Assessment of Oral Mucositis in Adult and Pediatric Oncology Patients

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Assessment of Oral Mucositis in Adult and
Pediatric Oncology Patients

• Laura Cullen, MA, RN, FAAN
• Grace Rempel, BS
• Evidence-Based Practice Coordinator
• Nursing Research and Evidence-Based Practice
• Department of Nursing Services and Patient Care
• University of Iowa Hospitals and Clinics
• Iowa City, IA

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Team
Co-Chairs R. Evans, BSN, RN, OCN M.
Farrington, BSN, RN

• Sharon Baumler, MSN, RN, CORLN
• Leslie Brautigam, MNHP, RN
• Deb Bruene, MA, RN
• Laura Cullen, MA, RN, FAAN
• Cindy Dawson, MSN, RN, CORLN
• Kristin Febus, BSN, RN
• Roger Gingrich, MD, PhD
• John Hellstein, DDS

• Sheryl Lang, MA, RN, CPNP, CNA-BC
• Jessica Jones, BSN, RN
• Rachel Lillis, BSN, RN
• Jean Ryan, RD, CSP, LD, CNSD
• Jimmy Reyes, MSN, RN, College of Nursing
• Anne Smith, MSN, RN
• Jane Utech, BSN, RN, OCN
• Brandon Viet, M.A. CCC-SLP

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What is Oral Mucositis?
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Purpose and Rationale

• Purpose-Phase I To implement an evidence-based
  oral assessment for adult and pediatric oncology
  populations (ambulatory inpatient)
• Purpose-Phase II To implement evidence-based
  prevention strategies for oral mucositis for
  adult and pediatric oncology populations
  (ambulatory inpatient)

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Synthesis of Evidence

• 40 of oncology patients develop oral mucositis
  (Brown Wingard, 2004 Dodd, 2004 Fulton,
  Middleton McPail, 2002) resulting from both
  chemotherapy radiation therapy (Avritscher,
  Cooksley Eden, 2006 Brown Wingard, 2004)
• 70-100 of head and neck patients will experience
  oral mucositis (Elting, Cooksley, Chambers
  Garden, 2007 Murphy, 2007)

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Synthesis of Evidence

• Patients report that oral mucositis is the most
  distressing side effect from cancer treatment
  (Jaroneski, 2006)

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Synthesis of Evidence

• Oral mucositis is problematic and results in
  delayed treatments, reduced treatment dosages,
  altered nutrition, dehydration, infections,
  xerostomia, pain and increased healthcare costs
  (Brown Wingard, 2004 Sonis, Elting, Keefe,
  Peterson, Schubert, Hauer-Jensen, Bekele,
  Raber-Durlacher, Donnelly Rubenstein, 2004)

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Phase II Purpose and Rationale

• Purpose-Phase II To implement evidence-based
  prevention strategies for oral mucositis for
  adult and pediatric oncology populations
  (ambulatory inpatient)

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Phase II Prevention and Treatment

• The most frequently identified source of sepsis
  is the mouth, creating unintended risk for
  patients (van der Velden, Blijlevens, Feuth
  Donnelly, 2009)
• Oral mucositis potentially increases the risk of
  a local and/or systemic infection (Eilers, 2004
  Lalla, Sonis Peterson, 2008 Worthington,
  Clarkson, Eden, 2007)
• Clinician knowledge skill EBP oral care is
  limited (Barker, Epstein, Williams, Gorsky,
  Raber-Durlacher, 2005 Binkley, Furr, Carrico,
  McCurren, 2004 Potting, Mank, Blijlevens,
  Donnelly van Achterberg, 2008)
• Nurses knowledge and skill can improve with
  education (Potting, Mank, Blijlevens, Donnelly
  van Achterberg, 2008)

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Phase II Prevention and Treatment

• Effective strategies are available to prevent
  oral mucositis and treat oral mucositis
  (Clarkson, Worthington Eden, 2007 MASCC ONS)
• Cryotherapy for 5-FU, Melphalan, and Edatrexate
  (Keefe, Schubert, et al., 2007 Mori, Yamazaki,
  et al., 2006 Worthington, Clarkson, Bryan, et
  al., 2011)
• Keratinocyte growth factor (palifermin)
  (Worthington, Clarkson, Bryan, et al., 2011)
• Sucralfate is effective in reducing the severity
  (Worthington, Clarkson, Bryan, et al., 2011)
• Oral care/rinses (Brennan, Elting Spijkervet,
  2010 Cheng, Molassiotis, Chang, et al., 2001
  Glenny, Gibson, Auld, et al., 2010 Harris,
  Eiler, harriman, et al., 2009 Hogan, 2009
  Joshi, 2010 Keefe, Schubert, et al., 2007
  Lalla, Sonis Peterson, 2008 Meurman
  Grönroos, 2010 Peterson, Bensadoun Roila, 2008
  Sieracki, Voelz, Johannik, et al., 2009 Sonis,
  2011)

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Cost Information

• Oral mucositis costs 1,700-12,600/patient (or
  higher) depending on the severity (Elting,
  Cooksley, Chambers Garden, 2007 Jones,
  Qazilbash, Shih, et al., 2008 Nonsee, Dandade,
  Markossian, et al., 2008)

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EBP Evaluation

• Staff knowledge
• Staff perceptions
• Nursing documentation of assessment/severity
• Nursing documentation of oral care
• Pediatric patient feedback on oral care kits

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Patient Description

• Groups
• Pre July 2009 to June 2010
• Post July 2010 to June 2011
• Age Range
• Infants to 21 years old

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Diagnosis Types

• Leukemia/Lymphoma
• Solid Tumors
• Marrow Failure

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Types of Transplants

• Matched Unrelated Donor Bone Marrow
• Autologous Peripheral Blood Stem Cells
• Unrelated Umbilical Cord Blood
• Mismatched Unrelated Donor Bone Marrow
• Matched Family Peripheral Blood Stem Cells
• Matched Sibling Bone Marrow

First transplant only
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Oral Mucositis Assessment

• Modified Eilers Oral Assessment Guide
• 8 categories
• Each category is scored 0-2
• Total Score 0-16
• 0Normal
• Documented on admission and then at least twice a
  day

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Data

• Received Excel file with list of all Pediatric
  Bone Marrow Patients
• Received Excel Flow Sheet data
• Imported Excel files into Access
• Narrowed data to transplants done in FY 2010 and
  those done in FY 2011
• Used only patients having first transplant
• Used not more than 2 score values per day per
  patient

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Severity of Oral MucositisPediatric Bone Marrow
Transplant
Confidential Data
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Data

• Clinical Question
• Is there a statistically significant improvement
  in oral mucositis in the post group patients?
• QA regarding the data

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Acknowledge

• Oral care kits
• Pediatrics
• Head neck cancer
• Adult leukemia and BMT
• Nursing Research and EBP Office

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Heres to a healthy mouth

• laura-cullen_at_uiowa.edu