Implementation and Outcomes of Oral Care Screening in a Skilled Nursing Facility: Examining Readmission Risk and Patient Care

Pneumonia is among the conditions targeted by the Hospital Readmissions Reduction Program because it has the highest morbidity and mortality rates of all hospital-acquired infections and is a major cause of mortality of residents of long-term care (LTC) facilities.¹ Risk factors for pneumonia include the presence of respiratory pathogens in the oral cavity as well as changes in swallowing (eg, dysphagia). Risk factors for aspiration pneumonia (ie, infection as a result of aspirating material into the lungs) include dependence for feeding and/or oral care, multiple medical diagnoses, high number of medications, and smoking. Poor oral hygiene has been found to be a significant risk factor for the development of pneumonia as well as to negatively impact overall well-being. 

To maintain adequate oral hygiene, appropriate oral care practices must be employed. Oral care includes both oral hygiene (cleaning) and oral function (training to improve swallowing, mastication, and secretion management), the latter of which is commonly impaired in patients with oral pharyngeal dysphagia. A major risk for patients with dysphagia is aspiration, or the passage of material below the level of the vocal folds, with or without expulsion. Aspirated material not effectively ejected from the airway may lead to aspiration pneumonia. Consequently, it is not surprising that research has found dysphagia to be highly correlated with aspiration pneumonia compared with nonaspiration pneumonia.² 

Dysphagia management aims to reduce the risk of aspiration, especially during the swallowing of food and liquids. However, aspiration may occur when swallowing secretions not associated with oral intake (nonprandial), including during sleep. In fact, aspiration of oropharyngeal secretions during sleep occurs in approximately half of the healthy population. When such aspiration occurs, the risk of developing an infection is increased if the aspirated material contains an elevated level of bacteria and if defense mechanisms such as cough reflex are weakened. Both risk factors are common in patients in skilled-nursing facilities (SNFs). As a result, oral care has been identified as a major factor in the prevention and management of aspiration pneumonia by reducing dental decay and the presence of bacteria in the oral cavity.³ 

While the need for appropriate oral care practices may seem obvious, many patients in SNFs are unable to complete such tasks independently and must rely on staff for them. Current research suggests that adequate oral care is oftentimes not provided to patients who need it. Patients who do not perform their own oral care are at a higher risk for developing pneumonia because of inadequate application of best practice by health care professionals.^4,5 However, research comparing oral hygiene in patients with and without dysphagia is limited. Given the increased risk of developing aspiration pneumonia, patients with dysphagia should be employing aggressive oral hygiene practices and have equivalent or higher oral hygiene scores compared with patients without dysphagia. 

Given the current understanding of hospital readmission risk and the relationship between dysphagia and aspiration pneumonia risk, we sought to analyze similarities and differences in oral care and outcomes across short-term care (STC) and LTC programs at an SNF. Using the LACE Index Scoring Tool for Risk Assessment of Hospital Readmission⁶ and the in-house developed Oral Cavity Health Assessment (OCHA) tool, this study focused on 4 specific questions: (1) Is the quality of oral hygiene significantly correlated to LACE scores of STC patients with and without dysphagia? (2) Compared with patients in STC, do patients in LTC present with poorer quality of oral hygiene as measured by OCHA scores? (3) Is there a significant difference in quality of oral hygiene as measured by OCHA scores between patients with and without a diagnosis of dysphagia? and (4) Does independence in oral care result in improved quality of oral hygiene as measured by OCHA scores?

Methods

Setting and Participants

The study was conducted at a combined STC rehabilitation and LTC SNF in Manhattan, New York. Institutional review board approval was not required for this study.

A total 214 residents participated in the study. One hundred eight patients in the facility’s short-term care (STC) rehabilitation program and 106 patients in the LTC program were recruited. Participants had a mean age of 79.58 years (range: 21-103). Participants were divided into STC, LTC, dysphagia diagnosis, and no dysphagia diagnosis subgroups (Table 1).

