WSR 14-11-015 PROPOSED RULES DEPARTMENT OF HEALTH (Dental Quality Assurance Commission) [Filed May 9, 2014, 8:31 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 14-01-085.
Title of Rule and Other Identifying Information: WAC 246-817-770 General anesthesia and deep sedation, adding end-tidal carbon dioxide (CO2) monitoring requirements when dentists administer general anesthesia or deep sedation.
Hearing Location(s): Department of Health, 310 Israel Road S.E., Room 152/153, Tumwater, WA 98501, on July 18, 2014, at 8:05 a.m.
Date of Intended Adoption: July 18, 2014.
Submit Written Comments to: Jennifer Santiago, P.O. Box 47852, Olympia, WA 98504-7852, e-mail http://www3.doh.wa.gov/policyreview/, fax (360) 236-2901, by July 11, 2014.
Assistance for Persons with Disabilities: Contact Jennifer Santiago by July 11, 2014, TTY (800) 833-6388 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rule adds end-tidal CO2 monitoring requirement to WAC 246-817-770, which sets out specific requirements to obtain the authorizing permit, and procedures, equipment, and medications for administration of general anesthesia.
Reasons Supporting Proposal: The proposed change to monitoring requirements will help ensure patient safety and to remain consistent with the recognized standard of care. A change in CO2 level is the first indication there may be a problem with a patient under general anesthesia. The American Association of Oral and Maxillofacial Surgeons required oral and maxillofacial surgeons with their national certification to begin end-tidal CO2 monitoring in January 2014. Requiring all dentists with a general anesthesia permit to monitor expired CO2 provides consistent practice standards.
Statutory Authority for Adoption: RCW 18.32.640 and 18.32.0365.
Statute Being Implemented: RCW 18.32.640.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Washington state dental quality assurance commission, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Jennifer Santiago, 111 Israel Road S.E., Tumwater, WA 98501, (360) 236-4893.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rule would not impose more than minor costs on businesses in an industry.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Jennifer Santiago, P.O. Box 47852, Olympia, WA 98504-7852, phone (360) 236-4893, fax (360) 236-2901, e-mail jennifer.santiago@doh.wa.gov.
May 9, 2014
LouAnn Mercier, D.D.S.
Chair
AMENDATORY SECTION (Amending WSR 09-04-042, filed 1/30/09, effective 3/2/09)
WAC 246-817-770 General anesthesia and deep sedation.
Deep sedation and general anesthesia must be administered by an individual qualified to do so under this chapter.
(1) Training requirements: To administer deep sedation or general anesthesia, the dentist must meet one or more of the following criteria:
(a) Any provider currently permitted as of the effective date of this revision to provide deep sedation or general anesthesia by the state of Washington will be grandfathered regarding formal training requirements, provided they meet current continuing education and other ongoing applicable requirements.
(b) New applicants with anesthesia residency training will be required to have had two years of continuous full-time anesthesia training meeting the following requirements based on when they began their anesthesia training:
(i) For dentists who began their anesthesia training prior to 2008, training must include two full years of continuous full-time training in anesthesiology beyond the undergraduate dental school level, in a training program as outlined in part 2 of "Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in Dentistry," published by the American Dental Association, Council on Dental Education (last revised October 2005).
(ii) For dentists who begin their anesthesia training in January 2008 or after, must have either received a certificate of completion.
(A) From a dental anesthesiology program accredited by CODA (ADA Commission on Dental Accreditation, "Accreditation Standards for Advanced General Dentistry Education Programs in Dental Anesthesiology," January 2007); or
(B) From a dental anesthesiology program approved by the Dental Quality Assurance Commission; or
(C) With a minimum of two years of full-time anesthesia residency training at a medical program accredited by the Accreditation Council for Graduate Medical Education (ACGME).
(c) New applicants who completed residency training in oral and maxillofacial surgery must meet at least one of the following requirements:
(i) Be a diplomate of the American Board of Oral and Maxillofacial Surgery;
(ii) Be a fellow of the American Association of Oral and Maxillofacial Surgeons; or
(iii) Be a graduate of an Oral and Maxillofacial Residency Program accredited by CODA.
(2) In addition to meeting one or more of the above criteria, the dentist must also have a current and documented proficiency in advanced cardiac life support (ACLS).
