Health Status of hospitalised children admitted in
Intensive Care Units of selected hospital of Haryana Shweta Handa, Sulakshna Chand, Jyoti Sarin,Varsha A Singh, Shalini Sharma Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 8 Keywords Effectiveness, oral care protocol, oral health status, hospitalized children. Introduction Oral care is a fundamental aspect of nursing that impacts the health, well-being 1 and comfort of patients .There is a complex integration of functional oral components necessary to maintain oral health and 2 wellness .Within 48 hours of admission, the oropharyngeal flora of critically ill children undergoes a change from predominantly gram positive organisms to predominantly Correspondence at Sulakshna Chand Assistant Professor MMIN, Mullana, Ambala Abstract: The importance of good oral health for intubated, unconscious patients reflects the dimension of preventive oral care in reducing colonization of potential respiratory pathogens.Traditionally, oral health and oral hygiene have been given low priority in the nursing care of critically ill children.To assess the effectiveness of Oral Care Protocol (with normal saline) in terms of Oral Health Status of hospitalized children admitted in intensive care unit (ICU), an experimental approach was adopted with pre-test post-test control group design. A sample of 60 hospitalized children admitted in ICU was selected by purposive sampling technique were randomly assigned to control and experimental group. Data in terms of Oral health status and microbiological colony count was assessed using Beck oral assessment scale and colonization scale. The Oral Health Status of hospitalized children improved in the experimental group as compared to the control group. Oral Care Protocol was also effective in terms of reduction of colony count of Candida albicans, Staphylococcusaureus. However there was no significant reduction in the colony count of Coagulase negative staphylococci, Kliebsella Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 9 gram negative organisms, creating more virulent flora. Due to anatomical connection between the oral cavity, the respiratory and circulatory systems, pathogens potentially transfer to cause systemic infections. Pneumonia has been reported as the most common infection in intensive care unit in Pakistan, Lebanon and India with prevalence 3 of 28%, 47%, and 81% respectively. Nosocomial pneumonia contributes to 60% of the fatal infections and is the leading cause 4 of death in critically ill children . In addition, length of hospital stay also impacts the mortality rate of children as there is statistically significant increase in dental plaque which is a potential source for dental colonization and nosocomial infections among children admitted in ICU for four days 5 or more . Critically ill children are usually dependent on nurses for oral care due to their inability to perform essential care for themselves. Assessment of the oropharynx and maintaining a favorable level of hygiene are challenging to perform in critically ill children. This task further becomes difficult due to the presence of mechanical barriers such as endotracheal tube, oral airway, oral gastric tube, and temperature probe which crowd the mouth of critically ill patient. In addition, fixation tapes quickly become heavily contaminated with pathogens in the presence of salivary disturbances leading to difficulties associated with cleansing of the 6 mouth . As a result, nurses are often reluctant to manipulate endotracheal tube for oral assessment and hygiene measures. However, assessment of oral health is essential to establish patient's baseline oral health status during the course of care and response to interventions. With early assessment and detection of oral health disturbances, oral care may be modified or frequency of interventions adjusted to prevent the i nci dence and further deterioration which negatively impact the 7 children's overall health .Thus,consistent efforts to improve oral care in the intensive care unit are important and the provision of a well-developed oral care protocol can improve the oral health of patients admitted 8 in the intensive care unit . Objective To assess the effectiveness of Oral Care Protocol in terms of Oral Health Status of hospitalized children admitted in intensive care units. Materials and Methods A quasi experimental research design was adopted to assess the effectiveness of Oral Care Protocol in terms of Oral Health Status of hospitalized children