evidence ep12-4, oral care education...1 quinn b, baker dl, cohen s, stewart jl, lima ca, parise c....

Evidence EP12-4, Oral Care Education

Importance of Oral Care for the

Non-vent Dependent Patient

Amy Freas MA, CCC-SLP

Erica Newberg MA, CCC-SLP

Rebekah Green MA, CCC-SLP

May 24, 2016


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Agenda

Enhanced education on:

Importance of oral care

Effective oral care supplies and

appropriate patients to utilize supplies on

Protocol regarding frequency


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Business Case

Regular oral care is not being completed on non-vent

dependent patients.

Data reflects the fact that oral care is currently being completed

less than 1 times per hospital day for each patient.

Staff surveys have indicated that 100% of staff feel that oral

care is important, and 46% of staff actually completes this

patient care task.


Gap Analysis

Barriers to care:

• Lack of training

• Lack of time

• Lack of accountability

• Lack of patient cooperation

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Background

Oral care research is largely limited to critical care units, with a

focus on ventilator associated pneumonia (VAP).

This research has lead to development of enhanced oral care

protocols to reduce VAP in critical care setting, yet when

patients transition from these areas to progressive care floors

oral care practices are less defined


Literature Support

During a hospital stay, significant changes occur in a patient’s

microbial flora and ability to maintain basic hygiene function,

such as daily care.

Studies show that within 48 hours of admission, critically ill

patients experience changes in oral bacterial colonization and

microaspirate in their sleep secondary to supine positioning and

drugs that suppress the central nervous system.

Microaspiration combined with decreased mobility and changes

in the oral flora create an ideal environment for microbes to

flourish within the pulmonary tract.

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Literature Support

Current literature indicates that insufficient oral care in patients

increases risk of Non Vented-Healthcare Aquired Pneumonia

(NV-HAP).

Non-ventilator hospital acquired pneumonia (NV-HAP) is the

most common HAI in the US-more common than CAUTIs

HAP leads to increased length of stay, increased costs, and are

at greater risk for readmission within 30 days that patients

without HAIs.

1 Quinn B, Baker DL, Cohen S, Stewart JL, Lima CA, Parise C. Basic nursing care to prevent nonventilator hospital-

acquired pneumonia. J Nurs Scholarsh. 2014 Jan;46(1):11-9.

2 Robertson T, Carter D. Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-

dependent, neurologically impaired patients. Can J Neurosci Nurs. 2013;35(2):10-7.

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Take Home Message

If we do not address oral care on non-

vent dependent patients, we may

continue to see preventable NV-HAP

cases, and other negative sequale

associated with poor oral hygiene.


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Action Plan

Given the personal and economical burden of NV-HAP, nurses

should monitor and implement effective NV-HAP prevention

program.

Therefore, nurses should receive enhanced education on:

• The importance of oral care

• Effective oral care supplies and appropriate patients to utilize supplies

on

• Protocols that specify the frequency of oral care and make sure it is

properly documented.


Cultural Change

Consider oral hygiene as a medical intervention rather

than grooming

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Protocol

The American Dental Association suggests brushing twice a day for two

minutes.

Best times to complete oral care are in the morning/after breakfast and

right before bed (MOST IMPORTANT)


Oral Health Assessment

1. Use tongue depressor and/or flashlight to assess pt’s

mouth

2. Assess pt’s teeth, gums, oral mucosa, lips and

complaints of any dental pain, lesions, sores, bleeding

and any broken teeth than can cause aspiration

3. Document any missing teeth, dentures or partials, risk

factors for aspiration, and the self-care ability of the pt

4. The Oral Care Protocol will be used to determine the

oral care ability of the pt and determine what

equipment, procedure, and frequency that oral care will

occur.13


Oral Health Assessment

Use this mnemonic for the patient board so care team is

aware of patient’s proper oral care plan:

I=Independent (able to perform own self care with set up)

S= Suction (dependent of oral care requiring 2x/day suction kit)

A= Assist (needs hand on or stand by assist with cues in

performing oral care)

V= Ventilator (dependent for oral care requiring Q4 suction kit)

D= Dentures (has dentures or removable partial)

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Oral Care Supplies

Regular toothbrush

Recommended for patients who can follow commands to expectorate

oral sections and who are on a diet.

