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Interventions to promote oral care regimen adherence in the critical care setting: A systematic review. Aust Crit Care 2022; 35:583-594. [PMID: 34764003 DOI: 10.1016/j.aucc.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 11/20/2022] Open
Abstract
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.
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Yin Y, Sun M, Li Z, Bu J, Chen Y, Zhang K, Hu Z. Exploring the Nursing Factors Related to Ventilator-Associated Pneumonia in the Intensive Care Unit. Front Public Health 2022; 10:715566. [PMID: 35462831 PMCID: PMC9019058 DOI: 10.3389/fpubh.2022.715566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 02/18/2022] [Indexed: 11/24/2022] Open
Abstract
Objective The purpose of this study was to investigate the key nursing factors associated with ventilator-associated pneumonia (VAP) in critical care patients. Methods Through the quality control platform of Hebei Province, questionnaires were sent to intensive care nurses in 32 tertiary hospitals in Hebei Province, China to collect data concerning the incidence of VAP and the status of the nursing staff. All the data were analyzed using an independent t-test and a one-way analysis of variance (ANOVA). The Pearson correlation coefficient was used to analyse the correlation between the nursing factors and the incidence of VAP. Multivariate logistic regression analysis was used to determine the risk factors affecting VAP. Results In terms of nursing, the incidence of VAP was affected by the differential nursing strategies. Multivariate logistic regression analysis showed that the incidence of VAP was significantly associated with the following six variables: the ratio of nurses to beds (p = 0.000), the ratio of nurses with a bachelor's degree or higher (p = 0.000), the ratio of specialist nurses (p = 0.000), the proportion of nurses with work experience of 5–10 years (p = 0.04), the number of patients nurses were responsible for at night (p = 0.01) and the frequency of oral care (p = 0.000). Conclusion The incidence of VAP is closely related to nursing factors. In terms of nursing human resources, even junior nurses (less experienced nurses) can play an essential role in reducing VAP. In addition, to reduce VAP, the number of patients that nurses are responsible for at night should be reduced as much as possible, and improving nursing qualifications.
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Affiliation(s)
- Yanling Yin
- Department of ICU, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meirong Sun
- Department of ICU, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhe Li
- Department of ICU, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingjing Bu
- Department of ICU, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yuhong Chen
- Department of ICU, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Kun Zhang
- Department of ICU, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhenjie Hu
- Department of ICU, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Doğu Kökcü Ö, Terzi B. Development of an intensive care oral care frequency assessment scale. Nurs Crit Care 2020; 27:667-675. [PMID: 32633044 DOI: 10.1111/nicc.12529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 04/22/2020] [Accepted: 06/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Oral care and frequency of oral care is important for intensive care patients in order to prevent the risk of ventilator-associated pneumonia. However, there are no scales to assess the frequency of oral care specific to intensive care units (ICUs). AIMS AND OBJECTIVES This study aimed to develop a valid and reliable tool, "Intensive Care Oral Care Frequency Assessment Scale (ICOCFAS)", for assessing the frequency of nurses' oral care in critical ill patients. DESIGN This was an instrument development study. METHODS The validity and reliability of the ICOCFAS, which consists of nine items, were tested using content validity (five expert opinions), construct validity (factor analysis), item analysis, and internal consistency analysis methods. The population of the research consisted of inpatients at the ICU of a hospital in Sakarya, Turkey. The research was conducted with 73 patients in the ICU. RESULTS Expert opinions on the content validity indicated that the scale was admissible. The Kaiser-Meyer-Olkin (KMO) coefficient was calculated at 0.800, and the Chi-square value of the Bartlett test was considerably significant (χ2 = 270.539; P < .001). Using a path diagram in confirmatory factor analysis, Chi-square/df ratio values were calculated as 1.49, standardized root mean square residual as 0.077, comparative fit index as 0.97, and root mean square error of approximation as 0.082. Cronbach's alpha was 0.851. The correlations between the items and total scores were 0.455 to 0.835 and were statistically significant (P < .001). CONCLUSIONS The ICOCFAS is an efficient tool with high validity and reliability for assessing oral care frequency in the ICU. RELEVANCE TO CLINICAL PRACTICE The ICOCFAS is a valid and reliable tool for Turkish society for assessing the frequency of oral care of patients in the ICU. It is recommended for various national and international studies with different patients in ICUs.
