FEATURE

Pilot Study of an Oral Care Protocol on PostStroke Survivors

Esther Chipps1, PhD, RN, Cindy Gatens1, MN, RN, CRRN, Lynn Genter1, MS, RN, CRRN, Maureen Musto1, MS, RN, CRRN, Angela Dubis-Bohn1, MS, CCC-SLP, Molly Gliemmo2, MS, CCC-SLP, Kelly Dudley1, MS, CCC-SLP, Christopher Holloman3, PhD, Armando E. Hoet4, DVM, PhD, DACVPM & Timothy Landers5, PhD, CNP 1 The Ohio State University Wexner Medical Center, Columbus, OH, USA 2 Carolinas Healthcare System, Charlotte, NC, USA 3 Statistical Consulting Service, The Ohio State University, Columbus, OH, USA 4 College of Veterinary Medicine, College of Public Health, The Ohio State University, Columbus, OH, USA 5 College of Nursing, The Ohio State University, Columbus, OH, USA

Keywords

Abstract

Oral care; stroke; randomized control trial. Correspondence Esther Chipps, The Ohio State University Wexner Medical Center, 1585 Neil Avenue, Columbus, OH 43210, USA. E-mail: [email protected] Accepted December 19, 2013. doi: 10.1002/rnj.154

Purpose: The pilot study purpose was to determine the effects of a new standardized oral care protocol (intervention) to usual care practices (control) in poststroke patients. Design: This study is a randomized controlled clinical trial. Method: Fifty-one subjects were enrolled. Subjects in the intervention group received oral care twice a day including tooth brushing, tongue brushing, flossing, mouth rinse, and lip care while control patients received usual oral care. Findings: Subjects in the control and intervention groups showed improvement in their oral health assessments, swallowing abilities and oral intake. There were no significant differences between the two groups. Although not statistically significant, overall prevalence of methicillin-resistant Staphylococcus aureus and methicillin-sensitiveStaphylococcus aureus colonization in the control group almost doubled (from 4.8% to 9.5%), while colonization in the intervention group decreased (from 20.8% to 16.7%). Conclusions/Clinical Relevance: These findings demonstrate the importance of oral care in the poststroke patient with dysphagia.

Maintaining oral health is a routine part of daily personal health practices. However, during hospitalization, oral care practices are often not considered of high priority. Currently, a standardized evidence-based practice for providing oral care to rehabilitation patients is lacking; oral care is often viewed as a comfort measure and oral cavity assessment is not part of routine nursing practice. A growing body of nursing literature has addressed the association between oral care and the prevention of ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) (Ames et al., 2011; Berry, Davidson, Masters

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& Rolls, 2007; Munro & Grap, 2004; Parsons, Lee, Strickert & Trumpp, 2013; Prendergast, Jakobsson, Renvert & Hallberg, 2012). Rigorous oral care protocols are now the standard of care in ICU patients because they have been shown to reduce the risk of infection especially VAP. This body of work has had an impact in changing clinical practices across critical care units in the United States. In the non-ICU setting, oral care is often viewed as a comfort and hygiene measure rather than a therapeutic intervention or a key component in reducing infections. Surveys of nurses and nursing assistants indicate that © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 39, 294–304

