Bhatt, V., Vendrell, N., Nau, K., Crumb, D., & Roy, V. (2010). Implementation of a standardized protocol for prevention and management of oral mucositis in patients undergoing hematopoietic cell transplantation. Journal of Oncology Pharmacy Practice, 16(3), 195–204.

To develop a mucositis oral care protocol and evaluate the impact of its implementation in the prevention and management of mucositis in the patient with hematopoietic cell transplant (HCT)

A standard protocol was developed. After development, the physician and nursing staff were educated about the protocol and effects of medications included in the protocol. Following education for three months, every patient admitted to the HCT service was managed according to the protocol. Retrospective review of the electronic medical record of mucositis management was done in cases during the three months prior to protocol use. The new protocol was included in the electronic order set used for HCT admissions.

The protocol included daily evaluation, brushing twice daily, ice chips 30 minutes prior to and throughout melphalan infusion, chlorhexidine gluconate mouthwash 15 ml 4 times daily, normal saline mouthwash 30 ml four times daily, calcium phosphate rinse 30 ml four times daily, magic mouthwash 15 ml four times daily as needed for oral pain, and phenol losenges every two hours as needed for oral pain. Palifermin was used at the physician’s discretion.

• The study reported on 24 patients receiving HCT (11 retrospective and 13 prospective).
• Mean age was 55 years (SD = 12) in the retrospective group and 59 years (SD = 12) in the prospective group.
• The sample was 76% female and 24% male.
• All were patients hospitalized for HCT. Most patients were receiving BEAM (carmustine, etoposide, cytarabine, melphalan) chemotherapy.

This was a single-site study conducted in an inpatient transplant unit at the Mayo Clinic in Florida.

The study used an exploratory descriptive design with historical controls.

• The National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grading system was used.
• Data was retrieved by retrospective chart review.
• Use and duration of total parenteral nutrition (TPN) was recorded, as well as hospital length of stay.

• Patients who received the oral care protocol had lower incidence of grade 1 mucositis and lower duration of grade 1 mucositis (p = 0.02).
• No differences were found at any other grade level between groups.

• The sample size was small.
• The data was from chart audit only.
• No information was provided about actual components used and protocol adherence.
• Although TPN on the grading scale is indicative of grade 3 mucositis, only 17% of patients receiving TPN with the new protocol were grade 3. This calls the validity of findings into question.

This study does not significantly add to our understanding for the management of mucositis but suggests that use of a standardized protocol increases attention to mucositis management. This study also raises questions about the use of the criteria as receiving TPN as a measure of mucositis grade, as use of TPN may not only be a result of mucositis. This area of limitation also may indicate issues of reliability in the documentation of mucositis grade, as data here were solely obtained from the electronic medical record.