nitrous oxide inhalation analgesia - Minnesota Board of Dentistry

MINNESOTA BOARD OF DENTISTRYUniversity Park Plaza, 2829 University Avenue SE, Suite 450Minneapolis, MN 55414-3249 www.dentalboard.state.mn.usPhone 612.617.2250 Fax 612.617.2260MN Relay Service for Hearing Impaired 800.627.3529Inspection for Dentists & Dental Offices OfferingModerate Sedation, Deep Sedation (General Anesthesia) and/orContract Sedation ProviderA. INSPECTION: All providers of moderate/deep sedation and /or general anesthesia are required to comply with theMarch 19, 2007 legislation concerning office inspections/credentialing. Inspections/Credentialing are not necessary fordoctors only providing minimal sedation (anxiolysis). Inspection/Credentialing are highly recommended for those dentistswho contract for sedation services: Contracting Sedation Services (CSS) dentists. If a contracted sedation provider is used,BOTH the CCS and the sedation provider must be present at the inspection.Sedation Dentists providing Moderate, or Deep Sedation, and/or General Anesthesia are to provide a completed copy ofthis form to your Inspector one week before the inspection with sections 1,2,3,4,5,6,7, completed. Section 8 is for Board use.Choose and call an Inspector from the list of Inspectors on the Board’s web site:http://www.dentalboard.state.mn.us/SedationInspection/SedationInspectors/tabid/1161/Default.aspxThe facility, equipment, medication, record keeping, and emergency preparedness will be evaluated by using the current “OfficeAnesthesia Evaluation Manual” of the American Association of Oral and Maxillofacial Surgeons. Items of difference between thismanual and the Board of Dentistry’s rules and regulations will be resolved according to the Board of Dentistry’s determination. TheBoard of Dentistry may modify, supplement or eliminate all or parts of this document at the Board’s discretion.B. TIME FRAME: Initial – An initial inspection must be completed within one (1) year of the SD obtaining MN certification inmoderate sedation, deep sedation, or general anesthesia.Renewal – Both the sedation certificate and the inspection are subject to expiration and renewal. The certificates must be renewedbiennially, concurrent with the dentist’s license renewal. A Credential Review must be completed at least once every (5) years. Thefive (5) year cycle will expire on the last day of the birth month of the licensee’s renewal year.C. MULTIPLE OFFICES: All offices where sedation is performed must comply with the minimum standards established by theBoard for a sedation practice. An SD or CSS who travels to other office locations to administer sedation will be responsible forensuring that each office location has the equipment and emergency medications required by this guideline and that the staff is properlytrained to handle sedation-related emergencies.D. INSPECTION FEES: The fee for the inspection may not exceed $250 plus the cost of travel expenses. Fees are to be paid by theapplicant directly to the inspector. The Minnesota Board of Dentistry does not receive any fees for the sedation inspection.E. TERMINATION: Late certificate renewals result in the SD certificate expiring, and require the dentist to apply for areinstatement of the certificate. If certification has expired, sedation services MUST be suspended until a reinstatement is completedand formally approved by the Board.F. COMPLETENESS/ACCURACY: Failure to complete any portion of the Credential Review or Renewal requirements, i.e.application/renewal forms, proof of emergency management course certification, proof of sedation training, completion of selfevaluationor the submission of appropriate fees, etc. could result in disciplinary action.G. DEFINITIONS:Minimal Sedation – a drug-induced state during which patients respond normally to verbal commands (also referred to as anxiolysis)Moderate Sedation – a drug-induced depression of consciousness during which patients respond purposefully to verbal commands,either alone or accompanied by light tactile stimulation (also referred to as conscious sedation)Deep Sedation – a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefullyfollowing repeated or painful stimulationGeneral Anesthesia – a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.Requirements – defined by Rule 3100.3600Recommendation – determined by dentist/s skill and knowledgeWrongful Event Prevention – protocol by the dentist to prevent the event of wrong treatment, anesthesia, sedation, patient, medicationAdverse Reaction/Reporting of Incidents (3100.3600 Subp.8) – “… any incident that arises from the administration of nitrous oxideinhalation analgesia, deep sedation, general anesthesia, moderate sedation, local anesthesia, analgesia or minimal sedation (anxiolysis)that results in: A. serious or unusual outcome; …. B. a sedation state becoming a deeper stage than originally intended …”Please Complete the Attached Pages1/23/20121

