Impact of a Systematic Oral Care Program in Post-Mechanically Ventilated Intensive Care Patients

Background:

Hospital acquired infections remain of very high priority internationally.  As a result of well disseminated nursing research, evidence-based oral care protocols for mechanically ventilated patients are now considered standard of care in the ICU setting (Ames, Sulima, & Yates, 2011; El-Rabbany, et al. 2013).  In contrast, no standard of oral care exists for patients who have been recently extubated despite considerable high acuity. 

Purpose:

The purpose of this randomized control trial was to determine the impact of a systematic oral care hygiene program on recently extubated patients including measures of oral health, rates of oral colonization of Staphylococcus aureus and methicillin-resistant Staphylococcus aureus, and patient satisfaction with their in-hospital oral care.

Methods:

This was a prospective randomized control trial comparing standard oral care (control group ) to an intervention protocol that included tooth brushing, tongue scraping, flossing, mouth rinse and lip care.  This study took place at a large academic medical center in the Midwest USA. Subjects were recruited from four Intensive Care Units.  Inclusion criteria included: 1). mechanical ventilation for 48 hours, 2). ventilation liberation criteria (PEEP ≤ 8 and FIO2 ≤ 50%) or recently Extubated, 3). minimum of 3 teeth.   Exclusion criteria included: 1). allergy to dental products, 2). bleeding disorder , 3) planned hospital discharge within 48 hours, 4) diagnosis of mucositis,, 5). current chemotherapy, 5). presence of tracheostomy, 6). history of oral/facial surgery/trauma 7).  family/care team not in favor of continued medical treatment.  An oral care protocol was developed based on our previous work (Chipps, et al., 2014), and consultation with dental experts.

The intervention arm included a 4-day systematic oral hygiene program which was initiated within 24 hours post-extubation.  This oral hygiene program was provided twice per day by trained Clinical Nurse Specialist and included battery operated tooth brushing , tongue scraping, flossing, mouth rinse and lip care with selected dental products.  Usual care was provided by the staff using the hospital’s available dental products and usual care delivery.  Major outcome measures included oral cavity assessment (Revised-THROAT), the overall prevalence of methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus(MRSA) on oral cultures, subject satisfaction with the oral care and subject’s quality of life (Edmonton Symptom Assessment System).  The R- Throat is an instrument which measures oral health and includes assessment of lips, gums, teeth, tongue, saliva, smell and mouth comfort.  Each category is assessed on a scale from 1 to 3 with 3 indicating the poorest health.  The scale ranges from 7-21 (Dickinson, Watkins, & Leathley, 2001).  MSSA and MRSA were identified from oral swabs using standard laboratory protocols in a Biosafety Level 2 laboratory. Patient satisfaction and nurse care practices with the oral care protocol were assessed using a series of standardized questions and subjects’ quality of life was assessed using the Edmonton Symptom Assessment System-R (ESAS-R).  This tool was originally designed to assist in the assessment of nine symptoms common in cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath.

Independent Student t-tests, chi square and Fisher’s exact test were used to compare the two groups on demographic characteristics, and bacteria culture results.  To assess the impact of the oral hygiene protocol we used a repeated measures regression model. To assess changes in colonization of MSSA and MRSA, the number of patients colonized at the second culture was compared in both groups using a chi-square test. The number of patients who had changes in culture status was identified for those who: (1) acquired MSSA/MRSA (a baseline negative swab followed by a positive swab); (2) cleared (a positive swab followed by a negative swab); or 3) were persistently colonized (positive swab followed by a positive swab).

Results:

Eight-five subjects were enrolled and 74 were randomized.  The analyses were completed on 54 subjects.  Both the usual care and intervention group demonstrated overall improvement in the oral cavity over the 4-day period.  However, the intervention group  demonstrated significantly more improvement than the usual care group with nearly a 2-point decrease on the R-THROAT compared to a 0.86 point decrease in the usual care group.(p=.04).  All of the seven categories of the oral care assessment on the R-THROAT except smell showed improvement in the intervention group. However, the interaction of group and time demonstrated a statistically significant difference in the tongue and mouth comfort categories (p = .02, p = .001, respectively), indicating that group assignment affected the trajectory of these scores over time. There were no significant differences in overall Staphylococcus aureuscolonization between groups.  Overall, subjects in the intervention group rated their satisfaction with the oral care program and products higher than did the subjects in the usual care group.  With respect to the quality of life assessment, there were no significant differences between the groups other than the symptom of drowsiness in which the intervention group reported less drowsiness (p=.03).

Conclusion:

The immediate post-intubation period following critical illness remains a vulnerable period in the patient’s care trajectory, and risks associated with hospital acquired infection still remain high.  This study examined oral care in this period of a critically ill patient’s care trajectory. Both groups showed overall improvement in oral health post-intubation. Using a tongue scraper was particularly effective in our study.  This finding was not surprising because subjects' tongues immediately following extubation were often visibly filled with debris, and tongue scraping made an obvious difference in clearing this debris.  However, the significant improvement in the intervention group suggests that consideration should be given to further development of an evidence-based oral care protocol targeted at acutely ill patients in the immediate post-intubation period.