Suction toothbrush

Recommended for patient who are unable to follow commands to

expectorate oral sections or are NPO secondary to aspiration risk.

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Technique

Toothbrush:

• It should take at least 2 minutes. Divide the mouth into four sections

and spend 30 seconds on each section.

• Be gentle. It doesn’t take a lot of force to remove plaque.

• Maintain proper positioning: During oral care, the individual and staff

should be in the same position as during mealtime or standing. If the

individual is able to lean safely forward, then this is an option as it will

help saliva and excess water flow from the mouth.

American Dental Association:

http://www.mouthhealthy.org/~/media/MouthHealthy/Files/Kids_Section/ADAHowToBrush_Eng.pdf?la=e

n


http://www.mouthhealthy.org/~/media/MouthHealthy/Files/Kids_Section/ADAHowToBrush_Eng.pdf?la=en

How to Brush Your Teeth

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Independence with Oral Care

Candidacy for independent oral care:

• Demonstrates appropriate upper extremity motor skills including:

grasp/maintain grasp of toothbrush and have ROM, strength and

endurance to sustain motion to complete thoroughly.

• Demonstrates appropriate cognitive skills for sequencing ADLs:

procedural memory, maintain attention

• RN or SLP/OT MUST observe completion of oral care

demonstrating appropriate skills as described in protocol 1x

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Independence with Oral Care

Ensuring compliance:

• Staff to provide supplies (toothbrush and toothpaste) at the

patient bedside or assist up to bathroom to complete oral

care 2x/day

• Consider using daily chart on white board to show

compliance

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What about Pediatric Patients?

Oral care should begin during the first few days of life.

• Wipe gums with moist gauze pad or washcloth

• When teeth appear: use pediatric soft toothbrush with water

• At age 3: use a pea-size amount of fluoride tooth paste

2x/day

American Dental Association: www.mouthhealthy.org/en/babies-and-

kids/

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http://www.mouthhealthy.org/en/babies-and-kids/

Did you know…

Foam swabs DO NOT remove plaque

bacteria from the teeth and gums.

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Suction Toothbrush

Q4 Oral Care Kit:

Best suited for patients that are vented and cannot expectorate oral

secretions independently

Would need to be completed 6x/day for best results

Can come in petite size for smaller patients and/or children

Easy burst package, fits to suction system in room, and can scan

barcode for easy documentation in system

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Suction Toothbrush

Continued Care Kit:

Best suited for patients that are non-vented and able to expectorate own

secretions

Would need to complete brushing 2x/day for best results

• 2 additional swabs provided if needed for moisture or additional cleaning

Easy burst package, fits to suction system in room, and can scan barcode for

easy documentation in system

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Suction Toothbrush Technique

1. Before opening package, turn package over and burst solution

with your thumbs

2. Peel lid to open

3. Remove Mouth Moisturizer and Applicator Swab

4. Attach toothbrush to suction line

5. Clean teeth and oral cavity (cheeks, hard palate, tongue) for 2

minutes – suction as needed by placing thumb over port

6. Discard toothbrush. Attach covered yaunker to suction line

7. Apply Mouth Moisturizer on applicator swab and apply as

needed to lips and inside oral cavity

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Suction Toothbrush Technique

http://www.sageproducts.ca/videos/toothette/THUMBPORT.

mp4

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http://www.sageproducts.ca/videos/toothette/THUMBPORT.mp4

Oral Hygiene Intervention

Dentures

• Brush morning/evening

• Routine disinfection

• Brush gums of edentulous patients

• Clean the denture cup too

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Behavioral Strategies

If your patient is resisting oral care:

• Tell them that you want to help eliminate food from their

mouth and improve their comfort.

• Establish a routine – have a specific phrase/time

established to indicate the need for oral care

• Try a different time

• Have someone else try (caregiver, other staff member)

• Try a different approach

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Encourage participation:

• Appropriate/familiar environment to trigger procedural

memory (i.e., bathroom not in bed)

• Place toothbrush in hand

• Hand over hand assist

• Chaining-initiate the task and encourage patient to

continue

• Mirroring-caregiver mimes task on self

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Distraction

• Give the patient something to hold or an activity

to complete while receiving oral care

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Bite Block

Safe way to prop open the mouth during oral care when

other behavior strategies were not successful. Ideal for

those who are confused or uncooperative such as

patient’s with altered mental status, children with

disabilities or those who have difficulty in keeping their

mouth open during oral care.