Type of Sedation To Be Provided (check all that apply):Moderate SedationSECTION 1Enteral Sedation (Oral)Parenteral Sedation (IV)Deep SedationGeneral AnesthesiaSECTION 2I. Dentist Information – (SD/CSS)Dentist Name: ______________________License Number: ___ CS/CSS/GA # ___ __*If the dentist is NOT providing the sedation, Section 2/Part II below MUST be completed,and a copy of the contracted individual’s licensure must be supplied to the Board.II. Sedation Provider Information –Nurse AnesthetistOMFSDentist Certified in SedationOther: ___________________SedationProvider Name: __________________________________License Number: ______________Signature: _____________________________________III. Location Information –Location Name: _____________________________________Inspection Date: _______________Address: _____________________________________ Telephone: _________________________________________________________If the SD or the CSS provides sedation at more than one location, the SD or CSS certifies that each of theoffices/clinics have the required emergency equipment and emergency medication.Yes No SD/CSS Signature: _____________________________________ Date: _______________*Please attach supplemental information indicating other sedation locations.*SECTION 3Attach a copy of Emergency Management Course Certification for the Professional Providing SedationProof of ACLS CertificationExpiration Date: _______________ORProof of PALS CertificationORProof of Board Approved EquivalentEmergency Management CourseCertificationExpiration Date: _______________Course Name: ____________________Expiration Date: __________________2

I. Facility & Equipment –________SECTION 4Facility, Equipment, and Emergency Medication ChecklistsA. All appropriate Sedation Certificates supplied by the Board must be displayed in the facility/clinic.B. Routine equipment maintenance record kept by the dentist to ensure that the equipment is kept inworking order.C. Enteral & Parenteral Sedation Facility Equipment -- RequirementsThe following equipment is REQUIRED for the emergency kit/cart for sedation/anesthesia emergencymanagement. The equipment should be readily accessible and should be used in a manner that is consistent withthe practitioner’s level of training and skill. The equipment must be age and weight appropriate for pediatric andadult patients. There must be a routine equipment maintenance record kept by the dentist to ensure that theequipment is kept in working order.Requirements for Sedation:*Applicant must initial each of the following to indicate compliance.*automated external defibrillator or fullfunction defibrillator is immediatelyaccessiblepositive pressure oxygen delivery system oxygen delivery system has adequate fullfacemasks oxygen delivery system has appropriateconnectors adequate backup oxygen delivery systemprovidedpulse oximetry device (audible and/orvisual)gas storage facilityfunctional suctioning device and backupsuction device backup suction device available suction equipment permits aspiration of theoral & pharyngeal cavitiesauxiliary lighting lighting system permits evaluation of thepatient’s skin & mucosal color battery-powered backup lighting systemprovided backup lighting system is of sufficientintensity to permit completion of anytreatment underway at the time of generalpower failureboard-approved emergency cart or kit thatmust be available and readily accessible, andincludes necessary and appropriate drugs andequipment to resuscitate a non-breathing orunconscious patient, and provide continuoussupport while the patient is transported to amedical facilityrecovery area recovery area has oxygen available recovery area has adequate suction available recovery area has adequate lighting recovery area has adequate electrical outlets patient can be observed by a member of thestaff at all times during the recovery periodmethod to monitor respiratory function3

