Clinical Protocol Documentation for Patients Attending for Exodontia under General Anaesthetic Clinical Records and Patient Information

Transcription

1 Clinical Protocol Documentation for Patients Attending for Exodontia under General Anaesthetic Clinical Records and Patient Information CP:92 [Version:1] Applies to:- Specialist Dental Services Sub Committee for Approval Clinical Effectiveness Group Date of Approval 17 th June 2016 Review Date June 2019 Title of Lead Manager Francesca Daley Policy Author Francesca Daley Summary key points:- Review/Update January 2016 UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 A completed Equality Impact Assessment will be available on the trusts website Consultation Subject Experts Group/s Consultation NICE Lead Consulted (As required) Infection Control Approved (As required) Francesca Daley Clinical Effectiveness Group Francesca Daley Version Control Version No Type of Change Date Approved 1 New 17 th June Description of change Status New / Revised / Trust Change IG10 Documentation for Patients Attending Exodontia Under General Anaesthetic Clinical Records and Patient Information

3 Clinical Protocol for Patient s attending for Exodontia under General Anaesthetic 1. INTRODUCTION The purpose of this clinical protocol is to ensure that the clinical records of patients attending for exodontia under general anaesthesia are accurate and complete, and, that each patient is suitably prepared for their appointment. 2. STATEMENT OF INTENT One of the specialist services provided by the Community Dental Service (CDS) is the General Anaesthesia (GA) exodontia service. Referral for GA extractions come from both General Dental Practitioners (GDP) and from Community Dentists and is a two visit process, following the Guidelines for the Use of General Anaesthesia in Paediatric Dentistry British Society for Paediatric Dentistry (BSPD 2008). The pre-operative assessment visit is carried out in one of the CDS clinics. It is at this visit that the diagnosis, treatment planning and medical checks are carried out. A complete set of GA clinical records, which is distinguishable from the rest of the clinical notes and which itemise each procedure to be carried out under GA, is prepared at this visit. Written consent is obtained, the Parental Responsibility (PR) form (the NHS acceptance form) is completed and full pre and post-operative instructions given for the second stage of the process, ie the extractions under GA, which is carried out at Wirral University Teaching Hospital (WUTH) As the extractions at WUTH are usually carried out by a different dentist than the one who has done the assessment, it is vital that the GA clinical notes are accurate and complete. 3. TARGET GROUP All dentists, dental nurses and receptionists employed by Wirral Community NHS Foundation Trust Salaried Dental Service. 4. TRAINING REQUIREMENTS All staff in the trust are required to comply with mandatory training as specified in the trusts Mandatory Training Matrix. Staff are also required to comply with job relevant training in their service as specified within their service training matrix and on the Learning and Development Section on the StaffZone. 5. RELATED POLICIES Please refer to relevant Trust policies and procedures always use the StaffZone to ensure most recent version is accessed 6. PREPARATION OF CLINICAL RECORD Following assessment of the patient, if treatment under GA is indicated, a complete set of GA clinical notes distinguishable from the rest of the clinical notes must be prepared, itemising each procedure to be carried out under GA. In the case of patients that have been referred into the service for GA extractions these will be the only set of records IG10 Documentation for Patients Attending Exodontia Under General Anaesthetic Clinical Records and Patient Information

4 All GA clinical notes will have: Patient assessment form Medical history form Consent form Parental Responsibility (PR) form General anaesthetic extraction sheet (yellow) If appropriate records will also have: Radiographs Original referral letter from GDP Orthodontic treatment plan GA alert card (Red) Patient Assessment Form The patient s demographic details and the name of the referring dentist will have been completed by the receptionist prior to them coming in to the surgery to see the dentist. If following clinical examination treatment under GA is indicated the dentist will specify this treatment option on the assessment form and will then prepare a complete and distinguishable set of GA clinical notes. Medical History Form The medical history form will generally be completed by the patient or their parents/carers in the waiting room prior to them coming in to the surgery to see the dentist. The dentist will check through this information to see if more detailed information is needed. If the medical history indicates that pre-operative tests and /or discussion with the anaesthetist are required, prior to the patient having a general anaesthetic, the dentist will complete a GA Alert Card and place it in the clinical record. Once the medical history checks have been completed, it is the responsibility of the dentist and dental nurse to ensure that the form has: Patient s name and Date of Birth (DOB) Name of the patient s GP/medical consultant Is signed and dated by the parent/carer. Completion of these details will be confirmed on the GA Extraction Form (yellow) by completion of the tick box. Consent Form Specific written consent will be obtained at the time of treatment planning using Department of Health (DH) consent form 2 or consent form 4 if the patient is unable to IG10 Documentation for Patients Attending Exodontia Under General Anaesthetic Clinical Records and Patient Information

