Touchstone Silver: Dental Pain in the Emergency Department

August 06, 2019
By: NHRMC
dental referrals 600w

In an average month, about 146 patients visit the New Hanover Regional Medical Center (NHRMC) Emergency Department for dental pain. Unfortunately, there is no definitive treatment available at the Emergency Department for dental pain patients.

This situation frustrated patients, who didn’t get the treatment they needed, and providers, who couldn’t help them.  Furthermore, patients who were unable to establish dental care often came back the ED for the same issue.

Most of the patients who visit the ED with dental pain are either self-pay (56%) or Medicaid (19%) and most do not have an established dentist.

The Project

In 2018, NHRMC established the Clinical Excellence program. The program’s goal is to drive high-quality, error-free and cost-effective care and to eliminate over- or under-treatment. Dental Pain was one of the first Clinical Excellence initiatives selected with the opportunity to improve patient outcomes and provider satisfaction.    

While this initiative began as a hospital-based Emergency Department project, it progressed into something much larger, establishing a system of care for dental patients. Community healthcare providers, NHRMC, and independent physicians collaborated to fill a gap in care for patients needing dental pain relief.

Using Lean strategies, the Clinical Excellence team engaged stakeholders from key departments, including the Emergency Department, Pharmacy, Oral Maxillofacial Surgery, Clinical Outcomes, and Radiology to form a team to determine what barriers needed to be overcome to treat dental pain patients. The team received input from front-line providers who shared past experiences.

The Emergency Department worked with the hospital’s Community Engagement Department to evaluate community options for dental care follow up.  MedNorth Health Clinic, a Federally Qualified Health Clinic, had recently established a stable dentistry practice, and were therefore approached for collaboration.

NHRMC’s Oral Maxillofacial Surgeons (OMFS) agreed to support the MedNorth dentists with medically complex patients.  When a patient was referred to MedNorth, their patient information was automatically sent to MedNorth.  This ensured a connection between the ED and MedNorth Dental clinic.

The Impact

Before the Clinical Excellence initiative began, 3% of dental pain patients received imaging, which was a CT scan. The group recommended using Panorex imaging when possible to decrease radiation exposure and cost to the patient as well as improving the ability to localize tooth-related problems for follow-up.  This education was completed with the ED providers, and an increase in the proportion of patients receiving Panorex imaging was observed.  

A total of 242 new referrals were generated in the first three months of the collaboration with MedNorth Dentistry.  Most patients referred through the new process are self-pay (67%) with the next largest volume being Medicaid patients (15%), from which the clinic may receive some reimbursement.  

The average 30-day ED return rate for the 9 months prior to the project was 8.82%, or about 13 patients per month returning to the ED for the same complaint of dental pain.  After the referral program initiation in October, the average return rate decreased to 5.42%, and was as low as 2.56% in January. This overall decrease equated to about 5 fewer patients returning to the emergency department each month for unresolved dental pain. This amounted to a cost savings of about $1,090 for the months of November 2018 to Jan 2019. The greater savings may have been in time saved in the ED, totaling 1,312 minutes of ED time avoided (average of 82 minutes per patient).

In addition, a survey of providers indicated increased satisfaction with the new process.

Team Members:

Clinical Excellence Team

Executive Sponsor: Clyde Harris, MD, VP of Clinical Excellence

  • Claire Corbett, MMS, MBA, NRP
  • Sandy Mitchell, MBA, MLIS
  • Abby Roetger, MS, CCCC

Dental Pain Team

  • Marianne Billeter, Pharm.D, BCPS
  • Doreatha Bradley
  • Shawn Conrad, DDS
  • Stephanie Croom, RN, MSN
  • Eddie Graham, DDS
  • Michael Jaskolka, MD, DDS, FACS
  • Joni Mitchem, MBA, RN, CEN
  • Karim Peppers, DDS
  • Joshua Tucker, MBA
  • Scott Whisnant
  • Amber Willenbring, RN, MSN
  • De Winter III, MD
  • Amber Woodard, MSN, RN-BC

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