Determining how nurses living with their families decide to work in a COVID-19 intensive care unit: grounded theory study
Description
Background: Ventilator-associated pneumonia (VAP) and post-extubation dysphagia (PED) are common complications in mechanically ventilated patients. Oral care, although recommended to prevent VAP, has limited evidence regarding its effectiveness in preventing PED, particularly during the intubation period. Objective: To develop and evaluate a nurse-led, assessment-based oral care protocol that is free from chlorhexidine (CHX) and adjusts moisturizing frequency based on the patient's oral health status Design: Quasi-experimental study Setting: Emergency ICU of a university hospital. Participants: Intubated adults (≥18 years; control n=50, intervention n=50). Methods: The protocol integrated tooth brushing with Oral Health Assessment Tool (OHAT)-guided moisturizing, with intensified care implemented when any OHAT item scored 2. Primary outcomes included OHAT scores, oral moisture, and oral bacterial counts, which were measured over the first three days in the ICU. Secondary outcomes encompassed ventilator duration, ICU length of stay, VAP (IVAC), PED, and ICU mortality. Analyses employed the Mann–Whitney U test, Fisher’s exact test, logistic regression, and Kaplan–Meier survival analysis. Results: Baseline characteristics were generally comparable between the groups. On day 3, the intervention group demonstrated significantly improved oral health compared with the control (OHAT scores, 1.88 vs. 5.20; moisture levels, 20.4 vs. 6.6; bacterial counts, 36.3 vs. 83.0, respectively; all p < .001). The duration of ventilation was shorter in the intervention group than in the control (5.0 days versus 9.5 days, respectively; p < .001), as was the length of ICU stay (8.0 days versus 11.0 days, respectively; p = .006). The incidence of PED was markedly reduced (4% versus 46%; adjusted odds ratio = 0.044, 95% confidence interval 0.009–0.209; number needed to treat = 3, p < .001). VAP occurred in 10% of the control group and in none of the intervention group; however, statistical significance was not achieved due to the limited number of events. Protocol adherence was 97.8%, with no adverse events reported. Conclusions: The protocol was effective in preserving oral health, substantially reduced PED, and decreased the duration of mechanical ventilation and the length of ICU stay for critically ill, intubated patients. The implementation utilized cost-effective, commercially available materials and demonstrated high adherence rates, indicating that the protocol is both feasible and scalable. These findings highlight the significant role of critical care nursing in improving patient-centered outcomes through systematic, assessment-based oral care.
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The OHAT comprises eight domains: lips, tongue, gums/mucosa, saliva, natural teeth, dentures, oral cleanliness, and dental pain. Each domain is scored on a 3-point scale ranging from healthy to pathological. Both the original and Japanese versions of the OHAT have demonstrated validity and reliability for nurse-led oral screening, and the tool is widely utilized in Japanese critical care settings (Chalmers et al., 2005). An oral care protocol was developed based on the OHAT, under the supervision of specialists, including dentists, dental hygienists, certified nurses in dysphagia care, certified emergency nurses, and certified nurse specialists in acute and critical care. One of the participating dentists contributed to the development of the Japanese version of the OHAT. • If all OHAT items are scored 0 or 1: routine toothbrushing twice daily and moisturizing every 4 hours. • If any OHAT item is scored 2: routine toothbrushing twice daily and moisturizing every 2 hours (Supplementary Figure 2). Prior to the study, all ICU staff underwent training to standardize oral care procedures. In both groups, the endotracheal tube was secured using Anchor Fast™ (Hollister Incorporated), and a tube-external type bite block was applied, with replacement conducted according to institutional standards. Before each oral care session, staff donned aprons with sleeves, face shields with masks, and gloves. Cuff pressure was adjusted to 25–30 mmHg, followed by subglottic and oral suctioning. Patients were positioned at an elevation of ≥30° or in a lateral/side position when elevation was not feasible. The OHAT was administered prior to the 6 a.m. oral care. For oral care, suction toothbrushes and sponge brushes (NOHCS Oral Care Kit, Nipro) were utilized. A moisturizing agent was initially applied with a sponge brush to the lips, tongue, gums, and mucosa, moving from posterior to anterior. Brushing was then conducted with a suction toothbrush soaked in mouthwash for a duration of two minutes, maintaining the same directional approach, followed by additional moisturizing with the sponge brush. Bite blocks were replaced if visibly contaminated. After confirming secure tube fixation, subglottic suctioning was repeated to complete the session. In the intervention group, the frequency of moisturizing was adjusted according to the OHAT. A gel-type oral moisturizer (ORALPEACE Clean & Moisture, Green) containing cetylpyridinium chloride (CPC) was utilized. A small quantity (approximately 1 cm in diameter) was applied to the back of a glove and then thinly distributed with a sponge brush to the lips, oral cavity, and tongue, moving from posterior to anterior. Compliance was monitored using a checklist that was completed at each care session, resulting in an adherence rate of 97.8%. Random observations conducted by the investigator confirmed adherence to the protocol.