Nurses carrying out dental procedures

RE: Nurses carrying out dental procedures

Evelyn Barbour-Hill — Fri, 17 Jul 2015 01:04:46 GMT

[quote user="Laurence Webb"]That's not to say that an experienced nurse can't see the X-ray and point out areas of suspicion[/quote]

Who to? Self? Admiring junior? OK if they want to. Veterinary surgeon? No.

[quote user="Laurence Webb"]I am not there yet (the practice has only recently become fully staffed) but my goal would be for a nurse to clean and radiograph one side of the mouth, a vet to examine it and make a treatment plan,[/quote] What about those treatment plans which require both sides of the mouth to be considered – i.e. all of them?

[quote user="Laurence Webb"]

Doing some paperwork for 20 minutes that you can drop at a seconds notice - good.

Thoughts?

[/quote]

If you are really so pushed for time that you have to snatch twenty minutes like that, I'd say you were understaffed.

[quote user="Laurence Webb"]Thoughts?[/quote]

Honestly? OK – why not just get on with it, instead of faffing about letting a nurse do bits? Thus releasing a nurse to do some nursing.

RE: Nurses carrying out dental procedures

Laurence Webb — Thu, 16 Jul 2015 23:31:55 GMT

[quote user="Evelyn Barbour-Hill"] (And personally I don't think nurses should be doing radiography all by themselves anyway )[/quote]

Taking X-ray - fine for nurses to perform

Interpreting X-rays - not fine for nurses to perform

That's not to say that an experienced nurse can't see the X-ray and point out areas of suspicion (I would hope that they would be looking at the X-rays to ensure that they are diagnostic anyway) but the ultimate responsibility for examining and interpreting the X-rays should lie with the vet.

Similarly a nurse could clean the teeth but a vet should examine them to decide what further treatment is required.

I am not there yet (the practice has only recently become fully staffed) but my goal would be for a nurse to clean and radiograph one side of the mouth, a vet to examine it and make a treatment plan, adminster nerve blocks as required then the process to be repeated on the other side. By the time the second side is clean the mouth is all ready for the vet to do whatever treatment is required

How much of a time saving for a vet is given will depend on what the vet is up to in the intervening time. Starting a bitch spay - bad. Doing some paperwork for 20 minutes that you can drop at a seconds notice - good.

Thoughts?

RE: Nurses carrying out dental procedures

Evelyn Barbour-Hill — Thu, 16 Jul 2015 18:57:29 GMT

[quote user="grumpyoldman"]On average 2-3 substantial extractions , plus serious advanced periodontal disease , possibly a carnassial abcess ,[/quote]

Well, all those are a veterinary surgeon's job. Whether I could do all that for £300 would depend on many things. Size of dog, for one. Then you mention "serious advanced periodontal disease": it depend what that consists of and what you need to do about it. Some careful curettage and/or periodontal bactericidal ultrasonic debridement doesn't take awfully long; manual root planing can be quite tedious; simple gingivectomy doesn't take much time at all; anything involving a gingivoperiosteal flap takes rather longer, and of course the suture material has to be charged for; and so on, and so on. Quite often it would be within the £300 I guess.

Your comparison with the TPLO which takes the same time for £1500 (I'll take your word for that, I don't do TPLO) does not really further the discussion: it would only be of relevance if you had TPLOs lined up to do all day and you were prevented from doing them by the need to do dental procedures.

[quote user="grumpyoldman"] Everything is cheaper here with cats ,they have no value with many clients . [/quote] I'm genuinely intrigued. Where is "here"?

RE: Nurses carrying out dental procedures

grumpyoldman — Thu, 16 Jul 2015 17:32:45 GMT

[quote user="Evelyn Barbour-Hill"]I can't comment on your figures, because I don't know where you practise and I don't really know what you mean by an average dental (though £300 sounds a lot to me for an ordinary sort of COHAT)[/quote]

On average 2-3 substantial extractions , plus serious advanced periodontal disease , possibly a carnassial abcess , cats cheaper 140-160 , they do take their time with the scaling ,every tooth is a patient being their mantra. The Sevoflo does tend to push the costs up a lot with elderly dogs . Everything is cheaper here with cats ,they have no value with many clients .