(3) Procedures for administration:
(a) Patients receiving deep sedation or general anesthesia must have continual monitoring of their heart rate, blood pressure, ((and)) respiration, and expired carbon dioxide (CO2). In so doing, the licensee must utilize electrocardiographic monitoring ((and)), pulse oximetry, and end-tidal CO2 monitoring;
(b) The patient's blood pressure and heart rate shall be recorded every five minutes and respiration rate shall be recorded at least every fifteen minutes;
(c) During deep sedation or general anesthesia, the person administering the anesthesia and the person monitoring the patient may not leave the immediate area;
(d) During the recovery phase, the patient must be continually observed by the anesthesia provider or credentialed personnel;
(e) A discharge entry shall be made in the patient's record indicating the patient's condition upon discharge and the responsible party to whom the patient was discharged.
(4) Dental records must contain appropriate medical history and patient evaluation. Anesthesia records shall be recorded during the procedure in a timely manner and must include:
(a) Blood pressure;
(b) Heart rate;
(c) Respiration;
((blood oxygen saturation)) (d) Pulse oximetry;
(e) End-tidal CO2;
(f) Drugs administered including amounts and time administered;
(g) Length of procedure; and
(h) Any complications of anesthesia.
(5) Equipment and emergency medications: All offices in which general anesthesia (including deep sedation) is administered must comply with the following equipment standards:
(a) An operating theater large enough to adequately accommodate the patient on a table or in an operating chair and permit an operating team consisting of at least three individuals to freely move about the patient;
(b) An operating table or chair which permits the patient to be positioned so the operating team can maintain the airway, quickly alter patient position in an emergency, and provide a firm platform for the administration of basic life support;
(c) A lighting system which is adequate to permit evaluation of the patient's skin and mucosal color and a backup lighting system of sufficient intensity to permit conclusion of any operation underway at the time of general power failure;
(d) Suction equipment capable of aspirating gastric contents from the mouth and pharyngeal cavities. A backup suction device must be available;
(e) An oxygen delivery system with adequate full face masks and appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, together with an adequate portable backup system;
(f) A recovery area that has available oxygen, adequate lighting, suction, and electrical outlets. The recovery area can be the operating theater;
(g) Ancillary equipment which must include the following:
(i) Laryngoscope complete with adequate selection of blades, spare batteries, and bulb;
(ii) Endotracheal tubes and appropriate connectors, and laryngeal mask airway (LMA) and other appropriate equipment necessary to do an intubation;
(iii) Oral airways;
(iv) Tonsillar or pharyngeal suction tip adaptable to all office outlets;
(v) Endotracheal tube forceps;
(vi) Sphygmomanometer and stethoscope;
(vii) Adequate equipment to establish an intravenous infusion;
(viii) Pulse oximeter or equivalent;
(ix) Electrocardiographic monitor;
(x) End-tidal CO2 monitor;
(xi) Defibrillator or automatic external defibrillator (AED) available and in reach within sixty seconds from any area where general or deep anesthesia care is being delivered. Multiple AEDs or defibrillators may be necessary in large facilities. The AED or defibrillator must be on the same floor. (In dental office settings where sedation or general anesthesia are not administered, AEDs or defibrillators are required as defined in WAC 246-817-722.)((;))
(h) Emergency drugs of the following types shall be maintained:
(i) Vasopressor or equivalent;
(ii) Corticosteroid or equivalent;
(iii) Bronchodilator;
(iv) Muscle relaxant;
(v) Intravenous medications for treatment of cardiac arrest;
(vi) Narcotic antagonist;
(vii) Benzodiazepine antagonist;
(viii) Antihistaminic;
(ix) Anticholinergic;
(x) Antiarrhythmic;
(xi) Coronary artery vasodilator;
(xii) Antihypertensive;
(xiii) Anticonvulsant.
(6) Continuing education:
(a) A dentist granted a permit to administer general anesthesia (including deep sedation) under this chapter, must complete eighteen hours of continuing education every three years.
A dentist granted a permit must maintain records that can be audited and must submit course titles, instructors, dates attended, sponsors, and number of hours for each course every three years.
(b) The education must be provided by organizations approved by the DQAC and must be in one or more of the following areas: General anesthesia; conscious sedation; physical evaluation; medical emergencies; pediatric advanced life support (PALS); monitoring and use of monitoring equipment; pharmacology of drugs; and agents used in sedation and anesthesia.
(c) Hourly credits earned from certification in health care provider basic life support (BLS) and advanced cardiac life support (ACLS) courses may not be used to meet the continuing education hourly requirements for obtaining or renewing a general anesthesia and deep sedation permit, however these continuing education hours may be used to meet the renewal requirement for the dental license.
(7) A permit of authorization is required. See WAC 246-817-774 for permitting requirements.
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