Abstract
In response to overlooked oral health needs among hospitalised children in Alder Hey Children’s Hospital (AHCH), an initiative known as ‘Mini Mouth Care Matters’ (MMCM), was implemented to improve children’s mouthcare by appropriately training healthcare professionals (HCPs) to be confident and knowledgeable in assessing, providing and promoting oral health among hospitalised children. Commissioned by Liverpool City Council, the launch of MMCM in AHCH commenced in February 2024. Previous surveys in the hospital indicated a need for oral care training. Implementation of MMCM involved streaming an e-learning course and videos for HCPs and children on the hospital website, drop-in sessions in the wards, study day training sessions, allocation and training of champions and provision of mouth care packs. Several challenges were encountered during the preparation of the resources and the implementation of the intervention. One key lesson learned is that it is preferable for the manager or team responsible for implementation to come from within the organisation. This allows them to leverage their connections and navigate the hospital’s workload dynamics. Theory-based process and outcomes evaluation is planned to understand the effect of MMCM implementation on its effectiveness and to study MMCM normalisation within routine clinical practice. The evaluation of MMCM will contribute to understanding the impact of oral health interventions in hospital settings and will inform future strategies to improve oral care practices and outcomes for hospitalised children.
Keywords
Impetus for action
Many children in the UK are hospitalised each year because of medical and life limiting conditions (Fraser et al., 2021). Oral hygiene is often overlooked, because the children experience fatigue and weariness (Blevins, 2013). In general, deterioration of oral health is evident among hospitalised patients (Terezakis et al., 2011). This may eventually affect the nutrition of the children and could negatively impact their recovery (Clinton et al., 2023). They may also be prescribed oral nutritional support supplements or medications containing sugar, which may intensify their poor oral condition (Blevins, 2011).
Moreover, medically complex children with severe disabilities or neurological impairment often need frequent and prolonged hospitalisations (Burns et al., 2010). Dental treatment in such patients may necessitate specialised skills, facilities, and equipment. Complex treatments could be mitigated with appropriate oral care and preventive measures. Furthermore, timely identification and referral to a dentist by hospital staff could reduce the need for more extensive dental interventions. Relatedly, ventilator associated pneumonia negatively influences the clinical outcome of hospitalised children and increases the hospital mortality rate (Srinivasan et al., 2009). Improving oral care reduces the risk of acquiring ventilator associated pneumonia in intubated patients (El-Rabbany et al., 2015; Mitchell et al., 2019).
Thus, oral care should be encouraged among inpatients and be provided for those who cannot maintain their oral hygiene because of their medical conditions (Hewson and Wood, 2023; Zhao et al., 2020). Healthcare Professionals (HCPs) have a pivotal role in promoting good oral health among hospitalised children and their families (Blevins, 2013; Hewson and Wood, 2023). However, there is a gap between theory and practise for oral care in paediatric inpatients (Blevins, 2013; Morley and Lotto, 2019). Although oral hygiene is an essential component of personal hygiene and falls within the core responsibilities of nursing and care assistant staff, it is often perceived as a low priority, particularly for hospitalised children (Morley and Lotto, 2019; Spurr et al., 2015).
Liverpool Local Authority recorded the highest dental decay experience (43.5%) in five-year-old-children in the North West (OHID, 2023). Consquently, surveys were conducted in Alder Hey Children’s Hospital (AHCH), one of the largest children’s hospitals in the UK in 2019, 2022 and 2023, to explore hospitalised children’s oral care needs and the level of care provided by HCPs. The 2023 survey included two Mini Mouth Care Matters (MMCM) questionnaires, one directed to HCPs asking about previous mouthcare training, current oral care practice and barriers to support children’s oral care. The second questionnaire was directed to children/parents/carers and enquired about brushing habits and diet.
