Development And Application Of Bundles Of Oral Care For Orally Intubated Critically Ill Patients

Objective To understand the status quo of clinical oral care practice for orotracheal intubated patients and to analyze the existing problems. To develop “the bundle of oral care for orally intubated critically ill patients” by appraising and synthesizing the best evidence, then make the bundles of care evaluate by experts, and to perfect the bundles by using in the clinical, so as to effectively guide the oral care practice for intubated critically ill patients and improve the quality of health care service and the satisfaction of patients.Methods1.The methods of bibliometrics were used to analyze the literature on oral care for the orotracheal intubated patients, so as to know the progress of research in oral care of patients with orotracheal intubation.2.A cross-sectional survey was conducted among 495 nurses, using a self-administered questionnaire, to know the current oral practice for intubated patients in China ICUs, to investigate the existing problems and determine the focus of the study.3.By sending emails to intensive care units from 27 hospitals in China,oral care procedures or specifications of orotracheal intubated patients were collected, then the methods of content analysis were used to analyze the data which includes the preparatory work before oral care,operation purpose, nursing assessment before oral care, oral care methods and oral care solution, to know the related information about oral care comprehensively.4.On the basis of preliminary investigation, the strict systematic review and expert consultation was performed, the bundles of oral care for orally intubated critically ill patients was established.5.Using the purpose sampling method, the bundles of oral care for orally intubated critically ill patients was appraised by nursing management or clinical nursing specialist who has many working experience in ICU.6.The bundle of oral care was put into implementation in a hospital in Wuhan after training the nurses in ICU.Results1.Three hundred and nine articles that met the inclusion and exclusion criteria from 1997 to2013 are collected. These papers are mainly included in 22 kinds of nursing journals. The methods of oral care for orotracheal intubated patients can be classified into five types:rinse and swabbing, traditional cotton(cotton swab) cleaning or gauze swabbing,toothbrushing, oral rinse, laryngoscope assistance. With 54 articles using traditional cotton balls as oral care tool, 55 papers using toothbrush. Oral care solution mainly include normal saline, traditional Chinese medicine, chlorhexidine, antibiotics, povidone iodine, sodium bicarbonate, etc.2.The self-administered questionnaire include two dimensions, one is oral care assessment dimension and the other is oral care practice scale dimension. The scale's content validity index is 0.952, Cronbach's alpha coefficient is 0.830, split half reliability is 0.757 and the scale has good reliability and validity. 70.9% and 26.1% of the nurses said that their hospitals have developed the specifications of oral care practice and oral assessment for orotracheal intubated patients, the average score of assessment dimension and practices dimension were 3.38±0.78 and 3.25±0.91, respectively. Cotton or gauze swabbing(52.1%)were the most common way of oral care, followed by swabbing with rinsing(31.1%), the tooth brushing method only accounted for 12%.3.There were 27 hospitals provided detailed procedures or specifications. The oral care methods for orotracheal intubated patients can be classified into three types: rinse and cotton or gauze swabbing(14 hospitals, 51.9%), cotton cleaning(11 hospitals, 40.7%) and oral rinse(2 hospitals, 7.4%).4.By searching different databases and critical quality appraisal of all retrieved literature, 6descriptive studies, 9 experimental studies, 13 systematic review and 5 evidence summaries were finally included. Information was integrated in different ways including oral care method, oral care solution and so on, so as to provide evidence support for developing the bundles of oral care for intubated patients. The draft bundles of oral care for intubated patients was developed on the basis of the cross-sectional study, systematic review and expert consultation, which mainly included the preparation before oral care, the oral assessment before and after oral care and the attentive problem during oral care, a total of18 recommendations.5.The scores of importance, exactness and feasibility of all recommendations from the bundles of oral care were 7.87±1.51~9.93±0.26, 7.67±1.76~9.87±0.35 and7.73±1.75~9.93±0.26, with coefficient of variation ranging 0.03~0.23, 0.04~0.25 and0.03~0.27 respectively.6.After the clinical trial of bundles of oral care for 70 intubated patients, the incidence of severe halitosis was decreased from 58.6% to 26.4%, and oral cleanliness was improved,the dental plague index was decreased from 3.58±0.67 to 3.29±0.52, with statistical significance(P<0.05).Conclusions1.The oral care level of intubated patients was not balanced, the related practice guidelines should be updated in time. The evidence-based of oral care practice specifications and oral assessment tools should be built, and the training of ICU nurses on oral care should be strengthened in an effort to direct nurses to provide oral care correctly.2.The bundles of oral care for orally intubated critically ill patients is based on ICU status quo,the evidence-based resources of dometic and overseas, combined with the professionals' comprehensive judgment.3.The implementation of bundles of oral care for orally intubated critically ill patients can reduce the incidence of patients' halitosis and dental plague index, improve their oral cleanliness and increase nurses' working efficiency in some way.