Care of Oral Patients in SNFs Receiving Feeding Tubes
1. + Care of
Oral
Patients Housed in a
SNF Receiving
Nutrition via Feeding
Tube: A Survey of
Nurses
Brittany H. Janowski
April 26th, 2011
University of West Georgia
2. + Introduction
1.5 million people housed in nursing homes
1.3 million over age 65 (CDC, 2004)
Medically complex = AT RISK
3. +
What does this have to do
with feeding tubes?
4. +
Leads to placement of feeding tube (FT)
146, 000 permanent feeding tubes placed in 2003
(National Center for Health Statistics)
FT considered when patient cannot eat or will not
eat, gut is functional, & can tolerate placement of
device (American Gastroenterological Association, 1994)
5. “Clinical indications for the SLP
+ in recommending tube feeding is
typically dysphagia.”
(ASHA, 2007)
6. +
Feeding Tubes, Oral Care, & the SLP
How are they related?
SLPs Roles Include:
1) Making recommendations about
management of swallowing & feeding
disorders
2) Educating other professionals
3) Advocating for services
(ASHA, 2002)
7. +
Current Literature
Most common complication following feeding
tube (FT) placement - aspiration pneumonia,
followed by PEG site infection & tube
blockage (Janes, Price & Kahn, 2005)
Individuals with dysphagia receiving tube
feedings remain at risk for aspiration of
saliva; also during episodes of vomitting or
gastric reflux (Langmore, Skarupski, Park, & Fries, 2002; Langmore
et al., 1998)
8. +
Current Literature
Aspiration
pneumonia may be reduced by
supplementing tube feedings with oral
hygiene care and positioning (Langmore et al., 2002;
Marik, 2001; Terpenning, 2005)
Oralcare significantly decreased the
incidence of ventilator-associated pneumonia
in ICU patients(Mori, Hirasawa, Oda, Shiga, Matsuda, &
Nakamura, 2006)
9. +
Current Literature
Number of pathogenic bacteria in oral cavity
significantly reduced by single oral care
procedure (Mori et al., 2006)
Lack of oral maintenance provide opportunity
for pathogens to colonize and multiply(Ashford
&Skelley, 2008)
Aspiration of certain oral pathogens into lower
respiratory tract associated with development of
pneumonia leading to illness, complications, and
death(Ashford &Skelley, 2008)
10. Published data regarding
+ specific outcomes associated
with tube feeding are limited and
varied.
( Janes, Price, & Kahn,2005)
11. +
Purpose
To assess skilled nursing facility
nurses’ knowledge and skills related
to oral care of patients receiving
nutrition from a feeding tube.
“Nurses are the first line of defense in preventing bacterial
colonization of the oropharynx and gastrointestinal
tract.” (Augustyn, 2007)
12. +
Specific Objectives
1) Survey SNF nurses’ knowledge and skills
2) Compare reported practices with evidence-
based guidelines
3) Describe current practice
4) Explore relationships with demographic
characteristics
13. +
Methods
Instrument: 20-Item questionnaire
Content validity
Population: SNF nursing staff w/
experience caring for patients with
feeding tubes
Location: 10 SNFs across the state of
GA
Procedure: anonymous; distributed by
SLPs prior to in-service; incentive; 100
surveys
14. +
Results
High return rate expected
Demographics expected
to reflect national trends
Age
Level of education
experience
15. +
Results
Expected to yield similar results as the
following:
Survey study of 1200 ICU nurses regarding
oral-care and hygiene practices of patients
with a ventilator (Cason, Tyler, & Broome, 2007)
Finding:
Guidelines for prevention of
pneumonia not consistently or uniformly
implemented
16. +
Conclusion
Has been documented in the literature that
decreased oral care and hygiene can increase
risk of aspiration pneumonia (AP) and other
conditions
Effect mortality, morbidity, & length of stay
SLPsplay vital role in prevention, advocation, &
education of other professionals
17. +
Conclusion
If findings were accurate,
recommendations would
include:
1) Oral care protocols
2) Continued education
(specifically, by SLP)
3) Performance reviews,
observational studies,
random daily audits
18. +
Future Research
Benefits of oral care protocols
Effects of inservices by SLP (before
& after)
Relationship between quality of oral
care and presence of AP in patients
on a feeding tube
19. +
Clinical Implications
Advocate
Improve
quality
of life
Prevent Educate
20. +
Limitations
Assessment of reliability
was not completed
Distributed to a limited
number of SLPs in a
small demographic region
All results were self-
reported
22. +
References
American Speech-Language-Hearing Association. (2006) Speech-language pathologists (SLPs) as the preferred
providers for dysphagiaservices. Available from www.asha.org/slp/clinical/dysphagia/
Ashford, J.R., Skelley, M. (2008). Oral care and the elderly. Perspectives on Swallowing and Swallowing Disorders
(Dysphagia), 17, 19-26. doi:10.1044/sasd17.1.19
Augustyn, B. (2007). Ventilator-associated pneumonia. Critical Care Nurse, 27 (4). 32-39.
