Dental health quality improvement plan for children with congenital heart disease

Quality Development in Advanced Practice field knowledge in nursing: Proposal on Enhancing the dental health of children suffering Congenital Heart Disease

One of the most prevalent development abnormalities found in children is heart disease, and it occurs in about 8-10 in every 1, 000 births. Dental supervision of children with congenital heart problems calls for special care, due to their increased susceptibility to contagious endocarditis, which is associated with bacteremia caused by persistent dental processes. Additionally, these patients always have developmental enamel abnormalities that raises caries risk, and always have deprived oral health. This latter condition may be said to be due to cardiac health problems, whose care and attention may lead to the under-estimation of oral health and inadequate consideration. Additionally, continual administration of liquid drugs containing sucrose as sweetener may cause caries and gingivitis cases in children (Andersson et al. 2013a). Dental ailment may cause dental extractions in young kids, probably needing some anesthesia, which compounds the problem with more financial, physical and emotional burdens.

The aim of the Quality Improvement Plan (QIP) is to build a framework for the efforts made at improving quality and to offer a structure for the development, monitoring, evaluation and promotion of these actions in CHB-Children Hospital Boston. PIT-Performance Improvement Team will make use of the yearly QIP to ensure the success of creating a tradition of quality and sustainable development that is in line with the strategic plans, visions, mission, and values of the department. The performance management system of the department creates the framework to set targets, assess progress, give reports on progress, and make necessary improvements (Pimentel et al., 2013). A very vital aspect of the PMS is the improvement of quality and implementing the quality improvement plan.

Background

A history of reviews on inherent heart disease services exists, which dates as far back as 2001 report of the inquiry of the public into issues concerning caring for children in need of serious cardiac surgeries (Balmer et al. 2010). There have been a lot of reviews with each of them making several recommendations, without any coordinated plan for change, and these issues have remained unresolved. This procedure of reviewing the CHD services in the absence of a suitable conclusion demoralized, angered, frustrated and exhausted a number of stakeholders and left some of them doubting the need to induce the required changes. The inability to implement the appropriate ultimate decisions has resulted in a sense of doubt within the field and destroyed relationships among different centers that thought they needed to be in competition with one another in order to survive. This has subsequently destroyed employment and retention, especially of surgeons who specialize in congenital heart conditions, which has in turn reduced the flexibility of the services of patients.

In spite of these issues, results have significantly improved in the past decade. A recent study has indicated a decline in mortality rates, a reduction within 10 years from 2004-2014, and favorably compare with available data gathered from several other international sources. Nearly 80% of children suffering congenital heart problems will now grow into adulthood, with the outcome that for the very first time, the number of grownups with CHD conditions is believed to be more than the number of young adults and children living with the condition. This affects service planning drastically, which will be later examined in this paper (Balmer et al., 2010).

Literature review

Balmer et al. (2010) made a comparison between the oral health condition of young children with congenital heart diseases against the heart condition of healthy children, and discovered that the cases of caries lesions were appreciably higher in the initial group. Furthermore, parents of such children were mostly unaware of the need to forestall dental diseases. Conversely, some researchers have shown that merely creating awareness with regards to the importance of having a good oral health condition does not really lead to suitable day-to-day oral care. Pimentel et al. (2013) discovered that there is a significant rise in the number of permanent dentition with cases of untreated caries in children suffering heart diseases, as compared to controls. They gave suggestions that negative attitudes with regards to dental care could be part of the reason why it is difficult to treat such children.

In a recent research, Balmer et al. (2010) discovered that no significant differences exist between children's oral health believed to be at an increased risk for infective endocarditis and children with no such conditions, despite the high caries score of the children. The number of children suffering untreated caries condition, in spite of the adequate dental awareness and care, was an issue that gave the concerned authorities much concern. In another recent study, a reduced caries index and lack of statistical difference appears when a comparison is made between young people with congenital heart conditions with those without any heart complications. The result made available by this study group indicated that there is a reduced oral health-related life quality in the test group, this was the case in certain domains, such stress from family issues and the psychological impact it has on the child.

