An audit of the recording of caries risk in adults in a general dental practice

Transcription

1 An audit of the recording of caries risk in adults in a general dental practice A collaborative audit by Andrew Shelley & Nicholas Cosgrove

2 Table of Contents 1. Introduction Aims and objectives Source material and references Project design Data to be recorded The sample Inclusion Criteria Standards Re-audit Method Results Discussion Conclusion Action Plan Materials System Summary Re-audit Discussion Conclusion Bibliography Table of figures Figure 1 - Data Capture Form... 6 Figure 2 - Bitewing stickers used on record cards... 8 Figure 3 - Caries assessment laminated guide... 9 Figure 4 - Caries Assessment Stickers... 9 Appendices Appendix 1 - Data capture form Appendix 2 - Sheet of caries assessment stickers Appendix 2 - Assessment guide Andrew Shelley & Nicholas Cosgrove Page 1

3 1. Introduction 1.1 Aims and objectives The aim of this audit is to determine if caries risk assessments are carried out and clearly recorded for adult patients of the practice. We further wished to establish whether periodic bitewing radiographs were prescribed appropriately where a caries risk assessment existed. Conventional written record cards are used in the practice. 1.2 Source material and references The subject of caries risk assessments has been discussed extensively in dental texts. Kidd i and Murray ii were consulted in research for this audit. These authors discuss the importance of caries assessments to prevention, operative dentistry and prescription of dental radiographs. In respect of caries in adults in particular, Thompson draws attention to the importance of risk assessments in his recent meta analysis. iii He reviewed four studies which met his criteria. He showed that in these studies the caries experience of adults was between 0.8 and 1.2 new carious surfaces per year. In adolescents the caries experience was between 0.4 and 1.2 new carious surfaces per year. Thompson remarks that The dental decay rate over time among older people is at least as great as that among adolescents. Davenport iv carried out a systematic review of the evidence base for recall intervals which was further discussed by Brunton v. Brunton states Individual recall intervals should be indicated by an assessment of the patient s risk of developing new disease. There are also several examples of published guidelines which draw attention to the necessity for caries assessments vi,vii. For example the Selection Criteria for Dental Radiography viii makes recommendations for intervals between periodic bitewing radiographs according to caries risk. Clinical Examination and Record Keeping ix also discusses the relevance of caries risk assessment to prevention and recall intervals. Andrew Shelley & Nicholas Cosgrove Page 2

4 In our discussions we consulted the above texts and guidelines and summarised the importance of caries assessment as follows: To target preventive advice o Fluoride o Diet To target preventive treatment o Prescription of fissure seals Prescription of radiographs o Intervals between periodic bitewing radiographs Decision making in operative treatment of caries o Watch & wait or treat? Treatment planning decisions o Definitive or provisional restorations? Recall Intervals o How often should the patient be recalled and risk status reassessed? 2. Project design 2.1 Data to be recorded We would examine whether a caries risk assessment was recorded. However we also felt that a caries risk assessment should be clearly marked on the record card. This would mean that the information was instantly available. We would therefore establish whether any recording was shown clearly on the record card or simply an entry in the body of the clinical notes. We also agreed that it would be advantageous if the caries risk factor in each case is recorded. For example a patient may be assessed as high risk because of clinical evidence, medical, social history etc. Finally we wished to take the opportunity to find out whether periodic bitewing radiographs were taken according to any caries risk assessment. We would therefore record the following: The name and date of birth of the patient for verification and future identification. Andrew Shelley & Nicholas Cosgrove Page 3

5 Was a caries risk assessment recorded? Was the risk factor recorded? Was the risk assessment recorded in the body of the records or as a clearly marked entry on the front of the record card? Where a caries risk assessment was recorded were radiographs correctly prescribed according to the assessment? 2.2 The sample Our practice maintains two main record filing areas: Dormant filing - patients who are not currently under treatment. This filing area contains several thousand record cards. Some of these patients have not attended in recent years. Current filing - patients under treatment. We anticipated that any changes made to record keeping procedures would first be made whilst patients were under current treatment. We therefore agreed that we would sample the current file. If the dormant files were sampled it may take many months or years for the effect of changes to be seen. On the other hand a sample of the current record cards would reveal any changes quickly. These changes would filter into the dormant filing area as patients completed their course of treatment. Following discussions with our local audit facilitator we agreed that we would take a sample of 100 regularly attending dentate or partially dentate patients over the age of eighteen years who were currently under treatment 2.3 Inclusion Criteria Patients who were casual attenders would be excluded from the audit. It was felt that the caries risk assessment was relevant to those patients who attend on a regular basis. The record cards would be selected on the basis of the first 100 records alphabetically that met the inclusion criteria. Inclusion criteria Over 18 years old Dentate or partially dentate Regular attenders Currently under treatment Andrew Shelley & Nicholas Cosgrove Page 4