Azarpazhooh A, Leake JL. (2006). Systematic review of the association between respiratory diseases and
oral health. JPeriodontol, 77(9): 1465-82.
Binkley C., Furr, L.A., Carrico, R., McCurren, C. (2004). Survey of oral care practices in US intensive care units.
American Journal of Infection Control, 32 (3), 161-169. doi:10.1016/j.ajic.2003.05.001
Cason, C.L., Tyner, T., Saunders, S., Broome, L. (2007). Nurses’ implementation of guidelines for ventiltor-associated
pneumonia from the centers for disease control and prevention. American Journal of Critical Care, 16, 28-37.
Centers for Disease Control and Prevention. (2003). Guidelines for preventing health-care associated pneumonia, 53
(RR03), 1-36.
Janes, S. E., Price, C. S., & Kahn, S. (2005). Percutaneous endoscopic gastrostomy: 30 day mortality trends and risk
factors. Journal of Postgraduate Medicine, 51, 23–2.
Jones, H., Newton, J.T., Bowen, E.J. (2004). A survey of the oral care practices of intensive care nurses. Critical Care
Nursing, 20 (2), 69-76. doi:10.1016/j.iccn.2004.01.004
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing
home residents. Dysphagia, 17(4), 298–307
23. +
References
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D.,
&Loesche, W. J. (1998). Predictors of aspiration pneumonia: How important is dysphagia?
Dysphagia, 13(2), 69–81.
Marik, P. E. (2001). Aspiration pneumonitis and aspiration pneumonia. New England Journal
of Medicine, 344, 665–671.
Mori H., Hirasawa, H., Oda, S., Shiga, H., Matsuda, K., Nakamura, M. (2006). Oral care
reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care
Medicine, 32 (2), 230-236. DOI: 10.1007/s00134-005-0014-4
National Center for Health Statistics, Centers for Disease Control and Prevention.
(2008).Table 107. Nursing home residents 65 years of age and over, by age, sex, and race:
United States, selected years 1973-2004. Hyattsville,
MD. http://www.cdc.gov/nchs/data/hus/hus08.pdf#107.
Pelletier, C.A. (2004). What do certified nurse assistants actually know about dysphagia and
feeding nursing home residents? American Journal of Speech-Language Pathology, 13,
99-113. doi:10.1044/1058-0360(2004/012)
Terpenning, M. S. (2005). Geriatric oral health and pneumonia risk. Clinical Infectious
Diseases ,40, 1807–1810
Notas del editor
AFTER MEDICALLY COMPLEX- Residents admitted to skilled nursing facilities (SNFs) from the hospital today often present with an acute, medically complex status.Jones, Newton, & Bowen (2004), these SNF residents are at risk for malnutrition, dehydration, and aspiration due to a variety of factors including multiple co-morbidities, neurological disorders, neuromuscular impairments, depression, and cognitive deficits (including dementia).Also - Long-term SNF residents may decline in condition with a resulting effect on oral intake due to such factors as changes in taste, effects of chronic disease, multiple medications, depression, decreased activity level, and decreased appetite (Pelletier, 2004).
Either of these situations for newly admitted or long-term SNF residents may lead to placement of a feeding tube due to concerns about malnutrition and aspiration (Jones, Newton, & Bowen, 2004; Pelletier, 2004). In 2003, the National Center for Health Statistics reported that 146,000 procedures were performed to insert permanent feeding tubes into patients. FT considered when patient cannot eat or will not eat, gut is functional, & can tolerate placement of device
According to the American Speech-Language and Hearing Association (2007), clinical indications for the SLP in recommending tube feeding is typically dysphagia.