admitted in intensive care units. The tools for data collection were: demographic and clinical variables. Oral health assessment score was calculated using Beck Oral health assessment scale (standardized scale) with scores ranging from 5-20 (higher scores indicating poor oral health status). The scores were categorized as 1-5 (No dysfunction), 6-10 (Mild dysfunction), 11-15 (Moderate dysfunction), 16- 20 ( Sever e dysf unct i on) . Or al microbiological colony count was done which included: Coagulase negative staphylococci, Klebsiella, Candida albicans, and Staphylococcus aureus. The colony count was categorized into: Confluent Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 10 Growth (>200 CFU), Moderate Growth (100- 200 CFU), Moderate Scanty Growth (20-99 CFU), Scanty Growth (< 20 CFU). The tools were validated by nine experts from concerned fields of; Child Health Nursing, Medi cal -Surgi cal Nursi ng, Pedi atri c Medicine, Microbiology Department, Dental department. Oral care protocol is an appropriate method to assist the clinical nurses by providing analytical framework for providing oral care to hospitalized children. Beck oral assessment scale was primarily accomplished by Beck which included 41 items pertaining to assessment of lips, gingival/oral mucosa, tongue, teeth and saliva. Scores ranges from 5-20 with higher scores indicating poor oral health status. Firstly the protocol was developed which included 29 items which primarily focused on oral care with disinfectant for four times a day (including inner tooth surface first, outer tooth surface, roof, gums, inside cheeks and tongue) for implementation of oral care to the hospitalized children. The target popul ati on i ncl uded hospitalized children admitted in intensive care units in the months of December 2012 to January 2013. Sixty hospitalized children admitted in intensive care unit i.e. for experimental group (30 subjects) and control group (30 subjects) were selected by purposive sampling technique and were randomly assigned to experimental and control group. Comatose hospitalized children between the age group of one year to 12 years admitted in intensive care units for more than 48 hours, available at the time of data collection and whose parents gave consent for participation of their children in study were included in the study. Pilot study was conducted in Maharishi Markandeshwar Institute of Medical Sciences Research & Hospital (MMIMSR&H) for assessing the feasibility of the study.Data was collected after obtaining formal administrative approval from the designated authority.Data was collected from December 2012 to January 2013.Informed consent was obtained from the parents of respondents after explaining the purpose of the study and ensuring confidentiality of their response. After recruiting the subjects for the study, demographic and clinical details were collected. On day one, Oral health assessment was done using Beck oral assessment scale (standardised) and obtaining gingival swab from the oral cavity of hospitalized children in experimental and control group for oral microbiological colony count. The obtained swab was transported and inoculated in blood agar. Microbiological flora was identified using gram staining and microbial colonies were counted using colony counter and recorded in oral microbiological recording sheet. After initial assessment and specimen collection, experimental group received oral care based on prepared protocol i.e. oral care with normal saline four times a day for three consecutive day (including inner tooth surface first, outer tooth surface, roof, gums, inside cheeks and tongue) and control group received routine oral care. On day four, oral health assessment was done using Beck oral assessment scale and obtaining gingival swab from the oral cavi t y of hospi t al i zed chi l dren i n experimental and control group for oral Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 11 microbiological colony count. The obtained swab was transported and inoculated in blood agar. Microbiological flora was identified using gram staining and microbial colonies were counted using colony counter and recorded in oral microbiological recording sheet. Final data was collected and analyzed using both descriptive and inferential statistics. Statistical analysis was done by SPSS version 17.0. Results Table1: Data presented in table-1 revealed that 33.4% of subjects in experimental group and 50% of subjects in control group were in the age group of 4-6 years. Both in experimental and control group, 56.6% of subjects were males. In experimental group, 33.4% of subjects were diagnosed with respiratory problem as compared to 30.2% of subjects in control group. Maximum number of the subjects in experimental group and control group were not receiving antiepileptic drugs (90%), (96.6%), corticosteroids (86.6%), (83.4%), antihistamines (93.4%), (90%) respectively. All the subjects (100%) in both the groups were receiving antibiotics. In both the groups 63.3% of subjects were with traction and other supportive device.The computed chi square values were not found to be significant (p>0.05).This indicated that subjects in the experimental group and control group were homogenous with regard to age, gender, diagnosis, prescribed medication, presence of nasogastric tube,ventilator support and supportive devices. Table 2: Data presented in table 2 revealed that in experimental group, the mean oral health assessment score of subjects was 13.77 and 9.67 before and after implementation of oral care as per protocol respectively with a mean difference of 4.10. The computed't' value of 9.17 was found to be statistically significant at 0.05 level. The data also revealed that in control group, the mean oral health assessment score of subjects was 12.93 and 13.00 before and after implementation of routine oral care respectively with a mean difference of 0.06. The computed ' t' value of 0.31 was not found to be statistically significant at 0.05 level.This showed that there was significant difference between the mean oral health assessment score of subjects before and after implementation of oral care protocol. Data further revealed that before implementation of oral care, the mean oral health assessment score of subjects was 13.77 in experimental group and 12.93 in control group with a mean difference of 0.83. The calculated 't' value of 1.27 was not found to be statistically significant at 0.05 level. This indicated that the subjects in experimental and control group did not differ initially in terms of oral health assessment scores. The findings also revealed that after implementation of oral care, the mean oral health assessment score of subjects was 9.67 in experimental group and 13 in control group with a mean difference of 3.33. The calculated 't' value of 6.44 was found to be statistically significant at 0.05 level of significance. Thus, it can be inferred that oral care as per protocol was effective in reducing oral health assessment score of subjects. Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 12 Table1: Characteristics of Subjects in Experimental and Control Group N =60 2 Sample Experiment Control group df c Characteristics Group (n=30) (n=30) f(%) f(%) Age in years 1-3 yrs 06 (20.0) 01 (3.4) 4-6 yrs 10 (33.4) 15 (50.0) NS 7-9 yrs 07 (23.3) 11 (36.6) 3 02.43 10-12 yrs 07 (23.3) 03 (10.0) Gender Male 17 (56.6) 17 (56.6) Female 13 (43.4) 13 (43.4) Diagnosis Respiratory system 10 (33.4) 09 (30.2) Renal system 04 (13.4) 05 (16.6) NS Gastrointestinal system 02 (6.6) 02 (6.6) 5 1.62 Neurological system 04 (13.4) 02 (6.6) Musculoskeletal system 08 (26.6) 11 (36.6) Integumentary system 02 (6.6) 01 (3.4) Prescribed Medication Anti-epileptic drugs NS Yes 03 (10) 01 (3.4) 1 1.64 No 27 (90) 29 (96.6) Corticosteroids NS Yes 04 (13.4) 05 (16.6) 1 0.13 No 26 (86.6) 25 (83.4) Antibiotics Yes 30 (100) 30 (100) Antihistamines NS Yes 02 (6.6) 03 (10.0) 1 0.21 No 28 (93.4) 27 (90.0) 5. Client with Nasogastric tube 03 (10.0) 04 (13.4) NS Ventilator support 08 (26.7) 07 (23.3) 2 0.25 Other supportive devices 19 (63.3) 19 (63.3) 2 c (1)=3.84), (2)=5.99, (3)=7.81, (5)= 11.07 ; NS - not significant (p>0.05) Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 13 Table 2: Oral Health Assessment Score of Subjects in the Experimental and Control Group Before and After Implementation of Oral Care Protocol. N =60 Group Before oral care After oral care MD,SD,SE, P Mean oral Mean oral t value assessment score assessment score Experimental 13.77 9.67 4.10, 2.26, 0.49 0.001 (n=30) 9.17* Control 12.93 13.00 0.07, 1.17, 0.69 0.757 NS (n=30) 0.31 MD, SD, SE, 0.83, 2.09, 0.67 3.33, 2.39, 0.47, NS t 1.27 6.44* P value 0.209 0.001 NS t (29)=2.05; *significant (p0.05), Not significant (p>0.05). t (58) = 2.00; was not significant at 0.05 level of significance. It was concluded that the Oral Care Protocol was effective in reducing col ony count of Candi da al bi cans, Staphylococcus aureus whereas not effective in reducing colony count of Coagulase negative staphylococci, Kliebsella Table 3: Data presented in table 3 revealed that in experimental group the computed 't' value for Candida albicans and Staphylococcus aureus [t (29)= 6.54] and [t (29)=9.83] was found to be significant at 0.05 level of significance whereas 't' value for Coagulase negative staphylococci and Kliebsella [t (29)=1.49] and [t (29)= 1.74] Table 3: Oral Microbiological Colony Count of Subjects before and after implementation of Oral Care in Experimental and Control Group N =60 Oral Group Mean Oral MD, SEMD, SDD 't' value, microbiological microbiological flora flora Count Before After oral oral care care NS Coagulase Experimental 151.26 150.66 0.60, 91.05, 2.29 1.49 . 