Nurses Develop Evidence-Based Guidelines for Mucositis

BOSTON-Optimal mucositis management requires a good assessment tool; an oral care protocol that includes cleaning, flossing, rinsing, and lip care; cryotherapy where appropriate; and pain management, Megan Dunne, RN, MA, APRN, said at the Oncology Nursing Society 31st Annual Congress (abstract 10). Ms. Dunne, of Memorial Sloan-Kettering Cancer Center (MSKCC), discussed mucositis guidelines that were developed by nurses at that institution and are now being tested for efficacy.

"Patients report mucositis as the most bothersome side effect of cancer therapies. It can result in pain, nutritional deficits, infection, and/or the need to alter the treatment plan," Ms. Dunne said.

She emphasized that the management of oral complications of cancer therapies is integral to the role of the oncology nurse. "A recent survey at this cancer center revealed discrepancies in practices and methods for assessment, prevention, and management of mucositis in populations most at risk. A need for change was consequently identified," she said.

Ms. Dunne said that problems identified by the survey included:

• Different assessment approaches for inpatients and ambulatory patients.

• Differences in what nurses were telling patients with regard to toothbrushing and other aspects of oral cleaning.

• Uncertainty about the best tools for assessing mucositis.

• Unclear guidelines for managing mucositis pain.

A multidisciplinary team was established that included ambulatory and inpatient nurses, dental and nutrition professionals, and a pharmacist, and a literature review was performed. Evidence-based standards were created based on this review.

The researchers recognized that oral hygiene guidelines require a standardized regimen to be taught in all departments, consistency of practice, and a consistent approach to patient education. Thus, a series of in-service training sessions were planned to educate staff, and patient education materials are being revised to reflect the standards, she said. 

Four Key Elements

Ms. Dunne said that the four key elements of oral care were defined as cleaning, flossing, rinsing, and lip care. "Patients are instructed to use a soft or ultrasoft toothbrush. We limit the use of toothettes because of the abrasiveness on their outer surface," she said. "If the patient is already flossing regularly, we tell them to continue, but not to start flossing if it isn't already done."

Although a number of formulations have been proposed for mouth rinsing to prevent or treat mucositis, Ms. Dunne said that the literature review found no data supporting the superiority of any of these approaches. "Specifically, there is no evidence that Magic Mouthwash or other multiagent solutions are superior," Ms. Dunne said.

The guidelines call for use of cryotherapy in appropriate circumstances. "Cryotherapy using rounded ice chips is effective when used before fluorouracil bolus. The patient should chew on ice for 30 minutes beginning 5 minutes before the beginning of chemotherapy. The ice reduces vein size, and less drug goes into the mucosal tissues," Ms. Dunne said.

Clinician guidelines for management of mucositis pain are being prepared. "Outcomes will be measured in a repeat survey of nursing practice, and it is expected that consistency in the assessment, prevention, and management of mucositis will be improved," Ms. Dunne concluded.