Survey of oral care practices in US intensive care units

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1 Survey of oral care practices in US intensive care units Catherine Binkley, DDS, MSPH, a L. Allen Furr, PhD, b Ruth Carrico, PhD, RN, d and Cynthia McCurren, PhD, RN c Louisville, Kentucky Background: Research has shown that oral care involving toothbrushes and topical antimicrobials improves the oral health of medically compromised patients and may reduce the incidence of nosocomial infections including pneumonia. This survey research was undertaken to determine the type and frequency of oral care in intensive care units (ICUs) in the United States and the attitudes, beliefs, and knowledge of health care workers. Methods: A randomly selected survey of 102 ICUs within the continental United States participated with 556 respondents; 97% of respondents were registered nurses. Measurements: Frequency and type of oral care provided, attitudes and beliefs, and knowledge and training in oral care were measured. Results: Ninety-two percent of respondents perceived oral care to be a high priority. The primary methods of oral care involved the use of foam swabs, moisturizers, and mouthwash. Toothbrushes and toothpaste were used infrequently by almost 80% of respondents. The majority of nurses indicated a need for research-proven oral care standards and desired to learn more. Conclusions: In this random sample of ICUs, oral care methods were not consistent with current research and oral care protocols. The translation of oral care research into practice in the ICU may improve the quality of care and decrease the incidence of ventilator-associated pneumonia. (Am J Infect Control 2004;32:161-9.) Bacteria commonly causing nosocomial pneumonia colonize the oral habitat of intensive care unit (ICU) patients, and microaspiration of oropharyngeal secretions is recognized as a major risk factor for nosocomial pneumonia. 1-4 Scannapieco et al 5 found that 65% of the plaque and/or oral mucosa in 34 medical ICU patients was colonized by respiratory pathogens, compared with only 16% in 25 preventive dentistry clinic patients (P \.05). Treloar and Stechmiller 6 showed that oropharyngeal cultures of 37.5% of orally intubated critical care patients grew either nosocomial bacterial or fungal pathogens and the same pathogens were cultured from sputum specimens. Thus, more serious nosocomial infections, such as ventilatorassociated pneumonia (VAP), might be avoided by preventing pathogen colonization of the oropharynx. From the Departments of Surgical and Hospital Dentistry, a Sociology, b and School of Nursing, d University of Louisville, and the University of Louisville Health Care. c Reprint requests: Catherine Binkley, DDS, MSPH, Department of Surgical and Hospital Dentistry, School of Dentistry, University of Louisville, Louisville, KY /$30.00 Copyright ª 2004 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi: /j.ajic Preventive strategies to reduce oral respiratory colonization and respiratory infections include selective oropharyngeal decontamination with topically applied antibiotics, 4,7-9 application of the antimicrobial chlorhexidine gluconate, and toothbrushing combined with dental prophylaxis The use of topically-applied antibiotics has not been widely accepted because of concerns about the development of antibiotic resistance. Chlorhexidine is an easily applied and relatively inexpensive preventive measure with minimal side effects. Toothbrushing at least twice per day has been shown to reduce pneumonia in dependent nursing home patients 14 and is also more cost-effective than routine use of foam swabs. 16 Oral care is an important component of nursing, and protocols have been proposed and are summarized in Table 1. Three protocols developed specifically for ICU patients involve the use of an oral assessment, a pediatric toothbrush, toothpaste, mouth rinses, and petroleum jelly for the lips with a frequency ranging from every 2 to 12 hours. 16,26,27 The toothbrush has been shown to perform substantially better than foam swabs or Toothettes (Sage Products Inc., Cary, Ill) in the ability to remove dental plaque, 28 and an electric toothbrush reduces plaque significantly better than manual toothbrushes. 29 Electric or powered toothbrushes have also been shown to improve the quality 161

