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BDJOpen www.nature.com/bdjopen ARTICLE OPEN A quality improvement project to assess the use of preventative measures against acute alveolar osteitis 1 2 3 Toby Andrew Mummery , Miriam John and Susan Mary Stokes AIMS: A quality improvement project was conducted in a General Dental Practice environment. The aim was to reduce the rate of Acute Alveolar Osteitis, which was locally found to be at 19.4%. METHODS: A range of quality improvement tools were utilised to determine and measure potential interventions, and the results from the initial Plan-Do-Study-Act cycle utilising perioperative 0.2% Chlorhexidine as a preventative method are presented. RESULTS: The use of perioperative 0.2% Chlorhexidine mouthwash showed an absolute risk reduction of 6.2%. DISCUSSION: Generalisation from the results is highly dependent on local factors, although the favourable reduction in acute alveolar osteitis and cost savings found supported the project. CONCLUSIONS: This project highlights the strengths of Quality Improvement methodologies in implementing and assessing changes to improve service provision and patient outcomes. BDJ Open (2019) 5:10 ; https://doi.org/10.1038/s41405-019-0019-7 BACKGROUND Methods for preventing AAO focus on two areas—modiﬁable The Dental Teaching Unit, Port Talbot Resource Centre (DTU) is patient behaviours such as smoking, with referral to smoking located in South Wales, and provides in-hours access (IHA) cessation services routinely offered in clinic and post-operative sessions for NHS Direct, as well as providing routine care and instructions recommending smoking abstinence for 48 h post treatment for the local area. Both patient groups present with an extraction, and protective interventions including the utilisation of overall high dental treatment need and varying levels of dental systemic or topical antibacterial and antibiotics agents such as neglect. Routine treatment plans frequently include planned amoxicillin and Chlorhexidine (CHx). The efﬁcacy of these extractions, and IHA patients often require emergency extractions interventions is varied, and the overall evidence base is limited, to manage pain and infection. however, it is recognised that the ability to modify patient Acute Alveolar Osteitis (AAO) is a relatively common post- behaviours is restricted, and the use of antibacterial agents, whilst extraction complication, which sees a failure of healing char- efﬁcacious in some studies in reducing AAO in third molar acterised by the loss of the clot from the socket, superﬁcial extractions has a weaker evidence base for routine extractions. infection and acute pain and discomfort that is often described as Furthermore, with increasing focus on antibiotic resistance and worse than the previous toothache. appropriate prescribing, coupled with the risks of anaphylaxis, the Anecdotally and observationally, a high number of DTU patients routine prescribing of antibiotics for preventative purposes is develop AAO. To evidence this, a 1-week review was undertaken increasingly contraindicated or not supported by current which showed that a total of 26 extractions were conducted, with guidelines. a total of ﬁve (19.2%) re-attending within 2 weeks due to AAO. A The “Model for Improvement” was selected as the most later large-scale audit of 1129 extraction appointments found 219 appropriate quality improvement framework for this project. This (19.4%) reattended due to AAO. As some IHA patients will utilise facilitated a progressive environment with changes being central NHS Direct again, rather than contacting the practice for follow-up to the overall aim. This stands in contrast to clinical audit (CA), care, the rate of AAO is feasibly higher than this observation where recent evidence has undermined the validity of using CA as indicates. the impetus of improvement with one study estimating only 5% of 6,7 The rate of AAO reported within the literature ranges between 1 audits led to any change in practice. This was supported by the and 4% and up to 30% for third molar removal with a number of utilisation of the Sustainability Model, which represents a useful risk factors have been identiﬁed, including complexity of tool in planning an intervention as it highlights 10 key factors 3 8 extraction, smoking status, and use of the contraceptive pill. which inﬂuence sustaining change. These cover the process, staff Current local practice is that patients are consented for extraction. and organisational factors, and are weighted to highlight the more This includes the risk of AAO with reference to identiﬁed risk central role that some of these factors play. factors. Additional preventative interventions are not currently The project was undertaken as part of the Silver Improving utilised with cases of AAO being management by irrigation with Quality Together curriculum, supported by the Quality Improve- saline and Alvogyl (an antiseptic and analgesic dressing) following ment Skills Training (QIST) Section of Health Education and occurrence. Improvement Wales. 1 2 School of Clinical Dentistry, University of Shefﬁeld, Shefﬁeld, UK; LINCymru Clinical Lead, Quality Improvement Skills Training Section, Health Education and Improvement Wales, Cardiff, UK and Dental Educator Quality Improvement, Dental Postgraduate Section Health Education Improvement Wales, Cardiff, UK Correspondence: Toby Andrew Mummery (tamummery1@shefﬁeld.ac.uk) Received: 26 February 2019 Revised: 23 April 2019 Accepted: 28 April 2019 © British Dental Association/Macmillan Publishers Limited 2019 A quality improvement project to assess the use of preventative measures. . . T.A. Mummery et al. AIMS AND OBJECTIVES Based on the higher-than-expected rate of AAO, the stated aim of this project was to reduce the rate of AAO in adult patients within the DTU undergoing extraction by 10% within a 3-month period. Objectives were: to determine the rate of AAO within the practice, to identify potential associated factors, to assess the efﬁcacy of an identiﬁed intervention in reducing the local rate of AAO, and to