Dental triage Hydebank Wood Prison and Young Offenders Centre, Belfast
IN BRIEF
• Highlights the need for a targeted
RESEARCH
approach to prison dental care.
• Suggests a dental triage protocol to be
conducted at the time of a prisoners induction. • Suggests a referral pathway to the dental service to be used by prison landing staff.
R. Gray*1 and T. Fawcett1 VERIFIABLE CPD PAPER
Objective The aim of this study was to devise and test a triage protocol to prioritise patients’ dental needs in a prison environment. Secondary aims were to include in the triage process oral health promotion and information about accessing prison dental services. Also to work collaboratively with the prison staff to improve referrals to the dental services. Method The triage system was devised to have three strands: (1) an oral health assessment conducted by the dental nurse during the induction process for each new prisoner; (2) a simple oral health examination conducted in monthly screening clinics; (3) the prioritisation of referrals from prison landing staff using the prisons computer system PRISM. The triage was evaluated by assessing the first 100 patients’ records with regard to the prioritisation of the triage category at the time of the clinical dental examination. Results Of the 100 patients triaged 95% were prioritised into the correct triage category. Seventy-two percent of patients were seen in the appropriate timeframe. Referral patterns from prison landing staff were improved along with interdisciplinary working in the prison. All new prisoners were seen within 72 hours of committal and received oral health advice and information on accessing dental services. Conclusion This is the first triage system to be introduced into Hydebank Wood Prison, facilitating a targeted approach to dental care. It has improved access to the prison dental services; introduced oral health advice and information into the regular prison healthcare structure; and improved the efficiency of the clinical dental sessions. It is hoped to strategically address problems with waiting times and inequity in service utilisation. INTRODUCTION
BACKGROUND
The prison population in Northern Ireland has three main features; it is largely young, male and has a high turnover. The report on the Northern Ireland prison population 2011/12 recorded that Hydebank Wood had an average 208 males and 45 females incarcerated. 1 The number of prison receptions in Hydebank Wood throughout the year April-April 2011/12 equalled 1,373.1 The average sentence length was 3.5 years for male and 5.8 years for female prisoners. The average remand stays were 4.5 months for males and 2.6 months for females.1 The age of male prisoners is 16‑21 years and all adult female prisoners are incarcerated in Hydebank Wood. The prison dental service is conducted by community dental teams contracted to five weekly clinical sessions in Hydebank Wood.
Oral health
1 Senior Dental Officer, Hydebank Wood Prison and Young Offenders Centre, Belfast. *Correspondence to: Ruth Gray Email: [email protected]
Online article number E19 Refereed Paper - accepted 17 January 2014 DOI: 10.1038/sj.bdj.2014.381 © British Dental Journal 2014; 216: E19
International studies conducted in prisons have concluded that the prison population has a much higher prevalence of decayed teeth and periodontal disease than the general population. 2–5 There is a high demand for dental care once a person is incarcerated. Research has been published that the prevalence of oral disease has a high impact on a prisoner’s quality of life.6–8 There is no standardised system for assessment and prioritisation of the oral health needs of prisoners in the UK and dental needs are not met during their admission time.9
Access to prison dental services Research in Australia and America has found that commonest reason for prison healthcare visits was for dental care.10,11 In the Scottish prison survey 76.8% of participants claimed to have difficulty accessing dental care.12 An initial screening exam has been proposed to be included in the general health assessment during prisoner reception; this assessment can be used to prioritise dental treatment and access.12–14
Oral health needs assessment: Hydebank Wood Prison and Young Offenders Centre A needs assessment was conducted in 2007, examining and interviewing 196 prisoners in Hydebank Wood. The results revealed a high prevalence of dental caries, periodontal disease and a high treatment need. Participants stated that access to dental services was difficult, but most were happy with the service they had received. They recorded that they had little access to information about health services available and low percentages had experienced general or oral health education.15
Prison committal process The committal practice by general nurses in Hydebank Wood occurs within a few hours of prisoner reception, there is a second committal interviews within 72 hours. The initial interview establishes any relevant medical history, mental health problems and a risk assessment; the 72-hour committal investigates general health and also incorporates a health care services induction. At the time of this study, during the committal process no questions were asked about oral health.
BRITISH DENTAL JOURNAL
1 © 2014 Macmillan Publishers Limited. All rights reserved.
RESEARCH Dental triage The demand for medical and dental care often far outweighs the resources to supply services. Equity of access to healthcare is a key government policy, which aims to address oral health inequalities by ensuring that everyone can get NHS dentistry if they need it. The 1994 Prison Service Healthcare Standards have the stated aim: ‘To give prisoners access to the same quality and range of healthcare services as the general public receives from the NHS.’ Dental triage systems have been established throughout the UK in conjunction with NHS direct. The Scottish Dental Emergency Services piloted a successful dental nurses triage system in 2006. Dental nurses undergo intensive training using an IT system using dental algorithms for eight key dental emergency protocols. Dental nurses then give telephone advice following three key outcomes; urgent care is needed within 24 hours, routine treatment is necessary or self-care advice is given.16 When devising an out of hours emergency service in Newcastle and North Tyneside a consensus was drawn up to differentiate between what constituted a dental emergency and which conditions should be prioritised. The study concluded that a dental emergency should be seen within 4 hours: • Haemorrhage following tooth extraction • Trauma to teeth and jaws • Swelling around the eye or swelling resulting in difficulty of swallowing. Dental urgency should be seen within 24 hours: • Severe dental and facial pain, not controlled by over the counter prescriptions • Dental and soft tissue acute infection. A review 6 months following the commencement of the triage telephone system revaled 82% of dentists considered it beneficial and an improvement of out of hour’s services.17 Algorithms for dental trauma are well used, focusing on avulsed teeth and problems with haemorrhage. The Scottish Clinical Effectiveness Programme published emergency dental care guidelines in 2007.16 The aim was to provide dental practices with a simple algorithm for prioritising dental emergencies and providing self -help advice to dental patients. The guidelines focus on four common symptoms 1. Swelling 2. Pain 3. Dental trauma 4. Post-extraction Bleeding.
Table 1 Triage questionnaire Induction Oral Health Triage - Hydebank Wood DATE: Pt Name:
ID No:
1. How do you feel about your teeth? 2. Do you have any problems with: I. Trauma Max fax symptoms Trismus II. SwellingOro-facial infection in size III. Pain Dental abscessIrreversible pulpitisReversible pulpitis-
Avulsion
Bleeding post ext.
Peri-orbital
Swallowing
intraoral swelling or sinus, throbbing pain dull ache, no stimulus, long lasting, waking at night, no relief with analgesic sharp short pain, stimulus, analgesic relief
IV. Teeth Decay RCT incomplete Staining Sensitivity Restorations Wisdom teeth Fracture- involving dentine/pulp Chipped enamel V. Gingiva Bleeding
Pain
VI. Oral Medicine Dry mouth Ulcers Other
Recession
ANUG
Halitosis
Trauma
VII. Prosthetics DentureAge Condition CrownsOK VIII. Other
Cosmetic
Candida
OHI
Ortho
3. When was the last time you visited a dentist? 4. How do you feel about going to the dentist? Any problems before? Sedation Anxious OK
Can’t be bothered
5. Medical History Any serious illnesses? Medicines? 6. Do you smoke? Y N How many? How long? 7. Do you drink alcohol? Y How much?
N
8. Do you use drugs? Y N Which ones? Any interventions planned? 9. How often do you brush your teeth? 10. Do you use interdental aids? 11. Do you use mouthwash? 12. Diet? 13. Estimated length of time in Hydebank 14. Sentenced OHI: Triage:
Remand
Presentation Emergency
Appt. made
Leaflets Urgent
Advice Routine
Demo Check-up
Refused
Date on waiting list
Date when patient seen
2
BRITISH DENTAL JOURNAL © 2014 Macmillan Publishers Limited. All rights reserved.
RESEARCH Table 2 Notes for triage
Table 3 Triage timeframe
Q 1 – To establish patient’s awareness of oral health and their expectations. Q 2 – Dental nurse to ask if patient has any problems, but not read symptom lists comprehensively. Any problems cited should be circled and space below used to expand information. Q 3 + 4 – To ascertain the patient’s past dental attendance and any anxieties and problems noted. Q 5 – Medical history and medications may highlight any medical conditions that may need any special dental attention eg diabetes, chemotherapy and bisphosponates. Q 6-8 – If patient has current history of smoking, or using alcohol or substances the dental nurse is to liaise with health care staff about any cessation or detoxification programmes planned. Q 9-12 – Baseline information is to be gained with regards to a person’s oral health habits, and used as a guideline for advice needed. Q 13-14 – The estimated length of time in Hydebank is relevant depending on the length of the dental waiting lists, at times may need to prioritise sentenced or longstay prisoners. Oral health information – a record of what oral health advice has been given by the dental nurse during the induction.
Emergency
Seen by health care staff immediately and liaison with a dentist or medic within 4 hours
Bleeding post extraction Oro-facial swelling – increase in size, periorbital and swallowing Trauma – lacerations, bony fractures Severe trismus Urgent
Patient to be seen at next dental clinical session or within 7 days. Telephone advice with dentist within 24 hours if staff concerned.
Dental abscess Irreversible pulpitis - not controlled by analgesics Fractured tooth – dentine or pulp involved Pericoronitis Oral medicine – long standing ulcer or problem Acute necrotising ulcerative gingivitis (ANUG) Fractured denture Routine
Patient to be seen in monthly check-up triage appointment by GDP and assigned treatment plan
Dental decay Reversible pulpitis - controlled by analgesics
Following a simple algorithm patients are advised to attend for routine care (within 7 days), urgent care (within 24 hours) or emergency care (within 60 mins). It is well recognised that dental services in prison are delivered under special circumstances. Major issues being high turnover or patients, high prevalence of disease, unique environment of the prison including security concerns and the commission to provide equivalent care with NHS services. Jones et al.12 recommended that an oral health screening assessment should be integrated into health assessment of all new prisoners. In response to these issues the prison health research network commissioned a demonstration project testing a screening process to prioritise prisoners. The method used a dental pain questionnaire (DePaQ) and categorised patients with pain into three groups: • Irreversible pulpitis and periapical peridontitis – urgent • Reversible pulpitis and dentine sensitivity – non-urgent • Pericoronitis – non-urgent. The assessment was administered by general nurses during the committal process and followed by a clinical dental exam to confirm accuracy of the diagnosis. Results revealed the test had a high sensitivity at identifying people with urgent treatment needs but a low specificity as was inefficient at excluding people with nonurgent needs.18
Root canal treatment to be completed Gingivitis Request for prosthetics, cosmetic to orthodontic treatment Check-up
Patient to be put on waiting list for 6 month check-up
Patient is a current attendee with own GDP and no outstanding treatment Patient happy with teeth Patient not interested in receiving treatment Appointment date to be noted when appointment made, or when patient placed on waiting list Evaluation will be made by recording
With a self-reported screening process in the prison there will be an issue of reporting bias, as people are aware that unless deemed urgent, routine waiting list times can be long and inaccessible. The Prison Health Research Network (PHRN) plan to do further qualitative work into assessment tools. In the Hydebank triage protocol elements beyond pain experience were incorporated to try and account for the low specificity of the DePaQ triage method.
Oral health assessment tools The British Society for Disability and Oral Health is a leading organisation in the provision of special care dentistry. The rationale for using an oral health assessment is to identify and target dental treatment care to people who are at risk of poor oral health. Their assessment tool uses simple questions to ascertain the subjective identification of oral health problems and combines this with information on denture possession,
smoking and medication history and dental attendance. A decision as to the urgency of dental need is necessary.19
AIMS The aim of this study was to devise and test a triage protocol to prioritise patients’ dental needs in a prison environment. Secondary aims would be to include in the triage process oral health promotion and information about accessing prison dental services. Objectives were to work collaboratively with the prison staff, both healthcare and landing, to improve referrals to the dental services through the triage process.
METHOD The triage system was devised to have three strands; the first being an oral health assessment conducted by the dental nurse during the induction process for each new prisoner. The second strand was a simple examination conducted in monthly screening
BRITISH DENTAL JOURNAL
3 © 2014 Macmillan Publishers Limited. All rights reserved.
RESEARCH clinics, assessing the accuracy of the triage process. All the prisoners who had been assessed as routine treatment or been placed on the waiting list by prison staff as routine were booked into this clinic by the dental nurse. The third strand was the prioritisation of referrals from prison landing staff using the prisons computer system PRISM. Advice and protocols were given to each staff member.