0.141 NS negative Control 179.17 181.07 1.90, 191.84, 7.35 1.41 . 0.163 staphylococci NS Klebsiella Experimental 188.13 187.46 067, 57.48, 2.09 1.74 . 0.087 NS Control 194.03 191.27 2.76, 83.36, 34.24 0.44 . 0.661 Candida albicans Experimental 218.23 163.86 54.37, 38.90, 45.47 6.54*, 0.001 NS Control 220.47 220.87 0.40, 230.39, 3.04 0.71 . 0.480 Staphylococcus Experimental 182.60 141.37 41.23, 19.10, 22.95 9.83*, 0.001 NS aureus Control 175.70 176.33 0.63, 124.65, 1.90 1.82 0.073 t(29)=2.05; NS Not significant (p>0.05), *significant -(p0.05) Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 14 Discussion Hospitalization has been found to negatively impact overall oral health as evidenced by increased dental plaque accumulation together with deterioration in mucous membr anes and gi ngi val inflammation in critically ill children. The importance of good oral hygiene for children with toothpaste, chlorhexidine gluconate, normal saline, sodium bicarbonate, hydrogen peroxide, lemon and glycerine swabs are recommended to provide oral care 9 for children admitted in intensive care unit. The present study findings indicated that oral care protocol i.e. in changing month with normal saline 4 times a day was effective in reducing oral health assessment score and reducing the colony count of Candida albicans, Staphylococcus aureus whereas no effect on reducing the colony count of Coagul ase negat i ve st aphyl ococci , Klebsiella. These findings are consistent with the findings of the study reported by Nancy J. 10 Ames (2011) which revealed that oral health assessment scores reduced after nurses implemented a protocol for systematic oral care. The present study findings also showed that oral care with normal saline was effective in maintaining the oral health of hospitalized children. These findings are consistent with the findings of the study which revealed that normal saline was effective in maintaining the oral health status of hospitalized children 11 Kim YK, Choi SH (2003) The present study findings revealed that oral care protocol was effective in reducing oral health assessment scores and oral microbiological flora of hospitalized children. These findings are in line with the findings of the study conducted by Randa 12 13 14 FA (2007), Ali H (2012), Kim LS (2010), 15 16 Sazlina SG (2012), Hadi R (2011), Angela 17 18 MB (2006), Olivia S (2011), Laura 19 A (2010), which revealed that well developed oral care protocol by bedside nurses can improve the oral health of patients admitted in intensive care unit. These studies also revealed that oral care protocol was effective in reducing the microbes and maintaining the oral health status of hospitalized children. Thus, oral care protocol was effective in improving the oral health status of hospitalized children. Hence it is recommended that the use of an assessment model such as the BRUSHED Assessment Model is recommended for the immediate identification of oral problems for all patient and should be carried out daily followed by regular oral care. The study can be replicated on a larger sample to validate the findings and make generalizations. References 1 Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive and Critical Care Nursing2004;20: 69- 76. 2 Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive and Critical Care Nursing2004;20: 69- 76. 3. Asghar KZ, Ahmad P, Abbas H, Hojatollah Y. The effects of an oral care practice on incidence of pneumonia among ventilator patients in ICUs o f s e l e c t e d h o s p i t a l s i n I s f a h a n 2012;(17)3:216-78 Nursing and Midwifery Research Journal, Vol-10, No.1, January 2014 12. RandaFA. 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Beggs, Et - Al 2008 (Increasing The Frequency of Handwashing by Healthcare Workers Does Not Lead To Commensurate Reductions in Staphylococcal Infection in A Hospital Ward)