1 All Wales Palliative Care Conference Improving Oral Care Standards for Palliative Care PatientsNovember 4th 2011 Ros Davies Ann Brennan OHP Specialist Macmillan Lead Community Dental Nurse Specialist Service Palliative Care

2 Overview of the Oral Health ProjectAim: Overview of the Oral Health Project in ABMU Health Board

3 Oral Health Project Objectives Foundations of the projectOutline the stages of development Present early findings and evaluation Identify where we go from here!

4 Justification Oral health care is an integral part of nursing careIs beneficial for all patients: long stay patients those with advanced disease critically ill, end of life1 Maintaining good oral health is imperative in reducing the risk of nosocomial infections and improving patient comfort2

5 Justification Many patients are at great risk for poor oral health:Palliative needs End of life Elderly Undernourished Dehydrated Immunosuppressed Smoking or alcohol history Intubated or on high-flow oxygen unable to mechanically remove dental plaque and maintain good oral hygiene

6 Emerging Evidence: Chronic oral inflammation and general health3,4A number of systemic diseases that have oral manifestations: cardiovascular disease, stroke respiratory infections, pancreatic cancer diabetes, and nutritional problems3,5 Aspiration Pneumonia/Hospital Acquired Pneumonia

12 The Community Dental ServiceHas an important role in providing oral health care and support to vulnerable population groups (children and adults) This role includes the provision of oral health initiatives

13 Background to Project

14 Evidence

15 A Need Was Identified Collaborative Working Group was established:Community Dental Service Assistant Director of Nursing (Quality & Safety) Palliative Care Lead Mental Health Lead Acute Lead

16 PDSA Cycle - Planning Aim: To improve oral health care standards for hospital patients Objectives – to develop: Oral Health Care Guidelines Deliver Oral Health Training OHAT / OHCP / OHCB Pilot: PDSA Cycles Roll out across ABMU when fit for purpose

17 End products from MDT 1: Oral Health Care Guidelines to Support Best Practice Verified by two Consultants in Max Fax Morriston Hospital Guidelines to be made available to all staff on each ward

18 End products from MDT 2: Oral Health Care TrainingDeveloped & delivered to staff Evaluation, Pre & Post (demonstrates gaps in OH knowledge) Consists of 3 modules: Module 1 Dental Caries – cause & prevention Module 2 Oral Hygiene – gingivitis/periodontitis Module 3 Complex OH care for medically compromised individuals This work is on going

19 End products from MDT Oral Health Assessment ToolOral Health Care Plans: Dentate Working Edentulous Group Oral Care Bundle Audit Tool Oral Health Care Documentation

20 PDSA Cycle - Baseline DataMay/June 2011 Ty Olwen & YBN 2 Oral Health Champions identified OHA were carried out on all patients one day a week for 4 weeks – no intervention**** Impossible: 4 patients identified with Xerostomia – intervention needed

21 Documentation Audit 16 (pre) & 17 (post) May/June 2011 - Pre StudyPatient files audited against a gold standard 16 (pre) & 17 (post)

22 Project Launched June/July 2011 Ty Olwen & YBNStaff were trained to use the documents Oral Care Guidelines made available to staff OH team were available Staff were encouraged to take ownership and glean to make ‘fit for purpose’

23 What we hoped to see Every patient would have: Daily Oral Health Assessment (recorded/signed daily) Oral Care Plan specific to their need Dentate Edentulous (recorded/signed daily) Oral Care Bundle for patients on pathway (recorded/signed daily) Improvements in Patient Oral Health Care Experience/Status

24 PDSA Cycle - Study It remains a challenge to measure direct improvements: Levels of active oral disease Quantify oral care as a main evaluation outcome IMPROVE STANDARDS IN ORAL CARE PRACTICE FOR HOSPITAL PATIENTS

25 PDSA Cycle - Study HOWEVER!The Oral Health Project outlines 2 measurable outcomes: Oral Care Documentation – via pt files Oral Cleanliness/Saliva/Tongue/Lips/Gum Tissue improvement – via OHAT Scores

26 PDSA Cycle - Study Audit Oral Care Documentation

27 There is an Oral Health Assessment Tool for mouth care - OHAT 7Key Factors Individual Score Possible Score F1 There is evidence-based Oral Health Care Guidelines to Support Best Practice - OHCG 3 F2 There is an Oral Health Assessment Tool for mouth care - OHAT 7 F3 There is evidence based individual specific daily Oral Health Care Plans to support best practice for mouth care – OHCP 5 F4 Mouth care is consistently documented, evaluated and re-assessed on a regular basis -OHCD Total Score 18

28 Pre: No OHCG available

29 Guidelines Ensure oral care delivered to the patient is of the highest standard Assist nursing professionals to deliver appropriate oral health care for specific oral circumstances

30 Pre: Oral Health Assessment ToolWas utilised Not up to date with current recommendations No evidence they were completed on admission.

31 Post Study: Clear Shift in Positive Direction

32 Analysis OHAT Compliance 15:17 filesOHAT: up to date 2 were not completed on 1 day = no reason given

33 Oral Health Assessment ToolDemonstrate good recording keeping Full account of patient oral health care assessment Represents the vital 'first step' in planning effective and appropriate mouth care for patients

34 Pre: – Oral Health Care PlanMy Oral Care Plan No oral health care plans available in patient files

35 Analysis OHCP: Compliance 16:1794% met the best criteria One file did not contain a denture care plan when it was identified in the OHAT. This is reflected in the scoring index

36 Factor 3: Oral Health Care Plans

37 Oral Health Care Plan A full account of specific patient daily oral health care need Documenting Planned Appropriate Assisted & provided mouth care

38 Pre: Oral Health Care DocumentationOral care was documented and a signature provided in 1 patient file

39 Analysis OHCD Compliance 15:17OHCD was completed but once patient reached a score of 0 > no OCP & no OHA Failure to insert new OHAT. Stopped recording at and audit on Patient refusal:> Significant OHA identifies oral health need. Any changes in mouth care will and should collate with documentation

40 Post Study - Clear & Consistent Documentation

41 Patient Experience Example 1 (OHAT)Patient TO9P There were clear indications in the scoring index when mouth care was achieved Admission: OHAT = 6 – 8 11 days later: OHAT = consistently The scores did fluctuate when mouth care was achieved and this was highlighted in the scoring index

42 Example 1 – when pt admitted to hospitalPatient TO9P Week 1 Example 1 – when pt admitted to hospital 29/6/11 30/6/11 1/7/11 2/7/11 3/7/11 4/7/11 5/7/11 Category Score Lips 1 Tongue Gums and Tissues Oral Cleanliness Saliva

43 (scoring index shows improvement in overall mouth status)Patient TO9P Week 2 Example 1 continued (scoring index shows improvement in overall mouth status) 6/7/11 7/7/11 8/7/11 9/7/11 10/7/11 11/7/11 12/7/11 Category Score Lips Tongue 1 Gums and Tissues Oral Cleanliness Saliva

44 Example 2 ‘Learning Curve’Patient TO7P OHAT completed on admission Patient scored 0 the file documented that no Oral Care Plan was required = no further OHA were carried out

45 Patient scores achieve 0 statusPatient TO7P Example 2 Patient scores achieve 0 status  6/7/11  7/7/11 8/7/11  9/7/11 10/7/11  11/7/11  12/7/11 Category Score Lips Tongue 1 Gums and Tissues Oral Cleanliness Saliva

46 Oral Health Care is Fundamental Care!Every patient admitted to hospital has the right to expect good levels of care Oral Health Care is Fundamental Care!

47 What we have learnt! Gaps in oral health care knowledge and skills exist (Report: Evaluation of Oral Health Care Training; RD) Right Tools to do the Right Job – Procurement Medical/Pharmacy Staff – to be involved

48 Oral Care Practice & ExperienceNurse: We thought we were doing mouth care well but clearly we weren’t – this is much better Nurse: Oral balance gel does really make a difference - wouldn’t have used it before Nurse: Patient came in and scored 12 but now the score is 4 Nurse on observation with relatives: Mad devices are great: relatives can use it Bank Nurse in interview: I have heard about the oral care project and I want to be part of it

49 Oral Care Practice & ExperiencePatient: It is very soothing (commenting on Mad Device) Consultant: Brilliant I have learnt so much! Nurse: Long term patient with reoccurring Candida Infection has now cleared Patient to nurse: Why do you keep on looking in my mouth? Nurse: I have noticed the bleeding gums have stopped

50 What we have achieved to date A project baseImprove oral care standards for patients Through a measured evidence based collaborative approach

51 Conclusion - Evidence Key FactorsAccumulative Score for 16 files PRE STUDY Accumulative Score for 17 files POST STUDY Achievable Score F1 Oral Health Care Guidelines 51 F2 Oral Health Assessment Tool 38 117 119 F3 Oral Health Care Plans 4 84 85 F4 Oral Health Care Documentation 48 Total Score 46 (288) 300 306

52 PDSA Cycle: Act Work is on going in Morriston Hospital – Acute SectorMaintenance Data

53 Patient Experience Vital in moving the project forwardFOC Audit – repeat audit to check on what difference has been made from patient experience and perspective

54 Long Term Objective Do not stop at hospital servicesProject to be rolled out to community services: Care in the community Residential / Care Settings

55 Long Term Vision Service users of any health/social/care settingOral Health Assessment Tool Oral Health Care Plan Oral Care Bundle for End of Life That will determine Appropriate Best Oral Care Practice

56 Thank You for ListeningMake Oral Health Everyone's Business