DEPARTMENT OF HEALTH

(Dental Quality Assurance Commission)

[Filed July 31, 2023, 3:43 p.m.]

Preproposal statement of inquiry was filed as WSR 17-17-089.

Title of Rule and Other Identifying Information: WAC 246-817-701 through 246-817-790 for administration of anesthetic agents for dental procedures. The dental quality assurance commission (commission) is proposing rule amendments to establish new and update requirements for the administration of anesthetic agents for dental procedures.

Hearing Location(s): On September 8, 2023, at 10:00 a.m., at Olympia Parks, Arts and Recreation, Meeting Room 103, 222 Columbia Street N.W., Olympia, WA 98501; or virtual https://us02web.zoom.us/webinar/register/WN_lQCfs4bfRGiiEyRvAouitw.

Date of Intended Adoption: September 8, 2023.

Submit Written Comments to: Amber Freeberg, P.O. Box 47852, Olympia, WA 98504-7852, email dental@doh.wa.gov, fax 360-236-2901, by August 24, 2023.

Assistance for Persons with Disabilities: Contact Amber Freeberg, phone 360-236-4893, fax 360-236-2901, TTY 711, email dental@doh.wa.gov, by August 24, 2023.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The commission filed an initial proposed rule on November 10, 2022, as WSR 22-23-076. The commission withdrew the original CR-102 on December 21, 2022, because of comments received from interested parties that could result in substantive changes to the rules as they were drafted. The commission decided to further contemplate the suggested changes to amend the rules to best ensure patient safety. The original proposal included 24 hour on-call availability, updates to basic life support (BLS) education, added requirements for emergency protocols and training, clarified recordkeeping and emergency medications, established self-inspections for all dentists when anesthetic is administered, updated on-site inspections for dentists with moderate sedation with parenteral agents or general anesthesia permits, and created a pediatric sedation endorsement. This proposal continues to include these amendments. However, this second proposal also makes the following changes to the originally proposed rules:

Reasons Supporting Proposal: Standards of care have changed since the current rule was adopted and a complete review was necessary. Creating a pediatric sedation endorsement is necessary to provide safeguards for the unique sedation needs of pediatric patients. Interested parties have expressed concern with lack of 24-hour on-call availability after dental procedures. Although current rule requires 24-hour on-call availability when anesthesia is used, there are complex dental procedures that do not involve anesthesia and on-call availability is necessary. Self-inspections are needed to ensure all dentists are prepared for dental emergencies when any type of anesthetic is administered during a dental procedure. Current rule requires on-site inspections for dentists holding general anesthesia permits; the proposed rule amendment adds moderate sedation with parenteral agents permits and creates standards for the on-site inspections to ensure patient safety.

Additional amendments were necessary because after further consideration it was determined that:


•	Requires vital sign monitoring for pediatric patients. Obtaining vital signs on American Society of Anesthesiologist (ASA) classification ASA 1 age 13 and under will be at the dentist's discretion (WAC 246-817-724).
•	Removes "other inhalation sedation agents" from the intro to WAC 246-817-740(4) as it is required in WAC 246-817-740 (4)(b).
•	Reverts the continuing education (CE) requirement for minimal sedation and minimal sedation with nitrous oxide back to a five year interval as written in current rule. The initial proposal had increased it to every three years along with other procedures (WAC 246-817-740 and 246-817-745).
•	Clarifies that prescribing for patient dosage prior to the appointment includes a single oral agent in a dose that is not to exceed the manufacturer's maximum recommended dose for home use (WAC 246-817-745).
•	Specifies that EKG monitoring is not required when a pediatric patient is uncooperative or the emotional condition means monitoring is not possible or the patient does not tolerate the monitoring pads (WAC 246-817-760).


•	Vital sign monitoring for pediatric patients is necessary to maintain patient safety.
•	Removes "other inhalation sedation agents" from the intro to WAC 246-817-740(4) as it is required in WAC 246-817-740 (4)(b).
•	A change in intervals for CE for minimal sedation and minimal sedation with nitrous oxide is not necessary because it was determined that the current rule meets standard of care for training requirements.
•	A clarification was needed for prescribing patient dosage prior to the appointment.
•	Provider judgment should be allowed for EKG monitoring of pediatric patients in order to provide the best patient care for these more vulnerable patients.

Statutory Authority for Adoption: RCW 18.32.002 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: Dental quality assurance commission, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Amber Freeberg, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-4893.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Amber Freeberg, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-4893, fax 360-236-2901, TTY 711, email dental@doh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect.

Explanation of exemptions: WAC 246-817-730 and 246-817-771 are both exempt under RCW 34.05.310 (4)(d) as the proposed rules in both clarify current requirements without material change.

Scope of exemption for rule proposal:

Is partially exempt:

Explanation of partial exemptions: See explanation above.

The proposed rule does impose more-than-minor costs on businesses.

Small Business Economic Impact Statement

Businesses that are required to comply with the proposed rule using the North American Industry Classification System (NAICS) codes and what the minor cost thresholds are:

NAICS Code (4, 5, or 6 digit)	NAICS Business Description	# of Businesses in WA	Minor Cost Threshold = 1% of Average Annual Payroll	Minor Cost Threshold = .3% of Average Annual Receipts
621210	Offices of dentists	3551	[(1,212,6891000)/3551](0.01) = $ 3,415

Analysis of the probable cost of compliance. The probable costs to comply with the proposed rule, including: Cost of equipment, supplies, labor, professional services and increased administrative costs; and whether compliance with the proposed rule will cause businesses to lose sales or revenue: There are costs for licensed dentists to comply with the proposed rules. Costs are associated with 14 sections of the proposed rules. Cost estimates are for the average dental office. There is no anticipation of loss of sales or revenue to comply with the proposed rules. Costs and time associated with complying with the proposed rules were gathered through various sources including:


•	Bureau of Labor Statistics;
•	Dental health care providers direct comments;
•	Dental supply vendors; and
•	Dental education providers.

WAC 246-817-701 Administration of anesthetic agents for dental procedures: The existing rule excludes procedures using only local anesthesia. The proposed rule amendment modifies 24-hour availability to include local anesthetic and adds options to meet requirements for availability.

The commission anticipates that for a dentist to establish a prearranged agreement with another provider for immediate care to a patient will take 15 to 30 minutes. The average hourly salary of a dentist is $79.001. Therefore, the anticipated cost of compliance to the proposed rule is $40.00.

Dentists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

WAC 246-817-720 Basic life support requirements: The existing rule requires health care provider basic life support certification requirements for dental staff. The proposed rule amendment adds a hands-on component for initial and renewal of health care provider BLS certification and education standards.

The commission anticipates no new cost to obtain health care provider BLS certification with a hands-on component as dentists are currently required to have health care provider BLS certification. There are a variety of courses and locations available to obtain health care provider BLS certification. The cost of a seven hour in-person course through American Red Cross is $1202 and there is no difference in cost in a health care provider BLS certification course with and without a hands-on component.

Search | Classes, Products, Articles | Red Cross.

WAC 246-817-722 Defibrillator: The existing rule requires a licensed dentist providing anesthetic agents to ensure a defibrillator or automated external defibrillator is accessible to all staff within 60 seconds and excludes local anesthesia from this requirement. The proposed rule amendment adds this requirement when local anesthetic is administered.

There is a new cost for dentists that do not already have a defibrillator or AED in office. It is not always possible to predict how a patient is going to respond to anesthetic agents and practitioners need to be able to rescue that patient. A defibrillator or AED average price range is $1200 to $19003. There are a variety of types, models, and distributors available to obtain a defibrillator or AED. There are a variety of courses and locations to obtain defibrillator or AED training.

AED Machine for Sale | AED Superstore AEDs.

WAC 246-817-724 Recordkeeping, equipment, and emergency medications or drugs: The existing rule requires specific patient record documentation, equipment, emergency drugs, and excludes minimal sedation by inhalation. The proposed rule amendments include the following:

There is a cost to develop and maintain written emergency protocols. There is an additional cost for staff training and documenting the annual review. Costs greatly differ depending on whether the dentist and staff establish their own written infection prevention policies and training or if the dentist determines to use an outside organization to develop policies and training.

The commission assumes that an average staff makeup in a dental office includes one dentist, two hygienists, two dental assistants, and one administrator. Salaries based on the Bureau of Labor Statistics are:

Dentists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Dental Hygienists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Dental Assistants: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Administrative Services and Facilities Managers: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

The commission assumes that either a staff person in the dental office or the dentist will develop, maintain, and provide training for emergency protocols. The time spent is estimated at 20 hours for initial development. It is estimated that two hours of initial training will be needed for all staff, and one-hour annual training for all staff.


•	Adds requirement for written emergency protocols, training, and annual review;
•	Details recordkeeping requirements;
•	Clarifies these requirements when anesthetics of any kind are administered, to include local anesthetic;
•	Adds exception for all pediatric patients receiving any anesthetic agent including local anesthesia or minimal sedation with nitrous oxide;
•	Adds obtaining vital signs on ASA 1 age 13 and under to be at the dentist's discretion;
•	Updates examples of emergency drugs; and
•	Adds requirement to have equipment calibrated to manufacturer instructions.


