American Journal of Infection Control 42 (2014) 921-2

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American Journal of Infection Control

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Brief report

Does the presence of oral care guidelines affect oral care delivery by intensive care unit nurses? A survey of Saudi intensive care unit nurses Ahmed K. Alotaibi BDS *, Mohammed Alshayiqi BDS, Sundar Ramalingam MDS, FFDRCS(Ire) Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Key Words: Dental hygiene Critically ill Nosocomial infection Ventilator-associated pneumonia Nursing practice

Mechanically ventilated patients rely on nurses for their oral care needs, signifying the importance of nurses in intensive care units (ICUs). This study aimed to evaluate the impact of oral care guidelines on the oral care delivered to mechanically ventilated patients by ICU nurses. A total of 215 nurses were enrolled. Demographic data and oral care practices were recorded through a self-administered survey. Participants governed by oral care guidelines had significantly higher oral care practice scores than their counterparts from ICUs without similar guidelines (P ¼ .034; t ¼ 2.13). Oral care guidelines in ICUs can contribute to reduction of morbidity and mortality caused by ventilator-associated pneumonia. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Hospital-acquired pneumonia is an infection of the lung parenchyma occurring after at least 48 hours of hospitalization. Ventilator-associated pneumonia (VAP) is a subtype of this infection that develops after a patient has been intubated and mechanically ventilated for at least 48 hours.1 Almost 65% of intubated critically ill patients have been found to harbor pathogens responsible for VAP in their oral mucosa and dental plaque.2 Genuit et al3 reported a 75% reduction in the rate of VAP and a 43% reduction in mortality among intensive care unit (ICU) patients after an oral care intervention. Mechanically ventilated patients are completely reliant on the nurses for their oral care needs, signifying the importance of nursing personnel in reducing the morbidity and mortality caused by VAP.4 The objective of this study was to evaluate the impact of oral care guidelines on the oral care delivered to mechanically ventilated patients by ICU nurses in Saudi Arabia.

MATERIALS AND METHODS After receiving ethical approval from the Ethical Committee at College of Dentistry Research Center, King Saud University, Riyadh, Saudi Arabia (IR # 0033), we conducted a cross-sectional survey of ICU * Address correspondence to Ahmed K. Alotaibi, BDS, College of Dentistry, King Saud University, PO Box 60169, Riyadh 11545, Kingdom of Saudi Arabia. E-mail address: [email protected] (A.K. Alotaibi). Conflict of interest: None to report.

nurses. The study sample was conveniently drawn from among the ICU nurses employed at 10 tertiary care hospitals in RiyadhArabia. Modified versions of a questionnaire developed by Binkley et al5 were used with permission of the authors. The questionnaire included a list of oral care practices prescribed for mechanically ventilated patients, from which the nurses were asked to select the practices followed and their frequency of use. The scoring system of

Table 1 Participants’ demographic data Characteristic Educational level, n (%) Nursing diploma program Bachelor’s degree or more Missing data Type of shift, n (%) Day Night Missing data ICU type, n (%) Medical/multidisciplinary Surgical Pediatric Cardiac Neurologic Other Missing data Age, y, mean SD (range) ICU experience, y, mean SD (range)

Value 73 (34.3) 140 (65.7) 2 103 (77.4) 30 (22.6) 82 148 44 5 8 2 3 5 33.06  7.19 7.49  5.58

(70.5) (21.0) (2.4) (3.8) (1.0) (1.4) (23-55) (1-26)

0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.05.019

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A.K. Alotaibi et al. / American Journal of Infection Control 42 (2014) 921-2

Table 2 Type and frequency of participants’ oral care practices for mechanically ventilated patients Practice Oral care system Foam swabs Manual toothbrushes Electric toothbrushes Moisture agents Toothpaste Mouthwashes

Never, n (%) 75 68 62 207 59 88 9

(34.6) (31.6) (28.8) (96.3) (27.4) (40.9) (4.2)

Once daily or less, n (%) 5 15 28 8 8 16 11

Every 12 h, n (%)

Every 8 h, n (%)

Every 4 h, n (%)

Every 1-3 h, n (%)

17 (7.9) 24 (11.2) 57 (26.5) 0 18 (8.4) 54 (25.1) 20 (9.3)

23 (10.7) 16 (7.4) 22 (10.2) 0 28 (13) 25 (11.6) 35 (16.3)

63 (29.4) 58 (27) 27 (12.6) 0 66 (30.7) 22 (10.2) 101 (47)

32 (15) 34 (15.8) 19 (8.8) 0 36 (16.7) 10 (4.7) 39 (18.1)

(2.3) (7) (13) (3.7) (3.7) (7.4) (5.1)

