Translating evidence into nursing practice: oral hygiene for care dependent adults

Oral Hygiene in Patients with Stroke: A Best Practice Implementation Project Protocol

Oral hygiene has been shown to reduce adverse events and promote the quality of life of patients with stroke. However, a stroke can result in the impairment of physical, sensory, and cognitive abilities, and comprise self-care. Although nurses recognize its benefits, there are areas for improvement in the implementation of the best evidence-based recommendations. The aim is to promote compliance with the best evidence-based recommendations on oral hygiene in patients with stroke. This project will follow the JBI Evidence Implementation approach. The JBI Practical Application of Clinical Evidence System (JBI PACES) and the Getting Research into Practice (GRiP) audit and feedback tool will be used. The implementation process will be divided into three phases: (i) establishing a project team and undertaking the baseline audit; (ii) providing feedback to the healthcare team, identifying barriers to the implementation of best practices, and co-designing and implementing strategies using GRIP, and (iii) undertaking a follow-up audit to assess the outcomes and plan for sustainability. So, the successful adoption of the best evidence-based recommendations on oral hygiene in patients with stroke will reduce the adverse events related to poor oral care and may improve patients' quality of care. This implementation project has great transferability potential to other contexts.

Using the Oral Assessment Guide to Predict the Onset of Pneumonia in Residents of Long-Term Care and Welfare Facilities: A One-Year Prospective Cohort Study

Appropriate oral health care, depending on oral assessments, reduces the onset of pneumonia. However, the relationship between risk evaluation using an oral assessment tool and pneumonia in residents of long-term care facilities has not been fully elucidated. In the present study, we aim to examine the relationship between the total scores of the Oral Assessment Guide (OAG) and the incidence of pneumonia after a one-year baseline study of residents in long-term care facilities. The settings for sampling include nine long-term care facilities in Hokkaido. At baseline, there were 267 study subjects. A total of 72 individuals dropped out and 11 individuals met the exclusion criteria. Therefore, the subject sample included 184 individuals. Among the subjects included in our analyses, eight individuals developed pneumonia (six males and two females). A multiple logistic regression analysis was performed with the risk factors for developing pneumonia. Evaluations were performed based on the odds ratio (OR) and 95% confidence interval (CI). We observed that the OR for pneumonia onset was 2.29 (CI: 1.27-4.14) after being adjusted for pneumonia risk factors. Therefore, it was suggested that the total scores of the OAG could be used to screen for the risk of pneumonia onset in residents of long-term care and welfare facilities.

Interventions to promote oral care regimen adherence in the critical care setting: A systematic review

BACKGROUND

Oral care is a fundamental nurse-led intervention in the critical care setting that provides patient comfort and prevents adverse outcomes in critically ill patients. To date, there has been minimal focus on nurse-focused interventions to improve adherence to oral care regimens in the adult intensive care unit setting.

OBJECTIVES

The objectives of this study were to (i) identify types and characteristics of interventions to improve oral care adherence amongst critical care nurses and intervention core components, (ii) evaluate the effectiveness of interventions to improve adherence of oral care regimens, and (iii) identify the types of outcome measures used to assess oral care regimen adherence.

DESIGN

This is a systematic review in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

Key bibliographic databases and platforms, including Scopus, Cochrane, MEDLINE, CINAHL, Embase, PsycINFO, ProQuest, and Web of Science, were searched for studies published before July 2020. The Joanna Briggs Institute's quality appraisal tool was used to assess risk of bias in included studies.

RESULTS

A total of 21 original research studies were identified, of which 18 studies used multifaceted interventions. In accordance with the Joanna Briggs Institute's quality appraisal tools, four of the 20 quasi-experimental studies were rated as high quality. The one randomised control trial was of moderate quality. Outcome measures included oral care adherence behaviours, oral care knowledge, self-reported adherence, and documentation. Improved effectiveness in oral care adherence was reported in 20 studies.

CONCLUSIONS

Review findings confirm interventions to change behaviours improve oral care adherence. The most effective interventional approach could not be determined owing to heterogeneity in intervention design and outcome measures. Oral care in the intensive care unit is a vital, nurse-led activity that reduces the risk of hospital-acquired infection. It is recommended that future research adopt implementation science methods to ensure stakeholder engagement and feasibility.

SYSTEMATIC REVIEW REGISTRATION NUMBER

This review was submitted and subsequently registered on PROSPERO, the International Perspective Register of Systematic Reviews PROSPERO 2019 CRD42019123142.

Oral care - identifying quality improvement areas

PURPOSE

The purpose of this paper is to describe and compare nurses' and healthcare assistants' oral care quality perceptions, including perceived reality (PR) and subjective importance (SI), to identify improvement areas in intensive care and short-term care, and to explore potential nursing satisfaction predictors regarding oral care.

DESIGN/METHODOLOGY/APPROACH

Swedish staff, 154 within intensive care and 278 within short-term care responded to a modified quality of care from a patient perspective questionnaire. Descriptive and analytical statistics were used.

FINDINGS

Staff scored oral care quality both high and low in relation to PR and SI. Improvement areas were identified, despite high satisfaction values regarding oral care. Setting, SI and PR explained 51.5 percent of the variance in staff satisfaction regarding oral care quality.

PRACTICAL IMPLICATIONS

Quality improvements could guide oral care development.

ORIGINALITY/VALUE

This study describes oral care by comparing nurse perceptions of how important they perceive different oral care aspects and to what extent these oral care aspects are performed.

Oral health knowledge, attitude and practices among nurses in a tertiary care hospital in Bangalore, India: a cross-sectional survey

Background: Maintaining good oral health among hospitalized individuals is essential for health outcomes and quality of life. Nurses, being the primary oral care givers require adequate knowledge, attitude and practice in this area to provide effective oral health care. However, limited studies have been undertaken to evaluate this aspect of nursing care in India. Aim: To determine the knowledge, attitude and practices of nurses regarding oral care for hospitalized patients. Design: Cross-sectional survey. Methods: A total of 244 nurses working in a tertiary care hospital in Bangalore, South India were purposively recruited for this study. Data was collected using a structured questionnaire with both closed and open-ended questions about knowledge, attitude and practice regarding oral care. Results: The mean oral health knowledge score was 6.74 out of maximum score of 22. Most nurses were aware of the importance of oral care among inpatients and the effect poor oral hygiene and systemic diseases have on oral health. Deficiencies in knowledge were prevalent in areas including common medications that affect oral health and regarding care of dentures. Nurses, with higher nursing qualifications and working in departments with longer length of stay had higher attitude scores. Most nurses assessed oral health needs within 24hrs of admission. However, there were inconsistencies in the oral health assessment and care protocols followed and documentation. Conclusion: Nurses' attitude towards oral health was positive yet their knowledge in specific aspects of care was inadequate. Their oral health practices needs improvement.

Effects of oral hygiene programme and home phone counselling for hepatitis C patients receiving antiviral treatment

AIMS

To explore the effectiveness of an oral hygiene programme combined with home phone counselling on hepatitis C patients during antiviral treatment.

BACKGROUND

Hepatitis C virus infection is the leading cause of liver diseases. Evidence indicates that the antiviral treatment for hepatitis C virus infection has been successful, albeit its many side effects, such as discomfort symptoms of oral ulcers, which, in turn, leads to discontinued treatment. Inappropriate oral hygiene may worsen the side effects and increase the risk of dropping out of the treatment.

DESIGN

A quasi-experimental pre-post-test design was used.

METHODS

The oral hygiene programme was based on a standardized protocol of oral health care combined with home phone counselling. The participants were recruited from an outpatient clinic between August 2016 and July 2017. The generalized estimating equation was used for repeated measures of oral health behaviour, oral health status and discomfort symptoms.

FINDINGS

Thirty-four participants completed this study. The findings indicated that the oral hygiene programme significantly improved tooth brushing, use of dental floss and oral comfort. The result showed that the participants' oral health status significantly improved in 3 months.

CONCLUSIONS

This pilot study supports the finding that an oral hygiene programme can reduce oral discomfort, improve oral hygiene behaviour, and enhance the oral health status of hepatitis C patients receiving treatment. This is a simple and low-cost programme, which can be performed at home easily and boosts the completion of antiviral treatment.