According to current evidence from animal models, bacteremia that leads to infective endocarditis may be caused by some routine conditions like, chewing and oral hygiene (Pimentel et al. 2013). Nevertheless, Hartzell et al. (2005) showed that patients who had satisfactory oral health conditions (without gingival bleeding) showed no bacteremia while brushing their teeth. This strengthens the need to take certain preventive measures and providing periodic information to both patients and their parents about the risks involved with having ineffective endocarditis and the importance of maintaining good oral health. The recommendations of antibiotic prophylaxis to checkmate infective endocarditis have dramatically changed in the last ten years, and the link between the dentition of the patient and the general systemic health has been extensively studied (Pimentel et al. 2013). The involvement of a preoperative dental assessment has been effectively used in a number of surgical procedures, though there are very little data available on the oral health condition of children suffering congenital heart conditions, mostly children from underdeveloped countries.

Children suffering CHD have higher risks of ECC for a number of reasons such as

(1) Extended intubation period when primary teeth are growing

(2) Coexisting genetic defects which includes abnormalities in the composition/structure of the teeth

(3) The prolonged use of medications in the type of sugar base that act as a coat for primary teeth and enhance tooth decay

(4) Nutritional shortfalls that require the use of formula with high calorie

(5) Serious emotional stress which necessitates comfort efforts like pacifiers or bottles during procedures or hospitalizations

(6) Co-existing gastroesophageal reflux, a major risk factor for ECC development

(7) Barriers to the institution of a dental center and preventive measures emanating from parents keeping their child away from other health care visits or the unwillingness of dentists to provide treatment for children with the most difficult cases of CHD.

There is a scope for improvement. The agency in charge of NCQA and Healthcare Quality have created benchmarks for visits to oral health care centers, preventive guidance enlightenment for parents and suggestions for continuous education for medical personnel to make sure every patient, mostly who are at the highest risks for the development of ECC, are recognized to ensure timely screening exercises and referral. The main aim of the project is to make sure that dental care for infants and children under the care of the Cardiovascular Program Safe, Effective, Patient-Centered, Efficient, Equitable and Timely. This project will concentrate on the improvement of the arrangement, procedure, and results of dental care made available to the vulnerable patients, with the help of Donabedian's Framework as an intangible framework (Pimentel et al. 2013; Andersson et al. 2013a).

Improvement strategy

From the onset, the stakeholders entered into an agreement that a consensus should be built around certain standards which explains the best quality services possible, identifying that it could consequently become necessary to take tough decisions when it comes to the best way to put them into practice. A wider range of subjects is covered by the proposed standards than the ones they replace, and for the very first time, cover the entire lifetime path of care for CHD patients. The setting of the standards has been overseen by the medics and representatives of the patients (Andersson et al. 2013b). Certain standards have been put in place for the following factors: Staffing and Skills; The Network Approach; Facilities; Training and Education; Transition; Governance and Audit; Pregnancy and Contraception; Fetal Diagnosis; Dentistry; Palliative Care and Bereavement (Andersson et al. 2013b). In the development of this improvement plan, a partnership approach has been taken-with the support of the National Advisory Committee on Heart Disease (NACHD). The implementation of this work will largely depend on the continued partnership between all the stakeholders. Every aspect of health care is very important and will matter to people with certain conditions. Thus, whilst the plan concentrates all its energy on certain areas for development, it is important to bear in mind that several areas of activity which are not in any way highlighted, are however issues that will always require continuous effort to take care of and constantly improve results for the patients.

Design approach

The case study technique is adopted as a research approach, an empirical study that studies a phenomenon in its real-life situation. In the specific case investigated in this recommendation, several aspects will be considered to study a larger picture of the program and enlighten different opinions that arise consequently. Case studies may be either explanatory or descriptive, and under this context, both techniques can be adopted. (Andersson et al. 2013a).

The information of describing the empirical situation will be gathered with unstructured interviews with the staff members with long knowledge of the behavior of children with congenital heart disease in the Children Hospital Boston. Additionally, there will be an examination of different documentation types, both new documents and old documents searched in the archives, the annual plans and strategy documents of the Hospital, while initial development techniques might be hidden in strategic planning documents. After studying and assessing the documents, further information and explanation will be gotten by a brief second interview. Every sentence such as words that relate to quality or development in any way was assembled in a chronological order (Andersson et al., 2013b).

