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Nurses transform mouth care with oral hygiene plan

Two nurses devised single-use oral hygiene kit that hangs on patients’ bedsides

Two nurses on the stroke ward at West Middlesex University Hospital devised a single-use oral hygiene kit that hangs on patients bedsides

  • Oral health has long been neglected in hospitals and care homes
  • Deterioration in oral health leads to increased lung infections and longer hospital stays
  • Older patients and those who have had strokes or have disabilities are most at risk of oral health issues

Six days after being admitted to hospital, Henry (not his real name), a frail older man with limited mobility, complained of a sore mouth. On examination he was found to have a dry tongue and said he had not removed or cleaned his dentures since admission.

More comfortable after being helped with his oral care and given a

Two nurses on the stroke ward at West Middlesex University Hospital devised a single-use oral hygiene kit that hangs on patients’ bedsides

  • Oral health has long been neglected in hospitals and care homes
  • Deterioration in oral health leads to increased lung infections and longer hospital stays
  • Older patients and those who have had strokes or have disabilities are most at risk of oral health issues
Picture shows nurses Angela Chick and Ahlam Wynne with their oral hygiene kits, which have transformed mouth care practice in their trust,  Chelsea and Westminster Hospital NHS Foundation Trust.
Nurses Angela Chick (left) and Ahlam Wynne with their oral hygiene kit
Picture: Ben Langdon

Six days after being admitted to hospital, Henry (not his real name), a frail older man with limited mobility, complained of a sore mouth. On examination he was found to have a dry tongue and said he had not removed or cleaned his dentures since admission.

More comfortable after being helped with his oral care and given a denture pot, he said he ‘hadn’t liked to ask for help because the nurses were busy’.

Oral health has long been the Cinderella of nursing care in hospitals and care homes. Henry’s experience reflects evidence linking hospital admission with a deterioration in patients’ oral health, leading to poor nutritional intake, an increase in lung infections and longer hospital stays.

Older patients and those who have had a stroke or have disabilities are at high risk of oral health issues.

Cases of hospital-acquired pneumonia fell after increasing nurses' compliance with mouth care

Acting on their awareness that the oral health of patients with swallowing difficulties on the stroke ward at West Middlesex University Hospital required improvement, ward manager Angela Chick and stroke nurse specialist Ahlam Wynne have succeeded in transforming mouth care practice on the ward and throughout Chelsea and Westminster Hospital NHS Foundation Trust.

67%

reduction in incidence of pneumonia for people with swallowing difficulties as a result of the mouth care initiative

Source: NHS Providers

In a three-month pilot in 2017 they increased ward nurses’ compliance with mouth care from 20% to 82%. By September 2018, cases of hospital-acquired pneumonia (HAP) had fallen from 30 to 10 and the number of HAP-related deaths from eight to two. Antibiotic use also fell, producing a saving of 79%.

How did they achieve these results? Ms Wynne says: ‘We knew some of our nurses lacked mouth care training, our equipment was poor and we had no formal ward oral hygiene assessment protocol in place.

‘When patients’ relatives and therapists started commenting on the poor condition of patients’ mouths and doctors noticed more stroke patients with swallowing difficulties were developing pneumonia, we knew we must act.’

Concerned that inhalation of oral bacteria was leading to patients developing pneumonia, Ms Chick and Ms Wynne piloted the mouth care audit.

Innovative, staff-led oral hygiene improvement plan

‘Our audit revealed how nurses were inconsistently using a variety of mouth care solutions and devices, from sponges and toothbrushes to suction equipment,’ says Ms Chick. ‘These tended to be stored in cupboards or patients’ lockers, where they were difficult to find, forgotten, easy to knock over and raised infection control issues.’

By coincidence their trust, which received an overall rating of ‘requires improvement’ from the Care Quality Commission (CQC) in 2014, had recently launched a competition aimed at funding innovative, staff-led ideas to improve the quality of care. Ms Wynne and Ms Chick jumped at the chance to pitch their oral hygiene improvement plan.

Picture shows nurses Angela Chick and Ahlam Wynne cleaning a patient's teeth using one of their oral hygiene kits, which have transformed mouth care practice in their trust,  Chelsea and Westminster Hospital NHS Foundation Trust.
Nurses Angela Chick (left) and Ahlam Wynne cleaning a patient's mouth
using one of their oral hygiene kits Picture: Ben Langdon

Thrilled to win the competition, with the support of the trust’s improvement and innovation team and £10,000 to implement their idea, the two nurses set about reducing the incidence of pneumonia in patients who had had a stroke and raising mouth care standards on the ward and trust-wide.

‘We knew that oral bacteria – particularly in stroke patients with swallowing difficulties – can lead to pneumonia or even death. Working closely with the manufacturer of a mouth care suction device, we provided our ward with a newly designed, easily visible, single-use oral hygiene kit, which hangs on patients’ bedsides,’ Ms Chick says.

They next ensured that all ward nurses were trained to assess and grade each patient’s mouth care needs on admission and during their hospital stay, using a traffic light system: a patient graded as high dependency (red) might need four-hourly mouth care, while low-dependency patients (green) might only require twice-daily assistance to access their toothbrush and toothpaste or denture-cleaning equipment.

‘Nurses’ feedback soon revealed that the kits were easier to operate with one hand and more likely to be used,’ says Ms Wynne. ‘Most importantly, patients felt more comfortable and their relatives happier. Our healthcare team also noticed an improvement in patients’ oral hygiene.’

‘Nurses on all wards should be aware how vulnerable hospitalised patients are to poor oral hygiene’

With the support of the trust’s practice development team, Ms Chick and Ms Wynne held a well-received mouth care awareness week and launched their mouth care protocol trust-wide.

79%

cost saving in reduced antibiotic use as a result of the mouth care initiative

Source: NHS Providers

Ms Chick says: ‘We believe nurses on all wards should be aware how vulnerable hospitalised patients – who may not be eating or drinking normally – are to poor oral hygiene. Older patients, those with Parkinson’s disease, dementia or delirium, or who are on immunosuppressant therapies, are particularly at risk.’

In 2018, the trust’s overall CQC rating was raised to ‘good’ and it was praised in an NHS Providers’ report as one of 11 trusts that had ‘significantly improved’ the quality of care.

‘Having a clean, healthy mouth is a human right’

The trust’s chief nursing officer Pippa Nightingale says: ‘Nurses and doctors often have the best ideas, because they know the problems and can find the best solutions. For this reason, our trust likes to empower its clinicians to drive care improvements from a bottom-up approach.’

Former RCN professional lead for long-term conditions and end of life care Amanda Cheesley says: ‘I’m delighted that the nurses who came up with this excellent mouth care initiative have been supported by their trust at the highest level.

‘Having a clean, healthy mouth is a human right, particularly for patients reaching the end of their lives. Oral hygiene provision is a fundamental nursing skill, so all nurses – including those at university – should be taught how to care for patients’ mouths.’

Link between poor oral hygiene and aspiration pneumonia

British Geriatrics Society (BGS) nurses and allied health professionals council chair Lucy Lewis agrees. ‘The BGS welcomes nurses taking a leadership initiative on healthcare issues, particularly as we know there’s a link between poor oral hygiene and aspiration pneumonia, which can increase a patient’s hospital stay by eight days,’ she says.

‘Every hospital and care home should have an oral hygiene policy in place, as having a healthy mouth helps patients feel comfortable and maintains their nutritional intake and communication skills.’

Top tips for oral hygiene

  • Assess on hospital admission every patient’s oral health status and record in care plans – and reassess regularly
  • Adequate fluid intake is essential to oral health and older people – who may experience a reduced thirst sensation – should be encouraged or assisted to drink regularly
  • Record on admission which patients wear dentures, and provide privacy for cleaning them and a labelled denture storage pot if required
  • Observe which older patients experience mealtime chewing difficulties, which can lead to malnutrition
  • Check with pharmacists if a patient’s sore, dry mouth is caused by one of 500 drugs, such as antibiotics, which can affect oral health
  • Patients receiving oxygen therapy may need extra oral assessments
  • Store mouth care equipment in a visible, hygienic location
  • Offer assistance to frail older patients and those with dementia, Parkinson’s disease or arthritis to reach or use toothbrushes
  • Patients with conditions such as diabetes may need regular mouth care assessments
  • Speak to your manager if your ward has no oral hygiene protocol or you would like mouth care training

Catharine Sadler is a health writer


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