A clinical audit by Mohammed Zafrul Islam.

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Abstract

Title Clinical audit: Is smoking cessation advice being recorded within dental notes?

Background Clinical audits are an integral part of clinical governance. The purpose of this audit is to explore if smoking cessation advice is being provided to patients. This is of high relevance to dental professionals as smoking has significant implications within the oral cavity affecting quality of life. In 2018, 14.4% of adults were classified as smokers in the UK.1

Aim To establish if smoking cessation advice is recorded in patient notes during a single course of treatment, provided by undergraduate BDS and dental hygiene and dental therapy (DHT) students, within the last six months.

Methods A sample size of 200 patient notes were selected at random, with the data collected over a four-week period. Patient notes were made available at the end of each undergraduate clinic day at the Royal London Dental Institute.

Conclusion The results fall below the benchmark set by NICE guidelines2 and the General Dental Council (GDC).3 Overall, actions to improve these results include raising awareness around smoking cessation, further training and a re-audit.

Introduction

NHS organisations are accountable for improving the quality of their services through a defined framework known as clinical governance.4 This framework involves the use of clinical audits. Additionally, the NHS Confederation, who commission and provide NHS services, request that all providers publish quality accounts annually. By objectively identifying if certain elements of care are being followed, in this case smoking cessation advice will highlight if further provision is required in delivering better care and outcomes for patients.

Undertaking an audit on the provision of smoking cessation advice and support within the Royal London Dental Institute seemed imperative, since its locality is in the borough of Tower Hamlets. In 2017, 19.7% of adults in Tower Hamlets were smokers which was 5.3% more than the UK's average proportion of smokers. More importantly, the Office for National Statistics found that in 2017/18 within the UK almost 490,000 hospital admissions were attributable to smoking, with 77,000 deaths being credited to smoking.1 Although the rate of smokers has decreased since 2011, there remains the alarming health risks patients are susceptible to by smoking which amplifies the importance of motivating patients to stop the habit of smoking.

Relevance

The scope of practice for DHTs includes providing smoking cessation advice for patients within their care. Smoking has well known systemic effects, but its oral manifestations can lead to oral cancer and pre-malignancy which can be detected during an oral cancer screening. Additionally, smoking increases patients' susceptibility to periodontal disease with increased attachment loss and recession, alongside lowering the chance for successful treatment following periodontal therapy.5

Control of periodontitis can only be obtained by controlling both local and systemic factors. Smoking remains a huge risk factor in the disease progression of periodontitis. Smoking has the following effects on the periodontal tissues:

  • Reduced tissue vascularity

  • Impaired phagocytes

  • Decreased T helpers and salivary IgA

  • Poor healing response following periodontal therapy.

The strong association between periodontitis and smoking is clear which leads to poorer prognosis and outcome. Although there is not substantial evidence claiming smoking cessation improves the outcome of periodontal therapy, from a holistic healthcare standpoint it is necessary to provide smoking cessation to patients.6

Methodology of audit

Patient notes were chosen at random, to ensure a mixture of smokers/non-smokers were selected as well as BDS/DHT undergraduate patient notes. Data were collected over a period of four weeks with a sample size of 200, which later will be discussed as justified. The patient dental notes were reviewed to ascertain if any advice or support was given to smokers. The two outcomes were either recorded as smoking cessation advice provided or not provided. Prior to the audit a standard was matched against NICE guidelines1 and GDC standard 4.1.2.6 It was expected that all patient notes were to have clearly documented any involvement in smoking cessation advice.

Method of smoking cessation advice

At the Royal London Dental Institute, undergraduates (BDS and DHT) are trained to provide very brief advice (VBA); this approach was developed by the National Centre for Smoking Cessation and Training (NCSCT). VBA offers a more compassionate and supportive way of engaging with patients, which can be used rather than engaging in a classic argumentative and blaming discussion. It involves three components:

  • ASK (Establishing and recording smoking status)

  • ADVISE (Tailor advice to patient of benefits of quitting)

  • ACT (Offer help).

This approach to smoking cessation advice is a relatively easy and reproducible method for the undergraduate students. It can be done over a span of 30 seconds and does not require such a lengthy conversation.

Although the VBA is proven to be well accredited and successful, there remain other ways in which advice can be deployed. Public Health England anticipate that patients will not want to quit smoking and this is where a harm reduction approach can be used.7 Rather than allowing the 30 second VBA to end at a stand-still, it is advisable to inform patients of considering using licensed nicotine containing products, which would help reduce the number of cigarettes they smoke. If patients then become interested, a referral to a smoking cessation centre should be made for nicotine replacement therapy.

Discussion

The sample size of this audit is representative of the area in which the clinical audit has been undertaken, with the proportion of smokers in Tower Hamlets being that of a similar proportion to the sample. NICE guidelines1 outline that every patient should be asked if they smoke and relevant advice should be provided taking into consideration each patient's circumstance. GDC standard 4.1.2 states to explicitly record as much detail as possible pertaining to patient conversations and to raise concerns if patients are at risk.3 From this evidence, smoking cessation advice should always be given and noted, along with recording socio-behavioural history which was fittingly recorded as 100% in this case. There was a result of only 72% of patients receiving smoking cessation advice. This is unacceptable as all patients have the right to receive an equal form of care. This audit has fallen below the benchmark set by NICE and GDC.

There are many possibilities explaining the results:

  • Undergraduate students can be overwhelmed with the complexities of treatment and may overlook the significance of smoking

  • A reminder for smoking cessation advice is provided on screening sheets, but for subsequent visits, writing notes on a day sheet does not remind clinicians to provide smoking cessation advice

  • Although the VBA technique is proven to be more effective than a normal consultation, it may not be effective towards all patients. Some patients could benefit from alternative techniques such as harm reduction and motivational interviewing

  • There seemed to have been a discrepancy in the amount of smoking cessation advice given by undergraduate dental student compared to DHT undergraduates. This may be since there is a much larger cohort of dental students leaving a larger room for error. Nonetheless, both DHT and BDS students are provided with the same level of training regarding smoking cessation advice.

Nevertheless, action is required to overcome these results. It will be beneficial to:

  • Raise general awareness by having posters pertaining to smoking cessation around the clinic to prompt clinicians and patients

  • Further training for undergraduates (BDS and DHT) should be implemented with emphasis on the 3As approach or alternative behavioural change technique

  • After some time has lapsed following the proposed actions, conduct a re-audit.

Re-audit

The only realistic way to quantify and understand if the provision in care through smoking cessation advice has improved is by conducting a re-audit. The re-audit will be undertaken in the same manner the initial audit was carried out after three months, which is enough time to implement the above actions, leading to more desirable results. The standards will remain the same with an expectation of all smokers to be provided with some form of smoking cessation advice. Dependent on the results, further consideration can be made on how to improve the standards within the Royal London Dental Institute.

Summary

Clinical audits play an integral part in clinical governance. As smoking affects various body systems, and additionally affects periodontal tissues and the oral cavity in the form of oral cancer, it is important that dental clinicians actively check the smoking status of their patients. The patient's response needs to be recorded in the patient's dental records at the time of the dental appointment/visit. The primary method of smoking cessation advice used by undergraduates with their patients is VBA; this audit highlighted that 72% of the patient notes had recorded any type of conversation regarding smoking cessation advice; this falls below the benchmark provided by the NICE guidelines and GDC requirements. An increase in awareness and additional training is required with a re-audit in three months, to identify if these actions have promoted change.