DEDICATED ORAL HYGIENE AIDE PROGRAM

1. DEDICATED ORAL HYGIENE AIDE PROGRAM BEDFORD VETERANS ADMINISTRATION HOSPITAL BEDFORD MA MOLLY DEHAAS BSN DDS CHRISTINE LEWIS RDH

2. BEDFORD VA HOSPITAL 461 BEDS LONG TERM CARE WARDS SUBACUTE AND REHABILITATION WARD ACUTE AND CHRONIC PSYCHIATRIC WARDS ALZHEIMER’S WARD (GRECC) MULTIPLE DRUG AND ALCOHOL REHABILIATATION PROGRAMS

3. WHAT DIDN’T WORK EFFORTS TO EDUCATE STAFF ON THE IMPORTANCE OF ORAL CARE • PRESENTATIONS AT GERIATRIC GRAND ROUNDS • PRESENTATIONS AT NURSING GRAND ROUNDS • PRESENTATIONS AT THE NURSE MANAGER’S MEETING • REGULAR FEEDBACK TO NURSE MANAGERS ON THE QUALITY OF ORAL CARE ON THEIR WARDS.

4. WHAT DIDN’T WORK EFFORTS TO SUPPORT DIRECT CARE STAFF WITH SAFE AND EFFECTIVE TECHNIQUES FOR ORAL CARE • REGULAR PRESENTATIONS AT WARD STAFF MEETINGS • BI-WEEKLY WARD VISITS BY HYGIENISTS TO AND PROVIDE FEEDBACK AND SUPPORT STAFF WITH DIFFICULT PATIENTS • PRESENTATIONS TO NEW STAFF MEMBERS RESEARCH SHOWS THAT BETWEEN 0 AND 16% OF NURSING HOME RESIDENTS ACTUALLY RECEIVE ORAL CARE EACH DAY ORAL CARE PRVIDED BY CERTIFIED NURSING ASSISTANTS IN NURSING HOMES JAGS 54:138-143 2006

5. WHAT DIDN’T WORK A PILOT PROGRAM WITH FOUR CERTIFIED NURSING ASSISTANTS TO PERFORM ALL ORAL CARE ON A LTC WARD • THE GOAL WAS TO DECREASE THE MODIFIED GINGIVITIS INDEX BY 35% • WE WERE ABLE TO DECREASE THE GINGIVITIS INDEX BY ALMOST 50 % • THE CNAs WERE TRAINED AND SUPPORTED BY OUR HYGIENISTS • THE PROGRAM WAS VERY POPULAR WITH THE STAFF AND PATIENTS • WHEN THE PROGRAM WAS FINISHED THE STAFF RETURNED TO THE PREVIOUS MODEL OF EACH CNA PROVIDING CARE FOR HIS/HER OWN PATIENTS BECAUSE IT WAS LOGISTICALLY DIFFICULT TO MAINTAIN

6. WHY THE VARIOUS APPROACHES DIDN’T WORK FOR US • WHILE NURSING STAFF AND MANAGEMENT VALUED ORAL CARE, THEY DID NOT MAKE EVALUATION OF THE QUALITY OF CARE DELIVERED A PRIORITY • SUPERVISORY STAFF WERE NOT COMFORTABLE WITH LOOKING IN THE PATIENT’S MOUTH’S • DIRECT CARE STAFF WERE NOT ACCOUNTABLE-ORAL NEGLECT WAS THE RESULT OF NEGLIGENCE OF THE PART OF MULTIPLE CAREGIVERS. • DIRECT CARE STAFF SOMETIMES LACKED SUPPLIES AND SKILLS • PRESCRIPTION MEDICATIONS LIKE 1.1% NaF AND CHLORHEXIDINE DIDN’T FIT INTO THE MEDICATION PASS ROUTINE SO FELL INTO A GRAY AREA BETWEEN NURSING AND CNAs

7. DEDICATED ORAL HYGIENE AIDE CONCEPT • ONE AIDE HAS THE RESPONSIBILITY FOR DELIVERING ALL ORAL CARE FOR A DESIGNATED NUMBER OF PATIENTS • THIS AIDE DOES NOT HAVE OTHER RESPONSIBILITIES • THIS IS CONTRARY TO CURRENT DIRECTION IN NURSING CARE WHICH SEEKS TO MINIMIZE THE NUMBER OF DIFFERENT CAREGIVERS • ONE STUDY SHOWED THAT THE DEDICATED ORAL HGYIENE AIDE CONCEPT DECREASED THE RISK OF PNEUMONIAS TO 1/3 OF THE CONTROL GROUP Jags 56:1601-1607, 2006

8. KAISER GRANT • WE WERE FUNDED FOR A 6 MONTH PROGRAM TO HIRE A PERSON 6 HOURS A DAY TO DO ALL ORAL CARE ON AN ALZHEIMER’S WARD • WE SAW AN AMAZING IMPROVEMENT IN THE ORAL CONDITION OF THE PATIENTS ON THIS WARD. • THE PROGRAM WAS VERY POPULAR WITH WARD STAFF AND THE PATIENT’S FAMILIES • WE CHOSE A WARD WITH A NURSE MANAGER WHO ALREADY HAD A STRONG CONCERN ABOUT THE QUALITY OF ORAL CARE.

