Oral and maxillofacial surgery: offering whole person care
Rachel Bowley, Clinical Nurse Specialist (CNS) at the Oral and Maxillofacial Surgery, King’s College Hospital NHS Foundation Trust, blogs about how the team are looking after the mental health of patients undergoing treatment.
Oral and maxillofacial surgery (OMFS) includes treating many diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral (mouth) and maxillofacial (jaws and face) region. We see patients with a range of traumatic injuries and even with the most expert surgeons, treating these problems can be a long and difficult process.
Considering all aspects of a person’s health
In 2013 Miss Kathleen Fan, Consultant Surgeon and Reader in Oral & Maxillofacial Surgery at King’s College Hospital NHS Foundation Trust, realised that caring for the physical aspects of patients might not necessary be enough to guarantee a full recovery of health.
As the academic lead she set in motion a plan for the maxillofacial team to collaborate with Integrating Mental & Physical healthcare: Research, Training & Service (IMPARTS) to provide a more whole person approach to care. She along with the IMPARTS team created a package to evaluate patients undergoing cranioplasty (a procedure to repair defects to the skull) under the oral and maxillofacial department. These patients were predominatly under Mr Rob Bentley, Consultant Cranio-Oral and Maxillofacial Surgeon at King’s College Hospital. The patients were asked to complete some questionnaires before and after their surgery. The questionnaires comprised of a series of validated screening tools: Generalised Anxiety Disorder questionnaire (GAD-7), Patient Health Questionnaire (PHQ-9), Post Traumatic Stress Disorder questionnaire (PTSD-4) and Quality of Life after Brain Injury (QOLBRI ). Protocols were put in place for patients who screened positively for any of the conditions, which assisted the clinician to provide timely and tailored evidence-based care. Due to its success, the use of the screening tool has expanded to other areas within the department.
Introducing IMPARTS screening tools
The IMPARTS screening tool facilitates routine collection of patient-reported outcomes, with real-time feedback to guide clinical care. Care pathways for referral have been developed to facilitate timely referral for those who suffer from anxiety, depression or post-traumatic stress disorder (PTSD) following their brain injury. It quickly became obvious that the tool would be beneficial for patients in all areas of our specialty and so further questionnaires were developed for use in facial trauma and TMD.
Maxillofacial nurses within the outpatient department highlight those patients who are being seen for one of the following conditions – cranioplasty, TMD or facial trauma, and offer them the questionnaire on an iPad to use in the waiting room, before being called into the clinic. Results are sent directly to EPR (electronic patient records system). During the consultation, the clinician is able to use the tool to guide their assessment of the patients’ mental health and any recommendations for referral are acted on. The protocols for referral work well and we have a standardised departmental clinic letter to send to patients’ GPs to inform them of the results and what actions we have taken. The questionnaires can be repeated at subsequent visits to monitor patients’ progress.
My OMFS CNS colleague and I are collectively available five days a week to assist the with the delivery of IMPARTS and act as a resource to both surgeons and patients. We find the tool to be helpful in beginning conversations about mental health and the results help give more weight in referrals to GPs and mental health services. During my training and since qualifying in 2002, mental health education for medical professionals has been sparse at best. Since the IMPARTS initiative began there have been more opportunities for education in mental health. I completed a module in 2014 towards my MSc run by the IMPARTS team, Mental Health for Non-Mental Health Professionals, which equipped me with a variety of tools to assist my everyday practice.
Challenges in delivering the IMPARTS initiative include ensuring that all patients who have completed a questionnaire have their results checked and discussed with them. This can be difficult to achieve in busy clinics. But through collaborative working, we have seen an increase in the numbers of patients both completing the questionnaire and being referred on appropriately. As with all medical specialties, there is a high turnover of junior staff on rotations, so the CNS acts as a constant within the team, ensuring processes are adhered to and assisting with induction of new staff.
The team check all completed results and keep a database – both for auditing purposes and as an additional safety mechanism, so that every patient who completes a questionnaire is guaranteed to have their results checked and acted upon.
IMPARTS has improved the care of patients being treated for maxillofacial conditions in many ways. Patients feel they are being listened to and cared for as a whole person and are able to cope better with their injuries and treatment. IMPARTS has also equipped the OMFS team with additional skills and awareness around mental health and it has become routine to include assessment of mental health in consultations. Having agreed referral pathways in place ensures timely referral for those patients that need specialist mental health assessment and treatment.
As a result of the need identified partly by the utilisation of IMPARTS, we are fortunate to have a team of psychologists in the Dental Institute at Denmark Hill who are accessible to OMFS for advice and referrals. They have produced an information sheet for patients which outlines what Improving Access to Psychological Therapies (IAPT) is, how they can be referred, and lists contacts for urgent help.
Future plans include introducing the questionnaires at our department on the Sidcup site, at Queen Mary’s Hospital. The OMFS CNS’s can be contacted on 020 3299 5216 or on email to rachelbowley@nhs.net or j.cruz@nhs.net
Visit the King’s Health Partners Mind & Body to find out more about how we’re driving integrated mental and physical healthcare.