D. Enteral & Parenteral Sedation Facility, and Equipment – RecommendationsThe following equipment is RECOMMENDED for the emergency kit/cart for Sedation/anesthesiaemergency management. The equipment should be readily accessible and should be used in a manner thatis consistent with the practitioner’s level of training and skill. The equipment must be age and weightappropriate for pediatric and adult patients. There must be a routine equipment maintenance record keptby the dentist to ensure that the equipment is kept in working order. Please attach a separate sheet (ifneeded) with rationale for absent or substituted medications.*Applicant must initial each of the following to indicate compliance.*____________Recommendations for Enteral Moderate Sedationblood pressure sphygmomanometer/cuffs ofappropriate sizes with stethoscope orautomatic blood pressure monitorECG monitoring device (may be combinedwith pulse oximetry device)IM equipment:___ gauze sponges___ needles of various sizes___ syringes___ sterile glovesseveral types/sizes of resuscitation masksRecommendations for Parenteral Moderate Sedation__________________blood pressure sphygmomanometer/cuffs ofappropriate sizes with stethoscope orautomatic blood pressure monitorECG monitoring device (may be combinedwith pulse oximetry device)IV and IM equipment:___ IV fluids, tubing and infusion sets___ tape___ sterile water___ gauze sponges___ needles of various sizes___ syringes___ tourniquet___ sterile glovesseveral types/sizes of resuscitation masksMagill forcepsadvanced airway management equipment (e.g.,LMA, Combi Tube, King Airway, etc.Additional Items to be Evaluated for both Enteral and Parenteral:___supplemental gas delivery system & back-upsystem___equipment age and weight appropriate forpediatric and/or adult patients____________patient transportation protocol in placesterilization area____ designated sterile area____ sterilization manual and protocol____ designated non-sterile areapreparation of sedation medication____ appropriate storage for medication____ appropriate mode/method of administrationequipment readily accessible - consistent withlicensee’s level of training and skill______treatment room/s___ treatment room permits the team (consistingof at least two individuals) to move freelyabout the patient___ chair utilized for treatment permits patient tobe positioned so the team can maintain theairway___ treatment chair permits the team to alterpatient’s position quickly in an emergency___ treatment chair provides a firm platform forthe management of CPR___ adequate equipment for establishment of anintravenous infusionlicensee has emergency protocol manualList any deficiencies:4

II. Emergency Medications –A. Enteral and Parenteral Emergency Medications or Equivalents – RecommendationsThese drugs may be included in the emergency cart/kit in forms/doses that the dentist canknowledgeably administer, and in typical routes of administration for enteral/parenteral sedation. Thesedrugs are listed by category, not by order of importance. These medications must be used appropriatelyfor both pediatric and adult emergency situations. Please attach a separate sheet (if needed) withrationale for absent or substituted medications.____B. Documentation that all emergency medications are checked and maintained on a prudent and regularlyscheduled basis.*Please indicate the expiration date of the following medications available in your practice.*Recommended Enteral SedationEmergency Medications or Current Equivalents*Recommended Parenteral SedationEmergency Medications or Current Equivalents*___Analgesic (nitrous oxide/oxygen, morphine sulfate IM)____Analgesic (morphine sulfate)____Anticonvulsant (diazepam IM)____Anticonvulsant (diazepam)________Antihypoglycemic (oral glucose/sucrose, glucagon HClIM or SC)Anti-inflammatory Corticosteroid (sodium succinate inIM form)________Antihypoglycemic (glucagon HCl, 50% dextrose)Allergic Reaction, Anaphylaxis____ epinephrine IM or SC____ epinephrine (ana-guard, epi-pen auto injector)________________________________________Endogenous Catecholamine____ epinephrine IM or SC for cardiac resuscitation____ epinephrine IM for allergic reaction (ana-guard,epi-pen auto-injector)____ epinephrine SC for asthmatic pediatric patientsVasodilator, Antianginal, Antihypertensive(nitroglycerin SL, SC, IM, PO)Bronchodilator (albuterol inhalant)Respiratory Stimulant (ammonia inhalant)Histamine Blocker (benadryl PO or IM)Vasopressor (methoxamine IM)Anticholinergic Antiarrhythmic (atropine IM or SC)ASA (acetylsalicylic acid, aspirin)Narcotic Antagonist (naloxone IM or SC)Benzodiazepine Antagonist (flumazenil SL)____________________________Corticosteroid (anti-inflammatory hydrocortisone,sodium succinate)Bronchodilator (albuterol)Respiratory Stimulant (ammonia inhalant)Histamine Blocker (diphenhydramine-benadryl,chlorpheniramine)Narcotic Antagonist (naloxone)Benzodiazepine Antagonist (flumazenil)Cardiac Medicationsendogenous catecholamine (epinephrine)anticholinergic, antiarrhythmic (atropine)vasopresssor (methoxamine)vasodilatorantianginalantihypertensive (nitroglycerin)antiarrhythmics (lidocaine, verapamil)tachycardia (adenosine)ventricular fibrillation (aminodarone)antihypertensive, antianginal, beta-adrenergicblocker (esmolol)ASA (acetylsalicylic acid, aspirin)____Neuromuscular Blocker (succinylcholine)Specific medications are provided above as examples, and are subject to changebased on currently published ACLS or Board approved standardsList any deficiencies, substitutions, and rationale (may continue on back):5