9. GETTING NURSING MANAGEMENT BUY IN. • THE NURSE MANAGER OF OUR PILOT WARD LOVED THE PROGRAM AND ADVOCATED WITH THE DIRECTOR OF NURSING • WE USED INTRAORAL PHOTOGRAPHS EXTENSIVELY: IT’S HARD TO IGNORE GRAPHIC EVIDENCE THAT A PATIENT HAS HAD ORAL NEGLECT FOR DAYS WITH THE TRADITIONAL SYSTEM • WE WERE GIVEN ONE CNA WHO WAS BUDGETED BY NURSING WHO WAS ON LIGHT DUTY TO CONTINUE THE PROGRAM ON BOTH WARDS OF THE ALZHEIMER’ BUILDING • OTHER NURSE MANAGERS BECAME AWARE OF THIS AND ADVOCATED TO HAVE AN ORAL HYGIENE AIDE ON THEIR WARDS

10. WE PRESENTLY HAVE THREE DEDICATED ORAL HYGIENE AIDES WHO COVER 8 WARDS. THEY WERE SELECTED BECAUSE THEY WERE SELF-MOTIVATED AND VALUED ORAL CARE • THEY ARE SUPERVISED AND SCHEDULED BY NURSING AND COME UNDER THE NURSING BUDGET • THEY RECEIVE FEEDBACK FROM DENTAL STAFF MEMBERS ABOUT QUALITY OF CARE, CONCERNS WITH SPECIFIC PATIENTS • THEY CAN SEE 30-40 PATIENTS/DAY • THEY WORK VARYING SHIFTS (6A-2P OR 2 P TO 10 PM)

11. THEY HAVE BEEN TRAINED BY OUR HYGIENIST WITH DIDACTIC INFORMATION, CHAIRSIDE TRAINING IN THE DENTAL CLINIC AND BY SHADOWING MORE EXPERIENCED ORAL HGYIENE AIDES • THEY CARRY THEIR SUPPLIERS IN TOTE BAGS SET UP TO AVOID CROSS CONTAMINATION • THEY BRUSH TEETH AND CLEAN INTERDENTALLY WITH FLOSS OR BRUSHES • THEY CLEAN DENTURES AS NEEDED • THEY APPLY 1.1% Na F GEL AND/OR CHLORHEXIDINE WHICH IS ORDERED BY DENTAL

12. ORAL HYGIENE BAG

13. BEDSIDE SET UP

14. PROS • ALMOST ALL PATIENTS REALLY LOOK FORWARD TO SEEING THE ORAL HYGIENE AIDES • MANY PATIENTS WHO CHONICALLY REFUSED CARE NOW ACCEPT CARE • THE AIDES ARE FAMILIAR WITH THE PATIENTS MOUTHS AND ARE QUICK TO REPORT CHANGES AND CONCERNS TO DENTAL STAFF • THE QUALITY OF OUR PATIENT’S ORAL CARE IS SO MUCH BETTER.

15. CONS • THE AIDES OCCASIONALLY GET DRAFTED TO PROVIDE FULL PATIENT CARE WHEN STAFFING IS SHORT • STAFF DEPENDS ON HAVING THE ORAL CARE DONE AND WHEN THE AIDES ARE NOT PRESENT, ORAL CARE IS POOR, EVEN WHEN STAFF IS NOTIFIED THAT THEY ARE RESPONSIBLE FOR ORAL CARE THAT DAY. • WE DON’T HAVE COVERAGE FOR ALL PATIENTS SEVEN DAYS A WEEK AND ORAL CARE IS ONCE A DAY AT BEST • PRESENTLY THE PROGRAM IS AT RISK BECAUSE IT HAS BEEN CLASSIFIED AS A LOWER LEVEL IN THE VA SYSTEM THAN OUR ORAL HYGIENE AIDES PRESENTLY ARE

16. THE FUTURE • WE WOULD LIKE TO FIND A RESEARCHER WHO COULD COMPARE THE NUMBER OF TRANSFERS TO AN ACUTE HOSPITAL FOR PNEUMONIA BEFORE AND AFTER INSTITUTING THE ORAL HYGIENE AIDE PROGRAM. • WE WOULD LIKE TO GET 7 DAYS A WEEK COVERAGE