An imaginative appointment by an Edinburgh referral practice has helped transform its way of working, increase the effectiveness of its clinicians and, through research, could help to influence how certain procedures are carried out across the profession
Australian academic and scientist Dr Nicola Kingsford joined Vermilion, a specialist referral practice in Edinburgh, in May 2016. Her task is to carry out research and internal audits, both of which are seen as essential components of the clinic’s patient safety and quality improvement processes. Her role includes qualitative research (investigating the success of practice procedures and products) and quantitative success (internal audits)
as well as obtaining ethics approval, experimental design and planning,
data collection, statistical analysis and reporting for internal and scientific peer reviewed publications.
Dr David Offord of Vermilion explained the thinking behind appointing someone with Nicola’s specific set of skills. “We are keen to continually improve what we do and how we do it. At the same time we want to make a contribution to the development of the profession. Improvement requires data collection and analysis, which requires time –
a luxury you don’t have when you are concentrating on carrying out clinical
work on your patients.
“The only way I could see to move things forward was to hire someone like Nicola who could devote time and energy to quality improvement and research. It has proved to be a big moment for us in a number of ways.”
The only way i could see to move things forward was to hire someone like Nicola who could devote time to quality improvement
Perhaps most significant as far as the wider dentistry community is concerned, Nicola’s expertise is allowing Vermilion to build on potentially influential clinical research. The practice recently published its first peer reviewed paper in the British Dental Journal Open*. As David explained, this pilot study on peri-implant health, clinical outcome and patient-centred outcomes of implant-supported over-dentures in the mandible and the maxilla, was conducted in collaboration with a team from the University of Ghent, Belgium.
“This work began at the Scottish Dental Show in 2014 when Dr Grant Mathieson and I presented our outcomes on implant retained over-dentures, in particular around immediate loading. At the time this was still regarded as fairly adventurous and I ended up sending my data to someone who had published on the subject – Professor Hugo de Bruyn, head of periodontology at the University of Ghent.”
The professor was excited by the information David sent and he came to Edinburgh in autumn 2014 with three of his colleagues. There, he and his team were able to examine the patients involved and independently assess the radiographic, soft tissue and quality of life outcomes.
The only way to build on this pilot project was to begin a continuing study. However, any prospective study requires ethics approval, which involves a very lengthy process. Here, Dr Kingsford’s talents and previous experience were invaluable. She explained: “It all starts with registering online and completing an 80-page form with more than 90 sections, each with its own set of questions.
“As well as setting out the planned experiment in great detail, it’s necessary to attract a sponsor and a research expert to oversee things. We have recruited Southern Implants as our sponsor for this study and Professor de Bruyn is our research expert.”
Despite having everything necessary in place, the approvals process for the study was lengthy; it began in May 2016 and a favourable opinion from the South East of Scotland Research and Ethics Committee was finally given in August 2017. This approval allows Vermilion to conduct a five-year study on Rough v Hybrid-surface implants for maxillary All-on-4 over-dentures: clinical, patient and cost outcomes. We have started recruiting patients to participate in this study.”
David believes it’s an important piece of work that will ultimately deliver very powerful data. “At the moment much of the existing material relates to studies conducted in university departments, which can be selective in terms of case selection. In the real world we have to deal with whatever complex cases that come over our threshold.”
Notably, with Nicola providing in-house analysis, the team at Vermilion will have greater control than in the pilot study when the researchers at Ghent undertook analysis. Equally important, her role will allow results to be published as soon as they are available.
As far as the practice is concerned, Nicola’s work has had wide-ranging effect. She said: “Since joining I’ve been able to carry out 12 large audits. One was based on the justification of radiographs. We have to show that the X-rays benefit the patient and the information gleaned is used correctly to guide the treatment plan. I collected information on the radiographs taken and subsequent outcomes.”
David confirmed this had a significant impact. “The justification on X-rays has been tightened up and is graded according to diagnostic value. It wasn’t until Nicola put the numbers together that we realised we had some laxity around that process.
