Feasibility and utility of video and photographic data for interprofessional exploration of oral hygiene application barriers in intubated and mechanically ventilated adults: A pilot study
CCCF ePoster library. Dale C. 10/28/15; 117328; P100 Disclosure(s)(s): STTI Lambda Pi-At-Large Research Seed Grant
Craig M. Dale
Craig M. Dale
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Feasibility and utility of video and photographic data for interprofessional exploration of oral hygiene application barriers in intubated and mechanically ventilated adults: A pilot study

Craig M. Dale, J. Angus, K. Montgomery, L. Nusdorfer, S. Keriazis, S. Sutherland, C. Yarascavitch, L. Rose

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada | Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada | Physiotherapy, Sunnybrook Health Sciences Centre, Toronto, Canada | Aging and Veterans Care, Sunnybrook Health Sciences Centre, Toronto, Canada | Respiratory Therapy, Sunnybrook Health Sciences Centre, Toronto, Canada | Dentistry, Sunnybrook Health Sciences Centre, Toronto, Canada | Faculty of Dentistry, University of Toronto, Toronto, Canada | Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada

Introduction: Although preventative mouth care can reduce patient-identified oral discomforts and the incidence of ventilator-associated pneumonia (VAP) in mechanically ventilated adults,1-4 the literature reports patient, clinician, and contextual barriers.5-10 Study of oral hygiene application is more important now than ever as newer topical oral regimens demonstrate important morbidity and mortality reductions.11,12 Notwithstanding the importance of this issue, no current recommendations exist to direct management of critically ill ventilated adults experiencing barriers to delivery of oral hygiene for the prevention of infection and the provision of comfort. Collaborative interprofessional investigation of oral care barriers in intubated and mechanically ventilated adults is currently lacking.13

Objectives: A qualitative, pilot feasibility study was conducted to evaluate the capacity to obtain patient informed consent and to explore clinician perceptions of the acceptability and utility of video and photographic data in the investigation of oral care barriers during critical illness. Assessment of the feasibility of consent for videography and intraoral photography is particularly important given frequent patient decisional incapacitation in critical illness and the need for surrogate consent to participate in clinical research. Patients and surrogates may not be familiar with video-facilitated health research and this may prolong participant recruitment. The acceptability and utility of intraoral photographs and videography is important to assess as these data formats may offer novel means of interprofessional stakeholder evaluation of oral hygiene barriers.

Methods: A 26-bed university-affiliated intensive care unit (ICU) was prospectively screened for intubated and ventilated patients meeting established barrier characteristics including oral crowding (≥ 2 oral tubes) and/or low care tolerance (≥ 1 aversive care response). Intraoral photographs and videography of oral care application were collected from consenting subjects. Images comprising three patient case studies were subsequently used to elicit exploratory discussion in one-on-one semi-structured interviews with 18 clinicians (9 ICU and 9 non-ICU health professionals, e.g., dentistry, dental hygiene, and allied health). Verbatim interview transcripts underwent qualitative content analysis using NVIVO10 software.

Results: 50% of substitute decision-makers (SDMs) of eligible ICU patients consented to study participation in a 2-week recruitment period. Initial SDM consent was necessary in 100% of eligible cases due to patient cognitive and verbal incapacity. Reasons for failed consent included the inability to contact a SDM in the 24-hour enrolment window (41.7%) and declined consent (8.3%). Frequent hygiene application barriers involved limited oral visibility (92%) and patient biting (67%) during care. Following review of visual data, interprofessional interview participants unanimously agreed that visual methods were an acceptable and robust mode of research. Intraoral photography was noted to reveal impaired oral tissue integrity that would not otherwise be visible (Table 1). Video was characterized as a transformational means of exploring the dynamic interplay of clinician and patient in real-time (Table 2). Participants reported that visual methods facilitated identification of potentially modifiable antecedents to oral hygiene barriers warranting further research (Video1).


Video and photography are feasible, useful, and innovative qualitative approaches for the exploration of oral care application barriers in critical illness. Visual methods offer the opportunity to bring the patient encounter to a wide variety of experts for a durable and recurring analysis. Visual methods can advance a collaborative interprofessional approach to the development of new knowledge in preventative oral care application in intubated and mechanically ventilated adults.

References: 1. Feider LL, Mitchell P, Bridges E. Oral care practices for orally intubated critically ill adults. Am J Crit Care. 2010;19(2):175-183.

2. Labeau S, Vandijck D, Rello J, et al. Evidence-based guidelines for the prevention of ventilator-associated pneumonia: Results of a knowledge test among European intensive care nurses. J Hosp Infect. 2008;70(2):180-185.

3. Berry AM, Davidson PM. Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit. Intensive Crit Care Nurs. 2006;22(6):318-328.

4. Rose L, Fraser IM. Patient characteristics and outcomes of a provincial prolonged-ventilation weaning centre: A retrospective cohort study. Can Resp J. 2012;19(3):216-220.

5. Dale C, Angus JE, Sinuff T, Mykhalovskiy E. Mouth care for orally intubated patients: A critical ethnographic review of the nursing literature. Intensive Crit Care Nurs. 2013;29(5):266-274.

6. Hillier B, Wilson, Christine RM, Chamberlain, D, King L. Preventing ventilator-associated pneumonia through oral care, product selection, and application method: A literature review. AACN Adv Crit Care. 2013;24(1):38-58.

7. Allen Furr L, Binkley CJ, McCurren C, Carrico R. Factors affecting quality of oral care in intensive care units. J Adv Nurs. 2004;48(5):454-462.

8. Dale C. Locating critical care nurses in mouth care: An institutional ethnography. [PhD]. Toronto: University of Toronto; 2013.

9. Holberton P, Liggett G, Lundberg D. Focus on quality: Researching mouth care in the ICU. Can Nurse. 1996;92(5):51-52.

10. McNeill HE. Biting back at poor oral hygiene. Intensive Crit Care Nurs. 2000;16(6):367-372.

11. Shi Z, Xie H, Wang P, et al. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2013(8): CD008367.

12. D'Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E, Liberati A. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev. 2009(4): CD000022.

13. Hein C, Schonwetter DJ, Iacopino AM. Inclusion of oral-systemic health in predoctoral/undergraduate curricula of pharmacy, nursing, and medical schools around the world: A preliminary study. J Dent Educ. 2011;75(9):1187-1199.

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