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Affiliation(s)
- Özlem Doğu Kökcü
- Faculty of Health Sciencies, Sakarya University, Sakarya, Turkey
| | - Banu Terzi
- Faculty of Nursing, Fundamentals of Nursing Department, Akdeniz University, Antalya, Turkey
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Jackson L, Jowsey T, Honey MLL. In-Service Education: Evolving Internationally to Meet Nurses' Lifelong Learning Needs. J Contin Educ Nurs 2020; 50:313-318. [PMID: 31233605 DOI: 10.3928/00220124-20190612-06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/04/2019] [Indexed: 11/20/2022]
Abstract
In-service education (ISE) in nursing is teaching that occurs in the workplace. Internationally, ISE activities have been evident in nursing for many years because it has been seen as a convenient and cost-effective way to deliver education to nurses with minimal disruption to staffing levels and the delivery of patient care. ISE-related literature was sought to address the aim of tracing development and focus of nursing ISE in New Zealand. A key finding of this literature review is that ISE has been adapted in New Zealand and internationally to meet the demands of evolving nursing practice, and for this reason it remains relevant and essential to nurses. The embeddedness of ISE within clinical environments also supports its relevance. Future research is called for to establish which aspects of ISE are critical to ensuring its ongoing success. [J Contin Educ Nurs. 2019;50(7):313-318.].
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Horwood C, Haskins L, Goga A, Doherty T, John V, Engebretsen IMS, Feucht U, Rollins N, Kroon M, Sanders D, Tylleskar T. An educational intervention to update health workers about HIV and infant feeding. MATERNAL AND CHILD NUTRITION 2019; 16:e12922. [PMID: 31845538 PMCID: PMC7083436 DOI: 10.1111/mcn.12922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/28/2019] [Accepted: 11/07/2019] [Indexed: 11/26/2022]
Abstract
Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources.
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Affiliation(s)
- Christiane Horwood
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Lyn Haskins
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, South Africa
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Vaughn John
- School of Education, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | | | - Ute Feucht
- Department of Paediatrics, University of Pretoria, Pretoria, South Africa.,Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of Pretoria, Pretoria, South Africa.,Maternal and Infant Health Care Strategies Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Nigel Rollins
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Max Kroon
- Department of Neonatology, Faculty of Health Sciences, University of Cape Town and Mowbray Maternity Hospital, Cape Town, South Africa
| | - David Sanders
- School of Public Health, University of the Western Cape, Cape Town, South Africa.,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
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Tanguay A, LeMay S, Reeves I, Gosselin É, St-Cyr-Tribble D. Factors influencing oral care in intubated intensive care patients. Nurs Crit Care 2019; 25:53-60. [PMID: 31305004 DOI: 10.1111/nicc.12456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND The practice of oral care in intensive care settings remains inconsistent among intubated patients, yet these patients are at high risk of developing ventilator-associated pneumonia. Therefore, it is important to adopt safe professional behaviour based on clinical practice guidelines. This study was based on Ajzen's (1985) theory of planned behavior, a conceptual framework that allows a better understanding of how internal and external factors influence behaviour adoption. AIMS AND OBJECTIVES To study influential factors in how nurses practice oral care with intubated clients in intensive care settings, referring to the theory of planned behavior (TPB) constructs. DESIGN A cross-sectional descriptive correlational design was conducted through a provincial postal survey in Quebec, Canada. METHODS A questionnaire was completed by 375 nurses working in intensive care units (ICUs). RESULTS Perceived behavioural control and attitude were the most important determinants in the level of intention to engage in oral care. Knowledge, available human and material resources, and number of years of experience in critical care nursing also seemed to be significant influencing factors. CONCLUSIONS This study improved our understanding of the factors influencing the practice of oral care in intubated patients in the ICU, relying on TPB as an explanatory framework. It would be important to continue to study this professional behaviour and to work in collaboration with health care facilities to promote the importance of oral care as an imperative for the safety and quality of health care. RELEVANCE TO CLINICAL PRACTICE The results of this study represent a solid foundation for advancing continuing education programmes and intensive care orientation programmes tailored to the needs of nurses.