Assessment Tools

The LACE Index Scoring Tool for Risk Assessment of Hospital Readmission and the OCHA were used in this study. The LACE tool is a predictive model that calculates a patient’s hospital readmission risk by assigning numeric values to 4 variables: (1) length of hospital stay; (2) acuity of admission; (3) comorbidities; and (4) emergency department visits within the past 6 months.⁶ The comorbidity parameter is based on the Charlson Comorbidity Index, which predicts the risk of 1-year mortality for patients with a range of comorbid conditions (eg, myocardial infarction, congestive heart failure, dementia).⁷ A LACE score of 10 points or more indicates high risk for readmission.⁸ The OCHA rates the condition of the lips, tongue, gingiva, dentition/dentures, and saliva on a 5-point scale. Possible scores range from 4 to 30, with higher scores reflecting poorer quality of oral hygiene.

Oral Hygiene and Care Screening

All STC and LTC participants received an oral hygiene and care screening, which was developed onsite and consisted of the OCHA questionnaire and visual assessment of the oral cavity (Table 2). Screening procedures included an inventory analysis of oral care materials present in the patient’s room (eg, toothbrush, toothpaste, mouthwash, and denture cup/cleaner, if applicable), identification of the person responsible for oral care (eg, staff member, family/caregiver, patient when provided materials, or independent), and a visual assessment of oral cavity structures via the OCHA. Following the screening, participants were provided with any missing oral care products. Education was provided to staff and patients as needed.

STC Group Procedure

STC participants were recruited using convenience sampling, which had every patient on 3 STC floors participate. Participant age, sex, LACE score, primary medical diagnosis, and dysphagia diagnosis, if present, were retrieved via a retrospective chart review using a Vision electronic medical records system. If a newly admitted patient was referred to a licensed speech-language pathologist (SLP) for a swallowing evaluation, the SLP would assess the presence, type, and severity of suspected dysphagia and recommend appropriate diet consistency and, as needed, initiation of skilled dysphagia therapy. 

LTC Group Procedure

LTC patients were recruited using convenience sampling, which had every resident on 3 LTC floors participate. Each participant underwent screening of oral hygiene and care. Participant age, sex, primary medical diagnosis, and dysphagia diagnosis, if present, were retrieved via a retrospective chart review using a Vision electronic medical records system. LACE score information for LTC participants was unavailable at the time of review.

Results

OCHA scores and LACE scores for STC patients were analyzed to answer the first research question: Is the quality of oral hygiene significantly correlated to the LACE score of STC patients with and without dysphagia? A Pearson correlation between OCHA scores and LACE scores for STC patients was calculated. No significant correlation was found between the two variables  (r=.067, P=.509). 

A one-way analysis of variance (ANOVA) was calculated to answer the second research question: Is there a significant difference in OCHA scores between STC and LTC floors? No significant difference in quality of oral hygiene as measured by OCHA scores was found between STC and LTC units (F(1, 210)=2.91, P>.05). A Pearson Chi-square test was calculated to investigate the relationship between floor type (STC vs LTC) and the presence of oral care products. Results showed patients on STC floors were significantly more likely to have oral care products present (X2(1, N=214)=41.98, P< .001). 

A one-way ANOVA was calculated to determine if there was a significant difference in oral health as measured by OCHA scores between patients with and without a dysphagia diagnosis. Patients with a dysphagia diagnosis had a mean OCHA score of 6.61 (standard deviation[SD]=1.81), whereas patients without a dysphagia diagnosis had a mean OCHA score of 6.07 (SD=1.30). This difference was significant (F(1, 210)=6.30, P<.05). Patients with dysphagia had significantly higher OCHA scores, indicating worse oral hygiene, than patients without dysphagia. Figure 1 illustrates the difference in mean OCHA scores between patients with and without dysphagia. 

To answer the fourth research question—Does independence in oral care result in improved quality of oral hygiene as measured by OCHA scores?—an ANOVA was calculated. Patient-reported level of independence was found to have a significant effect on the quality of oral hygiene as measured by OCHA scores (F(3, 208)=8.94, P<.001). A Tukey’s post hoc analysis was conducted to analyze differences between each level of independence: (1) oral care completed independently; (2) oral care completed when staff sets up materials; (3) oral care completed by the staff; and (4) oral care has not been performed. A significant difference in the mean OCHA score was found between patients who reported performing oral care independently and patients who reported relying on staff to perform oral care (P< .01) and patients who reported oral care had not been performed (P< .001). Patients who performed oral care independently had significantly lower OCHA scores, indicating greater oral hygiene, than patients who reported relying on staff to perform oral care and patients who reported oral care was not performed. Additionally, patients who reported performing oral care after materials were set up were found to have significantly lower OCHA scores (indicating better oral hygiene) compared with patients who reported oral care had not been performed (P<.01). There was no significant difference in OCHA score between patients who reported performing oral hygiene independently and patients who reported performing oral hygiene after materials were set up (P >.05). No significant difference in OCHA score was found between patients who reported performing oral hygiene after materials were set up and patients who reported staff provided their oral care. 