Feasibility of Providing Safe Mouth Care and Collecting Oral and Fecal Microbiome Samples from Nursing Home Residents with Dysphagia: Proof of Concept Study

Individuals with dysphagia who reside in nursing homes often receive inadequate mouth care and experience poor oral health. From a policy perspective, the combination of absent evidence-based mouth care protocols coupled with insufficient dental coverage create a pool of individuals at great risk for preventable infectious illnesses that contribute to high health care costs. The purpose of the current study was to determine (a) the safety of a mouth care protocol tailored for individuals with dysphagia residing in nursing homes without access to suction equipment, and (b) the feasibility of collecting oral and fecal samples for microbiota analyses. The mouth care protocol resulted in improved oral hygiene without aspiration, and oral and fecal samples were safely collected from participants. Policies supporting ongoing testing of evidence-based mouth care protocols for individuals with dysphagia are important to improve quality, demonstrate efficacy, and save health care costs. [Journal of Gerontological Nursing, 43(9), 9-15.].

A Retrospective Study of Non-Ventilator-Associated Hospital Acquired Pneumonia Incidence and Missed Opportunities for Nursing Care

OBJECTIVE

To determine non-ventilator-associated hospital-acquired pneumonia (NV-HAP) incidence, assess negative impacts on patient outcomes and cost, and identify missed preventive nursing care opportunities.

BACKGROUND

NV-HAP is inadequately studied and underreported. Missed nursing care opportunities, particularly oral care, may aid NV-HAP prevention.

METHODS

This descriptive, observational, retrospective chart review identified adult NV-HAP cases and associated demographic and hospital care data.

RESULTS

Two hundred five NV-HAP cases occurred in 1 year at Montefiore Medical Center, equating to an incidence of 0.47 per 1000 patient-days and an estimated excess cost of $8.2 million. ICU transfer following pneumonia occurred in 15.6% of cases. Care requirements from specialist nursing facilities increased at discharge (26.8%), as compared with care requirements on admission (17.6%). Complete nursing care documentation was missing for most patients, with oral care undocumented 60.5% of the time.

CONCLUSIONS

Preventable NV-HAP cases and their negative impact on cost and patient outcomes may decrease through improved basic nursing care.

Older people's perceptions of the quality of oral care in short-term care units: A cross-sectional study

BACKGROUND

There is a lack of knowledge about oral care among older people living in short-term care (STC) units and how the quality of oral care provided by nursing staff is perceived by the older people.

AIM

To (i) describe person-related conditions among older people in STC, (ii) describe and compare perceptions of the quality of oral care (including perceptions of care received and the subjective importance of such care), within and between older people who have the ability to perform oral self-care and those who are dependent on help with oral care and (iii) examine the relationship between person-related conditions and the quality of oral care.

METHODS

A cross-sectional study was conducted with 391 older people in STC units in Sweden based on self-reported questionnaire and clinical assessments.

RESULTS

The older people were assessed as having normal oral health (2%), moderate oral health problems (78%) or severe oral health problems (20%). When comparing older people's perceptions of quality of oral care in terms of perceived reality and subjective importance, significant differences appeared within and between groups. Psychological well-being had a significant relationship with perception of the quality of oral care (both perceived reality and subjective importance), and gender and oral health status had a significant relationship with subjective importance.

CONCLUSIONS

Older people's perceptions of areas for improvement regarding quality of oral care is a new and important knowledge for nursing staff in STC units. Older people want personalised information regarding oral health and oral care. Registered Nurses who take the responsibility in nursing care for older people's oral health may avoid unnecessary suffering by older people caused by oral health problems.

IMPLICATIONS FOR PRACTICE

Older people's perspective is an important component for quality work and might lead to improvements in the quality of oral care in STC.