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mouth care is often neglected. It is notable that 84% of RNs and 44% of nursing assistants working in the medical-surgical (non-ICU) setting indicated that mouth care is often not provided (Gravlin & Bittner, 2010). Another study reported that 82% of RNs reported missing mouth care (Kalisch, Landstrom & Williams, 2009). Patients who have had an acute care hospitalization may experience oral xerostomia, ulcerated and/or cracked lips, halitosis, bleeding, and tender gingiva as a result of lack of oral care or secondary to various treatments for their underlying medical problems. Additionally, many of these patients may have had poor baseline oral health, which has been associated with an increased risk of stroke, and potentially compounds the oral cavity impairments associated with acute treatment (Sfyroeras, Roussas, Saleptsis, Argyriou & Giannoukas, 2012). Poststroke patients often arrive in the acute rehabilitation setting with known swallowing and eating challenges. A stroke can have adverse effects on swallowing capabilities resulting in dysphagia. Dysphagia can affect the oral, pharyngeal, and esophageal stages of swallowing. After a stroke, patients may have difficulty manipulating and clearing saliva and/or the food bolus from the oral cavity. Furthermore, complications associated with dysphagia include malnutrition and dehydration. Kumar et al. (2014) demonstrated that aspiration secondary to dsyphagia in poststroke patients was the most significant predictor of prolonged recovery from dsyphagia. The management of nutrition and fluid intake is an important component of the poststroke rehabilitation plan in those patients with dysphagia. Poor hydration and nutrition status are linked to poorer outcomes in patients with stroke, and fluid and electrolyte imbalances are a significant predictor of rehospitalization (Kind, Smith, Frytak & Finch, 2007; Whelan, 2001). Few hospitalized poststroke elderly patients meet their minimum fluid intake requirement of 1500 mL/day (McGrail & Kelchner, 2012). The inability to swallow results in oral retention of food and bacteria in the oral cavity, and places these patients at high risk for aspiration (Marik & Kaplan, 2003). Colonization of the oral cavity can ensure and is a critical component in the pathogenesis of aspiration pneumonia (Marik & Kaplan, 2003). Aspiration pneumonia is defined as pneumonia typically bacterial in origin, occurring with patients who are at risk for increased oropharyngeal aspiration (Marik & Kaplan, 2003; Millns, Gosney, Jack, Martin & Wright, 2003). A systematic review of nine studies on dysphagia poststroke, demonstrated that the incidence of pneumonia in poststroke © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 39, 294–304

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patients with dysphagia ranges between 7% and 33% (Martino et al., 2005). After a stroke, patients are at an increased risk for reduced frequency of oral care and increased oral colonization for various reasons: physical impairment limiting mobility and self-care, decreased coordination of movements, cognitive deficits, dysphagia resulting in decreased salivary and bolus clearance, and medication-related xerostomia (Fitzpatrick, 2000; Talbot, Brady, Furlanetto, Frenkel & Williams, 2005). Staphylococcus aureus is an important cause of aspiration pneumonia in poststroke patients (Hassan et al., 2006; Sellars et al., 2007). In addition, the growing national and international concern regarding the emergence of antibiotic resistant strains of S. aureus has captured the attention of healthcare providers in rehabilitation and chronic care facilities (Aizen, Ljubuncic, Ljubuncic, Aizen & Potasman, 2007; Manian, Senkel, Zack & Meyer, 2002). Although S. aureus may exist as part of the normal flora, antibiotic resistant strains of S. aureus—methicillinresistant Staphylococcus aureus (MRSA)—are of particular concern because first-line treatment is often ineffective, and there are limited treatment options. Poor oral hygiene, the presence of food debris, and compromised mucosal surfaces are important factors in predicting colonization with S. aureus. Duration of hospitalization has been shown to be a risk factor for MRSA, and longer stays in acute care rehabilitation settings increase risk (Minary-Dohen, Bailly, Bertrand & Talon, 2003). There is substantial evidence to support the benefits of aggressive oral care programs in decreasing oral bacteria colonization in elderly patients and critically ill patients (Ames et al., 2011; Abe, Ishihara, Adachi & Okuda, 2006; Berry et al., 2007; Mori et al., 2006; Munro & Grap, 2004; Yoneyama et al., 2002). To date, only one study has examined the impact of oral care programs on oral opportunist pathogens in the acute rehabilitation setting. Lam, McMillan, Samaranayake, Li and McGrath (2013b) conducted a randomized control trial among stroke patients in the acute rehabilitation setting, assigning subjects to 1 of 3 oral hygiene protocols and examining the impact on aerobic and anaerobic gram-negative bacilli (AGNB), S. aureus, and yeasts. Baseline prevalence rates of AGNB (72.8%), S. aureus (56.8%), and yeasts (59.3%) were high with little change over the course of the study and no significant difference was found among the three oral protocol groups. Despite the burgeoning interest of oral care in vulnerable and critically ill patients, similar studies in poststroke

