Prevalence and predictors of difficulty accessing the mouths of intubated critically ill adults to deliver oral care: An observational study☆
Section snippets
What is already known about the topic?
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Oral health deterioration during intubation contributes to poor patient outcomes.
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Oral tubes and limited patient cooperation may impede oral access and delivery of oral care including ventilator-associated pneumonia prophylaxis.
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Prevalence and modifiable predictors of oral access difficulty are lacking.
What this study adds
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Prevalence of oral access difficulty amongst Canadian ICU nurses is high.
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More than 50% of intubated patients may be unable to cooperate during oral care.
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Potentially modifiable predictors of oral access difficulty include pain assessment and management.
Design, setting, and patient characteristics
We conducted a prospective observational multi-center study over 9-months (2015–2016) in 4 ICUs of 3 academic and 1 large community hospital. All participating units are Level 3 ICUs, which provide invasive mechanical ventilation and advanced life support for multi-system organ failure. Each ICU has a written oral care policy including tooth brushing every twelve hours, oral moistening every four hours, chlorhexidine 0.12% rinse prescribed for pneumonia prophylaxis four times a day, and lip
Results
We observed 428 patients with a median age of 59, who were primarily (61.8%) male and admitted with a medical diagnosis (58.1%). Most patients (59.4%) had been orally intubated between 3 and 7 days at the time of assessment and more than half (57.1%) had ≥2 indwelling oral devices (Table 1).
We identified presence of oral care difficulty in 83.2% of patients observed in one or more of the 3 difficulty categories: visualizing inside the mouth (74.3%); obtaining patient cooperation (55.1%); or
Discussion
This is the first prospective observational multi-center study to determine prevalence and predictors of difficulty accessing the mouths of orally intubated and mechanically ventilated adults for the delivery of oral care. Using real-time observation, we found more than 50% of patients demonstrated challenging behaviors when oral care was attempted, with most patients exhibiting moderate to high difficulty as rated by nurses. The frequency with which nurses reported difficulty visualizing the
Conclusion
In this multi-center study of the prevalence and predictors of difficulty accessing the mouths of intubated and mechanically ventilated patients to deliver oral care, we found prevalence was high at 83%; most patients exhibited moderate to high difficulty as rated by nurses. Extreme difficulty was associated with neurological or trauma diagnosis, lack of pain assessment and treatment, greater number of oral devices, and days intubated. Results emphasize the importance of routine assessment and
Competing interests
The authors have no competing interests to declare.
Ethics, consent and permissions
Research ethics approval and waiver of patient consent for the conduct of this study was received at Sunnybrook Health Sciences Centre (#132-2015), Mount Sinai Hospital (#15-0097E), St. Michael’s Hospital (#15-160C) and the Michael Garron Hospital (#632-1504-Mis-261).
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Funding
This work was funded by the Canadian Institutes of Health Research (CIHR) and the Lawrence S. Bloomberg Faculty of Nursing Bertha Rosenstadt Faculty Research Grant Program, University of Toronto.
Acknowledgments
We thank the research assistants who facilitated the conduct of this study at their respective institutions: Alicia Lara Gonzalez, Karen Nguyen, Julie Min, Kurtis Salway, Gyan Sandhu, Alexandra Cheung, Liz Lee and Hoda Moin. We also thank the nurses who participated in this study.
References (31)
- et al.
Beyond comfort: oral hygiene as a critical nursing activity in the intensive care unit
Intensive Crit. Care Nurs.
(2006) - et al.
Survey of oral care practices in US intensive care units
Am. J. Infect. Control
(2004) - et al.
Oral care practices among critical care nurses in Singapore: a questionnaire survey
Appl. Nurs. Res.
(2012) - et al.
Epidemiology and outcomes of ventilator-associated pneumonia in a large US database
Chest
(2002) - et al.
Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation
J. Crit. Care
(2017) - et al.
Ventilator-associated pneumonia: improving outcomes through guideline implementation
J. Crit. Care
(2008) - et al.
Assessment of coma and impaired consciousness
Lancet
(1974) - et al.
Toothbrushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia
Crit. Care Med.
(2013) - et al.
Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit
Crit. Care Med.
(2013) - et al.
The changing epidemiology of mechanical ventilation: a population-based study
J. Intensive Care Med.
(2006)
Impact of systematic evaluation of pain and agitation in an intensive care unit
Crit. Care Med.
Ethnographic investigation of oral care in the intensive care unit
Am. J. Crit. Care
Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients
Crit. Care Med.
Small-sample adjustments for Wald-type tests using sandwich estimators
Biometrics
Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit
J. Neurosci. Nurs.
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This work was conducted in the ICUs of Sunnybrook Health Sciences Centre, St. Michael’s Hospital, Mount Sinai Hospital and the Michael Garron Hospital, Toronto, Canada.