Improving the quality of dental procedures while minimising risks

Hi, I’m Anna Ewers-Clark, a vet and veterinary standards leads up Blue Cross. In case any of you don’t know, Blue Cross is a national pet charity that provides low cost veterinary care at our hospitals in London and Grimsby. Last year, we helped nearly 30,000 pets through our veterinary services. Blue Cross also finds new homes for pets in need, offers expert behavioural support, and provides our free confidential pet loss service. Today, I’m going to tell you about our dental timings audit that was awarded a highly commended runner up at this year’s RCVS Knowledge Awards.

We chose the topic of dental general anaesthetic time after it was discussed during a clinical team meeting. Concerns were raised about the long duration of dental anaesthetics and the impact this could have on patient outcomes, especially as patients undergoing dental procedures at our Blue Cross hospitals can often have severe dental disease. Prolonged dental procedures can lead to increased risk for patients. This is a major concern as many patients that require dentals have concurrent diseases and may be a higher ASA grade, which increases their anaesthetic risk and anticipatedly longer anaesthetics can also be challenging for hospital teams and make it difficult to plan workloads, which has a big impact on staff stress.

As this was an important topic for the welfare of patients and our staff, an audit was conducted to investigate dental anaesthetics times and look at whether staging should be encouraged in more dental procedures based on the Blue Cross welfare centric approach to veterinary care. The audit had three aims, to benchmark average dental times, investigate if dentals have been extended beyond 2.5 hours and set up guidance for a time point for considering staging during a dental. We set a target for average dental time to be under two hours. The secondary target was that less than 5 % of dentals should exceed 2.5 hours. Above this time, a staged dental was felt best.

We set our anaesthetic time checkpoint at two hours. This was felt to allow the vet to assess the patient’s stability under anaesthesia, evaluate the extent of remaining disease, and allow time to finish any central dentistry prior to the 2.5 anaesthetic cut-off we had set. We audited patients that had a dental at our Victoria Blue Cross Hospital during June to July, 2023. Data was collected from clinical and surgical anaesthetic records and analysed in Excel.

We found the average anaesthetic time was below our target of two hours with an average of 86 minutes GA time for the 2023 sample. No dentals for over 2.5 hours in this sample. This was a good surprise and we were reassured about the current length of dental anaesthetics. We discussed the findings as a team and were pleased that prolonged anaesthetics weren’t common from looking at this evidence. And it was felt the perception of long dentals was frequently likely to be because these were more memorable than the routine shorter procedures.

However, we did accept this was only a one month sample. So we wanted to ensure that the checkpoint was being used consistently. So we were constantly avoiding dentals that were over 2.5 hours. Strategies were discussed for things like prioritizing during dentals. So we removed the most severely effective teeth first, having the maximum welfare impact, especially where stage dentals were considered. We also talked about effective client communication to explain why stage dentals might be needed. In addition, we added this information to our clinical guidelines on dentistry.

These are pragmatic or first centred guidelines that help support decision making around contextualized care. They included the two hour anaesthetic checkpoint recommendation to show that we could book stage dentals as needed. When we repeated the audit in 2024, the results were similar to 2023, which was encouraging and made us feel that there was a good response to the guidelines and the support we made had lasting impact. As always, there were some limitations to our audit.

We would love to have a bigger sample size, but unfortunately this wasn’t possible with our resources. Overall though, we felt this audit was a success and has led to quality improvement in our hospital. It drew focus onto dental anaesthetic times and allowed us to provide additional support for decision making around stage dentals, especially when identifying where these were in the best interest of the patient. Finally, I would like to say a big thank you to all our team at Victoria Blue Cross, to Jack, our head vet at Victoria, who started this audit project, and to RCVS Knowledge for selecting us as a highly commended runner up. I hope you’ve enjoyed hearing a bit more about our audit, and I hope it encourages you to do one of your own.