A study of the provision of hospital based dental general anaesthetic services for children in the northwest of England: part 1--a comparison of service delivery between six hospitals

BACKGROUND

Extensive caries in children can result in a referral for tooth extraction under General Anaesthesia (GA). While there are guidelines for the use of GA within paediatric dentistry this process is ultimately dependent upon the decision making of the treating dentist. This decision can be influenced locally by the availability of services and their waiting list. GA services for paediatric extractions (DGA) have developed from different historical positions, including community dental services, maxillofacial services and paediatric led specialist services.

METHODS

This article explores the differences between DGA services provided by 6 randomly selected hospitals across the North West of England. 456 patients who attended a routine DGA appointment in each hospital over a period of two months from 2012 to 2013 gave consent to allow access to their clinical notes and completed a questionnaire (93% consent rate). Data were entered onto SPSS and appropriate statistical tests undertaken.

RESULTS

Differences between hospitals included the clinic structure, patient characteristics and the treatment provided. There was a significant difference in the number of previous child DGAs experienced within the family, ranging from 33% to 59% across hospitals. Hospital 1 attendees differed in a number of ways to other areas but notably in the stability of life time residency with 20% of patients having previously lived in another area and with just 58% of parents stating their child regularly attended the dentist (compared to an average of 9% and 81% respectively across other hospitals).

CONCLUSION

Findings suggest services throughout the region face different obstacles in providing support and treatment for young children referred for DGA. There are, however common practices such as preventative treatment, which could impact on caries experience and subsequent DGA referral, a particular issue given the high DGA repeat rate observed. For many children a DGA may be their first dental experience. It is therefore vital to engage with both child and family at this stage, attempt to initiate a pattern of dental attendance and to ensure this experience does not create an on-going cycle of poor dental behaviour and health.

A study of the provision of hospital based dental General Anaesthetic services for children in the North West of England: Part 2--the views and experience of families and dentists regarding service needs, treatment and prevention

BACKGROUND

Patterns of service delivery and the organisation of Dental General Anaesthesia (DGA) have been found to differ across hospitals. This paper reports on qualitative research aimed to understand the impact of such variation by exploring views and experiences of families receiving care in different hospital sites, as well as dentists involved in referral and delivery of care.

METHOD

Qualitative semi-structured interviews were conducted with 26 people comprising parents (n = 15), dentists working in primary care (n = 6) and operating dentists (n = 5) in relation to DGA. Participants were recruited from areas across the North West of England to ensure a variety referral and treatment experiences were captured. Field notes were made during visits to all settings included in the study and explored alongside interview transcripts to elicit key themes.

RESULTS

A variety of positive and negative impacts on children and parents throughout the referral process and operation day were apparent. Key themes established were clustered around three key topics: 1. Organisational and professional concerns regarding referrals, delivery of treatment and prevention. 2. The role of hospital environment and routine on the emotional experiences of children. 3. The influence of the wider social context on dental health.

CONCLUSION

These findings suggest the need and perceived value of: tailored services for children (such as play specialists) and improved information, such as clear guidance regarding wait times and what is to be expected on the day of the procedure. These features were viewed to be helpful in alleviating the stress and anxiety often associated with DGA. While some elements will always be restricted in part to the hospital setting in which they occur, there are several aspects where best practice could be shared amongst hospitals and, where issues such as wait times have been acknowledged, alternative pathways can be explored in order to address areas which can impact negatively on children.

Factors associated with the satisfaction of millennial generation dental residents

Data from the 2010 Learners' Perceptions Survey (LPS) administered through the Office of Academic Affiliations, Department of Veterans Affairs (VA) were analyzed to identify factors associated with dental residents' satisfaction with the VA as a clinical training environment. Satisfaction scores were linked to clinic workloads, dental procedure complexity levels, staffing patterns, and facility infrastructure data to explore conditions that may improve residents' satisfaction. Findings supported the construct validity of the LPS survey data and underscored the importance of maintaining optimal ratios of attending dentists, dental assistants, and administrative staff to residents so that each trainee will have opportunities to perform an adequate level of dental workload. As programs strive to improve the quality of graduate dental education, findings from this study are vital for setting curriculum design guidelines and for providing infrastructure support for dental resident education.