determine the long-term sustainability of the intervention within the clinical environment. METHODS Contextual elements of relevance were broadly considered under the sustainability of the project. Within the scope of this project, a Sustainability Model was developed in the planning phase to highlight potential factors to change moving forward (see Fig. 1). This highlighted the importance of considering and engaging stakeholders, particularly clinical and senior leaders, throughout the project. Under the Model for Improvement change is more central than Fig. 1 Sustainability model-planning phase in CA and falls under the umbrella of the Plan-Do-Study-Act approach (PDSA). In assessing the literature and local situation, it was unclear whether a root cause could be identiﬁed for the increased local rate; as such, extraction notes were reviewed to collect information regarding recognised risk factors (1129 extraction appointments, over a 1-year period). This showed that the overall risk within the unit at 19.4%, with recognised risks such as wisdom tooth removal and difﬁcult extractions (where ﬂaps had been raised or bone removed) increasing the risk. Of speciﬁc interest was a positive correlation with smoking (see Fig. 2), with smoking more than 20/day increasing the risk of AAO to over 30%. This was considered highly relevant to the higher-than-expected local level given that 49% of patients included in the review were active smokers. This is signiﬁcantly higher than the reported local rate of smoking within the Port Talbot area at 25%, which is already twice the Welsh national average. That being said, smoking cessation advice was already routine and smoking abstinence following extraction was already recommended. Furthermore, as a signiﬁcant proportion of the patients attended through IHA, the scope to provide continued cessation support was limited and smoking was considered an unmodiﬁable risk factor for AAO in this case. Based on these results, a number of interventions were Fig. 2 Local risk of AAO by quantity smoked per day considered to reduce the rate of AAO and a simple ease/beneﬁt analysis was performed to consider which of these were most feasible for an initial intervention. As the use of antibiotic agents was deemed inappropriate, the use of an oral antiseptic (CHx) was and the potential need to actively purchase chlorhexidine identiﬁed as the focus of the intervention. mouthwash. An intervention protocol was developed with the support and agreement of stakeholders, and implemented as part of this ﬁrst Study of the intervention—measures and analysis PDSA cycle (see Fig. 3). This intervention was designed to be Clinical notes were the main focus for measuring the efﬁcacy of utilised alongside a routine extraction appointment with simple the intervention. Clinicians were asked to record where the checks being required in the pre-, peri- and post-operative intervention had been utilised and reasons why it had been periods. If the patient was identiﬁed as high risk prior to excluded were appropriate. The key outcome measure was the extraction, the protocol recommended the use of 0.2% CHx overall rate of AAO. Staff were also invited to give regular mouthwash for 60 s prior to the commencement of extraction. feedback on perceived strengths and weaknesses, and utilisation Should the patient have already been identiﬁed as high risk, or of the protocol was reviewed in staff meetings. should the extraction introduce risk factors (such as root fractures, It was recognised that there was signiﬁcant weekly variation in or surgical removal of teeth), the protocol then recommended the pre-intervention data, and so 10 weeks were included to that the gauze used to achieve haemostasis be soaked in 0.2% attempt to minimise this. A statistical process chart was developed chlorhexidine. It was also recommended that these patients be to identify whether new data points were outside the control advised to continue with chlorhexidine mouthwash for the limits previously set, and hence infer the likelihood that a true shift following 5 days. It was stressed to patients that this should in the trend was being seen. bathe the area rather than actively rinsing or swilling as it was felt that this risked dislodging the clot and increasing the risk of AAO. Ethical considerations It was also felt that compliance to homecare instructions was likely As this was a service improvement project, it did not require to be poor due to the necessity that patients actualise the advice formal ethical approval. This was agreed by the Dental Teaching BDJ Open (2019) 5:10 1234567890();,: A quality improvement project to assess the use of preventative measures. . . T.A. Mummery et al. Fig. 3 Dry socket prevention protocol Unit and the Quality Improvement Skills Training Section of Health and at staff meetings these proved to be ineffective. As such, Education and Improvement Wales. Anonymous data were the number of the times the protocol was utilised or excluded collected to ensure data protection and conﬁdentiality. had to be abandoned as an outcome measure. Whilst the Further consideration was given to the risk of acute anaphy- clinicians were supportive and anecdotally engaged with lactic reaction to perioperative CHx mouthwash. The rate of the protocol, this highlights the importance of full stakeholder allergy to CHx within the UK is unknown although ranges between engagement throughout the quality improvement project and the 0.5 and 2%, with higher rates reported in individuals with known difﬁculties of data collection in the dynamic-active clinical anaphylactic reactions or eczema with 5% of these groups having environment. positive patch response. As such it was decided that any There was also compounding factors to the results, as individuals with a known allergy to CHx would be exempted from coincident quality improvement projects were undertaken by the protocol. It was also recommended that additional care would other members of staff. Whilst the majority of these were not felt be taken for patients with other known anaphylactic reactions or to be