2 162 Vol. 32 No. 3 Binkley et al Table 1. Nonantibiotic evidence-based oral care protocols for dependent patients Author Study type Setting Oral care protocol Outcomes DeRiso et al 10 (1996) Randomized controlled trial (173 control patients, 180 treatment patients) Dentate and edentulous: 30 s rinsing with 0.12 chlorhexidine + standard oral care Frequency: twice per day 1. 69% reduction in incidence of respiratory infections 2. 43% reduction in intravenous antibiotics Fitch et al 26 (1999) Longitudinal intervention evaluation, observational (30 patients in treatment group, 30 patients in comparison group) Dentate and edentulous: Pediatric toothbrush, toothpaste, ethyl alcohol-free antibacterial mouthwash, mosturizing gel to mucous membrane, petroleum jelly to lips Frequency: Every 12 h 1. Decreased gingival inflammation 2. Nurses preferred oral care protocol to previous methods 3. Nurse and dental hygienist oral evaluations similar after training Stiefel et al 16 (2000) Uncontrolled, intervention trial (8 patients, 20 nurses) Dentate: pediatric toothbrush, toothpaste, saline, Vaseline to lips Edentulous: Foam swabs, saline Frequency: Every 2-6 h 1. Improved oral conditions 2. Nurses report no additional time 3. Cost-savings by eliminating toothettes Fourrier et al 11 (2000) Prospective randomized intervention trial (30 control patients, 30 treatment patients) ICU, France Dentate and Edentulous: 0.2% chlorhexidine gel applied after rinsing with bicarbonate isotonic serum Frequency: 3 times per d 1. Decreased dental plaque 2. Decreased incidence density of VAP 3. Trend toward decreased nosocomial infections Genuit et al 12 (2001) Prospective, nonrandomized, intervention trial (39 control cases, 39 weaning only, 56 weaning + chlorhexidine) Dentate and Edentulous: 0.12% chlorhexidine swabbing of posterior oropharynx + weaning protocol. Frequency: Every 12 h 1. 75% reduction in late onset VAP 2. 43% reduction in mortality Yoneyama et al 14 (2002) Prospective randomized clinical trial (182 control patients, 184 oral care patients) 11 nursing homes, Japan Oral care intervention: 5 min toothbrushing after each meal by nurse or caregiver + professional dental care once per wk 1. Reduction in febrile days in oral care group to 15% compared with 29% in controls 2. Reduction in new pneumonia in oral care group to 11% compared with 19% in controls Schleder et al 27 (2002) 4;27-30 Retrospective observational all mechanically ventilated patients in 10 bed unit for (4 y) All patients: deep suctioning, brush teeth and tongue with suction toothbrush with water and alcohol free antiseptic oral rinse, mouth moisturizer, lip balm 1. VAP rate dropped from 5.6 VAPs per 1000 ventilator-days before protocol implementation to 2.2 VAPs per 1000 ventilator-days after implementation ICU, Intensive care unit; VAP, ventilator-associated pneumonia. of care and are easier to use than manual brushes when health care workers provide care for dependent patients. 29 Although evidence-based oral care protocols and oral preventive measures for VAP have been published, there is little information on current practice, oral care training, and nurses attitudes. This survey research was undertaken to determine the type and frequency of oral care in ICUs in the United States and the attitudes, beliefs, and knowledge of health care workers.

