This paper aims to review the literature surrounding the chosen intervention of oral hygiene. Specifically the effects of good oral hygiene of ventilated patients in a critical care environment. The intervention was selected after the author completed an 8 week placement in an ICU department and to improve evidence-based practice. To retain anonymity the name of the hospital will not be disclosed this complies with the NMC code of professional conduct (2008). It was based on an Intensive Care Unit (ICU) that specialized in the care of level 2 and 3 patients with neurological problems. The majority of the patients on this unit were on advanced respiratory support such as ventilators as well as having with support other vital organ systems. It was noted by the author during the placement that there was a high incidence chest infections. This may have been related to the patients’ oral hygiene despite the unit adhering to a strict cleansing regime and trust policy/protocols.
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Firstly, the department adhered to the current recommendations outlined by National Institute for Clinical Excellence (NICE, 2008). NICE states that to reduce the risk of pneumonia in patients on a ventilator patients should be in a semi upright position. Also that some sort of antiseptic is used within the mouth care routine for the patient. These are very vague guidelines and the writer feels further investigation is needed to claify what is best standard practice for mouth care. Intensive care patients have complex oral care needs, inadequate oral care can predispose ICU patients to nosocomial infections such as pneumonia (Ruffell and Admcova, 2008). Ventilator Associated Pneumonia (VAP) is defined as a nosocomical pneumonia that develops in a patient who has been on mechanical ventilary support (intubated) for 48 hour or more (Hutchins et el, 2009), it is a recognised problem in intubated patients, as well as a important cause of morbidity and mortality. In European Prevalence of Infection in ICU study (Vincent et al, 1995) VAP was the most frequent infection accouting for 45% of all infections in ICUs Recent evidence indicates the colonization of the mouth with respiratory pathogens may contribute to VAP. VAP has been associated with increase morbidity, higher mortality rates, increased healthcare cost and longer hospital stays(Hutchins et el,2009).VAP is the leading source of death due to nosocomicalinfection in ICUs (Berry, 2007)
Upon reflection, it was observed that there was a high prevalence of VAP on the ward despite the use of high impact interventions such as ventilator care bundles prescribed on the ward. (Saving Lives, 2007) The Health Act 2006 Code of Practice also states that the NHS organisations must audit key policy and procedures for infection control.This included brushing with toothpaste and a small toothbrush, chlorhexidine rinses, suctioning, checking cuff inflation, humidification of and a semi recumbarant positioning. This underpins the rational for selecting the nursing intervention of oral mouth care in VAP prevention. The author felt by reviewing the relevant literature surround the use over mouth care products and associated research the extent to which current literature support or question current evidence based guidelines, could anything else be done to prevent all these infections.
Gash defined a literature review as a systematic and thorough search of all types of published literature in order to identify as many items as possible that are relevant to a particular topic (Gash, 2000). Due to the time constraint and the limited number of words allowed the search has been specifically narrowed down and utilised the appropriate and relevant literature.
The key words used in the search were ‘oral hygiene’ and ‘intensive care’, with the variants of ‘oral decontamination’, ‘mouth care’, ‘intubated’ and ‘mechanically ventilated’. The research strategies for selecting literature to review for this paper involved the following databases where searched using EBSCO CINAHL, OVID MEDLINE, Cochrane Library search engines this returned 10224 hits, The search was then narrowed through filtering to only include the core clinical journals or academic papers. The inclusion criteria included research studies and reviews which focused on the oral hygiene in a intensive care setting, articles in this review where published in the last 10 years, focused on adults and written or translated into English. This produced 123 papers, with a search manually finding only 9 that where relevant and will be discussed below.
Oral Hygiene effective removal of plaque and debris to ensure the structures and tissues of the mouth are kept in a healthy condition (DOH, 2001). Effective oral health care makes an important contribution to peoples physical, psychological and social well being (Major, 2005). Maintaining oral health in the critically ill patient is imperative in reducing the risk of nosocomial infections and improving patient comfort and discharge outcomes. Critically ill patients are at great risk for poor oral health as many are elderly, undernourished, dehydrated, immunosuppressed, have a smoking or alcohol history, are intubated or on high-flow oxygen, and are unable to mechanically remove dental plaque.(AUS, 2003). Mircoaspiration may occur in patients with a depressed conscience level and reduced cough effort ability, or with a ill fitting or a partially deflated fitting cuff around the endotracheal tube. Critically ill patients lack of spontaneous movement of the tongue movement of the tongue and jaw, infrequent swallowing, and ability to brush teeth because of ventilation equipment as early as 24 hours after ICU admission. (2)
Having read through all the research it is evident that studies are contradictory. For example Hutchins (2009) believes the gold standard of oral hygiene is suctioned toothbrushes every four hours followed by Chlorhexidine mouth wash. This reduced VAP by 90% in their study over three years, however can this study be valid as there was no control group or randomization. Furthermore, is research completed in America transferable to the UK. This study was not designed as a RCT but rather as a quality improvement initiative. There was also no numbers of the study size only that all patients ventilated where included over a period of time. Therefore, it could be argued that this study required a sample to measure findings, also completed in America where they have a different a private health care structure and high budgets and funding. Hutchins states the oral hygiene should be completed every 4 hours but The Essence of Care (2001) document emphasises the importance of assessing individuals, in relation to how their oral hygiene can be maintained with its best practice bench mark: ‘All patients/clients are assessed to identify the advice and/or care required to maintain and promote their individual oral hygiene’ (DOH, 2001). So to do Mouth care on a patient every 4 hours when it needs to be done every hour is unethical, And if the patient only needs mouth care twice a day and your completing every 4 hours this is a waste of nursing time.
