Category Archives: Management ofthe Hospitalized Patient

Management of Postoperative Problems

Management of Postoperative Problems

problems. Routine dentoalveolar -surgery is unlikely to cause airway compromise unless a condition suchas Ludwig’soangina is present. However, patients in 110man endotracheal tube has been placed during genetal
anesthesia .are at risk for postextubation (l.e., after removal ‘of the endotracheal tube) airway narrowing or obstruction, which is caused by trauma to mucosa  of the upper respiratory tract that produces edema. The
narrowest portion of the upper respiratory tract is the

PrincipalComponents of Postoperative Orders

Principal Components of Postoperative Orders

• Diagnosis (or diagnoses) and surgical procedure
• Condition
• Allergies
• Instructions for monitoring vital signs
• Acti~ity and positioning
• Diet
• Medications , If
• Intravenous (IV) fluids
‘. Wound care
• Parameters for notification of physician or dentist
• Special instructions (e.g., ice packs, lip protection
hygfene instructions)

ed for; if they are not, a search must’ be made to find  them. If necessary, intraoral gauze packs should be placed for hemostasis, and the packs should have long ends thattrail out of the mouth for easy retrieval. . Nurses (under the supervision of ahesthesiologists)  make many of the immediate postoperative decisions inthe postanesthesia care unit. However, the dentist should write postoperative orders immediately after the completion
of surgery to ensure that any special instructions can be initiated in the postanesthesia care unit. Postoperative orders should include statements of the diagnosis, procedure performed, patient allergies, and general
condition of the patient after surgery. Nursing actions, such as Vital-sign monitoring, wound care, and medication administration schedule, should be clearly spelled out. The patient’s diet, activity level, bed positioning, and allowable personal hygiene should be delineated. Finally, parameters
should be outlined that, if breached, make immediate notification
of the dentist or physidan mandatory, An outline
for postoperative orders is listed in Box 31-2;’ a sample of
postoperative orders is shown in Fig. 31-11.
Shortly after the surgical procedure is completed, a
brief operative note should be placed in the ‘patient’s
record. This note is usually in a relatively standard format
that includes listing the preoperative and postoperative
diagnoses, the names of the procedures performed during
surgery, the name or names of the surgeon or surgeons”
the type. of anesthesia, the placement of any drains, the
estimated blood loss, and whether any specimens were
sent for pathologic examination. The hospital staff uses
this note to quickly learn general information about the
operative procedure. In addition, .before leaving the operating suite a full
report of the operation should be dictated, using the designated format of the facility at which the surgery was performed. The general outlines and examples of a brief  operative note and transcribed operative report are
shown in Boxes 31-3 and 31-4 and in Fig. 31-12. Patients generally remain in the postanesthesia care unituntil they are sufficiently alert, unlikely to injure themselves, and their vital signs are stable within acceptable limits.
An anesthesiologis t usually makes the decision about discharge to a hospital room or home, unless it is specifiedthat the dentist will make that decision. The discharged  patient should be placed directly under the care of a competent adult and not be allowed to go home unescorted.
Hospital rounds (i.e. patient visits) give the surgeon the opportunity to check the patient’s postoperative recovery personally and to revise orders as necessary. U nstable hospitalized patients require frequent visits; stable
,patients are u sually seen twice a day during the first



week after surgery and once daily thereafter. Each patient visit by the surgeon warrants a brief notation (i.e., progress note) in the record, that documents the patient’s progress and ~ny new plans for further care. Kates are usually written using a record format that Includes a brief description
of how the patient is progressing subject’ and objectively, an assessment of the patient’s condition, and a plan for further care (SOAP). Figure 31-13 shows a typical postoperative progress notation in the SOAP format. .
Discharge planning should begin as soon as the surgical procedure is completed and includes making arrangements for any necessary patient education  such as oral hygiene, wound care, and diet-ary instructions  In addition, the patient should be told of acceptable activitv levels and plans for follow-up office visits. Necessary prescriptions for medications should be provided, as well as instructions on how to contact the appropriate physician or dentist should problems arise. A written discharge note
should tie included in the progress note section of themedical record (Fig. 31-14 and Box 31-5).

