlorhexidine Use to Prevent Ventilator-Associated Pneumonia in Adults: Review of the Current Literature, Dimensions Of Critical Care Nursing: DCCN, 35, 1, pp. 25-36, MEDLINE with Full Text, EBSCOhost, viewed 5 January 2017.

http://journals.sagepub.com/doi/full/10.1177/1751143716644461.%20Last%20accessed%2009/07/2017

https://doi.org/10.1136/bmj.g2197

http://dx.doi.org.liverpool.idm.oclc.org/10.1016/j.cden.2014.06.005.%20Accessed%2005/01/2017


28

Oral Care within the Critical Care Department: Nursing Guidance

REDACTED – Section 40(2) July 2017

Rationale Ventilated patients can harbour respiratory pathogens increasing the risk of ventilated Associated Pneumonia. The Critically ill patient’s mouth can become colonized within 48 hours of admission to hospital with bacteria that tends to be more virulent then those found in healthy individuals mouths (Abidia, 2007; Turk et al, 2012). Aspiration of the infectious bacteria from the oral cavity will cause pneumonia (Scannapieco et al, 2014); therefore, placement of an endotracheal tube through the larynx and trachea can provide a route for bacteria to attach to the respiratory epithelium; Oral hygiene is an integral part of nursing and an inexpensive method of controlling oropharyngeal colonisation (Chan, 2005; Coker et al, 2013). Patient Inclusion Oral care is recommended for all patients admitted to Intensive care. Patient Exclusion/Considerations Patients with deranged clotting or a low platelet count are at a higher risk of bleeding; therefore, they should be discussed with the doctor. Medical advice should also be sought for patients with maxillofacial trauma or post oral surgery. Guidelines in providing mouth care to patients in Intensive Care & Preventing VAP:

Having access to the oral cavity can be limited when patients are intubated with an endotracheal tube. This can cause a fear of displacement or dislodging the tube when providing oral care.

Patients should be nursed in a semi-recumbent position (head elevation 30°-45°)

Oxygen should be humidified to prevent the oral mucosa drying excessively causing

cracks and sores which allows bacteria to multiply.

Mechanically ventilated patients should have their tracheal cuff pressure maintained

above 20 cmH20. Checked and documented 4 hourly. The presence of an Endotracheal

Tube allows direct entry of bacteria into the pulmonary tract, impairs the cough reflex and

promotes excessive oral secretion production.

Appendix 4: Copy of ITU bedside information folder


29

Oral secretions can be uncomfortable for patients to swallow and pose as a high risk of

aspiration or cause excessive dribbling. Oral suctioning should be performed with a

maximum pressure of 20kpa/150mmHg to minimise the risk of trauma to the oral tissues

Tooth brushing should be performed 12 hourly using a soft bristled brush and toothpaste.

Toothpaste will dry and harden on the mucosa impeding effort to keep the mouth clean.

Sterile water (a minimum of 20ml) should be used to rinse the oral cavity, using a yankeur

for suctioning to avoid aspiration.

2-4 hourly mouth care with sterile H20 and green sponges.

Moistening of lips with yellow soft paraffin and movement of ET tube position 4 hourly to

prevent cracking, sores and pressure damage. Intact lips provide a natural barrier

therefore If skin is not intact this leads to potential pathogens invading the oral cavity.

ET tapes should be clean and dry. They are to be changed at least 12 hourly to prevent

pressure/moisture damage. High risk patients should have them changed 6 hourly.

Documenting the position of ETT, tape changes and skin inspection.

Subglottic aspiration. A tracheal tube which has a subglottic secretion drainage port

should be considered for patients expected to be intubated >72 hours. Providing 1-2

hourly secretion aspirations.

