The Adolescent Intravenous Sedation Service (AIVS) one year on

Transcription

1 The Adolescent Intravenous Sedation Service (AIVS) one year on A position paper to outline the AIVS service development along with key research findings

2 INTRODUCTION The Department of Child Dental Health (CDH) acts as a regional referral centre for Paediatric Dental care in the North West of England. Emergency and elective referrals are taken from General Dental Practitioners, the Personal Dental Service, Community Dental Practitioners, General Medical Practitioners and Hospital Paediatric Consultants. Dental support is provided for paediatric medical/surgical specialties within CMFT and paediatric teams based in surrounding District General Hospitals. Training is provided for undergraduate students in each of 3 clinical years, PCDs, DF2s, Community Dental staff on placement and Higher Specialist Trainees. The Department of Child Dental Health in the University Dental Hospital of Manchester runs a regional referral service for anxious children requiring dental treatment. Although the majority of anxious children can be treated with careful behavioural management [1], some may require conscious sedation in order to complete their treatment. Inhalational sedation with nitrous oxide (IHS) has historically been the mainstay of paediatric dental conscious sedation. It is a successful, safe and well tolerated treatment with a strong evidence base [2,3]. However, IHS may be less successful when used on severely anxious children and adolescents [4] and alternative techniques have been explored [5,6,7,8]. Adolescent patients often present with high dental needs and severe dental anxiety. Many patients have either avoided dental treatment or failed to accept treatment on multiple occasions. Currently these patients are either managed with IHS with variable success, or referred for comprehensive dental care under general anaesthesia. This situation is far from ideal as treatment under general anaesthesia may contribute to, rather than alleviate dental anxiety, and serves no purpose in acclimatising a young person to dental treatment. There are small but significant risks in referring a child for general anaesthetic and increasing referrals to the Department of Child Dental Health are seeing mounting pressure on comprehensive dental care lists.

3 More recently, an adolescent intravenous sedation service (AIVS) has been developed. This service began in November 2010 and has since been successfully treating 3 patients per week under the care of Claire Stevens and Consultant Paediatric Anaesthetist, Dr Sian Rolfe. The AIVS cares for young people between the ages of We use intravenous propofol sedation to help patients with severe anxiety to accept dental treatment, which may be of a restorative or surgical nature. Propofol is an intravenous anaesthetic induction agent, which can be used in subanaesthetic concentrations as a sedative agent [5]. Early studies have suggested positive results when using this technique in children [9]. The use of propofol allows the level of sedation to be varied during treatment, for example increased during the administration of local anaesthetic. More recently, a study looking at the use of propofol in a group of 9-16 year old patients found 33 out of 34 patients were able to accept treatment with propofol, many of whom had previously failed to accept treatment by other means [10]. The introduction of an Adolescent Intravenous Sedation Service (AIVS) is a Young People Specific Service which is compliant with NSF guidelines [12] and You re Welcome Quality Criteria [13]. We are research active, with a current study which is the largest and most comprehensive study of propofol sedation in young people internationally and the first to look at patient acceptability of this technique. This paper summarises the key achievements of the adolescent intravenous sedation service (AIVS) at the Dental Hospital and presents the preliminary results from the clinical and research teams.

4 KEY RESEARCH FINDINGS Of the first 50 patients referred to the AIVS: 48 were able to manage with treatment, despite the fact that many had refused treatment on multiple previous occasions. There were no DNA s (missed appointments). Patient satisfaction was extremely high with 100% of patients stating that they would have the sedation again and 87% saying they would be very likely to recommend this service to a friend (see patient feedback section). 100% of patients were safely treated. We were able to complete around 2 to 3 times the amount of work per hour, compared with patients treated with IHS. STAFF FEEDBACK I am a Dental Therapist working with patients who are particularly anxious and consequently find dental treatment difficult. Many of my patients progress to have their treatment under local anaesthetic within the dental environment. However, a small number albeit due to their anxiety and/or the complexity of the treatment prescribed may ultimately be referred for treatment under general anaesthesia The introduction of the AIVS service has avoided this referral allowing the patients to progress with their treatment at the dental hospital. I am able to provide behaviour management and intensive preventive advice, liaise with Claire Stevens regarding the timing of treatment under IV sedation and finally support the patient during their IV treatment. Patients and parents welcome this flow of care and appreciate the continuity of staff throughout the course of treatment. This is an excellent addition to the services provided by our department benefitting both patients and staff. Well done Claire. Dr Jeanette Mooney, Dental Therapist. The AIVS is a new service that will ultimately become closely linked with our Orthodontic practice. In secondary care orthodontics there is a high need for additional dental services such as removal of impacted teeth and exposure and attachment placement to allow orthodontic alignment. Currently most of these patients are undergoing a General Anaesthetic procedure to allow the surgery to