Induction triage All new prisoners undergo a health assessment within 72 hours of reception. Two sessions were planned where all new inmates attended the healthcare centre for their health assessments. At this time the health services information presentation was made, focusing on which services were available and how to access them. Sexual health and healthy lifestyle information was included in this induction. It was proposed that this was the ideal time for the oral health triage to take place, which was accompanied by a short presentation of oral health prevention and advice. The dental nurse in Hydebank Wood developed an oral health presentation and was trained to present the general health induction. At each induction session using the screening pro-forma the dental nurse used the questionnaire (Table 1) to triage all new prisoners into four categories: 5. Emergency care 6. Urgent care 7. Routine care 8. No treatment needed ‑ 6 month review. Each prisoner was then assigned an appointment according to the triage timeframe or placed on the waiting list for the routine assessment clinic. Notes were included to guide the triage process (Table 2). The dental nurse followed the time frame appropriate for patients (Table 3). Liaison with other healthcare providers within Hydebank Wood was essential for the management of emergency and urgent care when a dentist was not on site. Multidisciplinary working was established. Out of hours emergency dental care was provided by a general dental practitioner through an arrangement with the Northern Ireland Prison Service. They were informed of the new triage system and their input and support was essential.
Screening examination All the prisoners who had been assessed as routine treatment or been placed on the waiting list by prison staff as routine were booked into this clinic by the dental nurse. These clinics were run specifically for the purpose of prioritising patient treatment
Table 4 Advice for referrals Prison Landing Staff- dental waiting lists PRISM- dental referral list, priority box only to be ticked if: 1. SwellingFacial swelling increasing in size Swelling restricting swallowing Extending to the eye 2. PainConstant Pain-
Keeping awake at night Not relieved by analgesics Intermittent Pain- Brought on by a stimulus Short acting 3. TraumaFacial Trauma Trismus- Jaw not opening or closing freely Tooth knocked out 4. Post Extraction BleedingInstructions have been followed, but it is still bleeding 5. FractureTooth Denture Crown 6. Dental AbscessSwelling or sinus in gums 7. Lost fillingBroken in last 48 hours and causing pain 8. Pain with wisdom teeth The category of Priority must be written in the PRISM referral box below the inmate’s details. Other categories are NOT a priority such as: - bleeding gums - stained teeth - broken teeth with no pain - check-up - person thinks they need fillings
by the dentist conducting treatment in Hydebank Wood. They were timetabled, initially, monthly and reviewed with regard to the patient throughput and waiting lists. The dentist prioritised patients with regard to dental disease, oral health condition, patient motivation and expected length of prison stay. The dental nurse then made appropriate appointments for treatment plans to be conducted. At the time of these screening appointments it was possible to compare the triage priority given with the clinical examination.
Prison landing referrals The landing staff were given a referral protocol. It was circulated to all staff by the prison healthcare governor and displayed on each landing. Oral health advice and instructions on what to do when a person was experiencing post-op bleeding or tooth avulsion, as well as information on spreading orofacial infection and the use of
analgesics, was distributed to each landing. It is intended that this format was evaluated when the person attended for the appointment with the clinical dentist and confirmation of the landing staff’s referral statement was made (Table 4). A small oral health advice pack was devised by the dental nurse, and at the time of distribution education for both the healthcare and landing staff was available. The triage protocol was discussed in the multidisciplinary healthcare team meetings. Once the referral was made on the PRISM system, the dental nurse using the triage protocols categorised the patients, using the additional information displayed in the PRISM referral box, and was appointed as appropriate.
RESULTS The records of the first 100 patients triaged were assessed with regards to the prioritisation of the triage process and the information gathered at the time of the
4
BRITISH DENTAL JOURNAL © 2014 Macmillan Publishers Limited. All rights reserved.
RESEARCH 3%
70 60
24%
50
32%
40 30 20
22%
19%
10
Happy OK Embarrassed Needs Treatment Check-up
Pr os th et ics
ed M Or al
Gi
ng iva
th Te e
Pa in
in g Sw ell
ax -F ax M
Tra um a
0
Fig. 1 Patient complaints
clinical examination. Triage forms and patient record charts could be compared.
Patient complaints Of the patients triaged, 62% were concerned about their teeth: this included issues of pain, infection, missing teeth and poor aesthetics. Forty-one percent of patients complained about their gingival health. Trauma (22%) and oral pain (20%) were next on the level of complaints. A small percentage of patients were concerned about prosthesis, this low level may be due to the relatively young age of the prisoners in the young offenders and women’s prison (Fig. 1).
Subjective views Patient’s views on their own teeth were recorded, 32% of patients triaged felt happy with their teeth and 19% felt their teeth were acceptable. Twenty-two percent claimed they were embarrassed by their teeth, 29% felt they needed some sort of treatment and 3% said they would like a check-up. Fifty percent of respondents had seen a dentist in the last year, mainly for emergency care and 26% of these had had treatment with the use of oral or IV sedation (Fig. 2). During the triage interview patients were questioned about lifestyle habits: 84% of patients smoked, 71% used alcohol heavily and 74% regularly misused substances, mainly cannabis, cocaine and ecstasy.
Triage categories Each patient was triaged according to the protocol and the majority were triages as needing a routine dental appointment, 59%. These patients were appointed in scheduled monthly routine clinics. Eleven percent were classed as having urgent need and
appointed to be seen at the next dental clinical session. Three percent of patients were prioritised as emergency and seen immediately within four hours by a dentist or medic. Nine percent were triaged as needing a check-up in six months’ time and 19% stated they had their own general dental practitioner (GDP) and did not want to undergo treatment while in prison, as the length of stay varied with this cohort (Fig. 3).
Fig. 2 Patients’ subjective views
8%
3% 11%
Patient attendance at the dental clinic
59%
On review of records 81% of patients were seen on the scheduled appointment made at the time of triage. The reasons for nonattendance included: the patient’s refusal to attend, the patient being released from prison, the patient attending a visitation, lockdown of the prison and the dental surgery undergoing renovations.
Triage evaluation Once the patients had attended for dental exam or treatment the senior dental officer evaluated if their triage information and prioritisation agreed with the presentation of oral health at the appointment. Ninetyfive percent of triage concurred with the dental exam for patient prioritisation.