Participants

To assess the opinions of the Hospital on the development plan entirely, every healthcare administration manager, Primary Care, Somatic Specialist Care, Psychiatric Special Care and Dental Care, at every level of the organization will be required for interviews on the development program. Concerning patient's views on improvement plans, parents or guardians of children with CHD will be interviewed. The children will not be made part of the study ethics because they are still minors, and equally because of the high possibility of being unaware of development effects (Pimentel et al., 2013).

Data analysis

Constant variables will be indicated using means ± median or standard deviation, and by the interquartile intermission when necessary, while categorical variables will be indicated using percentages and using a 95% confidence intermission. Either the chi-square test or the students test will be adopted for carrying out an investigation on the disparity between the groups. The Mann-Witney test will be adopted for evaluating irregular distribution of constant variables. The Statistica 8.0 (StatSoft Inc., Tulsa, USA) software package will be used for every type of analysis, while a p-value < 0.05 will be measured as statistically significant (Pimentel et al., 2013; Andersson et al., 2013b).

Evaluation

The change (planned) was evaluated for success after implementation. Evaluation was done basically by determining whether the set objectives for the implementation were met, and whether this was within the planned time plan. After implementation of all the outlined changes, the implementation team then reconvened for evaluation of the strategy. This was done by reporting from the various departments on compliance with the outlined changes which was then gauged per the set goals. The change and its implementation helped to streamline the various shortcomings in healthcare provision.

In particular, the major effect of the implementation of the change plan was increased provision of the relevant information to parents with children suffering from congenital heart disease.

The other major effect of the implementation was increased screening and earlier referral for preventive care.

Through these methods, considered effectual in healthcare provision mainly because they ensured that, EEC cases were significantly reduced through preventive care and that those that were not prevented, care was provided adequately with all the information the parents needed to better manage the condition.

The stakeholders involved in the change implementation included RN/NP providers, primary care MDs, and parents. RN/NP providers and primary care MDs are in the frontline in the implementation of this plan for they are in contact with the patient and have the primary role of healthcare provision. Evaluation on the success of these in their roles will be done through simply analyzing how they take up their new roles. In addition, verbal response will be sought from the care recipients on care improvement or otherwise in the respective areas.

Change improvement

This quality improvement project was done with limited resources and time. The change could be improved further by implementation of both internal and external training to better equip the care providers with the skills needed for effective implementation of the change if better resources are available. In its current design, change is to be implemented through only structural and service change. To better healthcare provision, these changes should be coupled with personnel skills improvement through training or retraining through internal conferences and seminars or external attachments or educational training.

Researcher Involvement

In the course of this research, the researcher was nothing more than that, a researcher. According to Andersson et al. (2013a), to help eliminate biasness in the research, the researcher ought to remain neutral. Even though the researcher is a qualified nurse, this skill was only applied in the relevant manner for example, dressing appropriately while in the healthcare facility or associating with patients. To promote neutrality, only the healthcare staff knew of the qualification of the researcher and not the patients. Involvement with the organization and the various stakeholders as a professional level was limited to researcher level.

Conclusion and Summary

This quality development approach is far beyond the development of something entirely new-it involves the unlocking and channeling of collective experience, knowledge and energy of individuals towards one common project of genuine and lasting development. With regards to this framework, this plan sets out come clear aims and objectives for Heart-related Diseases. The methodology behind the Improvement Framework is crafted to initiate self-evaluation and debate. It is all about starting and doing: establishing conditions for and the implementation of the developments that will ultimately make the required difference. It is very easy to get distracted by a number of assumptions depending on how things have been all along instead of attempting new things. It is all about trying to encourage people to work collaboratively at the base level, as a way of testing and trying out new techniques. And where the new attempts succeed, work together with advisory organizations to make sure that there is a spread and sustainability of such techniques. As this integration plan improves, there is a commitment to make sure patients and their guardians are part of the work done to make sure any future priorities is a reflection of their needs. Cares that are centered on persons will equally mean involving several people living with CHD and all other such conditions, which means having complex morbidities, and as this work progresses, efforts must be made to make sure there is a holistic way of approaching the issue of care.