Exploration of difficulty accessing the mouths of intubated and mechanically ventilated adults for oral care: A video and photographic elicitation study

Oral hygiene in critically ill patients at a tertiary hospital in São Paulo, Brazil: a best practice implementation project

OBJECTIVES

This project aimed to promote evidence-based practices relat. ed to the oral health of critically ill patients in an intensive care unit in Brazil.

INTRODUCTION

The oral hygiene of patients on mechanical ventilation is an essential component of nursing care quality, and well-defined guidelines ensure appropriate care. Mechanical ventilation is associated with the risk of ventilator-associated pneumonia, which can increase mortality, length of stay, time on mechanical ventilation, and hospital costs.

METHODS

This project was guided by the JBI Evidence Implementation Framework, which consists of seven stages: (1) identification of the area of practice to be changed, (2) involvement of change agents, (3) context assessment and readiness for change, (4) review of practices against evidence-based audit criteria, (5) implementation of practice changes, (6) reassessment of practices using a follow-up audit and (7) consideration of the sustainability of changes in practice.

RESULTS

Four audit criteria were developed to evaluate compliance with best practices. In the follow-up audit, Criteria 1, 2, and 3 obtained compliance of ≥ 80%. Thus, for Criterion 1, all the patients on mechanical ventilation for more than 24 hours were evaluated by the oral medicine team, resulting in 100% compliance. For Criterion 2 on appropriate oral hygiene measures, a compliance rate of 80% was achieved. For Criterion 3, 39 professionals (90.7%) participated in educational activities related to the oral health protocol for critically ill patients, obtaining 90.7% compliance. For Criterion 4 regarding patients being evaluated before receiving any oral health care, improvement was low (only 50%), revealing the need for further improvement.

CONCLUSION

This best practice project improved the professional practice of nursing staff and increased compliance with best practices for the oral health of critically ill patients.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A175.

Does the presence of oral health teams influence the incidence of ventilator-associated pneumonia and mortality of patients in intensive care units? Systematic review

AIMS

To verify whether oral health teams influence the oral health status, ventilator-associated pneumonia incidence and mortality rate of patients in Intensive Care Units (ICU).

MATERIALS AND METHODS

Bibliographic searches were performed in PubMed, Scopus, Web of Science, Lilacs, Embase, Livivo, Open Grey, Academic Google, and Cochrane databases. The assessment of the methodological quality and risk of bias of the included studies and a random-effects meta-analysis to summarize relative risk data for ventilator-associated pneumonia (VAP) and mortality were performed. An analysis of the certainty of the evidence was performed for the main outcomes analyzed.

RESULTS

Records of 518 studies were analyzed by reading titles and abstracts. Five studies were included according to eligibility criteria. The meta-analysis showed that ICU patients undergoing dental care by an oral health team had a lower incidence of VAP (OR = 0.33; 95% CI: 014-0.76) but did not lower mortality rates (OR = 0.46 95% CI: 0.16-1.32). The certainty of the evidence was considered very low.

CONCLUSION

Dental care provided by oral health teams in a hospital environment did not influence oral health status or mortality, although it contributed to a reduction in VAP of patients admitted to the ICU.

Effective learning activity to facilitate post-graduate nursing students' utilization of nursing theories - Using the fundamentals of care framework

AIMS

To explore how postgraduate nursing students used the Fundamentals of Care framework in a written assignment based on a clinical situation, and describe their learning process in using the framework.

DESIGN

A qualitative descriptive study design applying the Fundamentals of Care framework.

METHODS

Postgraduate nursing students' theoretical written assignments (n = 35) based on self-experienced clinical cases were included. The data were collected in 2021 in five specialties in a postgraduate nursing programme in Sweden. The data were analysed using content analysis.