5 take place. This places a considerable strain on the GA facilities with the result that patients are waiting too long for this treatment with, sometimes, serious complications such as resorption of adjacent teeth or prolonged orthodontic treatment. This service being adjacent to the orthodontic clinic will allow faster, safer and more predictable orthodontic treatment to develop and on behalf of the orthodontic team we fully support this development. Mr David Waring, Clinical Lead Orthodontics The recent introduction of IV Sedation treatment has been a God send. The team feel patients who have tried other options such as IHS or have been completely put off dental treatment gain so much from IV sedation. It s a valuable service we can t see why we didn t have it sooner. The team s ability to provide dental treatment to those so anxious and scared at first and then leave wondering why they were so worried has to be the best feeling of achievement anyone can have. Vanital Patel, Dental nurse, CDH

6 PATIENT FEEDBACK Here are some of the comments from our patients: Thank you, I am really pleased I got all four extractions done I have had the afternoon of my life! You have helped me cope with my fear of dentists At every point I was reassured by everyone that it would be fine It wasn t painful and everyone was dead nice to me I was so stressed out beforehand but the sedation made me feel much calmer It felt like rainbows and happy clouds It was fun. The nurses were really nice but I thought it was mad that I couldn t remember anything I felt comfortable in myself. I wouldn t have done it without the sedation The staff were really supportive I loved the feeling. It made me feel sleepy and relaxed It was really good, I don t think it could have been any better Everyone who was doing it was really nice At first I was really nervous, but everyone who was here calmed me down and chilled me out. So it was ideal for what I was having done. Thank you to all "Thank you I can t believe I have done it I am so proud of myself" It was good I wouldn t change anything. There isn t anything you can do to make it better." I wouldn t change anything because it is awesome! The other stuff (midazolam) was ok but this stuff (propofol) is amazing. When I had treatment under sedation before I just felt knocked out so that I was powerless to resist but this time I knew what was happening and it felt amazing. All I could think about was that I was so chuffed with myself for doing it. I can t thank you all enough.

7 PARENTAL FEEDBACK My son underwent a procedure at the dental hospital yesterday, under IV sedation, and I wanted to write to you to ask if you would pass on our thanks for what was a very professional but friendly time...with members of your team explaining everything succinctly and informatively and in layman s terms...they were an amazing team to deal with and really put Chris s and my mind at rest. This is an excellent service we were made to feel very at ease Just wanted to thank you and all the team who helped with Amelia's dental treatment on Monday, your patience, care and understanding was outstanding and ultimately achieved a fantastic result. Without the patience and kindness shown over the months Amelia has been attending, I honestly don't think we would have managed to get this treatment done. I am deeply grateful for your help and cannot thank you and your team enough. Hopefully over the next few weeks Amelia will be able to write a little testimony for other children with the same fears to read, to prove there is light at the end of the tunnel and that the way in which you work together with the patient means nothing is forced upon you and there is no time limit on how long it takes to achieve the result. Once again thank you so much. SERVICE ACHIEVEMENTS The Adolescent Intravenous Sedation service:- Has recruited and trained a Consultant-led team with specialist skills to deliver paediatric intravenous sedation. Delivers adolescent-specific services in a dedicated sedation unit which conforms to NSF recommendations and National Guidelines. Provides safe and effective, anaesthetist administered sedation. Is using patient satisfaction surveys to influence future service development. Communicates with our service users in an innovative and adolescent-friendly manner, with a service website under development. Has reduced the current waiting list pressures on the paediatric GA and IHS services. Provides patients with alternative, more appropriate, treatment techniques.

8 Ensures that the University Dental Hospital remains at the forefront of clinical advancements. BENEFITS OF SERVICE DEVEVELOPMENT Provision of a new and innovative service currently only provided in 3 other centres in the UK. Reduce pressure on inpatient General Anaesthetic and IHS waiting lists by offering an alternative treatment with intravenous sedation for adolescents. Provide additional capacity for 3 elective patients per week with the possibility for further expansion to 4.5 electives per week. Expansion of existing skill mix within the current paediatric dental workforce. An opportunity to improve the quality of service and choice for adolescents requiring dental treatment. Provide opportunities for research and facilitates post-graduate training. SECURING THE FINANCIAL VIABILITY OF THE AIVS The AIVS plans to see a total of 189 patients per year, based on a 42 week year. This is on the assumption that 3 children are treated on each list with 1.5 lists per week. The current service generates an income surplus of 27K based on current activity assumptions. In order to increase the financial viability of this service, work is currently underway to review the coding for AIVS patients so that the tariff reflects the specialist nature of this service. It is also anticipated that commissioners will be approached so that they are better informed about the AIVS and the benefits it can offer to our patients. RESEARCH FUNDING This research was funded by a CMFT 2010 RfPB grant.