•	Dentist - $79 hourly wage4
•	Dental Hygienist - $38 hourly wage5
•	Dental Assistant - $19 hourly wage6
•	Office Administrator - $48 hourly wage7


•	The cost for developing policies and procedures for 20 hours ranges from $372 (for a dental assistant) to $1570 (for a dentist) depending on who prepares and revises policies.
•	The initial cost for two hours of training is $477 for assumed staff of one dentist, two dental hygienists, two dental assistants, and one administrator.
•	The cost for one-hour annual training is $239 for assumed staff of one dentist, two dental hygienists, two dental assistants, and one administrator.
•	It is assumed time to document annual review is 15 minutes. The cost for the dentist to document is $20 annually.

By using straight-line depreciation (spreading the cost of an asset evenly over the asset's useful life) and assuming a five-year useful life (defined as the estimated time that an asset provides value) costs to comply with this section are provided below8:

Resch S, Menzies N, Portnoy A, Clarke-Deelder E, O'Keeffe L, Suharlim C, Brenzel L.

How to cost immunization programs: a practical guide on primary data collection and analysis. 2020. Cambridge, MA: immunizationeconomics.org/ Harvard T.H. Chan School of Public Health. Page 39. 7.3.5 Training "Initial training…should be treated as a capital cost and allocated over a multi-year time horizon. …training would be a capital cost with a useful life of five years." Page 40. 7.4 Annualization of capital costs. Also includes definitions of useful life (page 40) and straight-line depreciation (page 41). https://msh.org/wp-content/uploads/2021/06/howtocost_digital_12.24.20.pdf.

	Initial/First year cost	Two - Five year total cost/annually
Initial policy development	$372 - $1570	$0/$0
Initial two-hour training	$477	$0/$0
Documenting training	$20	$80/$20
Annual training	$0	$956/$239

WAC 246-817-740 Minimal sedation with nitrous oxide: The existing rule provides minimum requirements for a licensed dentist to administer (inhalation) minimal sedation. The proposed rule amendments include the following:


•	Changes the title of the section and the term inhalation to nitrous oxide;
•	Clarifies specific acceptable training requirements;
•	Updates recordkeeping requirement when nitrous oxide and oxygen is administered including removing "other inhalation sedation agents" from the introduction to WAC 246-817-740(4) as it is required in WAC 246-817-740 (4)(b);
•	Adds requirement for BLS certification; and
•	Moves CE requirements to new section WAC 246-817-773.

The commission anticipates there are no new additional costs for a dentist to comply with training requirements, recordkeeping, or BLS certification as none of the proposed amendments add additional time for a dentist to comply. Clarification for training requirements is consistent with American Dental Association's Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students9.

American Dental Association. (2021). Guidance for teaching pain control and sedation to dentists and dental students. Chicago: ADA https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/oral-health-topics/ada_guidelines_teaching_pediatric_sedation.pdf?rev=86a7c539ce9d4025bc2b291223f35328&hash=395FF38AD1E42109BC021760194CAC89.

WAC 246-817-745 Minimal sedation: The existing rule identifies the minimum requirements for a licensed dentist to administer a single dose or agent for minimal sedation with or without nitrous oxide. The proposed rule amendments include the following:


•	Reduces initial education and training from 21 to 16 hours;
•	Removes delineation of single agent versus combined or multiple agents;
•	Clarifies specific acceptable training requirements;
•	Adds patient evaluation requirement;
•	Adds reference to the requirements for recordkeeping, necessary equipment, and required emergency medications or drugs as identified in WAC 246-817-724;
•	Clarifies detailed recordkeeping requirement when nitrous oxide is administered;
•	Adds requirement for BLS certification; and
•	Moves CE requirements to new section WAC 246-817-773.

The commission anticipated that there is a potential cost savings by reducing the initial education and training hours from 21 to 16 hours. The average two-hour CE course offered by University of Washington, School of Dentistry is $6910. There are no new costs for a dentist to comply with training requirements, recordkeeping, or BLS certification as none of the proposed amendments add additional time for a dentist to comply. Reduction and clarification for training requirements are consistent with American Dental Association guidelines for teaching pain control and sedation to dentists and dental students.

CDE Requirements - UW School of Dentistry (washington.edu).

The commission anticipated that there is minimal or no additional cost for a dentist to complete a patient evaluation as patient evaluation is a standard of care currently expected. The proposed rule identifies the ASA patient classification requirements11.

American Society of Anesthesiologists. (2020). ASA physical status classification system. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system.

WAC 246-817-755 Moderate sedation with enteral agents: The existing rule identifies the training and administration requirements a licensed dentist must comply with to administer moderate sedation. The proposed rule amendments include the following:


•	Clarifies title as "Moderate sedation with enteral agents";
•	Increases education and training from 28 to 37 total hours;
•	Adds specific acceptable training requirements;
•	Adds hands-on skill training requirements;
•	Adds patient evaluation requirement;
•	Clarifies requirement for BLS certification;
•	Moves CE requirements to new section WAC 246-817-773; and
•	Increases CE requirement of seven hours from every five years to every three years.

The commission does not anticipate additional costs for the proposed rule increasing training hours and hands-on skill training. The proposed increase in hours and clarification for training requirements are consistent with American Dental Association guidelines for teaching pain control and sedation to dentists and dental students. The proposed increase of 37 hours of education and training from 28 hours includes the education of 16 hours required for minimal sedation proposed in WAC 246-817-745. The remaining proposed 21 hours of education and training must be in moderate sedation. There is a net increase by four hours between these two rules. These additional hours are routinely provided in sedation related available courses. Increased initial training costs range from $0 to $13812. The commission has reasonable belief that a dentist can comply with the proposed rule change at no cost for the increased training hours; therefore, the commission does not anticipate an additional cost to comply with the rule.

CDE Requirements - UW School of Dentistry (washington.edu).

The costs for CE change from every five years to every three years is provided in WAC 246-817-755 analysis.

WAC 246-817-760 Moderate sedation with parenteral agents: The existing rule identifies the training requirements a licensed dentist must complete to administer moderate sedation with parenteral agents. The proposed rule amendments include the following:


•	Increases initial education requirement from 15 patients to 20 patients of supervised experience;
•	Adds hands-on skill training requirements;
•	Changes term "minor" to "pediatric";
•	Adds list of prohibited drugs;
•	Adds patient evaluation requirement;
•	Clarifies anesthesia monitor requirement;
•	Increases pulse oximetry and respiratory recording to every five minutes from every 15 minutes;
•	Adds requirement to have equipment calibrated to manufacturer instructions;
•	Adds operating theater, table or chair, and lighting system requirements;
•	Adds laryngeal mask airway equipment requirement;
•	Adds electrocardiographic monitor equipment requirement with carve out for pediatric patients who are uncooperative, have emotional conditions such that monitoring is not possible or who do not tolerate the monitor pads or wiring;
•	Clarifies monitoring requirements;
•	Updates examples of emergency drugs;
•	Adds bronchodilator agent, advanced cardiovascular life support (ACLS) emergency drugs, and anti-hypoglycemic agent to emergency drugs;
•	Adds requirement for written contract requirement if providing sedation in another practitioner's dental office;
•	Clarifies requirement for ACLS certification;
•	Moves CE requirements to new WAC 246-817-773;
•	Reduces CE requirement from 18 hours to 14 hours every three years; and
•	Adds authorization to provide lower level of sedation.

The commission anticipates additional costs of the proposed rule to increase supervised patient experience from 15 to 20 patients. Supervised patient experience is obtained during training, most programs already provide at least 20 patient experiences as this is a requirement under American Dental Association guidelines for teaching pain control and sedation to dentists and dental students. DOCS education provides IV sedation training for dentists at a cost of $23,49513. This is not a new cost and not an increase in cost. Additionally, education and training costs may be higher than the documented range due to proposed added requirement that the training must include hands-on skills training. Although most training courses already include hands-on skills, there are several courses that have not incorporated this component as the rule has not previously required it.

IV Sedation Certification | DOCS Education.

The commission does not anticipate additional costs for clarifying language and terms, listing prohibited drugs, adding a patient evaluation requirement, clarifying monitoring requirements, updating examples of emergency drugs, clarifying ACLS certification, or adding authorization for lower-level sedation administration, because standard of care for dentists include all these standards.

The commission anticipates a negligible cost to increase pulse oximetry and respiratory recording from every 15 minutes to every five minutes. Costs are associated with dentist and staff time. The commission anticipates the average staff assisting in a sedation procedure is one dentist and two dental assistants. Salaries based on the Bureau of Labor Statistics are dentist - $7914 hourly wage and dental assistant - $1915 hourly wage. The proposed rule adds an additional two recordings are required every 15 minutes. Approximately 30 seconds is needed to view the monitor and to record, that is 60 seconds of increased time spent every 15 minutes for a dentist or dental assistant during a sedation procedure; approximately four minutes per hour. An average sedation procedure is one hour. The commission believes this proposed time increase for monitoring and recording during a sedation procedure is negligible for this reason.

Dentists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Dental Assistants (bls.gov).

The commission anticipates no new costs to have equipment calibrated, adding requirements for operating theater, table or chair, lighting system requirements, and additional emergency drugs. Existing standard of care currently includes ensuring offices where sedation is administered be appropriate for sedating patients and equipment is maintained and in good working order. Office and equipment standards are recommended by the American Association of Oral and Maxillofacial Surgeons16.

Practice Resources | AAOMS.

