Improving the evidence base for oral assessment in stroke patients

Abstract

Oral care is essential in maintaining oral hygiene and oral health. When oral care is neglected individuals are at risk of oral and systemic complications affecting general health. Stroke patients are one group who are at risk of poor oral health due to their physical and cognitive dependency. Providing oral care is normally the responsibility of the nurses, and currently there is little evidence to support oral care provided. Through a series of studies this thesis aims to explore oral care in hospitalised stroke patients with the aim of developing an oral assessment to inform oral care.
An integrative literature review examining oral assessments developed for use in a dependent population, identified that an oral assessment for use in stroke patients did not exist. The majority of oral assessments had been developed using the empirical literature and/or expert opinion, with a focus to assess oral health and cleanliness. Those assessments that were selected for review were found to be of a poor quality both in development and testing of psychometric properties. Where agreement had been tested, both within and between raters, agreement was variable across all items. The information gathered from the review was used to aid the design of a qualitative study to explore stakeholder’s views of oral care in stroke patients, and the development of a new oral assessment for use in stroke patients.
An interpretive approach was utilised to explore the views and experiences of experts in oral health and stroke; health professionals’; patients’ and carers’. Two different methods were used to capture this data: one to one interviews for the experts in oral health and stroke, patients and carers; and focus groups for the health professionals. Eight experts were interviewed, five patients, five carers and the two focus groups with six/seven health professionals. The findings illustrated that oral care is complex, and assessment is only one component of this process. Five concepts relating to oral assessment were identified by all the groups: ability to attend to oral care; oral health and cleanliness of the oral cavity; comfort of the oral cavity; contributing factors; assessment format and layout.
The findings from the qualitative interviews, focus groups, and the literature review, were presented to an expert panel that contained a representative from the oral health experts, stroke experts, health professionals, patients and carers. This group reviewed the data and, using a systematic approach, developed the new oral assessment; the Comprehensive Oral Assessment Tool for Stroke (COATS). Following development, the COATS was tested for within and between rater agreement, and diagnostic accuracy, in 82 stroke patients on an acute stroke unit. Agreement was tested, in registered and unregistered nurses, and ranged from fair to very good. The registered nurse showed better agreement than the unregistered nurse. The COATS also demonstrated in this initial testing that it could correctly identify a high proportion of patients either with or without a problem.
This thesis has provided some novel findings that will contribute to the existing knowledge of oral care in a stroke and dependent population. It has provided an overview of the quality of oral assessments available to nurses looking after acutely ill patients as well as highlighting all the potential issues that need to be considered when implementing a new oral assessment into clinical practice.