Donald Wood, CRNA, CPHRM, Patient Safety/Risk Manager
Multiple studies have shown that communication challenges can cause healthcare errors and complications. Dentists regularly provide care to patients who require a healthcare team with several medical specialties. In these circumstances, dental care provided to a patient requires effective communication among all team members and the patient.
A patient presented to a dentist for a scheduled procedure. As the patient was being prepared for the procedure, the patient inquired about the use of an antibiotic. The patient explained that he had undergone joint replacement surgery, and his orthopedic surgeon had instructed the patient that an antibiotic should be provided prior to any dental work. The dentist explained to the patient that current guidelines don’t support the concept of administering antibiotics prior to a dental procedure and was reluctant to prescribe an antibiotic. The patient wanted to discuss the dentist’s explanation with his orthopedic surgeon. He cancelled the procedure and left without being treated.
When a patient’s medical history reveals a prior surgery, the need for collaboration between the dentist and any previous treating physician may warrant a discussion. In this case, an orthopedic surgeon performed the joint replacement. The 2013 clinical practice guideline published jointly by the American Association of Orthopaedic Surgeons and the American Dental Association, further clarified by the 2014 guideline from the ADA Council on Scientific Affairs, does not specify the need for antibiotic prophylaxis for patients with a prior joint replacement surgery. However, many variables should be considered. The guidelines report that a patient with a medical history of osteomyelitis, acquired immunodeficiency, or drugs or disease that suppress the immune system may require antibiotic prophylaxis before dental procedures.
Effective collaboration, in this situation, includes notifying the orthopedic physician about the need for the dental procedure, the extensiveness of the procedure, and inquiring about the need for pre-operative antibiotics based on the patient’s orthopedic history. This collaborative process should begin as soon as a need for a dental procedure is determined.
A similar situation may arise with patients on antithrombotic therapy. This therapy requires a collaborative approach with the physician prescribing the medication. Although the number of antithrombotic medications was relatively limited in the past, several new medications have been approved. These new medications are noteworthy in that for some there is no testing for therapeutic effect and some have no antidote or reversal agent. In order to reduce the risk of excessive bleeding, it may be necessary for a patient who is undergoing antithrombotic therapy to temporarily cease taking the medication for several days. As a part of the communication process, the dentist and prescribing physician should determine when the patient can safely resume taking their medication. Documentation in the dental record should indicate the patient’s understanding of when to stop the antithrombotic medication and when to resume taking it. With effective communication among the dentist, treating physician, and patient, the overall impact on the patient’s health can be minimized.
Risk Management Strategies
Clear, concise communication can be enhanced by utilizing the SBAR (Situation-Background-Assessment-Recommendation) technique. This technique can help a dentist organize communication and present specific details while collaborating with a patient’s previous physician. The following is an example:
- Situation: A 58-year-old patient with pain, cold sensitivity, and advanced periodontal disease.
- Background: History of total knee replacements in 2010 and 2015.
- Assessment: Patient needs to have four teeth extracted, bone grafting and preparation for implants.
- Recommendation: Assess the need and timing of any antibiotic therapy that may be necessary prior to this procedure. If indicated, provide the patient with a prescription for the antibiotic.
Track these requests in a log or other format to determine if a response was received prior to the procedure. Follow up to ensure that communication among the dentist, prior specialists, and patient is successful.
Jevsevar D, Abt E. The new AAOS-ADA clinical practice guideline on prevention of orthopaedic implant infection in patients undergoing dental procedures, J Am Acad Orthop Surg 2013; 21: 195-197. http://www.aaos.org/Research/guidelines/PUDP/dentaleditorial.pdf
Sollecity T, Abt E, Lockhart P, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. J Am Dent Assoc. 2015; 146(1); 11-16 e8. http://jada.ada.org/article/S0002-8177(14)00019-1/fulltext#sec3
SBAR technique for communication: A situational briefing model. Institute for Healthcare Improvement website. http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx
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 healthcare 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.
CLAIM SCENARIOS PROVIDED BY THE DOCTORS COMPANY.