Public Health/Paediatrics

1. Public Health/Paediatrics • Audit Review of Paediatric Dental Extractions at Furness General Hospital (May 2015 – August 2015) • Dr JMathieson, Consultant in Public Health • DrJKenyon, Public Health Specialty Registrar • Dr AAbdu, FY2 in Public Health/Paediatrics • 23/11/2015

2. Introduction • The public health team at Cumbria County Council were made aware via Mark Lippett, Named Nurse for Safeguarding and Child Protectionat Furness General Hospital in Barrow-in-Furness, of many children coming through for dental extraction and that some appeared to have safeguarding issues. • There were more admissions for dental extraction in the 0-9 year age groups in Barrow-in-Furness compared to the 10-19 year age groups between 2011 and 2014 (table below). • Higher number & percentage of dental extractions in the 5-9 year age group in Barrow-in-Furness compared to the rest of Cumbria & England (next slide).

3. Introduction Admission to hospital for extraction of one or more decayed primary or permanent teeth 0 to 19 year olds, 2011/12 to 2013/14in England and Cumbria (Source: Public health England, Dental Public Health Intelligence Programme)

4. Introduction • Public Health Outcomes Framework • Tooth decay in children aged 5 years (Indicator 4.02) • Mean severity of tooth decay in children aged five years based on the mean number of teeth per child sampled which were either actively decayed or had been filled or extracted • – decayed/missing/filled teeth (d3mft) • Barrow-in-Furness 1.45 d3mft per child • Cumbria 1.16 d3mft per child • England 0.94 d3mft per child

5. Introduction Referral pathway HIGH STREET DENTIST • Independent dentists, paid for by NHSEngland • Refer patients to community dental • team • (High number of corporate high street dentists in Barrow) • Community Dental Team at BARROW • DENTAL CENTRE (Cumbria Partnership NHS Foundation Trust): • Review patient • Perform consent for treatment under general anaesthesia • FURNESSGENERAL HOSPITAL (University Hospitals of Morecambe Bay NHS Foundation Trust) • Place where dental extractions under general anaesthesia occur • Community dental team are from Barrow Dental Centre • Nursing team from Children’s Ward at FGH, part UHMBT • Anesthetic team are also part of UHMBT

6. Introduction Patient journey at FGH • Children’s ward (patient under care of FGH) • Operating theatre (patient under care of Anaesthetists and then during • dental extraction, they’re under care of Community dental team) • Recovery (patient care back under Anaesthetists) • Children’s ward (return to care of FGH) • Discharged back to care of high street dentist • NOTE • Paper operation note written by Community dental team for FGH with • electronic version created externally to FGH on Community dental team’s computer system • No FGH discharge summary on FGH electronic discharge letter system.

7. Introduction • This audit is a project, auditing the care and outcomes of a sample of 50 patients who have had tooth/teeth extraction(s) at Furness General Hospital between May 2015 - Aug 2015 • In this way we can monitor patient care and ensure that management is in accordance with current best practice guidance for optimum safety and outcomes • In addition provide evidence of quality and safety assurance for patients and staff.

8. Introduction This project also attempted to gather the following information, so as to attempt to identify trends which may be seen as risk factors for dental extractions: Home parental situation? (e.g. parents married, divorced, single, foster care, living with guardian) Was dietary intake recorded? Was advice then given on dietary behavior? Are they having regular dental checks? Are they registered with a dentist? Referring dentist name Referring dental practice name School attended History of previous dental extraction? Past medical history (e.g. diabetic, asthmatic, autism) Family history (e.g. any other sibling had teeth extracted?)

9. Aims • Audit review has two objectives • To assess and review practice of Paediatric dental extraction at Furness General Hospital (FGH) against published standards of clinical care in light of higher than expected number of paediatric dental extractions at Furness General Hospital compared to the rest of Cumbria and England • To make recommendations on how to improve the quality of care for children and young people undergoing dental extractions

10. Audit Questions • Five Audit Questions: • Audit question 1,2,3 are anaesthesia-related. • All from Guidelines For The Management Of Children Referred For Dental Extractions Under General Anaesthesia, August 2011 • Are children assessed using a single standard method of assessment and preparation that any child undergoing general anaesthesia (regardless of clinical reason for anaesthetic) at FGH is assessed against? • At assessment, is General Anaesthesia(including risks & benefits), explained to the parent and child? • For the children requiring a General Anaesthetic is there a documented clinical reason(in the dental clinic notes) for this to be the most clinically appropriate method of management for dental extraction at Furness General Hospital?

11. Audit Questions • Audit question 4: Documentation-related • From GMC Good medical practice, 2013 • 4. Do the clinical records state decisions made and actions agreed, and who is making • the decisions and agreeing the actions? • Audit question 5: Safeguarding-related • From UHMBT Safeguarding Children Policy 2012 • 5. Is every child assessed for safeguarding risk, in line with Furness General Hospital’s • guideline/policy?

