Developing a Dental Pre‐Assessment Pathway to Improve Theatre Utilisation and Quality Care

Between April 2023 and March 2024, 32 514 children in England were admitted to hospital with dental decay [1], with many of these admissions necessitating a general anaesthetic (GA) for dental treatment. As demand for this service results in often lengthy waiting lists, it is important that GA lists are used to capacity and cancellations minimised. To aid this, a robust pre-assessment process beginning at initial clinical assessment is needed; all children listed for GA should have a thorough medical history taken and a nurse-led pre-assessment prior to admission. However, where a child has a complex medical history or requires significant reasonable adjustments, a pre-assessment by a consultant anaesthetist may be required [2]. These anaesthetist-led pre-assessments are usually conducted via review of clinical notes, with or without an appointment. However, according to the Association of Paediatric Anaesthetists of Great Britain and Ireland, there is significant variation in the availability of these services around the United Kingdom [3]. The paediatric dentistry department in Leeds Teaching Hospitals Trust (LTHT), UK, has two GA pathways: an ‘extraction only’ list for fit and well children or those with mild systemic disease, and a pathway for medically complex children and comprehensive care treatment delivered at the Leeds Children's Hospital (LCH). Anaesthetist input for medically complex children is often requested as part of nurse-led pre-assessment [4], however, at LCH this additional input is requested by the dental clinician at the time of GA listing via an electronic listing form. This form becomes part of the patient's electronic record and is viewable by all specialities. Prior to this evaluation, no local protocol existed to inform the criteria for referral. Anecdotally, high variation was observed in the quality of referral and the dental clinician decision to refer for anaesthetist pre-assessment. Concern had been raised by the pre-assessment anaesthetists that the paediatric dental team were referring more patients than other surgical specialties, and that limited quality of referrals may result in preparation issues leading to cancellations at short notice or on the day of GA. A service evaluation was therefore conducted to explore the pre-assessment pathway for these patients and their GA outcomes. To evaluate and develop the pathway for consultant anaesthetic GA pre-assessments to improve referral quality and service utilisation. Evaluation One included a retrospective review of all patients on the waiting list for GA at LCH in October 2022. Those on the extraction only pathway and those awaiting comprehensive care who were fit and well were excluded from analysis, as these children would not require anaesthetist-led pre-assessment. All records were reviewed and evaluated for referral to the pre-assessment service. The dental notes (including medical history) of referred patients were reviewed to identify clinically critical information for inclusion in pre-assessment requests for each case. Where any quality criteria were deemed relevant from the dental notes and omitted from the pre-assessment request, the referral was marked as incomplete. Evaluation One was concluded with a retrospective review of a convenience sample of LCH GA lists over a 3-months period (February to April 2023), assessing reasons for cancellations or failures, to ascertain if these were related to the pre-assessment pathway. Anonymised data were extracted into Microsoft Excel 2021 (Version 2108 Build 14332.20771), and descriptive statistics were undertaken. Changes were implemented to improve the service, and 4 months later, Evaluation Two was completed using the same methodology, analysing the GA waiting list from October 2024 and the GA treatment lists from August to October 2024. Evaluation One consisted of 71 patients listed for GA and 103 procedures. There was a high variation in pre-assessment referral quality, and 10.3% (n = 10) of patients were cancelled at short notice or on the day of their procedure (Table 1). These cancellations were due to medical liaison failure and preparation issues for children with learning disabilities and autism, resulting in failure on the day at various points of the pre-operative pathway (including failed induction). Following Evaluation One a pre-assessment pathway was formalised through collaboration between dental and anaesthetic teams, including referral threshold and quality criteria (Table 2). This was disseminated to the paediatric dental team and an aide memoire developed for utilisation at GA listing. Teaching regarding referrals was delivered to the dental team by a paediatric pre-assessment anaesthetist. All patients who are under the care of a paediatric cardiology team should be pre-assessed by a paediatric anaesthetist prior to general anaesthetic. Leeds Children's Hospital has a large cohort of patients with complex and uncorrected cardiac disease who often require dental treatment prior to cardiac interventions In Evaluation Two, no referrals were made which did not meet threshold criteria; however, one patient with a complex cardiac history was not referred who required an anaesthetist-led pre-assessment (Table 1). There was also an increase in referral quality, with all referrals made in this time period containing all necessary quality criteria. A review of cancellations showed that there was a reduction in the proportion of cancellations due to pre-assessment issues. The four patients whose procedures were abandoned all had diagnoses of learning disabilities and autism, and cancellation occurred at various points of the GA pathway, from the ward to induction in the anaesthetic room. An annual review of referrals is planned, along with continued collaboration with the anaesthetic team to ensure contemporary pre-assessment criteria. All same-day cancellations in Evaluation Two related to patients with diagnoses of learning disabilities and autism. A separate project is underway to develop a bespoke pathway for these patients attending for dental GA, acknowledging the need for a more in-depth multi-disciplinary approach. This service evaluation has demonstrated the value of a local protocol to support anaesthetist pre-assessment referrals, with improvement in referral quality and reduction in short notice and same day cancellations, resulting in improved theatre utilisation. Standardisation of referrals has reduced unnecessary anaesthetic pre-assessment requests, supporting appropriate allocation of resources. Following standardisation of processes, dental clinicians included additional detail in pre-assessment requests in Evaluation Two, including specific questions for the anaesthetist. Improved referral quality also has the capacity to reduce duplication of work between the dental and anaesthetic teams in information gathering for medically complex patients ahead of GA admission at LCH, particularly those managed elsewhere for medical conditions. In many clinical settings, disparate dental and medical notes systems limit information sharing between specialties. One example of this includes behavioural challenges experienced in the dental setting which may impact the GA pathway on the day of the procedure; by dentists referring directly to anaesthetists this additional information can be included which may otherwise not be known. However, the potential impact of this lack of information sharing was demonstrated by the cancellations which still occurred in Evaluation Two, despite implementation of the pre-assessment protocol. A multi-disciplinary collaborative approach to this evaluation aims to bridge this gap and has supported improvement in patient care and shared learning for clinical teams. A limitation of this evaluation includes its convenience sampling of two disparate data sets, which limits the ability to follow individual patient journeys from pre-assessment to completion of GA and explore the direct effect. Where resources and time allow, a prospective evaluation may support understanding of this pathway on an individual patient level, but may be challenging due to GA waiting list times. Retrospective review of pre-assessment from completed GA lists may therefore be a preferred option for future evaluations. However, where cancellations have occurred, data collection may be complicated by the review of clinic, ward and theatre documentation. Implementation of similar practice nationally could reap benefits, but would require adaptation to local context given the wide variety in the availability and structure of paediatric dental GA services [5]. Spoke services utilising tertiary children's hospitals as hubs for their GA listings, such as Community Dental Services liaising directly with anaesthetists, may particularly benefit from development of a protocol. Overall, this evaluation demonstrated a reduction in same-day and short-notice cancellations due to pre-assessment related issues following implementation of a local pre-assessment protocol, demonstrating impact on patient experience and list utilisation. The authors declare no conflicts of interest.