In a major result of the study, no significant difference was found in OCHA scores between patients who reported staff performed their oral care and patients who reported oral care had not been performed (P>.05). This indicates no difference in oral hygiene between the two groups and suggests an inadequate performance of oral care by the nursing staff. Results are illustrated in Figure 2. 

Discussion

This study investigated oral hygiene assessments and hospital readmission, how oral hygiene differs in STC and LTC units, the effect of independence in oral care, and the difference in oral hygiene quality in patients with and without dysphagia. We found that patients with dysphagia had significantly lower oral hygiene scores. Patients dependent on staff for oral care had significantly lower oral hygiene scores compared with patients who independently performed oral care. No significant difference in oral hygiene scores was found between STC and LTC units. We answer each of our initial study questions in detail below.

Is the quality of oral hygiene significantly correlated to the LACE score of STC patients with and without dysphagia?

Given the prevalence and cost of hospital readmissions, an immediate need exists to reduce readmission risk. Oral hygiene plays an important role in maintaining good overall health and well-being. Poor oral hygiene is a significant risk factor for the development of pneumonia, which has the highest morbidity and mortality rates of all hospital-acquired infections.^1,9 This study sought to determine if oral hygiene itself was correlated with current measures of hospital readmission risk reflected in LACE scores. 

Overall, results did not indicate a significant correlation between quality of oral hygiene and LACE scores of STC patients with and without dysphagia (P=.509). Therefore, oral hygiene itself should not be used as a predictor of hospital readmission risk. Despite this result, the importance of oral care must still be stressed. Oral care should be maintained to reduce risk for aspiration pneumonia, especially in patients with dysphagia.

It should be noted that the OCHA score used to evaluate quality of oral hygiene was determined using a subjective rating scale. Ratings were provided via visual assessment by SLP graduate students familiar with oral anatomy. Future studies may benefit from the participation of health care professionals with expertise in dentistry to reduce the subjectivity of OCHA ratings. Additionally, OCHA scores would benefit from calculation of interrater reliability among scorers prior to the data-collection phase. 

Compared with STC patients, do LTC patients present with poorer quality of oral hygiene as measured by OCHA scores? 

Previous research has identified decreased quality of oral health and hygiene among LTC residents, particularly those dependent on others for oral care.¹⁰ The current study aimed to build on these findings and assess whether a significant difference exists between the quality of oral care in STC vs LTC units. Researchers also sought to compare STC and LTC floors to better understand trends in oral care at the specific facility, which may then show implications for nursing facilities in metropolitan areas with both STC and LTC patients.

Although the LTC group was expected to exhibit poorer quality of oral hygiene, results of this study show no significant differences in oral health between the STC and LTC groups. Of note, a significantly greater number of LTC residents were found to be missing basic oral care materials (eg, toothbrush, toothpaste, mouthwash) compared with STC patients. This difference may be due in part to the decreased cognitive awareness of LTC residents. While conducting screenings, a certified nursing assistant (CNA) reported that for many patients staff must bring new materials every time they complete oral care because patients misplace items. 

It is important to note that the current study was limited by sampling techniques. For convenience, samples were only taken from STC and LTC floors within a single building of a nursing home. Since additional buildings were not included, results may have been affected by a lack of representation. Future studies should incorporate more comprehensive sampling to include better representation of nursing home residents on STC and LTC floors. 

Is there a significant difference in quality of oral hygiene as measured by OCHA scores between patients with and without a diagnosis of dysphagia? 

As previously stated, patients with dysphagia are at increased risk of aspiration pneumonia. When participants were divided into two groups based on the presence or absence of a dysphagia diagnosis, a significant difference in oral hygiene scores emerged. Patients with a dysphagia diagnosis were found to have a decreased quality of oral hygiene. This finding is of grave concern considering the population’s increased risk of developing aspiration pneumonia. 

