http://doi.org/10.33698/NRF0170 – Shweta Handa, Sulakshna Chand, Jyoti Sarin, Varsha A Singh, Shalini Sharma
Abstract: The importance of good oral health for intubated, unconscious patients reflects the dimension of preventive oral care in reducing colonization of potential respiratory pathogens.Traditionally, oral health and oral hygiene have been given low priority in the nursing care of critically ill children.To assess the effectiveness of Oral Care Protocol (with normal saline) in terms of Oral Health Status of hospitalized children admitted in intensive care unit (ICU), an experimental approach was adopted with pre-test post-test control group design. A sample of 60 hospitalized children admitted in ICU was selected by purposive sampling technique were randomly assigned to control and experimental group. Data in terms of Oral health status and microbiological colony count was assessed using Beck oral assessment scale and colonization scale. The Oral Health Status of hospitalized children improved in the experimental group as compared to the control group. Oral Care Protocol was also effective in terms of reduction of colony count of Candida albicans, Staphylococcusaureus. However there was no significant reduction in the colony count of Coagulase negative staphylococci, Kliebsella
Keywords: Effectiveness, oral care protocol, oral health status, hospitalized children.
Correspondence at Sulakshna Chand Assistant Professor MMIN, Mullana, Ambala
Introduction:
Oral care is a fundamental aspect of nursing that impacts the health, well-being and comfort of patients1. There is a complex integration of functional oral components necessary to maintain oral health and wellness2. Within 48 hours of admission, the oropharyngeal flora of critically ill children undergoes a change from predominantly gram positive organisms to predominantly gram negative organisms, creating more virulent flora. Due to anatomical connection between the oral cavity, the respiratory and circulatory systems, pathogens potentially transfer to cause systemic infections. Pneumonia has been reported as the most common infection in intensive care unit in Pakistan, Lebanon and India with prevalence of 28%, 47%, and 81% respectively.3 Nosocomial pneumonia contributes to 60% of the fatal infections and is the leading cause of death in critically ill children4. In addition, length of hospital stay also impacts the mortality rate of children as there is statistically significant increase in dental plaque which is a potential source for dental colonization and nosocomial infections among children admitted in ICU for four days or more5. Critically ill children are usually dependent on nurses for oral care due to their inability to perform essential care for themselves. Assessment of the oropharynx and maintaining a favorable level of hygiene are challenging to perform in critically ill children. This task further becomes difficult due to the presence of mechanical barriers such as endotracheal tube, oral airway, oral gastric tube, and temperature probe which crowd the mouth of critically ill patient. In addition, fixation tapes quickly become heavily contaminated with pathogens in the presence of salivary disturbances leading to difficulties associated with cleansing of the mouth6. As a result, nurses are often reluctant to manipulate endotracheal tube for oral assessment and hygiene measures.However, assessment of oral health is essential to establish patient’s baseline oral health status during the course of care and response to interventions. With early assessment and detection of oral health disturbances, oral care may be modified or frequency of interventions adjusted to prevent the incidence and further deterioration which negatively impact the children’s overall health7. Thus,consistent efforts to improve oral care in the intensive care unit are important and the provision of a well-developed oral care protocol can improve the oral health of patients admitted in the intensive care unit8.
Objective:To assess the effectiveness of Oral Care Protocol in terms of Oral Health Status of hospitalized children admitted in intensive care units.