The commission anticipates an added cost to purchase additional emergency equipment for laryngeal mask airway and electrocardiographic equipment if the office does not already own them. There are many distributors of emergency equipment. Grayline Medical offers a laryngeal mask at $3517. Discount Cardiology offers an electrocardiographic monitor for $109518.

laryngeal mask\ - Grayline Medical.

Certified Pre-Owned | EKG Machines | Patient Monitors (discountcardiology.com).

The commission anticipates an additional cost for requiring a written contract when providing sedation in another practitioner's dental office. Costs include time spent developing and managing a written contract. There is a one-time cost developing standard contract language. The commission also anticipates additional costs when executing a contract with individual practitioners. The commission estimates up to one hour of both office administrator and dentist time to develop a standard contract and an additional one hour of time for the dentist to execute an individual contract. Salaries based on the Bureau of Labor Statistics are dentist - $7919 hourly wage and office administrator - $4820 hourly wage. The probable one-time costs to develop standard contract language include dentist and administrator time of $127. The probable cost to execute a contract is estimated at $79.

Dentists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Administrative Services and Facilities Managers: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

The commission anticipates a potential cost savings for proposed CE reducing hours from 18 to 14 hours every three years (reduction of four hours every three years). CE costs vary dramatically depending on number of hours obtaining, where, and method of obtaining CE. The average two hour CE course offered by University of Washington, School of Dentistry is $6921. The commission anticipates that a potential savings could be between $0 - $138 every three years.

CDE Requirements - UW School of Dentistry (washington.edu).

New WAC 246-817-765 Pediatric sedation endorsement: The proposed new section establishes a new pediatric endorsement requirement for a dentist to administer sedation to a pediatric patient when using moderate sedation with enteral and moderate sedation with parenteral permit holders. The proposed rule allows delayed implementation, allowance of administration of intranasal midazolam using moderate sedation with enteral agent permit authorization, clarifies administration of intranasal drugs, requires moderate sedation with parenteral agents permit for patients over age of 12, includes education and training requirements and BLS and pediatric advanced life support (PALS) requirement to obtain and maintenance of BLS and PALS certification, and establishes a CE requirement.

The commission anticipates additional costs to comply with this proposed rule for dentists who sedate pediatric patients. Not all dentists administer sedation nor do all dentists sedate pediatric patients. Pediatric dentists who are specialists obtain additional education and training as part of their national specialty certification provided in the proposed rule. The proposed rule is consistent with the American Academy of Pediatric Dentistry guidelines. The commission assumes most, if not all, dentists providing pediatric sedation already meet these standards. It is proposed that dentists without pediatric specialty training must complete an additional 14 hours in pediatric sedation education. Costs for this education ranges from $1500 to $250522.

Pediatric Sedation CE Courses for Dentists - Academy of Dental and Medical Anesthesia (admatraining.org).

The commission anticipates potential costs for adding 14 hours of CE every three years for a dentist who obtains the pediatric endorsement. The commission anticipates that the cost for complying to the proposed additional CE is $48323 every three years. Several acceptable ways to complete CE is proposed in new section WAC 246-817-773 and can be achieved at no cost, therefore the commission believes that there are no additional costs for a dentist to comply with this rule.

CDE Requirements - UW School of Dentistry (washington.edu).

WAC 246-817-770 General anesthesia and deep sedation: The existing rule establishes deep sedation and general anesthesia standards that must be met before administering. The proposed rule amendments include the following:

There are no costs for clarifying language and terms, listing prohibited drugs, adding patient evaluation requirement, clarifying monitoring requirements, updating examples of emergency drugs, clarifying ACLS certification, adding authorization for lower-level sedation administration, updating AED requirements, and moving CE requirements to new section.

The costs to have equipment calibrated, adding requirements for operating theater, table or chair, lighting system requirements, and additional emergency drugs is provided in WAC 246-817-760 analysis.

The commission anticipates no new additional cost to the proposed addition ACLS or PALS emergency drugs as existing standard of care includes ensuring the office is prepared for an emergency.

The cost for requiring a written contract when providing sedation in another practitioner's dental office is provided in WAC 246-817-760 analysis.

The commission anticipates an additional cost of one additional assistant when administering anesthesia. Based on the Bureau of Labor Statistics, the hourly wage for a dentist is $79 and $19 an hour for a dental assistant. An average sedation procedure is one hour, the anticipated additional cost is $19 per sedation procedure.

The cost to increase respiratory recording from every 15 minutes to every five minutes is provided in WAC 246-817-760 analysis.


•	Clarifies training requirements and removes outdated language;
•	Adds patient evaluation requirements;
•	Adds electrocardiograph continuous display requirement;
•	Adds requirement of three personnel, anesthesia provider, anesthesia monitor, and dental assistant;
•	Clarifies appropriate credentialed personnel;
•	Changes respiratory recording to every five minutes from every 15 minutes;
•	Adds requirement to have equipment calibrated to manufacturer instructions;
•	Changes AED or defibrillator requirement to reference WAC 246-817-722;
•	Updates examples of emergency drugs;
•	Adds ACLS or PALS emergency drugs;
•	Adds requirement for written contract requirement if providing sedation in another practitioner's dental office;
•	Moves CE requirements to new section WAC 246-817-773;
•	Clarifies requirement for maintaining ACLS certification; and
•	Adds authorization to provide lower level of sedation.

WAC 246-817-772 Requirements for anesthesia monitor: The existing rule provides anesthesia monitor training requirements and identifies when a licensed dentist administering anesthesia must also have an additional appropriately trained individual monitoring the patient. The proposed rule amendments include:


•	Adding a requirement that an anesthesia monitor is required when a dentist administers moderate sedation with parenteral agents;
•	Clarifying that an anesthesia monitor may not also perform dental assisting tasks during general anesthesia procedures, another individual is necessary to perform dental assistant tasks;
•	Clarifying on-site, or in-office as acceptable training for an anesthesia monitor; and
•	Requiring dentists to maintain anesthesia monitor training documentation.

The commission anticipates a cost to obtain additional anesthesia monitoring. Anesthesia monitoring education and training can be obtained through an education course or in-office training by the dentist. An education course provided through American Association of Oral and Maxillofacial Surgeon Dental Anesthesia Assistant National Certification Examination costs $54524. In-office training is estimated to cost $1,372 based on average hourly wage for a dentist at $7925 hourly wage and dental assistant at $1926 hourly wage for 14 hours each.

daance_handbook.pdf (aaoms.org).

Dentists : Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Dental Assistants : Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

New WAC 246-817-773 Continuing education for dentists administering sedation: The proposed new section consolidates all sedation permit CE requirements into one section, provides for content of CE, methods to complete CE, and allows delayed implementation to comply with new requirements.

The commission anticipates additional costs for the proposed CE change from every five years to every three years. Costs to comply with this section is provided in WAC 246-817-755, 246-817-760, and 246-817-765 analysis. The commission concludes that there is no additional cost to consolidate CE requirements into one section.

WAC 246-817-774 Permitting and renewal requirements: The existing rule identifies the requirements to receive and renew a permit to administer moderate sedation oral or parenteral or general anesthesia, including deep sedation. The proposed rule amendments include the following:

The cost to obtain the pediatric endorsement is provided in WAC 246-817-765 analysis. There is no additional cost to clarification of the rule requirements. The commission does anticipate potential additional cost for a dentist to obtain on-site inspections, conduct emergency drills, and to maintain site visit and drill documentation. The commission anticipates that average staff participating in on-site inspections and drills include one dentist, and two dental assistants. Salaries based on the Bureau of Labor Statistics are:

Dentists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Dental Assistants: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).


•	Adds a pediatric endorsement;
•	Adds requirement of on-site inspection from commission discretion to every five years to renew sedation permit and maintenance of on-site inspection reports;
•	Adds requirement of 12 emergency drill scenarios, performed at least two times per year;
•	Adds requirement of emergency drill declaration to renew sedation permit and maintenance of drill documentation;
•	Clarifies random audits for each requirement; and
•	Moves site visit requirements to new section WAC 246-817-775.


•	Dentist - $79 hourly wage27.
•	Dental Assistant - $19 hourly wage28.

The commission anticipates that the average on-site inspection takes four hours. Nationally certified oral and maxillofacial surgeons are currently required to have an on-site inspection every five years to maintain their professional certification by the American Association of Oral and Maxillofacial Surgeons29. The commission anticipates no additional increased cost for certified oral and maxillofacial surgeons as under current rule they already comply with the proposed rule. Other dentists providing anesthesia may conduct peer on-site inspections at no cost or choose to obtain on-site inspection through the authorized organizations at a cost of $0 - $50030. In addition to on-site inspection costs it is anticipated that potential staff time for on-site inspections for one dentist and two dental assistants. On-site inspections are required once every five years, annual recurring costs for inspection and staff time range from $93.60 to $193.60.

A standard emergency drill may take up to 15 minutes per drill. The proposed rule now requires 24 drills annually. At 15 minutes per drill, total of six hours of dental staff time could be expected annually. Staff time is for one dentist and two dental assistants. The anticipated costs to comply with proposed rule is $702 annually.

The commission anticipates an additional cost to document and maintain on-site and emergency drill information. The commission estimates two hours per year for an office administrator to document and maintain information. Salaries based on the Bureau of Labor Statistics for Office Administrator is $4831 hourly wage. The anticipated costs to comply with the proposed rule is $96 annually.

Administrative Services and Facilities Managers: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

New WAC 246-817-775 On-site inspections: The proposed new section consolidates self and on-site inspections into one section with the following:


•	Adds annual self-inspections of emergency preparedness for all dentists;
•	Defines annual self-inspection for moderate sedation with parenteral agents and general anesthesia permits annually;
•	Defines new on-site inspection requirement every five years for general anesthesia and moderate sedation with parenteral agent permit holders;


■	Provides on-site inspection requirement every five years by organization or self-arranged using approved form;
■	Provides standards for those self-arranged inspections using approved form;
■	Provides list of approved organizations; and
■	Provides delayed implementation of on-site inspections; and


•	Includes requirement to maintain on-site inspection documentation for five years.

The commission anticipates additional costs for dentists to self-assess their office for emergency preparedness. The commission anticipates that an annual assessment will take 30 to 60 minutes annually and cost range is $29.50 to $79 for a dentist32. The commission does not anticipate any additional costs for a dentist who holds a moderate sedation with parenteral agents or general anesthesia permit, as it is assumed that they also hold a dentist license and must complete the annual self-assessment under proposed rule. The commission does not anticipate any additional cost to use the commission approved form.

Dentists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics (bls.gov).

Onsite inspection costs are provided in WAC 246-817-774 analysis.

WAC 246-817-776 Discharge criteria: The existing rule requires licensed dentist follow specific discharge criteria after administering sedation. The proposed rule amendment adds two exceptions when taking vital signs is not required. There is no cost to comply with this rule amendment.

WAC 246-817-780 Mandatory reporting: The existing rule requires a licensed dentist without a general anesthesia permit to establish a contract outlining responsibilities of other providers administering anesthesia in a dental office. The proposed rule amendments update the section title from nondental to nondentist and creates specific requirements and responsibilities for written contract requirements that includes:

The commission does not anticipate any new costs to comply with the proposed rule amendments. A written contract is a current requirement under rule. The proposed rule amendments create and clarify specific written contract content requirements.


•	Facility, equipment, monitoring, and training requirements;
•	Anesthesia provider responsibilities;
•	Delineation of responsibilities;
•	Whom non-dentist anesthesia provider includes;
•	Criteria of anesthesia provider; and
•	Responsibilities of licensed dentist.

WAC 246-817-780 Mandatory reporting: The existing rule identifies mandatory reporting requirements for licensed dental providers. The proposed rule amendment adds hospital discharge records if available to be submitted.

The commission anticipates a negligible cost for a dentist to comply with this proposed rule amendment. The commission anticipates that for a dentist to request and obtain hospital records prior to submitting a report to the commission takes an average of five minutes and for this reason the commission anticipates the cost to comply with the proposed rule to be negligible.

WAC 246-817-790 Application of chapter 18.130 RCW: The existing rule applies chapter 18.130 RCW for sedation permits. The proposed rule amendment adds issuance and renewal of the proposed pediatric endorsement to authority under chapter 18.130 RCW.

The commission anticipated there is no additional cost for a dentist to comply with this proposed rule amendment because chapter 18.130 RCW applies to all credentialed health care practitioners.

Summary: The commission anticipated the probable cost estimate for a dentist to comply with the proposed rule changes in WAC 246-817-701 through 246-817-790 is between $0 to $9,277 one-time costs and $0 to $1,408.60 annually.

WAC Section	Initial one-time costs(Range)	Recurrent annual costs*(Range)
246-817-701	$0	$40
246-817-722	$1,200 - $1,900	$0
246-817-724	$372 - $2,047	$259
246-817-745	$69	$0
246-817-760	$1,257	($59) net savings
246-817-765	$500 - $2,505	$0
246-817-770	$127	$98
246-817-772	$1,372	$0
246-817-774	$0	$93.60 - $991.60
246-817-775	$0	$29.50 - $79
Probable Costs	$0 - $9,277	$0 - $1,408.60

Analysis of whether the proposed rule may impose more-than minor-costs on businesses in the industry: The commission has determined that $0 to $9,277 one-time costs and $0 to $1,408.60 annual costs for the proposed rules will exceed minor economic impact of $3,415 for dentist offices. Costs associated with sedating patients and responding to emergencies range significantly because not all sedation cases or emergencies are the same. Specific levels of education depend on level of sedation being performed; variety of monitoring and emergency equipment and drugs are necessary to ensure the dentist is prepared for any emergency.

Rule making supports the overarching goal of chapter 18.32 RCW by assuring dentists, anesthesia providers, and patients that dentists are adequately trained, complying with nationally accepted standards of practice, and prepared to respond to emergencies during administration of anesthetics, confirming that the public policy goals of the dental commission are achieved.

Determination of whether the proposed rule may have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule: The proposed rule may have a disproportionate impact on small businesses versus large businesses. Whether a licensed dentist is practicing in an independent practice setting or is part of a larger group or clinic, the administration of anesthetic agent requirements applies to wherever anesthetic agents for dentistry are administered in the state of Washington.

Licensed dentists work in many settings: Independent practice, partnerships, group practices, community clinics, general dental clinics, and universities. There are approximately 7,200 licensed dentists as of April 2022. We are unable to determine how many licensed dentists work in each of the different practice settings. Dentists in independent practice or partnerships will incur all the costs to comply with the proposed rules. Dentists that are part of larger group practices will be able to share in the costs to comply with the proposed rules. Dentists that work for community clinics, general dental clinics, or universities will most likely incur minimal, if any, costs to comply with the proposed rules. As business models differ so does the expectation of who will cover the costs to comply with the proposed rules. Ultimately, the licensed dentist needs to ensure all requirements have been met where anesthetic agents for dentistry is administered in the state of Washington.

If the proposed rule has a disproportionate impact on small businesses, the steps taken to reduce the costs of the rule on small businesses. If the costs can not be reduced provide a clear explanation of why: Although the proposed rule may have disproportionate impact on small businesses versus large businesses, the commission determined to delay implementation of pediatric endorsement, CE changes, and on-site inspections in proposed rules WAC 246-817-765, 246-817-773, and 246-817-775 to help reduce the first-year cost impact of the proposed rules.

Description of how small businesses were involved in the development of the proposed rule: The commission worked closely with interested parties and other constituents to minimize the burden of this proposed rule. The commission held open public meetings from December 2017 through February 2022 allowing interested parties, including the Washington State Dental Association, Washington State Society of Oral and Maxillofacial Surgeons, and Washington State Society of Mobile Dental Anesthesia, provided suggested rule changes and comments. During open public rules meetings, alternative versions of the rules were discussed. After careful consideration, some of the suggested changes were accepted while others were rejected. Mutual interests were identified and considered through deliberations.

The commission's public participation process encouraged interested individuals to:

The proposed rule amendments went through several stages of edits, review, and discussion and then further refinement before arriving at the final proposal. The results of this process are proposed changes that will provide increased rule clarity, guidance and will ultimately be less burdensome than the original rule. The commission filed an initial proposed rule on November 10, 2022. The commission withdrew the original CR-102 on December 21, 2022, because of comments received from interested parties. This second proposal includes changes that are responsive to input from interested parties to decrease burdensome areas of the rule such as decreasing the interval for reporting CE for minimal sedation and minimal sedation with nitrous oxide, granting dentists discretion when using EKG monitoring on children, and other helpful changes.


•	Identify burdensome areas of the existing rule and proposed rule;
•	Propose initial or draft rule changes; and
•	Refine those changes.

The estimated number of jobs that will be created or lost as the result of compliance with the proposed rule: The commission does not anticipate any jobs created or lost because of compliance with the proposed rule.

A copy of the statement may be obtained by contacting Amber Freeberg, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-4893, fax 360-236-2901, TTY 711, email Dental@doh.wa.gov.

David L. Carsten, DDS, Chair

Dental Quality Assurance Commission

AMENDATORY SECTION(Amending WSR 10-23-001, filed 11/3/10, effective 12/4/10)

WAC 246-817-701Administration of anesthetic agents for dental procedures.

The purpose of WAC 246-817-701 through 246-817-790 is to govern the administration of anesthetic, sedation, and general anesthesia by dentists licensed in the state of Washington in settings other than hospitals as defined in WAC 246-320-010 and ambulatory surgical facilities as defined in WAC 246-310-010, pursuant to the DQAC authority in RCW 18.32.640.

(1) The DQAC has determined that sedation and anesthesia permitting should be based on the (("))level((")) of ((anesthesia))sedation or anesthesia because ((anesthesia/sedation))sedation or anesthesia is a continuum, and the route of administration and drug combinations are both capable of producing a deeper level of ((sedation/anesthesia))sedation or anesthesia than is initially intended. Practitioners intending to produce a given level of sedation should be able to rescue patients who enter a state deeper than initially intended.

(2) All anesthesia providers must provide ((twenty-four))24 hour, on-call availability following an anesthesia procedure((, excluding those procedures using only local anesthetic)).

(a) A licensed dentist that only administers local anesthesia shall provide timely telephonic or electronic communication with the patient or their representative by the provider or a designated provider.

(b) In the event a licensed dentist will be unavailable for timely assistance, the licensed dentist shall have a prearranged agreement with another provider that is available to provide timely care to a patient.

(3) The dental assistant and expanded function dental auxiliary may not administer any general or local anesthetic, including intravenous sedation.

AMENDATORY SECTION(Amending WSR 13-15-144, filed 7/23/13, effective 8/23/13)

WAC 246-817-710Definitions.