RE: Nurses carrying out dental procedures

Martin Atkinson — Thu, 16 Jul 2015 17:01:48 GMT

[quote user="Nhombokisheni"]I need a bit of help here sir. Competency to practice presupposes that one has the theoretical and technical skill to do what they do. Is a dental simply about pulling the tooth out...I dont think so.[/quote]OK lets get something straight. I'm not suggesting that unqualified staff be allowed to routinely perform surgical procedures, including acts of dental surgery, as indeed this would be unethical, merely that there is a presumption that because someone has MRCVS after their name they automatically can perform these more competently than someone who doesn't. We all know vets who are quite frankly crap surgeons and unqualified people who have good motor skills who could make fantastic surgeons. It is possible to train these people to do at least as competent a job.

More than anything it was a response to Evelyn's remark that he couldn't understand why nurses would want to perform surgery. Maybe because they want to do something more interesting than their usual humdrum tasks? A very short poll of my 2 was met with a very positive response of' 'we'd love to'.

PS I'm not sure you calling me 'sir' is being condescending or overly humble - neither are necessary.

RE: Nurses carrying out dental procedures

Francisco Gomez — Thu, 16 Jul 2015 14:26:31 GMT

[quote user="Bob Russell"]

My nurses do a more thorough job at scaling than I do. They are very particular and capable. I alternate roles. I monitor the anaesthetic while they work and they monitor while I work. We both set up and take X-rays as a team and I look at them but listen when they have concerns about anything on the images.

Nurses do not do 'dentals' alone but I would have more confidence in them than some vets!

Teamwork!

[/quote]

My approach is very similar to Bob's... I don't think is that unusual to let QVNs descale and giving you their opinion as regards to their own experience.

I'm not that sure about QVNs performing extractions, I don't think it would be wrong if the RCVS allowed QVNs to perform routine extractions. But it were to happen, I would expect a much more clear role of the QVN in the area.

If jaw goes while extracting a feline canine, Is it still the QVNs who's going to tell the client about the complication? And, will the client be happy about it?

These are questions, not digs

RE: Nurses carrying out dental procedures

Bob Russell — Thu, 16 Jul 2015 14:25:54 GMT

Our nurses perform their designated and delegated roles, I do mine. They do not perform tasks that should be carried out by a vet. They are extremely patient and this leads to a very thorough scale and polish. They may comment on individual teeth but all treatment decisions are mine.

No abdication of my responsibility, no blurring of lines so no legal problems to justify. I am perfectly open that nurses do the scale and polish bits because they are good at it.

There are no rules or regulations that prevent them doing the tasks they do. Not making a mockery of the RCVS or anyone else. Not quite sure what your problem is.

Will add that I am present with the patient throughout the procedure!

RE: Nurses carrying out dental procedures

Nhombokisheni — Thu, 16 Jul 2015 13:11:36 GMT

[quote user="Martin Atkinson"]

[quote user="Evelyn Barbour-Hill"] Nurses shouldn't be doing soft tissue surgery. I really can't understand why they would want to[/quote] That is a very condescending remark Evelyn and further comments on dental procedures smack of protectionism. I wouldn't make in front of my nurses if I was you.

It is ridiculous to have a blanket rule that a competent unqualified person cannot extract a tooth or perform minor surgery. The skill wasn't learned the day we qualified it is a learned skill. There are plenty of vets who are worse at it than many nurses. Veterinary nurses are allowed to take blood samples and place IV catheters which quite frankly can be a more difficult/technical task then wiggling a root out. Only 'the rules' say they can't!

[/quote] I need a bit of help here sir. Competency to practice presupposes that one has the theoretical and technical skill to do what they do. Is a dental simply about pulling the tooth out...I dont think so. While in the majority this procedure never throws up surprises....that does not mean the potential for things going wrong is Zero. I appreciate how some procedures are very low risk, tedious and frankly boring, but that is part of the trade. Do them we must and leave the nurses to grow in their areas of practice. Being "ten seconds away" is not what I tell clients (and probably many of us never do), and when the dental is done by the nurse, does your nurse discuss the outcomes with the client or is it you.......speaking like one who did the procedure????? However if you do inform your clients about this and they are happy to let your nurses do it, then I guess that would qualify as informed consent.....anything else is unethical period.