BOX 31-3

Common Format for Recording Brief Operative Note

• Preoperative diagnosis
• Postoperative diagnosis’
• Procedure
• Srgeon or surgeons

BOX. 31-4

Common Format for Dictating Operative Note

• State that operative note is being dictated
• State patient’s mime, spelling out last ‘name
.State patient’s medical record (hospital) number

BOX 31-15

L:i Complete a standard SOAP pru~r”~s note and
include the following under P (plans) section:
r: Deposition (to where and with whom patient will be
f” Listof medications that the patient is prescribed Or
instructed to take, including drug name, dosing regimen,
and instructions for use
[: Dietary instructions
r: Activity instructions
LC Hygiene instructions
r~ Follow-up appointment











Care of Hospitalized Patient

Care of HospitaliCare of Hospitalized Patientzed Patient

Operating room protocols. The patient’s operating dentist bears the ultimate responsibility for any mishaps that occur in the operating room other than those relating to duties relegated to anesthesiology. Therefore the dentist must be meticulous in monitoring all that is done to the patient and should take charge if anything is being done that may harm the patient.
The operating team usually consists of the operating surgeon and an assistant. The assistant should have suffidentfamiliarity with the planned procedure to help the dentist by suctioning, retracting, and cutting sutures,
Many hospitals allow the dentist to bring an office assistant to assist in the operating suite. Anesthesia may beprovided by an anesthesiologist (a medical physician) or by an anesthetist (a nurse. with special training in anesthesiology who usually must work under an anesthesiologist’s
supervision). A scrub nurse, who is sterilely gowned and gloved, passes instruments to the surgeonduring the procedure and, among other duties, keeps track of the sponges and needles used. The circulating
nurse remains ungowned and assists in setting up equipment, retrieving supplies, and completing nursing records of the operation. The dentist should try to see the patient in the preoperative area before anesthetic premedication to help clarify any final questions the patient may have, learn who the patient wants notified at the completion of the operation, and give emotional support to the patient. . During final preanesthetic patient preparation, the dentist should review the operative plans with the anesthesiologist.These plans include surgical site, length of procedure, oral hazards (e.g., loose teeth, restricted opening), route of intubation desired, and whether the patient will be admitted to the hospital. The dentist should
remain near the patient’s head during intubation to assist f necessary.
Once the patient is under general anesthesia, the dentist should ensure that steps are taken to prevent accidental injuries. Dental patients are usually operated on in a supine position, with the head end of the operating table raised about 15 degrees. The extremitiesmust be placed in physiologic positions ti.e., positionspatients would find comfortable for long periods if they were not anesthetized). Proper positioning helps pre-vent nerve injuries and excess loading of any part of the anatomy. In addition+padding should be placed in any area of pressure concentration, such as under heels and around elbows, particularly if the dental procedure is likely to last longerthan 1 hour. Most hospitals currently place all patients on foam or gel-filled cushions or airmattresses during surgery to help prevent pressure  sores. The head should be placed on a contoured cushion to help prevent excessive movement of the head during surgery. Patient protection during anesthesia is also provided by several other means. Jf the procedure is expected to last more than 4 hours, a urinary (Foley) catheter should be
placed, to prevent overdistention of the bladder. The anesthesiologist
may want this done even for shorter operations for monitoring urinary output. If an electrocautery unit will be used, a grounding pad must be placed. To protect the patient’s eyes, a lubricating ointment should be
applied and the eyelids should be taped closed. Patients who are intubated nasally require close attention to proper tube stabilization; tubes that place excess pressure on the nasal alar cartilage can easily cause pressure sores that result in an unsightly deformity (Fig ~1-6). The final step before surgery IS preparation of the patient’s operative site. If necessary, any Iacial hair can be shaved. Then the skin in the maxillofacial and anterior
neck regions should be prepared by scrubbing with a . soap-containing solution and painted with a disinfecting solution, such as iodophor. The patient is then draped with two layers of linen material or one layer of waterproof paper material to cover all portions of the body except the operative site. The oral cavity is prepared for the procedure by first gently suctioning the pharynx, placing a moist throat pack, and using large volumes of irrigation solution to help decrease the bacterial count by
. dilution. Theuse of ~ sterile toothbrush and chlorhexidine improves the effectiveness of oral cavity preparation.  The anesthesiologist and circulating nurse should be asked to make a note that the throat has been packed so they can help remind the surgeon to remove the pack after the surgery is complete. Local anesthesia is typically administered even when patients will be under general anesthesia to help delay the onset of any postoperative discomfort. Dental surgeon and assistant preparation. The
dental surgeon prepares for surgery by first checking that all instruments and patient records required to perform the surgery succe ssfully are available. This. preparation should ‘be done before the day of surgery if the dentist does not regularly use a particular facility (in case any essential equipment or records must be brought from the surgeon’s office on the day of surgery).  Before entering the operating room suite, the surgical team changes from street clothes into surgical scrub uniforms. Shoes worn outside of the operating suite are covered with shoe covers. Scalp hair is covered with a cap. Members of the surgical team with long beards should
wear head covers that extend across the chin and nteriorneck. All jewelry, including watches, rings, necklaces, and earrings, should be’. removed before scrubbing. A mask that covers the nose and mouth should b tied in