relevant to AAO, a coincident smoking-cessation project eczema. potentially increased the efﬁcacy of utilising CHx. In review of the results, however, it was felt that the impact of this is likely reduced as it would only impact on regular patients who made up the RESULTS minority of extractions conducted. No alterations were made to the protocol following implementa- In total, 250 patients attended for extraction in the 10 weeks tion, and the weekly rates of dry socket before and after following implementation of the protocol. The statistical process intervention are displayed in Fig. 4. chart showed a signiﬁcant reduction in the mean and upper It became apparent in reviewing clinical notes that there control limit, with a minor reduction in the lower control limit. was signiﬁcant variation in how and when it was recorded that Whilst an overall reduction of 6.2% and a relative reduction of 32% the protocol was utilised. Whilst attempts were made to reinforce were considered clinically signiﬁcant, the rate of AAO within the the importance of recording, this information to clinicians unit was still above the reported rate in the literature. BDJ Open (2019) 5:10 A quality improvement project to assess the use of preventative measures. . . T.A. Mummery et al. Fig. 4 Statistical process chart for AAO On review of the clinical notes for extraction appointments, 82 Strengths and limitations (32.8%) were deemed to have met the protocol guidance for the Whilst it was felt overall that the project resulted in a positive use of CHx preventative measures, however, it was clearly outcome, several key limitations are recognised. These include the recorded in the notes that CHx had been given in 12 (14.6%) of incomplete data collection limiting the conclusion of how often these cases. CHx was not recorded as used in any other extraction the protocol was implemented, and the risk of concurrent projects appointments. In all, 33 (13.2%) patients were treated for AAO compounding the result. Gaining insight into the patient within 2 weeks of their extraction appointment. experience of the intervention would have been beneﬁcial regarding how acceptable they found the use of CHx. That being said, under the framework of Model for Improvement, the project DISCUSSION recognised the dynamic and changing clinical environment and allowed for the introduction of changes recognising the limita- Whilst record keeping was identiﬁed as an issue, there were no reported adverse events, no reported or anecdotal optional tions of clinical practice. This resulted in sustainable change to patient opt-outs of cases where patients did not given consent daily practice and saw a signiﬁcant reduction in the rate of AAO. for the intervention, and anecdotally a high level of utilisation of It is recognised that the results of this project are highly speciﬁc the protocol. Whilst the intervention was initially designed to to the local clinical environment and should be generalised with require minimal changes from routine practice, the limitations care and consideration of the high rate of local risk factors. For regarding data collection were signiﬁcant. Consequently, a new those considering replication of this intervention, understanding data collection form was designed and distributed to clinicians to local context will be key to its safe and successful implementation. complete following extraction appointments with the intention that this would increase compliance and recording of the use of the protocol. This was initially met with resistance from clinicians due to increasing workloads, however, following feedback of the CONCLUSION results there was general recognition for the value of this. A range of quality improvement tools were utilised throughout Whilst there are potentially compounding factors including this project to aid in identifying relevant variables. The identiﬁed increased clinicians’ awareness of risk factors leading to changes intervention was advantageous in its simplicity to implement and to case selection and concurrent quality improvement initiatives, it availability of resources. The support of local stakeholders and was felt given the primarily urgent nature of the extractions that clinical leaders was considered vital to the overall success of the the reduction seen was due directly or indirectly to the project, however, in the current climate of “evidence-based intervention. Furthermore, the reduction seen was in keeping practice,” the Model for Improvement allows clinicians to with the reported effect of CHx in the literature, further supporting recognise the highly variable nature of different clinics, patient the efﬁcacy in this case of the intervention. A cost analysis was base and managerial styles, on the provision of care. It can undertaken, based on the absolute risk difference of 6.2%, the support clinicians to select the most appropriate policies and, number needed to treat to prevent 1 case of AAO was 17. Within through a structured framework, assess whether these changes local ordering, 0.2% CHx costs £2.09/300 ml, resulting in a cost of match with clinical need and result in improved outcomes. £0.21 per patient treated with this protocol. Comparatively, within the DTU an emergency appointment usually equates to 15 min of clinical time equating to an estimated cost of £13.78, including peripheral staff and equipment costs. This equates to a net saving ACKNOWLEDGEMENTS The project was undertaken with the support of the Welsh Deanery, with allocated of ~£10.21 for each case prevented. It also increases availability of time given as part of the Dental Foundation Training Program. clinical time and increases opportunities for access to the service. BDJ Open (2019) 5:10 A quality improvement project to assess the use of preventative measures. . . T.A. Mummery et al. ADDITIONAL INFORMATION 9. Pannick, S., Sevdalis, N. & Athanasiou, T. 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BDJ Open (2019) 5:10
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Published: Jun 26, 2019
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