A description of a specialist led primary care based oral surgery service

AIM

To describe the establishment of a referral only oral surgery service in a primary care setting together with the challenges, benefits and successes of the service.

PROBLEM

In 1994 waiting times for hospital for oral surgery and maxillofacial procedures were unacceptably long. A proposal to establish a primary care oral surgery service aimed to complement the hospital-based service, reduce treatment delays.

OUTCOME

Referrals commenced immediately in response to a managed launch with local dentists recognising the service as a source of expedient and convenient treatment for their patients. The service now treats up to 1300 patients per year.

LEARNING POINTS

New dental services to dentistry can encompass different specialities. Initial capital investment is needed to develop a more cost-effective service. Recruitment of suitable specialist staff is a critical for success. Staffing, organisation and funding must be sustained.

Characteristics of dental clinics in US children's hospitals

PURPOSE

This study's purpose was to describe the workforce, patient, and service characteristics of dental clinics affiliated with US children's hospitals belonging to the National Association of Children's Hospital and Related Institutions (NACHRI).

METHODS

A 2-stage survey mechanism using ad hoc questionnaires sought responses from hospital administrators and dental clinic administrators. Questionnaires asked about: (1) clinic purpose; (2) workforce; (3) patient population; (4) dental services provided; (5) community professional relations; and (5) relationships with medical services.

RESULTS

Of the 222 NACHRI-affiliated hospitals, 87 reported comprehensive dental clinics (CDCs) and 64 (74%) of CDCs provided data. Provision of tertiary medical services was significantly related to presence of a CDC. Most CDCs were clustered east of the Mississippi River. Size, workload, and patient characteristics were variable across CDCs. Most were not profitable. Medical diagnosis was the primary criterion for eligibility, with all but 1 clinic treating special needs children. Most clinics (74%) had dental residencies. Over 75% reported providing dental care prior to major medical care (cardiac, oncology, transplantation), but follow-up care was variable.

CONCLUSIONS

Many children's hospitals reported comprehensive dental clinics, but the characteristics were highly variable, suggesting this element of the pediatric oral health care safety net may be fragile.

[Experience of using a filmless system in dental practice at Hiroshima University Hospital, a former university dental hospital]

Our university hospital has had a policy of electronic patient recordkeeping, replacing paper-based recordkeeping, since September 1, 2008. Because the Department of Oral and Maxillofacial Radiology had already been using computed radiography for X-ray systems except for intraoral radiography and storing data in Digital Imaging and Communications in Medicine (DICOM) format, the following three conditions form the basis of the changes we made in relation to the introduction of this policy. We started 1. using imaging plates for intraoral radiography as well and storing the data in DICOM format; 2. diagnosed without the need for film; and 3. referred to past images displayed on the screen of our Radiology Information System (RIS). The introduction of digital intraoral radiography has many advantages: not only does it not require film and can all past images be referred to on the screen of the RIS, but radiation exposure times are also shorter, images can be saved electronically, and thus, film processing is redundant. The system improves efficiency and is also advantageous to patients and staff in other departments.

An audit to assess the quality and efficiency of complete and partial dentures delivered by junior hospital staff

The average number of visits for the construction of metal-based and acrylic dentures by junior hospital staff was 10 visits. Our hypothesis was that supervision would optimise the number of visits and reduce any need for remakes. The first audit cycle was retrospective and included all patients treated by SHOs in the Prosthodontics Department. The standard of care was compared to the British Society for the Study of Prosthetic Dentistry. The re-audit showed that the time taken to completion was reduced by 2 visits for both denture types and the average length of time was reduced from 31 weeks to 22 weeks. These improvements were directly related to improved supervision by senior staff.

Documentation of clinical workflow: a key step in a plan to facilitate implementation of an Electronic Patient Record

After a year of preparation, the UT Dental Branch implemented an Electronic Patient Record (EPR) and a Picture Archiving and Communication System (PACS) for digital imaging. Central to the preparatory process was documentation of existing clinic workflow as a set of detailed flowcharts, which eased cultural and logistical changes and had the immediate benefit of increasing system efficiencies.

