Précis: An audit of the delivery and documentation of postoperative instructions to patients undergoing root canal treatment in the DDUH demonstrated unfavourable results compared to the ideal benchmark. Introduction of a postoperative leaflet significantly improved the content and consistency of the advice and will be implemented in future.

Abstract
Statement of the problem: Concerns were expressed that postoperative written instructions following endodontic treatment are not available in the Dublin Dental University Hospital.
Materials and methods: Data was collected in three phases: retrospective analysis of clinical notes for evidence of the delivery of postoperative instructions; a randomly distributed questionnaire to patients undergoing root canal treatment prior to the introduction of a written postoperative advice sheet; and, another survey following introduction of the advice sheet.
Results: Some 56% of patients’ charts documented that postoperative advice was given. Analysis of phase two revealed that patients were not consistently informed of any key postoperative messages. In phase 3 analysis, the proposed benchmarks were met in four out of six categories.
Conclusions: Postoperative advice after root canal treatment in the DDUH is both poorly recorded and inconsistently delivered. A combination of oral postoperative instructions and written postoperative advice provided the most effective delivery of  patient information.

Introduction
Postoperative advice and instruction leaflets are important adjuncts to verbal communication and serve to reinforce and confirm any information given verbally. They play a vital role in helping patients to deal with postoperative concerns and management.
Concern has been expressed by both dentists and patients that written postoperative instructions following root canal treatment were not available in the Dublin Dental University Hospital (DDUH). The provision of postoperative advice and instructions, and its documentation, is considered best practice. In addition, studies have shown that adequate postoperative education can improve patient satisfaction and reduce postoperative morbidity.1 Some evidence would suggest that verbal information alone is not retained by patients after they leave the surgery.2,3 Failure to deliver appropriate postoperative information can lead to misunderstandings, unnecessary complications, complaints and even allegations of negligence.4
At present, a patient information leaflet exists in the DDUH for patients preparing to undergo root canal treatment; however, this leaflet contains no postoperative advice and instructions, and only gives an outline of the root canal treatment as a procedure for patients preoperatively.

Aims of the audit
The purpose of these DDUH clinical audits was to:

  1. Retrospectively audit patients’ charts to assess the delivery of instructions following root canal treatment procedures (phase one).
  2. Prospectively audit the practice of instructions given to patients following root canal treatment procedures (phase two).
  3. Design a postoperative patient information leaflet to supply after root canal treatment procedures.
  4. Prospectively compare the delivery of instructions to patients following root canal treatment procedures after the leaflet’s implementation (phase three).
  5. Propose and develop a standardised approach in the practice and documentation of patient postoperative advice and instructions following root canal treatment procedures.

Benchmark
Endodontic inter-appointment emergency is a clinical condition arising after an endodontic procedure is commenced or completed that requires an unscheduled patient visit, during which some treatment procedures have to be performed.5 Available literature has shown that its incidence is between 1.4% and 45%.6-8 Despite this, no universally agreed national or European benchmark regarding the practice and documentation of postoperative advice and instructions following endodontic treatment is available. However, the General Dental Council in the UK states that postoperatively a dentist’s role is to “communicate advice appropriately, effectively and sensitively by spoken, written and electronic methods, and maintain and develop these skills”.9 It is generally considered best practice to verbally inform patients of the likely outcome of treatment, what measures should be taken in case of pain or postoperative complication, and to document this advice in the patient’s clinical notes. Research has also indicated that this information is better retained by the patient if it is also supplied in written format.2,3,10

The benchmark used in this audit was:
1.     The delivery of postoperative advice and instructions should be documented in 100% of clinical notes.
2.    The advice and instructions given to patients should include six categories:

  • 100% of patients should be given advice regarding the risk of developing postoperative pain;
  • 100% of patients should be given instructions on how to manage postoperative pain;
  • if root canal treatment has been commenced in the DDUH only for emergency pain relief, 100% of patients should be instructed to visit their general dental practitioner for its completion;
  • 100% of patients should be advised that development of a visible swelling inside and/or outside the mouth requires emergency attention;
  • 100% of patients should be advised on the importance of an intact temporary restoration in the access cavity of the tooth involved; and,
  • 100% of patients should be advised of the need for an adequate final restoration of the tooth involved.