12. Audit Standards

13. Methodology • Data Sources: Random sample of 50 hospital case notes of children between ages of 0-9 years age group admitted for dental extraction. Children were identified from admissions list provided by Clinical Audit Office • Guidelines: 1) Guidelines For The Management Of Children Referred For Dental Extractions Under General Anaesthesia, August 2011 http://bspd.co.uk/Resources/Partner-Guidelines) • 2) Good medical practice, 2013 http://www.gmc-uk.org/guidance/good_medical_practice/record_work.asp) • 3) UHMBT Safeguarding Children Policy 2012 • Data collection: Microsoft Excel Spreadsheet for retrospective data collection • Audit Period: 01/05/2015 - 31/08/2015 • Total cases identified: n=60 • Data source availability, n=50 • Actual audit sample: n= 50/60=83%

14. Results • Majority (21/50) of these samples were in June 2015 • Ages of admissions: 2-8 years (average of 5.22 years) - most admissions sampled were between 4-7years (41 children) • The sample included 29 Males & 21 Females • 10 of these children had their co-morbidities recorded • (6 had autism/Attention deficit hyperactivity disorder /DiGeorge syndrome) • Most common school attended by patients: St Pius Catholic Primary School (4) followed by Sacred Heart Catholic Primary School & Millom Infant School (3) then Vickerstown Primary and Brisham Palace(2)

15. Results • LA14 versus • other postcodes

16. Results 1 2 3 3 4 1 1 1 5 24 5

17. Results • Average number of teeth extracted was 5.14 teeth per child • 46/50 children had multiple teeth extracted • 4/50 had a single tooth extracted • The average time delay of procedure was 20 minutes = actual time of procedure - scheduled time of procedure • Range between 1.5 hours early to 3 hours 24 minutes late • 22/50 of procedures were delayed by >30 minutes • 8/50 of procedures were delayed by >1 hour

18. Results • The following data were not encountered in the patients’ notes : • Dietary intake • Advice on dietary behaviour given? • Regular dental checks? • Registration with a dentist? • Referring dentist name • Referring dental practice name • History of previous dental extraction • Family history (e.g. any other sibling had teeth extracted?) • Home parental situation (both parents, single parent, fostered etc) • School occasionally documented

19. Results

20. Results • Safeguarding assessments(Done vs Not done)

21. Conclusion • The results show that there was 100% adherence to the set standards 2 / 5 areas • Audit standard three and four fell below par as there were no operation notes/dental clinic notes in six of the case files. This could be due to either misplacement of the notes or insufficient documentation.

22. Conclusion • However, our compliance with safeguarding checks is something that we need to improve on, as this is a high priority issue – both locally and nationally. Every contact with health services should be an opportunity to pick up potential cases & thus stop harm to children. • In addition the average number of teeth extracted could potentially be reduced if more was done on preventing caries (school campaigns, postal advice to certain postcodes) • Also, most of the cases in this sample were from Barrow-in-Furness, so this may need to be investigated further i.e. to see if most children are from a certain postcode in Barrow.

23. Recommendations • 1.Maintain the compliance demonstrated so far. • 2. Checklist to make sure Barrow Dental Centre notes as well as operation notes are in Furness General Hospital case files before these leave the ward. • 3.Highlight the importance of safeguarding assessment for every patient at Nurse training days and induction. • 4.Change the dental admission pro forma. At present nursing staff should place safeguarding stickers in the notes after an assessment - if “safeguarding assessment” was already part of the pro forma then it would serve as an additional prompt to staff carry out the assessment. This may make it easier for nursing staff to remember to carry out the assessments. • 5.Audit a larger sample of patients so results are more representative.

24. Recommendations • 6. Lorenzo electronic Furness General Hospital discharge summaries should be completed ideally before patient discharge, but at least within 24 hours of discharge. • 7.Liase with high street dentists (who are ultimately responsible for long-term dental care of these children) regarding ways in which we can reduce the number of admissions for dental extractions under general anaesthesia e.g. education of parents, children, schools etc. • 8. Although high street dentists are responsible for the long-term dental care of these children. The fact that they come into FGH for extractions means that this is opportunity for intervention with regards to educating parents and children and think that this should be done as part of their routine care at every opportunity possible.

25. Limitations of the audit • Small sample size • Small number of months that were included in the audit • Possible confounding factors leading to relatively high number of admissions for dental extraction: • Relatively high level of deprivation in Barrow-in-Furness (e.g. dental health may not be a priority for many families, lifestyle, diet) • Variability in the experience of referring dentists leading to more referrals for extraction under GA • Environment – water fluoridation on/off in Cumbria • Error in the figures

26. Acknowledgements • A special thank you to Dr J Kenyon & Dr J Mathieson for all their help & support throughout my rotation in Public Health. • Also thanks to Mark Lippett for identifying the safeguarding issue & Dr Stephen Jones, Clinical Director Community Dental Service, for facilitating this audit.