If the individual's swallowing safety and efficiency cannot reach a level of adequate function, or does not support nutrition and hydration adequately, the swallowing and feeding team may recommend alternative avenues of intake (e.g., nasogastric tube [NG], gastrostomy).Appropriate roles for speech-language pathologists include, but are not limited to (in addition to evaluation & treatment):1)Making recommendations about management of swallowing and feeding disorders.2)Educating other professionals regarding the needs of individuals with dysphagia, and the speech-language pathologists' role in the evaluation and management of swallowing and feeding disorders.3)Serving as an integral part of a multidisciplinary and/or interdisciplinary team as appropriate.4)Advocating for services for individuals with swallowing and feeding disorders.Education and counseling may be provided concerning issues related to tube feeding, such as appropriate positioning and duration of feeding times. Alternative feeding does not preclude the need for habilitative/rehabilitative techniques to facilitate sensory and motor capabilities necessary for oral feeding.
Janes, Price, & Kahn (2005) reported that the most common complication following feeding tube placement was aspiration pneumonia, followed by PEG site infection and tube blockage. The use of tube feeding may reduce aspiration of mealtime food and liquid into the airway; however, according to many researchers, individuals with dysphagia who receive tube feedings remain at risk for aspiration of saliva if the sensory or motor components of airway protection are impaired (Langmore, Skarupski, Park, & Fries, 2002; Langmore et al., 1998). Likewise, patients with dysphagia may aspirate during episodes of gastric reflux or vomiting.
Several researchers have documented that an individual’s risk for aspiration pneumonia or pneumonitis may be reduced by supplementing tube feedings with oral hygiene care as well as medical and positioning approaches to reduce gastric reflux and vomiting (Langmore et al., 2002; Marik, 2001; Terpenning, 2005). Similarly, Mori et al. (2006) compared the use of oral care with no oral care in mechanically ventilated patients admitted to the intensive care unit (ICU) and found that oral care significantly decreased the incidence of ventilator-accociated pneumonia (VAP). While these patients were not on a feeding tube, adequate oral care of mechanically ventilated patients requires specific knowledge and skills related to the use of the device and it’s affects on swallowing/feeding, similar to the specific knowledge and skills needed in caring for patients on a feeding tube.
Mori et al. (2006) also reported that the number of pathogenic bacteria in the oral cavity was significantly reduced by a single oral care procedure. According to Ashford & Skelley (2008), normal bacteria florae existing within the oropharynx are limited in their efforts to colonize in the moist oral tissues by immune properties present in saliva and mucous. However, a lack of oral maintenance may provide an opportunity for these pathogens to colonize and multiply. Ashford & Skelley (2008) pointed out that aspiration of certain oral pathogens into the lower respiratory tract has been associated with the development of pneumonia leading to illness, complications, and death in some elderly or sick persons; however, oral care using brushed and oral rinses have been shown to significantly reduce pneumonia development and fever in the sick and elderly populations.
Janes, Price, & Kahn point out the need for research
REITERATE Roles:Making recommendations about management of swallowing & feeding disordersEducating other professionalsAdvocating for services Knowing the difference between recommended and reported practices permits development, implementation, and evaluation of strategies that have the potential to improve care and care outcomes.
Specific objectives of this study involvesurveying SNF nurses’ knowledge and skills related to oral care of patients receiving nutrition from a feeding tube, describing the extent to which reported oral care practices match CDC guidelines for the prevention of aspiration pneumonia3) describe current practice4) explore relationships between oral care practices and the demographic characteristics of the nurse respondent – such as level of education, age, experience
Instrument The 20-item questionnaire included yes-no, true-false, fill-in-the-blank, and rating scale items (see Appendix A). The questionnaire was distributed to nurses in ten skilled nursing facilities across the state of Georgia and included certified nursing assistants (CPN), licensed practical nurses (LPN), associate degree registered nurses (ADRN), and baccalaureate degree registered nurses (BDRN). The survey included questions related to CDC guidelines for oral care(suctioning, elevation of the head of the bed, presence of oral care protocols, and use of an oral rinse), questions to provide information about current oral care practices involving patients on a feeding tube, and demographic questions.Procedure A cover sheet on each survey instructed respondents to place no identifying information on the survey to protect anonymity. Respondents who completed and returned the survey implied their consent to participate. Surveys were distributed by SLPs providing in-services to nursing staff on the signs and risks of aspiration. Each SLP received instructions for distribution and collection of the surveys. To reduce bias related to new knowledge of oral care acquired during the inservice, SLPs distributed and collected all surveys before discussion began. Each participant placed the completed surveys into envelopes and returned the sealed envelopes to the SLP. Upon completion of the survey, nurses received a ticket to participate in a drawing for a gift certificate from an online scrubs store. This provided an incentive for participating in the survey.Completed surveys were scanned into an electronic data file. SPSS for Windows, Version 12.0 (SPSS Inc, Chicago, Ill) was used to describe the characteristics of the respondents and their responses. CONTENT VALIDITY: Content validation of the survey was obtained by using a panel of 4 persons: an infection control nurse, and infection control physician, an SLP with extensive experience in SNFs, and a nurse with expertise in topics related to respiratory disease and alternative hydration and nutrition. Each person was provided with an opportunity to comment and critique items included on the survey. No new items were suggested, and no items were suggested for revision or deletion. The survey was then distributed to 10 nurses (1 from each SNF) to evaluate readability and time to complete. None of these 10 nurses had questions or concerns about the questions, and they were able to complete the survey in 5 minutes. SPSS Statistics is a comprehensive, easy-to-use set of data and predictive analytics tools
a high percentage of return rate due to the nature of the distribution.Incomplete surveys would be discarded and not included in the analysis of results. It is also expected that the nurses completing the survey would reflect the national trends regarding nurses’ age, level of education, and years of experience.
