strategies – Beyond the Bite

By Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company

Lack of familiarity with hospital systems can pose serious risk management implications.

Patients present to an acute care facility for a variety of reasons, such as emergency care, admission for ongoing treatment, surgical procedures and specialized nursing care. Unfortunately, appropriate dental care often is overlooked or not identified as a priority at the beginning of a patient’s course of hospitalization.

Good dental care is an important component to maintain overall health and well-being. When unchecked and untreated, bacteria that forms on teeth often can lead to more serious health problems. Poor oral care has been known to contribute to cardiovascular disease and respiratory infections, as well as other serious health conditions.

Dentists and oral surgeons often are credentialed and included in a hospital’s medical staff roster to provide dental services to emergency department patients and inpatients when needed. Providing dental care for a hospitalized patient is uncommon, and dentists and oral surgeons are not routinely consulted to provide dental services.

Because of the infrequency of providing dental care in the hospital setting, many dentists are unfamiliar with hospital and medical staff requirements that apply to the providers who examine and treat inpatients. The lack of familiarity with hospital systems and medical staff rules can pose serious risk management implications for the dental care provider.

Risk Management Strategies

Be wary of “curbside consultations” in which informal collaboration may find its way into the medical record. Consulting dentists have been sued by patients that they neither met nor examined because of inaccurate documentation by other providers in the medical record. If you are asked for input on a specific patient situation, it may be best to request a formal consultation so that you can document your thoughts and opinions in your own words.
Communicate clearly with other providers on the expectations regarding your involvement in patient care. Once you become a part of the care team, the lines often get blurred among providers regarding who is responsible for each aspect of care. Key information often can get lost in the transitions of care that occur in a hospital among caregivers. Clarify your role in the record, and communicate with other providers when there is confusion or cause for concern.
Familiarize yourself with the medical record beforehand — ask for training. Electronic medical records (EMRs) present unique nuances and special challenges to a user who is unfamiliar with the system. There may be templates or designated sections for your documentation. The EMR may not be easily navigated, so it is helpful to take the time to learn the various sections that you will need to use. It can be a powerful tool for provider collaboration if you know where to look for information.
Understand your documentation requirements. How often are you required to document your care of the patient? When does your documentation need to be finalized and available in the medical record? What do you need to include in your consultation notes? This information should be provided at the time of your appointment to the medical staff.
Request updates and revisions to processes and systems. Hospitals regularly update and revise facility operations as well as clinical policies and processes. Make sure that you periodically request updated information regarding any facility or patient care-related changes. Notice of physical plant changes may prove extremely helpful to you when you need to locate your patient to provide dental services. Notice of process changes will help you fulfill your obligation as a medical staff member to follow current policies and procedures.
Have a go-to person to contact for assistance when needed. Despite taking appropriate steps to be prepared to care for your patient, there are always unexpected challenges that may occur. Get to know your medical staff department coordinator or the facility risk manager. They can prove to be great resources when you need quick access to information. Also, if you can’t find someone for assistance after regular hours, reach out to the hospital administrator on call who will connect you with someone who can assist you.

By Rosanne Cain, BSN, LHRM, Patient Safety/Risk Manager II, The Doctors Company

Recognizing latex allergies is an important patient safety precaution.

A 43-year-old registered nurse presented to his dentist for a regular teeth cleaning procedure. After several years of daily use of latex gloves and medical supplies, he developed a severe sensitivity to latex that ultimately resulted in anaphylactic reactions to most latex exposures.

Prior to his scheduled appointment, he contacted the dental office and informed the staff about his severe latex allergy. The dental staff made a note in his dental record and prepared the exam room with nitrile gloves. When he arrived, the dental hygienist recommended protective eyewear. The patient asked the hygienist if the foam cushioning around the eyepieces was latex-free. The hygienist could not confirm. The hygienist also failed to note that she placed small rubber bands, which also contain latex, around the handles of her dental instruments.

The hygienist began the procedure. The patient began to itch, which was quickly followed by wheezing. The procedure was stopped, and the patient immediately administered his medication. The patient’s action avoided a severe anaphylactic reaction.

Discussion
During the past 30 years, latex allergies have been recognized as a significant problem for both specific patient and provider populations. The incidence of latex allergy in the general population has been estimated to be between 1 and 6 percent. Some adolescents experience incidences as high as 73 percent (notably those individuals with spina bifida and related pathologies). Women account for approximately 70 percent of latex-related anaphylactic reactions (most commonly during ob/gyn procedures).¹ Adults with spinal cord trauma, neurogenic bladder or documented history of unexplained intraoperative anaphylaxis also can be affected by frequent exposure to latex supplies. Health care workers maintain an incidence of allergic response that ranges from 8 to 17 percent.² Other at-risk populations with repeated exposure to latex gloves include lifeguards, emergency responders, law enforcement professionals and cosmetologists.

In addition, glove powder has been shown to aerosolize latex proteins and increases the risks of a reaction in latex-sensitized patients or staff. The U.S. Food and Drug Administration recently announced a ban of the use of powdered gloves in surgery, powdered patient examination gloves and absorbable powder used on surgical gloves. The ban was issued after an investigation determined that the powdered products present an “unreasonable and substantial risk of illness or injury, and that the risk cannot be corrected or eliminated by labeling or a change in labeling.”³

Although most dentists are familiar with latex allergies, the infrequency of a severe reaction during a dental procedure can cause inadequate precautionary measures in a dental practice. Implement the following risk management strategies to reduce latex-related risks.

Risk Management Strategies

Know your patient’s latex allergy status, and note it prominently in the patient’s medical records. Allergy status should be updated on each patient visit.
Remove toys that contain latex from your practice’s common areas and play zones.
Practice latex avoidance precautions. Create a patient area that is latex-free and educate staff about all dental-related products that are restricted from the room.
Identify dental products that contain latex, including gingival stimulators, irrigation tips, dental dams, bulb syringes, cushioned eye protection goggles, tourniquets, rubber stoppers on medicine vials, adhesive tapes and bandages, water tubing, prophy cups, and rubber toothbrush heads and grips.
Use latex-free carts, bandages, reservoir bags, airways, endotracheal tubes, laryngeal mask airways and ventilator bellows.
Maintain a list of latex-free dental devices and office products and ensure that it is readily available for staff reference.
Remember that touching any latex object can cause transmission of the allergen by hand to the patient.
Ensure that your supplies include emergency medications with non-latex syringes and medicine stoppers.
Perform practice drills with your staff so they are prepared for latex-related medical emergencies.

For a free brochure on latex allergy, contact the American College of Allergy, Asthma and Immunology (ACAAI) by calling toll-free 800.842.7777. Additional information is available on the ACAAI website at http://acaai.org/allergies/types/skin-allergies/latex-allergy.

References:
1. Allergic reactions during labour analgesia and caesarean section anaesthesia. Adriaensens, I., Vercauteren, M., Janssen, L., Leysen, J., Ebo, D. International Journal of Obstetric Anesthesia 2013 Jul; 22(3): 231-242.

2. American Latex Allergy Association, http://latexallergyresources.org/statistics

3. FDA Rule, Banned Devices; Powdered Surgeon’s Gloves, Powdered Patient Examination Gloves, and Absorbable Powder for Lubricating a Surgeon’s Glove, 81 FR 91722, December 19, 2016, https://www.federalregister.gov/documents/2016/12/19/2016-30382/banned-devices-powdered-surgeons-gloves-powdered-patient-examination-gloves-and-absorbable-powder

The guidelines suggested here are not rules, do not constitute legal advice and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Tag: strategies

Providing Dental Services in the Hospital Setting

Latex Precautions in the Dental Setting