Materials and Methods:A quasi experimental research design was adopted to assess the effectiveness of Oral Care Protocol in terms of Oral Health Status of hospitalized children admitted in intensive care units.The tools for data collection were: demographic and clinical variables. Oral health assessment score was calculated using Beck Oral health assessment scale (standardized scale) with scores ranging from 5-20 (higher scores indicating poor oral health status). The scores were categorized as 1-5 (No dysfunction), 6-10 (Mild dysfunction), 11-15 (Moderate dysfunction), 16 – 20 ( Severe dysfunction). Oral microbiological colony count was done which included: Coagulase negative staphylococci, Klebsiella, Candida albicans, and Staphylococcus aureus. The colony count was categorized into: Confluent Growth (>200 CFU), Moderate Growth (100-200 CFU), Moderate Scanty Growth (20-99 CFU), Scanty Growth (< 20 CFU). The tools were validated by nine experts from concerned fields of; Child Health Nursing, Medical-Surgical Nursing, Pediatric Medicine, Microbiology Department, Dental department. Oral care protocol is an appropriate method to assist the clinical nurses by providing analytical framework for providing oral care to hospitalized children. Beck oral assessment scale was primarily accomplished by Beck which included 41 items pertaining to assessment of lips, gingival/oral mucosa, tongue, teeth and saliva. Scores ranges from 5-20 with higher scores indicating poor oral health status. Firstly the protocol was developed which included 29 items which primarily focused on oral care with disinfectant for four times a day (including inner tooth surface first, outer tooth surface, roof, gums, inside cheeks and tongue) for implementation of oral care to the hospitalized children.The target population included hospitalized children admitted in intensive care units in the months of December 2012 to January 2013. Sixty hospitalized children admitted in intensive care unit i.e. for experimental group (30 subjects) and control group (30 subjects) were selected by purposive sampling technique and were randomly assigned to experimental and control group. Comatose hospitalized children between the age group of one year to 12 years admitted in intensive care units for more than 48 hours, available at the time of data collection and whose parents gave consent for participation of their children in study were included in the study. Pilot study was conducted in Maharishi Markandeshwar Institute of Medical Sciences Research & Hospital (MMIMSR&H) for assessing the feasibility of the study.Data was collected after obtaining formal administrative approval from the designated authority.Data was collected from December 2012 to January 2013.Informed consent was obtained from the parents of respondents after explaining the purpose of the study and ensuring confidentiality of their response. After recruiting the subjects for the study, demographic and clinical details were collected. On day one, Oral health assessment was done using Beck oral assessment scale (standardised) and obtaining gingival swab from the oral cavity of hospitalized children in experimental and control group for oral microbiological colony count. The obtained swab was transported and inoculated in blood agar. Microbiological flora was identified using gram staining and microbial colonies were counted using colony counter and recorded in oral microbiological recording sheet.After initial assessment and specimen collection, experimental group received oral care based on prepared protocol i.e. oral care with normal saline four times a day for three consecutive day (including inner tooth surface first, outer tooth surface, roof, gums, inside cheeks and tongue) and control group received routine oral care.On day four, oral health assessment was done using Beck oral assessment scale and obtaining gingival swab from the oral cavity of hospitalized children in experimental and control group for oral microbiological colony count. The obtained swab was transported and inoculated in blood agar. Microbiological flora was identified using gram staining and microbial colonies were counted using colony counter and recorded in oral microbiological recording sheet. Final data was collected and analyzed using both descriptive and inferential statistics. Statistical analysis was done by SPSS version 17.0.
Results
Table1: Data presented in table-1 revealed that 33.4% of subjects in experimental group and 50% of subjects in control group were in the age group of 4-6 years. Both in experimental and control group, 56.6% of subjects were males. In experimental group, 33.4% of subjects were diagnosed with respiratory problem as compared to 30.2% of subjects in control group. Maximum number of the subjects in experimental group and control group were not receiving antiepileptic drugs (90%), (96.6%), corticosteroids (86.6%), (83.4%), antihistamines (93.4%), (90%) respectively.All the subjects (100%) in both the groups were receiving antibiotics. In both the groups 63.3% of subjects were with traction and other supportive device.The computed chi square values were not found to be significant (p>0.05).This indicated that subjects in the experimental group and control group were homogenous with regard to age, gender, diagnosis, prescribed medication, presence of nasogastric tube,ventilator support and supportive devices.Table 2: Data presented in table 2 revealed that in experimental group, the mean oral health assessment score of subjects was 13.77 and 9.67 before and after implementation of oral care as per protocol respectively with a mean difference of 4.10. The computed’t’ value of 9.17 was found to be statistically significant at 0.05 level.The data also revealed that in control group, the mean oral health assessment score of subjects was 12.93 and 13.00 before and after implementation of routine oral care respectively with a mean difference of 0.06. The computed ‘ t’ value of 0.31 was not found to be statistically significant at 0.05 level.This showed that there was significant difference between the mean oral health assessment score of subjects before and after implementation of oral care protocol. Data further revealed that before implementation of oral care, the mean oral health assessment score of subjects was 13.77 in experimental group and 12.93 in control group with a mean difference of 0.83. The calculated ‘t’ value of 1.27 was not found to be statistically significant at 0.05 level. This indicated that the subjects in experimental and control group did not differ initially in terms of oral health assessment scores. The findings also revealed that after implementation of oral care, the mean oral health assessment score of subjects was 9.67 in experimental group and 13 in control group with a mean difference of 3.33. The calculated ‘t’ value of 6.44 was found to be statistically significant at 0.05 level of significance. Thus, it can be inferred that oral care as per protocol was effective in reducing oral health assessment score of subjects.