Results for landing staff referrals Approximate number of referrals per month was 56 prisoners. The referrals for the prison landing staff were overall more focused with less use of the priority referral category. The main reasons for priority referrals were pain and a fractured tooth or filling. When the priority box was ticked, only 41% of times were the reasons for priority stated. Telephone messages to the dental surgery and to the health service staff for referrals
19%
Own GDP Emergency Urgent Routine Check-up Fig. 3 Triage category
were still made involving post-it notes being left in various parts of the surgery.
DISCUSSION The triage protocol was run in Hydebank Wood prison as a pilot to evaluate the effectiveness and appropriateness of such a service. The results reveal that it has shown to be successful in enabling all new committals to be assessed for dental care by changing the previous demand led service to a targeted approach of dental provision. It is no longer reliant on which patient ‘shouts the loudest’ or whose landing staff are most proactive in referrals. All new prisoners are now assessed for their oral health needs within 72 hours of committal as stated in prison health service standards.20
BRITISH DENTAL JOURNAL
5 © 2014 Macmillan Publishers Limited. All rights reserved.
RESEARCH They also receive advice about general and oral health and information on accessing dental and medical care. This is tackling the published barriers for prisoners attending dental services.12,14 It is well recognised that the general and oral health of prisoners is poor and often worsens during prison stay.2,12,15 Initially encouraging prisoners to consider their oral health, and providing information on accessing dental services, healthy eating and oral health promotion is hoped to have a positive impact on the prisoner’s oral health during their time incarcerated. The triage process also highlighted the high prevalence of the misuse of substances and dependency on smoking and alcohol. This enables a discussion with the prisoner about the oral and general health effects of such misuse at the initial dental appointment and continued support during incarceration. The results reveal 62% of prisoners were concerned with some aspect of their oral health. The patient has an opportunity to talk about their concerns and hopes for their oral health during the triage process, and if this impacts on their confidence, self-esteem and quality of life in prison.6,7 This leads to a patient-centred approach to care as the patients’ concerns are recorded and are noted at the time of the first dental appointment. On evaluation of the triage process it was deemed to be valuable with 95% of patients triage category in concurrence with the subsequent dental appointment. This facilitated a standardised prioritisation of patients in need of care, enabling patients to be seen in a timely and appropriate manner, in accordance with health services standards.21 Eighty-one percent of patients triaged were seen to the categorisation schedule of the protocol. Although there is room for improvement, this was a high appointment success compared to published dental appointment attendance in prison.14
There will always be a conflict of schedules within prisons with health services needing to be flexible around prison and legal appointments. The dental service must be responsive to changes in its schedules and improve on the percentage of patients seen. As with all dentistry the aim is to work in a multidisciplinary fashion and to work well with the other healthcare and medical staff. The dental triage protocol has facilitated good working relationships and an interdisciplinary approach to service provision. Further referral work and education with prison landing staff is planned to improve this system and support the landing staff in providing appropriate oral health advice and referrals. An appropriate skill mix of dental personnel is optimal to provide prison dentistry; this triage process has highlighted the value in enabling well trained and motivated dental care professionals to be the first point of contact for dental care and oral health advice in prisons. It has highlighted the effectiveness of good team working and has shown to be cost effective with the use of skill mix and high percentage of patients attending for dental care post triage. Less failed appointments leads to more efficient dental clinical sessions.
CONCLUSION This is the first triage system to be introduced into Hydebank Wood Prison, facilitating a targeted approach to dental care. It has improved access to the prison dental services; introduced oral health advice and information into the regular prison healthcare structure; and improved the efficiency of the clinical dental sessions. It is hoped to strategically address problems with waiting times and inequity in service utilisation. 1. Northern Ireland Prison Service. Annual report and accounts 2012. Belfast: NIPS, 2012.
2. Heng C, Morse D. Dental caries experience of female inmates. J Public Health Dent 2002; 62: 57–61. 3. Jones C, McCann M, Nugent Z. Scottish Prisons’ dental health survey 2002. Edinburgh: Scottish Executive, 2004. 4. Lunn H, Morris J, Jacob A, Grummitt C. The oral health of a group of prison inmates. Dent Update 2003; 30: 135–138. 5. Nobile C G, Fortunato L, Pavia M, Angelillo I F. Oral health status of male prisoners in Italy. Int Dent J 2007; 57: 27–35. 6. McGrath C. Oral health behind bars: a study of oral disease and its impact on the quality of an older prison population. Gerodontology 2002; 19: 109–114. 7. Naidoo S, Yengopal V, Cohen B. A baseline survey: oral health status of prisoners‑Western Cape. SADJ 2005; 60: 24–27. 8. Heidari E, Dickinson C, Fiske J. An investigation into the oral health status of male prisoners in the UK. J Disability Oral Health 2008; 9: 3–12. 9. HM Chief Inspector of Prisons for England and Wales. Annual Report 2008. Healthcare Chapter No 4. HC 323. London: The Stationary Office 10. Anderson B, Farrow J. Incarcerated adolescents in Washington State. Health services and utilisation. J Adolesc Health 1998; 22: 363–367. 11. Osborn M, Butler T, Barnard P. Oral health status of prison inmates‑New South Wales, Australia. Aust Dent J 2003; 48: 34–38. 12. Jones C, Woods K, Neville J, Gary Whittle J. Dental health of prisoners in the north west of England in 2000: literature review and dental health survey results. Community Dent Health 2005; 22: 113–117. 13. Conte T. Realistic dental care in jails and prisons: summary of proceedings J Am Dent Assoc 1981; 102: 343. 14. Harvey S, Anderson B, Cantore S, King E, Malik F. Reforming prison dental services in England ‑ a guide to good practice. London: Department of Health, 2005. 15. Gray R. Oral health needs assessment in Hydebank Wood Prison and YOC. Northern Ireland, 2008. Report of the Northern Ireland Prison Service (NIPS). 16. Scottish Dental Clinical Effectiveness Programme. Emergency dental care: dental clinical guidance. Dundee: SDCEP, 2007. 17. Evans D J, Smith M P, Grant S M, Crawford M A, Bond J. Out‑of‑hours emergency dental services ‑ development of one possible local solution. Br Dent J 2001; 191: 550–554. 18. Tickle M. Dentistry demonstration project. Prison Health Research Network Presentation, 2006. 19. Fiske J, Griffiths J, Jamieson R, Manger D, British Society for Disability and Oral Health. Guidelines for oral health care for long-stay patients and residents. Gerodontology 2000; 17: 55–64. 20. Northern Ireland Prison Service. The prison and young offenders centre rules. Belfast: NIPS, 1995. 21. Department of Health, Social Services and Public Safety. Transforming your care. A review of the health and social care in Northern Ireland. DHSSPSNI, 2011.
