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.
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).
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...
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).
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…
Andersson, A-C., Elg, M., Perseius, K-I. & Idvall, E. (2013a) Evaluating a questionnaire to measure improvements initiatives in Swedish healthcare. BMC Health Services Research, 13(48)
Andersson, A-C., Idvall, E., Perseius, K-I. & Elg, M. (2013b) Sustainable Outcomes of an Improvement Program: Do Financial Incentives Matter? Total Quality Management & Business Excellence
Balmer, R., Booras, G. & Parsons, J. (2010). The oral health of children considered very high risk for infective endocarditis. Int J Paediatr Dent. 20(3):173-8
Frankl, S.N., Shiere, F.R., Fogels, H.R. (1962). Should the parent remain with the child in the dental operatory? J Dent Child.29:150-163.
Source: http://circ.ahajournals.org/cgi/content-nw/full/111/23/e394/TBLIB Echocardiographic Features That Suggest Potential Need for Surgical Intervention Vegetation Persistent vegetation after systemic embolization Anterior mitral leaflet vegetation, particularly with size >10 mm* embolic events during first 2 wk of antimicrobial therapy* Increase in vegetation size despite appropriate antimicrobial http://circ.ahajournals.org/math/dagger.gif Valvular dysfunction Acute aortic or mitral insufficiency with signs of ventricular http://circ.ahajournals.org/math/dagger.gif Heart failure unresponsive to medical http://circ.ahajournals.org/math/dagger.gif Valve perforation or http://circ.ahajournals.org/math/dagger.gif Perivalvular extension Valvular dehiscence, rupture, or http://circ.ahajournals.org/math/dagger.gif New heart http://circ.ahajournals.org/math/dagger.gif Large abscess or extension of abscess despite appropriate
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