Table1: Characteristics of Subjects in Experimental and Control Group
N =60
| Sample Characteristics | Experiment
Group (n=30) f(%) |
Control group (n=30)
f(%) |
df | c2 |
| Age in years | ||||
| 1-3 yrs | 06 (20.0) | 01 (3.4) | ||
| 4-6 yrs | 10 (33.4) | 15 (50.0) | ||
| 7-9 yrs | 07 (23.3) | 11 (36.6) | 3 | 02.43NS |
| 10-12 yrs | 07 (23.3) | 03 (10.0) | ||
| Gender | ||||
| Male | 17 (56.6) | 17 (56.6) | ||
| Female | 13 (43.4) | 13 (43.4) | ||
| Diagnosis | ||||
| Respiratory system | 10 (33.4) | 09 (30.2) | ||
| Renal system | 04 (13.4) | 05 (16.6) | ||
| Gastrointestinal system | 02 (6.6) | 02 (6.6) | 5 | 1.62NS |
| Neurological system | 04 (13.4) | 02 (6.6) | ||
| Musculoskeletal system | 08 (26.6) | 11 (36.6) | ||
| Integumentary system | 02 (6.6) | 01 (3.4) | ||
| Prescribed Medication | ||||
| Anti-epileptic drugs | ||||
| Yes | 03 (10) | 01 (3.4) | 1 | 1.64NS |
| No | 27 (90) | 29 (96.6) | ||
| Corticosteroids | ||||
| Yes | 04 (13.4) | 05 (16.6) | 1 | 0.13NS |
| No | 26 (86.6) | 25 (83.4) | ||
| Antibiotics | ||||
| Yes | 30 (100) | 30 (100) | ||
| Antihistamines | ||||
| Yes | 02 (6.6) | 03 (10.0) | 1 | 0.21NS |
| No | 28 (93.4) | 27 (90.0) | ||
| 5. Client with | ||||
| Nasogastric tube | 03 (10.0) | 04 (13.4) | ||
| Ventilator support | 08 (26.7) | 07 (23.3) | 2 | 0.25NS |
| Other supportive devices | 19 (63.3) | 19 (63.3) |
c2 (1)=3.84), (2)=5.99, (3)=7.81, (5)= 11.07 ; NS – not significant (p>0.05)
Table 2: Oral Health Assessment Score of Subjects in the Experimental and Control Group Before and After Implementation of Oral Care Protocol.
N =60
| Group | Before oral care Mean oral assessment score | After oral care Mean oral assessment score | MD,SD,SE,
t |
P
value |
| Experimental
(n=30) Control (n=30) MD, SD, SE, t P value |
13.77
12.93
0.83, 2.09, 0.67 1.27NS 0.209 |
9.67
13.00
3.33, 2.39, 0.47, 6.44* 0.001 |
4.10, 2.26, 0.49
9.17* 0.07, 1.17, 0.69 0.31NS |
0.001
0.757 |
t (29)=2.05; *significant (p≤0.05), NSNot significant (p>0.05). t (58) = 2.00;
Table 3: Data presented in table 3 revealed that in experimental group the computed ‘t’ value for Candida albicans and Staphylococcus aureus [t (29)= 6.54] and [t (29)=9.83] was found to be significant at 0.05 level of significance whereas ‘t’ value for Coagulase negative staphylococci and Kliebsella [t (29)=1.49] and [t (29)= 1.74] was not significant at 0.05 level of significance. It was concluded that the Oral Care Protocol was effective in reducing colony count of Candida albicans, Staphylococcus aureus whereas not effective in reducing colony count of Coagulase negative staphylococci, Kliebsella
Table 3: Oral Microbiological Colony Count of Subjects before and after implementation of Oral Care in Experimental and Control Group N =60
| Oral microbiological flora | Group | Mean Oral microbiological flora Count | MD, SEMD, SDD | ‘t’ value, |
| Before After oral
oral care care |
||||
| Coagulase
negative staphylococci |
Experimental Control | 151.26 150.66
179.17 181.07 |
0.60, 91.05, 2.29
1.90, 191.84, 7.35 |
1.49NS. 0.141
1.41NS. 0.163 |
| Klebsiella | Experimental
Control |
188.13 187.46
194.03 191.27 |
067, 57.48, 2.09
2.76, 83.36, 34.24 |
1.74NS. 0.087
0.44NS. 0.661 |
| Candida albicans | Experimental Control | 218.23 163.86
220.47 220.87 |
54.37, 38.90, 45.47
0.40, 230.39, 3.04 |
6.54*, 0.001
0.71NS. 0.480 |
| Staphylococcus
aureus |
Experimental
Control |
182.60 141.37
175.70 176.33 |
41.23, 19.10, 22.95
0.63, 124.65, 1.90 |
9.83*, 0.001
1.82NS 0.073 |
t(29)=2.05; NS Not significant (p>0.05), *significant -(p≤0.05)
Discussion
Hospitalization has been found to negatively impact overall oral health as evidenced by increased dental plaque accumulation together with deterioration in mucous membranes and gingival inflammation in critically ill children. The importance of good oral hygiene for children with toothpaste, chlorhexidine gluconate, normal saline, sodium bicarbonate, hydrogen peroxide, lemon and glycerine swabs are recommended to provide oral care for children admitted in intensive care unit.9 The present study findings indicated that oral care protocol i.e. in changing month with normal saline 4 times a day was effective in reducing oral health assessment score and reducing the colony count of Candida albicans, Staphylococcus aureus whereas no effect on reducing the colony count of Coagulase negative staphylococci, Klebsiella. These findings