To our knowledge, this is the first concurrent survey conducted across the UK and Australia to identify and compare current practice of oral care post-stroke, as well as the factors associated with providing this care.
A significant number of hospitals in both countries did not have a protocol nor use an assessment tool on their stroke units, despite standardised assessment tools being recommended for people post-stroke (22). Where an assessment tool was used, it was more likely to be a hospital-based tool. Our findings suggest a gradual improvement in the availability of oral care protocols post-stroke in UK hospitals when compared to previous surveys. Protocol availability in hospitals has increased from between 0 and 21% (11, 13) to 52% in the current study.
Almost half of UK and two-thirds of Australian responding hospitals did not report providing oral care training. This finding directly contradicts the National Clinical Guidelines of both countries (6, 7), which recommend that staff should be trained in the assessment and management of oral care. However, the provision of training in the UK has increased from between 0 and 33% of units (11, 13) to 55% in the current study. The availability of staff training in Australia (30%) was similar to a previous survey across Malaysia (28%) (12). Our findings also highlighted that training was mostly provided to junior members of the nursing team such as healthcare assistants who are more likely to undertake oral care post-stroke in UK hospitals. The training available was generally provided by speech and language therapists. Dentists or dental hygienists only provided the training in a small number of hospitals.
The equipment available in hospitals varied considerably in both countries. Consistent with previous surveys (11, 13), basic equipment such as toothbrushes and toothpastes were available in most hospitals, in fact the availability of toothbrushes in UK hospitals has increased from 74% in a previous survey to 96%. The use of available rinses varied between UK and Australian settings; Corsodyl/chlorhexidine was available more in the UK than Australia, while sodium carbonate was available more in Australian settings. These variations may not be clinically important as a randomised controlled trial showed that 0.2% chlorhexidine, saline solution, and sodium bicarbonate all maintained the oral mucous membrane in critically ill patients (23). However, there is limited evidence to guide the choice of best cleaning agents and equipment to use in oral care in stroke, as well as the use of protocols, assessment and training (15).
Despite the lack of high quality evidence on best oral care practices for people with stroke, good clinical practice recommendations are available, underpinned by evidence from small randomised controlled trials (24–26), a scoping review (5) and a Cochrane review (27). However, our findings suggest that these recommendations are only being implemented in some hospitals. In the UK, the guidelines suggest that people with stroke should have oral care three times a day and use a suitable cleaning agent (toothpaste and/or chlorhexidine) to brush teeth and clean gums (6). In Australia, the guidelines suggest that chlorohexidine with oral hygiene instructions, and/or assisted brushing may be used to improve patient outcomes (7). Both guidelines recommend that people with stroke, staff and carers should be educated in oral care.
A further, more recent Cochrane review identified 15 randomised controlled trials that improved oral care for people with stroke (15). These trials ranged from education interventions to complex interventions including (training, oral healthcare protocol, assessment and equipment) (28). Only two trials focussed on specialist training, one for registered nurses (29) and one for informal carers (26) in stroke. Across these trials training improved knowledge of oral care however, the quality of evidence was low. As highlighted in our study, further research could focus on staff training needs, increase protocol availability and the use of standardised assessment tools in practice.
Strengths & limitations
The survey had a good response rate in both countries, which suggests that staff viewed oral care as an important topic and engaged with the study. However, the study used a self-reporting questionnaire which could have led to response and recall bias. Despite the respondents being encouraged to consult other team members, it is unclear to what extent this happened, thus responses may only reflect the respondent’s experience and may not be fully indicative of practice within their hospital.