JCPSLP Vol 20 No 3 November 2018

schedule. Adequate oral hygiene was defined as results fitting into the “Usual care or low risk” category (constituting a score of 0–2 on the MOHAT). The score (collected on admission to the rehabilitation unit) relating to a rating of severity then prompts a standardised oral care regime, targeting key areas of impaired oral hygiene. Following engagement and education of all relevant stakeholders, the MOHAT was implemented as part of routine nursing care in the Logan Hospital Rehabilitation Unit. Educational plans included preparation of in-service education sessions (presented by the speech pathologist), handouts, pictures/images showing oral health with attributed rating scales on MOHAT, as well as a staff engagement survey. The MOHAT also includes a clinical form for filing within the medical record, with training provided to nursing staff on how to accurately complete the new record sheets. Side-by-side auditing was conducted by the nurse clinical facilitator to monitor compliance and validity of tool completion. Barriers Barriers during this implementation phase were continuously monitored and reviewed. In particular, concerns regarding oversensitivity of the MOHAT tool resulting in increased demands on nursing time, increased documentation requirements (including completion of additional forms), and concerns regarding appropriateness (including patient embarrassment) when assessing the oral cavity were identified. Facilitators Identified barriers were addressed with purposeful education, stakeholder engagement (including focus groups, in-services and informal discussions) and modifications to clinical forms and documentation processes to better fit with existing documentation parameters. and the implementation of patient surveys to ensure appropriateness of care. These actions facilitated staff engagement, identified change champions, and helped engender a collaborative workplace culture. Evaluating the oral care protocol Ethical approval was sought and obtained for the evaluation of the oral care protocol (HREC/17/QPAH/5). Evaluation method To identify and address barriers and perceptions of key stakeholders, pilot data was collected using two surveys (one for patients and one for staff) which collected both quantitative (5 point Likert scale) and qualitative feedback (in the form of open responses). Patients provided ratings of their oral health prior to hospitalisation, post hospitalisation and post transfer to the rehabilitation unit, in addition to providing feedback on the oral care protocol. Staff primarily reported on their awareness of the mouth care protocol, their perceptions of the protocol (including impact on workload, perceived impact on patient care and satisfaction and suggestions for continued utilisation) in the form of open responses. The surveys were completed by patients (n = 42) and staff (n = 9) . Evaluation outcomes Self report of oral hygiene from home to hospital improved in only 12% (n = 5) of patients and deteriorated in 43% (n = 18) of patients. Following transfer to the rehabilitation unit from hospital, 36% (n = 15) reported improvement in oral hygiene, compared to only 17% (n = 7) who reported deterioration (see Figure 2).

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Figure 2. Self rating of oral hygiene from home-hospital and hospital-rehabilitation

Patient perceptions (n = 35) of the oral care protocol are shown in Table 1. While initial concerns were identified by nursing staff that patients might find oral care invasive or uncomfortable, most patients did not report being uncomfortable, offended or feeling awkward during mouth care assessment (86%) or during associated questioning regarding their teeth cleaning performance (80%). Further, 34% of patients indicated that offering assistance to clean their mouth was appreciated. To identify the impact of the implementation of the oral care protocol on staff workloads, surveys of staff particularly targeted nursing colleagues. All staff responders (n = 9) stated that they were aware of the oral hygiene protocol and 100% (n = 9) felt that it improved oral hygiene for their patients. Positive responses included comments such as “The oral hygiene initiative is a good prompting tool” and reports of “more awareness of patient’s swallowing and aspiration risks”. In addition, nursing staff reported benefits such as “Making the patient more involved in their activities of daily living” and “Making patients feel more comfortable”. However, 33.3% (n = 3) of nurses felt that implementing the protocol significantly increased their workload. Despite increases in workload, all nurses (n = 9) felt that the standardised process should continue. Thus, while workload was increased, nursing staff implementing the protocol were able to identify the clinical rationale for implementation and appreciate its value. Developing the free water protocol Alongside the oral care protocol development and evaluation, a formalised Logan Hospital FWP was developed using available evidence from FWPs implemented in Canada, USA and Australia (Carlaw et al., 2012; Frey & Ramsberger, 2011; Garon et al., 1997; Gillman et al., 2017; Karagiannis & Karagiannis, 2014; Karagiannis et al., 2011; Murray et al., 2016; Pooyania et al., 2015). Ethical approval for this project was sought and obtained (HREC/15/QPAH/835). The evidence clearly indicated that to limit patient risk of developing aspiration

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology