Evidence-Based Implementation of oral care procedures for patients with Non-Invasive Mechanical Ventilation

Evidence-Based Implementation of oral care procedures for patients with Non-Invasive Mechanical Ventilation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evidence-Based Implementation of oral care procedures for patients with Non-Invasive Mechanical Ventilation Minggui Chen, Lin Wei, Hanhua Guo, Yumei Zhong, Lixia Huang, Zhuo Cao, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8183510/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Oral care for ICU patients is critical, yet current practices predominantly target those on invasive ventilation, neglecting individuals receiving Non-Invasive Mechanical Ventilation (NIMV). This study aimed to develop and implement an evidence-based protocol for oral care assessment in NIMV patients to enhance clinical outcomes. Methods A mixed-methods approach was employed, including a literature review, critical appraisal, and evidence-based practice changes. Outcomes measured included nursing staff knowledge, patient plaque index, oral odor, oral dryness, and hospitalization costs. Data were collected from 60 nurses and 60 patients (30 pre-intervention, 30 post-intervention). Results Eleven articles informed the evidence synthesis. Post-implementation, nurses , knowledge scores significantly improved (51.32 vs. 66.42/100, p < 0.001).The plaque index decreased notably in the intervention group by day 5 (1.90 vs. 2.27, p = 0.020). Oral odor scores differed significantly at day 3 ( p = 0.031) and day 5 ( p < 0.001). Oral dryness incidence declined from 46.7% to 16.7% ( p = 0.012). Hospitalization costs were reduced (¥45,774 vs. ¥66,798, p = 0.011). Conclusion Implementing evidence-based oral care protocols for NIMV patients improved nursing knowledge and patient outcomes while reducing healthcare costs. These findings support standardized oral care integration in ICU settings. Non-invasive mechanical ventilation Oral care Evidence-based practice Intensive care unit Nursing education Figures Figure 1 Figure 2 Figure 3 Introduction Critically ill patients, particularly those on Non-Invasive Mechanical Ventilation (NIMV), face heightened risks of oral dysbiosis due to impaired mucosal protection, antibiotic use, and reduced self-cleaning mechanisms[ 1 , 2 ]. Oral care has been recommended to improve the oral environment of critically ill patients[ 3 ]. Effective oral care assessment can be followed by better oral care for the patient and achieve the goal of improving the patient's oral environment, reducing the risk of VAP, increasing patient comfort and improving oral dryness. However, most domestic and international guidelines or standards focus on the clinical practice of oral care for adults and have been studied in oncology, cancer or elderly patients, with few guidelines and studies on the assessment and clinical practice of oral care for patients on NIMV[ 2 , 4 , 5 ]. This makes it difficult for ICU nurses to systematically and comprehensively assess patients' oral conditions and form individualized oral care plans when performing oral care for patients on NIMV. Due to the lack of assessment criteria, low knowledge base and lack of professional training, most nurses use outdated oral care assessment procedures in practice. It is evident that the knowledge, attitude and behavioral compliance of nurses to conduct systematic assessments prior to performing oral care for patients on NIMV need to be improved. In the long term, if nurses are unable to effectively assess their oral cavity and propose and implement individualized intervention plans, not only will they fail to allow effective clearance of flora from the oral cavity of patients on NIMV and shorten their stay in the ICU, they will also increase the incidence of adverse events, the risk of infectious diseases and the burden of healthcare expenditure. Therefore, it is urgent to develop standards for the assessment and clinical practice of oral care of patients undergoing NIMV. In order to standardize oral care procedures in patients on NIMV, this study proposes to use an evidence-based approach to identify the best clinical evidence for the assessment of oral care in patients on NIMV and apply it in the clinical setting. The application of the evidence will raise nurses' awareness of the need for oral care in patients on NIMV, improve the cleanliness of patients' mouths, reduce the incidence of mouth dryness and other aims, and provide a reference for the standardization of oral care in patients on NIMV in critical illness. Methods Study Design and Ethics This quasi-experimental study compared pre- and post-intervention outcomes in a single ICU. Ethical approval was obtained from the Guangdong Provincial Hospital of Chinese Medicine Ethics Committee (ZE2022-247-01). Informed consent was secured from all participants or guardians. Evidence Synthesis Between March 2022 and July 2022, we systematically reviewed various databases, including the Joanna Briggs Institute Library, UpToDate, Embase, Elsevier, Web of Knowledge, Ovid, China National Knowledge Infrastructure, and the Chinese Wanfang database. A Web-based review of relevant guideline websites and professional websites, including the National Institute for Health and Care Excellence(NICE), the National Guideline Clearinghouse (NGC) and the Registered Nurses’ Association of Ontario (RNAO), were also conducted. The key terms used in this project included “NIMV / non positive pressure ventilation / NPPV / non invasive positive pressure ventilation / NIPPV / noninvasive ventilation / non-invasive ventilation / continuous positive airway pressure / CPAP ventilation / Biphasic continuous positive airway pressure / bilevel continuous positive airway pressure” AND “oral hygiene / oral care / oral decontamination / oral nursing / oral care assessment / oral evaluation”. The search period is from the inception of the database to March 2023.The search yielded 430 peer-reviewed articles, of which 11 were relevant. These included 1 JBI evidence summary[6], 1 guideline[7],1 class trial[8], 1 expert consensus[1], 2 evidence-based[9, 10], 1 systematic review[11], and 1 cross-sectional study[12]; of these, the evidence summaries went back to the original article, yielding 2 Observational Studys [5, 13] and 1 class trial[14]. The details are shown in Table 1.The JBI evidence hierarchy [15,16] and AGREE II [17] frameworks guided critical appraisal. Intervention 1. The evidence-based protocol included: 1.1 {Collins, 2021 #2}Subject of assessment Patients receiving treatment in the intensive care unit should have their oral mucosa closely and systematically assessed. (Level 4b)[6, 12] 1.2 Timing of assessment Patients on NIMV should have an oral assessment completed within 6 hours of admission. The standardised oral care assessment tool encourages assessment every 12 hours. (Level 5b)[1] 1.3 Assessment tools 1.3.1 All nurses should have standardised training and assessment of the assessment tool to ensure familiarity with it; (Level 5b)[1] 1.3.2 All critically ill patients are assessed using the standardised oral care assessment tool and the results should be documented; (Level 5b)[6, 7] 1.3.3 The assessment tool for mechanically ventilated patients also applies to non-invasive mechanically ventilated patients; (Level 5b)[9]. 1.3.4 The dynamic development of oral care interventions using the modified Beck oral score can reduce the occurrence of odour, reduce bacterial colonisation of the oropharynx and improve oral health; (Level 1c)[8] 1.3.5 The use of the Modified Beck Scale allows for standardised oral assessment and guides nurses in the delivery of oral interventions. (Level 2d)[14, 18] 1.4 Implementation assessment The frequency of oral care is determined by the Beck Oral Score. (Level 2d) [14] The patient's level of consciousness, ability to follow instructions, posture and lung stability should be observed when administering oral care, and the patient should be stable enough to tolerate the switch to alternative oxygen therapy equipment for the limited time required to administer oral care activities. (Level 4b)[13] 1.5 Quality control Daily supervision by the manager of the correctness of the oral assessment of the charge nurse. (Level 1c)[8] Oral assessments should often be performed as part of a systematic patient assessment and should be used to identify those patients who are at increased risk of oral complications.