RESULTS

Applying the framework to a self-experienced clinical case illuminated the importance of nurse-patient relationships and clarified the meaning of person-centred care. The students assessed the framework as easy-to-use bedside as a guide to providing nursing care. By using the framework, the students were aided in reasoning about the fundamental values of care such as ethics, equality in healthcare and patient rights. When students reflected on their learning process, they stated that the assignment taught them how to use the framework, as well as paving the way for finding and applying other theories of nursing.

CONCLUSION

Learning activities with an opportunity to practice analysing nursing care guided by a theory, combined with a self-evaluating element, are conducive to deepening students' learning and improving their ability to use theories in clinical practice.

IMPACT

The framework illuminated the importance of the nurse-patient relationship in nursing care to the students and made them recognize and value the clinical use of theories. It is the responsibility of leaders in nurse education and healthcare to provide the next generation of specialist nurses-future nursing leaders-with regular opportunities to analyse nursing care through theories and frameworks. Nurses call for continuous learning on theories; leaders in nurse education and healthcare must meet these needs.

Impact of a dental care intervention on the hospital mortality of critically ill patients admitted to intensive care units: A quasi-experimental study

BACKGROUND

We aimed to evaluate the impact of providing dental care to critically ill patients on their risk of death and ventilator-associated pneumonia (VAP).

METHODS

A quasi-experimental study was conducted in 2 intensive care units (ICU) from 2016 to 2019. The intervention consisted of implementing routine dental care, focusing on oral hygiene and periodontal treatment, at least 3 times a week, for patients admitted to the study units. In the pre-intervention period, routine oral hygiene was provided by the ICU nursing staff. The primary and secondary study outcomes were mortality, evaluated at the end of the ICU stay, and VAP incidence density, respectively. Data were analyzed using the ARIMA (autoregressive integrated moving average) time series model in R software.

RESULTS

During the intervention period, 5,147 dental procedures were performed among 355 patients. The time series showed that ICU mortality was 36.11%, 32.71%, and 32.30% within the 3 years before the intervention, and 28.71% during the intervention period (P = .015). VAP incidence density did not significantly change during the study period (P = .716).

CONCLUSION

A dental care intervention focused on oral hygiene and periodontal treatment regularly provided by dentists to critically ill patients may decrease their risk of dying in the ICU. Randomized clinical trials should be performed to confirm these findings.

TRIAL REGISTRATION

WHO-affiliated Brazilian Clinical Trials Registry. RBR-4jmz36. Registered 7 October 2018, before first patient enrollment.

Recall of pain and discomfort during oral procedures experienced by intubated critically ill patients in the intensive care unit: A qualitative elicitation study

Background: Intubated and mechanically ventilated patients in the intensive care unit (ICU) may experience pain during routine oral procedures such as oral suctioning and tooth brushing. Despite the importance of pain prevention and management, little is known about patients’ experiences of procedural oral pain.

Aims: The aim of this study was to explore patients’ recollections and recommendations for pain and discomfort during routine oral procedures.

Methods: A qualitative descriptive design was used. Adult patients were recruited from a mixed medical–surgical–trauma ICU in an academic hospital in Toronto, Canada. Participants were interviewed using object elicitation methods within 7 days of discharge from the ICU. Data were analyzed using directed content analysis methods.

Results: We recruited 33 participants who were primarily male (23, 70%), with an average age of 54 (SD = 18) years, admitted with a medical (13, 39%), trauma (11, 33%), or surgical (9, 27%) diagnosis and dentate (27, 82%). Most participants described oral procedures as painful, discomforting, and emotionally distressing. Identified sources of pain included dry, inflamed oral tissues and procedural technique. Procedural pain behaviors were perceived to be frequently misinterpreted by clinicians as agitation, with consequences including physical restraint and unrelieved suffering. Participants advocated for greater frequency of oral care to prevent oral health deterioration, anticipatory procedural guidance, and structured pain assessment to mitigate the dehumanizing experience of unmanaged pain.

Conclusions: Patients described routine oral care procedures as painful and recalled suboptimal management of such pain. Procedural oral pain is an important target for practice improvement.