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patients are lacking. To date, only two randomized control trials have examined oral hygiene protocols in poststroke patients (Brady, Furlanetto, Hunter, Lewis & Milne, 2006; Lam et al., 2013a,b). Brady et al. (2006) demonstrated that an oral care training program provided to home health assistants caring for poststroke patients improved staff attitudes and knowledge toward oral care, but not specific oral hygiene outcome measures. Lam, McMillan, Samaranayake, Li and McGrath (2013a) demonstrated a reduction in oral plaque and gingival bleeding among those subjects who were randomized to the groups that received chlorohexidine rinse. Neither of these studies included an oral care protocol delivered by a registered nurse (RN). Given the significant impact of dysphagia and risk for aspiration, the goal of this study was to address the impact of improved oral care in poststroke patients. The purpose of this study was to determine the impact of the adoption of a new standardized oral care protocol in the rehabilitation setting.

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inclusion criteria were offered inclusion in the study: (1) age 18 years or older, able to communicate in English, and able to give informed consent; (2) primary diagnosis of a stroke within 30 days of admission to the rehabilitation unit; (3) admitted directly from an acute care facility; (4) oral or pharyngeal dysphagia identified by a bedside swallow exam by a Speech-Language Pathologist (SLPs), Modified Barium Swallow, or Fiberoptic Endoscopic Evaluation of Swallowing. Exclusion criteria were (1) current comorbid diagnosis of pneumonia, (2) known infection of the oral cavity and/or receiving therapy for infection of the oral cavity, (3) documented history of a hematological disorder, (4) medically restricted fluid intake, (5) allergy to ListerineTM or other study products, (6) currently wearing dentures, (7) pregnant or nursing mothers, or (8) a history of MRSA infection or colonization. Sample size was based on a 22-point difference in the Mann Assessment of Swallowing Ability (MASA) test. To obtain 70% power for a two-sample t-test of difference in means, 21 subjects were needed for each group.

Specific Aims The specific aims of this study were to compare the effects of a new standardized oral care protocol (intervention) to usual care practices (control) on: (a) condition of the oral cavity, (b) the intake of food and liquids, (c) severity of dysphagia, and (d) mucosal colonization with methicillin-sensitive S. aureus (MSSA) and MRSA in poststroke patients with dysphagia in the rehabilitation setting. Method Study design This was a pilot, 10-day randomized controlled pilot study. The study was approved by the university’s Institutional Review Board (Department of Health and Human Services Federalwide Assurance# 00006378) and all participants completed informed consent before enrolling in the study. Setting and sample The study took place at a free-standing 60-bed acute rehabilitation hospital that is part of a major academic medical center in the Midwest. Poststroke patients admitted to our rehabilitation hospital who met the following

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Procedures Before initiating the study, all nursing staff and patient care assistants (PCAs) who work on the study unit were provided an in-service describing the study protocol. The training provided details of the study and included the importance of the blinded oral assessments done by the SLPs. Subjects in the control group (usual care) received routine oral care provided by the PCAs and the RNs on the unit. A subgroup of RNs on the unit were selected to be the study interventionists providing oral care to the intervention group. This subgroup of RNs was provided training sessions by a College of Dentistry faculty consultant on the intervention protocol (new standardized protocol). To maintain study fidelity, in-service trainings, and return demonstrations were repeated at selected intervals during the study. Upon consenting to participate, subjects were randomly assigned to either the control group (usual care) or a standardized oral care protocol. A computer-generated randomized table was used and following consent, the study coordinators pulled a sealed envelope determining study group. Subjects assigned to the control group received routine oral care according to facility policy. Subjects in the intervention oral care group received an “oral care box,” which contained supplies required for the intervention oral care protocol. This box was placed out of view of the SLPs. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 39, 294–304