(Level 5b)[1, 10]. Indicators such as risk of pneumonia, incidence of oral odour and dental plaque index can be used as indicators to evaluate the effectiveness of oral care interventions. (Level 1a) [9, 11]. 2. Integrating Evidence Before applying the evidence, we formed a project team led by a nurse researcher, directed by the Head Nurse, and supported by the Hospital Nursing Director. The process of integrating evidence into practice involved five steps: assessing barriers and supports, identifying current deficiencies from best evidence, developing the NIMV oral care assessment procedure, designing and completing training courses, and adopting and monitoring the innovations. Step 1. Assess barriers and supports Prior to the application of the evidence, a scenario analysis was conducted to identify possible barriers and facilitators to driving the implementation of best practice. Based on the theory of the analysis of barriers in the assessment phase of the Ottawa Research Application Model,[19] our team assessed 3 aspects of evidence, adopters of evidence and the context of implementation and obtained the following barriers: (a)There is no clinical tool for the assessment of oral care in NIMV;(b)Lack of standardised quality checklists for dental care assessment in clinical practice;(c)The nurse is not trained in oral care assessment and is not familiar with oral assessment tools; There are no standardised guidelines to guide nurses in conducting oral care assessments. Step 2. Identify current deficiencies from best evidence and developing the Non-invasive oral care assessment procedure Based on the assessment of evidence from the literature and our existing processes, supports or barriers were identified and analyzed, and strategies of maximum resources utilization and evidence based implementation were developed. For example, we require bedside nurses to assess the oral care of patients on NIMV within 6 hours of admission. The modified Beck Assessment Scale is recommended as the oral care assessment tool and the corresponding oral care measures are given in response to the assessment results. [1, 14]The nurse should be aware of the patient's level of consciousness and ability to follow instructions when administering oral care. Patients should be stable enough to tolerate switching to alternative oxygen therapy equipment, such as high-flow oxygen, for the limited time required to perform oral care activities. Finally, managers are able to do a good job of daily supervision and nurses know the indicators related to the effectiveness of oral care assessment. Step 3. Design and complete the Non-invasive oral care assessment training courses The preliminary investigation conducted before the evidence-based changes were implemented revealed that nurses' awareness of oral care assessment of patients on NIMV is low. Therefore, we organised and trained the study of the oral scale to enable nurses to understand the feasibility and necessity of the modified Beck scale in standardising the oral care assessment of patients on NIMV and to strengthen nurses' awareness of oral care assessment. To enable nurses to learn the assessment better, we have converted the modified Beck Scale into colour charts and made an instructional video of the assessment for nurses to learn. As a result, full preparation for the transition to the new, evidence-based the NIMV oral care assessment practice was provided. Step 4. Adopt and monitor the innovations Elements of the oral care assessment for NIMV were implemented in clinical practice after obtaining permission from the hospital's institutional ethical review board. We have developed an oral assessment process for patients on NIMV to provide nurses with standardised process guidelines, thereby improving clinical efficiency. In conjunction with the Information Department, the oral care assessment scale was implanted into the ICU electronic system to achieve dynamic assessment. The nursing team leader conducts daily quality checks on the oral care assessment of patients on NIMV to strengthen the assessment awareness of the responsible nurses and effectively improve the nurses' execution. Clinical improvement of the patient's dry oral environment by using a small portable spray bottle to facilitate nurses to moisten the mouth and lips of patients on NIMV to ensure effective implementation of evidence. The use of plaque amplifiers - "plaque revealers" - to facilitate plaque observation by nurses, effectively ensuring the standardisation and implementation of oral care. Step 5. Summarize and reflect After the completion of the clinical implementation, the managers and all clinical nurses met for a discussion and summary to determine areas for further improvement. Results The data for 30 patients who underwent NIMV in the Department of Intensive Care Medicine was collected from August 5, 2022 to October 15, 2022 before the evidence-based practices were implemented. The period from October 20, 2022 to December 12, 2022 was the implementation phase for evidence-based Oral Care Assessment procedures. The data with 30 patients on NIMV were recorded and then compared with those before the implementation of the evidence-based protocol. There was no significant difference between the two groups about baseline characteristics, including sex, age, Hypertension, History of diabetes, History of the smoker, History of drinking, LVEF, APACHE-II, WBC and Oral Odour, as shown in Table 2. With the provision of education, the average knowledge score of 60 nursing staff increased from 51.32 to 66.42 out of a total score of 100 on the Oral care assessment knowledge test for patients on NIMV designed by the team. As part of the education program, all ICU nurses were trained about Knowledge of oral care assessment for patients on NIMV. The quality of oral care in NIMV was compared by plaque index, oral odour and oral dryness. The plaque index is scored according to Turesky's modified Q-H plaque index assessment method[ 20 ]. Oral odour is rated using the visual analogue scale (VAS), with a score of 0 indicating no odour, 1 to 3 indicating mild odour, 4 to 6 indicating moderate odour, 7 to 9 indicating severe odour and 10 indicating strong odour[ 21 ]. Dry mouth is a reference to the grading scale for dry mouth disease proposed by Wang Zhonghe: Grade 0 indicates no oral dryness, Grade 1 indicates mild oral dryness; Grade 2 indicates mild oral dryness; Grade 3 indicates moderate oral dryness; and Grade 4 indicates severe oral dryness[ 22 ]. The implementation of this evidence-based intervention improved the quality of oral care for patients on NIMV as shown in Table 3. Although there is a statistical difference in the decreasing trend of plaque index between the two groups.However, there was a considerable reduction of plaque index in Postapplication of evidence group [1.90 (95%CI, 1.75–2.05) vs. 2.27(95%CI,1.99–2.54), respectively,p = 0.020] at the 5th day(Fig. 1 ).The result display that there was no significant difference in Odor fraction between the two groups on the baseline[7.10(95%CI,6.63–7,57] vs.6.55(95%CI,5.95–7.17,p = 0.162].However,the difference between the two groups was statistically significant at the 3rd day [5.47 (95% CI, 4.97–5.94] vs. 4.59 (95% CI, 4.00–5.21, p = 0.031] and the 5th day [2.97 (95% CI, 2.57–3.40] vs. 4.26 (95% CI, 3.79–4.72,p = 0.000] (Fig. 2 ). The proportion of patients experiencing mild or no dry mouth increased from 53.3% before evidence of response to 83.3% (p = 0.012). In Table 4,compared with the Preapplication of evidence group, there was an effective reduction in the hospitalization expenses[45774(95%CI,35594–56041) vs.66798(95%CI,56099– 77767), respectively, p = 0.011](Fig. 3 ). Discussion Implementing evidence-based