The use of theatre time for paediatric dentistry under general anaesthesia

OBJECTIVE

The aim of this paper was to determine the use of theatre time for all procedures performed under general anaesthetic on a paediatric dental list.

METHODS

A prospective study of paediatric dental general anaesthetic procedures was undertaken at Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK. Data were collected prospectively for 71 operating lists over a 3-year period from April 2003 to March 2006. Both operator status and the procedure being undertaken were recorded. In addition, pre-anaesthetic, anaesthetic, operating and disconnection times were recorded.

RESULTS

Of the 71 lists examined, 61 either finished early or on time, with a median unused time of 32.50 min (interquartile range = 19.50, 50.00 min), whilst 10 lists finished late with a median overrun time of 30.50 min (interquartile range = 9.25, 45.50 min). Comparing lists which finished late with those which were completed within time, the median pre-anaesthetic time was significantly longer (Mann-Whitney U-test, W = 20.05, P = 0.048). Overall, the theatre was in use for 78.22% of time combining pre-anaesthetic, anaesthetic, operating and disconnection times; hence, there was poor time utilization of theatre for 21.78% of the total theatre time.

CONCLUSIONS

Overall, 85.9% of theatre sessions for dental procedures under general anaesthetic in children finished early or on time. Where lists finished late, the duration of the pre-anaesthetic time appeared to be the significant factor.

Results of the centralisation of adult emergency oral and maxillofacial surgical services at the University Hospital, Birmingham

In 2001, the oral and maxillofacial surgical (OMFS) services for adults in Birmingham were centralised at the Selly Oak site of the University Hospital and the OMFS department was given access to the emergency operating theatre every day. We examined the effects of this on the emergency workload during the 6 months after centralisation and compared it with the emergency workload at the University Hospital during the 6 months before centralisation. The number of adult patients who attended the University Hospital as emergencies increased from 242 in the 6 months before centralisation to 545 in the subsequent 6 months (an increase of 127%). Of the latter 164 (30%) were admitted and operated on, 138 (84%) within 24h of admission. Despite the large increase in the number of patients, 102 (74%) were operated on during normal working hours. After centralisation, all operations were done on multidisciplinary emergency lists compared with only 55% before centralisation. Centralisation did not reduce the access of patients to the emergency service and conformed with the guidelines of the National Confidential Enquiry into Perioperative Deaths (NCEPOD).

Is the two week rule of any benefit to patients with oral cancer?

In the UK the government introduced the 'two week rule' for head and neck cancer in December 2000, which sought to guarantee that any patient with suspected cancer would be seen by a specialist within 2 weeks of being referred. Our aim was to find out whether referral under the 'two week rule' resulted in patients being given an appointment and starting treatment faster than those who had been referred urgently directly to a consultant surgeon. A retrospective review of case notes of all patients diagnosed with oral cancer over a six-month period showed that only 3 of 22 were referred under the 'two week rule'. A total of 48 referrals under the 'two week rule' were recorded during the same period. There was no significant difference between the two groups in terms of time waiting for an outpatient appointment and time spent waiting for treatment.

The use of postal reminders to reduce non-attendance at an orthodontic clinic: a randomised controlled trial

OBJECTIVES

To evaluate the effect of issuing a patient reminder plus a confirmation slip on the attendance of orthodontic new patients.

SETTING

Department of Orthodontics, University Dental Hospital of Manchester.

DESIGN

A randomised controlled trial.

METHODS

New patients were randomly allocated to:receive a reminder letter and return a confirmation slip ornot receive a reminder.

OUTCOME MEASURES

Patient attendance at the clinic.

RESULTS

A total of 232 patients were entered into the study between June 18, 2001 and August 29, 2001. These were randomly allocated to 115 (49.8%) in the reminder group and 116 (50.2%) in the no reminder group. If the patient received a reminder and returned the confirmation they were less likely to fail the appointment than if they did not receive a reminder (OR 0.4, 95% CI 0.2 to 0.96) There was an effect of social deprivation, if the patients lived in an area of high social deprivation they were 2.7 (95% CI 1.1 to 6.5) times more likely to fail to attend an appointment than people who were more affluent.

