Increasing Activities of Daily Living Is As Easy As 1-2-3

Abstract

Topic Significance & Study Purpose/Background/ Rationale: The organisms of the human flora are the most common cause of bacteremia and sepsis in immunocompromised and bone marrow transplant (BMT) patients. Activities of daily living (ADL) may potentially lower the risk of infection by decreasing pathogenic bacteria on the skin and mouth. A literature review was inconclusive for ADLs lowering the risk of infections in BMT patients. To address ADL compliance, a multidisciplinary team of both oncology and BMT units consisting of PCAs, RNs, nursing leadership and physicians was created. Methods, Intervention, & Analysis: To improve compliance, the team adopted the ADL 1-2-3 initiative: Daily bath/ chlorhexidine (CHG) bath and linen change, at least 2 activities per day, and oral care 3 times per day. Using the Model of Improvement and through Plan Do Study Act (PDSA) testing, we created a standardized ADL process that involved all providers. Interventions included addressing 1-2-3 compliance during rounds, creating accountability in care delivery, creation of an algorithm and order set for oral care, daily text message reminders, and physician intervention with non-compliant and high-risk patients. Findings & Interpretation: Our baseline compliance with the 1-2-3 initiative was 25%. With our interventions we increased our median compliance to 66% in 90 days. The greatest impact on compliance was seen with text message reminders to staff to complete the 1-2-3 components, designated roles and responsibilities, and physician discussion with noncompliant and high-risk patients. Our current compliance, as of September 3 rd, 2015, is 78.7%. Discussion & Implications: The 53% increase in ADL compliance for BMT validates the importance of a multidisciplinary team collaborating with the patient and family. Multiple factors were found to disrupt the flow of care being provided to the patient. Utilizing the oral care algorithm and order set, daily text message reminders, and physician intervention with non-compliant and high-risk patients were found to offset these disruptions. Units where compliance with ADL participation is low would be an ideal environment to incorporate the ADL 1-2-3 initiative.

Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis

“…Bland rinses such as 0.9% saline or sodium bicarbonate/saline as well as analgesics, mucosal coating agents and topical anesthetic solutions like viscous lidocaine and diphenhydramine solutions have been studied. 120,121 Chlorhexidine has also been widely used as a bacteriostatic/cidal agent to reduce bacterial colony-forming units (CFUs), but has not been shown to reduce BSI from oral flora. 122,123 Furthermore, chlorhexidine has a bitter taste, and is unpalatable to patients, particularly children, reducing compliance.…”

“…124 A definitive dental treatment plan that includes oral hygiene reduces the incidence and severity of mucositis and may prevent infections and decrease infection-related mortality. 121,[125][126][127] In a small prospective evaluation of periodontal disease in adult HCT recipients, periodontal status correlated with frequency of bacteremia, particularly due to viridans streptococci and Staphylococcus epidermidis. 118 Recent oral care guidelines recommend brushing with an ultra-soft toothbrush two to three times daily and using non-flavored chlorhexidine gluconate 0.12-0.2% solution as an oral antiseptic twice daily when oral hygiene is suboptimal after HCT.…”

Token economy to improve adherence to activities of daily living

“…24 Medical teams have previously relied on nurse or provider specific interventions including persistent encouragement and reminding when refusing to complete ADL, increasing the likelihood of patient-provider conflict and undermining patient autonomy. 18,23,25 Research often focuses on adherence to medication, but adherence also encompasses many other health-related behaviors and is defined as "the extent to which the patient follows medical instructions". 26,27 Adherence results from a complex set of behaviors with multiple determinants that vary among individuals.…”

“…All patients are prescribed three ADL ("ADL 1-2-3") including daily bathing with chlorhexidine gluconate (CHG), physical activity twice per day, and an oral hygiene regimen three times per day as previously described. 18,23 Our current standard of care to ensure adherence to ADL includes routine education regarding the importance of ADL, reporting ADL during rounds between the nursing and physician team, and discussing nonadherence with patients and providers. We used an "all or none" measurement for each component of the ADL 1-2-3 initiative.…”

“…16,17 Recent studies indicate that the risk for BSIs, oral complications, and deconditioning can be reduced by participation in key activities of daily living (ADL), including daily bathing, physical activity, and oral hygiene. Despite this, many patients fail to perform these important ADL during their inpatient stay 18 at a time they are most vulnerable. 7,[19][20][21] There is a critical need to develop robust and sustainable mechanisms to improve ADL adherence, which will prevent BSI, oral complications, and challenges related to inactivity in high-risk immune-compromised pediatric oncology/HSCT patients.…”