practice presents a challenge in the form of normalizing this evidence. Beyond training, a potent method for consistently reinforcing practice is to embed it within the daily routines of nursing. In our study, we integrated a modified version of the BECK oral assessment scale as a tool for evaluating oral care in patients undergoing NIMV. This tool was incorporated into the department's critical care system, followed by comprehensive training sessions. We also incorporated NIMV oral care assessment tasks into the operational protocols. By altering operational procedures, we can influence the behavior of nurses, ultimately empowering them to embrace and apply evidence in their daily tasks, thereby facilitating the normalization of new evidence-based practices. Ongoing and enhanced monitoring of evidence-based implementation measures is a key factor in normalising best evidence[ 23 ]. The primary role of monitoring is to ensure the effective implementation of clinical evidence-based measures and to normalise clinical change. In addition, ongoing monitoring can indicate whether current measures need to be modified or whether new measures need to be added. The nursing team leader monitored the implementation of evidence-based innovations in the project using the NIMV Oral Care Assessment Checklist. The frequency of patient oral moistening by nurses using a portable spray can effectively implemented best evidence in the clinic. During the project's group discussions on evidence implementation, nurse researchers and clinical nurses identified a number of barriers to adherence to evidence-based NIMV oral care assessment procedures, such as the fact that the evidence required them to use assessment scales, but clinically they used the criteria inconsistently. The key to overcoming this barrier and reducing these inconsistencies is to enable the knowledge gained to be effectively applied in clinical practice. Evidence tells clinical nurses what to do, but specific procedures still need to be further refined and developed by researchers and practitioners for specific clinical scenarios, including details about assessment timing, frequency, methods, documentation and feedback. It is important that the evolution from experience-based to evidence-based practice and the use of scientific evidence to guide our practice ensures the safety of our patients and improves the quality of our care. The functional roles played by researchers, care managers and clinical nurses must be fully utilised in the implementation of best practice. Effective strategies that are consistent with the clinical setting are fully applied and efforts are made to apply the evidence on a daily basis to ensure effective implementation. Dissemination The outcomes of the implementation project were presented at a hospital nursing competition. Plans are in place to promote this EBP project at local hospital Nursing Grand Rounds and evidence-based nursing committees. Finally, the organisers of the project are considering presenting this EBP project at an academic conference next year. Declarations Ethics approval and consent to participate This trial was conducted in accordance with the ethical principles set forth in the Declaration of Helsinki, referenced directives, regulations, and guidelines.The Guangdong Provincial Hospital of Chinese Medicine’s Human Research Ethics Committee approved this study(ZE2022-247-01).Written informed consent was obtained from each patient or their parents or guardians.The Clinical trial number is ITMCTR2025001956. Consent for publication A written consent for publication was obtained from each patient or their parents or guardians. Availability of data and materials The datasets analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that there are no competing interests. Funding This work was funded by The scientific and technological research of traditional Chinese medicine, Guangdong Provincial Hospital of Chinese Medicine (No.YN2016HL03,YN2020HL03,YN2020HL14,YN2022HL06,YN2023HL04,YN2023HL13).Research Projects of Guangdong Nurses Association (gdshsxh2023ms57, gdshsxh2023ms60, gdnurse2024xz01). Authors' contributions All authors contributed to data collection, and reviewed and approved the final manuscript. Xiaoxuan Zhang is the guarantor of the paper, taking responsibility for the integrity of the work, from inception to published article. Ming-Gui Chen wrote the main manuscript text.Haizhen Chen, Nan Mu, Yuqing Li collected the cases. Hanhua Guo,Yumei Zhong,Lixia Huang ,and Zhuo Cao carried out data collection and revision of the manuscript. Lin Wei carried out study design and revision of the manuscript. References Collins T, Plowright C, Gibson V, Stayt L, Clarke S, Caisley J, Watkins CH. British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units. Nurs Crit Care. 2020;26(4):224–33. https://www.ncbi.nlm.nih.gov/pubmed/33124119 . Tang X, Shen Y, Pan X, Liao J, Xu Y, Luo W, Zhang X, Li Ce, Wan Q, Cai X, Zhang X, Wang T, Zhang G. Oral care for intensive care unit patients without mechanical ventilation: protocol for a systematic review and meta-analysis. Syst Reviews 2022, 11(1). Zhao T, Wu X, Zhang Q, Li C, Worthington HV, Hua F. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2020;12(12):CD008367. .https://www.ncbi.nlm.nih.gov/pubmed/33368159 . Hong CHL, Gueiros LA, Fulton JS, Cheng KKF, Kandwal A, Galiti D, Fall-Dickson JM, Johansen J, Ameringer S, Kataoka T, Weikel D, Eilers J, Ranna V, Vaddi A, Lalla RV, Bossi P, Elad S, Mucositis Study Group of the Multinational. Association of Supportive Care in Cancer/International Society for Oral O: Systematic review of basic oral care for the management of oral mucositis in cancer patients and clinical practice guidelines. Support Care Cancer. 2019;27(10):3949–67. https://www.ncbi.nlm.nih.gov/pubmed/31286232 . Ganz FD, Ofra R, Khalaila R, Levy H, Arad D, Kolpak O, Ben Nun M, Drori Y, Benbenishty J. Translation of oral care practice guidelines into clinical practice by intensive care unit nurses. J Nurs Scholarsh. 2013;45(4):355–62. https://www.ncbi.nlm.nih.gov/pubmed/23731065 . BSStat FCV. ORAL HYGIENE CARE: CRITICALLY ILL. JBI EVIDENCE SUMMARY 2021:1–3. NICE: Oral health for adults in care homes. 2016:1–37. Lijie P, Suqin Y, Yongxiu L, Liping S. Comprehensive oral care intervention with modified Beck oral score in ICU patients with mechanical ventilation. J Nurs Adm. 2019;19:906–10. Johnny JD, Drury Z, Ly T, Scholine J. Oral Care in Critically Ill Patients Requiring Noninvasive Ventilation: An Evidence-Based Review. Crit Care Nurse. 2021;41(4):66–70. https://www.ncbi.nlm.nih.gov/pubmed/34333612 . Emery KP, Guido-Sanz F. Oral care practices in non-mechanically ventilated intensive care unit patients: An integrative review. J Clin Nurs. 2019;28(13–14):2462–71. https://www.ncbi.nlm.nih.gov/pubmed/30793402 . Kaneoka A, Pisegna JM, Miloro KV, Lo M, Saito H, Riquelme LF, LaValley MP, Langmore SE. Prevention of Healthcare-Associated Pneumonia with Oral Care in Individuals Without Mechanical Ventilation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Infect Control Hosp Epidemiol. 2015;36(8):899–906. Yildiz M, Durna Z, Akin S. Assessment of oral care needs of patients treated at the intensive care unit. J Clin Nurs. 2013;22(19–20):2734–47. https://www.ncbi.nlm.nih.gov/pubmed/23534462 . Smith TA, Ingham JM, Jenkins CR. Respiratory Failure, Noninvasive Ventilation, and Symptom Burden: An Observational Study. J Pain Symptom Manage. 2019;57(2):282–9. e281.https://www.ncbi.nlm.nih.gov/pubmed/30389607 . Ames NJ, Sulima P, Yates JM, McCullagh L, Gollins SL, Soeken K, Wallen GR. Effects of systematic oral care in critically ill patients: a multicenter study. Am J Crit Care. 2011;20(5):e103–114. .https://www.ncbi.nlm.nih.gov/pubmed/21885453 . The Joanna Briggs Institute.Critical Appraisal Check Listfor Textand. Opinion (JBI)[EB/OL].(2017-11-24)[2022- 01-18].http//joannabriggs.org/research/critical-appraisal-tools.html chunqing W, Yan H. JBI evidence pre-classification and evidence rank system (2014 Edition). J Nurses Train. 2015;30:964–7. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, Consortium ANS. AGREE II: advancing guideline development, reporting, and evaluation in health care. Prev Med. 2010;51(5):421–4. https://www.ncbi.nlm.nih.gov/pubmed/20728466 . Batiha AM, Bashaireh I, Albashtawy M, Shennaq S. Exploring the competency of the Jordanian intensive care nurses towards endotracheal tube and oral care practices for mechanically ventilated patients: an observational study. Glob J Health Sci. 2012;5(1):203–13. https://www.ncbi.nlm.nih.gov/pubmed/23283054 . Logan J, Harrison MB, Graham ID, Dunn K, Bissonnette J. Evidence-based pressure-ulcer practice: the Ottawa model of research use. Can J Nurs Res = Revue canadienne de recherche en Sci infirmieres. 1999;31(1):37–52. Escribano M, Figuero E, Martin C, Tobias A, Serrano J, Roldan S, Herrera D. Efficacy of adjunctive anti-plaque chemical agents: a systematic review and network meta-analyses of the Turesky modification of the Quigley and Hein plaque index. J Clin Periodontol. 2016;43(12):1059–73. https://www.ncbi.nlm.nih.gov/pubmed/27531174 . Chiarotto A, Maxwell LJ, Ostelo RW, Boers M, Tugwell P, Terwee CB. Measurement Properties of Visual Analogue Scale, Numeric Rating Scale, and Pain Severity Subscale of the Brief Pain Inventory in Patients With Low Back Pain: A Systematic Review. J Pain. 2019;20(3):245–63. https://www.ncbi.nlm.nih.gov/pubmed/30099210 . Wang Z. Call for the establishment of our dry mouth classification criteria. Chin J Stomatology 2010, 45. Zhang X, Lu Z, Hu Y, Xue M, Dai H. Evidence-Based Implementation of Peripherally Inserted Central Catheters (PICCs) Insertion at a Vascular Access Care Outpatient Clinic. Worldviews on Evidence-Based Nursing; 2017. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.zip Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 17 Apr, 2026 Reviews received at journal 14 Apr, 2026 Reviewers agreed at journal 07 Apr, 2026 Reviews received at journal 20 Feb, 2026 Reviews received at journal 16 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor invited by journal 09 Jan, 2026 Editor assigned by journal 24 Nov, 2025 Submission checks completed at journal 24 Nov, 2025 First submitted to journal 23 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8183510","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":586247204,"identity":"304d3e23-457c-48c9-ba43-18f6ca423511","order_by":0,"name":"Minggui Chen","email":"","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":false,"prefix":"","firstName":"Minggui","middleName":"","lastName":"Chen","suffix":""},{"id":586247205,"identity":"707bb462-0bb7-48a7-ba64-361013dda8c6","order_by":1,"name":"Lin Wei","email":"","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Wei","suffix":""},{"id":586247206,"identity":"b1481a05-080e-48c7-b72e-7bdd448b9054","order_by":2,"name":"Hanhua Guo","email":"","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":false,"prefix":"","firstName":"Hanhua","middleName":"","lastName":"Guo","suffix":""},{"id":586247207,"identity":"d8eb6195-645f-4c4e-bf15-c2a099a116d9","order_by":3,"name":"Yumei Zhong","email":"","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":false,"prefix":"","firstName":"Yumei","middleName":"","lastName":"Zhong","suffix":""},{"id":586247208,"identity":"b9fa358e-3f54-4b91-b4a5-d61aebd142ce","order_by":4,"name":"Lixia Huang","email":"","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":false,"prefix":"","firstName":"Lixia","middleName":"","lastName":"Huang","suffix":""},{"id":586247209,"identity":"ae131f6f-3b08-4d9d-b9b6-9fafe15e9851","order_by":5,"name":"Zhuo Cao","email":"","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":false,"prefix":"","firstName":"Zhuo","middleName":"","lastName":"Cao","suffix":""},{"id":586247210,"identity":"1f51a284-b2fa-4aa6-9b65-bbc132dddcd5","order_by":6,"name":"Haizhen Chen","email":"","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":false,"prefix":"","firstName":"Haizhen","middleName":"","lastName":"Chen","suffix":""},{"id":586247211,"identity":"8d1798f9-83db-4d5f-ae9a-ec9fc76ec49e","order_by":7,"name":"Nan Mu","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Mu","suffix":""},{"id":586247212,"identity":"1bd4ff16-2451-4adf-ba0c-8bdc6ff277be","order_by":8,"name":"Yuqing Li","email":"","orcid":"","institution":"Guangzhou University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yuqing","middleName":"","lastName":"Li","suffix":""},{"id":586247213,"identity":"48437c86-3acb-450f-afdb-c6401a0da716","order_by":9,"name":"Xiao xuan Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYDACCQaGAxAW84EDCT9sePj5G4jWwpb44GNPmozkjAOEtUABj7HhDLbDNgYNCfh1yM/uMTzwo+JwYv/sBjNpHp7zPAYMBxg/fMzBrYVxzrGEgz1n0hJn3DmQJs1jcZvHnLmBWXLmNtxamCWSDxzgbbNJbLiRcAxoy20ey4YDbMy8eLSwSSQ2HPzbJpE4/0ZimzQP2zkegwMJ+LXwAG05DLJlw41kZqD3DxDWIiGRlnBY5kya8cYbaYzAQE7mkZxxsBmvX+Rn5Bh/fFNxWHbejfwPwKi0s+fnbz744SMeLdgAYwNp6kfBKBgFo2AUYAAAT+hX5ulTd80AAAAASUVORK5CYII=","orcid":"","institution":"The Second Affiliated Hospital of Guangzhou University of Chinese","correspondingAuthor":true,"prefix":"","firstName":"Xiao","middleName":"xuan","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-11-23 05:23:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8183510/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8183510/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102214184,"identity":"079dd84b-e3b4-4dbc-8d98-f71db546de4f","added_by":"auto","created_at":"2026-02-09 12:43:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":504012,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Changes in participants ' performance of the plaque index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eValues are presented as median with the interquartile range.The change of plaque index from baseline, Day3 and Day5. Intragroup comparison, \u003csup\u003e\u003cem\u003e##\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01;Comparison among groups,\u003cem\u003e*P\u003c/em\u003e＜0.05,ns=no significance.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8183510/v1/30d9a6d5689100ecd1a32214.png"},{"id":102214185,"identity":"9ae1925e-9b12-412e-b5b7-360c5ce9938e","added_by":"auto","created_at":"2026-02-09 12:43:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":537187,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Changes in participants ' performance of the Odor fraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eValues are presented as median with the interquartile range. Odor fraction score between the two groups on the baseline,Day3 and Day5. Intragroup comparison, \u003csup\u003e\u003cem\u003e##\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.01;Comparison among groups,\u003cem\u003e*P\u003c/em\u003e＜0.05,\u003cem\u003e**P\u003c/em\u003e＜0.01,ns=no significance.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8183510/v1/ab6d1357f2e384569da9eabd.png"},{"id":102214191,"identity":"85da6537-ce32-49e1-8bd4-3e7e06841c9f","added_by":"auto","created_at":"2026-02-09 12:43:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":337161,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHospitalization expense between two group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eValues are presented as median with the interquartile range.Comparison of the hospitalization expenses between the two groups.\u003cem\u003e*P\u003c/em\u003e＜0.05.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8183510/v1/638f715b649ca5408fb95172.png"},{"id":102214537,"identity":"9ee23208-7149-4992-9821-acc2344fd804","added_by":"auto","created_at":"2026-02-09 12:43:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2167436,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8183510/v1/acb3e364-e72c-41a3-9ea1-d441665bf671.pdf"},{"id":102214365,"identity":"5b58a41f-4a09-4020-afb3-08fb9d3e1871","added_by":"auto","created_at":"2026-02-09 12:43:34","extension":"zip","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":51928,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.zip","url":"https://assets-eu.researchsquare.com/files/rs-8183510/v1/2ec1e9b41645fa99dd6738e5.zip"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evidence-Based Implementation of oral care procedures for patients with Non-Invasive Mechanical Ventilation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCritically ill patients, particularly those on Non-Invasive Mechanical Ventilation (NIMV), face heightened risks of oral dysbiosis due to impaired mucosal protection, antibiotic use, and reduced self-cleaning mechanisms[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Oral care has been recommended to improve the oral environment of critically ill patients[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Effective oral care assessment can be followed by better oral care for the patient and achieve the goal of improving the patient's oral environment, reducing the risk of VAP, increasing patient comfort and improving oral dryness.\u003c/p\u003e \u003cp\u003eHowever, most domestic and international guidelines or standards focus on the clinical practice of oral care for adults and have been studied in oncology, cancer or elderly patients, with few guidelines and studies on the assessment and clinical practice of oral care for patients on NIMV[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This makes it difficult for ICU nurses to systematically and comprehensively assess patients' oral conditions and form individualized oral care plans when performing oral care for patients on NIMV. Due to the lack of assessment criteria, low knowledge base and lack of professional training, most nurses use outdated oral care assessment procedures in practice. It is evident that the knowledge, attitude and behavioral compliance of nurses to conduct systematic assessments prior to performing oral care for patients on NIMV need to be improved. In the long term, if nurses are unable to effectively assess their oral cavity and propose and implement individualized intervention plans, not only will they fail to allow effective clearance of flora from the oral cavity of patients on NIMV and shorten their stay in the ICU, they will also increase the incidence of adverse events, the risk of infectious diseases and the burden of healthcare expenditure. Therefore, it is urgent to develop standards for the assessment and clinical practice of oral care of patients undergoing NIMV.\u003c/p\u003e \u003cp\u003e In order to standardize oral care procedures in patients on NIMV, this study proposes to use an evidence-based approach to identify the best clinical evidence for the assessment of oral care in patients on NIMV and apply it in the clinical setting. The application of the evidence will raise nurses' awareness of the need for oral care in patients on NIMV, improve the cleanliness of patients' mouths, reduce the incidence of mouth dryness and other aims, and provide a reference for the standardization of oral care in patients on NIMV in critical illness.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis quasi-experimental study compared pre- and post-intervention outcomes in a single ICU. Ethical approval was obtained from the Guangdong Provincial Hospital of Chinese Medicine Ethics Committee (ZE2022-247-01). Informed consent was secured from all participants or guardians. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvidence Synthesis \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween March 2022 and July 2022, we systematically reviewed various databases, including the Joanna Briggs Institute Library, UpToDate, Embase, Elsevier, Web of Knowledge, Ovid, China National Knowledge Infrastructure, and the Chinese Wanfang database. A Web-based review of relevant guideline websites and professional websites, including the National Institute for Health and Care Excellence(NICE), the National Guideline Clearinghouse (NGC) and the Registered Nurses\u0026rsquo; Association of Ontario (RNAO), were also conducted. The key terms used in this project included \u0026ldquo;NIMV / non positive pressure ventilation / NPPV / non invasive positive pressure ventilation / NIPPV / noninvasive ventilation / non-invasive ventilation / continuous positive airway pressure / CPAP ventilation / Biphasic continuous positive airway pressure / bilevel continuous positive airway pressure\u0026rdquo; AND \u0026ldquo;oral hygiene / oral care / oral decontamination / oral nursing / oral care assessment / oral evaluation\u0026rdquo;. The search period is from the inception of the database to March 2023.The search yielded 430 peer-reviewed articles, of which 11 were relevant. These included 1 JBI evidence summary[6], 1 guideline[7],1 class trial[8], 1 expert consensus[1], 2 evidence-based[9, 10], 1 systematic review[11], and 1 cross-sectional study[12]; of these, the evidence summaries went back to the original article, yielding 2 Observational Studys [5, 13] and 1 class trial[14]. The details are shown in Table 1.The JBI evidence hierarchy [15,16] and AGREE II [17] frameworks guided critical appraisal. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. The evidence-based protocol included:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.1 {Collins, 2021 #2}Subject of assessment \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients receiving treatment in the intensive care unit should have their oral mucosa closely and systematically assessed. (Level 4b)[6, 12]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.2 Timing of assessment\u003c/p\u003e\n\u003cp\u003ePatients on NIMV should have an oral assessment completed within 6 hours of admission. The standardised oral care assessment tool encourages assessment every 12 hours. (Level 5b)[1]\u003c/p\u003e\n\u003cp\u003e1.3 Assessment tools\u003c/p\u003e\n\u003cp\u003e1.3.1 All nurses should have standardised training and assessment of the assessment tool to ensure familiarity with it; (Level 5b)[1]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3.2 All critically ill patients are assessed using the standardised oral care assessment tool and the results should be documented; (Level 5b)[6, 7]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3.3 The assessment tool for mechanically ventilated patients also applies to non-invasive mechanically ventilated patients; (Level 5b)[9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3.4 The dynamic development of oral care interventions using the modified Beck oral score can reduce the occurrence of odour, reduce bacterial colonisation of the oropharynx and improve oral health; (Level 1c)[8]\u003c/p\u003e\n\u003cp\u003e1.3.5 The use of the Modified Beck Scale allows for standardised oral assessment and guides nurses in the delivery of oral interventions. (Level 2d)[14, 18]\u003c/p\u003e\n\u003cp\u003e1.4 Implementation assessment\u003c/p\u003e\n\u003cp\u003eThe frequency of oral care is determined by the Beck Oral Score. (Level 2d) [14] The patient\u0026apos;s level of consciousness, ability to follow instructions, posture and lung stability should be observed when administering oral care, and the patient should be stable enough to tolerate the switch to alternative oxygen therapy equipment for the limited time required to administer oral care activities. (Level 4b)[13]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.5 Quality control\u003c/p\u003e\n\u003cp\u003eDaily supervision by the manager of the correctness of the oral assessment of the charge nurse. (Level 1c)[8] Oral assessments should often be performed as part of a systematic patient assessment and should be used to identify those patients who are at increased risk of oral complications.(Level 5b)[1, 10]. Indicators such as risk of pneumonia, incidence of oral odour and dental plaque index can be used as indicators to evaluate the effectiveness of oral care interventions. (Level 1a) [9, 11].