The definitions in this section apply throughout WAC 246-817-701 through 246-817-790 unless the context clearly requires otherwise.

(1) "Advanced cardiac life support" or "ACLS" means a set of clinical interventions for the urgent treatment of cardiac arrest, stroke, and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.

(2) "American Society of Anesthesiologists patient classification I" means a normal healthy patient.

(3) "American Society of Anesthesiologists patient classification II" means a patient with mild systemic disease.

(4) "American Society of Anesthesiologists patient classification III" means a patient with severe systemic disease.

(5) "American Society of Anesthesiologists patient classification IV" means a patient with severe systemic disease that is a constant threat to life.

(6) "Analgesia" ((is))means the diminution of pain in the conscious patient.

(((2)))(7) "Anesthesia" ((is))means the loss of feeling or sensation, especially loss of sensation of pain.

(((3)))(8) "Anesthesia monitor" means a credentialed health care provider specifically trained in monitoring patients under sedation and capable of assisting with procedures, problems and emergency incidents that may occur as a result of the sedation or secondary to an unexpected medical complication.

(((4)))(9) "Anesthesia provider" means a dentist, physician anesthesiologist, dental hygienist, or certified registered nurse anesthetist (CRNA) licensed ((and)), authorized, competent, and qualified to ((practice))perform anesthesia within the state of Washington.

(((5)))(10) "Automated external defibrillator" or "AED" means a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation and pulseless ventricular tachycardia, and is able to treat through defibrillation.

(11) "Basic life support" or "BLS" means a type of care health care providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress, or an obstructed airway.

(12) "Carbon dioxide" or "CO2" means a gas consisting of one part carbon and two parts oxygen.

(13) "Close supervision" means that a supervising dentist whose patient is being treated has personally diagnosed the condition to be treated and has personally authorized the procedures to be performed. The supervising dentist is continuously on-site and physically present in the treatment facility while the procedures are performed by the assistive personnel and capable of responding immediately in the event of an emergency. ((The term))Close supervision does not require a supervising dentist to be physically present in the operatory.

(((6)))(14) "Commission on Dental Accreditation" or "CODA" means a national organization that develops and implements accreditation standards that promote and monitor the continuous quality and improvement of dental education programs.

(15) "Deep ((sedation/analgesia" is))sedation" means a drug induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

(((7)))(16) "Dental anesthesia assistant" means a health care provider certified under chapter 18.350 RCW and specifically trained to perform the functions authorized in RCW 18.350.040 under supervision of an oral and maxillofacial surgeon or dental anesthesiologist.

(((8) "Direct visual supervision" means supervision by an oral and maxillofacial surgeon or dental anesthesiologist by verbal command and under direct line of sight.

(9)))(17) "Enteral" means any technique of administration in which an agent is absorbed through the gastrointestinal tract.

(18) "General anesthesia" ((is))means a drug induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain an airway and respond purposefully to physical stimulation or verbal command, produced by a pharmacologic or nonpharmacologic method, or combination thereof may be impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

(((10) "Local anesthesia" is the elimination of sensations, especially pain, in one part of the body by the topical application or regional injection of a drug.

(11)))(19) "Minimal sedation" ((is a drug induced state during which patients))means a minimally depressed level of consciousness, produced by a pharmacological method, that retains the patient's ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal commands. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.

(((12)))(20) "Moderate sedation" ((is))means a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Moderate sedation can include both ((moderate sedation/analgesia (conscious sedation) and moderate sedation with))enteral and parenteral ((agent))routes of administration.

(((13)))(21) "Nothing by mouth" or "NPO" means the time before an examination or procedure during which a patient cannot eat or drink.

(22) "Parenteral" means a technique of administration in which the drug bypasses the gastrointestinal (GI) tract (((i.e.))including, but not limited to, intramuscular, intravenous, intranasal, submuscosal, subcutaneous, and intraosseous(())).

(23) "Pediatric" means a child 12 years of age or younger.

(24) "Pediatric advanced life support" or "PALS" means a type of care that focuses on providing advanced airway and life support skills in immediate emergency care to children.

AMENDATORY SECTION(Amending WSR 13-15-144, filed 7/23/13, effective 8/23/13)

WAC 246-817-720Basic life support requirements.

(1) Dental staff providing direct patient care in an in-office or out-patient setting must hold a current and valid health care provider ((basic life support ())BLS(())) certification. Initial and renewal certification must include both didactic and hands-on components.

(2) Health care provider BLS certification must be obtained from an individual, organization, or training center who holds a current and valid BLS instructor certification and teaches the current International Liaison Committee on Resuscitation or ILCOR standard including, but not limited to, American Heart Association or American Red Cross.

(3) Health care provider BLS instruction must include online or in-person didactic instruction with a written assessment, in-person skills assessment on high quality chest compressions, rescue breathing using the bag valve mask, correct use of AED or defibrillator for adults, children, and infants, feedback to students, and a valid health care provider BLS certification card upon completion.

(4) Dental staff providing direct patient care include: Licensed dentists, licensed dental hygienists, licensed expanded function dental auxiliaries, certified dental anesthesia assistants, and registered dental assistants.

(5) Newly hired office staff providing direct patient care are required to obtain the required certification within ((forty-five))45 days from the date hired.

AMENDATORY SECTION(Amending WSR 10-23-001, filed 11/3/10, effective 12/4/10)

WAC 246-817-722Defibrillator.

(((1) Every dental office in the state of Washington that administers minimal, moderate, or deep sedation, or general anesthesia, as defined in WAC 246-817-710, must have an automated external defibrillator (AED) or defibrillator.

(2)))When anesthetic agents of any kind are administered, the dentist and staff must have access to ((the))an AED or defibrillator ((in an emergency, and it)). The AED or defibrillator must be available and in reach within ((sixty))60 seconds.

(((3) A dental office may share a single AED or defibrillator with adjacent businesses if it meets the requirements in this section.))

AMENDATORY SECTION(Amending WSR 16-06-106, filed 3/1/16, effective 4/1/16)

WAC 246-817-724Recordkeeping, equipment, and emergency medications or drugs ((required in all sites where anesthetic agents of any kind are administered)).

When anesthetic agents of any kind are administered, the dentist must comply with the requirements in this section.

(1) ((Dental records must contain an appropriate medical history and patient evaluation. Any adverse reactions, and))The anesthesia provider or anesthesia monitor shall record the patient's condition. The record must include documentation of all medications ((and))administered with dosages((, must be recorded)), regular and consistent time intervals, and route of administration. The provider administering the sedation may determine time intervals.

(2) ((When sedation of any level is to be administered, excluding minimal sedation by inhalation, presedation))All patients receiving any anesthetic agent including local anesthesia or minimal sedation with nitrous oxide, vital((s))signs including, but not limited to, blood pressure and heart rate must be ((obtained and)) recorded, unless the cooperation of the patient or circumstances of the case will not allow it. If ((presedation))pretreatment vitals cannot be obtained, the reason(((s)))or reasons why must be recorded. Obtaining vital signs on ASA 1 age 13 and under will be at the dentist's discretion.

(3) ((Office facilities and))The following equipment must be available and include:

(a) Suction equipment capable of aspirating gastric contents from the mouth and pharynx;

(b) Portable oxygen delivery system including full face masks and a bag-valve-mask combination with appropriate connectors capable of delivering positive pressure, oxygen enriched ventilation to the patient;

(d) Stethoscope or equivalent monitoring device.

(4) The following emergency drugs must be available and maintained:

(a) Bronchodilator including, but not limited to, albuterol;

(b) Sugar ((())or glucose(()));

(d) Antihistaminic including, but not limited to, diphenhydramine;

(e) Coronary artery vasodilator including, but not limited to, nitroglycerin;

(f) Anti-anaphylactic agent including, but not limited to, epinephrine.

(5) A licensed dentist shall develop and maintain written emergency protocols and ensure:

(a) All staff are trained in the protocols wherever anesthetic agents of any kind are administered.

(b) The emergency preparedness written protocols include training requirements and procedures specific to the licensed dentist's equipment and drugs for responding to emergency situations involving sedation or anesthesia, including information specific to respiratory emergencies.

(d) The protocols include basic life support protocols, advanced cardiac life support protocols, or pediatric advanced life support protocols based on the level of anesthetics being administered.

(6) Equipment used for monitoring patients must be calibrated or performance verified according to manufacturer's instructions.

AMENDATORY SECTION(Amending WSR 09-04-042, filed 1/30/09, effective 3/2/09)

WAC 246-817-730Local anesthesia.

Local anesthesia ((shall))must only be administered ((only)) by a ((person))provider qualified under this chapter and dental hygienists as provided in chapter 18.29 RCW.

(1) ((All offices must))"Local anesthesia" means the elimination of sensations, especially pain, in one part of the body by the topical application or regional injection of a drug.

(2) A licensed dentist administering local anesthetic agents shall comply with ((the))recordkeeping, equipment, and emergency medication requirements ((listed)) in WAC 246-817-724.

(((2)))(3) A permit of authorization is not required.

AMENDATORY SECTION(Amending WSR 16-06-106, filed 3/1/16, effective 4/1/16)

WAC 246-817-740(("))Minimal sedation ((by inhalation" (to include, but not limited to,))with nitrous oxide(())).

