Oral Mucositis At AUBMC

Oral Mucositis At Oral Mucositis At AUBMCAUBMC

Nada Nassar, RN, BSN, MSN, Nursing Quality Improvement

Program

Zeina Kassem, BSN, RN

November 2008

OutlineOutlineI. Oral mucositis: definition and descriptionII. Incidence, prevalence III. Risk factorsIV. ManagementV. Patient educationVI. ImplicationsVII. Oral Mucositis Project at AUBMCVIII. EvaluationIX. Future projects

ObjectivesObjectives

By the end of the session the audience will be able to:

Acknowledge what is oral mucositis and its impact on patient’s condition and quality of life

Identify risk factors for oral mucositis Identify different stages of oral mucositis Acknowledge the new AUBMC Oral

Mucositis Assessment Tool Perform complete physical assessment Identify strategies to prevent oral

mucositis and to manage oral mucositis if present

Definition of Oral MucositisDefinition of Oral Mucositis

Mucositis is an inflammatory and potentially ulcerative process that affects the mucous membranes of the oral cavity and gastrointestinal tract of individuals receiving chemotherapy and radiation therapy as treatments for cancer.

Definition Oral MucositisDefinition Oral Mucositis

Oral Mucositis can lead to serious clinical complications including hemorrhage, pain, taste changes, erythema, swelling, infection and impaired nutritional status.

It significantly affects the patient’s quality of life, jeopardizes treatment outcomes, prolongs patient’s length of stay, increases morbidity and increases the financial burden on patients.

Historically, literature used the terms mucositis and stomatitis in combination (i.e., mucositis/ stomatitis) are almost interchangeably.


Individuals with mucositis use the terms pain, bleeding, taste changes, and dry mouth to report the symptoms that they experience and have reported mucositis to be the most distressing symptom of high-dose therapy

Definition Oral Mucositis

Mucositis remains a major dose-limiting side effect of cancer therapy.

This dose-limiting effect is related to the risk of life-threatening infections secondary to breakdown in the mucosal lining that normally provides the first line of defence against microbial invasion by the organisms in the oral cavity.


Incidence and Prevalence

Oral mucositis occurs in 40% of cancer patients receiving cytotoxic chemotherapy.

Studies report that 70 to 80% of patients undergoing bone marrow transplantation suffer from oral mucositis during treatment. One million episodes of oral mucositis occur annually in America.

Risk FactorsRisk Factors

Age ( young children and elderly) Gender ( women are at greater

risk for severe mucositis) Oral health and oral hygiene Reduced salivary function High expression of cytokines Altered drug metabolisms

Smoking Alcohol Specific chemotherapeutic

agents( ex: Bleomycin, Cytarabine, Doxorubicin, 5 FU)

Bone marrow transplantation Radiotherapy

Risk FactorsRisk Factors

ManagementManagement

Assessment—use of standardized assessment tool

Collaborative management Oral care protocol, including patient education Pre treatment dental evaluation, repair, and

prevention Nutrition and fluid management Prevention of mucositis with 5-fluorouracil—use of

30 minutes of cryotherapy Treatment—symptom-focused interventions


AssessmentThe oral cavity should be assessed

regularly using valid and reliable instruments to document “normal pattern” of changes seen with cancer treatment regimens.

Implement an oral care protocol using a. Non-irritating agents

i. Normal saline with or without baking soda ii. Sterile water iii. Avoid mouth washes with alcohol.

b. Soft-bristle toothbrush

i. Continue as long as tolerated if no uncontrolled bleeding present

ii. Changed frequently especially when patient is neutropenic (at least every week during aplasia)


c. Floss

If a regular part of patient’s oral care, continue as long as tolerated if no uncontrolled bleeding present.

d. Use foam toothettes for cleansing of soft tissues and for teeth when tooth brush is not tolerated.