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All staff members were made aware of the patient’s inclusion in the study with a sign over the bed. The intervention oral care protocol was developed in consultation with the investigators, RNs, SLPs, and a College of Dentistry faculty member. The five elements of the intervention oral care protocol included timed tooth brushing with an battery powered toothbrush, tongue brushing, flossing, mouth rinse, and lip care performed twice daily by the trained RN interventionists. A pea-sized amount of toothpaste was placed on a batterypowered toothbrush. Using an oscillating type motion, 30 seconds was spent brushing teeth in each quadrant in a standard sequence (upper right, upper left, lower left, and lower right). The brushing was done on the buccal (cheek side), lingual (tongue side), and occlusal (chewing surfaces) in each quadrant. Next, flossing of the areas between all teeth was done using a gentle seesawing type motion. Following flossing for patients able to tolerate liquids, the patient rinsed with 10–15 mL of mouth rinse, swished for a minimum of 15 seconds without swallowing, and spit out. For subjects unable to tolerate liquids, a toothette dipped in mouth rinse was used and applied all through the oral cavity. Last, lip balm was applied. Additionally, lip balm could be applied as needed throughout the day. Patients assigned to the control oral care group received oral care as per hospital policy, which includes toothbrushing, mouth rinse, and lip balm with standard stock hospital oral care products (Table 1).

Nasal and oropharyngeal cultures were obtained at baseline (Time 1), on study day 5 (Time 2), and following completion of the 10-day protocol (Time 3). Nasal swabs were collected by instilling 3–5 ml of saline from a prepackaged vial gently into the nostril (Salijet, Winchester Labs, St. Charles, IL). The swab was inserted 2–3 cm into the anterior nares and rotated gently and repeated in the second nostril. The oropharyngeal swab was obtained by swabbing the tonsillar area from side to side, making contact with the posterior pharynx. Oral cavity assessments (R-THROAT) were obtained by two blinded SLPs who had established interrater reliability. These assessments were completed obtained on study days 1, 5, and 10 (plus 1 day if the assessment fell on weekend/holiday). Swallowing abilities were also assessed by the SLPs using the Mann Assessment of Swallowing Abilities (MASA) on study days 1 and 10 (plus 1 day if assessment fell on weekend/holiday). Progression of liquid and solid intake was measured on study days 2 and 10 using the Functional Oral Intake Scale (FOIS). Measures Revised-THROAT The THROAT oral assessment tool (Dickinson, Watkins & Leathley, 2001) consists of descriptive ratings and numerical scoring in nine areas: lips, teeth, gums/gingiva, mucous membranes, palate, tongue, floor of mouth, smell, and saliva. Each category is assessed on a numeric

Table 1 Comparison of Usual Care and Standardized Oral Care Protocols Control Protocol

Intervention Protocol

Personnel

Once/twice day or as clinically appropriate Documented in research record and clinical record Delegated task to nursing assistants by RN

Twice daily at predetermined time points Components of protocol documented in patient’s research record and clinical record RN trained by dentist and dental hygienists in use of equipment and approach. Periodic monitoring and feedback on oral care technique.

Equipment Toothbrushing

Hospital toothbrush Sage;TM Twice daily

Battery-Operated Toothbrush, Braun Oral B with timerTM twice daily; Timed toothbrushing-30 seconds in each quadrant of the mouth Crest-Pro-Health

Frequency Documentation

Toothpaste

Sage Oral Care Sodium Bicarbonate Mouthpaste CarelineTM alcohol free mouthwash; Once per day; rinse and spit – – Regular ChapletTM

TM

TM

Mouthrinse Flossing Tongue brushing Lip care

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ListerineTM -10–15 mL once per day Glide Disposable Floss PicksTM SunstarTM Dual Action Tongue Cleaner CarmexTM lip balm