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Affiliation(s)
- Andréanne Tanguay
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke 3001, Sherbrooke, Canada
| | - Sylvie LeMay
- Faculty of Nursing, Université de Montréal (Pavillon Marguerite-d'Youville), Montréal, Canada
| | - Isabelle Reeves
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke 3001, Sherbrooke, Canada
| | - Émilie Gosselin
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke 3001, Sherbrooke, Canada
| | - Denise St-Cyr-Tribble
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke 3001, Sherbrooke, Canada
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Khasanah IH, Sae-Sia W, Damkliang J. The Effectiveness of Oral Care Guideline Implementation on Oral Health Status in Critically Ill Patients. SAGE Open Nurs 2019; 5:2377960819850975. [PMID: 33415244 PMCID: PMC7774391 DOI: 10.1177/2377960819850975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 04/01/2019] [Accepted: 04/20/2019] [Indexed: 11/29/2022] Open
Abstract
Intubated patients need specific oral care due to the use of endotracheal tubes. An oral nursing care guideline needs to be implemented to guide nurses in oral care in intubated patients. To test the effectiveness of oral nursing care guideline implementation. The Rogers' Diffusion of Innovations Theory was used to introduce an oral nursing care guideline to 28 nurses working in an intensive care unit in a hospital within 2 months, using mass and private communication within a hospital management system. The oral care guideline was introduced to 47 intubated patients. The accuracy of oral care practice was assessed by nurse research assistants, and patients' oral health status was examined by dental nurse research assistants. The accuracy of practice among nurses was found between 88% and 100%. Total 97.47% (n = 46) of patients had an acceptable oral health status after receiving oral care based on the oral nursing care guideline. The oral nursing care guideline was effectively implemented with high accuracy and could increase patient oral integrity after its implementation.
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Affiliation(s)
| | - Wipa Sae-Sia
- Faculty of Nursing, Prince of Songkla University, Thailand
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8
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Andersson M, Wilde-Larsson B, Persenius M. Intensive care nurses fail to translate knowledge and skills into practice - A mixed-methods study on perceptions of oral care. Intensive Crit Care Nurs 2018; 52:51-60. [PMID: 30297151 DOI: 10.1016/j.iccn.2018.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/05/2018] [Accepted: 09/18/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To identify intensive care nurses' perceptions of oral care according to Coker et al.'s (2013) conceptual framework and to contribute to the knowledge base of oral care in intensive care. DESIGN/METHODS This was a concurrent embedded mixed-methods design, with more weight given to the quantitative part. Participants responded to the Nursing Care related to Oral Health questionnaire, including perceptions of oral care antecedents (18 items), defining attributes (17 items), and consequences (6 items) and two open-ended questions. The data were analysed with descriptive and correlation statistics and qualitative content analysis. SETTING Intensive care nurses (n = 88) in six general intensive care units. RESULTS Intensive care nurses perceived that an important part of nursing care was oral care, especially to intubated patients. They perceived that the nursing staff was competent in oral care skills and had access to different kinds of equipment and supplies to provide oral care. The oral cavity was inspected on a daily basis, mostly without the use of any assessment instruments. Oral care seemed to be task-oriented, and documentation of the patients' experiences of the oral care process was rare. CONCLUSIONS The antecedents, knowledge and skills are available to provide quality oral care, but intensive care nurses seem to have difficulties translating these components into practice. Thus they might have to shift their task-oriented approach towards oral care to a more person-centred approach in order to be able to meet patients' needs.
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Affiliation(s)
- Maria Andersson
- Department of Health Science, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden.
| | - Bodil Wilde-Larsson
- Department of Health Science, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden; Faculty of Public Health Studies, Inland Norway University of Applied Sciences, Elverum, Norway
| | - Mona Persenius
- Department of Health Science, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden
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9
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Celik GG, Eser I. Examination of intensive care unit patients' oral health. Int J Nurs Pract 2017; 23. [PMID: 28960619 DOI: 10.1111/ijn.12592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 07/24/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Oral health problems are common complications that most intensive care unit patients experience. There are many factors that affect oral health negatively and nurses have important responsibilities in this regard. AIM The aim of this study was assessment of the intensive care unit patients' oral health and risk factors. METHODS This study was planned as a descriptive study and conducted between December 2015 and June 2016, with 202 patients in 20 intensive care units of 6 hospitals in Turkey. Data were collected via Data Collection Form and Bedside Oral Exam guide. Oral health assessment of patients was made using a source of light and a tongue depressor. RESULTS We observed a significant difference in score of the Bedside Oral Exam guide by age, consciousness, type of respiration and feeding, the frequency of oral health, the total number of drugs, and technique of oral care (P < 0.05). None of the intensive care units were using the oral assessment guide. CONCLUSION The result of this study shows that there are various risk factors that adversely affect the oral health of intensive care unit patients. Nurses should undertake assessments on the basis of oral care protocols for patients at risk and carry out evidence-based individualized oral care applications.