SECTION 5Office/Clinic & Patient Record KeepingIn addition to the following list, the inspectors will review selected sedation patient records for procedures donewithin the previous twelve (12) months. One record MUST be submitted to the Board for review with patientnames redacted from it.___ _ Health/Medical History Form____________*Applicant must initial each of the following to indicate compliance*Anesthesia Chart showing continuous monitoring ofblood pressure, heart rate, pulse oximetry andelectocardiographic (EKG) monitoring every 5 minutesfor deep sedation/general anesthesiaDischarge Criteria FormDocumentation of Adverse Reaction & Board ofDentistry Notified with Form (found on-line)____________Emergency Treatment Documents in Progress NotesPatient Sedation Consent FormNarcotic or Scheduled Drug Inventory Log and Recordof Drugs Dispensed to Patients:____ Dispensed____ AdministeredAdditional Items to be Inspected/Evaluated: Patient’s chief complaint documentedTreatment plan documentedCore questions included on medical history form:____ 1. Are you now under a physician’s care or have you beenduring the past 5 years, including hospitalization(s) &surgery____ 2. Are you currently under a doctor’s orders or taking anymedication(s), including any birth control pills, overthe-counterdrugs, herbal supplements or home-opathicpreparations?____ 3. Do you have any allergies or are you sensitive to anydrugs or substances such penicillin, novacaine, aspirin,latex, or codeine?____ 4. Have you ever bled excessively after a cut, wound, orsurgery? Have you ever received a blood transfusion?____ 5. Are you subject to fainting, dizziness, nervousdisorders, seizures, or epilepsy?____ 6. Have you ever had any breathing difficulty, includingasthma, emphysema, chronic cough, pneumonia, TB, orany other lung disorders? Do you snore or have youbeen diagnosed with sleep apnea? Do you use tobaccoproducts?____ 7. Have you or your family members ever had anyanesthesia-related problems?____ 8. Do you have heart disease or a history of chest pain orpalpations?____ 9. Is there anything you would like to discuss alone withthe doctor?____10. Do you currently use or have a history of usingrecreational drugs?____11. Are you or might you be pregnant?____________________Radiographs – appropriately labeledWeightASA ClassificationSedation record1. ____ Agents, amounts, times administered2. ____Time-oriented anesthesia documented recordindicating supplemental oxygen-if used3. ____ Pre-treatment vital signs4. ____ Post-Treatment vital signs5. ____ Discharge vital signs6. ____ Documented continuous or periodicmonitoring of:____ blood pressure____ heart rate____ pulse oximetry____ electrocardiographic (EKG)monitoring― if required7. ____ Minimum recordings made of:____ Before beginning procedure____ Following the administrationof sedation/analgesic agents____ Completion of procedure____ During initial recovery____ Time of discharge____ Recording documented every five (5)minutes for deep sed./gen. anesthesia8. ____ Patient’s status at time of dischargeRecord of prescriptions____________Health History accomplished at every visitExamination charted with proposed procedures andprobable complicationsInformed consent____Wrongful Event Protocol:_____ Prevention protocol_____ Event protocol______ protocol includes notification to MN Bd ofDentistry6

