Prevalence and predictors of difficulty accessing the mouths of intubated critically ill adults to deliver oral care: An observational study

https://doi.org/10.1016/j.ijnurstu.2017.12.009Get rights and content

Abstract

Background

Oral care of intubated patients is essential to the prevention of infection and patient discomfort. However, barriers to oral access and delivery of oral care have received little attention.

Objective

To determine prevalence and predictors of oral access difficulty.

Design

A prospective, observational, multi-center study.

Settings

Four intensive care units in Toronto, Canada.

Participants

Adult patients orally intubated for ≥48 h.

Methods

We screened consecutive admissions once a week to identify eligible participants. We observed each patient and asked the patient’s nurse about presence or absence of difficulty accessing the mouth to deliver oral care across three categories: (1) visualizing inside the mouth; (2) obtaining patient cooperation, or (3) inserting instruments for delivery of oral care. We asked nurses to identify presence of patient behaviors contributing to oral access difficulty and perceived level of difficulty on a Likert response scale. We examined patient and treatment characteristics associated with extreme difficulty (i.e., difficulty in all 3 categories) using a generalized estimating equation regression model.

Results

A total of 428 patients were observed, 58% admitted with a medical diagnosis. More than half (57%) had ≥2 oral devices up to maximum of 4. Oral care difficulty was identified in 83% of patients and rated as moderate to high for 217 (51%). Difficulty concerned visibility (74%), patient cooperation (55%), and space to insert instruments (53%). Patient behaviors contributing difficulty included coughing/gagging (60%), mouth closing (49%), biting (45%) and localizing (27%) during care. Variables associated with extreme difficulty included neurological (OR 1.92, 95% CI 1.42–2.60) or trauma admission (OR 1.83, 95% CI 1.16–2.89), lack of pain assessment or treatment in the 4 h prior to oral care (OR 1.43, 95% CI 1.14–1.80), more oral devices (OR 1.40, 95% CI 1.05–1.87), and duration of intubation (OR 1.05, 95% CI 1.01–1.10). Absence of documented agitation in the 4 h prior to oral care was associated with less difficulty (OR 0.68, 95% CI 0.54–0.86).

Conclusions

Oral care is complex and difficulties are experienced in a vast majority of intubated patients. Some difficulties are amenable to correction such as pain management.

Section snippets

What is already known about the topic?

  • Oral health deterioration during intubation contributes to poor patient outcomes.

  • Oral tubes and limited patient cooperation may impede oral access and delivery of oral care including ventilator-associated pneumonia prophylaxis.

  • Prevalence and modifiable predictors of oral access difficulty are lacking.

What this study adds

  • Prevalence of oral access difficulty amongst Canadian ICU nurses is high.

  • More than 50% of intubated patients may be unable to cooperate during oral care.

  • 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.

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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.

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