3 Binkley et al May METHODS Subjects and sampling The Human Studies Committee of the University of Louisville approved the Survey of Oral Care Practices in Intensive Care Units conducted from March to July The 27-item questionnaire was designed to gather information related to current oral care practices, training, and attitudes among nurses in ICUs across the United States. Demographic information and nurses training experiences were included as well. The questionnaire was developed by the research team because of a lack of a previously developed and tested instrument and was based on the research questions and a review of the literature. The research questions were: (1) What is the type and frequency of oral care provided to ICU patients?; (2) What are the attitudes and beliefs of ICU health care workers (HCWs) regarding oral care?; and (3) How are ICU HCWs trained in oral care? The review of the literature provided previously published oral care protocols and guidance regarding frequency of oral care commonly used in ICUs. A dentist, an infectious disease specialist, an ICU director, 10 nurses, and a sociologist with expertise in survey research methods reviewed the instrument, which was pretested in the ICUs of the University of Louisville Hospital. In the pretest, 10 ICU HCWs completed the questionnaire and were then debriefed by the author to determine clarity and completeness of the instrument. Revisions were made to the survey and it was again pretested for clarity in the University of Louisville Hospital with 10 ICU HCWs. A 2-stage cluster sampling method was used to draw a national sample of nurses working in ICUs. Cluster sampling is a technique used when a targeted population is geographically dispersed and a sampling frame is not immediately accessible or determinable. Although a national sampling frame of nurses in ICUs is not available, the American Hospital Association maintains a list of ICUs, or clusters, locations where ICU nurses congregate by definition. After units in US military installations and territories were excluded, the sampling frame provided by the American Hospital Association listed 5191 ICUs. Based on a power analysis calculation, a random sample of 421 ICUs was chosen using a systematic interval technique. Systematic sampling is a process for randomly selecting cases by taking every k th case from a list of all cases. After starting at a random point, the interval, which is determined by dividing the desired sample size into the population size, is then used to identify cases for inclusion in the study. Second, directors of each selected unit were contacted by mail to ask permission for participation. In addition, the contact letter described the study and Table 2. Respondent characteristics (N = 556) Demographics % n Shift Day Night Position* Registered nurse LPN Clinical assistant.4 2 Respiratory therapist.4 2 Other.7 4 Nurse s education 2-y associate degree y program Bachelor s degree Master s degree Oral care training (multiple responses) Nursing school Continuing education Inservice Self-taught Hospital type University/academic Private non-profit Private for-profit Other (federal, community) ICU types (multiple responses) Medical Surgical Trauma Cardiac Neurosurgical Pediatric Other (OB/GYN, oncology) ICU, Intensive care unit; OB/GYN, obstetrics/gynecology. Mean age = (range, y); Mean years in ICU = (range, ). *Missing data for 7 respondents. asked for basic classifying information about the unit itself, (eg, the number of shifts worked in the unit and how many nurses staff each shift). Among those agreeing to respond, targeted shifts were rotated so that nurses who worked days or nights had equal chances of being included in the sample. A packet of questionnaires was sent to those directors who agreed to distribute them to the nurses in their unit working the shift identified by the researchers. Directors retrieved the forms from the participating nurses and mailed them by post to the primary investigator. Nurses participation in the study was voluntary and anonymous, as stated on the informed consent document. Several responding units were eliminated from the sample upon receipt of the contact letter. These hospitals had closed their ICUs or had other disqualifying characteristics (eg, no separate ICU). Consequently, the total number of directors agreeing to participate or