CONCLUSIONS

The use of postal reminders for orthodontic consultation appointments appears to result in a useful increase of appointments that are kept or cancelled in advance.

Experience of 2 dental clinics registered to ISO 9002

This paper describes the 3-year experience of managing 2 hospital-based dental clinics registered to ISO 9002:1994; it also examines the revision of previous quality management standards in 2 separate institutions to prepare for registration under the new ISO 9001:2000 standard. Daily equipment and process checks, combined with internal audits, were the backbone of the quality system at both locations. Corrective and protective actions had been underused, because of the partial duplication produced by 2 different institutionally mandated risk management and incident reporting systems. ISO 9002 registration provided both dental clinics with responsive quality systems, emphasizing patient satisfaction and providing measurable continuous quality improvement.

Stretching the safety net too far waiting times for dental treatment

PURPOSE

The objective of this study was to survey pediatric dentistry program directors on perceived resource needs and changes over the last 5 years in the characteristics of their patient population and on waiting times for dental treatment with sedation or general anesthesia (GA) for children with complex dental and medical histories in hospital- and dental school-based training programs.

METHODS

A 47-question survey was sent electronically to all pediatric dentistry program directors in the United States using the University of Washington's Catalyst Tools program. Two reminder messages were sent. After 3 months, the data was downloaded and descriptive statistics were performed using the SPSS for Windows version 8.0.

RESULTS

Twenty-eight of 54 program directors responded with 26 usable survey responses (48%). Thirty-one percent reported outpatient clinics located in a dental school, 31% reported that their clinics were in a hospital, and 38% had clinics in both settings. Program directors perceive that the number of new, recall and emergency patients and the number of pre-school aged children and children with special health care needs had increased in their programs in the last 5 years. Payment by Medicaid was the most common insurance for children cared for in these settings. The mean waiting time for scheduling treatment with GA for a child in pain is 28 days; without pain 71 days. The mean waiting time for scheduling treatment with sedation is 36 days. The majority of program directors reported they had an adequate number of faculty and residents (61% and 66%, respectively) even though 52% of the directors were presently actively recruiting faculty.

CONCLUSIONS

1. Dental school and hospital-based training programs are an important source for an increasing number of children with complex dental needs; 2. The majority of patients treated in the programs are Medicaid beneficiaries; 3. Average waiting times for complex dental care for children in pain is 28 days with GA; without pain and need for GA 71 days; 4. There was an average 36-day wait for treatment with sedation.

Integrating hospital dentistry into the general dental practice

Societal trends and medical advances have resulted in increased numbers of physically and/or psychologically challenged individuals living within our communities. For some of these individuals, hospital dentistry with general anesthesia provides the only means by which general dental services may be provided. This paper presents considerations of significance to the general dentist wishing to incorporate outpatient hospital dentistry into his or her private practice.

Counselling and communication in hospital dentistry

Many of the people who are members of hospital dental teams are highly motivated, caring individuals. Unfortunately, though, they are not given the kind of training or support that is necessary to enable them to perform their tasks most effectively. This study was initiated at a hospital dental clinic where burdensome cutbacks and reorganization had been keenly felt by the personnel. A counselling group was formed under the leadership of a professional counsellor, and in the course of the year there were seven meetings, each of which lasted 1.5-2 hours. The open way in which counselling was designed presented opportunities for the six group members to influence the topics of each meeting, something all of them preferred to more structured sessions. Different stress factors in the environment were discussed. The group members concluded that the counselling programme had increased their self-esteem and facilitated effective communication between the group and patients by giving them all the opportunity to discuss barriers and confusing clinical situations. Counselling had also facilitated interpersonal relationships between the team members by revealing hierarchical difficulties. Apart from the clear humanitarian need for counselling there is a good economic argument. Effective staff support is not a luxury, nor is it a waste of time. Adequate time for counselling must be provided, simply.

Seattle hospital opens renovated children's dental clinic. Joins effort to promote children's oral health

The pediatric dental clinic at Seattle's Children's Hospital and Regional Medical Center is filled to capacity, so marketers can invest efforts in community outreach and educational projects.

