Two new clinical protocols to promote the overall oral health of patients in acute care and residential care settings.

How do these impact students and faculty instructors?

The new Clinical Protocols involve practice changes that must be adhered to. Students and faculty instructors must complete the associated Practice Accountability Quizzes in The LearningHub to demonstrate compliance with these protocols. Doing so also meets the terms outlined in educational institutions’ Affiliation Agreements with Fraser Health for student placements.

What are the clinical protocols and practice changes involved?

Clinical Protocol

Oral Hygiene: 
Adult – Independent, Acute Care 

Oral Heath:
Adult – Integrated Standards for Residential Care Facilities and Group Homes 


To optimize the oral health of patients and reduce the risk of non-ventilator-associated hospital acquired pneumonia (NV-HAP).*

To promote oral health and comfort, and best practice for the maintenance of clients’ oral health.

Effect Date

December 9, 2017

November 16, 2017.

Practice Changes

  • All patients entering into acute care will be assessed for level of risk of acquiring NV-HAP and level of dependency requiring assistance with oral hygiene.

  • All patients entering into acute care will have oral hygiene included as part of their care and in accordance with individual need for assistance throughout their hospital stay.

  • Oral hygiene will be documented in the patient’s chart.

  • All clients/residents will be provided with a soft toothbrush and necessary oral care supplies. A soft toothbrush is recommended over oral swabs for mouth care except in special circumstances or if recommended by a Health Care Professional.

  • Dentures are recommended to be stored dry to reduce the growth of pathogenic bacteria.

Impacted Disciplines

Nursing – acute care sites.

Dental Services, Residential Care, Community Living, and Home Health.

Education and Implementaion

  • Clinical Nurse Educators, Clinical Resource Nurses, and Clinical Nurse Leaders will ensure staff at the point of care are aware of this Clinical Protocol.

  • Students and faculty instructors in acute care settings are required to complete the associated Practice Accountability Quiz.

  • Education and implementation will be site-specific.

  • Students and faculty instructors in these practice settings are required to complete the associated Practice Accountability Quiz.

* Abbreviation is consistent with Fraser Health’s approved Clinical Abbreviations Catalogue.


Please contact the Student Practice Team.

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