6
BRITISH DENTAL JOURNAL © 2014 Macmillan Publishers Limited. All rights reserved.
IN BRIEF
• Highlights the need for a targeted
RESEARCH
approach to prison dental care.
• Suggests a dental triage protocol to be
conducted at the time of a prisoners induction. • Suggests a referral pathway to the dental service to be used by prison landing staff.
R. Gray*1 and T. Fawcett1 VERIFIABLE CPD PAPER
Objective The aim of this study was to devise and test a triage protocol to prioritise patients’ dental needs in a prison environment. Secondary aims were to include in the triage process oral health promotion and information about accessing prison dental services. Also to work collaboratively with the prison staff to improve referrals to the dental services. Method The triage system was devised to have three strands: (1) an oral health assessment conducted by the dental nurse during the induction process for each new prisoner; (2) a simple oral health examination conducted in monthly screening clinics; (3) the prioritisation of referrals from prison landing staff using the prisons computer system PRISM. The triage was evaluated by assessing the first 100 patients’ records with regard to the prioritisation of the triage category at the time of the clinical dental examination. Results Of the 100 patients triaged 95% were prioritised into the correct triage category. Seventy-two percent of patients were seen in the appropriate timeframe. Referral patterns from prison landing staff were improved along with interdisciplinary working in the prison. All new prisoners were seen within 72 hours of committal and received oral health advice and information on accessing dental services. Conclusion This is the first triage system to be introduced into Hydebank Wood Prison, facilitating a targeted approach to dental care. It has improved access to the prison dental services; introduced oral health advice and information into the regular prison healthcare structure; and improved the efficiency of the clinical dental sessions. It is hoped to strategically address problems with waiting times and inequity in service utilisation. INTRODUCTION
BACKGROUND
The prison population in Northern Ireland has three main features; it is largely young, male and has a high turnover. The report on the Northern Ireland prison population 2011/12 recorded that Hydebank Wood had an average 208 males and 45 females incarcerated. 1 The number of prison receptions in Hydebank Wood throughout the year April-April 2011/12 equalled 1,373.1 The average sentence length was 3.5 years for male and 5.8 years for female prisoners. The average remand stays were 4.5 months for males and 2.6 months for females.1 The age of male prisoners is 16‑21 years and all adult female prisoners are incarcerated in Hydebank Wood. The prison dental service is conducted by community dental teams contracted to five weekly clinical sessions in Hydebank Wood.
Oral health
1 Senior Dental Officer, Hydebank Wood Prison and Young Offenders Centre, Belfast. *Correspondence to: Ruth Gray Email: [email protected]
Online article number E19 Refereed Paper - accepted 17 January 2014 DOI: 10.1038/sj.bdj.2014.381 © British Dental Journal 2014; 216: E19
International studies conducted in prisons have concluded that the prison population has a much higher prevalence of decayed teeth and periodontal disease than the general population. 2–5 There is a high demand for dental care once a person is incarcerated. Research has been published that the prevalence of oral disease has a high impact on a prisoner’s quality of life.6–8 There is no standardised system for assessment and prioritisation of the oral health needs of prisoners in the UK and dental needs are not met during their admission time.9
Access to prison dental services Research in Australia and America has found that commonest reason for prison healthcare visits was for dental care.10,11 In the Scottish prison survey 76.8% of participants claimed to have difficulty accessing dental care.12 An initial screening exam has been proposed to be included in the general health assessment during prisoner reception; this assessment can be used to prioritise dental treatment and access.12–14
Oral health needs assessment: Hydebank Wood Prison and Young Offenders Centre A needs assessment was conducted in 2007, examining and interviewing 196 prisoners in Hydebank Wood. The results revealed a high prevalence of dental caries, periodontal disease and a high treatment need. Participants stated that access to dental services was difficult, but most were happy with the service they had received. They recorded that they had little access to information about health services available and low percentages had experienced general or oral health education.15
Prison committal process The committal practice by general nurses in Hydebank Wood occurs within a few hours of prisoner reception, there is a second committal interviews within 72 hours. The initial interview establishes any relevant medical history, mental health problems and a risk assessment; the 72-hour committal investigates general health and also incorporates a health care services induction. At the time of this study, during the committal process no questions were asked about oral health.
BRITISH DENTAL JOURNAL
1 © 2014 Macmillan Publishers Limited. All rights reserved.
RESEARCH Dental triage The demand for medical and dental care often far outweighs the resources to supply services. Equity of access to healthcare is a key government policy, which aims to address oral health inequalities by ensuring that everyone can get NHS dentistry if they need it. The 1994 Prison Service Healthcare Standards have the stated aim: ‘To give prisoners access to the same quality and range of healthcare services as the general public receives from the NHS.’ Dental triage systems have been established throughout the UK in conjunction with NHS direct. The Scottish Dental Emergency Services piloted a successful dental nurses triage system in 2006. Dental nurses undergo intensive training using an IT system using dental algorithms for eight key dental emergency protocols. Dental nurses then give telephone advice following three key outcomes; urgent care is needed within 24 hours, routine treatment is necessary or self-care advice is given.16 When devising an out of hours emergency service in Newcastle and North Tyneside a consensus was drawn up to differentiate between what constituted a dental emergency and which conditions should be prioritised. The study concluded that a dental emergency should be seen within 4 hours: • Haemorrhage following tooth extraction • Trauma to teeth and jaws • Swelling around the eye or swelling resulting in difficulty of swallowing. Dental urgency should be seen within 24 hours: • Severe dental and facial pain, not controlled by over the counter prescriptions • Dental and soft tissue acute infection. A review 6 months following the commencement of the triage telephone system revaled 82% of dentists considered it beneficial and an improvement of out of hour’s services.17 Algorithms for dental trauma are well used, focusing on avulsed teeth and problems with haemorrhage. The Scottish Clinical Effectiveness Programme published emergency dental care guidelines in 2007.16 The aim was to provide dental practices with a simple algorithm for prioritising dental emergencies and providing self -help advice to dental patients. The guidelines focus on four common symptoms 1. Swelling 2. Pain 3. Dental trauma 4. Post-extraction Bleeding.