(1) ((Training requirements:)) To administer ((inhalation)) minimal sedation with nitrous oxide, a licensed dentist ((must have completed a course containing))shall successfully complete a minimum of ((fourteen))14 hours of ((either predoctoral dental school or postgraduate instruction in inhalation minimal sedation))education and training in one of the following:

(a) Minimal sedation with nitrous oxide; or

(b) Moderate sedation with nitrous oxide; or

(c) Advanced education program accredited by the CODA that meets comprehensive and appropriate training necessary to administer and manage minimal sedation with nitrous oxide; or

(d) Education and training must be consistent with ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students, adopted by ADA House of Delegates October 2016 or prior adopted version in effect at the time training was completed.

(2) ((Procedures for administration: Inhalation))A licensed dentist shall ensure:

(a) Delegation of administration for minimal sedation ((must be administered))with nitrous oxide is under the close supervision of ((a person))an anesthesia provider qualified under this chapter ((and dental hygienists as provided in chapter 18.29 RCW:

(a) When administering inhalation minimal sedation,)).

(b) A second individual ((must be on))is in the office ((premises)) and able to immediately respond to any request from the ((person administering the inhalation minimal sedation;

(b)))licensed dentist or anesthesia provider.

(3) A licensed dentist shall comply with recordkeeping, equipment, and emergency medication((s: All offices in which inhalation minimal sedation is administered must comply with the recordkeeping and equipment standards listed))requirements in WAC 246-817-724.

(4) Dental records must contain documentation in the chart of ((either)) nitrous oxide, and oxygen ((or any other inhalation sedation agent))administered or dispensed.

(a) In the case of nitrous oxide sedation only (("N2O used" is required)), the record must include the maximum nitrous oxide concentration used and the times started and stopped or total time of administration.

(b) Other inhalation agents require a dose record noting the time each concentration or agent was ((used))administered or dispensed.

(5) ((Continuing education:)) A licensed dentist who administers ((inhalation))minimal sedation ((to patients must participate in))with nitrous oxide shall complete seven hours of continuing education ((or equivalent)) every five years as required in WAC 246-817-773.

(((a) The education must include instruction in one or more of the following areas:

(i) Sedation;

(ii) Physiology;

(iii) Pharmacology;

(iv) Inhalation analgesia;

(v) Patient evaluation;

(vi) Patient monitoring; and

(vii) Medical emergencies.

(b) In addition to education requirements in (a) of this subsection, the dentist must obtain health care provider basic life support (BLS), or advanced cardiac life support (ACLS) certification. Hourly credits earned from certification in BLS or ACLS courses may not be used to meet the education requirements in (a) of this subsection. However, the hourly credits earned in BLS or ACLS certification may be used to meet the requirements of WAC 246-817-440 to renew the dentist license.))

(6) A licensed dentist who administers minimal sedation with nitrous oxide must hold a current and valid BLS certification.

(7) A permit of authorization is not required.

AMENDATORY SECTION(Amending WSR 16-06-106, filed 3/1/16, effective 4/1/16)

WAC 246-817-745(("))Minimal sedation.(("))

(1) ((Training requirements: To administer "minimal sedation," including:

(a) A single oral agent, a dentist must have completed a course containing a minimum of fourteen hours of a predoctoral dental school, postgraduate instruction, or continuing education (as defined in WAC 246-817-440) in the use of oral agents;

(b) Any oral agent in combination with a different agent or multiple agents other than nitrous oxide or injectable agents, a dentist must have completed a course containing))To administer minimal sedation which is limited to a single dose of a single oral agent with or without nitrous oxide, a licensed dentist shall successfully complete a minimum of ((twenty-one))16 hours of ((either predoctoral dental school or postgraduate instruction.

(2) Procedures for administration:

(a)))education and training in one of the following:

(a) Minimal sedation; or

(b) Moderate sedation; or

(c) Advanced education program accredited by the CODA that meets comprehensive and appropriate training necessary to administer and manage minimal sedation; or

(2) A licensed dentist shall:

(a) Evaluate patient considered for minimal sedation prior to the administration of any sedative procedure.

(i) Review of the patient's current medical history and medication use is required for healthy or medically stable individuals with American Society of Anesthesiologists patient classification of I or II.

(ii) Consultation with the patient's primary care physician or consulting medical specialist is required for patients with significant medical considerations whom have American Society of Anesthesiologists patient classification III or IV. If the licensed dentist is unsuccessful in contacting or consulting with the patient's physician or physicians, the licensed dentist shall document the attempt or document the patient has no physician to contact.

(b) Administer oral sedative agents ((can be administered)) in the treatment setting or ((prescribed))prescribe for patient dosage prior to the appointment((;)). Single oral agents must be in a dose that is not to exceed the manufacturer's maximum recommended for home use.

(((b)))(c) Ensure a second individual ((must be on))is in the office ((premises)) and able to immediately respond to any request from the ((person))anesthesia provider administering ((the drug;))minimal sedation.

(((c)))(d) Ensure the patient ((must be))is continuously observed while in the office under the influence of ((the drug;))minimal sedation.

(((d)))(e) Comply with the recordkeeping, equipment, and emergency medication requirements in WAC 246-817-724.

(f) Ensure any adverse reactions ((must be))are documented in the ((records;))patient record.

(((e)))(g) If a patient unintentionally enters into a moderate level of sedation, ensure the patient ((must be))is returned to a level of minimal sedation as quickly as possible. While returning the patient to the minimal sedation level, periodic monitoring of pulse, respiration, and blood pressure must be maintained. In such cases, these same parameters must be taken and recorded at appropriate intervals throughout the procedure and vital signs and level of consciousness must be recorded during the sedation and prior to dismissal of the patient.

(3) ((Dental records must contain documentation))A licensed dentist shall document in the ((chart of))patient record all agents administered, time administered, and dosage for minimal sedation.

(((a) In the case of nitrous oxide sedation only "N2O used" is required.

(b) Other inhalation agents require a dose record noting the time each concentration and agent was used.))

(4) ((Continuing education:)) A licensed dentist who administers minimal sedation ((to patients must participate in))shall complete seven hours of continuing education ((or equivalent)) every five years as required in WAC 246-817-773.

(((a) The education must include instruction in one or more of the following areas:

(i) Sedation;

(ii) Physiology;

(iii) Pharmacology;

(iv) Nitrous oxide analgesia;

(v) Patient evaluation;

(vi) Patient monitoring; and

(vii) Medical emergencies.

(b) In addition to education requirements in (a) of this subsection, the dentist must obtain health care provider basic life support (BLS) or advanced cardiac life support (ACLS) certification. Hourly credits earned from certification in BLS or ACLS courses may not be used to meet the education requirements in (a) of this subsection. However, the hourly credit hours earned in BLS or ACLS certification may be used to meet the renewal requirements of WAC 246-817-440 to renew the dentist license.))

(5) A licensed dentist who administers minimal sedation must hold a current and valid BLS certification.

(6) A permit of authorization is not required.

AMENDATORY SECTION(Amending WSR 16-06-106, filed 3/1/16, effective 4/1/16)

WAC 246-817-755Moderate sedation with enteral agents.

(1) ((Training requirements: To administer moderate sedation the dentist must have completed a course containing))A licensed dentist is required to hold a permit of authorization to administer moderate sedation with enteral agents.

(2) To obtain a moderate sedation with enteral agents permit, a licensed dentist shall:

(a) Comply with the permitting and renewal requirements in WAC 246-817-774; and

(b) Successfully complete:

(i) A minimum of 16 hours of education and training in minimal sedation as required in WAC 246-817-745(1); and

(ii) A minimum of ((seven))21 hours of ((a predoctoral dental school, postgraduate instruction, or continuing education (as defined in WAC 246-817-440)))education and training in moderate sedation ((in addition to twenty-one hours for minimal sedation)).

(((2) Procedures for administration:

(a)))(iii) Moderate sedation education and training must:

(A) Meet ADA Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students, adopted by ADA House of Delegates October 2016 or prior adopted version in effect at the time training was completed; and

(B) Include medical emergency management, not limited to airway management, conducted in-person with hands-on skills.

(3) A licensed dentist shall:

(a) Ensure the patient is evaluated for moderate sedation with enteral agents prior to the administration of any sedative.

(i) Review at an appropriate time the patient's medical history and medication use and NPO or nothing by mouth status.

(ii) Consult with the patient's primary care physician or consulting medical specialist for a patient with significant medical considerations whom have American Society of Anesthesiologists patient classification of III or IV. If the anesthesia provider is unsuccessful in contacting or consulting with the patient's physician or physicians, document the attempt or document the patient has no physician to contact.

(iii) Patients body mass index must be assessed as part of a preprocedural workup.

(b) Administer oral sedative agents ((can be administered)) in the treatment setting or ((prescribed))prescribe for patient dosage prior to the appointment.

(((b)))(c) Ensure a second individual ((must be on))is in the office ((premises)) who can immediately respond to any request from the ((person administering the drug))anesthesia provider.

(((c)))(d) Ensure the patient ((must be))is continuously observed while in the office ((under the influence of the drug)).

(((d)))(e) Record any adverse reactions ((must be documented)) in the patient record((s)).

(((e) If a patient unintentionally enters a deeper level of sedation,))(f) Ensure the patient ((must be))is returned to a level of moderate sedation as quickly as possible, if a patient unintentionally enters a deeper level of sedation. While returning the patient to the moderate level of sedation, periodic monitoring of pulse, respiration, and blood pressure and pulse oximetry must be maintained. In such cases, these same parameters must be taken and recorded at appropriate intervals throughout the procedure and vital signs and level of consciousness must be recorded during the sedation and prior to dismissal of the patient.