Responses were collected from 101 HCPs and 94 children/parents/carers. Most HCPs (66%) had never received oral care training. Almost half of HCPs (41%) mentioned lack of training as a barrier to providing oral care and 92% felt they would benefit for further training. Interestingly, 85% of children/parents/carers asserted that none of the HCPs inquired about the children’s oral care. Implementing an oral care policy in the hospital offers an opportunity to promote oral health more widely by developing the personal skills and knowledge of the healthcare staff, many of whom will reside in the local community therefore using the hospital as a health promoting community asset as well as a supportive environment for children’s oral health (WHO, 1986).
Suggested solution
The dental team from AHCH, proposed Mini Mouth Care Matters as a solution. MMCM is an initiative led nationally by Urshla Devalia, a consultant in paediatric dentistry, which aims to empower HCPs to assess, provide and promote oral care for hospitalised children (Schofield et al., 2022). The role of HCPs in supporting oral care involves three major components. • Assessing child mouthcare status on admission. This can be repeated regularly depending on the condition of the child. The assessment can be carried out by lifting the lip to identify any urgent oral or dental problem, documenting mouthcare status and referring child to dental department if necessary (Blevins, 2011). • Promoting the evidence-based oral health messages published by the Office of Health Improvement & Disparities (OHID, 2021). • Providing oral care for dependent children who are unable to maintain their oral hygiene by themselves.
Champions serve as a connection between the wards and the MMCM manager, and support HCPs who need assistance in recording the status of the children. In the future, champions could assume the MMCM manager’s role if funding ceases, as they are volunteers.
Although MMCM has been promoted in many trusts across the UK (Schofield et al., 2022) there is limited evidence whether it improves the level of oral health support or oral care among hospitalised children. A service evaluation conducted in Acorns children’s hospices in the Midlands (Schofield et al., 2022) found that conducting virtual MMCM training increased the mouthcare provided for children, the detection of mouth-related problems and mouthcare assessments. However, detailed evaluation of MMCM implementation and outcomes are lacking. Evidence is available from Mouth Care Matters focussing on the oral care of adult inpatients (Clinton et al., 2023; Pindoria et al., 2023). Therefore, we planned to implement and evaluate MMCM in AHCH to see if there was any improvement from the baseline, and to serve as a roadmap to inform other hospitals planning to implement this initiative. This evaluation will reveal HCP’s perceptions about the MMCH and benefit from their valuable insights to improve the programme.
Actual outcome
The dental team received funding from Liverpool City Council to implement MMCM. The MMCM team in AHCH consisted of a consultant orthodontist, consultant and trainee in paediatric dentistry, dental therapist, paediatric nurse, and associate director of strategy & partnerships. A manager was appointed and contacted the national lead of MMCM to obtain the permission to use MMCM branding on any resources. Preparation involved two tasks: First, training resources were prepared, including an e-learning course and videos for staff demonstrating how to assess oral health, and videos for children illustrating the importance of oral care and diet in maintaining good oral health. Second, mouthcare packs were provided for the wards.
The MMCM team chose a company contracted by the project nationally to adapt the existing e-learning course. To determine the type and content of the videos, two different focus groups were formed: one consisted of the Alder Hey youth forum (children who volunteered to work with the hospital), and the other comprising staff members from various staffing groups. Feedback from both groups helped in the design of videos, and the youth forum suggested two videos, one for oral hygiene and the other for diet. Both groups preferred real life videos filmed in AHCH, featuring children in the hospital performing brushing and staff conducting mouthcare assessments. These activities were conducted as part of stakeholder engagement. Both e-learning course and videos were reviewed by MMCM team, the national lead of MMCM, and another external expert in paediatric dentistry to ensure adherence of the information to national guidelines.
The team selected three mouthcare packs suitable for different ages and secured a central storage space to keep track of the expendable and remaining packs. A baby pack included a baby toothbrush and a 100 ml tube of paraben-free fluoride toothpaste with a concentration of 1000 ppm. A junior pack consisted of junior toothbrush, a 100 ml tube of fluoride toothpaste containing 1450 ppm, and a toy timer. A special junior pack was tailored for children with sensory issues and difficulty with using flavoured toothpaste, and it included a triplex toothbrush and 50 ml of unflavoured fluoride toothpaste with 1450 ppm.