5 consent, complying with the Trust s Patient Information and Consent policy. A copy of the consent form will be given to the parent/carer at this visit. It is the responsibility of the dentist and dental nurse to ensure that the consent form: Has the patient s name and DOB Is signed and dated by the parent/carer Is signed and dated by the dentist Itemises the treatment to be undertaken The teeth to be extracted match those recorded on the GA extraction form (yellow form) Has brief explanation of the benefits and risks of treatment referencing the appropriate patient information leaflets. Completion of these details will be confirmed on the GA Extraction Form (yellow) by completion of the tick box. If the consent form cannot be signed at this visit eg parent/carer not available, then a GA Alert Card will be completed and placed in the clinical record. PR form The PR form will be completed by the receptionist at the reception desk, and will be signed and dated by the patient or their parent/carer before the patient comes in to the surgery to see the dentist. The receptionist will fill in the patient s details and will complete the date of acceptance box. It is the responsibility of the dentist and dental nurse to ensure that this form has been completed and that the course of treatment number has been entered. Completion of these details will be confirmed on the GA Extraction Form (yellow) by completion of the tick box. If the PR form is not completed at this visit then a GA Alert Card will be filled in and placed in the clinical record. General Anaesthetic Extraction Sheet (yellow form) The GA extraction sheet (appendix 1) will be completed by the dentist following the clinical examination. It is the responsibility of the dentist to ensure: The form has the patient s name and DOB The name of the GP/medical consultant An indication of relevant medical history The teeth to be extracted are clearly recorded on the dental chart in permanent black ink. The teeth marked for extraction match those recorded on the consent form No other dental charting is recorded on this form (eg cavities/fillings). The tick boxes to confirm completion of medical history, consent and PR forms and to confirm the presence of radiographs will be completed and signed off as each IG10 Documentation for Patients Attending Exodontia Under General Anaesthetic Clinical Records and Patient Information

6 process is complete. If a GA Alert Card is in the clinical record then the box relating to the incomplete process must not be signed until the GA Alert Card has been removed. Radiographs It is the responsibility of the dentist carrying out the assessment, to ensure that the clinical record has radiographs for all permanent teeth that have been treatment planned for extraction. Digital radiographs will be printed and placed in the record card. The availability of radiographs will be confirmed on the GA Extraction Sheet (yellow form) by ticking the radiograph box. If radiographs are not available at the time of the assessment then a GA Alert Card must be completed and placed in the clinical record. Referral Letter from GDP If the patient has been referred in to the service by a GDP, the referral letter from the practice must form part of the clinical record. Orthodontic Treatment Plan If teeth are to be extracted for orthodontic reasons, then a copy of the orthodontic treatment plan must form part of the clinical record. If the orthodontic treatment plan is not available at the time of the assessment then a GA Alert Card must be completed and placed in the clinical record. GA Alert Card (red) The GA Alert Card (appendix 2) will be used to highlight a problem that has arisen at the assessment appointment which means that a GA appointment cannot be booked, eg patient needs pre-operative tests, consent signing, radiographs are needed The dentist will complete the GA Alert Card, stating the reason for the alert, and place it in the clinical record card. Only when the outstanding issue has been dealt with can the card be removed from the clinical record and signed off on the alert card by a dentist or dental nurse. The GA Alert Card will then be filed and held in the clinic where the assessment has taken place. The dentist/dental nurse will then complete and sign the GA Alert outcome box on the GA Extraction Form (yellow) The appointment for exodontia under general anaesthetic can then be made. 7. PATIENT INFORMATION At the assessment appointment the patient will be given information about the procedure and will be provided with pre and post-operative instructions. This information will be provided in both verbal and written form by either the dentist or dental nurse as follows: IG10 Documentation for Patients Attending Exodontia Under General Anaesthetic Clinical Records and Patient Information