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Affiliation(s)
| | - Ismet Eser
- Ege University Nursing Faculty, İzmir, Turkey
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10
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Chipps EM, Carr M, Kearney R, MacDermott J, Von Visger T, Calvitti K, Vermillion B, Weber ML, Newton C, St Clair J, Harper D, Yamokoski T, Belcher M, Ali N, Hoet AE, Van Balen J, Holloman C, Landers T. Outcomes of an Oral Care Protocol in Postmechanically Ventilated Patients. Worldviews Evid Based Nurs 2016; 13:102-11. [PMID: 26765505 DOI: 10.1111/wvn.12124] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Oral care is standard practice to prevent hospital-associated infections while patients are intubated and in the intensive care unit. Following extubation and transfer, infections remain an important risk for patients, but less attention is paid to oral care. Few studies have assessed the impact of oral care in recently extubated acutely ill patients. AIMS To develop an evidence-based oral care protocol for hospitalized patients and determine the impact of this protocol on health outcomes in recently extubated patients. METHODS In this randomized controlled trial, subjects were randomized to usual care or an intervention protocol that included tooth brushing, tongue scraping, flossing, mouth rinsing, and lip care. Major outcome measures were the revised THROAT (R-THROAT; oral cavity assessment) and overall prevalence of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus on oral cultures. RESULTS Seventy-four subjects were randomized. As measured by the R-THROAT, oral cavity health improved over time in both groups, but the intervention group demonstrated significantly more improvement than the control group (R-THROAT score improved by 1.97 intervention vs. 0.87 control; p = .04). Two categories, tongue and mouth comfort, demonstrated the most significant improvement. There was no difference in MSSA/MRSA colonization between the groups at the conclusion of the study. Overall, subjects in the intervention group were more satisfied with their protocol than subjects in the usual care group. LINKING EVIDENCE TO ACTION This study offers an important evaluation of an oral care protocol after extubation. Results demonstrated improvement in the oral cavity assessment with the designed oral care protocol. Patients expressed a preference for the intervention protocol, which included a battery-operated toothbrush, higher-quality toothpaste and mouth rinse, tongue scraper, floss, and lip balm. The implementation of an oral care protocol specifically addressing patients in the immediate postintubation is essential.
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Affiliation(s)
- Esther M Chipps
- Clinical Nurse Scientist, Wexner Medical Center, Clinical Associate Professor, College of Nursing, The Ohio State University, Columbus, OH
| | - Michele Carr
- Associate Professor, College of Dentistry, The Ohio State University, Columbus, OH
| | - Rachel Kearney
- Assistant Professor-Dental Hygiene, The Ohio State University, Columbus, OH
| | - Jennifer MacDermott
- Clinical Nurse Specialist, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Tania Von Visger
- Clinical Nurse Specialist, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Kristin Calvitti
- Clinical Nurse Specialist, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Brenda Vermillion
- Nursing Education Assistant Professor-Practice, College of Nursing, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Michele L Weber
- Clinical Nurse Specialist, Clinical Assistant Professor, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Cheryl Newton
- Clinical Nurse Specialist, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Jamie St Clair
- Clinical Nurse Specialist, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Dorina Harper
- Clinical Nurse Specialist, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Todd Yamokoski
- Clinical Nurse Specialist, Richard M. Ross Heart Hospital, The Ohio State University, Columbus, OH
| | - Marcia Belcher
- Clinical Nurse Specialist, Richard M. Ross Heart Hospital, The Ohio State University, Columbus, OH
| | - Naeem Ali
- Associate Professor-Clinical, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Armando E Hoet
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, College of Public Health, The Ohio State University, Columbus, OH
| | - Joany Van Balen
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, OH
| | | | - Timothy Landers
- Assistant Professor, College of Nursing, The Ohio State University, Columbus, OH
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