Full details and guidelines can be found on the Critical Care Resources File. References

Abidia, R. F. (2007). Oral Care in the Intensive Care Unit: A Review. The Journal of Contemporary Dental Practice. 8 (1), 1-8 Chan, E. Y. (2005) sited in: Oral decontamination with chlorhexidine reduced ventilator

associated pneumonia in patients needing mechanical ventilation for ⩾48 hours http://ebn.bmj.com/content/10/1/19.full#cited-by Accessed 18/12/2016 Coker, E. Ploeg, J. Kaasalainen, S. & Fisher, A. (2013) A concept analysis of oral hygiene care in dependent older adults Journal Of Advanced Nursing, 69, 10, pp. 2360-2371, MEDLINE with Full Text, EBSCOhost, viewed 5 January 2017. Guidelines for the Provision of Intensive Care Services (GPICS). (2015) Edition 1. Scannapieco, F.A and Shay, K. (2014). Oral Health Disparities in Older Adults: Oral Bacteria, Inflammation, and Aspiration Pneumonia. Geriatric Dentistry. 58 (4), 771-782. http://dx.doi.org.liverpool.idm.oclc.org/10.1016/j.cden.2014.06.005. Accessed 05/01/2017 Turk, G. Kocacal, G.E. Eser, I. Khorshid, L. (2012). Oral Care Practices of Intensive Care Nurses: A descriptive Study. International Journal of Nursing Practice. 18, 347-353.

http://dx.doi.org.liverpool.idm.oclc.org/10.1016/j.cden.2014.06.005.%20Accessed%2005/01/2017


30

Appendix 5: Liverpool University Dental Hospital; Urgent Dental Advice and Management for RLH/BGH Patients

Liverpool University Dental Hospital (LUDH) is an out-patient service operating Monday to Friday 9.00 am - 4.30 pm only (excluding public holidays). There is no access to advice or support outside of these hours.

1. In-patient Urgent Dental Referral - This service is restricted to patients with:

Acute dental pain not relieved by simple analgesia

Facial swellings without systemic upset or airway compromise

Mobile teeth at risk of aspiration

Suspicious, widespread or persistent ulceration

Undiagnosed oral mucosal lesions/ conditions

Persistent oral candidiasis

Referrals can be made by faxing the relevant referral form to 0151 706 5806 or by telephoning Ext: 5061/ 5047/5000 In the majority of cases, after telephone triage, the patient will require ward arranged transport to LUDH. The patient must be accompanied by a member of RLUH staff and any paper casenotes must accompany the patient. Where a patient is not fit for transfer to the Dental Hospital e.g. patients in ITU/HDU/theatres, a member of LUDH staff will carry out initial assessment on the in- patient ward. For ward patients without systemic upset outside office hours, please mange symptomatically and refer at earliest opportunity. Patients requiring urgent advice or guidance:

For a full copy of the Guidance “Liverpool University Dental Hospital Urgent Dental Advice and Management for RLUH/BGH Patients” including Referral Forms please contact the Liverpool Dental Hospital. Ext: 5061/ 5047/5000.


31

Appendix 6: Mouth Care Product Ordering Poster


32

Appendix 7: Document History/Version Control

Version Date Comments Authors

0.1

13/08/13

Need for policy identified. Draft 1 produced Reviewed within Hospital Specialist Palliative Care Team Directorate Manager review Literature Search

REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2)

0.2

19/08/13

Policy amended following review by Directorate Manager Draft 2

REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2)

0.3

26/11/13

Policy amended following review by Directorate Manger Draft 3

REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2)

0.4

28/11/13

Policy amended following review by Directorate Manager Draft 4


0.5

10/04/14

Further review and amends

REDACTED – Section 40(2) REDACTED – Section 40(2)


33


0.6

01/06/15

Further review and amends

REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2)

0.7

03/06/15

Review and amends for: Medication and dental information, References, Assessment tool


1.0

19/06/15

Approved at Clinical Policy and Practice

REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2)

2.0

01/12/16

Reviewed no changes needed



34

3.0

16/03/17 15/11/17 01/07/2018

Need for policy review identified. This version is a re-draft with amendments in relation to NBM and Dysphagia completed Further review and amends following a Multidisciplinary Task and Finish Group, Academic Palliative and End of Life Care Department, Speech and Language Therapy, Dietetics, Intensive Therapy, Pharmacy, Dental Hospital; supported by the Trust Service Improvement Team Implementation in line with Mouth Care Matters National Initiative Review and amendments to ensure all recommendations are in line with Dental Hospital and BNF Taken to SPACE committee to discuss product use

REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2) REDACTED – Section 40(2)


Review Process Prior to Ratification:

Name of Group/Department/Committee Date

Reviewed by Hospital Specialist Palliative Care Team August 2013 to 2015

Infection Control Team and Liverpool University Dental Hospital June 2015

SALT/Liverpool University Dental Hospital November 2017

SALT/Liverpool University Dental Hospital June 2018