RE: Nurses carrying out dental procedures

Nhombokisheni — Thu, 16 Jul 2015 12:54:57 GMT

[quote user="Bob Russell"]

Nurses do not do 'dentals' alone but I would have more confidence in them than some vets!

Teamwork!

[/quote] My simple understanding of team building involves the defining of "Role Clarity". Vets and nurses should have clear roles.....swapping around is an abdication of one's responsibility. Blurring the lines between tasks for the two groups can also be difficult to justify legally ........do the clients actually know this is what you are doing and are happy to have the nurse do it? Do you charge less when a nurse does it to reflect level of expertise and training (I believe you get paid more than the nurse doing the same task). Its very true that there are plenty of nurses, even trainee nurses who are more adept than their vets..........But that does not allow a vet to use them to carry out his tasks....... Non RCVS vets cannot practice, yet they are more qualified than the nurses.........are you not making a mockery of the RCVS quality control measures? The human medical field allowed the delegation of tasks to para-staff.........its now reached a level where we have nurses/paramedics/and call staff making telephone diagnoses and recommending treatments...........always remember that a deluge/flood starts with just one small drop of rain. Hopefully we will not look back one day and regret delegating tasks only to end up with figurehead vets.

RE: Nurses carrying out dental procedures

Evelyn Barbour-Hill — Thu, 16 Jul 2015 11:38:44 GMT

[quote user="Bob Russell"]My nurses do a more thorough job at scaling than I do. They are very particular and capable. I alternate roles. I monitor the anaesthetic while they work and they monitor while I work. We both set up and take X-rays as a team and I look at them but listen when they have concerns about anything on the images.[/quote]

I'd guess that is a very unusual modus operandi.

Most people who "let the nurses do the dentals" mean they leave a nurse to get on with it.

Scaling, by the way, is a mere small part of a dental procedure.

[quote user="grumpyoldman"] Sadly its all about the economics really . An average dental in this area is £300 and takes as long as a TPLO for £1500 . [/quote]

I can't comment on your figures, because I don't know where you practise and I don't really know what you mean by an average dental (though £300 sounds a lot to me for an ordinary sort of COHAT). And when I pointed out a couple of years ago that nurses were being used as cheap substitutes for vets, unreasoning abuse descended from all directions.

RE: Nurses carrying out dental procedures

Bob Russell — Thu, 16 Jul 2015 10:45:36 GMT

Nurses do not do 'dentals' alone but I would have more confidence in them than some vets!

Teamwork!

RE: Nurses carrying out dental procedures

Martin Atkinson — Thu, 16 Jul 2015 09:54:31 GMT

[quote user="Thomas Johnson"]........although we are used to nurses monitoring the anaesthetic, the vet is responsible for it, and I am not comfortable leaving an anaesthetised patient without a vet in the room.[/quote] I think that is a good point Thomas but like my previous comments, experienced nurses are often better at this than vets who don't do it regularly. Yes the buck stops with me if something goes tits up but I'm only 10 seconds away doing something in another room, I wouldn't go the shops and leave them to it.

RE: Nurses carrying out dental procedures

Thomas Johnson — Thu, 16 Jul 2015 09:08:06 GMT

[quote user="Evelyn Barbour-Hill"]

Yes, but you still need the vet to do the preliminary examination once the patient is anaesthetised, and in and out at intervals to do the probing and radiography and make all the decisions, and to do any extractions or rootplaning or subgingival curettage or periodontal surgery or other treatments that might be required......and to check at the end that the job has been done correctly.... so does using the nurse really save much time?

[/quote]

The other question that I wonder about with nurses doing dental work is, what about the general anaesthetic? You need a second nurse to monitor the anaesthetic, and although we are used to nurses monitoring the anaesthetic, the vet is responsible for it, and I am not comfortable leaving an anaesthetised patient without a vet in the room.