Hospitalizing Patients lor Dental Care

Hospitalizing Patients lor Dental Care

Deciding 011 hospitatization. The vast majority of patients needing routine dental care, induding oral and maxillofacial surgery, can be safely managed in the dental office. However, occasionally some patients require that dental care be provided in a hospital or surgery cener environment. A patient may be better treated in a hospitalstttng for several reasons. One of the most common reasons is behavioral management. Patients unable to cooperate  (e.g., because of mental retardation), unwilling to cooperate  e.g., uncontrollable children), or who refuse dental care while awake can be deeply sedated or placed under general anesthesia; this allows routine dental care to be delivered to these individuals quickly and safely. An operating room setting for dental treatment may also be necessaryfor the physically handicapped patient who is either unable to gain access to a dental office or is unable to remain relatively motionless during .procedures.’An operating room is also often needed to provide dental care for patients with high-risk medical conditions, such as patients requiring care that cannot be delayed until t_he medical condition is alleviated or
improved, or patients requiring emergency dental care shortly after a serious myocardial infarction (MI). In somecases a patient’s physician may be able to provide guidance as to the safety of office-based dental care. A final reason for planning a procedure in an operating room facility is for patients in whom acceptable local anesthesiacannot be attained, such as those requiring care on teeth in an area of severe infection. Usually these patients are best referred to an oral and maxillofacial surgeon, but
hospitalization may be an alternative if the dentist feels capable of managing the surgical problem. Day surgery facilities. In the past, operating room  acilities were available only In hospitals, and patients
had to be admitted the day before dental surgery and remain in the hospital until the dentist believed discharge was indicated (commonly 1 to 2 days postoperatively).However, changes have occurred’ in methods of
delivering operating room care. Free-standing or hospitalbased
surgical centers now exist that offer staffed operating and recovery rooms and anesthesiologists for patients not needing preoperative or postoperative hospitalization. Many hospitals also offer the use of their operating room and staff, without requiring hospital admission. A
dentist may find that many patients unable to be cared  for in the dental office can be effectively treated in daysurgery facilities without hospitalization. reoperative patient evaluation. Once the decision to
use an operating room facility has been made, several steps must be taken before the operation. The operating room staff must’be contacted and the operating time scheduled. Most facilities need some biographic information about the patient, the reason for the procedure, the procedure planned, who will perform the procedure, how long the operating room will be in use, the type of anesthesia required (i.e., sedation only or general anesthesia), and whether special equipment will be required. A hospitalbased operating room must also know if the patient will be admitted; patients to be admitted must have a room reservation made and an estimated length of stay.
All operating room facilities require that a medical history and physical examination be performed before the operation. See Chapter 1 for guidelines for recording the history and physical examination results in the medical record. This recording can be performed either by the patient’s physician before the day of the operation or, in some facilities, by the anesthesiologist during the preanesthetic consultation. Most facilities also require thatany medically indicated laboratory tests, radiographs, or
electrocardiograms be done at a time proximate’ to the surgery. Requirements vary from place to place, but the _usual minimal testing necessary is a hematocrit. “Doctor’s orders” communicate patient care instructions to nurses and other hospital staff members. The dentist’s orders should be accurate. clearly written, and comprehensive.


Preoperative orders are necessary for patients being admitted to a hospital or scheduled to be ti:eated in an operating room setting without hospital admission. Orders are best written by the dentist but may be given to nurses over the telephone (dentists must eventually sign
telephone orders). An example of adrnissron and preoperative
orders is given in Fig. 31-4. Before surgery the operating dentist should place a  note in the patient’s record that briefly describes the nature of the patient’s medical and dental problems and the expected operating room and hospital course. The hospital staff can then use this note to familiarize themselves with the patient’s general condition and reason for admission (Fig. 31-5).