Use a multidisciplinary team approach to oral care to include the integration of dental health professionals as indicated by the status of a patient’s oral cavity.

a. Clean and repair teeth prior to initiation of immunosuppressive therapy.

b. Treat potential problems prior to initiation of immunosuppressive therapy

Patient EducationPatient Education

Patients and family care providers should learn about

a. The importance of oral care during cancer treatment to decrease morbidity and mortality

b. Systematic care of oral cavity—promote health and avoid trauma

c. Assessment of the oral cavity (i.e., at least daily during therapy)

d. Signs and symptoms to report (i.e., changes in sensation or taste, presence of ulcerations and/or bleeding)

Patient EducationPatient Education

ImplicationsImplications

The first crucial step in treating oral mucositis is performing a thorough assessment of patient’s oral cavity.

The nursing daily physical assessment form at AUB MC includes a part related to integumentary system which does not clearly specify proper assessment of oral cavity; thus nurses are not properly assessing oral mucositis based on an evidence based assessment tool.

ImplicationsImplications

Oral Mucositis Project at Oral Mucositis Project at AUBMCAUBMC

The purpose of the project done at AUBMC is to adopt or create a tool for assessing oral mucositis that is well defined, evidence based, reliable, and culturally sensitive.


Organizing the Team:

A team was formed from nurses working on oncology units:

Seven registered nurses 1 clinical educator 1 advanced practice nurse

Assessment of oncology patient’s medical records was done at the American University of Beirut Medical Center (AUBMC) that revealed 39.74% of patients receiving chemotherapy developed oral mucositis. This result is similar to those results reported by the literature and thus oral mucositis is an important issue that needs to be surveyed by oncology nurses at AUB MC.


This raises an alarm to the magnitude of the problem and the importance of exploring it profoundly in an attempt to promote patient outcomes.


Briefing: A prospective and retrospective

review of patient medical records for the presence of mucositis was conducted at AUB MC on the oncology units (3 units) during the period from November 2007 to January 2008 (3 months).


Method: A form for data collection was developed to

assess the evidence of mucositis, age, gender, admitting diagnosis, and initiation of mucositis treatment.

Retrospective review: patient medical records were assessed for the documentation of the evidence of oral mucositis in the progress notes (doctors and nurses) and medical orders (for initiation of therapy).


Method:

Prospective review: patient’s charts on the units were surveyed for the presence of assessment and documentation of oral mucositis.


Results:

The retrospective study (N=50) revealed a prevalence of 18% of oral mucositis while in the prospective study (N=28) revealed 78.57% prevalence. This may be explained as a result of the awareness about oral mucositis the importance of its assessment that was discussed by the team members collecting data with the nurses.


Results

The combined data showed a prevalence of 39.74% of oral mucositis where 40% only received treatment. Despite its large magnitude, this result is similar to what is reported by the literature (Debra & Knobf, 2004).


Variables Age GenderEvidence of Mucositis

Treatment for Mucositis

Retrospective Data 20-50 > 50 Male Female Yes No Yes No

N. ( Sample = 50) 14 36 21 29 9 41 9 41

Percentage 28% 72% 42% 58% 18% 82% 18% 82%



Prospective Data 20-50 > 50 Male Female Yes No Yes No

N. ( Sample = 28) 12 16 13 15 22 6 22 6

Percentage 42.80% 57.14% 46.42% 53.57% 78.57% 21.42% 78.57% 21.42%




Combined Data 20-50 > 50 Male Female Yes No Yes No

N. ( Sample = 78) 26 52 34 44 31 47 31 47

Percentage 33.33% 66.67% 43.58% 56.41% 39.74% 60.25% 40.00% 60.00%


Results: Despite the small sample of this

assessment exercise, the need to properly assess oral mucositis in oncology patients is identified as a need for AUB MC nurses. As a result of this needs assessment, a proposal of an oral mucositis assessment tool was initiated by the team members.


Literature review Literature review exploring the

published assessment tools is conducted utilizing CINAHL, PubMed, Cochrane…

The tools were assessed for reliability, validity, clinical usefulness, level of evidence, and other reviews available.


Oral Mucositis Assessment toolsOral Mucositis Assessment tools

There are several assessment tools available in the literature for performing assessment of oral mucositis (Elier, 2005).