RE: Nurses carrying out dental procedures

Martin Atkinson — Thu, 16 Jul 2015 09:04:17 GMT

I once again invoke the famous quote of Salon the Lawmaker of Athens 559 BC.

RE: Nurses carrying out dental procedures

grumpyoldman — Thu, 16 Jul 2015 00:48:41 GMT

As far as lumps minor wounds etc ,Some are quite keen ,went to the BSAVA nurse wound suturing masterclass this year, others less so ,quite sensible actually, worried what appears to be a cyst or hystiocytoma turns into an adnexal nasty or a mast cell villain mid surgery, in general its just faster to do it yourself ,and need to be careful not to try and use them to replace the new graduates confidence building tasks, with nursing duties .

RE: Nurses carrying out dental procedures

grumpyoldman — Thu, 16 Jul 2015 00:41:32 GMT

If its falling out I would probably not stop them helping it on its way, Anything involving a burr, and possibly lifting a flap and suturing canines carnassials molars , is veterinary territory , The radiography i let them get on with using Victor ,the dental Xray machine and those tiny self processing films they are so fond of . Dental work happens in prep . Sadly its all about the economics really . An average dental in this area is £300 and takes as long as a TPLO for £1500 .

RE: Nurses carrying out dental procedures

Evelyn Barbour-Hill — Thu, 16 Jul 2015 00:17:54 GMT

[quote user="Michael Woodhouse"]Is it just me that finds it rather odd a VN can do soft tissue surgery that doesn't enter a body cavity, but not extract a tooth?[/quote]

Not at all just you. Nurses shouldn't be doing soft tissue surgery. I really can't understand why they would want to, apart from egotism maybe, although I can understand well why some employers might want them to.

[quote user="Michael Woodhouse"]I would hope a VN with a postgraduate cert in vet dentistry could probe and take dental radiographs.[/quote]

Perhaps. (After all, with training a nurse could do anterior cruciate ligament surgery, or a cow caesarean). Not the point. (And personally I don't think nurses should be doing radiography all by themselves anyway ) But they are not allowed to make the diagnoses and therapeutic decisions which arise therefrom. And the animal is under GA. So a vet would have to be buzzing in and out anyway, to do these things immediately. They can hardly tell Binky to go and take a seat in the waiting room for twenty minutes until Mr. X can see them, or maybe go to the desk and make another appointment next week.

[quote user="Michael Woodhouse"]Are root planing or subgingival curettage acts of veterinary surgery?[/quote]

Of course they are.

[quote user="Michael Woodhouse"]A human hygienist doesn't need anyone to check their work. They are quite capable of identifying any issues and passing them on to the dentist.[/quote]

But they need the dentist there to pass them on to. And they are more highly trained than a VN in this field. And in the better run dental practices they don't operate absolutely independently – either the dentist examines first then sends you to the hygienist, or the protocol for your regular "check-up" is that the hygienist gets to you first, then you go in with the dentist. And a lot of the human hygienist's work is more cosmetic than anything – in the veterinary field we don't often get a pure "supra-gingival scale and polish and nothing else".... certainly should not do, anyway.

In the veterinary world, every dental procedure is at least a COHAT (complete oral health assessment and treatment), which requires a veterinary surgeon, even if he delegates any supragingival scaling and polishing to a nurse (doesn't seem a very efficient use of time or staff to me).

What human hygienists can or cannot do is really irrelevant.

RE: Nurses carrying out dental procedures

Michael Woodhouse — Wed, 15 Jul 2015 23:47:04 GMT

Devils advocate as don't have nurses or dental x-ray (yet) but:

I would hope a VN with a postgraduate cert in vet dentistry could probe and take dental radiographs.
Are root planing or subgingivval curettage acts of veterinary surgery? A quick google suggests they are in the remit of a dental hygienist.
A human hygienist doesn't need anyone to check their work. They are quite capable of identifying any issues and passing them on to the dentist. Why is that not the case with a VN?

Is it just me that finds it rather odd a VN can do soft tissue surgery that doesn't enter a body cavity, but not extract a tooth?

I appreciate as things are tooth removal would be a vet job.