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How to Use Bite Block

• Use when performing oral care on patients with

altered levels of consciousness

• Place padded part of bite block in mouth

between the teeth

• If teeth have clamped shut, do not attempt to

force mouth open or force bite block in

• Discard after use. May not function as intended

if reused

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Oral Care Protocol Algorithm

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Patient Status Equipment Procedure Frequency

Independent

Or Assist

• able to perform self-care or needs minimal assist

• able to expectorate

SAGE Short Term swab system (general oral care supplies)

• Soft toothbrush

• Plaque removing toothpaste

• Alcohol-free antiseptic oral rinse

• Mouth moisturizer and 1 or 2 swabs to apply

• Set patient up at sink or in bed with equipment

• Instruct or assist patient to brush teeth for 2 minutes

• Instruct patient to swish and spit antiseptic oral rinse

• If desired, moisturize interior of oral cavity & lips using a swab

• Discard disposable equipment & swab in receptacle

• Brush 2x/day

• Moisturizer swabs 2x/day as

needed

Suction

• Dependent for oral care & unable to expectorate

• At risk for aspiration

SAGE Continued Care Kit

• Suction toothbrush

• Oral cleaning solution

• Mouth moisturizer and 1 or 2 swabs to apply

•Before opening package, turn package over and burst solution with your thumbs

•Peel lid to open

•Remove Mouth Moisturizer and Applicator Swab

•Attach toothbrush to suction line

•Clean teeth and oral cavity (cheeks, hard palate, tongue) for 2 minutes – suction as needed by placing

thumb over port

•Discard toothbrush. Attach covered yaunker to suction line

•Apply Mouth Moisturizer on applicator swab and apply as needed to lips and inside oral cavity

• Brush 2x/day

• Moisturizer swabs 2x/day as

needed

Dentures

• Has dentures or no teeth

• Select equipment & procedure based on patient

status (independent or suction)

•Denture Cup

• Denture Cleaning Tabs

• SAGE kit based on patient status

• Remove dentures and soak overnight in denture cleaner

• Use soft toothbrush with water and denture cleaner to remove visual debris from dentures as needed (do

not use regular toothpaste)

• Set patient up at sink or in bed with equipment

• Instruct patient to brush tongue & gums for 2 minutes, assist as needed

• Instruct patient to swish and spit antiseptic oral rinse

• If desired, moisturize interior of oral cavity & lips using a swab

• 2x/day

• Moisturizer swabs 2x/day

• Soak dentures overnight

Ventilator

• Dependent for oral care

• On mechanical ventilation

SAGE Q4 Oral Care Kit

• suction toothbrush

• Oral cleansing solution

•Mouth moisturizer and swabs to apply

•Before opening package, turn package over and burst solution with your thumbs

•Peel lid to open

•Remove Mouth Moisturizer and Applicator Swab

•Attach toothbrush to suction line

•Clean teeth and oral cavity (cheeks, hard palate, tongue) for 2 minutes – suction as needed by placing

thumb over port

•Discard toothbrush. Attach covered yaunker to suction line

•Apply Mouth Moisturizer on applicator swab and apply as needed to lips and inside oral cavity

• Q4


Conclusion

Standardizing practice across our system will improve

outcomes.

Your help to reinforce the importance of oral care will lead to

the prevention of hospital acquired pneumonia.

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References

Quinn B, Baker DL, Cohen S, Stewart JL, Lima CA, Parise C. Basic nursing care to prevent nonventilator hospital-

acquired pneumonia. J Nurs Scholarsh. 2014 Jan;46(1):11-9.

Robertson T, Carter D. Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in care-

dependent, neurologically impaired patients. Can J Neurosci Nurs. 2013;35(2):10-7.

Cohn, J., & Fulton, J. (2006). Nursing staff perspectives on oral care for neuroscience patients. Journal of

Neuroscience Nursing, 38(1), 22-30.

DeWalt, E.M. Nurs Research (1975); 24 (2), 104-108.

Drimmelen & Rollins. Nurs Research (1969(; 18, 327-332.

Grinsberg, MK. Amer J Nursing (1961); 61, 67-69.

American Dental Association

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evidence ep12-4, oral care education...1 quinn b, baker dl, cohen s, stewart jl, lima ca, parise c....

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