Summary of: An audit of referrals to a secondary care sedation unit

Key Points

• A proportion of practitioners refer significantly higher numbers of patients than their peers.

• Referral letters for anxiety management are generally poor.

• Non-pharmacological techniques are seldom requested by practitioners.

Abstract

Aims and objectives This audit was carried out to assess referrals received by a clinic treating anxious patients within a dental hospital setting. The audit aimed to provide a baseline measurement prior to the publication of a referral protocol. Referral frequencies were examined to explore the concept of serial referrers.

Methods A retrospective design was used. The referrals of all patients given assessment appointments for treatment within the Sedation Suite between 1 January and 31 December 2006 were examined. In addition, a random sample of 100 cases was examined for the referral request.

Results Three hundred and six referrals were sent assessment appointments by the Sedation Suite in 2006. The majority of referrals received (76.1%, n = 233) were from practitioners working in the general dental services. On average 1.68 referrals were received per clinician, with a maximum of 18 referrals from one clinician. The majority of patients were female and had an average age of 33.5. One hundred and eighty-seven patients attended for assessment. One hundred and forty-three (46.7%) were treatment planned to receive treatment with pharmacological help. Twenty-two (7.2%) were planned to receive treatment without pharmacological help, though none of the referrals received had considered requesting behavioural management.

Conclusion This audit confirmed results from previous audits. The standards set for referral were not met. Despite the efficacy of psychological treatments, referring clinicians do not seem to consider their use for anxious patients. Referral patterns seemed to support the idea that a minority of practitioners refer significantly higher numbers of patients than their peers.

Main

S. M. Woolley British Dental Journal 2009; 206: E10

Editor's summary

This study's aim was to obtain a baseline measurement of the referrals received by a secondary care sedation unit before a hospital referral protocol was published, as well as investigating anecdotal reports of some practitioners being 'serial referrers'. While it concentrates only on a single hospital sedation unit, the paper provides useful information for anyone interested in dental anxiety and sedation.

Dental anxiety can be incredibly difficult for patients to overcome and so it is important that it is managed appropriately in order to safeguard sufferers' oral health. As well as conscious sedation and general anaesthesia, psychological management such as cognitive behavioural therapy can be effective in helping patients to overcome their fear, with units such as the new Health Psychology Service at King's College London highlighting the demand for this kind of treatment (see 'Using psychology to help patients with dental anxiety', BDJ 2008; 205: 528). However, none of the referrals received in this study requested behavioural management, suggesting that referring practitioners are either unaware that this treatment modality is available, or else that they feel they have attempted behavioural management themselves prior to referral, with no effect. As the author points out, further information and education for dentists could help to raise awareness of this treatment modality, as well as increasing practitioners' competence in psychological management of dental anxiety.

Additionally, the results suggested that there was a minority of practitioners who referred significantly higher numbers of patients than their peers, supporting the original anecdotal reports of serial referrers. While the author stresses that there will be many variables affecting the referral patterns of practitioners and we must be careful in attributing significance to this finding, it is nonetheless interesting and warrants further investigation.

This audit succeeded in its aims, providing useful baseline information from which to detect changes in future audits of the unit. In so doing, however, it has also raised some points of broader significance and interest, both to readers and to UK dentistry as a whole.

The full paper can be accessed from the BDJ website ( http://www.bdj.co.uk ), under 'Research' in the table of contents for Volume 206 issue 5.

Rowena Milan, Journal Editor

Author questions and answers

1. Why did you undertake this research?

The motivation for this research stems from my thinking around the concept of conscious sedation – what is it, what is it for, what are the long-term effects of being engaging with a sedation service? Do we assume the answers to these simple and obvious-sounding questions are the same for all participants involved? This research was undertaken with two aims: to provide a baseline audit of referrals to a secondary care anxiety management clinic and to empirically confirm anecdotal evidence of 'serial referrers'.

2. What would you like to do next in this area to follow on from this work?

Quantification of referral patterns and treatments planned or received is helpful in understanding what is happening, but to understand why it is the case requires a qualitative approach to data. Future research aims to qualitatively investigate the reasons practitioners refer, and their understanding of the impact and outcomes of referral to a secondary care clinic for their practice and for the patients concerned. The motivations and expectations of patients regarding referral are a significant part of the success of treatment and are also part of an ongoing qualitative study.

Comment

A referral audit provides useful information for the development and assessment of referral criteria and is helpful for service planning and commissioning. In addition, referrers who do not comply with guidelines can be identified and remedial procedures put in place.

This audit, based in Wales, highlights some of the referral problems that many sedation services encounter. One perennial problem is the high cancellation and failure to attend rates – a third of patients (119) did not attend for assessment. This information on non-attenders is valuable as it can help clinicians to decide on a strategy to overbook assessment clinics. The author highlights that patients referred from the emergency clinic had a particularly poor attendance record, however, the high failure rate (48%) of patients from dentists employed by corporate bodies merits further investigation. The provision of targeted training and patient information leaflets may be worth considering for certain clinics and practices.

This audit also identifies educational issues that need to be addressed to improve the quality and appropriateness of referrals. The importance of behavioural management is one area that has been identified. Out of the 165 patients accepted for treatment, 22 were allocated for behavioural management only. While this figure is considerably lower than a similar study carried out in Dundee,1 it would have been interesting to know if all 22 of these patients were successfully managed with behavioural techniques alone. While the use of psychological modalities is integral to the management of all patients, they are especially important in anxious patients. Continuity of care is an important variable for patients who suffer from dental anxiety and this should be easier to achieve in dental practice or community clinics than in secondary care, where it is not uncommon for different clinicians/students to be involved with one course of treatment.

Despite the limitations of retrospective audits this paper identifies concerns that are relevant to many secondary care referral centres and highlights the role of undergraduate and postgraduate education in raising awareness of psychological management strategies for the anxious patient.