Treating patients at home
Rupert Hoppenbrouwers outlines some of the hurdles faced when offering domiciliary care.
A surgery is the ideal place to give and receive dental care, but this isn’t always a practical option. People who are housebound or who have special needs rely on dental professionals to come to them instead.
In an ageing population, there are more people with complex medical conditions who struggle to access conventional health and social services. The provision of support and care in their own homes enables these patients to enjoy a better quality of life.
Home visits are usually carried out by dental professionals from Community Dental Services, but if you are asked to see a patient at home, it’s important to be aware of what is required of you when undertaking domiciliary treatment, and to be able to minimise the added risks that it can pose.
The GDC states in its guidance, Standards for the dental team, that you must not treat patients in circumstances that you consider are unsafe.
It also states that you should be supported by a dental nurse or another ‘appropriately trained care professional’ if you are providing treatment in a care or domiciliary setting.
The right equipment
When carrying out home visits, it’s important to consider what equipment will be available. The Resuscitation Council (UK) Quality standards for cardiopulmonary resuscitation practice and training for primary dental care (endorsed by the GDC) outlines the minimum equipment list for all primary care dental premises including AED, oxygen, airways and emergency drugs.
While those standards do not specifically mention domiciliary treatment, in its overview the Resuscitation Council explains: ‘There are numerous types of setting where clinical care is provided. This guidance does not provide standards for every possible setting or scenario. The standards in this document can be used to help guide development of standards in clinical settings that are not included in this document.’
A dental professional might be criticised if a patient suffered a medical emergency during a home visit and portable items from the Resuscitation Council minimum list were available in a practice, but had not been taken on the visit and so couldn’t be used to treat the emergency.
From a practical perspective, there may be a distinction to be drawn between the risks of non-invasive domiciliary treatment, such as an examination or work in connection with the construction of a denture, and invasive treatment, for example tooth extraction, when a local anaesthetic will be administered. The Scottish National Dental Advisory Committee gives guidance on emergency drugs and equipment for domiciliary care and draws this distinction, recommending a risk assessment approach.
The Scots guidance recommends that: ‘Every episode of domiciliary care should be risk assessed, assigned a risk category and a decision made as to whether it is necessary and, if so, how any risk should be mitigated’. The guidance adds that: ‘If the risk assessment determines that there would be a significant risk of patient collapse or reaction to the dental procedure in a domiciliary setting, the dental team should refer the patient to the public dental service or local hospital dental department as appropriate.’
It is advisable that every dental practice develops a domiciliary visits protocol for staff, which addresses the issue of emergency equipment on domiciliary visits. If an adverse incident were to arise on a domiciliary visit and the dental professional concerned had complied with an internal protocol that was reasonable and based upon the currently available national guidance, that dental professional is unlikely to be justifiably criticised.
Protecting patient data
Dental professionals should be extra vigilant and take additional security measures to protect patient data when outside the standard practice setting.
It is important that while patient information is outside the practice, every effort is taken to ensure that it is secure and that data is not compromised.
The DDU advises dental professionals to take the following steps to ensure that patient records are safe while outside the practice setting:
- Ensure practice policies on data security and patient confidentiality are in place for dental professionals who need to take patient records outside of the practice
- Make sure that laptops and documents stored on them containing patient information are encrypted and that the laptop is password protected
- Never leave laptops, diaries or folders containing patient information unattended in a locked car
- If patient records must be kept outside of the practice overnight, make sure they are stored in a secure location, for example, inside the dental professional’s locked home
- Do not connect a laptop to an external network, for example a home internet network, without first seeking professional advice – the network may not be secure and patient information could be compromised.
Home visits play an important role in ensuring everyone has access to dental care, but they also bring added risks and responsibilities.
The checklist below can help you to consider the dentolegal risks of home dental visits.
If a patient requests a home visit
- Follow local procedures for referring patients to the Community Dental Service. Contact the local CDS or special care dental service if you are unsure
- If possible encourage patients to attend a dental surgery. Discuss with the local CDS whether it is possible to arrange transport
- Ensure patients’ expectations of domiciliary care are realistic
- Always work with a dental nurse when making a home visit
- Keep detailed contemporaneous notes of any home visits you make
- Understand the process for assessing legal capacity and best interests decisions, as set out in the Mental Capacity Act 2005 and its accompanying Code or the Adults with Incapacity (Scotland) Act 2000
- Review guidelines for the delivery of a domiciliary oral healthcare service for more about preparation, training, equipment and risk assessment
- Contact the DDU if you need specific dentolegal advice.
Find out more by visiting www.theddu.com.
Visit the DDU at the following events during May:
• The Dentistry Show, Birmingham – 12-13 May
• The Scottish Dental Show, Glasgow – 19-20 May
• British Dental Conference and Exhibition, Manchester – 25-27 May.
We look forward to seeing you.