Oral Assessment Guide. Oral Mucosa Rating Scale. Oral Mucositis Index (uses subset of

Mucosa Rating Scale). Oral Mucositis Assessment Scale. Spijkervet Radiation Mucositis Scale.




Western Consortium for Cancer Nursing Research Scale.World Health Organization (WHO).National Cancer Institute Common Toxicity Criteria (NCICTC) scale.

Several studies conducted favor the utilization of WHO, Oral Assessment Guide and National Cancer Institute Common Toxicity Criteria (NCICTC) assessment tools due to their practicality (Raber et al, 2000).


The WHO tool assesses the oral mucositis for erythema, ulceration, and diet tolerance without clearly identifying the severity of pain.

The Oral Assessment Guide assesses erythema and functioning of the oral cavity without identifying the other aspects such as diet tolerance and pain.

National Cancer Institute Common Toxicity Criteria (NCICTC) assesses ulceration erythema and pain but is not very clear and comprehensive.


Creating Our Own ToolCreating Our Own Tool

After studying the above mentioned tools, the team members opted to create an assessment tool to include all the needed criteria included in the 3 tools.


Approvals

Approval from the administration was secured.

Two oncologists were consulted and they validated the usage of this tool to enhance multidiscplinary involvement.


Pilot Phase

The Piloting process: Unit Process Timeline

9North Training of RNs 2 weeks

Implementation 2 months (Nov, Dec 2008)

Evaluation Ongoing with the implementation

BMT Training of RNs 1 week

Implementation 2 months (Nov, Dec 2008)

Evaluation Ongoing with the implementation

Team members

Overall Evaluation All through


Training PhaseTraining Phase

The training of RNs included:

Stages of oral mucositis Timing and duration of assessment Assessment sequence Equipment needed Sites to be evaluated How to perform the physical

examination



Training PhaseTraining Phase

How to document findings How to link the findings from the Oral

Mucositis Assessment Tool to the Nursing Care Plan, Multidisciplinary Notes and the intershift report.

Pocket guide oral mucositis assessment tool was developed for all oncology nurses

ImplementationImplementation PhasePhase

The Oral Mucositis Assessment Tool will be launched on all oncology units after the completion of the pilot and evaluation by the team members.


EvaluationEvaluation

The continuous evaluation that is being conducted till now (15 days) is very promising and showing high rates of compliance on behalf of nurses.

Expected Patient Expected Patient OutcomesOutcomes

Optimized practice patterns, use of the best evidence based nursing interventions for oral mucositis that will improve the quality of life of cancer patients receiving chemotherapy and radiotherapy.

Future ProjectsFuture Projects

The project is considered to be a research study and is presented to the nursing research council in AUBMC.

ReferencesReferences Auritcher et al (2004). Scope and Epidemiology

of Cancer Therapy –Induced Oral and Gastrointestinal Mucositis. Seminars in Oncology Nursing, 20, 3-10.

Debra, J. and Knobf, M. (2004).Assessing and Managing Chemotherapy-Induced Mucositis Pain. Clinical Journal of Oncology Nursing, 8,662-628.

Duncan, M. and Grant, G.(2003). Review Article: Oral and Intestinal Mucositis –Causes and Possible Treatments. Aliment Pharmacotherapy, 18,853-874.

Elier, J. (2005). Measuring Oncology Sensitive Patient Outcomes: Evidenced Based Summary.

Oncology Nursing Society (2007). Mucositis. What Interventions are Effective for Managing Oral Mucositis in People Receiving Treatment for Cancer?

Raber, J. et al. (2000).Oral Mucositis in Patients Treated with Chemotherapy for Solid Tumors: A Retrospective Analysis of 150 Cases. Supportive Care in Cancer, 8,366-371.

Rubenestein, E. et al, (2004). Clinical practice Guidelines for the Prevention and Treatment of Cancer Therapy –Induced Oral and Gastrointestinal Mucositis. Cancer 100, 2025-2026.

Sonis, ST. et al. (2004). Perspective on Cancer Therapy Induced mucosal injury: Pathogenesis, Measurement Epidemiology, and Consequences for patients. Cancer 100, 1995-2025.

ReferencesReferences

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Oral Mucositis At AUBMC