Oral care in the adult intensive care unit
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Posted By: Sharon McKinley
Posted Date: 6 January, 2003
Title: Oral care in the adult intensive care unit
Authors: Julie A Fitch;Cindy L Munro;Connie A Glass;Joan M Pellegrini
Reference: Fitch JA et al. Am J Crit Care 1999 8:314-318
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Abstract: BACKGROUND Nurses have not been formally trained in assessing the oral status of patients in intensive care units, and no oral care protocols for these patients are available.
OBJECTIVES To assess the oral status of patients in an intensive care unit, evaluate the effects of a defined oral care protocol on the oral health status of patients in an intensive care unit, and compare oral assessments of a dental hygienist with those of intensive care nurses.
METHODS A nonequivalent comparison group, longitudinal design with repeated measures was used. In phase 1, oral assessment data on the comparison group were collected by a dental hygienist. In phase 2, nurses were instructed in oral assessment and an oral care protocol. In phase 3, the oral care protocol was implemented in the treatment group, and oral assessment data were collected separately by the dental hygienist and by nurses.
RESULTS The mean inflammation score was significantly lower (t test P = .03) in the treatment group (mean, 3.9; SEM, 3.0) than in the comparison group (mean, 12.4; SEM, 2.2). Although not significant, the mean scores of the treatment group were also lower than those of the comparison group on scales of candidiasis, purulence, bleeding, and plaque. Correlations between scores for individual items on the oral assessment tool obtained by the dental hygienist and those obtained by nurses were all greater than 0.6386.
CONCLUSION Implementation of a well-developed oral care protocol by bedside nurses can improve oral health of patients in the intensive care unit (American Journal of Critical Care. 1999;8:314-318)
Are the Results Valid?
1. Was the assignment of patients to treatments randomized? ( Was allocation concealment maintained?)
No. A comparison was made of outcomes in 30 patients prior to the intervention and 20 patients after implementation of the intervention, which was carried out 12 hourly.
2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?
2a. Was followup complete?
2b. Were patients analyzed in the groups to which they were randomized?
3. Were patients, health workers, and study personnel blind to treatment?
4. Were the groups similar at the start of the trial?
Not stated for clinical and demographic characteristics, but there were no differences in the results of oral assessments done at the time of patient enrolment.
5. Aside from the experimental intervention, were the groups treated equally?
Not stated
What are the Results?
1. How large was the treatment effect?
Comparison vs intervention group on 100mm VAS:
  • Inflammation 12.4 vs 3.9 (p=.03); 8.5% difference
  • Candidiasis 20.8 vs 0.00 (NS)
  • Purulence 0.02 vs 0.0 (NS)
  • Bleeding 0.9 vs 0.0 (NS)
  • Plaque 08.3 vs 14.2 (NS)
  • Salivary flow 33.9 vs 34.3 (NS)
  • 2. How precise was the estimate of the treatment effect?
    SEM for inflammation 2.2 vs 3.0, therefore fairly large variability in scores for intervention group.
    Will the Results Help Me In Caring For My Patients?
    1. Can the results be applied to my patient care?
    Probably, for patients in ICU for longer than 48 hours. However note that the patients were younger (48 years old), more likely to be male (50%) and more likely to have a medical (rather than surgical) reason for ICU admission than patients in most Australian ICUs.
    2. Were all clinically important outcomes considered?
    Patient comfort may be a clinically meaningful outcome. Although the authors did not report this, many studies have found that dryness of the mouth is often experienced by ICU patients. The authors link oral hygiene with colonisation of the oral mucosa, consequent pulmonary colonisation and ventilator associated pneumonia. The investigators did not quantitate mucosal colonisation. While this would be easy to do, the sample size required to detect its reduction could preclude such a study. The surrogate outcome is three steps removed from the outcome of ventilator associated pneumonia, which may be clinically important.
    3. Are the likely treatment benefits worth the potential harms and costs?
    Potential harms and costs are minimal, whereas the authors argue that prevention of colonisation of the oral mucosa may reduce pulmonary colonisation and ventilator associated pneumonia. There are definite benefits for patient comfort, which is a clinically meaningful outcome of nursing care.

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