Oral Hygiene Evidence Based Standards of Care For The Dysphagic Patient

1. Oral HygieneEvidence Based Standards of CareFor The Dysphagic Patient Stephen Fraser, Speech-Language Pathologist Dept . of Communication Disorders St. Joseph’s Healthcare Hamilton, Ontario

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

3. Components to Developing Standards of Care  Literature Review  Consultation with other hospitals regarding their standards  Consultation with appropriate departments (e.g.., pharmacy)

4. 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)

5. 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

6. Why is Speech-Language Pathology Addressing the issue of Oral Care?Susan Langmore, Dysphagia (1998)Susan Langmore, Dysphagia (2002)

7. How Does Aspiration Pneumonia (including VAP) Occur? ASPIRATION + GRAM - BACTERIA + OVERWHELM IMMUNE SYSTEM MUST HAVE ALL 3

8. 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)

9. 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)

10. Oral Care Research Treatment with oral hygiene alone, reduced occurrence of pneumonia in older adults in nursing homes by 30% Yoneyama et.al. (2002)

11. 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)

12. 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)

13. However, The foamstick is still the tool of choice, for most critical care nurses. Critical Care Nursing (1995)

14. 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

15. Standards of Practice for Providing Oral Care to The Dysphagic Patient

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. Supplies • 1 PLAK VAC oral evacuator brush. • Toothpaste • Suction source • Yankauer suction handle OR • Chlorhexidene 0.12% oral rinse • Mouthswab

24. 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.

25. 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

26. 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

27. 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

28. Procedure • Continue with routine until patient is receiving thin fluids. • Use moistened toothettes (with water) every 2 hours following oral care

29. ICU Research

32. Questions?

33. 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.