4 164 Vol. 32 No. 3 Binkley et al Table 3. Attitudes regarding oral care Oral care is a very high priority Cleaning the oral cavity is an unpleasant task The oral cavity is difficult to clean The mouths of most ventilated patients get worse no matter what I do I have been given adequate training in providing oral care Strongly agree 68.3 (380) 10.8 (60) 15.6 (87) 21.2 (118) 65.3 (362) Somewhat agree 22.5 (125) 31.7 (176) 46.7 (259) 38.8 (216) 22.7 (126) Neither agree nor 3.8 (21) 25.7 (143) 11.9 (66) 12.8 (71) 7.6 (42) disagree Somewhat disagree 3.6 (21) 14.6 (81) 13.7 (76) 19.8 (110) 3.2 (18) Strongly disagree 1.4 (8) 17.1 (95) 12.1 (67) 7.2 (40) 1.1 (6) Missing.4 (2).2 (1).2 (1).2 (1).4 (2) Table 4. Type and frequency of oral care Foam swabs Moisturizer Mouthwashes Manual brushes Tooth paste Electric brush Every 3 h 48.4 (262) 36.8 (198) 24.4 (131).4 (2) 1.7 (9) 0 Every 4 h 29.2 (158) 26.4 (142) 23.7 (127) 2.5 (13) 1.5 (8) 0 Every 8 h 14.4 (78) 15.1 (81) 14.7 (79) 6.3 (33) 7.5 (39) 0 Every 12 h 4.8 (26) 5.6 (30) 9.1 (49) 12.7 (67) 14.1 (73) 0 Once a day or less 1.8 (10) 6.7 (36) 15.7 (84) 40.1 (211) 40.5 (210) 3.8 (20) Never.2 (1) 9.5 (51) 11.9 (64) 38 (200) 34.6 (179) 96.2 (509) who were from qualifying units was 126, an initial response rate of 30%. Of the 126 ICU directors, 102 (83%) returned questionnaires. The total number of nurses available for study was 556, of whom over 97% were registered nurses. Characteristics of the responding nurses (Table 2) indicate considerable heterogeneity within the sample. Respondents were solicited from several types of hospitals. In the study group, 54.9% were from private nonprofit hospitals, 18.9% from university hospitals, 15.5% from private for-profit hospitals, and the remaining 8% from other facilities such as federal hospitals. Sixty-two percent of respondents worked the day shift; the remaining 37.4% worked the night shift. More than 77% of the ICUs had a mixed caseload of medical, surgical, and cardiac patients. Participating institutions were geographically well distributed across the continental United States. Respondents mean age was about 39 years, with an average of 10.7 years ICU work experience (median = 9 years). Approximately 38% of the respondents original nursing education program was a 2-year associate s degree, 29% completed a 3-year diploma program, 38% held bachelor s degrees, and about 1% held master s degrees. More of the older subjects had completed a 3-year program, whereas the younger respondents tended to have either a bachelor s or associate degree in nursing. The demographics of the respondents parallel those of all nurses employed in hospitals as reported by the National Sample Survey of Registered Nurses. 30 Measurements Attitudes, beliefs, and knowledge. A 5-point Likert scale of Strongly Agree, Somewhat Agree, Neither Agree nor Disagree, Somewhat Disagree, or Strongly Disagree was used to assess respondents attitudes and beliefs about oral care (Table 3). Type and frequency of oral care provided. Respondents were asked how often, if ever, they use the following supplies: foam swabs, manual toothbrushes, electric toothbrushes, moisture agents, toothpaste, and mouthwash. If mouthwash was used, respondents were asked to identify the type as either over-thecounter, alcohol-free, chlorhexidine, normal saline, peroxide, povidone-iodine, or other (Table 4). Training in oral care. Two items addressed previous oral care training, and 3 queried respondents attitudes regarding additional oral care training (Tables 1 and 3). Hospital support and supplies. To assess the support and emphasis provided by the institution, respondents were asked to respond on a Likert scale to the questions regarding supplies, equipment, and time (Table 5). Analysis Collected data were processed statistically using SPSS 11.0 (SPSS Inc, Chicago, Ill). Descriptive statistics (frequencies, standard deviations, means, ranges, and

5 Binkley et al May Table 5. Hospital support factors I need better supplies and equipment Supplies are readily available I have adequate time to provide oral care The toothbrushes provided are suitable I prefer that a dental hygienist perform oral care tasks Strongly agree 17.6 (97) 80.9 (450) 80.9 (450) 33.8 (188) 5.8 (32) Somewhat agree 28.7 (158) 15.1 (84) 16.2 (90) 30.9 (172) 7 (39) Neither agree nor 26.5 (146) 1.8 (10) 1.1 (6) 9.5 (53) 34 (188) disagree Somewhat disagree 17.6 (97) 1.8 (10) 1.4 (8) 18.5 (103) 16.6 (92) Strongly disagree 9.3 (51).2 (1) 0 7 (39) 36.5 (202) Missing 1.1 (6).2 (1).4 (2).2 (1).5 (3) proportions) were used to summarize the data. Differences in attitudes and oral care provision among groups based on nursing education, oral care training, and type of hospital were analyzed with independent sample t tests. Results were reported as statistically significant at a =.05 or less. Table 6. Scenario results Mechanism Aspiration of contaminated secretions 7.46 from oropharynx Transmission from health care 5.26 workers hands Transmission from contaminated 4.87 respiratory equipment Preadmission colonization 4.13 Transmission from other patients 3.02 *On scale of 1-10; 1, least likely; 10, most likely. RESULTS Attitudes, beliefs, and knowledge Oral care was perceived as a very high priority for mechanically ventilated patients by over 91% of nurses. Although 63% (n = 346) of respondents found cleaning the oral cavity to be difficult, only 43% (n = 236) found it to be unpleasant. More than 60% (n = 334) of the nurses found that no matter what they did, the mouths of