(((f) Patients))(g) Ensure a patient receiving ((these forms of))moderate sedation ((must be))with enteral agents is accompanied by a responsible adult upon departure from the treatment facility.

(((3)))(4) A licensed dentist shall comply with the recordkeeping, equipment, and emergency ((medications: All offices must comply with the requirements listed in WAC 246-817-724.))medication requirements in WAC 246-817-724.

(a) When a sedative drug is used that has a reversal agent, the reversal agent must be in the office emergency kit and the equipment to administer the reversal agent must be stored with the delivery device.

(b) Pulse oximetry equipment or equivalent respiratory monitoring equipment must be available in the office.

(((4) Continuing education:))(5) A licensed dentist who ((administers))holds a valid moderate sedation ((to patients must participate in))with enteral agents permit shall complete seven hours of continuing education ((or equivalent)) every ((five))three years as required in WAC 246-817-773.

(((a) The education must include instruction in one or more of the following areas:

(i) Sedation;

(ii) Physiology;

(iii) Pharmacology;

(iv) Nitrous oxide analgesia;

(v) Patient evaluation;

(vi) Patient monitoring; and

(vii) Medical emergencies.

(b) In addition to education requirements in (a) of this subsection, the dentist must obtain health care provider basic life support (BLS), advanced cardiac life support (ACLS), or pediatric advanced life support (PALS) certification to renew the moderate sedation permit. Hourly credits earned from certification in BLS, ACLS, or PALS courses may not be used to meet the education requirements in (a) of this subsection. However, the hourly credits earned in BLS, ACLS, or PALS certification may be used to meet the requirements of WAC 246-817-440 to renew the dentist license.

(5) A permit of authorization is required. See WAC 246-817-774 for permitting requirements.))(6) A licensed dentist who holds a valid moderate sedation with enteral agents permit must hold a current and valid BLS certification.

AMENDATORY SECTION(Amending WSR 17-07-037, filed 3/8/17, effective 4/8/17)

WAC 246-817-760Moderate sedation with parenteral agents.

(1) ((Training requirements: To administer moderate sedation with parenteral agents, the dentist must have successfully completed))A licensed dentist is required to hold a permit of authorization to administer moderate sedation with parenteral agents. A moderate sedation with parenteral agents permit allows the holder to deliver moderate sedation with enteral agents without obtaining a separate permit.

(2) To obtain a moderate sedation with parenteral agents permit, a licensed dentist shall:

(a) Comply with the permitting and renewal requirements in WAC 246-817-774;

(b) Successfully complete a postdoctoral course(((s)))or courses of ((sixty))60 clock hours or more which includes ((training in)):

(i) Basic moderate sedation((,));

(ii) Physical evaluation((,));

(iii) Venipuncture((,))and intravenous drug administration, training is a hands-on skill and must be completed in-person;

(iv) Technical administration((,));

(v) Recognition and management of complications and emergencies, training is a hands-on skill and must be completed in-person;

(vi) Monitoring((,)); and

(vii) Supervised experience in providing moderate sedation with parenteral agents to ((fifteen))20 or more patients. ((If treating an adult, the dentist must have))

(d) Training in pediatric sedation, if treating a pediatric patient.

(((2)))(3) In addition to meeting the criteria in subsection (((1)))(2) of this section, the licensed dentist ((must also have))shall hold and maintain a current certification in ((advanced cardiac life support ())ACLS(())) or ((pediatric advanced life support ())PALS(())).

(a) If treating an adult, the dentist must have ACLS certification.

(b) If treating a ((minor))pediatric patient, the dentist must have PALS certification.

(((3)))(4) The use of any drugs classified under the Food and Drug Administration as general anesthetic agents including, but not limited to, Propofol, Ketamine, Sevoflurane, Halothane, and Isoflurane are considered outside the scope of a moderate sedation with parenteral agents permit.

(5) The drugs, drug amounts, and techniques used must carry a margin of safety wide enough to render unintended loss of consciousness highly unlikely.

(((4) Procedures for administration of moderate sedation with parenteral agents by a dentist and an individual trained in monitoring sedated patients:))(6) A licensed dentist shall:

(a) ((In the treatment setting,))Ensure a patient receiving moderate sedation with parenteral agents ((must have that))receives the sedation ((administered by a person))from an anesthesia provider qualified under this chapter.

(b) Ensure the patient is evaluated for moderate sedation with parenteral agents prior to the administration of any sedative.

(i) Review, at an appropriate time, the patient's medical history and medication use and NPO or nothing by mouth status.

(iii) Patient's body mass index must be assessed as part of a preprocedural workup.

(iv) A focused physical examination to include vital signs, evaluation of the airway, and auscultation of the heart and lungs is required before administration of any sedative or anesthesia agent.

(c) Ensure a patient ((may not be))is not left alone in a room and ((must be))is continually monitored by a ((dentist with a valid moderate sedation with parenteral agent permit))anesthesia provider or trained anesthesia monitor as defined in WAC 246-817-772.

(((c)))(d) Ensure an intravenous infusion ((must be))is maintained during the administration of a parenteral agent. Two exceptions for intravenous infusion may occur, but reasons why intravenous infusion was not used must be documented for:

(i) Pediatric sedation cases using agents for brief procedures; and

(ii) When the pediatric patient is uncooperative or the emotional condition is such that intravenous access is not possible.

(((d)))(e) Ensure when the operative dentist is also the ((person))provider administering the moderate sedation with parenteral agents, the operative dentist ((must be))is continuously assisted by ((at least one individual experienced in monitoring sedated patients))a trained anesthesia monitor as defined in WAC 246-817-772. The trained anesthesia monitor may function as the dental or surgical assistant.

(i) If treating an adult, the additional individual must have experience or training in adult sedation.

(ii) If treating a ((minor))pediatric patient, the additional individual must have experience or training in pediatric sedation.

(((e) In the treatment setting,))(f) Ensure a patient ((experiencing moderate sedation with parenteral agents must be))is visually and tactilely monitored ((by the dentist))either by themselves or an individual trained in monitoring sedated patients. Patient monitoring must include:

(i) Heart rate;

(ii) Blood pressure;

(iii) ((Respiration;))Respiratory rate;

(iv) ((Pulse oximetry; and))Oxygen saturation;

(v) ((Expired carbon dioxide (CO2). Two exceptions for expired CO2 monitoring may occur, but reasons why expired CO2 monitoring was not used must be documented for))Continuous electrocardiographic monitoring when the patient has clinically significant cardiovascular disease.

(A) Clinically significant cardiovascular disease can be classified, but not limited to, coronary artery disease, arrhythmias, congenital heart defects, heart valve disease, disease of the heart muscle, and heart infection.

(B) Electrocardiographic monitoring of a pediatric patient is not required when the pediatric patient is uncooperative, the emotional condition is such that monitoring is not possible, or who does not tolerate the monitor pads or wiring. Reasons why electrocardiographic monitoring was not used must be documented.

(vi) End-tidal CO2. Monitoring is not required when:

(A) A pediatric sedation ((cases using))case uses agents for a brief ((procedures; and))procedure; or

(B) ((When the))A pediatric patient is uncooperative or the emotional condition is such that end-tidal CO2 monitoring is not possible.

(((f)))(C) Reasons why end-tidal CO2 monitoring was not performed must be documented.

(g) Comply with requirements of immobilization devices for pediatric patients((:)).

(i) Immobilization devices, such as, papoose boards, must be applied in such a way as to avoid airway obstruction or chest restriction.

(ii) The pediatric patient head position and respiratory excursions must be checked frequently to ensure airway patency.

(iii) If an immobilization device is used, a hand or foot must be kept exposed.

(((g)))(h) Ensure the patient's blood pressure ((and)), heart rate ((must be)), pulse oximetry, and respiration rate is recorded every five minutes((, pulse oximetry recorded every five minutes, and respiration rate must be recorded at least every fifteen minutes)).

(((h)))(i) Ensure the patient's level of consciousness ((must be))is recorded prior to the dismissal of the patient.

(((i) Patients receiving moderate sedation with parenteral agents must be))(j) Ensure patient is accompanied by a responsible adult upon departure from the treatment facility.

(((j) If a patient unintentionally enters a deeper level of sedation,))(k) Ensure the patient ((must be))is returned to a level of moderate sedation as quickly as possible, if the patient unintentionally enters a deeper level of sedation. While returning the patient to the moderate level of sedation, periodic monitoring of pulse, respiration, blood pressure and continuous monitoring of oxygen saturation must be maintained. In such cases, these same parameters must be taken and recorded at appropriate intervals throughout the procedure and vital signs and level of consciousness must be recorded during the sedation and prior to dismissal of the patient.

(((5) Dental records must contain))(7) A licensed dentist shall document in the patient record appropriate medical history and patient evaluation. Sedation records must be recorded during the procedure in a timely manner and must include:

(a) Blood pressure;

(b) Heart rate;

(d) Pulse oximetry;

(e) End-tidal CO2. ((Two exceptions for end-tidal CO2 monitoring may occur, but reasons why end-tidal CO2 monitoring was not used must be documented for:))Monitoring is not required when:

(i) Pediatric sedation ((cases using))case uses agents for brief procedure((s; and)); or

(ii) ((When the))A pediatric patient is uncooperative or the emotional condition is such that end-tidal CO2 monitoring is not possible.