Method
Patients undergoing root canal treatment in accident and emergency clinics and/or undergraduate restorative dentistry clinics in the DDUH during the period of December 2014 to March 2015 were randomly selected to participate in this audit. As this study was an audit project to assess current hospital practice and compare to best practice, ethical approval was not sought. All patients had non-surgical de novo root canal treatment carried out. In the first phase of the audit process, the clinical notes for the chosen patients were retrospectively evaluated to check for any documentary evidence of postoperative advice and instructions given to the patient.
In phases two and three, in order to evaluate the nature of the postoperative patient advice (verbal, written or a combination), prospective data collection through the use of a questionnaire was completed (Appendix 1). The questions asked were based on the six proposed benchmark standards (listed earlier). Participants were also asked whether they find written instructions helpful or not. In addition, a written postoperative advice and instruction leaflet was developed (Appendix 2) for use in phase three.
Phase one dealt with the evaluation of a sample of randomly selected patient clinical notes (n = 50) in their respective electronic dental records (EDR) following root canal treatment procedures. These clinical notes were examined to check for any documentary evidence of postoperative advice and instructions. In phase two, immediately following the completion of scheduled/emergency appointments, patients (n = 50) were asked verbally if they would like to participate in the audit process. If agreeable, patients were given the mentioned questionnaire to complete in designated patient waiting areas. Patients included in phase two were not exposed to the newly designed postoperative information leaflet (only to verbal information). Patients (n = 50) included in phase three were given the newly designed leaflet by the treating clinician/student, as well as the postoperative instructions being communicated verbally prior to completion of the questionnaire. Following completion, all anonymous questionnaires were gathered and stored, and the data collected was analysed.

postoperative appendix 1

postoperative appendix 2

Results
Phase one showed that only 56% of clinical notes examined had evidence of documentation of postoperative advice (Table 1). Phase two, which was undertaken prior to the introduction of written instructions, revealed that the proposed benchmark was not met in any of the six categories described (Table 2). However, phase three (after the introduction of written instructions) showed that the proposed benchmark was met in four of the six categories (Table 3). The results demonstrated that 100% of the patients found written instructions helpful following the introduction of the leaflet. However, only 70% of patients thought that written instructions would be helpful when asked in phase two.

postoperative table 2 Postoperative Table 3

Discussion
Notably, the results from phase two fell well below the proposed benchmark. Currently in the DDUH, clinical notes are recorded on the patient’s EDR following completion of treatment. Operators have an option of selecting “Yes” or “No” in a dropdown box to state if “Postoperative instructions given?” If prompted “Yes”, operators have an option to detail what instructions were given. In only 56% of the clinical notes evaluated, operators opted to select “Yes” and gave any details of the postoperative instructions given to patients. In the remainder of the clinical notes examined, operators left this option blank and did not mention any details of the delivery of any postoperative advice in any section of their clinical notes. Documentation of such information is of paramount importance, not only for medico-legal purposes, but also for clinical continuity (‘handover’) where, for example, a patient may have been seen by different operators for emergency treatment and subsequent care.
Prior to the introduction of the postoperative advice and instruction leaflet, advice was delivered exclusively by verbal means to patients. Of all the advice and instructions given to patients in phase two, the proposed benchmark was not met for any of the categories. Possible reasons for this include poor retention of information communicated orally postoperatively, or failure of the operator to deliver all relevant instructions and advice to the patient (due to time constraints, lack of knowledge or a combination of these factors).
Following the introduction of the postoperative advice and instruction leaflet, advice was delivered through verbal communication, which was supplemented by written information. This combination resulted in the proposed benchmark being met in four categories, leaving two categories below the proposed benchmark, even though the designed leaflet addressed all categories of the proposed benchmark. Compliance with a verbal walk through of the content of the leaflet may have been a limitation of this audit and may account for the remaining two categories not being met in the second phase of the audit process.
One of these categories addressed advice given to patients to attend their GDP for completion of root canal treatment if the treatment itself was only completed for emergency pain relief (first stage endodontics). Some 58% of patients in phase three responded “Yes” to having received this advice, compared to 46% in phase two. The reason that there was such a small increase could be that the patients who attend the DDUH usually prefer, for a host of reasons, the DDUH itself to complete the root canal treatment instead of their own GDP, thus stating “No” on the questionnaire. The specific reasons for this were not investigated in this study; however, they may be financial, a preference for hospital treatment, or for reasons of treatment continuity. It is vitally important for the DDUH to advise patients to attend their own GDP for completion of root canal treatment (when undertaken as an emergency treatment option), as not doing this may lead to an increase in postoperative complications and unnecessary repeated visits to the DDUH Accident & Emergency Department.
It is accepted that the current audit may be limited by the small numbers in each group; however, it is uncertain if analysis of larger groups would have revealed further information. In addition, when attempting to extrapolate these findings into general practice some care must be exercised, as although the reported findings are largely universal, the chosen patient samples represent a dental school subpopulation, which may not be reflective of the general population. Furthermore, language difficulties or reduced health literacy may also impede appropriate clinician/patient communication and may have influenced the results for phases two and/or three. This, in combination with post-treatment-related stress or anxiety, may interfere with the patient’s ability to concentrate on instructions given.11,12 However, these final limitations would further strengthen the argument for supplying written instructions to patients.

