Understanding and Practices of Oral Hygiene in the Intensive Care Units: Perspectives of Medical Staff at Two University Hospital Centers

Abstract

Objective

This study assesses the knowledge, practices, and attitudes of medical staff in intensive care units (ICUs) regarding oral hygiene care for critically ill, bedridden patients.

Material and methods

A cross-sectional study included 65 employees from the Intensive Care Units of the Sestre Milosrdnice Clinical Hospital Centre (CHC SM) and the Clinic for Anesthesiology and Intensive Care at the University Clinical Hospital Centre Zagreb (CHC ZG). A self-administered questionnaire was used to assess knowledge, methods, frequency, and attitudes towards oral care for mechanically ventilated patients. The data were examined through descriptive statistical methods, presented in terms of proportions (percentages). For the purpose of comparing the feedback across the two hospital centers and different educational backgrounds, the Chi-square and Fisher's exact tests were employed.

Results

Results of a survey of 65 participants (18 from CHC SM and 47 from CHC ZG) revealed a notable disparity in oral hygiene knowledge, with graduate nurses displaying the highest proportion of adequate knowledge (100%) and regular nurses showing the least (30.3%) (p<.001). Although the execution of oral care practices did not vary significantly among the groups, graduate nurses performed oral care more frequently (80% vs. baccalaureate technicians 33.33% and nurses 57.6%, three or more times a day) and demonstrated better proficiency in both mechanical (p=.005) and chemical (p<.001) biofilm management compared to their counterparts. No significant difference was observed in the delivery of oral care to orotracheally intubated patients across different educational levels (p=.127). However, a marked difference was noted in the perception of being adequately trained for such care, with nurses feeling less prepared (12.1%, p<.001). Despite these variances, all respondents recognized the importance of oral hygiene, thus showing a strong dedication to oral health care. Conclusions: This study highlights variability in ICU oral hygiene practices and points to the importance of standardized care protocols and improved training for healthcare staff.

Introduction

In Intensive Care Units (ICUs), the critical nature of oral hygiene for patient health is well-documented, with numerous studies emphasizing its paramount importance (1, 2). Oral care is not just about maintaining oral health; it plays a significant role in preventing the progression of severe complications in critically ill patients. One of the primary concerns in ICUs is the risk of nosocomial infections, particularly hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), which are notorious for causing significant morbidity and mortality among this vulnerable population (3, 4). The mortality rate associated with these conditions can reach as high as 13%, highlighting the grave implications of these infections (3). Moreover, the incidence of VAP varies significantly, leading to severe adverse outcomes for patients, including increased mortality, financial burden, and extended hospital stays (5-7). A notable factor contributing to the increased risk of these infections is the shift in oral microflora towards gram-negative bacteria, which occurs typically within 48 hours of ICU admission. This shift is a key contributor to the development of nosocomial infections (8, 9), emphasizing the need for timely and effective oral hygiene practices. Indeed, studies have shown that diligent oral care can markedly reduce the risk of developing such infections, thus underscoring the vital role of oral hygiene in the overall management and care of ICU patients (10-15). Despite widespread recognition of its importance, there remains a considerable variability in oral care practices among healthcare professionals. This inconsistency points to a significant gap in the standardization of oral care protocols and the need for improved training programs tailored for ICU settings (16-27). The disparities in knowledge and skills concerning oral care practices further underline the critical need for evidence-based training and education. Such initiatives are essential for enhancing the competence of nursing staff in providing effective oral hygiene care, which is paramount to prevent complications and improving patient outcomes in ICUs (28). This study aimed to assess the level of knowledge among ICU nurses in two major hospitals in Zagreb, Croatia, regarding oral hygiene in critically ill patients. It focuses on the methods employed by these nurses and the challenges they encounter in maintaining effective oral hygiene in ICUs.