their mechanically ventilated patients seemed to get worse the longer they were on the ventilator (Table 3). Nurses attitudes regarding oral care were examined using a t test by type of hospital and by nursing education. No significant differences were found by type of hospital except that nurses in nonprofit hospitals reported oral care to be a higher priority than nurses working in for-profit hospitals (t = 2.34, P =.02). No significant differences were found in oral care attitudes between bachelor s- and master s-degree-trained nurses and 2- or 3-year training program nurses. To determine whether current evidence (microaspiration of oropharyngeal secretions is a risk factor for VAP) has been disseminated to practicing nurses, we presented the following scenario: An 18-year-male was involved in an all-terrain-vehicle accident 5 days ago and was admitted to your ICU. He has been mechanically ventilated since admission and has now developed pneumonia. On a scale of 1 to 10, what is the likelihood of each of the following being the mechanism of transmission? See Table 6 for results. The mean responses would indicate that nurses recognize that microaspiration of contaminated oropharyngeal secretions (mean = 7.46) is the most likely mechanism of transmission of bacteria into the lungs of ventilated patients, as opposed to other sources of potential respiratory pathogens (mean = 3.02 ÿ 5.26). Oral care training Mean Response* Early in the survey, nurses were asked to respond to the statement I have been given adequate training in providing oral care. Using a Likert scale with 5 representing Strongly Agree, the mean response was 4.48, with approximately 88% (n = 488) of respondents agreeing that they had received adequate training (Table 3). Nurses were also asked where they learned about providing oral care for intubated patients, with multiple responses possible. Nursing training was the primary source of education for 67% (n = 376) of the respondents; while 48% (n = 266) also indicated they were self-taught. Only 21% (n = 116) reported receiving training during continuing education courses, and 30% (n = 165) had learned during in-service sessions (Table 1). Interestingly, 19.4% (n = 108) of the sample reported learning about oral care practice only through self-instruction. Those who were solely self-taught were more likely to find oral care unpleasant (t = 2.064, P =.039) than those who received instruction during nurse training. In addition, self-taught nurses used all types of oral care methods significantly

6 166 Vol. 32 No. 3 Binkley et al Table 7. Attitudes regarding oral care training Would you like to learn more about the best way to provide oral care? I need more information on research-proven oral care standards Attending a continuing education workshop on oral care is a priority for me Strongly agree 79.8 (439) 34.9 (192) 8.3 (46) Somewhat agree 37.1 (204) 21.7 (120) Neither agree nor disagree 6.5 (36) 20.9 (115) 39.2 (217) Somewhat disagree 2.5 (14) 17.9 (99) Strongly disagree 11.6 (64) 4.4 (24) 13 (72) Missing 3 (17) 1.3 (7).4 (2) less frequently than nurses formally trained in oral care (P \.05). Finally, when asked, Would you like to learn more about the best way to provide oral care? 80% (n = 439) responded Yes, whereas 6.5% (n = 36) were not sure and 12% (n = 64) answered No. Similarly, in response to the statement I need more information on research-proven oral care standards, 72% (n = 396) responded affirmatively, 21% (n = 115) neither agreed nor disagreed, and 7% (n = 38) disagreed. How this information should be disseminated, however, was unclear. Responses to the statement Attending a continuing education workshop on ICU oral care is a priority for me were mixed, with 30% (n = 146) agreeing, 31% (n = 171) disagreeing, and 39% (n = 217) neither agreeing nor disagreeing (Table 7). Oral care practices Oral care practices varied within each institution, with nurses providing different care with varying frequency. Foam swabs, mouthwashes, and moisture agents were the primary materials used. Manual toothbrushes and toothpaste were used once a day or less by 40% (n = 210) of respondents, and approximately 38% (n = 200) never used manual toothbrushes. Not surprisingly, none of the nurses used electric toothbrushes to provide oral care for their ventilated patients (Table 4). Ninety-six percent of respondents used some kind of mouthwash, with a mean of 1.4 of different types of washes. Fifty-six percent (n = 309) used alcohol-free mouthwash, 20% (n = 114) used chlorhexidine, and 17% (n = 96) used peroxide or over-the-counter mouthwashes, whereas 10% (n = 59) used saline. None of the nurses used povidone-iodine, and only 0.2% used lemon-glycerin solutions. Oral care practices varied between university and private nonprofit hospitals, with the nonprofit hospitals providing more care. In addition, with the exception of moisture agents, nonprofit hospitals provided slightly more