Emergency dental care triage during the COVID-19 pandemic
Introduction Due to the COVID-19 pandemic, from 23 March 2020, routine dental treatment was stopped by the Chief Dental Officer, with the emphasis towards urgent dental care only.
Aim To evaluate the activities of the emergency service at a secondary care Urgent Dental Care (UDC) hub during the COVID-19 pandemic.
Materials and methods The total number of patients seen from 30 March to 20 June 2020 was recorded. The effectiveness of telephone triage and the appropriateness of patients invited for a clinical assessment were evaluated over a two-week period.
Results The number of calls into the UDC hub were highest during the first few weeks, with up to 249 per day. The most commonly provided emergency treatments included extractions and pulp extirpations.
Discussion As other UDC hubs opened, the number of calls reduced, with patients being directed to a UDC nearer to where they lived.
Conclusions The dental profession had to make some significant changes in the way they worked due to the risk of COVID-19 transmission and due to the effects of the lockdown. This review highlights the effectiveness of telephone triage as well as its drawbacks.
- Rapid and up-to-date service transformation, as well as sufficient local provision of services via Urgent Dental Care hubs, is essential to respond to public health challenges.
- Certain dental conditions can be easily managed with advice over the phone, such as temporomandibular joint dysfunction, while telephone triage is an effective way of prioritising emergency patients for a face-to-face appointment.
- A secondary care dental hospital provides a good setting to cope with a significant proportion of the dental needs during a pandemic owing to its large number of dental chairs, staff from a range of disciplines and an appropriate administrative team.
Due to the lockdown as a result of the COVID-19 pandemic from 23 March 2020, the emphasis in oral healthcare shifted away from the delivery of routine dental care to urgent care only. Urgent Dental Care (UDC) hubs were established at short notice to receive patients with dental emergencies.
The emergency service at King’s College Hospital was previously a walk-in service, where patients would queue for an appointment, but in August 2019, it evolved into an appointment service in response to patient feedback, with 40 appointments being available and the first 40 patients calling in receiving an appointment. This service saw approximately 200 patients per week from across London.
This call-in service was converted into a UDC hub during the pandemic, with a telephone triage system developed to identify patients requiring emergency dental care and invite them in for a face-to-face consultation. The pathway was set up to minimise unnecessary footfall through the hospital and help maintain social distancing rules, thereby reducing the potential for virus transmission.
The hub was led by an oral surgeon and had staff from restorative, paediatrics, orthodontics and special care dentistry departments. There was no shortage of staff since all routine clinics were cancelled. During the periods when the data were collected, telephone triage was provided by NHS consultants using seven telephones. Triage ran daily from 8 am until 4 pm, Monday to Friday.
As outlined in the Chief Dental Officer’s (CDO’s) letter of preparedness,1 emergency conditions which met the acceptance criteria for a clinical assessment included serious and life-threatening conditions as well as uncontrollable pain, swelling and trauma. Patients involved in trauma and those with swollen faces were invited to send photographs to an NHS e-mail address, and in situations where there was any uncertainty over the telephone, photographs helped confirm whether to invite the patient for a clinical assessment.
The clinicians involved also gave advice about analgesics and how to cope with non-urgent problems, as well as prescribing antibiotics when necessary. Patients who were to be seen for clinical assessment were also triaged for vulnerability and potential infection with COVID-19 so they could be seen in clearly identified and separate areas of the hospital.
Aims and objectives
The aim of this service review is to evaluate the activities of the emergency service at a secondary care UDC hub during the COVID-19 pandemic. Firstly, it assesses the total number of patients seen from 30 March to 20 June 2020. Secondly, it looks at the effectiveness of telephone triage over two separate weeks, one month apart. In addition, the appropriateness of the patients invited for a clinical assessment was evaluated by looking at the patients’ signs and symptoms recorded on the triage notes and whether these matched the signs and symptoms recorded at the clinical assessment. The patient demographics and the type of treatments provided were also analysed.
The total number of patients contacting the service and the number of patients invited to attend for a clinical assessment were recorded from 30 March to 20 June 2020.