Lin et al6 was used to assess oral care practices, based on which 1 point was given to the participants when they performed one of the following oral care methods: (1) using a toothbrush once every 8-12 hours; (2) using a foam swab or oral care system once every 6-8 hours; (3) using mouthwash while suctioning oral secretions once every 2-4 hours; and (4) using an oral moisturizer with oral suctioning. The questionnaire was reviewed by an intensivist and pilot-tested for clarity and accuracy on 12 nurses. Study data were analyzed using SPSS version 20.0 (IBM, Armonk, NY). Differences in oral care practices between groups based on the presence or absence of oral care guidelines were analyzed using the independent t test, with the significance level set at P < .05. RESULTS The sample size was estimated at 210 based on a population size of 465, 50% expected frequency, type I error (a ¼ 0.05), and 95% confidence interval (StatCalc; EpiInfo 7.1.3.3). A total of 225 questionnaires were distributed, of which 215 were completed and returned (97.7% response rate). The mean age and nursing experience of the participants were 33.06 years (range, 23-55 years) and 7.49 years (range, 126 years), respectively. The majority of participants (n ¼ 146; 67.9%) had at least a bachelor’s degree in nursing (Table 1). Oral care delivered by the nurses varied in type and frequency (Table 2). More than one-half of the participants (n ¼ 140; 65.1%) reported delivering a mouthwash once every 4 hours, with chlorhexidine 0.12% the unanimous choice (n ¼ 194; 94.4%). Manual toothbrushing once every 12 hours was reported by almost one-half of the participants (n ¼ 125; 58.1%). Only one-third of the participants reported performing subglottic suctioning (n ¼ 80; 37.6%). The mean score for oral care practices by the participants was 2.38 (SD  1.12). Whereas the maximun score was seen in only 32 participants (15%), a score of 3 was the most frequent (n ¼ 79; 37.1%). The majority of the nurses (n ¼ 169; 78.6%) agreed to the presence of oral care guidelines for mechanically ventilated patients in their respective ICUs. Participants governed by oral care guidelines had significantly higher oral care practice scores compared with their counterparts from ICUs without similar guidelines (mean score, 2.46  1.10 [n ¼ 168] vs 2.06  1.13 [n ¼ 45]; P ¼ .034; t ¼ 2.13). DISCUSSION Nurses’ oral care practices varied among hospitals, among ICUs, and even among nurses of the same ICU. The use of chlorhexidine 0.12% mouthwash by the majority of the participants was an encouraging finding. A systematic review of randomized clinical trials showed that chlorhexidine mouthwash was effective in reducing the incidence of VAP.7 Even though chlorhexidine is reportedly superior to toothbrushing in reducing VAP in patients without pneumonia at baseline,8 more recent evidence suggests the importance of toothbrushing in reducing oral colonization by pathogens.9 In the present study, toothbrushing was reportedly performed by only one-half of

the participants. In a meta-analysis, subglottic suctioning was found to reduce the risk of VAP by 50%.10 Only one-third of the participants agreed to performing subglottic suctioning in this study. Statistically significant differences in the oral care practice scores were observed between nurses from ICUs with and without oral care guidelines. This underscores the importance of such guidelines in reducing the incidence of VAP among mechanically ventilated patients. Moreover, our results indicate the need to encourage toothbrushing and subglottic suctioning as a standard oral care practice in addition to mouthwashes in mechanically ventilated patients. Being a self-administered survey, the present study did not evaluate actual oral care delivery in the clinical setting. Furthermore, outcomes of oral care practices and guidelines on the incidence of VAP could not be assessed, owing to the study’s cross-sectional nature. Within the limitations of the present study, it can be concluded that the presence of oral care guidelines significantly influences oral care delivery to mechanically ventilated patients in Saudi ICUs. Evidence-based oral care protocols for mechanically ventilated patients must be implemented in all ICUs, and sufficient training should be provided to the nursing personnel to deliver the same. Acknowledgment We thank Binkley and colleagues for allowing us to use and modify their survey. We also acknowledge the help of our biostatistician consultant Nasser Al-Maflehi. References 1. Niederman MS. Hospital-acquired pneumonia, health careeassociated pneumonia, ventilator-associated pneumonia, and ventilator-associated tracheobronchitis: definitions and challenges in trial design. Clin Infect Dis 2010; 51(Suppl 1):S12-7. 2. Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Criti Care Med 1992; 20:740-5. 3. Genuit T, Bochicchio G, Napolitano LM, McCarter RJ, Roghman MC. Prophylactic chlorhexidine oral rinse decreases ventilator-associated pneumonia in surgical ICU patients. Surg Infect 2001;2:5-18. 4. Stonecypher K. Ventilator-associated pneumonia: the importance of oral care in intubated adults. Crit Care Nurs Q 2010;33:339-47. 5. Binkley C, Furr LA, Carrico R, McCurren C. Survey of oral care practices in US intensive care units. Am J Infect Control 2004;32:161-9. 6. Lin YS, Chang JC, Chang TH, Lou MF. Critical care nurses’ knowledge, attitudes and practices of oral care for patients with oral endotracheal intubation: a questionnaire survey. J Clin Nurs 2011;20:3204-14. 7. Silvestri L, Weir I, Gregori D, Taylor N, Zandstra D, Van Saene J, et al. Effectiveness of oral chlorhexidine on nosocomial pneumonia, causative microorganisms and mortality in critically ill patients: a systematic review and meta-analysis. Minerva Anestesiol; 2013 [Epub ahead of print.] 8. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care 2009;18:428-37. 9. Berry AM, Davidson PM, Nicholson L, Pasqualotto C, Rolls K. Consensus-based clinical guideline for oral hygiene in the critically ill. Intens Crit Care Nurs 2011; 27:180-5. 10. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a metaanalysis. Am J Med 2005;118:11-8.

Does the presence of oral care guidelines affect oral care delivery by intensive care unit nurses? A survey of Saudi intensive care unit nurses.

Mechanically ventilated patients rely on nurses for their oral care needs, signifying the importance of nurses in intensive care units (ICUs). This st...
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