Material and methods

This study was carried out in May 2022 at two prominent hospital centers: the Clinical Hospital Center Sestre Milosrdnice (CHC SM) and the Clinic for Anesthesiology and Intensive Care at the Clinical Hospital Center Zagreb (CHC ZG). The research protocol received approval from the Research Ethics Committee of CHC SM and the School of Dental Medicine, University of Zagreb, Croatia. An introductory section of the questionnaire provided participants with a concise overview of the study's objectives, along with assurances regarding data confidentiality, anonymity, and the voluntary nature of participation. A comprehensive questionnaire served as the primary research tool to evaluate various aspects of oral hygiene practices in the ICU. This questionnaire was developed by synthesizing elements from previous studies in this field (29, 30). It consisted of four distinct sections: demographic information (gender, professional experience in the ICU, level of education, length of work shift), three YES/NO questions regarding knowledge considering three terms (“Have you ever heard of coated tongue/biofilm/nosocomial pneumonia?”), 6 YES/NO and multiple-choice questions regarding methods and frequency of oral hygiene procedures (questions: “Do you perform oral care on patients?”, “Do you perform oral care in patients with orotracheal intubation?”, “Do you use vacuum aspiration after cleaning the oral cavity?”, frequency of performing oral care, mechanical and chemical control of biofilm) and one YES/NO question as well as three YES/NO statements regarding the medical staff's attitude and motivation towards oral care (“Are you adequately trained in performing oral hygiene?”, “Oral hygiene has a very high priority for mechanically ventilated patients.”, “Cleaning the “oral cavity is an unpleasant task.”; “The oral cavity is difficult to clean.”). The knowledge was considered “adequate” only if the participants had all three answers to knowledge questions answered positively.

Data were analyzed using the SPSS Statistics for Windows, version 17.0 software (SPSS Inc., Chicago, IL, USA). The variables were analyzed using descriptive statistics reported as proportions (percentages). To compare responses between the two hospital centers and among education levels, the Chi-square and Fisher's exact tests were utilized. A p-value threshold of less than .05 (p<.05) was set for determining statistical significance.

Results

The study surveyed 65 health professionals in the ICUs of two major hospitals in Zagreb, Croatia. The majority were nurses (50.7%) and baccalaureate technicians (41.5%). They typically worked 12-hour days, with most having 1–5 years (30.8%) or over 10 years (29.2%) of ICU experience. The study found varied knowledge among professionals about coated tongues, biofilms, and nosocomial pneumonia. While 66.6% of them were aware of coated tongue and 50.7% understood nosocomial pneumonia, 40.0% of professionals lacked knowledge about biofilm. Oral cavity cleaning was common practice, with 93.8% of them cleaning both intubated and non-intubated patients' oral cavities. Approximately half of the professionals practiced oral care at least twice daily, while about 39.3% of them did so three times a day. The methods used for oral care varied: 70.5% of professionals used toothbrushes and foam swaps, 29.5% of them used spatulas and gauze, 46.9% of them used 0.12% CHX mouthwash, 22.2% of professionals used toothpaste, and 9.9% of them used both. Interestingly, 21% of professionals only used water without chemical agents for biofilm control. Most professionals viewed oral care for ICU patients positively, with 97.0% of them considering it a high-priority for ventilated patients. Only 53.8% of professionals felt adequately trained in oral hygiene, and 81 of them.5% used an aspiration vacuum for these procedures. However, nearly half of professionals found cleaning the oral cavity challenging. Comparison of knowledge and awareness about oral hygiene depending on the education level is presented in Table 1. There were notable differences between the two hospitals. ICU of the CHC ZG had more baccalaureate technicians (p=.009) and higher knowledge levels about coated tongue (p<.001), biofilm (p=.017), and nosocomial pneumonia (p=.007) compared to the ICU of the CHC SM. Moreover, the use of 0.12% CHX (p<.001) was also more common at CHC ZG. These findings are detailed in Table 2.

Table 1. Comparison of knowledge and awareness about oral hygiene implementation in ICU patients, depending on the education level.

Education level
Question		Graduate nurse	baccalaureate technician	Nurse	p value
Knowledge	Adequate	100.0%	66.7%%	30.3%
	Inadequate	0.0%	33.3%	69.7%	<.001
Do you perform oral care on patients?	Yes	100.0%	100.0%	87.9%
	No	0.0%	0.0%	12.1%	.127
Frequency of performing oral care	3x times or more	80.0%	33.3%	57.6%	<.001
	Twice a day	20.0%	59.3%	42.4%
	Once a day	0.0%	7.4%	0.0%
Mechanical control of biofilm	Spatulas and gauze	40.0%	59.3%	18.2%
	Toothbrush/foam swap	60.0%	40.7%	81.8%	.005
Chemical control of biofilm	Water	0.0%	11.1%	27.3%	<.001
	Toothpaste	0.0%	14.8%	24.2%
	0.12% chlorhexidine	0.0%	70.4%	48.5%
	0.12% chlorhexidine and toothpaste	100.0%	3.7%	0.0%
Do you perform oral care in patients with orotracheal intubation?	Yes	100.0%	100.0%	87.9%
	No	0.0%	0.0%	12.1%	.127
Are you adequately trained in performing oral hygiene?	Yes	100.0%	96.3%	12.1%	<.001
	No	0.0%	3.7%	87.9%
Oral hygiene has a very high priority for mechanical ventilated patients	Yes	100.0%	100.0%	93.9%	.368
	No	0.0%	0.0%	6.1%
Cleaning the oral cavity is an unpleasant task	Yes	80.0%	51.9%	27.3%	.003
	No	20.0%	48.1%	72.7%
The oral cavity is difficult to clean	Yes	20.0%	66.7%	39.4%	.043
	No	80.0%	33.3%	60.6%
Do you use vacuum aspiration after cleaning the oral cavity?	Yes	100.0%	100.0%	63.6%	<.001
	No	0.0%	0.0%	36.4%
*Chi-squared/ Fisher exact test

Table 2. Comparative analysis of oral hygiene implementation in ICU patients at two Zagreb hospitals: CHC SM and CHC ZG, based on survey questionnaire results. Chi square or Fisher Exact test (*).

Questionnaire	CHC SM (n=18)	CHC ZG (n=47)	p
Gender     Male     Female	4 (22.2%) 14 (77.8%)	11 (23.4%) 36 (76.6%)	.919
Professional experience in the ICU     < 1 year     1-5 years     5-10 years     > 10 years	3 (23.0%) 5 (27.8%) 4 (22.3%) 6 (33.3%)	7 (14.9%) 15 (31.9%) 12 (25.5%) 13 (27.6%)	.960
Level of education     graduate nurse     baccalaureate technician     nurse	2 (11.1%) 2 (11.1%) 14 (77.7%)	3 (6.4%) 25 (53.2%) 19 (40.4%)	.009
Length of work shift     8h/day     12h/day     24 h	1 (11.1%) 16 (89.0%) 1 (11.1%)	3 (9.7%) 25 (80.6%) 3 (9.7%)	.753
Knowledge about coated tongue     Yes     No	18 (100%) 0 (0%)	25 (53.2%) 22 (46.8%)	< .001
Knowledge about biofilm     Yes     No	15 (83.3%) 3 (16.7%)	24 (51.0%) 23 (49.0%)	.017
Knowledge about nosocomial pneumonia     Yes     No	14 (77.7%) 4 (22.3%)	19 (40.4%) 28 (59.6%)	.007
Do you perform oral care on patients?     Yes     No	16 (88.9%) 2 (11.1%)	45 (95.7%) 2 (4.3%)	.303
Frequency of performing oral care     Once a day     Twice a day     Three times a day or more	3 (16.7%) 10 (55.6%) 5 (27.7%)	4 (8.5%) 21 (44.7%) 22 (46.8%)	.323
Mechanical control of biofilm     Spatulas and gauze     Toothbrush / Foam swap (for toothless patients)	4 (20%) 16 (80%)	20 (42.6%) 27 (57.4%)	.078
Chemical control of biofilm     Water     Toothpaste     0,12% chlorhexidine     0,12% chlorhexidine and toothpaste	11 (32.3%) 13 (38.3%) 6 (17.6%) 4 (11.8%)	6 (12.8%) 5 (10.6%) 32 (68.1%) 4 (8.5%)	< .001
Do you perform oral care in patients with orotracheal intubation?     Yes     No	16 (88.8%) 2 (11.2%)	45 (95.7%) 2 (4.3%)	.303
Are you adequately trained in performing oral hygiene?     Yes     No	8 (44.5%) 10 (55.5%)	27 (57.4%) 20 (42.6%)	.347
Oral hygiene has a very high priority for mechanically ventilated patients     Yes     No	18 (100%) 0 (0%)	45 (95.7%) 2 (4.3%)	.374
Cleaning the oral cavity is an unpleasant task     Yes     No	7 (38.9%) 11 (61.1%)	20 (42.6%) 27 (57.4%)	.789
The oral cavity is difficult to clean     Yes     No	10 (55.6%) 8 (44.4%)	22 (46.8%) 25 (53.2%)	.528
Do you use vacuum aspiration after cleaning the oral cavity?     Yes     No	16 (88.8%) 2 (11.2%)	37 (78.7%) 10 (21.3%)	.344

CHC SM - the Clinical Hospital Center Sestre Milosrdnice; CHC ZG - the Clinic for Anesthesiology and Intensive Care at the Clinical Hospital Center Zagreb; ICU – Intensive care unit