An orthodontic patient administration system (OPAS) for complete departmental management

There is a requirement for effective management and audit in today's hospital environment. This paper discusses some of the principal requirements of a computer program for comprehensive orthodontic department management and describes in detail one system.

Integration of the digital imaging and communications in medicine standard into an oral and maxillofacial image management and communication system

OBJECTIVE

The purpose of this study was to provide developmental information about digital imaging and communications in medicine (DICOM) support applications for an image management and communication system (IMACS).

STUDY DESIGN

An oral and maxillofacial radiology IMACS that uses a proprietary image format was implemented in March 1997 in a general hospital dental clinic that supports more than 100 cubicles. DICOM was implemented into this system in 1998.

RESULTS

In March 1997, the clinic directly began processing oral and maxillofacial radiographs with digital image acquisition devices or converted them into proprietary digital format with a film digitizer. The digital images could then be viewed at workstations in the 11 different divisions of the department. A DICOM module was implemented to convert proprietary images into DICOM in June 1998. After the release of DICOM Supplement 32 on a digital x-ray, DICOM was implemented into the oral and maxillofacial radiology IMACS with a DICOM server and browser in June 1999. We describe the steps we took to implement this system in our institution with a brief report on the evaluation of this system.

CONCLUSION

We implemented a DICOM oral and maxillofacial IMACS that complies with the American College of Radiology and the National Electrical Manufacturers Association Standard DICOM, version 3.0. Most DICOM service classes and roles are supported.

Assessment of objectives of post-doctoral general dentistry programs in Canada

Objectives of hospital-based post-doctoral general dentistry programs in Canada were assessed by questionnaire. Seventy percent (14 of 20) of the program directors responded. Educational goals and objectives were assessed in professional skills and practice management, public health and preventive dentistry, oral medicine and pathology, special needs patient care, trauma and emergency care, restorative/prosthodontic care, endodontics, orthodontics/pediatric dentistry, oral surgery, periodontics, pharmacology, and functioning in a hospital. High rankings of proficiency were related to primary care, restorative/prosthodontic, endodontic, and surgical care. Emergency care, sedation, and pharmacology were also ranked highly. Lower rankings of proficiency were reported in orthodontics, aspects of public health dentistry, practice management, and advanced oral and maxiliofacial surgery. When the results of the Canadian survey were compared with those of a survey of US post-doctoral general dentistry programs, substantial similarity was seen. The findings support continuing reciprocity in accreditation standards between the Canadian and American Commissions on Dental Education and Dental Accreditation.

A study of the career development of male and female dental practitioners

AIM

The aim of the study was to determine differences between male and female dental practitioners in the positions they occupy within their employment, and to analyse the correlates of such differences.

METHOD

Postal questionnaire survey of a 1 in 10 sample of individuals taken from the General Dental Council register.

RESULTS

Female dental practitioners occupy lower positions in the employment hierarchies of the Community Dental Service and the Hospital Dental Service. Women general dental practitioners are significantly less likely to be sole proprietor of, or a partner in, a general practice. Ownership of a general practice is related to: sex, age, number of years qualified, number of children, and hours worked. Consultants in the Hospital Dental Service are more likely to be male, older, to have been qualified longer and (obviously) to hold more additional qualifications than their non-consultant colleagues. Senior Dental Officers and Directors of the Community Dental Service are more likely to be male, work longer hours and (again obviously) to hold more additional qualifications than Community Dental Officers.

CONCLUSIONS

Differences exist between male and female dental practitioners in the positions they occupy within employment hierarchies. Age, length of time since qualification and the acquisition of additional qualifications are consistently found to differentiate dental practitioners' status.

