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Oral Hygiene Evidence Based Standards of Care For The Dysphagic Patient. Stephen Fraser, Speech-Language Pathologist Dept . of Communication Disorders St. Joseph’s Healthcare Hamilton, Ontario. Today's Presentation. Background information. Current oral care practices in healthcare.

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oral hygiene evidence based standards of care for the dysphagic patient

Oral HygieneEvidence Based Standards of CareFor The Dysphagic Patient

Stephen Fraser,

Speech-Language Pathologist

Dept . of Communication Disorders

St. Joseph’s Healthcare

Hamilton, Ontario

today s presentation
Today's Presentation
  • Background information.
  • Current oral care practices in healthcare.
  • Implementation methods.
  • The Oral Care Standards.
  • Research at St. Josephs.
slide3
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 so much about the oral cavity
Why should hospitals care somuch 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)
  • Nosocomial pneumonia accounts for 10-15% of all hospital acquired infections.20-50% of all infected patients will die as a result of the infectionJ.Can.Dent.Assoc.(2002)
slide5
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

slide6
Why is Speech-Language Pathology Addressing the issue of Oral Care?Susan Langmore, Dysphagia (1998)Susan Langmore, Dysphagia (2002)
how does aspiration pneumonia including vap occur
How Does Aspiration Pneumonia (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 pharyngeal flora
How do we stop this change in oral pharyngeal flora?
  • Mechanical Interventions (tooth brushing)
  • Use of pharmacological anti-microbial agents (ex. Chlorhexidene)
  • Combination Effect

American Journal of Critical Care ( 2004)

oral care research
Oral Care Research

Treatment with oral hygiene alone, reduced occurrence of pneumonia in older adults in nursing homes by 30%

Yoneyama et.al. (2002)

currently reported oral care practices
Currently Reported Oral Care Practices
  • Protocols for oral care measures are generally intended to improve patient comfort, rather than removal of microbes.AACN,Clinical Issues (1998)
  • Oral care procedures are not based on research evidence but on tradition, anecdotal evidence and subjective assessments.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)
current oral care practices continued
Current Oral Care Practices Continued…

Foam swabs are commonly used to provide

mouth care to patients who cannot provide

their own care.

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

Nursing Times (1996)

slide13
However,

The foamstick is still the tool of

choice, for most critical care nurses.

Critical Care Nursing (1995)

slide14
ICU

Standard Already Created. Told to change anything but the key points

(Win Win Situation)

Worked with Nurse Manager and

Nurse 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

Two Models of Implementation(see Winter 2007 Communique Article)Firstly, poster presentation on Evidence Based Practice Day. Invited units to implement Oral Care Initiatives

icu standard
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
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
procedure part a brushing
ProcedurePart A - Brushing
  • Wash hands and put on gloves
  • Obtain 1 pkg. Sage – 6572 – c
  • Attach suction to toothbrush, moisten brush and apply perox-a-mint solution
  • Brush patient’s teeth, gums, tongue, palate and inside cheeks
  • Apply suction to cleansed areas
  • Rinse brush in water and repeat step 4-5
  • Soak dentures in denture solution
procedure part b chlorhexidene 0 12
ProcedurePart B – Chlorhexidene 0.12%
  • Check patient chart for allergies to chlorhexidene
  • Obtain doctor’s order for chlorhexidene
  • Place 15ml of chlorhexidene in medication cup
  • Soak toothette in chlorhexidene
  • Rub teeth, tongue, gums, and sides of mouth in circular motion
  • Suction oral cavity and do not rinse
  • Apply oral moisturizer to lips
procedure
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
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 care standard
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.
supplies1
Supplies
  • 1 PLAK VAC oral evacuator brush.
  • Toothpaste
  • Suction source
  • Yankauer suction handle

OR

  • Chlorhexidene 0.12% oral rinse
  • Mouthswab
toothpaste why not
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 not1
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
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
Alternate Procedure Chlorhexidene 0.12%
  • Place 15ml of chlorhexidene in medication cup
  • Soak toothette in chlorhexidene
  • Rub teeth, tongue, gums, and sides of mouth in circular motion
  • Suction oral cavity and do not rinse
  • Apply oral moisturizer to lips
procedure1
Procedure
  • Continue with routine until patient is receiving thin fluids.
  • Use moistened toothettes (with water) every 2 hours following oral care
references
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.