It was clear we could improve reporting of our radiographs and recording of
Equally influential has been a clinical records audit covering 2015 and repeated in 2016, with the third cycle almost complete for 2017. Analysis of the results and subsequent changes in approach has seen a marked improvement in the way that Vermilion’s clinicians collect data. David observed: “There were definitely holes in our note-taking. Everyone can be blind to potential inefficiencies in the way they do things until someone stops them and analyses their records.”
In addition, there has been a positive effect on the clinicians’ use of equipment. Grant Mathieson a prosthodontist at Vermilion uses the 3 Shape Trios intra-oral scanner to help build prostheses. He has carried out a huge body of work involving 165 patients. One of the aspects of this audit was to look at the time the patient spent in the dental chair as a measure of cost to the patient and the practice. Records showed that over 10 per cent of total time was involved in re-makes and revisions. Now those details are down in black and white the team can concentrate on ways to reduce the remakes, whether that’s through recognising the scanner’s limitations or modifying processes.
Nicola is relishing her role. She said: “I’m really enjoying the work. I did think that I might struggle with learning a completely new science and having no dental background at all. However, a lot of reading has helped. I can see that the work I do is making everyone think harder about the way they record their procedures. The fact that there has been a massive change in the way everything is noted, including the introduction of an electronics-based system that allows constant and accurate updates, means we are covering all our bases when it comes to doing analysis.
“Meantime, the research also gets the clinicians thinking about the way they carry out their very difficult and technical procedures.”
David is unsure if this arrangement is unique but it’s one that members of the practice are very excited about it. “Significantly, it lets the dentists who refer to us know that we take our work very seriously and we care deeply for their patients.
“The audit side throws up a mirror to the work you do and, although that can be quite disconcerting initially, you soon realise its value. The research, and the fact that we are publishing, is so exciting. In the prospective implant study, we have started to acquire long term data from a real-life setting here in Edinburgh. Like other developments that have taken place, this wouldn’t be possible without Nicola’s presence since she has the expertise and experience to get us over the line.”
*You can view the paper at: www.nature.com/articles/bdjopen201717
Home and away
Nicola Kingsford was born in Kenya and raised in Australia. She has lived in the UK for seven years. She attended Sydney University where she gained a Bachelor of Science in Agriculture majoring in animal husbandry. Thereafter, she went on to work in the School of Physiology and Pharmacology, Faculty of Medicine at the University of New South Wales.
“As part of my work at the University of NSW as a research assistant I did an honours degree. Then, deciding I wanted to stay in research and academia, I received an Internal University Scholarship to undertake a PhD at the University of Sydney in the Faculty of Veterinary Science. That mostly centred on disease resistance in sheep and also involved molecular formulation and testing of a vaccine to counter an external bacterial condition in sheep.
“Before coming to Scotland I worked in a number of different scientific fields.”
Nicola believes that her extensive experience is one of the reasons she finds her work at Vermilion so satisfying. “Now that we are working on topics such as conscious sedation it takes me back to work in physiology and pharmacology that I did at the University of New South Wales.”
As well as getting the chance to explore a completely different science, Vermilion provides the kind of flexibility that wouldn’t be available if she were to take on a post-doctoral fellowship or similar role.
“Among other things this allows me to go back and forth to Australia – my family retains a small sheep property there and it is important to take regular trips home.”
Conscious sedation on Show
Advanced conscious sedation techniques is a topic that causes much debate, and it’s a discussion that David will be adding to when he speaks at the Scottish Dental Show in 2018.
His contention is that when you undertake procedures that last three to four hours – as he regularly does – there is a major difference in the patient outcome when you have a consultant anaesthetist sedating the patient with multi-drug sedation.
Anaesthetist Dr Ross Paterson joined Vermilion in 2015. Dr Nicola Kingsford’s analysis showing the results both before and after that time confirm that his presence has helped create a much smoother process all round.
David said: “It’s important the dental community keeps in mind that there are practices across the country doing a different kind of dentistry and we can’t be limited to the use of just midazolam for sedation. We need to have an open mind as to what works best and what makes for a safer patient experience.
“There have long been calls for more primary care research and we’d love to share this story with people who might embark on a similar route. The fact that we have ‘cut our teeth’ on this, so to speak, means we would be able to offer some useful insight.”
Meanwhile, others interested in the topic can find out much more at next year’s Scottish Dental Show, visit www.sdshow.co.uk for details.