Discussion

Oral care within hospital settings, particularly emphasized for ICUs, emerges as a cornerstone in averting dental issues and bolstering the overall health status of critically ill or medically fragile patients (23, 31, 32). Despite its crucial importance, oral care frequently finds itself relegated to the background, often perceived as an unwelcome chore by nursing staff, which unfortunately leads to its oversight and neglect (32-34). This situation beckons a paradigm shift in nursing perceptions, highlighting the necessity for nurses to acknowledge oral care as a quintessential element of comprehensive patient care, pivotal for diminishing aspiration risks and fostering enhanced patient outcomes. Spearheading efforts to rectify this issue involves a robust push towards enriching educational and training frameworks, alongside the formulation and dissemination of clear, actionable oral care guidelines (33, 35).

Insightful research delineates that an overwhelming majority, exceeding 90%, of nurses and technicians actively partake in oral care regimens within ICUs, spotlighting the critical role of plaque eradication and meticulous tongue cleansing in warding off potential complications (36). Such findings illuminate the path forward, underscoring an urgent need for the elevation of educational standards and the harmonization of oral care practices to mitigate knowledge disparities among the nursing cadre, especially with a lens towards the prevention of VAP - a prevalent challenge among mechanically ventilated patients (19, 21, 37, 38). Nurses, fully cognizant of their indispensable role in upholding oral hygiene in ICUs, face the intricacies posed by intubated patients head-on, harboring a strong inclination towards mastering more efficacious oral care methodologies, a resolve shaped significantly by their hands-on experiences and the regularity of oral care engagement (23, 33, 39-42). The discourse extends to the intricate landscape of oral care in ICU environments, where peculiar challenges such as xerostomia (dry mouth) and the employment of endotracheal tubes necessitate an uncompromising approach to oral hygiene (15, 43-50). A commanding majority of nurses advocate for the strategic inclusion of dental professionals within ICU teams, thus acknowledging the incontrovertible link between dental plaque accumulation, microbial colonization, and the heightened risk of VAP, affecting a notable 10-20% of mechanically ventilated patients across Europe (29, 51-54). This stance dovetails with the overarching goals of dental programs, squarely aimed at prevention and curtailing healthcare resource utilization (55-57). Focusing on the hospitals in Zagreb, our investigations reveal a steadfast dedication to oral hygiene in ICU settings, with a remarkable 93.8% of respondents actively participating in oral care routines, though in the absence of a universally adopted protocol. The lean towards mechanical cleaning methods by a substantial 70.5% of the surveyed group, coupled with the strategic use of 0.12% CHX by 46.9%, mirrors a proactive orientation towards oral health (58-62). Additionally, the inquiry brings to light the significant influence of the nursing staff's educational background on the embracement of specialized biofilm management protocols, accentuating the criticality of standardized hygiene protocols for the delivery of consistent and efficacious care (55, 56, 59-63). The practice of vacuum aspiration by 81.5% of the participants is spotlighted as a pivotal regimen for the maintenance of oral health within ICUs (1, 60, 62). Scholarly reviews and studies champion the synergistic application of chemical and mechanical cleansing methodologies as a strategic measure to slash hospital infection rates, spotlighting the integral role dental professionals play in sculpting oral care stratagems for ICU contexts (9, 30, 58, 64-75). The observed heterogeneity in oral care practices underscores an acute need for the establishment of uniform protocols aimed at amplifying the effectiveness of these regimens in curtailing pathogen proliferation and reducing the incidence of pneumonia (11, 15, 17, 60). In addressing these multifaceted challenges, it becomes imperative to craft and promulgate clear oral care policies, bolster educational initiatives, and champion the practical application of knowledge through the active engagement of dental professionals. These strategic measures are envisioned to elevate the standards of oral care within ICUs, subsequently enhancing patient outcomes (24, 76-83). While the focus of this study on a limited number of hospitals might constrain its broader applicability across Croatia, it nonetheless offers invaluable insights into prevailing practices and perceptions surrounding oral care in ICUs, thus laying a solid foundation for targeted enhancements in the realm of ICU oral healthcare.

Conclusions

The study reveals that while ICU personnel have a high level of knowledge about oral hygiene, there is noticeable variability in the frequency and methods of oral care. Nurses, as primary caregivers, are well-aware of the importance of oral hygiene on systemic health. These findings emphasize the need for standardizing oral care protocols in ICUs and advocate for ongoing education of medical professionals to ensure effective and consistent oral hygiene practices, which are crucial for patient outcomes.