6 2.4 Standards We agreed that a caries risk assessment was necessary for every patient meeting the inclusion criteria. However we felt that a 100% standard was an unrealistic objective for what is likely to be a new system. We therefore set an achievable standard of 80% as a starting point. We also set a standard of 80% for the other parameters as follows: Caries risk assessment recorded? 80% Caries risk factor recorded? 80% Risk assessment a clearly marked entry on the front of the record card? 80% Radiographs correctly prescribed according to the caries risk assessment? 80% 2.5 Re-audit The results of the audit would be discussed and changes to current practice considered. Another audit would be carried out after a period of three months to measure the effect of changes. We felt that this would be sufficient time for treatment to be completed for the patients in the first sample so that a new sample of record cards would be examined. We also felt that this would give sufficient time for any changes to be implemented. Andrew Shelley & Nicholas Cosgrove Page 5

7 3. Method Patient record cards were selected from the current file in accordance with the rationale set out in paragraph 2.2 page 4. A date capture form was designed and used to sample record forms according to the inclusion criteria above. (Paragraph 2.3 page 4). Figure 1 - Data Capture Form Andrew Shelley & Nicholas Cosgrove Page 6

8 4. Results A first audit on 7/11/03 revealed the following results: Caries risk assessment recorded? Risk assessment a clearly marked entry on the front of the record card? Caries risk factor recorded? When caries risk recorded, radiographs correctly prescribed? 7% 2% 0% 100% These results show that the level of recording of caries assessments was very low indeed. Caries risk assessment was recorded on 7% of records but only 2% of records cards showed this assessment clearly on the front of the record card. No records showed the caries risk factors. On every occasion that a caries risk assessment was recorded, radiographs had been correctly prescribed. Although this was in excess of the standards set, it was based on only 7% of records which had a caries assessment recording. 4.1 Discussion On further discussion between the two dentists we found that we were both making subjective judgements about the caries risk of individuals and prescribing radiographs, preventive advice etc accordingly. We would both make our judgements based on caries risk factors. However it was rare that either the risk assessment or the justification for the assessment (ie. the caries risk factor) was clearly noted in the records. Where an assessment or caries risk factor was noted it was most often in the body of the narrative of the clinical notes. However we use adhesive stickers to record the dates of bitewing radiography for patients. Occasionally a pencilled note would be entered in the next box that further bitewings were due to be taken on a certain date (Figure 2 page 8 ). Andrew Shelley & Nicholas Cosgrove Page 7

9 Figure 2 - Bitewing stickers used on record cards 4.2 Conclusion It appeared therefore that we were making subjective judgements of caries risk for patients but rarely recording the assessment or the caries risk factors in each case. It was agreed that this situation was unsatisfactory given the importance of caries risk assessments in the delivery of good dental care. (Paragraph 1.2 page 2). We were clearly a very long way from our standard and we agreed that changes should be introduced. 5. Action Plan We recognised the necessity of a system that would: Be simple and quick to use Cost effective Would display the information on the front of the record card Would enable updates to be easily recorded Would record the caries risk factors in each case. Following discussion we proposed to extend the use of the sticker system which had been used to success in the recording of dental radiographs within the practice. We would issue a laminated guide to caries risk assessment and risk factors to each surgery. Staff meetings would be carried out to discuss the system and ensure it s correct implementation. Andrew Shelley & Nicholas Cosgrove Page 8

10 5.1 Materials 1. Caries assessment laminated guide. This was based on the caries assessment guidance given in Essentials of Dental Caries i and Selection Criteria in Dental Radiography viii. Figure 3 - Caries assessment laminated guide 2. Caries Assessment Stickers. These were produced using the same computer labels as the radiography stickers already in use in the practice. Figure 4 - Caries Assessment Stickers Andrew Shelley & Nicholas Cosgrove Page 9