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIntegrating Evidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore applying the evidence, we formed a project team led by a nurse researcher, directed by the Head Nurse, and supported by the Hospital Nursing Director. The process of integrating evidence into practice involved five steps: assessing barriers and supports, identifying current deficiencies from best evidence, developing the NIMV oral care assessment procedure, designing and completing training courses, and adopting and monitoring the innovations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 1. Assess barriers and supports\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to the application of the evidence, a scenario analysis was conducted to identify possible barriers and facilitators to driving the implementation of best practice. Based on the theory of the analysis of barriers in the assessment phase of the Ottawa Research Application Model,[19] our team assessed 3 aspects of evidence, adopters of evidence and the context of implementation and obtained the following barriers: (a)There is no clinical tool for the assessment of oral care in NIMV;(b)Lack of standardised quality checklists for dental care assessment in clinical practice;(c)The nurse is not trained in oral care assessment and is not familiar with oral assessment tools; There are no standardised guidelines to guide nurses in conducting oral care assessments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 2. Identify current deficiencies from best evidence and developing the Non-invasive oral care assessment procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the assessment of evidence from the literature and our existing processes, supports or barriers were identified and analyzed, and strategies of maximum resources utilization and evidence based implementation were developed. For example, we require bedside nurses to assess the oral care of patients on NIMV within 6 hours of admission. The modified\u0026nbsp;Beck Assessment Scale is recommended as the oral care assessment tool and the corresponding oral care measures are given in response to the assessment results. [1, 14]The nurse should be aware of the patient\u0026apos;s level of consciousness and ability to follow instructions when administering oral care. Patients should be stable enough to tolerate switching to alternative oxygen therapy equipment, such as high-flow oxygen, for the limited time required to perform oral care activities. Finally, managers are able to do a good job of daily supervision and nurses know the indicators related to the effectiveness of oral care assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 3. Design and complete the Non-invasive oral care assessment training courses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe preliminary investigation conducted before the evidence-based changes were implemented revealed that nurses\u0026apos; awareness of oral care assessment of patients on NIMV is low. Therefore, we organised and trained the study of the oral scale to enable nurses to understand the feasibility and necessity of the modified Beck scale in standardising the oral care assessment of patients on NIMV and to strengthen nurses\u0026apos; awareness of oral care assessment. To enable nurses to learn the assessment better, we have converted the modified Beck Scale into colour charts and made an instructional video of the assessment for nurses to learn. As a result, full preparation for the transition to the new, evidence-based the NIMV oral care assessment practice was provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 4. Adopt and monitor the innovations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElements of the oral care assessment for NIMV were implemented in clinical practice after obtaining permission from the hospital\u0026apos;s institutional ethical review board. We have developed an oral assessment process for patients on NIMV to provide nurses with standardised process guidelines, thereby improving clinical efficiency. In conjunction with the Information Department, the oral care assessment scale was implanted into the ICU electronic system to achieve dynamic assessment. The nursing team leader conducts daily quality checks on the oral care assessment of patients on NIMV to strengthen the assessment awareness of the responsible nurses and effectively improve the nurses\u0026apos; execution. Clinical improvement of the patient\u0026apos;s dry oral environment by using a small portable spray bottle to facilitate nurses to moisten the mouth and lips of patients on NIMV to ensure effective implementation of evidence. The use of plaque amplifiers - \u0026quot;plaque revealers\u0026quot; - to facilitate plaque observation by nurses, effectively ensuring the standardisation and implementation of oral care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 5. Summarize and reflect\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter the completion of the clinical implementation, the managers and all clinical nurses met for a discussion and summary to determine areas for further improvement.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe data for 30 patients who underwent NIMV in the Department of Intensive Care Medicine was collected from August 5, 2022 to October 15, 2022 before the evidence-based practices were implemented. The period from October 20, 2022 to December 12, 2022 was the implementation phase for evidence-based Oral Care Assessment procedures. The data with 30 patients on NIMV were recorded and then compared with those before the implementation of the evidence-based protocol. There was no significant difference between the two groups about baseline characteristics, including sex, age, Hypertension, History of diabetes, History of the smoker, History of drinking, LVEF, APACHE-II, WBC and Oral Odour, as shown in Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eWith the provision of education, the average knowledge score of 60 nursing staff increased from 51.32 to 66.42 out of a total score of 100 on the Oral care assessment knowledge test for patients on NIMV designed by the team. As part of the education program, all ICU nurses were trained about Knowledge of oral care assessment for patients on NIMV.\u003c/p\u003e \u003cp\u003e The quality of oral care in NIMV was compared by plaque index, oral odour and oral dryness. The plaque index is scored according to Turesky's modified Q-H plaque index assessment method[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Oral odour is rated using the visual analogue scale (VAS), with a score of 0 indicating no odour, 1 to 3 indicating mild odour, 4 to 6 indicating moderate odour, 7 to 9 indicating severe odour and 10 indicating strong odour[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Dry mouth is a reference to the grading scale for dry mouth disease proposed by Wang Zhonghe: Grade 0 indicates no oral dryness, Grade 1 indicates mild oral dryness; Grade 2 indicates mild oral dryness; Grade 3 indicates moderate oral dryness; and Grade 4 indicates severe oral dryness[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe implementation of this evidence-based intervention improved the quality of oral care for patients on NIMV as shown in Table\u0026nbsp;3. Although there is a statistical difference in the decreasing trend of plaque index between the two groups.However, there was a considerable reduction of plaque index in Postapplication of evidence group [1.90 (95%CI, 1.75\u0026ndash;2.05) vs. 2.27(95%CI,1.99\u0026ndash;2.54), respectively,p\u0026thinsp;=\u0026thinsp;0.020] at the 5th day(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).The result display that there was no significant difference in Odor fraction between the two groups on the baseline[7.10(95%CI,6.63\u0026ndash;7,57] vs.6.55(95%CI,5.95\u0026ndash;7.17,p\u0026thinsp;=\u0026thinsp;0.162].However,the difference between the two groups was statistically significant at the 3rd day [5.47 (95% CI, 4.97\u0026ndash;5.94] vs. 4.59 (95% CI, 4.00\u0026ndash;5.21, p\u0026thinsp;=\u0026thinsp;0.031] and the 5th day [2.97 (95% CI, 2.57\u0026ndash;3.40] vs. 4.26 (95% CI, 3.79\u0026ndash;4.72,p\u0026thinsp;=\u0026thinsp;0.000] (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The proportion of patients experiencing mild or no dry mouth increased from 53.3% before evidence of response to 83.3% (p\u0026thinsp;=\u0026thinsp;0.012).