SECTION 6Emergency PreparednessPART I. Emergency Scenarios ― Complete protocols for all scenarios. Attach additional pages ifneeded.The SD/CSS and his/her clinical team must indicate competency in treating the following emergencies. If any areas of theMock Emergency Scenarios need immediate correction, then the SD or CSS must keep a record of the systems’ failures andwrite a plan to amend the staff protocol. A second mock drill should be conducted and subsequently evaluated.* Reminder: Clinical staff involved in the delivery of sedation dental services must be CPR/BLS certified *ALLERGY1. Immediate Allergic Reaction/Anaphylaxis― less than one hourAre you and your staff competent and prepared to recognize and treat Immediate Allergic Reaction/Anaphylaxis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. Delayed Allergic Reaction― greater than one hourAre you and your staff competent and prepared to recognize and treat Delayed Allergic Reaction?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________RESPIRATORY3. Asthmatic Attack (Bronchospasm)Are you and your staff competent and prepared to recognize and treat Asthmatic Attack?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. HyperventilationAre you and your staff competent and prepared to recognize and treat Hyperventilation?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5. Apnea – Airway ManagementAre you and your staff competent and prepared to recognize and treat Apnea?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. Foreign Body Obstruction/EmesisAre you and your staff competent and prepared to recognize and treat Foreign Body Obstruction/Emesis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7

7. LaryngospasmAre you and your staff competent and prepared to recognize and treat Laryngospasm?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CARDIOVASCULAR8. SyncopeAre you and your staff competent and prepared to recognize and treat Syncope?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________9. Angina Pectoris (Chest Pain)Are you and your staff competent and prepared to recognize and treat Angina Pectoris?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________10. Myocardial Infarction (Heart Attack)/Sudden Cardiac ArrestAre you and your staff competent and prepared to recognize and treat Myocardial Infarction/Sudden Cardiac Arrest?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________11. Hypotensive CrisisAre you and your staff competent and prepared to recognize and treat Hypotensive Crisis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________12. Hypertensive CrisisAre you and your staff competent and prepared to recognize and treat Hypertensive Crisis?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________13. Stroke (Cerebrovascular Accident)Are you and your staff competent and prepared to recognize and treat Stroke?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8

NEUROLOGICAL14. Seizures (Convulsions)Are you and your staff competent and prepared to recognize and treat Seizures?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DRUG OVERDOSE15. Local Anesthetic OverdoseAre you and your staff competent and prepared to recognize and treat Local Anesthetic Overdose?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________16. Narcotic OverdoseAre you and your staff competent and prepared to recognize and treat Narcotic Overdose?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________17. Benzodiazepine OverdoseAre you and your staff competent and prepared to recognize and treat Benzodiazepine Overdose?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ENDOCRINE18. HypoglycemiaAre you and your staff competent and prepared to recognize and treat Hypoglycemia?YES NO SD/CSS Dentist Initials _________ Staff Initials ______________________________What is the clinic protocol?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SECTION 7Personal Attestation – SD/CSSI attest that I have reviewed the information in this document, and that the information is complete and accurate.Signature: _____________________________________Date: ____________________9

SECTION 8: Board/Sedation Committee (for office use only)Summary of Inspection/EvaluationComments/Concerns:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendations:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Inspector must return completed forms to the Board of Dentistry within two weeksInspector Name_______________________________Signature_________________________________Date _________________Sedation Committee Approval: _____________________Signature: _____________________________________Date: _______________*Pursuant to Minnesota Rule 3100.3600, Supt. 11: On-site inspection; requirements and procedures, and Rule 3100.3600,Subp.9,B,(4) and (6).The Minnesota Board of Dentistry greatly appreciates the material provided for thisdocument by:• The American Association of Oral and Maxillofacial Surgeons (AAOMS)• The Institute of Medical Emergency Preparedness ( IMEP)10