[Two or three things about the PMSI in stomatology and maxillofacial surgery]

The Information Systems Medicalization Program (PMSI in French) was created in 1985 for Public Health Service Hospitalisation Structures. It appeared to be directly derived from the North-American Diagnosis Related Groups (DRGs) system. Since them, the PMSI has been progressively developed in private structures as well. The authors have had the opportunity to use the latest version of the computer program which was elaborated in order to share the patients into more than 500 different groups of pathology. These groups were called "Homogeneous Patients Groups" (GHM in French). To each group corresponds a "Synthetic Activity Index" number (ISA in French). It is supposed to be representative of the average cost of the management of each kind of patients, based on the diagnosis and the surgery possibly done. Several astonishing findings have been made. Some of them can be summarized as mentioned below: In maxillofacial Surgery, each group (GHM) seems in fact to be extremely inhomogeneous: for example, total parotidectomy with preservation of the facial nerve belongs to the same group as accessory salivary gland exeresis. Total skin graft is in the same group as free composite osseous flap with vascular anastomosis. Coding a surgical procedure leads often to reduce the ISA number in comparison with the same patient without surgery: "impacted third molar" gives 754 points without surgery but only 658 if surgery is performed. Carcinologic surgery is wholly grouped in the same category, even for rather short procedures as isolated partial glossectomy. This group corresponds to a great number of ISA points (6486) while bimaxillary surgery or free flap transfer gives less than 2500 points. In conclusion, the use of the PMSI to allocate financial means can be extremely dangerous for maxillofacial surgery units and consequently for the quality of the medical care in our Specialty. Further studies are obviously necessary to complete a critical analysis of the current system and to improve it.

[Ways of restructuring ambulatory stomatological care network]

The most important problems in modern Russian dentistry are defined. An obligatory condition for their successful solution is clear-cut orientation at the priority use of economic and medicolegal approaches to reformation of the service.

The changing role of specialist care in NHS dentistry

Specialisation and Specialist Training in Dentistry in the UK have been central issues for debate in the last few years. The profession has emerged stronger in understanding the respective roles of the generalist who should remain free to practise across the whole spectrum of dentistry and the specialist who can work in primary and secondary care. The overriding principle is that the patient remains the true beneficiary of a specialised service within the NHS.

A matter of minutes--a history of The Hospitals Group 1947-1997

As The Hospitals Group of the BDA reach their 50th anniversary their history has become more than a matter of minutes but spans a considerable number of years of impressive achievements and sheer determination. The following account of the Group's history has been extracted from the minutes of their meetings at the BDA and reflects issues that are still prevalent today.

General dental practitioners' opinions on orthodontics in primary and secondary care

A survey of 232 general dental practitioners was undertaken by the purchasing authorities in Hereford and Worcester, England, in 1993, to establish local practitioners' views on primary and secondary care orthodontics. The response rate was 90.1%. The dentists overestimated their orthodontic case-load: 66.6% of contract holders submitted no claims for upper removable appliances (URA) treatment, but 70.8% claimed they undertook removable appliance therapy. Dentists believed orthodontics should be a feature of the General Dental Services (GDS) but did not seem inclined to commit themselves to providing it. A majority of GDPs (54.9%) felt orthodontics was uneconomic under the GDS. There was support for the treatment planning role of hospitals, but although this was available locally it did not appear to have stimulated primary care provision. Consultant outreach clinics were not generally supported but there was a desire for more opportunities for hospital clinical attachments in orthodontics. The implications for the policies of National Health Service (NHS) purchasers are considered: purchasing health authorities need to carry out systematic assessment of the views of their general dental practitioners and take account of their desired patterns of specialist provision. Policies encouraging the shift of orthodontics into primary care are called into question by this study. If demand for orthodontics is to be met, policy should concentrate on the development of hospital services and specialist practitioners.

Dentaline: an out of hours emergency dental service in Kent

Following wide consultation in 1991 on how to meet the requirement for out-of-hours emergency service provision, Kent Family Health Services Authority established three emergency dental clinics. The sites chosen were in or adjacent to District General Hospital Accident and Emergency Departments. Local dentists were contracted to provide a service each evening and also weekend and bank holiday mornings. Activity is reported for the three and a quarter year period from October 1991 to December 1994 with 300 dentists operating a rota to attend the clinics to provide 'occasional treatment' for all-comers. Drugs, if required, are dispensed directly and, where appropriate, NHS charges levied. On average, each operator works once every 3 months.

Consultant services in restorative dentistry

Since restorative dentistry was established as a specialty in the UK in 1973, consultant appointments in the field have largely centred around the dental teaching hospitals with a considerable shortage of posts in the district general hospitals. This article explains the growing demand for restorative consultants and calls for the expansion of the hospital restorative dental service.