The request for consultation carries different connotations among health professionals. To some, the consult: ant is only expected to tender an opinion and’ not to begin implementing any advice until given permission
by the patient’s admtting physician or, in the case of the emergency room, <bythe patient’s designated emergency  department physician. However, many physicians allowconsultants to perform any test or procedure necessary to act on their opinion. Therefore the dental consultant  must clarify witH the requesting doctor whether only an ,.opinion is being sought or if the dentist can proceed to order tests and render treatment before seeing the patient. In some cases, the consultation request form provides
a section in which the .requesting doctor can indicate the type of onsultation desired. Emergency roo”, consultations. Emergency room
consultations are usually requested verbally because of the urgency of the situation. The dentist should make useof any history and physical examination, lab oratory, and radiographic results already available, to avoid excessive duplication. However, thedentist still needs to do a careful,
comprehensive history and physical examination of the oral and maxillofacial region and order special radiographs as necessary to allow a complete, well-organized assessment of the patient’s dentofacial problems. All of  his information is recorded in the medical record on a
consultation form, in the progress notes, or in the emergency
room record. A recommendation should be offered that considers other medical problems, acute or longstanding, and the urgency of the treatment. Guidelines for answering consultations are shown in Box 31-1, and a
sample of a written emergency suite dental consultation is shown in Fig. 31-2. The way emergency suites are equipped for dental therapy varies. If the dentist cannot offer high-quality care in the emergency setting, the problem should be emporized and an appointment made for definitive care –
in the dental office, Dentists who are frequently called to hospital emergency rooms sometimes find it useful to carry in their car a set of instruments and supplies neces-: sary for initially handling common oral emergencies, If more than one dentist serves as a dental consultant to


an emergency room, a call schedule is usuallv established to designate, on a daily, weekly, or monthly basis, which dentist is expected to be available in case o  an emergency, When on call, the dentist should keep the hospital aware of how the dentist can be quickly contacted. lnnatieut ronvult ation«. Dental consultatic ..•l for a hospitalized patient is similar to consultations for emergency patients: the dentist is expected to evaluate the oral
and maxillofacial region, offer an assessment, and Iorrnulate a dental treatment plan that considers the overall clinical vituation. Dental consultation requests should be written on standard hospital consultation forms on which the requesting physician states the question or questions to be answered by the dental .consultant. Therequesting doctor should also provide a brief statement of other active problems the patient may have. It a dentist receives an unwritten Or unclearly written consultation
request” the dentist should make an effort to clarify what is desired. The dentist should make every attempt to answer all consultation requests within 12 to 2-1 hours. written consultations should be sufficiently complete to document all significant findings (both positive and

problem list, and the treatment plan should be clearly written, with an indication of the priority and ljrgency of  any necessary care. The terms used should be those physicians and nurses can understand, rather than technicaldell tal terms. Excessive verbiage should be avoided. If the dentist finds it impossible to finish the evaluation without  additional tests, arrangements should be made toobtain necessary tests in the near future, and a preliminary consultation note should be made to inform the
requesting physician of the findings and preliminary recommendations.
After seeing the patient, it is good practice to call the physicia ‘ who requested the consultation to ‘inform the patient of findings and recommendations. However, it is still necessary to record a formal answer
directly on the consultation form or on a progress note, with an indication on the consultation form of where the . answer has been written. In addition, if the consultation request asks for care to be provided, the dentist should carefully document that care. In addition, as in any care provided in the hospital setting, the dentist should collect enough data about the patients to allow the office staff to properly bill for services rendered. Codes for such care and consultations are available in standard medical coding manuals. An example of a dental consultation form is presented in Fig. 31-3.
Requesting a consultation. When a patient has a problem. the dentist does not feel qualified to evaluate or manage’ alone, a formal consultation request can be made: When requesting a medicalconsultation. the dentist
should indicate whether the consultant is free to rder necessary tests and to proceed with any necessarytreatment. Preferably the requesting dentist should personally call to as]; the consultant for an opinion. Alterna-
• tively, an order can be written directing a hospital clerk to
call the consultant’s office. A consultant’s recommendations should be viewed as an (‘(!ucall’d opinion. A dentist is under no obligation to follow
:1 consultant s advice in its enurcry or at all. The patient’s attending docor must. make the final decision of which 110stictests to perform and what care the patient win iccclvc, including when ihc attending doctor is a dentist.