It is imperative to increase awareness of aspiration pneumonia risk among nursing staff working with patients with dysphagia as well as among patients themselves to facilitate self-advocacy. Education initiatives should target staff, patients, and caregivers. Additionally, patients with an altered mental state or change in cognitive status should receive support for completion of oral care and their families should receive information explaining the importance of oral hygiene. 

Does independence in oral care result in improved quality of oral hygiene as measured by OCHA scores? 

Previous research has suggested relying on others for the completion of oral care may negatively impact oral hygiene due to poor implementation of appropriate care procedures.⁵ This study sought to build upon that research. One of the core responsibilities of CNAs is to provide appropriate daily oral care for both STC and LTC patients unable to do so independently. The results of this study indicate that dependence on others for oral care may be an underlying cause of poorer oral hygiene as measured by participants’ OCHA scores. This study corroborates previous research findings demonstrating the negative effects of decreased independence in oral care.⁵ 

Our analysis found no significant difference in OCHA scores between patients who reported needing staff to perform oral care and patients who reported oral care had not been performed. These results indicate a need for better education and accountability among staff responsible for oral care. The results further indicate that patients who rely on others for oral care may be at higher risk for contracting diseases related to poor oral hygiene (eg, gingivitis, pneumonia) due to the increased presence of mucosal lesions, dental plaque, and xerostomia as reflected in their elevated OCHA scores.⁴ This is of particular concern considering the high prevalence of dysphagia and associative risk for aspiration of oral bacteria within the oral care-assisted group. Future studies encompassing multiple nursing facility sites should be completed to determine if these results are isolated to the facility in this study or are representative of trends across facilities.

According to Wintch et al, poor oral hygiene among LTC residents may be caused by limited knowledge and resources regarding adequate oral care. It can also be caused by fluctuations in resident physical and/or cognitive status that challenge the ability to complete oral care or to advocate for its completion.¹¹ 

Researchers cannot guarantee informant reliability for reports of oral care performance. Many patients included in this study have cooccurring diagnoses that affect mental status (eg, dementia, Alzheimer disease, stroke). This could have confounded results if patients did not report accurate information regarding oral care. 

Conclusion

This study highlights the importance of oral care and oral hygiene literacy across STC and LTC settings. Lack of awareness about recommended oral hygiene practices and risk factors associated with poor oral hygiene may partly account for poor implementation of oral care by staff and caregivers and may contribute to poor oral hygiene observed in patients who rely on external support for oral care. Therefore, it is essential that all health care team members stay current on recommended oral care procedures as well as research highlighting associative risk factors, including its relationship with pneumonia. Future work is warranted to expand the scope of this study to other healthcare settings and across longer periods of time. Additionally, educational initiatives should be outlined and investigated in pilot studies to determine the most efficacious method for improving the quality and frequency of oral care provided to patients. 

References

1. Tada A, Miura H. Prevention of aspiration pneumonia (AP) with oral care. Arch Gerontol Geriatr. 2012;55(1):16-21.

2. Martin BJ, Corlew MM, Wood H, et al. The association of swallowing dysfunction and aspiration pneumonia. Dysphagia. 1994;9(1):1-6.

3. Yoon MN, Steele CM. The oral care imperative: the link between oral hygiene and aspiration pneumonia. Top Geriatr Rehabil. 2007:23(3):280-288.

4. Langmore SE, Terpenning MS, Schork A, et al. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 1998;13(2):69-81.

5. Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc. 2006;54(1)138-143.

6. van Walraven C, Dhalla IA, Bell C, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010; 182(6):551-557.

7. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383.

8. How to calculate the LACE risk score. Princeton, NJ: Besler. https://www.besler.com/lace-risk-score/. Accessed January 3, 2019. 

9. Boczko F, McKeon S, Schwartz BE. Oral care and the elderly. Perspectives on Gerontology. 2006;11(2):13-18.

10. Boczko F, McKeon S, Sturkie, D. Long-term care and oral health knowledge. J Am Med Dir Assoc. 2009;10(3):204-206.

11. Wintch PM, Johnson T, Gurenlian J, Neil K. Executive directors’ perceptions of oral health care of aging adults in long-term care settings. J Dent Hyg. 2014;88(5):302-308.