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scale from 0 to 3 with three representing the most compromised; the total score ranges from 0 to 21. Based on the Intra Class Correlation (ICC) in each category, which fell between slight and substantial and feedback for our evaluators and dental consultant, we revised the original THROAT instrument. Our evaluators found it challenging to distinguish between the four outcomes of normal, mild, moderate, and severe. Based on this feedback, we reduced the categories to three; normal (1), mild/moderate (2), and severe (3). We eliminated the floor of the mouth, mucous membranes, and palate based on the reliability scores and the clinical relevance of these categories as outcome measures. Additionally, we believed that mouth comfort was an important clinical variable to assess, so this was added to the instrument. RevisedTHROAT (R-THROAT) scores ranged from 7 to 21. Pilot study testing of the R-THROAT was completed before initiating this study in a rehabilitation patient population and demonstrated an ICC (2,1) of 0.68. Mann Assessment of Swallowing Ability The MASA is a bedside assessment tool that identifies dysphagia and risk for aspiration. The 24-item assessment tool scores the subject’s cognitive, communicative, and motor abilities that impact swallowing. A score of less than 178 of a possible 200 defines a patient with clinical symptoms associated with dysphagia; a score of less than 170 identifies a patient at risk for aspiration (Crary, Carnaby-Mann, Miller, Antonios & Silliman, 2006; Mann, 2002). Reliability of the MASA has been reported in stroke patients (Cronbach alpha = 0.90) with acceptable interobserver agreement (Mann, 2002). Functional Oral Intake Scale The FOIS was developed to document the functional level of oral intake of food and liquid in stroke patients (Crary, Mann & Groher, 2005). This scale has seven levels: levels 1–3 reflect nonoral feeding/tube feeding abilities, levels 4–6 reflect oral feedings with varying degrees of consistencies, and level 7 is a total oral diet with no restrictions (Table 2). This scale has been shown to have good interrater reliability (interrater reliability rank coefficient of .98–.99) and validity (Kendall’s concordance of .90; Crary et al., 2005). Microbiological methods Standard laboratory microbiological methods, including preenrichment and selective media, were used to detect

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Table 2 Functional Oral Intake Scale for Dysphagia Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

Level 7

Nothing by mouth Tube dependent with minimal attempts of food or liquid Tube dependent with consistent oral intake of food or liquid Total oral diet of a single consistency Total oral diet with multiple consistencies, but requiring special preparation or compensation Total oral diet with multiple consistencies without special preparation, but with specific food limitations Total oral diet with no restrictions

From: Crary et al. (2005).

the growth of S. aureus from swab samples. The laboratory algorithm is similar to the one used by the National Health and Nutritional Examination Survey (CDC, 2003). Typical morphological colonies of S. aureus were confirmed using biochemical tests. Phenotypic MRSA confirmation was performed by growth on Oxacillin Screen Agarâ (OSA) plates containing 6 lg/mL of Oxacillin supplemented with NaCl (BD BBLTM, Becton Dickinson and Company, MD, USA). Microbiological reports were reported as positive for colonies with typical morphological and biochemical results for S. aureus. Colonies which grew on plates with oxacillin were reported as MRSA. Data analysis Data were analyzed using “intent-to-treat” analysis (based on 51 subjects; SPSS, version 19.0). Descriptive statistics were used to summarize sample characteristics. Demographic and clinical variables were compared using independent student t tests for continuous variables, chi-square, and Fisher Exact tests for categorical variables. For the intent-to-treat analysis, missing values for R-THROAT, MASA, and FOIS were imputed using a regression methodology. A repeated measures regression model was used to determine the impact of the oral care protocol on the RTHROAT and MASA. The model for each outcome measure was fitted with time as a within-subjects effect and group as a between-subjects effect. The interaction of time and group was also included in the models. For the FOIS scores, subjects were classified dichotomously into two categories: nonoral (FOIS Level 1–3) or total oral diet with consistency restriction/no restrictions © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 39, 294–304

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Enrolled (n-51) Intervention (n=29) Completed (n=21)

Incomplete (n=8)

Control (n=22) Complete (n=21)

Incomplete (n=1)

Transfer to acute care (n=2)

Transfer to acute care(n=1)

Discharged from Rehab (n=3)

Discharged from Rehab (n=0)

Voluntary Withdrawal (n=3)

Figure 1 Flow diagram of patients through the clinical trial.

(FOIS LEVEL 4–7). Chi-square analysis was done to evaluate differences in clinical improvement between the control and intervention group from nonoral (Level 1–3) to a total oral diet with/without restrictions (Level 4–7). Additionally, clinical improvement from oral intake with restrictions (Level 4–5) to full oral intake (Level 6–7) was evaluated. The number of patients colonized at baseline in each group was compared to the number colonized at the completion of the study period. For patients who did not complete Time 3, we used the last observation (Time 2). Results A total of 51 subjects were enrolled in the study, and 42 subjects completed the 10-day protocol. Eight subjects in the intervention group did not complete the protocol, and one patient from the control group did not complete the protocol (Figure 1). There were no significant differences in patient characteristics (age, gender, and race) or swallowing ability

(MASA score) between the intervention and control group at baseline. However, at baseline, the control group had a significantly higher baseline R-THROAT score, and the intervention group had a higher baseline incidence of positive S. aureus cultures (Table 3). Controlling for age, both groups showed improvement in oral cavity assessment over time but this was not statistically significant (p = .10). The primary outcome of interest, the interaction of time and group were not significant (p = .08) indicating that group assignment did not impact the trajectory of the R-THROAT scores overtime. Although not statistically significant, R-THROAT scores in the control group increased from time 2 to time 3 in contrast to the intervention group, which did not show improvement in R-THROAT scores from time 2 to 3 (Figure 2). Both the control and intervention group showed a significant improvement in dysphagia over time (p < .001). However, there was no difference in the improvement in dysphagia over time between the two groups (p = .74). Both groups demonstrated improvement in the FOIS scale over time. Clinical improvement in oral intake is defined as moving from a nonoral tube feed state (FOIS 1–3) to some level of oral intake (FOIS 4–7; McMicken & Muzzy, 2009). Fifty percent (one of two subjects) of the subjects in the intervention group who began the study with tube feedings/nonoral feeding (FOIS Level 1–3) moved to some level of oral intake (FOIS LEVEL 4–7). Among subjects in the control group, none of the subjects who began the study at FOIS Level 1–3 (0 of the two subjects) moved to some level of oral intake. Ten subjects in the standardized oral protocol group progressed from FOIS Level 4–5 to FOIS Level 6–7, and seven subjects in the control group progressed from FOIS Level 4–5 to FOIS Level 6. These differences were not statistically significant (p = .31).

Table 3 Baseline Characteristics of Subjects

Age (years) Gender (male) Race (%)

Baseline R-THROAT (X, SD) Baseline-MASA Baseline (+) SA cultures

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Control (n = 22)

Intervention (n = 29)

p

63.74 (SD, 15.6) Male: 65.5% Caucasian: 65.2% African American: 30.4% Asian American: 4.3% 12.2 (SD = 2.1) 167.1 (SD = 20.2) 1 (4.8%)

62.54 (SD, 13.5) Male: 52.2% Caucasian: 77.8% African American: 22.2% Asian American: 0% 10.8 (SD = 2.6) 168.9 (SD = 13.7) 5 (20.8%)

.77 .40 .41

.03 .71 .19

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Figure 2 Revised-THROAT: Changes from time 1 to time 2 to time 3.

Of patients with at least two culture results for S. aureus (n = 45), baseline colonization was 20.8% (intervention; 5/24) vs. 4.8% (control 1/21). At the last time point, colonization rate was 16.7% (4/24; intervention) vs. 9.5% (2/21; control). Differences between rates of positive cultures were not statistically different between the intervention and control group at the final culture (Fisher’s exact p = .193). Discussion A systematic oral care protocol is important to the patient undergoing intensive acute rehabilitation after a stroke as they begin to recover physically and psychologically. Poststroke patient with dysphagia enter the acute rehabilitation setting, often having very restricted oral intake secondary to dysphagia. For many stroke patients, the admission to the rehabilitation unit marks the beginning of the reintroduction of oral intake after receiving nutrition augmentation either via tube feedings or intravenously. Our work represents the first nursing study to examine oral hygiene among poststroke patients in acute rehabilitation. The overall oral cavity assessment of subjects in both the control and intervention group showed improvement with oral hygiene. The control group demonstrated the largest improvement in oral cavity assessment between time 1 and time 2; however, this did not sustain itself from time 2 to time 3. In contrast, the intervention group, which had a significantly lower baseline R-

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THROAT, did show a small but consistent improvement in oral health over the two measured time periods. Although there was not a significant difference in improvement in the oral cavity assessment, both groups did demonstrate significant improvement over time, which emphasizes the overall importance of establishing a program of oral hygiene in the acute rehabilitation setting. Subjects in the control group began the study with a significantly higher R-THROAT score indicating that their oral hygiene was poor at baseline. Given that this was a small pilot study, and that the intervention bundled both new products and new oral care techniques, the unique contribution that each of the oral care products makes to the overall outcome cannot be analyzed. Future studies should involve multiple arm randomized control trials that focus on the impact of specific products and techniques within an oral hygiene program among rehabilitation patients. Recovery from dysphagia poststroke is most likely to occur within the first 3 weeks of a stroke. This is consistent with the improvement documented in the MASA scores in our study sample. We did not demonstrate any difference in time to recovery from dysphagia between the two groups, and this is likely because the recovery from dysphagia is multifactorial (Kumar et al., 2014). Progression in oral intake was observed in both groups. Subjects in the intervention protocol did show more progress in oral intake than those in the control group (although not statistically significant). Often neglected in the literature is the impact of the sensory © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 39, 294–304

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triggers of taste and smell of food (Perry, 2004). The synergistic relationship between oral hygiene, the sensory triggers of taste and smell, and nutritional intake cannot be overstated, particularly in patients with dysphagia. A major rehabilitation goal of poststroke patients with dysphagia is to maximize their oral nutritional intake and to resume the consumption of a prescribed diet. Studies of individuals who have oral health deficits have demonstrated that these individuals are more likely to engage in food avoidance behaviors, a conflicting goal with rehabilitation (Quandt et al., 2010). Thus, healthcare providers in the acute rehabilitation setting must be mindful of the relationship between a clean oral cavity and the desire and motivation to resume oral intake. The findings from this study support the need for further research efforts examining the links between oral hygiene and an individual’s motivation to resume oral intake. These results do not demonstrate reductions in colonization with MSSA or MRSA with use of a rigorous oral care protocol, nor do they suggest that additional manipulation or handling applied during this oral care protocol increases the risk of colonization. Although not statistically significant, overall prevalence of colonization in the control group almost doubled (from 4.8% to 9.5%), while colonization in the intervention group decreased. This study has several limitations. Since it is a pilot study, the subject recruitment was limited to a small sample size. The small sample size yielded a baseline difference between the two groups on the oral health assessment and S. Aureous colonization rates. This chance bias results in lack of equivalence in the baseline oral health assessments between the two groups which potentially impacted our results. There was significant variability in usual care practices, but the frequency and composition of oral care provided to patients was not assessed in the control group. Interfacility variation in usual oral care practices could complicate future studies if the variability in care is not adequately addressed. Additionally, the overall study of oral hygiene practices has been severely limited by the lack of a standardized instrument to assess the integrity of the oral care cavity in the generalized nursing setting. Oral assessment guidelines have been established in oncology nursing practice and to a limited extent in geriatric practice, but nursing practice at large has omitted oral assessment in nursing care (Hanne, Ingelise, Linda & Ulrich, 2012; € Paulsson, W
ardh, Andersson & Ohrn, 2008). Assessment guidelines can serve as a trigger to initiate nursing care, © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2014, 39, 294–304