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;4,compared with the Preapplication of evidence group, there was an effective reduction in the hospitalization expenses[45774(95%CI,35594\u0026ndash;56041) vs.66798(95%CI,56099\u0026ndash; 77767), respectively, p\u0026thinsp;=\u0026thinsp;0.011](Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eImplementing evidence-based practice presents a challenge in the form of normalizing this evidence. Beyond training, a potent method for consistently reinforcing practice is to embed it within the daily routines of nursing. In our study, we integrated a modified version of the BECK oral assessment scale as a tool for evaluating oral care in patients undergoing NIMV. This tool was incorporated into the department's critical care system, followed by comprehensive training sessions. We also incorporated NIMV oral care assessment tasks into the operational protocols. By altering operational procedures, we can influence the behavior of nurses, ultimately empowering them to embrace and apply evidence in their daily tasks, thereby facilitating the normalization of new evidence-based practices.\u003c/p\u003e \u003cp\u003eOngoing and enhanced monitoring of evidence-based implementation measures is a key factor in normalising best evidence[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The primary role of monitoring is to ensure the effective implementation of clinical evidence-based measures and to normalise clinical change. In addition, ongoing monitoring can indicate whether current measures need to be modified or whether new measures need to be added. The nursing team leader monitored the implementation of evidence-based innovations in the project using the NIMV Oral Care Assessment Checklist. The frequency of patient oral moistening by nurses using a portable spray can effectively implemented best evidence in the clinic.\u003c/p\u003e \u003cp\u003eDuring the project's group discussions on evidence implementation, nurse researchers and clinical nurses identified a number of barriers to adherence to evidence-based NIMV oral care assessment procedures, such as the fact that the evidence required them to use assessment scales, but clinically they used the criteria inconsistently. The key to overcoming this barrier and reducing these inconsistencies is to enable the knowledge gained to be effectively applied in clinical practice. Evidence tells clinical nurses what to do, but specific procedures still need to be further refined and developed by researchers and practitioners for specific clinical scenarios, including details about assessment timing, frequency, methods, documentation and feedback.\u003c/p\u003e \u003cp\u003eIt is important that the evolution from experience-based to evidence-based practice and the use of scientific evidence to guide our practice ensures the safety of our patients and improves the quality of our care. The functional roles played by researchers, care managers and clinical nurses must be fully utilised in the implementation of best practice. Effective strategies that are consistent with the clinical setting are fully applied and efforts are made to apply the evidence on a daily basis to ensure effective implementation.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDissemination\u003c/h2\u003e \u003cp\u003eThe outcomes of the implementation project were presented at a hospital nursing competition. Plans are in place to promote this EBP project at local hospital Nursing Grand Rounds and evidence-based nursing committees. Finally, the organisers of the project are considering presenting this EBP project at an academic conference next year.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis trial was conducted in accordance with the ethical principles set forth in the Declaration of Helsinki, referenced directives, regulations, and guidelines.The Guangdong Provincial Hospital of Chinese Medicine\u0026rsquo;s Human Research Ethics Committee approved this study(ZE2022-247-01).Written informed consent was obtained from each patient or their parents or guardians.The Clinical trial number is ITMCTR2025001956.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA written consent for publication was obtained from each patient or their parents or guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by The scientific and technological research of traditional Chinese medicine, Guangdong Provincial Hospital of Chinese Medicine (No.YN2016HL03,YN2020HL03,YN2020HL14,YN2022HL06,YN2023HL04,YN2023HL13).Research Projects of Guangdong Nurses Association (gdshsxh2023ms57, gdshsxh2023ms60, gdnurse2024xz01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to data collection, and reviewed and approved the final manuscript. Xiaoxuan Zhang is the guarantor of the paper, taking responsibility for the integrity of the work, from inception to published article. Ming-Gui Chen wrote the main manuscript text.Haizhen Chen, Nan Mu, Yuqing Li collected the cases. Hanhua Guo,Yumei Zhong,Lixia Huang ,and Zhuo Cao carried out data collection and revision of the manuscript. Lin Wei carried out study design and revision of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCollins T, Plowright C, Gibson V, Stayt L, Clarke S, Caisley J, Watkins CH. British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units. Nurs Crit Care. 2020;26(4):224\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/33124119\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/33124119\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang X, Shen Y, Pan X, Liao J, Xu Y, Luo W, Zhang X, Li Ce, Wan Q, Cai X, Zhang X, Wang T, Zhang G. Oral care for intensive care unit patients without mechanical ventilation: protocol for a systematic review and meta-analysis. Syst Reviews 2022, 11(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao T, Wu X, Zhang Q, Li C, Worthington HV, Hua F. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2020;12(12):CD008367. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.https://www.ncbi.nlm.nih.gov/pubmed/33368159\u003c/span\u003e\u003cspan address=\"http://.https://www.ncbi.nlm.nih.gov/pubmed/33368159\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHong CHL, Gueiros LA, Fulton JS, Cheng KKF, Kandwal A, Galiti D, Fall-Dickson JM, Johansen J, Ameringer S, Kataoka T, Weikel D, Eilers J, Ranna V, Vaddi A, Lalla RV, Bossi P, Elad S, Mucositis Study Group of the Multinational. Association of Supportive Care in Cancer/International Society for Oral O: Systematic review of basic oral care for the management of oral mucositis in cancer patients and clinical practice guidelines. Support Care Cancer. 2019;27(10):3949\u0026ndash;67. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/31286232\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/31286232\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGanz FD, Ofra R, Khalaila R, Levy H, Arad D, Kolpak O, Ben Nun M, Drori Y, Benbenishty J. Translation of oral care practice guidelines into clinical practice by intensive care unit nurses. J Nurs Scholarsh. 2013;45(4):355\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/23731065\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/23731065\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBSStat FCV. ORAL HYGIENE CARE: CRITICALLY ILL. JBI EVIDENCE SUMMARY 2021:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE: Oral health for adults in care homes. 2016:1\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLijie P, Suqin Y, Yongxiu L, Liping S. Comprehensive oral care intervention with modified Beck oral score in ICU patients with mechanical ventilation. J Nurs Adm. 2019;19:906\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnny JD, Drury Z, Ly T, Scholine J. Oral Care in Critically Ill Patients Requiring Noninvasive Ventilation: An Evidence-Based Review. Crit Care Nurse. 