JCPSLP Vol 20 No 3 November 2018

The link between aspiration pneumonia and dysphagia is complex, with multiple risk factors. One known risk factor is the presence of oral pathogens (Carlaw et al., 2012; Langmore, 1999; Langmore et al., 1998). This link between aspiration pneumonia and oral health has been highlighted in several studies (Langmore, 1999; Langmore et al., 1998; Marik & Kaplan, 2003; Pace & McCullough, 2010; Sarin, Balasubramaniam, Corcoran, Laudenbach, & Stoopler, 2008; Scannapieco, 2006; Scannapieco & Mylotte, 1996; Terpenning et al., 2001). Given this relationship, we contend that the completion of oral care is a key component of dysphagia management and the implementation of a FWP cannot be considered without assessment and management of oral care through a standardised oral care protocol. Value and significance The evidence for the role of oral care in reducing risk of aspiration pneumonia, as well as the evidence to support the safe implementation of FWPs for select patients is growing in the literature but remains poorly implemented in clinical practice. This evidence–practice gap needs to be addressed. The rehabilitation unit described in this study was an ideal location to consider implementation of evidence-based practice as the unit supports a strong culture of evidence-based practice and clinical innovation, due to the unit being a relatively new service with emerging clinical practice guidelines. While implementation of either a formalised oral care protocol or a FWP can be considered in isolation, the significant relationship between oral care and risk of aspiration pneumonia dictates that these protocols be implemented concurrently. Change to clinical practice is known to be fraught with barriers, so this study aims to provide a collaborative, stepwise and accessible process to implement practice change as proposed by Grol (1997) (see Figure 1), in an attempt to assist clinicians to implement best evidence practice within their clinical areas. Developing the oral care protocol As highlighted, implementing standardised oral care alongside FWP is desirable and evidence based. Evidence to support the case for standardised oral care with FWP was presented to the multidisciplinary rehabilitation team, including medical and allied health representatives. During this consultation, it became apparent that a larger body of evidence was available to guide the implementation of the FWP (this included clearly set-out inclusion and exclusion criteria and suggestions for medical monitoring and supervision during oral intake). The establishment of a standardised oral care protocol, however, appeared to be more complex, given a lack of clear assessment and management guidelines, limited training resources and lack of documentation standards. In light of these issues, the implementation of the oral care protocol required an initial evaluation to ensure its feasibility as a practice concurrent with FWPs. Collaboratively, a formalised oral hygiene assessment tool (OHAT) (Chalmers & Johnson, 2004; Chalmers, King, Spencer, Wright, & Carter, 2005; Chalmers & Pearson, 2005) was selected, trialled by nursing staff, and subsequently modified following consumer and nursing staff feedback to include a guided oral care regime which resulted in the Modified Oral Health Assessment Tool (MOHAT). The MOHAT was used to assess the client’s oral health and guide decision-making regarding oral care. Modification did not change the rating of oral hygiene or

Develop a change proposal: 1 Literature review 2 Training and audit tools developed 3 Stakeholder engagement 4 Training Identify obstacles to change: 1 Time and staff demands 2 Water contamination 3 Perceived liability 4 Culture change Link interventions to obstacles: 1 Standard educational materials 2 Interactive small group meetings 3 Opinion leaders 4 Auditing and feedback 5 Multidisciplinary engagement

Adapt change proposal

Identify new obstacles

Select new interventions

Develop plan: 1 Formalised oral

Anne Coccetti (top) and Elizabeth Cardell

Adapt a plan

hygiene assessment and management tool 2 Formalised Free Water protocol

Carry out the plan and evaluate progress: 1 mOHAT as routine nursing care 2 Regular auditing and feedback 3 Free Water protocol for eligible patients

Target not achieved

Target achieved

Figure 1. Standardised oral cares implementation model

the scoring procedure; rather the modification resulted in a designated pathway of care depending on the score. The changes were incorporated into a “screening tool” for ease of use (please see Appendix). A revision of the necessary forms, equipment, regimes and education was undertaken incorporating relevant feedback. Each category of the MOHAT (lips, tongue, gums and tissues, saliva, natural teeth, dentures, oral cleanliness and dental pain) is given a score of 0–2, with final scores being added up and assigned to a risk category relating to an oral care

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JCPSLP Volume 20, Number 3 2018

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