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. Implementation methods. The Oral Care Standards. Research at St. Josephs.

Components to Developing Standards of Care  Literature Review  Consultation with other hospitals regarding their standards  Consultation with appropriate departments (e.g.., pharmacy) Literature review revealed the closer you are in acuity to Critical Care the stronger the evidence to support the benefits of oral care. How did this initiative come about at St Josephs? NPO MOUTH and the inability to really manage it. High rates of VAP in the ICU Susan Langmore lecture and the information that more than aspiration is needed for Asp Pn to occur. So it began by, Literature review – to evaluate what evidence there is and what is just based on tradition and “What our teacher did”. I assume there is no need to assume why SLP needs to address Oral care.

Why should hospitals care so much 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 infection J.Can.Dent.Assoc.(2002) SLPs want to do this as a matter of our professions. Why should a hospital care and spend money on this? Wanted to point out this is not just SLP’s hypothesizing the link between oral bacteria and pneumonia. It is also th CDC and Can dental Assoc.

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

Why is Speech-Language Pathology Addressing the issue of Oral Care Why is Speech-Language Pathology Addressing the issue of Oral Care? Susan Langmore, Dysphagia (1998) Susan Langmore, Dysphagia (2002) I assume everyone is aware of Susan’s research ( or can go to her presentation tomorrow) Dependent for oral care OR 2.8 Speech-Language Pathologists, as part of their Dysphagia management, strive to reduce the negative health consequences of Aspiration, including Aspiration Pneumonia and VAP. speech-Language Pathologists, as part of Slp strive to reduce the negative health consequences of Asp including asp pn and VAP

How Does Aspiration Pneumonia (including VAP) Occur? + GRAM - BACTERIA + OVERWHELM IMMUNE SYSTEM Already doing much of we can do for #1 by being NPO #3 already addressing medically. #2 – seems to be the piece not being addressed. Can’t stop #1, already addressing #3, So #2 is our chance to reduce the occurrence of Asp Pn and VAP MUST HAVE ALL 3

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? Mechanical Interventions (tooth brushing) Use of pharmacological anti-microbial agents (ex. Chlorhexidene) Combination Effect American Journal of Critical Care ( 2004) Research on the effect of either mechanical vs pharmacological oral interventions used independently is limited. Combination interventions ( i.e., mechanical plus pharmacological interventions) have not been studied. Yet, combination interventions might have interactive effects that would enhance removal of dental plaque and oral microbial flora. The physiological process underlying the interventions provide support for this notion. For example, because oral organisms live in a complex biofilm, pharmacological killing of adherent organisms might decrease the adherence of any remaining organisms, making the remaining microbes more susceptible to removal by mechanical means. Conversely, physically reducing the number of organisms through the effectiveness of a bactericidal agent on the remaining organisms. Evidence of mechanical intervention – a long history of dental care Evidence of pharmacological use – 100% kill rate You will see that for acute care we have chosen brushing as the default treament, not Pharmacological. This is for a Q of L aspect to the treament. Fresh clean, moist feeling as well as removing bacteria.

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 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) For presentation to nurses these references were made from nursing journal. I am careful to point out that these are true all over the world.

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)

The foamstick is still the tool of However, The foamstick is still the tool of choice, for most critical care nurses. Critical Care Nursing (1995) So this is the state of the art in Oral Care. AND we know it does not work. ( PINK Pill test)

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 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 So how was the information presented here today shared at St Josephs Hospital, and how were the oral care Standards implemented. The information presented do far today was presented in a POSTER PRESENTATION at a Evidence Based Practice Workshop at St Josephs. 2 Unit managers seemed interested in following up. ICU was motivated by the opportunity to reduce VAP rates. Acute Care wanted a Nursing Care Initiative. I told both I could present them with prewritten oral care standards which they would be able to modify to for their units. 1) Oral care must occur at least 2 times daily. 2) Oral care must not use foam swabs as they do not remove bacteria and only provide moisture relief. 3) Oral Care must involve use of a Suction toothbrush to reduce the likelihood of aspiration during care. 4) Chlorhexedine swabbing must occur post brushing for critically ill patients.

Standards of Practice for Providing Oral Care to The Dysphagic Patient

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 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 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% 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 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 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 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.

Supplies 1 PLAK VAC oral evacuator brush. Toothpaste Suction source Yankauer suction handle OR Chlorhexidene 0.12% oral rinse Mouthswab Why a SUCTION Toothbrush? ORDER REQUIRED FOR CHLORHEXEDINE

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. As opposed to glycerin swabs, baking soda, Biotene toothpaste.

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 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% 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 For patients unable to tolerate brushing. Have not found any yet.

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

ICU Research One small measure – 95% compliance at 4 months post initiation.

Questions?

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.