The triage forms and the clinical records were retrospectively scrutinised and analysed for patients seen for clinical assessment during the weeks commencing 6 April 2020 and 11 May 2020. The anticipation was that we would be able to compare activity early on in the lockdown, when the service had just transitioned into an UDC hub, with activity one month later to see any changes in trends such as patient demographics and treatment provided.
During the whole timeframe from 30 March to 20 June 2020, the following data were collected:
- Total numbers of patients receiving telephone triage
- Total number of patients receiving clinical assessment.
During the two weeks chosen for data analysis in April and May, the following data were collected:
- Total numbers of failures to attend
- Total numbers of repeat triages
- Total numbers of repeat attendances
- Patient demongraphics:
- Home postcode
- Triage data:
- Triage date and appointment date
- Whether use of analgesics and antibiotics had been recorded on the triage form
- Whether the patient was medically compromised or vulnerable
- Clinical data:
- Whether the triage information matched the clinical information
- Whether the patients offered a clinical assessment fulfilled the criteria for an appointment
- Treatment provided.
During the timeframe from 30 March to 20 June 2020, a total of 7,448 patients called the telephone triage service at King’s College Hospital. Of these, 1,978 patients were invited to attend for a clinical assessment and the weekly breakdown of activity, as well as the percentage of callers invited to attend for a clinical assessment.
Data from the week commencing 6 April (period 1) reveal 162 of the total 835 callers were invited for a clinical assessment, of which three patients failed to attend; therefore, 159 patients’ notes were analysed. By comparison, data from the week commencing 11 May (period 2) revealed 219 of the total 693 callers were invited for clinical assessment, of which four patients failed to attend; therefore, 215 patients’ notes were analysed.
During period 1, 91.8% of patients were seen on the same day that they called, compared to 83.7% of patients in period 2.
Of the 159 patients who attended for a clinical assessment in period 1, eight (5%) had previously contacted the triage service and received advice during the COVID-19 period.
Four patients (2.5%) had previously attended for a clinical assessment. By comparison, during period 2, 21 patients (9.8%) contacted the triage service for a second time and 21 patients (9.8%) were seen for a second clinical appointment.
Twelve patients (7.5%) seen during period 1 were medically compromised or vulnerable compared to 19 (8.8%) during period 2.
The age range of patients that received clinical assessment in period 1 was 17-83 years and in period 2 was 16-84 years. Patients above 70 years of age were directed to a separate waiting area and were seen on a ‘vulnerable’ clinic with enclosed bays.
The gender distribution for both periods, showing 73 men and 86 women accessed the service during period 1 and 107 men and 108 women during period 2.
Use of analgesics and antibiotics recorded on the telephone triage form
In general, only patients who had already taken appropriate analgesics and antibiotics (if indicated) with no relief of their symptoms met the criteria to attend for a face-to-face clinical consultation. Whether this was the case was looked at restrospectively on the telephone triage form.
During period 1, 125 patients (78.6%) reported taking the correct analgesics but with inadequate relief of their pain and 34 (11.4%) recorded not having taken any. Sixty-six patients (41.5%) reported having had at least one course of antibiotics with no impact on their symptoms, with 93 (58.5%) not having taken any. By comparison, during period 2, 135 patients (62.7%) reported taking the correct analgesic but with inadequate relief of their pain and 80 (37.3%) recorded not having taken any. One hundred and two patients (47.4%) reported having had at least one course of antibiotics with no impact on their symptoms, with 113 (52.6%) not having taken any.
During periods 1 and 2, apical periodontitis was responsible for the majority of the emergency cases, with 47 patients (29.6%) with acute cases and 44 patients (27.7%) with chronic cases in period 1 and 45 (20.9%) and 87 (40.5%), respectively, in period 2
There was little difference in the number of patients diagnosed with irreversible pulpitis, periodontal abscess and fractured teeth between periods 1 and 2 (Table 3). There were, however, more cases of dental trauma during period 2.
The most common treatment modality was extraction, with 119 patients receiving one or more extractions during period 1 and 154 patients during period 2. Pulp extirpations were the next most common, with ten patients in period 1 and 21 patients in period 2 having at least one tooth extirpated (Fig. 3).