Maintaining patient safety when administrating mouth care so not to dislodge the endotractcal tube, failing to remove all the toothpaste and mouth wash, putting the patient at risk of aspiration, are all expressed concerns by nurses as concerns when doing mouth care. These reasons as well as patient comfort all influence the nurse to the frequency of mouth care (Berry and Davidson, 2006).
Unfortunately, emphasis on the provision of oral care hygiene is allocated as a low priority in nursing duties and student teaching(Berry and Davidson, 2006) although considered to be a basic nursing practice it is relegated to the bottom of the list of duties when caring for a complex intensive care patient.
A paper written in 2003 found that Reinforcing proper oral care in education programmes, de-sensitizing nurses to the often-perceived unpleasantness of cleaning oral cavities, and working with hospital managers to allow sufficient time to attend to oral care are recommended.(Furr et el, 2004) Nurse education in oral health practice has remained relatively unchanged for 120 years, and qualified staff lack of adequate knowledge of oral health. In a systematic review (Berry, 20?) sites that nurses in the absence of evidence based guidelines to direct best practice, perform oral hygiene according to individual preferences and historical patterns. These are normally a combination of product availability and nurses previous experience. But the NMC The Code Standards of Conduct, Performance and Ethics (NMC 2008): “You must deliver care based on the best available evidence of best practice.”, although nurses are unclear about what is the best practice, there are many unclear studies and vague guidelines when it comes to Oral hygiene..
The benefits of oral decontamination in reducing VAP have been reviewed in a recent meta-analysis published by the British Journal of Nursing (BJN) This is a peer reviewed journal meaning that to publish within it, others of the same standing have read and agreed with its findings (LoBiondo and Wood, 2002).
Toothbrushes/ Mouth swobs
The use of the toothbrush in the mechanical removal of plaque, even in the intubated patient, has been proven to be superior to the swab,(AUS)(10) although electric toothbrushes are preferable, their cost, size and the potential for cross-infection limits their use AUS, (2003). Hutchins et al, (2009) research an icu where they had a ventilator bundle that included the use of suction tooth brushes. Swob sticks have been reported as ineffective in removing debris between the teeth and gum borders (Berry at el, 2007) although it was suggested that the use of foam swabs soaked in Chlorhexidine if a toothbrush is considered inappropriate. Although some research shows that mouth swobs should never be used due to them falling apart in the mouth (?)studies indicate that swabbing is the preferred method of oral care in the ICU (Furr et el, 2004)
Tooth brushing with a child sized brush is superior to form swobs in removing dental plaque and bacteria in nurse administered oral care (Furr et el, 2004)
Mouth wash
Although few have been tested in the critical care population, the mouth care rises include chlorhexidine, sodium bicarbonate, hydrogen peroxide and potassium permanganate
In a study conducted by Chan (Chan et el,) published in 2007 they found that the oral decontamination of vented patients using antiseptics is associated with a lower risk of VAP(Chan et el, 2007) but they did not reduce mortality or duration of mechanical ventilation or stay in hospital. Although in (Panchabhai et el, 2009) found that use of chlorhexidine did not reduce the amount of VAP compared to the control group, although both groups had reduced numbers of infection, but it did reduce the length of ICU stay. This may have been because they used potassium permanganate as a control rather than a placebo, also when the study was in progress periodic briefing of ICU nurses regarding the importance of mouth care and regular supervision and auditing where done so may have contributed to the decrease of VAP and length of stay.
Chlorhexidine is the most investigated and recommended oral care product for preventing VAP.(Senol et el, 2007), although not all studies have found this. There have been reported cases of allergic reactions to Chlorhexidine. (?) Chlorhexidine may also cause brown discolouration to the teeth. (?)
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Other ways of helping reduce are
To reduce the incidence of VAP incline the head up to 35 percent, interruptions to sedation and the use of subglottic suctioning of secretions. Patients are also but on Tazocine
Senol et el (2007) describes that an organised approach to VAP prevention can reduce the rate of VAP. A ventilator bundle is a group of interventions for the intubated patient found to be effective in the reduction rate of VAP. This included elevating the head, sedation vacations, prophylaxis for peptic ulcers and DVT thrombosis.
At present there is a review in China underway that is look at Oral hygiene care for critically ill patients to prevent ventilator associated pneumonia, for the Cochrane library. Unfortunately at the time of writing this hasn’t come to print (Shi et el, 2010)
Berry et el (2007) systematic review concluded need more research
Conclusion
As indicated in (Marra et el, 2009) to control VAP in the ICU, it is not sufficient to implement 1 measure, or even an ventilator bundle, but rather it requires a culture change involving the entire ICU team.
The writer feels that rather than just good oral hygiene to prevent VAP, The ventilator bundle seems to have good results. Education for all ICU nurses, prescribed mouth care products, and valid and reliable assessment tools are needed.
The Writer feels that the reading and the literature search have extended their understanding of the key concepts, theories and methodologies surrounding oral decontamination, they have an increased awareness and knowledge and understanding of mouth care and are in a better position to make an informed choice about what practice to use.
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