Summary of MMCM activities performed in AHCH.
Challenges
The launch of MMCM was delayed several times due to challenges encountered during preparation. These challenges included communication difficulties with the external company producing the e-learning packages and videos. Securing an appropriate central storage space for the packs was an unanticipated obstacle. A challenge during implementation, was ensuring that there were sufficient champions volunteering across all wards to support HCPs. The MMCM manager contacted the practice educators to identify people interested in becoming champions. However, the main challenge for these champions is to be given enough time to support HCPs assessing mouthcare. Sometimes, these champions transfer to other areas to support the staff with other tasks, especially when there is a high workload. HCPs have many duties, and mouthcare assessment is not one of those things, which may reflect that mouthcare assessment is not seen as a priority. There is a plan to make mouthcare assessment mandatory included in the electronic patient record. New challenges may surface during evaluation, such as balancing generalisable evidence against a context specific evaluation to capture the longitudinal effects of initiative.
Learning points and recommendation
One key lesson learned from the implementation of MMCM at AHCH is that the manager or team responsible for implementation must work closely with HCPs on the wards. The manager was often asked to deliver training sessions at short notice, with these sessions varying from 15 to 30 minutes, depending on the schedule and availability. For effective implementation, it is preferrable that the manager or team come from within the organisation so that they can use their connections and navigate the hospital’s workload dynamics. For example, MMCM managers and teams use their connection with certain staff members to help them contact other staff who help prepare face-to-face sessions and record them for later use. Additionally, wards with children with neurological impairments needed more suction toothbrushes because of their swallowing difficulties. Understanding these specific needs enabled managers to allocate resources efficiently. Organizational insight and flexibility were crucial to adapt the intervention to the unique needs of each ward. An additional learning point was readiness to overcome this variety of challenges across the program. The value of the team, process, and stakeholder engagement should not be underestimated when keeping track of work inside the organisation.
Future implication
The evaluation will begin with series of workshops to involve key stakeholders, especially HCPs in developing a theory of change (ToC). The ToC will illustrate the steps that link the intervention resources and activities to its long-term goal providing a robust evaluation framework. By depicting the pathway for change, ToC will identify indicators of success, which will support effective tracking of the progress. Involving HCPs in creating the ToC helps clarify which outcomes should be monitored in the short, intermediate, and long term. This participatory approach will refine the intervention and enhance its sustainability by fostering a sense of ownership among HCPs. Insights gathered from ToC workshops will be used to formulate a logic model which is a simplified sequence of steps that the intervention should follow to achieve its desired outcomes. The logic model will be developed alongside the ToC to detail the specific data needed at each step to evaluate the intervention.
Mixed method evaluation will combine quantitative and qualitative data to examine the assumptions and expected outcomes established during ToC workshops and in the logic model. Data will be collected through audits, surveys and semi-structured interviews to investigate MMCM implementation process, outcomes and HCP’s perceptions of the intervention. This approach will also investigate how MMCM modifies the practices and normalises oral care i.e. whether MMCM policy becomes an integral part of routine duties of HCPs. Since both the ToC and the logic model are dynamic documents, the evaluation findings will be used to refine these frameworks, so they can be effectively tailored and applied to similar settings in the future.
Identifying key factors influencing normalisation of MMCM policy will yield a roadmap to inform other hospitals planning to implement this initiative (Murray et al., 2010). The knowledge from this study will support oral health policies within hospitals. If hospitals normalise this oral health policy, it could play a role in improving the oral health of a particularly vulnerable group of children, thereby contributing towards a reducing oral health inequality. Continued exploration into the effects of this preventive intervention on oral health inequalities is essential.
Footnotes
Acknowledgement
The authors would like to express their gratitude to Laura Shuter, dental therapist and MMCM manager for providing the latest updates regarding the implementation, and Doctor Urshla Devalia for supplying the Mini Mouth Care Matters questionnaires used in the baseline surveys.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study formed part of doctoral research project at the University of Liverpool. The Higher Committee of Education Development in Iraq is the sponsor of the PhD study from which this research originates.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.