an audit into the repeat attendance by paediatric patients on ga lists



an audit into the repeat attendance by paediatric patients on ga lists
‘Repeat attendance by paediatric patients
on general anaesthetic lists over 5 years OSPCDS’
Emma Nguyen, Natalie Ackuaku
The Oxfordshire Salaried Primary Care Dental Service (OSPCDS) is based
over 6 dental clinics within Oxfordshire. It aims to provide dental treatment and
advice to a wide range of patients including children and adults requiring
specialised care. Dental treatment which involves sedation and general
anaesthesia (GA) may form a part of this. 1,2
For children, GA is either carried out at the Horton Hospital for routine cases,
or the John Radcliffe – West Wing for children who are have been assessed
as having complex medical histories, special needs and learning disabilities.
The treatment carried out commonly includes; EUA (Examination Under
Anaesthesia), radiographs and prevention- (for example fissure sealants),
fillings or extractions.
Paediatric patients are first seen at one of the 6 clinics for examination and
assessment. Children are either referred to us from general dental practice or
they are our own CDS patients. At this initial appointment a definitive or
provisional treatment plan may be formulated, treatment options given and
any further referrals discussed. The parent is then given the opportunity to
ask any questions and make a decision on what treatment they would like to
undertake. If a GA is seen as the most appropriate treatment option for the
patient all relevant paperwork would be completed and pre-operative
instructions given- both verbal and written.
It is important that a comprehensive plan is developed to try to avoid the need
for repeat GA episodes (comprehensive planning aims to ensure that all
treatment required is carried out under a single GA episode.)2
Aims of Audit
The aim of this audit was to investigate the number of paediatric patients (16
years and below) who over a 5 year period underwent more than one GA.
We selected to analyse any repeat GA cases between 01/04/2009 to the
31/03/2014. The data collected should allow for assessment of the possible
reasons for this- whether it was due to a lack of comprehensive treatment
planning, or preventive advice, or perhaps linked to a medical or behavioural
issue making treatment without GA challenging.
Audit team
The audit team consisted of:1. Emma Nguyen- Audit Lead -Dental Officer at Oxford Health Foundation
2. Natalie Ackuaku- Current Dental Core Trainee at Oxford Health
Foundation Trust
Audit Protocol
The number of repeat episodes of dental care for children receiving treatment
under GA in OSPCDS will be investigated over a 5 year period from 01/04/09
to the 31/03/14. In those patients who have undergone more than one
episode of treatment under GA during this time period, the treatment provided
during each treatment episode will be noted. Data will be recorded on a
proforma (appendix 1). A written report of the findings with recommendations
and suggestions for future re-audits will be produced.
Time Frame and Data collection
Collection of data was carried out during August to October 2014. A written
report will be produced by December 2014.
In order to find relevant patients, an R4 query will be run to look up all patients
with appointment type ‘DSU Paediatric List’ (Paediatric General Anaesthetic
clinic) all duplicates will then be identified and these patients’ details recorded
and analysed.
At present there are only guidelines relating to GA and no set standards. The
Guidelines as to the indications of general anaesthesia for children as defined
by the UK National Clinical Guidelines in Paediatric dentistry (2008), suggest
that GA in children should only be carried out if the child requires full
anaesthesia before dental treatment can be attempted or if the surgeon
requires the child to have full anaesthesia prior to treatment.
Guidelines suggest that factors to be taken into consideration may include;
 Child co-operation
 Perceived anxiety
 Complexity of treatment
 Extent of surgical trauma anticipated
 Medical status2
See appendix 2 for full list.