Table 1 Triage questionnaire Induction Oral Health Triage - Hydebank Wood DATE: Pt Name:
ID No:
1. How do you feel about your teeth? 2. Do you have any problems with: I. Trauma Max fax symptoms Trismus II. SwellingOro-facial infection in size III. Pain Dental abscessIrreversible pulpitisReversible pulpitis-
Avulsion
Bleeding post ext.
Peri-orbital
Swallowing
intraoral swelling or sinus, throbbing pain dull ache, no stimulus, long lasting, waking at night, no relief with analgesic sharp short pain, stimulus, analgesic relief
IV. Teeth Decay RCT incomplete Staining Sensitivity Restorations Wisdom teeth Fracture- involving dentine/pulp Chipped enamel V. Gingiva Bleeding
Pain
VI. Oral Medicine Dry mouth Ulcers Other
Recession
ANUG
Halitosis
Trauma
VII. Prosthetics DentureAge Condition CrownsOK VIII. Other
Cosmetic
Candida
OHI
Ortho
3. When was the last time you visited a dentist? 4. How do you feel about going to the dentist? Any problems before? Sedation Anxious OK
Can’t be bothered
5. Medical History Any serious illnesses? Medicines? 6. Do you smoke? Y N How many? How long? 7. Do you drink alcohol? Y How much?
N
8. Do you use drugs? Y N Which ones? Any interventions planned? 9. How often do you brush your teeth? 10. Do you use interdental aids? 11. Do you use mouthwash? 12. Diet? 13. Estimated length of time in Hydebank 14. Sentenced OHI: Triage:
Remand
Presentation Emergency
Appt. made
Leaflets Urgent
Advice Routine
Demo Check-up
Refused
Date on waiting list
Date when patient seen
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RESEARCH Table 2 Notes for triage
Table 3 Triage timeframe
Q 1 – To establish patient’s awareness of oral health and their expectations. Q 2 – Dental nurse to ask if patient has any problems, but not read symptom lists comprehensively. Any problems cited should be circled and space below used to expand information. Q 3 + 4 – To ascertain the patient’s past dental attendance and any anxieties and problems noted. Q 5 – Medical history and medications may highlight any medical conditions that may need any special dental attention eg diabetes, chemotherapy and bisphosponates. Q 6-8 – If patient has current history of smoking, or using alcohol or substances the dental nurse is to liaise with health care staff about any cessation or detoxification programmes planned. Q 9-12 – Baseline information is to be gained with regards to a person’s oral health habits, and used as a guideline for advice needed. Q 13-14 – The estimated length of time in Hydebank is relevant depending on the length of the dental waiting lists, at times may need to prioritise sentenced or longstay prisoners. Oral health information – a record of what oral health advice has been given by the dental nurse during the induction.
Emergency
Seen by health care staff immediately and liaison with a dentist or medic within 4 hours
Bleeding post extraction Oro-facial swelling – increase in size, periorbital and swallowing Trauma – lacerations, bony fractures Severe trismus Urgent
Patient to be seen at next dental clinical session or within 7 days. Telephone advice with dentist within 24 hours if staff concerned.
Dental abscess Irreversible pulpitis - not controlled by analgesics Fractured tooth – dentine or pulp involved Pericoronitis Oral medicine – long standing ulcer or problem Acute necrotising ulcerative gingivitis (ANUG) Fractured denture Routine
Patient to be seen in monthly check-up triage appointment by GDP and assigned treatment plan
Dental decay Reversible pulpitis - controlled by analgesics
Following a simple algorithm patients are advised to attend for routine care (within 7 days), urgent care (within 24 hours) or emergency care (within 60 mins). It is well recognised that dental services in prison are delivered under special circumstances. Major issues being high turnover or patients, high prevalence of disease, unique environment of the prison including security concerns and the commission to provide equivalent care with NHS services. Jones et al.12 recommended that an oral health screening assessment should be integrated into health assessment of all new prisoners. In response to these issues the prison health research network commissioned a demonstration project testing a screening process to prioritise prisoners. The method used a dental pain questionnaire (DePaQ) and categorised patients with pain into three groups: • Irreversible pulpitis and periapical peridontitis – urgent • Reversible pulpitis and dentine sensitivity – non-urgent • Pericoronitis – non-urgent. The assessment was administered by general nurses during the committal process and followed by a clinical dental exam to confirm accuracy of the diagnosis. Results revealed the test had a high sensitivity at identifying people with urgent treatment needs but a low specificity as was inefficient at excluding people with nonurgent needs.18
Root canal treatment to be completed Gingivitis Request for prosthetics, cosmetic to orthodontic treatment Check-up
Patient to be put on waiting list for 6 month check-up
Patient is a current attendee with own GDP and no outstanding treatment Patient happy with teeth Patient not interested in receiving treatment Appointment date to be noted when appointment made, or when patient placed on waiting list Evaluation will be made by recording
With a self-reported screening process in the prison there will be an issue of reporting bias, as people are aware that unless deemed urgent, routine waiting list times can be long and inaccessible. The Prison Health Research Network (PHRN) plan to do further qualitative work into assessment tools. In the Hydebank triage protocol elements beyond pain experience were incorporated to try and account for the low specificity of the DePaQ triage method.
Oral health assessment tools The British Society for Disability and Oral Health is a leading organisation in the provision of special care dentistry. The rationale for using an oral health assessment is to identify and target dental treatment care to people who are at risk of poor oral health. Their assessment tool uses simple questions to ascertain the subjective identification of oral health problems and combines this with information on denture possession,
smoking and medication history and dental attendance. A decision as to the urgency of dental need is necessary.19
AIMS The aim of this study was to devise and test a triage protocol to prioritise patients’ dental needs in a prison environment. Secondary aims would be to include in the triage process oral health promotion and information about accessing prison dental services. Objectives were to work collaboratively with the prison staff, both healthcare and landing, to improve referrals to the dental services through the triage process.
METHOD The triage system was devised to have three strands; the first being an oral health assessment conducted by the dental nurse during the induction process for each new prisoner. The second strand was a simple examination conducted in monthly screening
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RESEARCH clinics, assessing the accuracy of the triage process. All the prisoners who had been assessed as routine treatment or been placed on the waiting list by prison staff as routine were booked into this clinic by the dental nurse. The third strand was the prioritisation of referrals from prison landing staff using the prisons computer system PRISM. Advice and protocols were given to each staff member.
Induction triage All new prisoners undergo a health assessment within 72 hours of reception. Two sessions were planned where all new inmates attended the healthcare centre for their health assessments. At this time the health services information presentation was made, focusing on which services were available and how to access them. Sexual health and healthy lifestyle information was included in this induction. It was proposed that this was the ideal time for the oral health triage to take place, which was accompanied by a short presentation of oral health prevention and advice. The dental nurse in Hydebank Wood developed an oral health presentation and was trained to present the general health induction. At each induction session using the screening pro-forma the dental nurse used the questionnaire (Table 1) to triage all new prisoners into four categories: 5. Emergency care 6. Urgent care 7. Routine care 8. No treatment needed ‑ 6 month review. Each prisoner was then assigned an appointment according to the triage timeframe or placed on the waiting list for the routine assessment clinic. Notes were included to guide the triage process (Table 2). The dental nurse followed the time frame appropriate for patients (Table 3). Liaison with other healthcare providers within Hydebank Wood was essential for the management of emergency and urgent care when a dentist was not on site. Multidisciplinary working was established. Out of hours emergency dental care was provided by a general dental practitioner through an arrangement with the Northern Ireland Prison Service. They were informed of the new triage system and their input and support was essential.
Screening examination All the prisoners who had been assessed as routine treatment or been placed on the waiting list by prison staff as routine were booked into this clinic by the dental nurse. These clinics were run specifically for the purpose of prioritising patient treatment
Table 4 Advice for referrals Prison Landing Staff- dental waiting lists PRISM- dental referral list, priority box only to be ticked if: 1. SwellingFacial swelling increasing in size Swelling restricting swallowing Extending to the eye 2. PainConstant Pain-
Keeping awake at night Not relieved by analgesics Intermittent Pain- Brought on by a stimulus Short acting 3. TraumaFacial Trauma Trismus- Jaw not opening or closing freely Tooth knocked out 4. Post Extraction BleedingInstructions have been followed, but it is still bleeding 5. FractureTooth Denture Crown 6. Dental AbscessSwelling or sinus in gums 7. Lost fillingBroken in last 48 hours and causing pain 8. Pain with wisdom teeth The category of Priority must be written in the PRISM referral box below the inmate’s details. Other categories are NOT a priority such as: - bleeding gums - stained teeth - broken teeth with no pain - check-up - person thinks they need fillings
by the dentist conducting treatment in Hydebank Wood. They were timetabled, initially, monthly and reviewed with regard to the patient throughput and waiting lists. The dentist prioritised patients with regard to dental disease, oral health condition, patient motivation and expected length of prison stay. The dental nurse then made appropriate appointments for treatment plans to be conducted. At the time of these screening appointments it was possible to compare the triage priority given with the clinical examination.
Prison landing referrals The landing staff were given a referral protocol. It was circulated to all staff by the prison healthcare governor and displayed on each landing. Oral health advice and instructions on what to do when a person was experiencing post-op bleeding or tooth avulsion, as well as information on spreading orofacial infection and the use of
analgesics, was distributed to each landing. It is intended that this format was evaluated when the person attended for the appointment with the clinical dentist and confirmation of the landing staff’s referral statement was made (Table 4). A small oral health advice pack was devised by the dental nurse, and at the time of distribution education for both the healthcare and landing staff was available. The triage protocol was discussed in the multidisciplinary healthcare team meetings. Once the referral was made on the PRISM system, the dental nurse using the triage protocols categorised the patients, using the additional information displayed in the PRISM referral box, and was appointed as appropriate.
RESULTS The records of the first 100 patients triaged were assessed with regards to the prioritisation of the triage process and the information gathered at the time of the
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RESEARCH 3%
70 60
24%
50
32%
40 30 20
22%
19%
10
Happy OK Embarrassed Needs Treatment Check-up
Pr os th et ics
ed M Or al
Gi
ng iva
th Te e
Pa in
in g Sw ell
ax -F ax M
Tra um a
0
Fig. 1 Patient complaints
clinical examination. Triage forms and patient record charts could be compared.
Patient complaints Of the patients triaged, 62% were concerned about their teeth: this included issues of pain, infection, missing teeth and poor aesthetics. Forty-one percent of patients complained about their gingival health. Trauma (22%) and oral pain (20%) were next on the level of complaints. A small percentage of patients were concerned about prosthesis, this low level may be due to the relatively young age of the prisoners in the young offenders and women’s prison (Fig. 1).
Subjective views Patient’s views on their own teeth were recorded, 32% of patients triaged felt happy with their teeth and 19% felt their teeth were acceptable. Twenty-two percent claimed they were embarrassed by their teeth, 29% felt they needed some sort of treatment and 3% said they would like a check-up. Fifty percent of respondents had seen a dentist in the last year, mainly for emergency care and 26% of these had had treatment with the use of oral or IV sedation (Fig. 2). During the triage interview patients were questioned about lifestyle habits: 84% of patients smoked, 71% used alcohol heavily and 74% regularly misused substances, mainly cannabis, cocaine and ecstasy.
Triage categories Each patient was triaged according to the protocol and the majority were triages as needing a routine dental appointment, 59%. These patients were appointed in scheduled monthly routine clinics. Eleven percent were classed as having urgent need and
appointed to be seen at the next dental clinical session. Three percent of patients were prioritised as emergency and seen immediately within four hours by a dentist or medic. Nine percent were triaged as needing a check-up in six months’ time and 19% stated they had their own general dental practitioner (GDP) and did not want to undergo treatment while in prison, as the length of stay varied with this cohort (Fig. 3).
Fig. 2 Patients’ subjective views
8%
3% 11%
Patient attendance at the dental clinic
59%
On review of records 81% of patients were seen on the scheduled appointment made at the time of triage. The reasons for nonattendance included: the patient’s refusal to attend, the patient being released from prison, the patient attending a visitation, lockdown of the prison and the dental surgery undergoing renovations.
Triage evaluation Once the patients had attended for dental exam or treatment the senior dental officer evaluated if their triage information and prioritisation agreed with the presentation of oral health at the appointment. Ninetyfive percent of triage concurred with the dental exam for patient prioritisation.
Results for landing staff referrals Approximate number of referrals per month was 56 prisoners. The referrals for the prison landing staff were overall more focused with less use of the priority referral category. The main reasons for priority referrals were pain and a fractured tooth or filling. When the priority box was ticked, only 41% of times were the reasons for priority stated. Telephone messages to the dental surgery and to the health service staff for referrals
19%
Own GDP Emergency Urgent Routine Check-up Fig. 3 Triage category
were still made involving post-it notes being left in various parts of the surgery.
DISCUSSION The triage protocol was run in Hydebank Wood prison as a pilot to evaluate the effectiveness and appropriateness of such a service. The results reveal that it has shown to be successful in enabling all new committals to be assessed for dental care by changing the previous demand led service to a targeted approach of dental provision. It is no longer reliant on which patient ‘shouts the loudest’ or whose landing staff are most proactive in referrals. All new prisoners are now assessed for their oral health needs within 72 hours of committal as stated in prison health service standards.20
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RESEARCH They also receive advice about general and oral health and information on accessing dental and medical care. This is tackling the published barriers for prisoners attending dental services.12,14 It is well recognised that the general and oral health of prisoners is poor and often worsens during prison stay.2,12,15 Initially encouraging prisoners to consider their oral health, and providing information on accessing dental services, healthy eating and oral health promotion is hoped to have a positive impact on the prisoner’s oral health during their time incarcerated. The triage process also highlighted the high prevalence of the misuse of substances and dependency on smoking and alcohol. This enables a discussion with the prisoner about the oral and general health effects of such misuse at the initial dental appointment and continued support during incarceration. The results reveal 62% of prisoners were concerned with some aspect of their oral health. The patient has an opportunity to talk about their concerns and hopes for their oral health during the triage process, and if this impacts on their confidence, self-esteem and quality of life in prison.6,7 This leads to a patient-centred approach to care as the patients’ concerns are recorded and are noted at the time of the first dental appointment. On evaluation of the triage process it was deemed to be valuable with 95% of patients triage category in concurrence with the subsequent dental appointment. This facilitated a standardised prioritisation of patients in need of care, enabling patients to be seen in a timely and appropriate manner, in accordance with health services standards.21 Eighty-one percent of patients triaged were seen to the categorisation schedule of the protocol. Although there is room for improvement, this was a high appointment success compared to published dental appointment attendance in prison.14
There will always be a conflict of schedules within prisons with health services needing to be flexible around prison and legal appointments. The dental service must be responsive to changes in its schedules and improve on the percentage of patients seen. As with all dentistry the aim is to work in a multidisciplinary fashion and to work well with the other healthcare and medical staff. The dental triage protocol has facilitated good working relationships and an interdisciplinary approach to service provision. Further referral work and education with prison landing staff is planned to improve this system and support the landing staff in providing appropriate oral health advice and referrals. An appropriate skill mix of dental personnel is optimal to provide prison dentistry; this triage process has highlighted the value in enabling well trained and motivated dental care professionals to be the first point of contact for dental care and oral health advice in prisons. It has highlighted the effectiveness of good team working and has shown to be cost effective with the use of skill mix and high percentage of patients attending for dental care post triage. Less failed appointments leads to more efficient dental clinical sessions.
CONCLUSION This is the first triage system to be introduced into Hydebank Wood Prison, facilitating a targeted approach to dental care. It has improved access to the prison dental services; introduced oral health advice and information into the regular prison healthcare structure; and improved the efficiency of the clinical dental sessions. It is hoped to strategically address problems with waiting times and inequity in service utilisation. 1. Northern Ireland Prison Service. Annual report and accounts 2012. Belfast: NIPS, 2012.
2. Heng C, Morse D. Dental caries experience of female inmates. J Public Health Dent 2002; 62: 57–61. 3. Jones C, McCann M, Nugent Z. Scottish Prisons’ dental health survey 2002. Edinburgh: Scottish Executive, 2004. 4. Lunn H, Morris J, Jacob A, Grummitt C. The oral health of a group of prison inmates. Dent Update 2003; 30: 135–138. 5. Nobile C G, Fortunato L, Pavia M, Angelillo I F. Oral health status of male prisoners in Italy. Int Dent J 2007; 57: 27–35. 6. McGrath C. Oral health behind bars: a study of oral disease and its impact on the quality of an older prison population. Gerodontology 2002; 19: 109–114. 7. Naidoo S, Yengopal V, Cohen B. A baseline survey: oral health status of prisoners‑Western Cape. SADJ 2005; 60: 24–27. 8. Heidari E, Dickinson C, Fiske J. An investigation into the oral health status of male prisoners in the UK. J Disability Oral Health 2008; 9: 3–12. 9. HM Chief Inspector of Prisons for England and Wales. Annual Report 2008. Healthcare Chapter No 4. HC 323. London: The Stationary Office 10. Anderson B, Farrow J. Incarcerated adolescents in Washington State. Health services and utilisation. J Adolesc Health 1998; 22: 363–367. 11. Osborn M, Butler T, Barnard P. Oral health status of prison inmates‑New South Wales, Australia. Aust Dent J 2003; 48: 34–38. 12. Jones C, Woods K, Neville J, Gary Whittle J. Dental health of prisoners in the north west of England in 2000: literature review and dental health survey results. Community Dent Health 2005; 22: 113–117. 13. Conte T. Realistic dental care in jails and prisons: summary of proceedings J Am Dent Assoc 1981; 102: 343. 14. Harvey S, Anderson B, Cantore S, King E, Malik F. Reforming prison dental services in England ‑ a guide to good practice. London: Department of Health, 2005. 15. Gray R. Oral health needs assessment in Hydebank Wood Prison and YOC. Northern Ireland, 2008. Report of the Northern Ireland Prison Service (NIPS). 16. Scottish Dental Clinical Effectiveness Programme. Emergency dental care: dental clinical guidance. Dundee: SDCEP, 2007. 17. Evans D J, Smith M P, Grant S M, Crawford M A, Bond J. Out‑of‑hours emergency dental services ‑ development of one possible local solution. Br Dent J 2001; 191: 550–554. 18. Tickle M. Dentistry demonstration project. Prison Health Research Network Presentation, 2006. 19. Fiske J, Griffiths J, Jamieson R, Manger D, British Society for Disability and Oral Health. Guidelines for oral health care for long-stay patients and residents. Gerodontology 2000; 17: 55–64. 20. Northern Ireland Prison Service. The prison and young offenders centre rules. Belfast: NIPS, 1995. 21. Department of Health, Social Services and Public Safety. Transforming your care. A review of the health and social care in Northern Ireland. DHSSPSNI, 2011.
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