Figure1

Recommendations
The provision of postoperative instructions is considered best practice after completion of clinical treatment. Documentation of such advice in clinical notes, particularly with regard to pain relief and swelling, is also vitally important. Endodontic treatment is no exception. A lack of standardised advice to patients was noted. The value of a postoperative advice and instruction leaflet to supplement verbal instructions has been demonstrated by this audit. At the end of this audit, the following recommendations can be made:

  1. The introduction of a postoperative advice and instruction leaflet following root canal treatment has been proposed in the DDUH.
  2. Introduction of a postoperative advice and instruction leaflet should contribute towards a uniform hospital-wide approach to postoperative advice and instructions.
  3. The designed leaflet will be widely distributed to the undergraduate/ postgraduate/NCHD/Accident & Emergency, and consultant clinics where root canal treatment may be undertaken, and given to patients following completion of root canal treatment.
  4. Following its introduction, an audit of patient satisfaction/operator compliance with the use and documentation of postoperative instructions in operator clinical noes will be undertaken.
  5. The findings of this audit should be used as a template for GDPs within Ireland to use after root canal treatment in their own practices.

References

  1. Alexander, R.E. Patient understanding of postsurgical instruction forms. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87: 153.
  2. Blinder, D., Rotenberg, L., Peleg, M., Taicher, S. Patient compliance to instructions after oral surgical procedures. Int J Oral Maxillofac Surg 2001; 30 (3): 216-219.
  3. Katz, L.G. The use of printed instruction sheets to enhance patient compliance. Semin Dermatol 1991: 10: 91-95.
  4. Vallerand, W.P., Vallerand, A.H., Heft, M. The effects of postoperative preparatory information on the clinical course following third molar extractions. J Oral Maxillofac Surg 1994; 52: 1165-1170.
  5. Alaçam, T., Tinaz, A.C. Interappointment emergencies in teeth with necrotic pulps. J Endod 2002; 28 (5): 375-377.
  6. Walton, R., Fouad, A. Endodontic interappointment flare-ups: a prospective study of incidence and related factors. J Endodon 1992; 18: 172-177.
  7. Cheng, Y., Cheung, G.S., Bian, Z., Peng, B. Incidence and factors associated with endodontic inter-appointment emergency in a dental teaching hospital in China. J Dent 2006; 34 (7): 516-521.
  8. Barnett, F., Tronstad, L. The incidence of flare-ups following endodontic treatment. Journal of Dental Research 1989; 68: 338 [Abstract 1253].
  9. General Dental Council UK. Preparing for practice. Available at: https://www.gdc-uk.org/Aboutus/education/Documents/Preparing%20for%20Practice%20%28revised%202015%29.pdf (accessed October 19, 2015).
  10. Weiner, N.F., Lovitt, R. An examination of patients’ understanding of information from health care providers. Hospital and Community Psychiatry 1984; 35: 619-620.
  11. Atchison, K.A., Black, E.E., Leathers, R., Belin, T.R., Abrego, M., Gironda, M.W., et al. A qualitative report of patient problems and postoperative instructions. J Oral Maxillofac Surg 2005; 63 (4): 449-456.
  12. Jackson, R.H., Davis, T.C., Bairnsfather, L.E., et al. Patient reading ability: An overlooked problem in health care. South Med J 1991; 84: 1172.

 

Advan Moorthy

A Moorthy  BA BDentSc MFDS RCPS (Glasg)
NCHD, Dublin Dental University Hospital,
Lincoln Place, Trinity College Dublin

AF Alkadhimi BA BDentSc MFD RCSI
NCHD, Dublin Dental University Hospital,
Lincoln Place, Trinity College Dublin

Leo F Stassen
FRCSI FDS RCS MA FTCD FFSEM FFD RCSI FICD
Professor/Chair of Oral and Maxillofacial Surgery, Trinity College Dublin Dublin, and Dublin Dental University Hospital, Lincoln Place, Dublin 2

HF Duncan
BDS FDS RCS (Edin) MClinDent MRD RCS (Edin)
Assistant Professor/Consultant in Endodontics, Dublin Dental University Hospital, Lincoln Place, Dublin 2

Corresponding author
Dr Hal Duncan
Assistant Professor/Consultant in Endodontics, Dublin Dental University Hospital, Lincoln Place, Dublin 2
T +353 (0)1 612 7316   F +353 (0)1 671 1255   E: Hal.Duncan@dental.tcd.ie