A nursing student s experience of a quality improvement project on mouth care in an acute setting Caitlin Griffiths
Why mouth care? - Scenario Inpatient receiving chemotherapy Last days of life Came to unit with a dry mouth and bleeding lip Shocked and disappointed in the quality of his care Mouth swabs left for him to use No tooth brushing since admission
Why is mouth care an issue? - Research Daniel et al (2004) educational needs in relation to oral care, training for HCPs, patients, families and carers is needed to increase knowledge and therefore standards Coleman (2005) Need for attention to oral hygiene, increased awareness = increased standard for oral care in the elderly Forsell et al (2011) statistical correlations between poor oral hygiene an incidences of systemic diseases eg pneumonia Curtis et al (2007) prioritisation of advanced practice leaves little room for mouth care, the most basic of nursing activities. Mouth swabs are ineffective.
Rationale continued - Headlines
I, for one have seen too much of this...
So what can we do about it?
What changes can be made to improve mouth care? My ideas Provide inpatients with a toothbrush and toothpaste Assess whether patient needs assistance with oral hygiene and assist with oral hygiene if necessary Strictly adhere to oral regime for patients on chemo Educate patient, family, carers, and staff on mouth care and its importance Establish collaborative working between nursing and dental staff Implement oral care record chart including daily assessment
My QI Project One week of observation on the ward very little mouth care seen Act Plan Study Do
My Plan Plan Objective: To test a change idea Where: On a medical ward where I am on placement Who: All nursing/hca staff on shift, no training, just introduction of change Data collection and interpretation: I decided to follow up all results small scale project Prediction: To have valuable data feedback from staff following change
My Plan Plan Implementation of the Inpatient Mouth Care Chart Date and Time Indication for mouth care 1 = 12 hourly brush 2 = 2 hourly moistening 3 = other indication (please state) Condition pre-mouth care 1 = Dry/cracked 2 = Healthy/moist 3 = other (please state) Action taken 1 = Teeth/denture brush 2 = mouth care using sponges 3= other (please state) Evaluation post-mouth care 1 = Moist/healthy 2 = To repeat mouth care after (?) hours 3=other (please state) Initials
Do Do Implemented the chart over a period of 4 days Support from ward Sister Safety Briefings Identified whether patients had a need for mouth care chart based on if they had a problem identified in their nursing admission or if they were for all care Put chart on bed clip board alongside intentional roundings and fluid balance etc easily visible to staff
Study Study Positive I found that compliance of filling in of the charts was very good on day one On day two, some charts were filled out for some patients Some nursing staff/hcas were very receptive of the chart and filled it in well When used well, it prompted staff to return to patients after two hours and moisten the mouth Patients appreciated time being taken to bushing their dentures/teeth Mouths did appear in healthier condition (those patients who the chart was used properly) Negative By day three and four, the charts were no longer being completed Some staff seemed disinterested by the subject Some saw it as another piece of paperwork Filling in an extra form was seen as time consuming Comparison to the intentional rounding chart which mentions mouth care too
Act Act Next stage improve and change idea Positive that some improvements to patient mouth care occurred as a result of using the mouth care chart build on this No cooperation = no change = no improvement So... Reduce paperwork Alter Intentional Rounding instead by expanding on what is already on it
My Plan In order to implement a (hopefully) more effective change, altering the Intentional Rounding is my next stage Will now read: Benefits of this: Mouth Care Needs: Is mouth dry? Y/N Is mouth sore? Y/N 12 hourly brush done today? Y/N Mouth care given? Y/N Treatment given? Y/N (eg, Nystatin) Mouth moist following mouth care? Y/N Includes pre and post mouth care assessment Tracks whether mouth care and 12 hourly brush is being done as well as treatment Has to be done as part of IR cannot be avoided Not an extra paper exercise
What we have learned - Key messages You must be committed to making a change and must use your time wisely Get support from a mentor, ward sister, academic in your university At first, trying to change a small part of practice felt a bit daunting and we thought it would be a major task Since working through IHI we have realised that implementing a small change is not such a big task, but it can have excellent benefits. Our aim is to show other students that it is possible to make big improvements in health care by initiating small changes. These skills will enable us to become better practitioners, team members, leaders and a greater workforce that our patients can trust in.
REMEMBER - We are the future of healthcare and must continually seek to improve it.