11 5.2 System A patient attends for an examination A caries risk assessment sticker is placed on the front of the card Following the history and examination the laminated guide is consulted The caries risk assessment is recorded as high, medium or low. The operator makes a judgement of the most important risk factor and records this using the shorthand symbols given Radiographs, preventive care and treatment are prescribed in accordance with the assessment. All the materials to carry out this system already existed in the practice since we use a very similar system for the recording of radiographs. The stickers were produced on the practice computer on commercially available computer labels. The practice has a laminating machine to produce the laminated guides. The cost of introducing the new system is therefore minimal. The system also uses a shorthand to record the assessment and risk factors. With the use of the laminated guide and pre-printed stickers the assessment and record takes less than a minute to complete. 6. Summary This audit revealed that although judgements of caries risk were being made and care delivered accordingly, records of caries assessments and caries risk factors were rarely recorded. A clear, simple recording system using computer labels, a shorthand recording system and a laminated guide was introduced. A re-audit was planned three months after introduction of the system. Andrew Shelley & Nicholas Cosgrove Page 10

12 7. Re-audit A second audit on 20/2/04 revealed the following results: Caries risk assessment recorded? Risk assessment a clearly marked entry on the front of the record card? Caries risk factor recorded? When caries risk recorded, radiographs correctly prescribed? 89% 89% 89% 97% 7.1 Discussion The results show a remarkable improvement in the recording of risk assessments and associated risk factors for caries. The results now are in excess of the standards originally set above. ( paragraph 2.4, page 2 ) The results also show that in 3% of cases radiographs were not prescribed in accordance with the caries risk factor. This represented only three patients. Discussion revealed that in each case radiographs were planned at future visits. The caries assessment and subsequent audit had been carried out in advance of the radiographs. In 11% of cases caries risk assessments had not been recorded. Discussions revealed that this was most often when the patient had attended with a dental problem between regular examination visits. The dentist had dealt with the urgent problem but had not reflected at that time on the patient s caries risk. Further discussion revealed that a limitation of the system is that only the one most important caries risk factor is normally recorded. The clinical situation may be a good deal more complex than that. However there is room for two or perhaps three shorthand symbols to be written in the space available. We therefore agreed that we would experiment with recording more than one caries risk factor. Discussions also took place concerning the abundance of stickers present on the record cards. This system could soon become cumbersome particularly if a new sticker was introduced, for example for periodontal risk assessment. Also on the older record cards there was insufficient room to place another Andrew Shelley & Nicholas Cosgrove Page 11

13 sticker clearly on the outside of the card. We are currently discussing an amendment to the system which would summarise information such as dates of radiographs, caries risk assessment or periodontal risk assessment on a single page. This could perhaps take the form of a separate form or card. One large sticker for the front of new record cards such as that formerly produced by BUPA DentalCover is another possibility. 8. Conclusion Caries risk assessment was felt to be an essential part of good clinical dentistry. (paragraph 1.2, page 2 ) We found that although subjective judgements were often made these were not recorded. The process of this audit led to the introduction of a new system of simple and clear recording of caries risk and risk factors for adult patients. On re-audit there was a dramatic rise in the number of adult patients for whom a caries risk assessment and risk factors were recorded. The success of the system in adults has shown that this could also be a very useful tool for children. We are currently discussing a rationalisation of the sticker system to produce clear recording of essential information such as caries risk assessment on a single page. This could be the subject of a future audit. Andrew Shelley & Nicholas Cosgrove Page 12

14 9. Bibliography i Kidd E A M, Joyston-Bechal S. Essentials of Dental Caries. 2 nd ed. Oxford University Press, 1997 ii Murray J J (ed). Prevention of Oral Disease. 3rd ed. Oxford University Press, 1996 iii Thompson W M. Dental Caries Experience in older people over time: what can the large cohort studies tell us? Br Dent J 2004; 196: iv Davenport CF et al. The effectiveness of routine dental checks : a systematic review of the evidence base. Br Dent J 2003; 195:87-98 v Brunton P. Six-month dental examinations: what s the evidence base? Surgeons News 2004; 3:18 vi Self Assessment Manual & Standards Clinical Standards in General dental practice. Faculty of Dental Surgery, Royal College of Surgeons of England 1991 vii Current Guidance for General Dental Practice. Faculty of General Dental Practitioners (UK) Royal College of Surgeons of England, 2000 viii Selection Criteria in Dental Radiography. Faculty of General Dental Practitioners (UK) Royal College of Surgeons of England, 1998 ix Clinical Examination and Record Keeping. Faculty of General Dental Practitioners (UK) Royal College of Surgeons of England, 2001 Andrew Shelley & Nicholas Cosgrove Page 13