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and further efforts should validate oral assessment tools with acceptable interrater reliability and demonstrated clinical utility. A limitation of this study was that we did not formally assess subject and our staff’s satisfaction with the protocol. An important goal of all patients in the acute rehabilitation setting is independence in hygiene and activities of daily living. Previous studies have demonstrated that battery-operated toothbrushes are recommended for self-care routines for individuals with a disability (Bozkurt, Fentoglu & Yetkin, 2004). Anecdotally, many of the subjects in the intervention group commented that they enjoyed the oral care treatment. Staff reported that use of the battery-operated toothbrushes facilitated the ease of providing oral hygiene. An additional consideration when selecting toothbrushes is acceptability of the caregivers. A study of caregivers of institutionalized elderly found that the caregivers preferred battery-operated toothbrushes to manual toothbrushes (Wolden, Strand & Gjellestad, 2006). To date, there has been no research that has examined the preference and ease of use of manual versus battery-operated toothbrushes among poststroke patients and their caregivers. Further research on patient and caregiver preferences for toothbrushes is needed. Due to concern about patient and family anxiety, we excluded patients who had known MRSA colonization or infection, which limited the power of the study to detect clearance from patients with known MSSA/MRSA. Prior research has demonstrated that approximately 9% of patients admitted to rehabilitation facilities are colonized with MRSA, and these patients were excluded from this study (Bilvasky et al., 2012). The oral microbiome is a rich environment, and a limitation of this study is that we only assess the presence of S. aureus from the oral cavity. Emerging technologies will enable documentation of the complexity of the oral microbiome and the impact of oral care on other potential pathogens. To validly apply existing oral care assessment tools and to ensure implementation of all elements of the standardized oral care protocol, edentulous patients were also excluded. However, this limits the generalizability of the study to those patients who have teeth. Future studies of oral care should include staff and patient formal assessment of the acceptability of the oral hygiene intervention. Patient and staff acceptability of dental products has been shown to increase adherence and participation in oral hygiene programs (Wolden, 2006). In the acute rehabilitation setting, future oral care

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Key Practice Points

References

 Oral care is an important, but under-emphasized aspect of nursing care of patients following stroke.

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 Both control and intervention groups demonstrated an improvement in oral cavity health, swallowing, oral intake, but the differences were not statistically significant. Although not statistically significant, overall prevalence of MRSA/MSSA colonization in the control group almost doubled (from 4.8% to 9.5%), while colonization in the intervention group decreased (from 20.8% to 16.7%).  Providers must be mindful of the relationship between a clean oral cavity and the desire to resume oral intake in patients with dysphagia.

study protocols should incorporate assessments of the patient’s ability to independently provide oral care, including the required cognitive and motor skills as well as the ability to manage oral secretions.

Conclusion Poststroke rehabilitation patients benefit from an evidence-based oral care protocol to improve mouth comfort, promote swallowing function, reduce colonization and aspiration risk, as well as promote participation and improve satisfaction with the rehabilitation experience. Oral care is an under-emphasized aspect of nursing care of patients poststroke. This study demonstrates the tolerability of a standardized oral care protocol including timed tooth brushing with a battery-operated toothbrush, flossing, tongue brushing, mouth rinse, and lip care. Both groups demonstrated improvement in oral cavity health, swallowing, and oral intake over the course of the study. Evidence-based oral care protocols can improve patient mouth comfort, promote swallowing function, reduce colonization and aspiration risk, promote patient and caregiver participation, and improve overall satisfaction with the rehabilitation experience. Acknowledgments This project was funded through Sigma Theta Tau International and the Rehabilitation Nurses Foundation. The authors would like to thank and recognize the Dodd Hall staff for their participation and enthusiasm and Dr. Joany Van Balen for laboratory support.

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