7 Pre-operative preparation, including fasting The proposed treatment including benefits and risks The general anaesthetic including side effects and complications Appropriate escorts for the child on the day of the procedure Post-operative care and analgesia. This information is available in leaflets: Information for parents/carers bringing a child for treatment under general anaesthetic (appendix 3). Information for patients having a tooth out (appendix 4). Advice after tooth extraction under general anaesthetic (appendix 5). Instructions regarding fasting time will also be written onto the patient s appointment card, and confirmation that the patient has received all instruction will be recorded in the tick box on the GA Extraction Form (yellow). 8. EVIDENCE THAT STANDARDS HAVE BEEN MET Confirmation that the patient has complied with all instruction, and re-checking of all documentation will be undertaken by the nurse responsible for clerking in the patient at WUTH. Cross checking of documentation with the GA extraction sheet (yellow) will provide evidence that all records have been completed appropriately. 9. CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Patient Information and Consent Policy for further information and guidance and the Clinical Protocol for Assessing Mental Capacity and Best Interests and Best Interests Form 10. SHARED DECISION MAKING When developing a personalised care plan, advising on treatment options or making referrals, this need to be a joint decision with the patient and recorded in the patients health records 11. REASONABLE ADJUSTMENTS Staff should make reasonable adjustments to enable people with Learning Disabilities (LD) or who have other protected characteristic s access to our services. A reasonable adjustment is a change that has been made to a service so that people can access care and information regarding their treatment, as anyone else. This may mean having a longer appointment time; booking a pre-appointment visit to the service; providing easy read information; appropriate communication or other changes that mean our services are easier to use. Patients with learning disabilities will have an individualised Health Action IG10 Documentation for Patients Attending Exodontia Under General Anaesthetic Clinical Records and Patient Information

8 Plan and will be supported to have access to annual health checks to ensure all health needs are met. 12. INCIDENT REPORTING Clinical incidents must be reported via the trust s incident reporting system. 13. NEAR MISSES In cases where there has been a near miss, it is important to report as an incident as trends can be analysed and addressed. This system is a proactive way of preventing future incidents from actually occurring 14. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, child or young person they need to follow trust Safeguarding Policies and those of the Local Safeguarding Children s Board and discuss action plans with line manager and document outcomes. 15. EQUALITY ASSESSMENT In line with the trusts commitment to meet its statutory requirements outlined in the Equality and Diversity Strategy each procedural document is screened using an Equality Impact Assessment (EIA) Screening Tool. This demonstrates the trusts commitment to equality and human rights by recognising that the experiences and needs of every individual are unique and strives to value and respect the diversity of staff, patients, carers and the public. EIA s support organisations to avoid discrimination on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Carers are also protected from discrimination, as they are associated with people with a protected characteristic i.e. disabled people. Should staff become aware of any exclusions that do not comply with this statement would need to complete an incident form and an appropriate action plan put in place An equality impact assessment tool has been completed and forwarded to the Equality and Diversity Lead the EIA will be available on the trusts website. 16. REFERENCES British Society of Paediatric Dentistry (BSPD), (2008). Guidelines for the use of General Anaesthesia (GA) in Paediatric Dentistry IG10 Documentation for Patients Attending Exodontia Under General Anaesthetic Clinical Records and Patient Information