9 FUTURE RESEARCH AIMS We are currently applying for research grants to evaluate the safety, efficacy and patient acceptability of patient versus operator controlled intravenous propofol sedation in adolescent patients requiring dental care. Patient controlled sedation has been shown to improve patient satisfaction but has not been investigated in the adolescent population. This area of study was highlighted by the recent NICE guideline, Sedation in Children and Young People. DISSEMINATION OF RESEARCH FINDINGS Preliminary research findings have already been or are scheduled to be presented at the following conferences and meetings (by Claire Stevens unless stated otherwise): September 2011 October 2011 November 2011 February 2012 March 2012 May 2012 May 2012 British Society of Paediatric Dentistry (BSPD) ASM Young Researcher s Prize - Andrea Aspinall BSPD Sheffield Branch meeting CMFT Research and Innovation Conference (Winner of Trust R&I prize for oral presentation) BSPD North West Branch meeting Invited to speak to CMFT Trust Charitable Funds Committee MANDEC evening lecture series Dental Sedation Teachers Group National Conference (Keynote presentation) The research findings will be submitted to peer reviewed journals in the fields of Paediatric Dentistry and Paediatric Anaesthesia for publication. PUBLICITY STRATEGY The AIVS featured on the ITV Children s Hospital TV series. This resulted in a dramatic influx of patients to the service. Many referrals now come from peer recommendation. The AIVS team is also working closely with the CMFT communications team to prepare external press releases.

10 FUTURE SERVICE AIMS Work with coding team to ensure financial viability of the AIVS. Develop the AIVS website to improve the delivery of patient information. Increase capacity from 3 to 4.5 patients per week to meet service demand (there is currently a 14 week wait for first appointments). Increase training opportunities for Anaesthetic registrars in CMFT and Paediatric Dental Trainees across the North-West. Recruit new team members to ensure continuity of service. CONCLUSION The AIVS is an innovative and successful service which has demonstrated high levels of patient satisfaction. The AIVS team would like to thank the CMFT RfPB grant for funding the research which has ultimately led to this service development. Claire Stevens (2 nd from left) receiving the CMFT Prize for best oral presentation 2011 from Professor Dame Nancy Rothwell, President of the University of Manchester (centre)

11 REFERENCES 1. MacCormac C, Kinirons M. Reasons for referral of children to a general anaesthetic service in Northern Ireland. International Journal of Paediatric Dentistry 1998; 8: Lindsay SJ, Roberts GJ, Gibson A. The techniques of oxygen-nitrous oxide sedation (relative analgesia) in the treatment of apprehensive children. Proceedings of the British Paedodontic Society 1978; 8: Shaw AJ, Meechan JG, Kilpatrick NM, Welbury RR. The use of inhalation sedation and local anaesthesia instead of general anaesthesia for extractions and minor oral surgery in children: a prospective study. International Journal of Paediatric Dentistry 1996; 6: Major E, Winder M, Brook AH, Berman DS. An evaluation of nitrous oxide in the dental treatment of anxious children. A physiological and clinical study. British Dental Journal 1981; 151: Managing anxious children: the use of conscious sedation in paediatric dentistry. International Journal of Paediatric Dentistry 2002; 12: Standards for Conscious Sedation in Dentistry: Alternative techniques. A report from the Standing Committee on Sedation for Dentistry. Royal College of Surgeons of England Wilson KE, Welbury RR and Girdler NM. A randomised, controlled, crossover trial of oral midazolam and nitrous oxide for paediatric dental sedation. Anaesthesia 2001; 57: Soldani F, Manton S, Stirrups DR, Cumming C, Foley J. A comparison of inhalation sedation agents in the management of children receiving dental treatment: a randomized, controlled, cross-over pilot trial. Journal of Paediatric Dentistry 2010; 20: Veerkamp JS, Porcelijn T, Gruuythuysen RJ. Intravenous sedation for outpatient treatment of child dental patients: an exploratory study. ASDC Journal of Dentistry for Children 1997; 64:

12 10. Hosey MT et al. Propofol intravenous conscious sedation for anxious children in a specialist paediatric dentistry unit. International Journal of Paediatric Dentistry 2004; 14: National Service Framework for Children, Young People and Maternity Services. Department of Health. 4 th October You re Welcome quality criteria. Making health services young people friendly. Department of Health. 18th October NICE guideline CG112: Sedation for diagnostic and therapeutic procedures in children and young people. National Clinical Guideline Centre. December An operational policy for the delivery of inhalation and intravenous sedation, Department of Paediatric Dentistry. Claire Stevens and Sian Rolfe. Central Manchester University Hospitals NHS Foundation Trust Aartman IHA et al. Self-report measurements of dental anxiety and fear in children: a critical assessment. Journal of Dentistry for Children 1998; 65: Hosey MT, Blinkhorn AS. An evaluation of four methods of assessing the behaviour of anxious child dental patients. International Journal of Paediatric Dentistry 1995; 5: