Bronx VAMC Innovations in Dental Services for Spinal Cord Injured Vets

Bronx, NY - A lack of attention to oral care can adversely affect nutritional intake and have a serious negative impact on the patients' overall physical health and well-being. This is particularly true of the Spinal Cord Injury (SCI) inpatient whose serious medical conditions make them especially vulnerable. The Bronx VA Medical Center, with an SCI ward of over 60 resident inpatients, has developed and implemented protocols to improve the delivery of dental care for this large and complex patient population. "Our SCI veterans face many special challenges on a day-to-day basis," said Doctor Daniel MacDonald, Director of the SCI Dental Service, "getting them to our dental clinic from the SCI ward presented difficulties for patients and practitioners. Treating them at their bedsides, presented other difficulties. We felt it was imperative that we improve this process."

In the past, staff experienced great difficulty in preparing and transporting patients from the SCI unit to the dental service located on different floors. Patients on respirators and complex therapies required great care and resources that were not always available. Ventilation of these patients required nursing personnel, a respiratory therapist, and physical therapist to negotiate safe transport to the dental service and monitoring during the procedure. Endeavoring to bring the care to bedside presented additional challenges. Beds in SCI are wide, making it awkward for the dentist to properly provide treatment. Larger dental equipment requiring compressed air, specialized water lines, evacuation, and electrical requirements could not be negotiated in the patient's room. Moreover, the lack of patient privacy and safety concerns with dental x-rays in a room shared by other physically challenged patient's further complicated matters. These limitations made the delivery of routine dental care extremely difficult. In the interest of maintaining the best possible overall health for this important population, changes would have to be made.

"Proper dental care fosters appropriate nutrition, maintenance of immune status, and good general health." Said Lynda Olender, Chief Nurse Executive. "Moreover, the cosmetic aspect of dentistry will help increase patients' self-esteem and acceptance in public. We believe it's important to treat the patient by a holistic approach, considering all contributing factors; not just the obvious physical injury alone."

New Approach:
To circumvent these limitations and in an effort to encourage good dental hygiene for our SCI patients, the Bronx established a distinctive point-of-care dental facility (The SCI Dental Clinic) in a "site-specific" location within the SCI ward. This facility is equipped to handle most emergency and preventive dental needs, and permits patient privacy. All dental equipment is mobile with additional equipment to provide support to the respiratory compromised patient. The dental equipment necessary includes: an x-ray machine, high intensity lighting, a dental delivery unit, and suction apparatus. Drive air for the dental hand-pieces and vacuum for suction is provided simultaneously with an enclosed dry-compressor system (advantageous over oil driven compressors that produces disturbing mechanical noise and generates unpleasant organic odors). To reduce microbial biofilms and aerosols, coolant water for dental ultrasonic cleaning devices and dental hand pieces can be purified directly by employing a portable UV device mounted directly to the dental delivery unit.

Patients are transferred from their beds onto an adjustable, mobile Howsted APC chair by lifting equipment. For the respirator-dependent SCI patient, respiratory-trained personnel are available to aid in the disconnection/reconnection of the patients' airway prior to and after dental treatment. During transport to the dental treatment location, these patients receive supplemental oxygen by "Ambu" bag through their tracheotomy port. A higher percentage of oxygen is provided during patient transport by a Howsted chair mounted E-cylinder. Figure 1. illustrates dental treatment being provided to a respiratory-dependent patient. Our protocol requires a separate respiratory delivery unit to be present in the dental treatment suite.

Communication is Key:
A successful transition to "point of care" dental services (FIGURE 2) requires good communication with nursing, physicians, clinic administrators, and other hospital departments (i.e., dental, respiratory, pharmacy). One method of effective communication is via the interdisciplinary plan of care. This interdisciplinary plan of care should consider the potential dental barriers and plan for medical management during dental procedures. For the registered nurse (RN), this communication is particularly important at the initial visit or access point; such as, admission into a unit or entry into a clinic. Typically in these environments, it is the RN who is responsible for identifying potential oral health concerns. The RN needs to be a careful observer. Subtle signs; such as, the patient experiencing difficulty with oral intake of food, having difficulty masticating food, not wanting to wear his/her denture, or unilateral facial swelling, should prompt the RN to report her findings to the assigned SCI physician. A dental consult request is then executed.

The Referral for Point-of-Care Dental Services:
To facilitate this new interdepartmental initiative, the Bronx VA implemented an dental service referral process whereby physicians can select which dental point-of-care service location is most appropriate for a particular SCI patient. Once a dental need is identified, a consult referral is generated in the Computerized Patient Record System (CPRS) and forwarded to a specified SCI Dental website communicating which location the patient should be treated based on transportability and medical concerns (point-of-care SCI Dental Clinic vs. Dental Department, see FIGURE 3.). The patient is then screened bedside by a staff dentist or hygienist to ascertain the chief dental complaint and, if appropriate, the patient is then scheduled for examination in the SCI Dental Clinic. The patients' physician(s) is then consulted to rule out any medical concerns or pharmaceutical cross-reactivity (FIGURE 4.). In some cases, the patient may need to stop anticoagulant therapy, require medical clearance, special handling, or antibiotic coverage prior to commencing dental therapy.

Plan of Care for Dental Services:
The interdisciplinary care plan for dental services includes peri-procedural interventions. With a pending dental appointment, nursing staff needs to be informed by the physician about changes in medications to administer/withhold, as well as any changes in the patient's activities of daily living (ADL) regiment prior to the dental visit. This needs to be carefully coordinated with the SCI Dental team. Since this population is characterized by having complex medical therapies (i.e., ventilator, multiple intravenous (IV) delivery systems), the level of personnel required and competency for safe patient transportation to the SCI Dental Clinic should be determined. Those patients who are on fully automatic wheelchairs are safely treated in our main dental department.

Patient and Staff Education:
Patient and staff dental education should be a continuing process. In order to maintain oral health, patients need to be educated about the importance of good daily oral hygiene practices by both the dental and SCI staff. The importance of SCI staff dental continuing education cannot be overemphasized.

"Dental education is essential," noted Dr. MacDonald, "any information you can impart to your SCI staff regarding the importance of oral health transcends to the patient."

Progress Thus Far:
The outcome data suggests that there is a significant rise in the number of SCI patients receiving oral health services since the inception of the SCI Dental Clinic. Additionally, point-of-care dental services and the related consult management system have resulted in an improvement in consult timeliness and completion rate. The provision of point-of-care dental services for our SCI patients has made a positive impact on our SCI patient population.

"This has really made a difference for our patients." says Registered Nurse, Ms. Vivienne Barton, Clinical Manager of the SCI Unit, "Our patients are highly satisfied with the accessibility of dental services and it has added a new, positive dimension to our department." "It is comforting and relaxing," added Ventilator-Dependent patient, Glen Marrow, "I really feel they've put the CARE in Dental Care."