Improving frequency of oral care in the medical intensive care unit

ISSUE: Frequent oral hygiene is thought to reduce the risk of ventilator-acquired pneumonia (VAP), promote patient comfort, and help prevent the occurrence of ulcerations of the lips and oral mucosa. We increased the frequency of oral care on this 17-bed medical intensive care unit (MICU) by raising awareness, listening to staff input, and implementing a plan to address the barriers they identified. PROJECT: Simple observations were used at the onset of the project to measure oral care frequency. Awake and oriented patients were asked if their teeth had been brushed, and patient rooms were checked for toothbrushes or other oral care supplies. Nurses were asked how often they provided oral care. Thirty-one percent (31%) of patients were having their teeth brushed. Results of both surveys were shared with the MICU staff. Staff identified several barriers to oral care, including difficulty getting around the endotracheal tube and concern about aspiration of fluid during oral care. Tape was being used to secure endotracheal tubes, and so movement of the tube was done infrequently and required the presence of two nurses. Stepwise changes were made over the following year, including the following: education about the advantages of oral care, introduction of a combined suction device and toothbrush, and development and implementation of guidelines for the care of the intubated patient. An endotracheal tube holder was selected for use to facilitate movement of the tube (Endotracheal Tube Attachment Device, Hollister Inc., Libertyville, IL). RESULTS: Staff reported that it was easier to do oral care and move the endotracheal tube and that they performed those actions more frequently. Oral care documentation increased to 100%. Ninety-seven percent (97%) of patients had oral care equipment in their rooms. There were no reports of oral ulcers. Our VAP rate has remained well below the 7.0 national benchmark throughout the duration of the project. LESSONS LEARNED: Simple changes in the routine of care can create vast improvements in patient outcomes. Product changes helped address at least two of the barriers that reduced the frequency of oral hygiene activities in our MICU. Multidisciplinary involvement, frank discussion about risk factors and barriers, and repeated educational programs were all key ingredients for success in this process.