9 Appendix One COMMUNITY DENTAL SERVICE GA EXODONTIA SERVICE Name: D.O.B: / / Age: NHS No: Relevant M.H: G.M.P: Checked in at (24h): : Please Keep Teeth: Yes N No Parent Letter Needed: Yes No Previous G.A. Medical Yes/No Dental Yes/No Medical Pre-Op: Yes No RED ALERT Yes No GA ALERT OUTCOME AND ADDITIONAL INFORMATION Date: / / Signature Signed Dated Completed Pre-Op Instructions Radiographs MH Verbal Written N/A PR Form Consent Accompanied By: Baseline B.P: Pulse: Visual: W Weight: F Fluid: E Energies: A Adrenaline: T Tube Size (ET) G Glucose: Teeth to be Extracted All Team Members have introduced themselves by Name and Role Right Left

10 e d C b a a b c d e Teeth Extracted Date: Time (24 hr): : Dental Officer: Signature: Total No. of Teeth Extracted Total No. of Packs Used Total No. of Packs Removed General Anaesthetic Details Date: / / Anaesthetist: O 2 N 2 O Sevoflurane I.V. Induction ECG SAO 2 CO 2 Signed Additional Information S:\Dental\JEN Updated January 20

11 Appendix Two COMMUNITY DENTAL SERVICE GENERAL ANAESTHETIC ALERT CARD NAME: DATE OF BIRTH: REASON: OUTCOME: DENTIST SIGNATURE: DATE: COMMUNITY DENTAL SERVICE GENERAL ANAESTHETIC ALERT CARD NAME: DATE OF BIRTH: REASON: OUTCOME: DENTIST SIGNATURE: DATE:

12 If you have any questions, please do ask your Dentist, we are here to help you. Devonshire Park Dental Centre 1 st Floor, Greenway Road Tranmere Wirral, CH42 7LX Leasowe Dental Clinic Hudson Road Leasowe Wirral, CH46 2QQ Victoria Central Hospital Dental Clinic Mill Lane Wallasey Wirral, CH44 5UF If you would like a copy in another format or in another language, please telephone us on: or patient.experience@wirralct.nhs.uk Appendix Three Information for Parents/Carers bringing a child for treatment under General Anaesthetic Specialised Dental Service Outpatients Department Victoria Central Health Centre Mill Lane Wallasey Wirral, CH44 5UF Phone: Wirral Community NHS Trust 2016

13 What is a General Anaesthetic (G.A.)? Having a G.A. means that your child will be asleep and completely unaware of their treatment. The G.A. is given either by breathing a mixture of gases through a nosepiece or by an injection in the back of the hand followed by breathing the same gases. The G.A. is administered by a Consultant Anaesthetist who is able to advise on the best type of anaesthetic for your child. Once he or she is asleep you will be asked to leave the surgery before the dental treatment starts. Your child will only need to be anaesthetised for a short period which means that the recovery period is also quite short. Following their treatment you will have to wait for the effect of the anaesthetic on your child to wear off sufficiently before you take him or her home. What are the benefits? The G.A. allows a child to accept treatment when they are very anxious or unable to co-operate. This will have been discussed with you at the assessment appointment at a clinic. How to prepare your child for the G.A. Please: Ensure they wear loose fitting clothing, flat shoes and tie back long hair. Give them routine medication unless you have been told not to. Ensure they attend with a parent or legal guardian. Tell a member of staff if your child has seen your doctor or been to hospital since your assessment appointment or if there have been any changes in their medication. Do not allow your child to eat any food for 6 hours before their procedure. They can sip a small amount of water up to 2 hours before their appointment. Ensure your child is not wearing any make-up, jewellery or contact lenses. Problems After treatment your child may feel nauseous and could vomit, they could have a headache for a few hours. You will be given a phone number to contact if you are unhappy about the condition of your child. If the anaesthetic was given by injection there could be some discomfort or bruising at the site of the injection. Very rarely breathing or heart problems can develop. After the G.A. Your child will need to be supervised for the rest of the day following a G.A. They should not be allowed to play outdoors unattended or ride a bike, skateboard or scooter especially not on a road. You will be given a leaflet to provide information on care for your child post G.A. if you have any worries please phone the help numbers on that leaflet.

14 Appendix Four

15 Appendix Five