are consistent with the findings of the study reported by Nancy J. Ames10 (2011) which revealed that oral health assessment scores reduced after nurses implemented a protocol for systematic oral care. The present study findings also showed that oral care with normal saline was effective in maintaining the oral health of hospitalized children. These findings are consistent with the findings of the study which revealed that normal saline was effective in maintaining the oral health status of hospitalized children Kim YK, Choi SH11(2003)The present study findings revealed that oral care protocol was effective in reducing oral health assessment scores and oral microbiological flora of hospitalized children. These findings are in line with the findings of the study conducted by Randa FA12(2007), Ali H13(2012), Kim LS14(2010),Sazlina SG15(2012), Hadi R16(2011), Angela MB17 (2006), Olivia S18 (2011), Laura A19 (2010), which revealed that well developed oral care protocol by bedside nurses can improve the oral health of patients admitted in intensive care unit. These studies also revealed that oral care protocol was effective in reducing the microbes and maintaining the oral health status of hospitalized children. Thus, oral care protocol was effective in improving the oral health status of hospitalized children. Hence it is recommended that the use of an assessment model such as the BRUSHED Assessment Model is recommended for the immediate identification of oral problems for all patient and should be carried out daily followed by regular oral care. The study can be replicated on a larger sample to validate the findings and make generalizations.
References
- Jones H, Newton JT, Bower A survey of the oral care practices of intensive care nurses. Intensive and Critical Care Nursing2004;20: 69- 76.
- Jones H, Newton JT, Bower A survey of the oral care practices of intensive care nurses. Intensive and Critical Care Nursing2004;20: 69- 76.
- Asghar KZ, Ahmad P, Abbas H, Hojatollah The effects of an oral care practice on incidence of pneumonia among ventilator patients in ICUs o f s e l e c t e d h o s p i t a l s i n I s f a h a n 2012;(17)3:216-78
- Chastre J. Ventilator-associated Pneumonia: Standardized epidemiology. Pediatric Nursing 2002;165(7):45-76
- Fourrier FD. Colonization of dental plaque: a source ofnosocomial infections in intensive c a r e u n i t p a t i e n t s . C r i t C a r e Med1998;26(2):301-8.Trieger Oral care in the intensive care unit. Am J Crit Care2004;13(1):24.
- Chan EY, Lee YK. Translating evidence into nursing practice: oralhygiene for care dependent adults.Int J Evid Based Health 2011;9(2):172-83
- Mori H. Oral Care effects: Incidence of Ventilator-Associated Pneumonia in Emergency and Critical Care medicine 2003;12(31):121-136
- Terezakis E, Needleman I. The impact of hospitalization on oral health: a systematic review. J ClinPeriodontol 2011;38(7):628-36.
- Ames .NJ.Effects of systematic Oral care in critically Ill patients:A multicenter A m e r i c a n j o u r n a l o f c r i t i c a l care2011:20(5);104-110
- Choi SH, Kim YK. Effect of Oral Care with Normal Saline on Oral State of Patients in Intensive Care Korean Journal of Nursing2003:16(3);12-28
- Oral Care in the Intensive Care Unit: A ReviewJournal of Contemporary Dental Practice2007:8(1);10-26
- Mouth Care in Patients Receiving Mechanical Ventilation: A Systematic Review. Nursing Midwifery Studies 2012;1(2) :38-54
- Kim LS,Salimah J. A cross-sectional study on nurses’ oral care practice for mechanically ventilated patients in Malaysia. Journal of clinical nursing2011;20(16): 733-42
- Sazlina SG, Ong L. Oral care practice for the ventilated patients in intensive care units: a pilot J infect Dev Ctries 2012;6(4):333-39
- Affective factors on oral care and its documentation in ICU of hospitals affiliated to Kerman university of medical sciences. Iranian journal of critical care nursing2011;4(1):45-52
- Angela Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care u n i t . I n t e n s i v e a n d c r i t i c a l nursing2006;22:318-28
- Oral chlorhexidine in the prevention of ventilator associated pneumonia in critically ill adults in the ICU: A systematic review. Neurocritical care unit 2011;27(2):48-59
Stokowski Laura A.Preventing Ventilator- Associated Pneumonia in Infants and Children: Ventilator Bundles.PediatrClin North Am 2006;53:1231-1