Before patients begin chemotherapy, nurses introduce them and their parents to the program. The nurses make sure that patients and their parents know that they will enforce the rules: They need to brush their teeth and use a lip balm twice a day and use a mouth rinse three times a day. Johns Hopkins provides patients with all the supplies.
The care team also ensures that patients practice cryotherapy, which uses cold to help prevent mouth sores, during and after chemotherapy. Patients can suck on ice chips, drink icy beverages like slushies and eat cold foods like popsicles.
The oral care bundle is the brainchild of the Children's Hospitals' Solutions for Patient Safety, a collaborative of pediatric hospitals across the U.S. that work together to develop solutions to reduce infections among children. Johns Hopkins All Children's was among the first hospitals to introduce the bundle. Roughly 40 pediatric hospitals have since implemented it.
Compliance with the bundle is tracked in Johns Hopkins' electronic health record. Every time the patient brushes, uses the rinse and applies the lip balm, it's logged by nurses or patient care technicians into the EHR. Cryotherapy usage is also tracked. The patient is considered in compliance with the bundle only if all four steps are completed every day, Del Favero said.
It sometimes falls to parents to play the role of enforcer. In those cases, the care team sends parents reminders to make sure their children comply with the protocols.
The current compliance rate is 60%. The hospital's cancer unit averages about 20 patients per day. Del Favero said compliance can be challenging because so many steps are required to complete the bundle, and sometimes clinicians forget to log each one. Other times it's because the young patients just don't want to brush their teeth or rinse their mouth. Chemotherapy typically leaves patients feeling weak and exhausted. Sometimes clinicians even have to wake up the patients from a nap to brush or rinse.
The program "interrupts the patient flow of being able to rest, so they are not always happy about it," Del Favero said.
Members of the clinical staff have made efforts to motivate the children to brush. Jessi Anderson, a patient technician at Johns Hopkins, sings and makes jokes with the patients. She also will brush her teeth with the children as a form of motivation.
"I try to make it a game for the kids, especially the younger ones," she said.
Anderson said it was easy to integrate the program into her daily workflow because her responsibilities involve supporting patients and families during their stay, including helping patients go to the bathroom and checking their vital signs.
Del Favero said that the bundle has added additional responsibilities for the nurses, but most have eagerly adopted it because of how much it helps patients. The program has led to a 50% reduction in mucosal barrier infections.
"Everyone was excited because our patients don't have to go to the ICU, and if they don't have an infection they can go home 10 days earlier," she said.
When patients are ready to leave the hospital, they are sent home with educational materials about the importance of maintaining their oral hygiene routine. Some children continue the chemotherapy on an outpatient basis so it's important they keep up the routine, Del Favero said.
"This is the easiest thing for them to do when they go home," she said. "Usually they go home with a lot of medication."