frequent oral care using foam swabs, mouthwashes, toothbrushes, and toothpaste than for-profit hospitals. In response to Who do you think should be responsible for cleaning the oral cavity of intubated patients? more than 91% (n = 509) responded Nurses, 4.3% (n = 23) thought an aide should clean the mouth, and the remainder (n = 9) indicated dental hygienists or family. When asked if they would prefer that a dental hygienist perform oral care tasks, 53% (n = 294) disagreed, 13% (n = 71) agreed, and 34% (n = 188) neither agreed nor disagreed. Although electric toothbrushes have been shown to improve the quality of oral care and to be easier to use than manual brushes in dependent patients (29), only 19% (n = 105) stated they would prefer using an electric toothbrush. Forty-eight percent (n = 267) disagreed that they would prefer using an electric brush, and 33% (n = 181) neither agreed nor disagreed. Correspondingly, when asked if they thought staff would be more likely to brush patients teeth with an electric brush than with a manual brush, again 20% (n = 111) agreed, 48% (n = 268) disagreed, and 32% (n = 175) neither agreed nor disagreed. Hospital supplies and equipment There was also an interest in determining the effect of hospital support in the form of staffing patterns and supplies on the provision of oral care. To assess staff time, nurses were asked to respond to the statement I have adequate time to provide oral care at least once a day using a Likert scale with 5 = Strongly Agree. The mean response was 4.77, with 98% (n = 540) of the respondents agreeing that they had adequate time for oral care. General supplies provided by the hospital were perceived as being available to 96% (n = 534) of the respondents who gave a mean response of 4.75 on a Likert scale with 5 = Strongly Agree to the statement There are supplies readily available to provide oral care in our unit. The toothbrushes provided by the

7 Binkley et al May hospital are suitable for our patients, however, was not acceptable to 26% (n = 142) of respondents, with a mean response of 3.66 on the Likert scale. In response to I need better supplies and equipment, 46% (n=255) strongly agreed or agreed, suggesting that although toothbrushes may be suitable, the respondents may prefer other supplies such as chlorhexidine or recently developed oral care systems that are commercially available (Table 5). DISCUSSION Aspiration of contaminated secretions was recognized as the most likely mechanism of transmission of bacteria into the lungs, resulting in pneumonia in the scenario presented in the survey. This finding would seem to indicate that the respondents recognize that the oropharynx serves as a reservoir for potential respiratory pathogens. The predominant use of foam swabs, moisturizers, and alcohol-free mouthwashes and the majority of respondents reporting a decline in oral status among mechanically ventilated patients may indicate that current oral care efforts are ineffective. Nursing programs are increasingly challenged to ensure that nursing students master a wide variety of complex and technology-driven skills that may seem to supersede the simple task of oral care. In fact, many nursing programs preparing professional nurses no longer teach the basics of nursing care (handwashing, bathing, oral care, vital signs, etc) and require students to enter the program as certified nursing assistants with these skills already mastered, thus allowing time for focus on more complex skills. A review of the certified nursing assistant curriculum indicates that oral care is a focused skill, but the activities involved in the process are not well defined and, in fact, defer to the individual procedures of the employing organization. Certainly the basic skills are reinforced in the professional program and the rationale for actions emphasized, but we may still need to direct our concerns about oral care to the certified nursing assistant programs where initial impressions are made. An accepted oral health assessment tool or related instrument for use at the bedside is an important consideration. Such an instrument cues the bedside nurse to remember the issue of oral care, provides critical thinking cues as to who is at high risk for problems related to oral contamination, and provides a method for monitoring effectiveness of interventions. The participants of this study reported that, despite efforts at oral care, the oral status of their patients continued to decline. The use of an assessment tool might avoid this problem. Limitations Little information is available in the literature regarding oral care practices, and no validated instruments could be found to address the research questions. The research team developed the survey instrument, and the measurements used were supported mainly by the face validity conferred by the team. There is the likelihood that a minority of the questions could have induced a certain response. We