Guidelines also state that repeat GA’s are undesirable in terms of morbidity,
potential mortality, associated behavioural and emotional effects as well as
cost. (The current mortality rates associated with GA in developed countries is
1:400,000) 3
Results summary
See appendix for full table of results
Total number of patients having GA in the 5 year span= 2793
No of paediatric
patients receiving
repeat GA treatments
within 5 years
No of patients
receiving 2 GA
treatments within 5
No of paediatric
patients receiving 3
treatments under GA
within the 5 years
looked at
Total number of
retreated teeth
Total number of
patients with retreated
Total number of
patients with possible
contributing MH/SH
No of patients with
evidence of OHI/ diet
Total number of
patients who had
diagnostic imaging for
Average patient age
5 years
Number of patients receiving treatment under GA in 5 year span = 2793
Number of GA episodes that were repeats = 62
% of patients having more than one GA for dental treatment = 2.2 %
Table showing age distribution or repeat GA patients
Patient age
No of patients
Percentage of
2% 5% 10% 21% 23% 11% 5% 2% 5% 2% 5% 8% 2%
Figures of results
Figure 1-bar chart showing age distribution of patients undergoing repeat GAs
Figure 2- bar chart showing patient factors to consider with regard to repeat
Figure 3- showing proportion of patients with GA repeats
The above results show that 62 patients received more than one episode of
dental treatment under GA within 5 years and that 1 patient had three
treatment episodes under GA within the 5 years investigated.
In total, 28 patients had repeat dental treatment on the same tooth/teeth
under GA within 5 years.
There are a number of factors that may have influenced these repeat
treatment results, perhaps a more comprehensive and radical plan was
indicated for a number of patients due to social or medical factors. It may
have been that the dental treatment provided failed or that poor patient
compliance led to new disease developing on the same tooth.
Other findings included that there were a total of 17 patients whose medical
history may have influenced the decision to treat under GA and perhaps also
the need for a repeat GA. A total of 3 out of the 62 patients had no medical
history that could be found.
Oral hygiene instruction was documented to have been provided for 47 of the
62 cases (76%)
Justification for a dental GA was not always recorded in R4 notes.
It should also be noted that there was not always a recall interval given for
CDS patients following their GA treatment and that the most common interval
was 6/12 months.
Most patients who were referred in by their GDP were discharged back to
their practitioner following their treatment and so a recall was not indicated
and therefore not documented in our notes. In these cases a letter would be
sent to the referring practitioner and GP.
Overall the audit has provided some useful information; however it must be
taken into consideration that the statistical data represents a five year period
and therefore may not necessarily be a reflection of poor treatment planning,
for example, new caries at previously sound teeth may have developed in this
time span. We must also note that patients with complex social or medical
histories will certainly undertake further treatment if these factors contribute to
a lack of cooperation for treatment under LA or RA.
It would not be unreasonable to note that patients may have had repeat dental
GAs carried out by other trusts or private practitioners and this information
was unavailable to us.
The main recommendations from this audit are:1. Reinforcement of OHI/ preventative advice for high risk patients (
including all those who have had a GA episode at frequent intervals
ideally every 3 months (NICE recall guidelines)- perhaps recall should
also be suggested for referring GDPs 4
2. Ensuring full contemporaneous notes are kept for all patients including
patient details, MH, SH, FH, records of dental imaging and OHI/ diet
advice, and GA justification.
3. More dental imaging if tolerated by child patients to allow for more
informed treatment planning. If patients are unable to co-operate with
imaging in the dental setting to ensure that bitewings are carried out
under GA for all patients.
4. Considering the implementation of more frequent use of stainless steel
crowns – hall technique.
5. Considering whether primary teeth should be filled under GA or
extracted only
6. Stricter qualification for GA- ensuring only primary teeth with pain/
evidence of infection are treated under GA
A suggested re-audit would be in 5 years’ time to reassess the repeat
treatment episodes under general anaesthesia for child patients in
Oxfordshire Salaried Primary Care Dental Service.
Oxford Health NHS Foundation Trust Oxfordshire Salaried Primary Care
Dental Service
2. C. Davies, M. Harrison, G. Roberts (2008) UK National Clinical Guidelines in
Paediatric dentistry
3. Boyle C. (2007).Sedation and general anaesthesia in special care dentistry. In
Wilson NHF ed. Special Care Dentistry. Quintessence. London
Dental recall: Recall interval between routine dental examination. National
institute for health care excellence
5. UK National Clinical Guidelines in Paediatric Dentistry. Guideline for the Use
of General Anaesthesia (GA) in Paediatric Dentistry. Dr. Caroline Davies
(Consultant Paediatric Anaesthetist), Mr. Mike Harrison (Consultant in
Paediatric Dentistry) Prof. Graham Roberts (Professor and Honorary
Consultant in Dental Paediatrics)

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