Oral Health Care Guidelines, Training, and Resources among Stroke Care Providers

During a stroke, the mouth tends to become an unhealthy place and may give rise to various life-threatening conditions. To this end, there have been repeated calls to incorporate oral hygiene guidelines and practices for hospitalized stroke patients to prevent aspiration pneumonia and improve patients' oral health. The objective of the study was to determine health care providers' practices of oral health care among patients hospitalized after an occurrence of stroke and to determine health care providers' background and work environment effect on these practices. A cross-sectional study was conducted among stroke care providers in 13 public hospitals in Malaysia. The questionnaires distributed were self-administered, where nursing staff provided details of their oral health care practices for stroke patients. Information on the background of health care providers and work environment was also collected. Overall, a total of 780 responses from the registered nurses were obtained. Almost half of the respondents (48.1%) reported that they recommended toothbrushing twice or more per day to stroke patients. Two-thirds (64.7%) reported that they performed daily mouthwashing on their patient, while less than half (38.8%) reported daily oral hygiene assistance. Result of the analysis revealed that oral hygiene practices were significantly associated with having working wards ( P < 0.05), level of qualification ( P < 0.05), having oral health care guidelines ( P < 0.001), specific resources ( P < 0.05), and attending previous training in oral care ( P < 0.001). Provision of oral hygiene practices for hospitalized stroke patients is important. A lack of oral health care guidelines, support from dental professionals, specific resources, training, and assistance in daily oral care for patients is evident and detrimental to oral hygiene practices. The current findings have significant implications for new initiatives to support health care providers, particularly the registered nurses performing oral health care for hospitalized stroke patients. Knowledge Transfer Statement: This study may provide a basis of information for improving the delivery of oral health care to stroke patients. Enhancement in the training and improvement in the existing guidelines and resources is pivotal for the provision of better oral health care for the potential benefits to these patients, including their improved quality of life and disease prevention.

The Bedside Oral Exam and the Barrow Oral Care Protocol: translating evidence-based oral care into practice

AIM

To introduce the Bedside Oral Exam (BOE) and the Barrow Oral Care Protocol (BOCP) to guide oral care for intensive care unit patients. Secondary aim: To explore quality improvement data for incidence of ventilator associated pneumonia (VAP), cost effectiveness of oral hygiene supplies and staff response to change in practice.

METHODS

Descriptive case design for implementation and evaluation of oral assessments and oral hygiene. Incidence of VAP and the cost of oral care supplies before and after implementation was compared. Staff responses were elicited both pre- and post-implementation.

RESULTS

Incidence of VAP fell significantly from 4.21 to 2.1 per 1000 ventilator days (p =.04). A cost savings of 65% was noted on a monthly basis for oral hygiene supplies. Staff reported increased satisfaction in providing oral hygiene with a combination of oral care products.

CONCLUSIONS

A significant reduction in VAP was noted using the BOCP. The BOE guided individualised oral care with contemporary supplies, including a tongue scraper, electric toothbrush, non-foaming toothpaste and oral moisturisers. Cost-effective, comprehensive oral care appears to be effective in reducing VAP. Further studies are needed to assess impact of oral hygiene on oral health and patient comfort.

Facilitating implementation of the translational research pipeline in neurological rehabilitation

PURPOSE OF REVIEW

Knowledge translation is a growing area of specialisation. This review summarises the field perspectives and highlights recent work that has particular relevance to neurological rehabilitation.

RECENT FINDINGS

Research in knowledge translation can usefully be organised into three overlapping perspectives, namely a linear transfer of codified knowledge, a social interaction perspective, or a multilevel implementation perspective that incorporates contextual factors. Although systematic reviews remain foundational in supporting knowledge translation, they often lack structured updating and can be problematic to implement in complex cases. Knowledge brokers play an important role in evidence use; these may be managers or administrators of rehabilitation services. Organisational support that sustains and structures knowledge brokering roles has been found lacking. Numerous contextual factors influence knowledge translation, including leadership, fidelity monitoring, and divergent stakeholder perspectives. Integrative frameworks have been developed that consolidate the multiple contingencies.

SUMMARY

Knowledge translation is a complex process with an incomplete knowledge base; its uniprofessional focus is particularly limiting for neurological rehabilitation. Developing accessible systematic reviews remains central, as well as supporting knowledge brokers, being aware of stakeholder absorptive capacity in developing translational strategies and using integrative frameworks to guide knowledge translation for complex interventions.