Medical Staff Mernbership

Medical Staff Mernbership

Membership on a hospital medical staff is not usually gained by simple request. The hospital’s credentials committee, consisting of physicians and dentists on the medical staff and their admlnlsrratlve support staff, carefully
reviews the qualifications of doctors applying for staff membership to ensure that individualsgranted privlleges . are competent to practice in the ‘hospital environment and have no evidence of criminal, ethical, or other such
problems in their past Various levels of medical staff membership exist (e.g”

BOX 31-1

Guidelines for Answering Consultations

• State reason for consultation in”opening sentence
• State that chart has been reviewed and patient
examined’ .
J • Be brief but thorough, particularly with dentofacial
portion of the examination
• Be specific with recommendations
• Provide contingency plans
• Follow up written consultation with verbal contact
with requesting doctor ‘ ‘ i • Follow patient’s progress until dental problem is

active, associate, courtesy), each ,carrying certain pnvrleges and restrictions. Staff membership, however, ‘ne\’er automatically gives the dentist the privilege to admit the hospital or to use the 0’perating room facilities. These privileges are granted based. on a review of the applying dentist’s education and. experience. Dentists who have completed a general practice residency or dental specialty training that provided hospital experience usually have little difficulty gaining medical staff membership and some admitting privileges. However, because of hospital regultions, most dental patients admitted to a hospital by dentists other than oral and maxillofacial surgeons will require a physician’s participation in the ad~ission process

Administrative Organization

Administrative Organization

Hospital organization varies from institution to institution, but most are based on standards of the Joint Commission for the Accreditation of Healthcare Organizations OCAHO). This national body’s mission is to set standards for hospitals and ambulatory care centers, to monitor these facilities to ensure that those standards are being met, and then to accredit hospitals and arnbulatory centers meeting the standards.  Most general, acute care community hospitals have a board of trustees that include community leaders who make up the highest governing body of the institution. They are advised in health matters by a joint  onferencecommittee, which is·a liaison group that includes members
fom hospital management, the medical staff, and the board of trustees. The hospital’s chief executive officer (CEO) is in charge of the dailyoperation of the hospital and reports to the board of trustees. Hospital gover-.
nance from this point is divided into two major organi- “zational bodies: medical staff and. hospital administration. The medical staff includes all the health care professionals who work at the hospital. The chief of staff is the most  senior governing member of the medical staff and reports to the hospital president and joint conference committee, and chairs the medical board. The medical board or executive committee commonly includes the chiefs of all the medical departments of the hospital and often includes
representatives from nursing and hospital administration. Dentists who join the medical staff typically become members of the dental department or division. Although at some large hospitals dentistry is on equal footing with
other major departments, such as psychiatry or pediatrics,it is more often made a division, Of section, of the department of surgery, similar to other surgical disciplines, such as urology and neurosurgery. As a member of the medical staff, a ‘dentist is usually asked to ‘serve on committees in
which dental expertise is needed, such as those on infection
control, as well as and pharmacy and therapeutics. Hospital administration is managed by the hospital CED, who has several vice presidents or assistant directors  to direct various areas of hospital operations, such as
nursing, support services, and finance (Fig. 31-1).

Management ofthe Hospitalized Patient


Administrative Organization
Medical Staff Membership
Emergency Room Consultations
Inpatient Consultations
Requesting a Consultation
Hospitalizing Patients for Dental Care
. Deciding on Hospita’tTzation
Day Surgery Facilities
Preoperative Patient Evaluation

Care of Hospitalized Patient
Operating Room Protocols
Dental Surgeon and AssIstant Preparation
Postoperative Responsibilities
Management of Postoperative Problems.
Airway Problems
Nausea and Vomiting
Fluids and Electrolytes
Blood Component Transfusion

Most dentists find they can practice without hospital facilities, but the ability to care for patients in a hospital setting adds a stimulating-dlmension
to a dentist’s professlonal life. As a vital member of a community’s health care team, the hospital-affiliated dentist is consulted about the dental needs of patients in the emergencyroom and of those admitted to the hospital by other doctors or the dentist. Dentists who join a hospital medical staff arc permitted to perform dental consultations for hospitalized patients and to bring patients to the hospital to perfurm procedures best done there. In addition, for dentists seeking to provide-care with their patients under general anesthesia, .comrnunity surgery centers are often the ideal answer