In a survey study of 1200 ICU nurses regarding implementation of oral care and hygiene guidelines, Cason, Tyner, & Broome (2007) found that the guidelines for the prevention of ventilator-associated pneumonia from the CDC were not consistently or uniformly implemented. Results of the study were as follows: most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. It is expected that results of the survey of SNF nurses and the oral care of patients on a feeding tube would yield similar results and oral care practices would not parallel with evidence-based practices described in the literature. Findings may be even lower due to level or education, experience, and/or monitoring (seems that the highest qualified nurses would work in ICU)
It has been documented in the literature that decreased oral care and hygiene can increase the risk of aspiration pneumonia. The effects of aspiration pneumonia can vastly affect morbidity, mortality, length of stay, and cost of patients with or without a feeding tube. While the SLP’s role with these patient’s is focused on the evaluation process and development of a treatment plan, SLPs also play a vital role in prevention and education of other professionals. It is expected that results of the survey would indicate inadequate knowledge and implementation of oral care guidelines by nursing staff when dealing with patients on a feeding tube in a SNF.
If these findings were accurate, the following recommendations would be made: All SNFs should implement oral care protocols, which should include the specific needs of patient’s receiving nutrition via feeding tube. Continuing education for nursing staff should be supported and encouraged by SNFs to heighten awareness of the importance of oral care and hygiene and to improve adherence to the evidence-based guidelines. Continuing education may include inservices provided by SLPs in the SNF setting, and the SLP should advocate for patients by highlighting the needs for these services. 3) To prevent the consequences of decreased oral care in patients on a feeding tube, SNFs should consider performance reviews, observational studies, and/or random daily audits to ensure guidelines are being practiced. Areas of future research may include the benefits associated with use of oral care protocols, a quantitative study of oral care practices before and after inservices are provided by SLPs, and an investigation of the relationship between quality of oral-care and the presence of aspiration pneumonia in patients receiving nutrition via feeding tube in a variety of settings.
Areas of future research may include the benefits associated with use of oral care protocols an investigation of the relationship between quality of oral-care and presence of aspiration pneumonia in patients receiving nutrition via feeding tube in a variety of settings
Is it the SLPs responsibility to monitor nursing staff at their facility? No. But it IS our role to prevent and advocate for our pts with a feeding tube? YES. If oral care is not adequate do we attack? No. We educate other professionals, and by doing so we ultimately reduce healthcare cost and mortality while increasing the quality of life. If a cause-effect relationship is noticed – REEARCH.
Limitations This survey study had at least 3 primary limitations.First, a formal assessment of the reliability of the survey was not completed. Consequently, there is no way of knowing how responses would differ if respondents completed the survey a second time. Second, our survey was distributed at a limited number of SNFs only in the state of Georgia. This method of distribution does not illustrate a sample comparable to the national population. As a result, it is difficult to determine if our findings can be generalized to a larger population such as those nurses in other states and settings. 3) all results were self-reported. There was an attempt to minimize the prospect for response bias by providing anonymity and instructing participants to record what they actually do in practice versus what is recommended, but, as mentioned, the results of this study most likely overestimate compliance with recommended practices.