2021;41(4):66\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/34333612\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/34333612\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmery KP, Guido-Sanz F. Oral care practices in non-mechanically ventilated intensive care unit patients: An integrative review. J Clin Nurs. 2019;28(13\u0026ndash;14):2462\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/30793402\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/30793402\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaneoka A, Pisegna JM, Miloro KV, Lo M, Saito H, Riquelme LF, LaValley MP, Langmore SE. Prevention of Healthcare-Associated Pneumonia with Oral Care in Individuals Without Mechanical Ventilation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Infect Control Hosp Epidemiol. 2015;36(8):899\u0026ndash;906.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYildiz M, Durna Z, Akin S. Assessment of oral care needs of patients treated at the intensive care unit. J Clin Nurs. 2013;22(19\u0026ndash;20):2734\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/23534462\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/23534462\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith TA, Ingham JM, Jenkins CR. Respiratory Failure, Noninvasive Ventilation, and Symptom Burden: An Observational Study. J Pain Symptom Manage. 2019;57(2):282\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ee281.https://www.ncbi.nlm.nih.gov/pubmed/30389607\u003c/span\u003e\u003cspan address=\"http://e281.https://www.ncbi.nlm.nih.gov/pubmed/30389607\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmes NJ, Sulima P, Yates JM, McCullagh L, Gollins SL, Soeken K, Wallen GR. Effects of systematic oral care in critically ill patients: a multicenter study. Am J Crit Care. 2011;20(5):e103\u0026ndash;114. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.https://www.ncbi.nlm.nih.gov/pubmed/21885453\u003c/span\u003e\u003cspan address=\"http://.https://www.ncbi.nlm.nih.gov/pubmed/21885453\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Joanna Briggs Institute.Critical Appraisal Check Listfor Textand. Opinion (JBI)[EB/OL].(2017-11-24)[2022-\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e01-18].http//joannabriggs.org/research/critical-appraisal-tools.html\u003c/span\u003e\u003cspan address=\"http://01-18].http//joannabriggs.org/research/critical-appraisal-tools.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003echunqing W, Yan H. JBI evidence pre-classification and evidence rank system (2014 Edition). J Nurses Train. 2015;30:964\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, Consortium ANS. AGREE II: advancing guideline development, reporting, and evaluation in health care. Prev Med. 2010;51(5):421\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/20728466\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/20728466\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBatiha AM, Bashaireh I, Albashtawy M, Shennaq S. Exploring the competency of the Jordanian intensive care nurses towards endotracheal tube and oral care practices for mechanically ventilated patients: an observational study. Glob J Health Sci. 2012;5(1):203\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/23283054\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/23283054\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLogan J, Harrison MB, Graham ID, Dunn K, Bissonnette J. Evidence-based pressure-ulcer practice: the Ottawa model of research use. Can J Nurs Res = Revue canadienne de recherche en Sci infirmieres. 1999;31(1):37\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEscribano M, Figuero E, Martin C, Tobias A, Serrano J, Roldan S, Herrera D. Efficacy of adjunctive anti-plaque chemical agents: a systematic review and network meta-analyses of the Turesky modification of the Quigley and Hein plaque index. J Clin Periodontol. 2016;43(12):1059\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/27531174\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/27531174\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiarotto A, Maxwell LJ, Ostelo RW, Boers M, Tugwell P, Terwee CB. Measurement Properties of Visual Analogue Scale, Numeric Rating Scale, and Pain Severity Subscale of the Brief Pain Inventory in Patients With Low Back Pain: A Systematic Review. J Pain. 2019;20(3):245\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/30099210\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/30099210\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Z. Call for the establishment of our dry mouth classification criteria. Chin J Stomatology 2010, 45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang X, Lu Z, Hu Y, Xue M, Dai H. Evidence-Based Implementation of Peripherally Inserted Central Catheters (PICCs) Insertion at a Vascular Access Care Outpatient Clinic. Worldviews on Evidence-Based Nursing; 2017.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Non-invasive mechanical ventilation, Oral care, Evidence-based practice, Intensive care unit, Nursing education","lastPublishedDoi":"10.21203/rs.3.rs-8183510/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8183510/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOral care for ICU patients is critical, yet current practices predominantly target those on invasive ventilation, neglecting individuals receiving Non-Invasive Mechanical Ventilation (NIMV). This study aimed to develop and implement an evidence-based protocol for oral care assessment in NIMV patients to enhance clinical outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A mixed-methods approach was employed, including a literature review, critical appraisal, and evidence-based practice changes. Outcomes measured included nursing staff knowledge, patient plaque index, oral odor, oral dryness, and hospitalization costs. Data were collected from 60 nurses and 60 patients (30 pre-intervention, 30 post-intervention).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEleven articles informed the evidence synthesis. Post-implementation, nurses\u003csup\u003e,\u003c/sup\u003eknowledge scores significantly improved (51.32 vs. 66.42/100, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).The plaque index decreased notably in the intervention group by day 5 (1.90 vs. 2.27, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020). Oral odor scores differed significantly at day 3 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031) and day 5 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Oral dryness incidence declined from 46.7% to 16.7% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012). Hospitalization costs were reduced (\u0026yen;45,774 vs. \u0026yen;66,798, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eImplementing evidence-based oral care protocols for NIMV patients improved nursing knowledge and patient outcomes while reducing healthcare costs. These findings support standardized oral care integration in ICU settings.\u003c/p\u003e","manuscriptTitle":"Evidence-Based Implementation of oral care procedures for patients with Non-Invasive Mechanical Ventilation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 12:40:53","doi":"10.21203/rs.3.rs-8183510/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-17T08:45:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T09:07:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-04-07T05:39:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-20T19:38:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T19:58:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138299710452405757949672836317250743505","date":"2026-02-15T16:35:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181123372823402335508853889602906247128","date":"2026-02-05T08:50:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T05:03:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-09T11:46:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-24T13:09:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-24T13:08:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-11-23T05:12:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8c08aa1a-c0b9-4508-8a11-7386fdc5c6f4","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T08:57:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 12:40:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8183510","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8183510","identity":"rs-8183510","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}