were initially disappointed in the low percentage (30%) of ICU directors in the randomly selected institutions that agreed to participate in this survey research project. Follow-up telephone calls indicated that those who failed to respond felt they had no interest or time to distribute the questionnaires to their staff, a finding that was not surprising in the busy ICU environment, where survey research is difficult to conduct. The 2-stage sampling technique that was necessary in this research makes a high initial response rate difficult to achieve. The 81% response rate of those who did agree to participate, however, was satisfactory, and we believe that a representative sample based on geographic distribution and heterogeneity of the institutions and respondents was achieved. Selection bias must also be considered as a limitation of this study. As in any survey research, ICU directors most interested in oral care were most likely to have agreed to participate. It is possible that the directors may have influenced the responses of the participants and skewed the results, even though the individual surveys were anonymous. The survey instrument failed to include any questions regarding existing or planned ICU oral care protocols. The presence of protocols could affect the oral care provided, as well as the attitudes and knowledge of nurses, and indicate greater hospital support. Information regarding protocols would have enriched the analysis of the data but was unavailable. Future directions 1. The dissemination of current evidence to the professions can be accomplished with publication of research and oral care protocols and presentations at scientific meetings. The infection control director is in a unique position to relay oral care information to physicians and nurses and to assist in evaluating current practices and implementing change in the ICU. 2. National guidelines formulated by the Centers for Disease Control and Prevention and professional organizations are generally based on meta-analysis of the literature and the results of large, multiplesite clinical trials. Until this research base is

8 168 Vol. 32 No. 3 Binkley et al established, it is unlikely that such guidelines will be published, as evidenced by the Centers for Disease Control and Prevention recent Draft Guideline for Prevention of Healthcare-Associated Pneumonia, 2002, which did not include recommendations for oral care or dental plaque removal. Multiple-site clinical trials that definitively establish the relationship between effective oral care and the reduction in nosocomial infections (such as pneumonia) are needed to provide a broad scientific base of evidence. 3. Oral care educational programs in the undergraduate nursing curriculum and textbooks should include evidence-based research. Appropriately qualified instructors should provide clinical training in ICUs and should conduct competency testing of students. Continuing education and in-service programs presented by knowledgeable individuals respected by nurses have been shown to be more credible and effective than textbooks or other written literature. 31 A primary component of these programs should be an extensive review of research or context-relevant information 32 that substantiates the role of oral care in systemic health. Hospital and nursing administrators should be actively involved in any educational programs and in assuring support for continuing education. 4. Multifaceted interventions have been shown to be effective in changing nursing practice. Individual factors that should be addressed in designing interventions include specific oral care training that includes an evidence-based rationale and framework, especially for nurses who have less experience. Institutional factors that need to be addressed include hospital provision of appropriate supplies such as pediatric toothbrushes and antimicrobial rinses or gels. Assuring that adequate time is available for oral care and making it a priority should be the responsibility of hospital and nursing administrators. Finally, oral assessment and care documentation forms for patient records would facilitate standardization and could serve as quality improvement monitors. CONCLUSION Effective oral care that includes toothbrushing and antimicrobial solutions has been shown to improve patient oral health and may significantly reduce respiratory infections in mechanically ventilated patients. The results of this survey indicate that oral care currently provided in ICUs may be ineffective in removing dental plaque and respiratory pathogens from the oropharynx of ventilated patients. Large, multiple-site clinical trials, changes in nursing curricula, national guidelines, and multifaceted interventions may be required to change oral care practice in ICUs. References 1. Trouillet JL, Chastre J, Vuagnat A, Joly-Guillot ML, Combaux D, Dombret MC, et al. 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