(iii) Reasons why end-tidal CO2 monitoring was not performed must be documented.

(f) Drugs administered including amounts and time administered;

(g) Length of procedure; and

(h) Any complications of sedation.

(((6)))(8) A licensed dentist shall comply with the following recordkeeping, equipment, and emergency ((medications: All offices in which moderate sedation with parenteral agents is administered or prescribed must comply with the following equipment standards:

Office facilities and equipment shall include:

(a)))medication requirements:

(a) Equipment used for monitoring patients must be calibrated or performance verified according to manufacturer's instructions.

(b) An operating theater must be large enough to adequately accommodate the patient on a table or in an operating chair and permit an operating team consisting of at least two individuals to freely move about the patient;

(c) An operating table or chair must permit 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;

(d) A lighting system must be 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 procedure underway at the time of general power failure;

(e) Suction equipment capable of aspirating gastric contents from the mouth and ((pharynx))pharyngeal cavities. A backup suction device must be available;

(((b) Portable))(f) An oxygen delivery system ((including))with adequate full face masks and ((a bag-valve-mask combination with)) appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, ((oxygen-enriched patient ventilation and oral and nasal pharyngeal airways.))together with an adequate portable backup system;

(i) If treating an adult, the equipment must be appropriate for adult sedation((.));

(ii) If treating a ((minor))pediatric patient, the equipment must be appropriate for pediatric sedation;

(((c)))(iii) Appropriate sized laryngeal mask airway must be ready for emergency use;

(g) A blood pressure cuff ((())or sphygmomanometer(())) of appropriate size and stethoscope; or equivalent monitoring devices;

(((d)))(h) End-tidal CO2 monitor;

(((e)))(i) Pulse oximetry; and

(((f)))(j) An emergency drug kit with minimum contents of:

(i) Sterile needles, syringes, and tourniquet;

(ii) Narcotic antagonist;

(iii) Alpha and beta adrenergic stimulant;

(iv) Vasopressor;

(v) Coronary vasodilator including, but not limited to, nitroglycerin;

(vi) Antihistamine including, but not limited to, diphenhydramine;

(vii) Parasympatholytic;

(viii) Intravenous fluids, tubing, and infusion set; ((and))

(ix) Sedative antagonists for drugs used, if available;

(x) Bronchodilator agent including, but not limited to, albuterol;

(xi) ACLS or PALS emergency drugs; and

(xii) Anti-hypoglycemic agent.

(((7) Continuing education: A dentist who administers moderate sedation with parenteral agents must participate in eighteen))(9) A licensed dentist who holds a valid moderate sedation with parenteral agents permit and administers moderate sedation with parenteral agents in another licensed dentist office, must have a contract in place that contains the provisions described in WAC 246-817-778 (1)(a) through (c).

(10) A licensed dentist who holds a valid moderate sedation with parental agents permit shall complete 14 hours of continuing education ((or equivalent)) every three years as required in WAC 246-817-773.

(((a) The education must include instruction in one or more of the following areas:

(i) Venipuncture;

(ii) Intravenous sedation;

(iii) Physiology;

(iv) Pharmacology;

(v) Nitrous oxide analgesia;

(vi) Patient evaluation;

(vii) Patient monitoring; and

(viii) Medical emergencies.

(b) In addition to the education requirements in (a) of this subsection, the dentist must have a current certification in advanced cardiac life support (ACLS) or pediatric advanced life support (PALS) to renew the moderate sedation with parenteral agents permit. Hourly credits earned from certification in BLS, ACLS, or PALS courses may not be used to meet the education requirements in (a) of this subsection to renew a moderate sedation with parenteral agents permit. However, the hourly credits earned in ACLS or PALS certification may be used to meet the requirements of WAC 246-817-440 to renew the dentist license.

(8) A permit of authorization is required. See WAC 246-817-774 for permitting requirements.))(11) A licensed dentist who holds a valid moderate sedation with parenteral agents permit must hold a current and valid ACLS certification.

NEW SECTION

WAC 246-817-765Pediatric sedation endorsement.

A pediatric patient is physiologically and anatomically unlike an adult, and different sedation drugs and practices may be used for this population, it is necessary to ensure that adequately trained and skilled individuals are treating pediatric patients.

(1) Effective January 1, 2024, a pediatric sedation endorsement is required to administer moderate sedation with enteral agents or moderate sedation with parenteral agents, to pediatric patients.

(2) A licensed dentist who holds a valid moderate sedation with enteral agents permit and a pediatric sedation endorsement may administer intranasal midazolam to a pediatric patient. This modality may be administered without a moderate sedation with parenteral agents permit. Administration of intranasal drugs on patients over the age of 12 requires the licensed dentist to hold a moderate sedation with parenteral agents or general anesthesia permit.

(3) To obtain a pediatric sedation endorsement a licensed dentist shall:

(a) Hold a valid moderate sedation with enteral agents or moderate sedation with parenteral agents permit;

(b) Comply with the permitting and renewal requirements in WAC 246-817-774;

(i) A CODA postgraduate instruction in pediatric dentistry, oral and maxillofacial surgery, or dental anesthesiology; or

(ii) Predoctoral dental school, postgraduate instruction, or continuing education of at least 37 hours in minimal and moderate sedation and an additional 14 hours in pediatric sedation.

(A) The 14 hours in pediatric sedation must include:

(I) Pediatric specific anatomical and physiological considerations;

(II) Pediatric behavioral management during administration of sedating medication and intraoperatively;

(III) Pediatric drugs, dosages, and routes of administration;

(IV) Appropriate use of immobilization devices;

(V) Recordkeeping;

(VI) Nitrous oxide in combination with other sedating medications;

(VII) Prevention, recognition and management of complications; and

(VIII) Four or more hours must include hands-on instruction, simulations, live supervised pediatric sedation case management, or a combination of those modalities. Observation alone is not acceptable.

(B) The 37 hours in minimal and moderate sedation must include:

(I) Physical evaluation;

(II) Technical administration;

(III) Drugs and routes of administration;

(IV) Recognition and management of complications and emergencies; and

(V) Monitoring and monitoring equipment including training in expired CO2.

(d) Provide current health care provider BLS and PALS certifications.

(4) A licensed dentist who holds a valid pediatric sedation endorsement shall complete 14 hours of continuing education every three years as required in WAC 246-817-773.

(5) A licensed dentist who holds a valid pediatric endorsement must maintain a current and valid BLS and PALS certification.

AMENDATORY SECTION(Amending WSR 14-21-068, filed 10/10/14, effective 11/10/14)

WAC 246-817-770General 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))(1) A licensed dentist is required to hold a permit of authorization to administer deep sedation or general anesthesia. A general anesthesia permit allows the holder to deliver moderate sedation with enteral or moderate sedation with parenteral agents without obtaining a separate permit.

(2) To obtain a general anesthesia permit, a licensed dentist shall:

(a) Comply with permitting and renewal requirements in WAC 246-817-774;

(b) Successfully complete two years of continuous full-time anesthesia training in at least one of the following:

(i) 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)))at the time the training was completed; or

(((B) From))(ii) A dental anesthesiology program approved by the ((Dental Quality Assurance Commission))DQAC; or

(((C) With a minimum of two years of full-time))(iii) An anesthesia residency training, with a minimum of two years full-time, at a medical program accredited by the Accreditation Council for Graduate Medical Education (((ACGME).

(iv) An oral and maxillofacial surgery ((must meet))residency and obtain at least one of the following ((requirements)):

(((i) Be a))(A) Diplomate status of the American Board of Oral and Maxillofacial Surgery;

(((ii) Be a))(B) Fellow status of the American Association of Oral and Maxillofacial Surgeons; or

(((iii) Be a graduate of))(C) Diploma in an Oral and Maxillofacial Residency Program accredited by CODA at the time the training was completed.

(((2)))(3) In addition to meeting one or more of the ((above criteria))requirements in subsection (1) of this section, the licensed dentist ((must also))shall have a current ((and documented proficiency in advanced cardiac life support ())ACLS(()))certification.

(((3) Procedures for administration:))(4) A licensed dentist shall:

(a) Ensure a patient is evaluated for general anesthesia prior to the administration of any sedative.

(i) Review the patient's medical history, medication use, and NPO or nothing by mouth status.

(ii) Consult with the patient's primary care physician or consulting medical specialist for significant medical considerations whom have American Society of Anesthesiologists patient classification of III or IV.

(iii) A patient's body mass index must be assessed as part of a preprocedural workup.

(iv) A focused physical examination to include vital signs, evaluation of the airway, and auscultation of the heart and lungs is required before administration of any sedative or anesthesia agent.

(b) Ensure a patient((s)) receiving deep sedation or general anesthesia ((must have))has continual monitoring of their heart rate, blood pressure, respiration, and expired ((carbon dioxide ())CO2(())). ((In so doing, the licensee must))

(i) The licensed dentist shall utilize electrocardiographic monitoring, pulse oximetry, and end-tidal CO2 monitoring((;

(b))).

(ii) Electrocardiograph monitoring must be continuously displayed from the beginning of general anesthesia and until the patient reaches the level of stage 1 anesthesia after treatment is completed.

(c) The patient's blood pressure ((and)), heart rate, and respiration rate shall be recorded every five minutes ((and respiration rate shall be recorded at least every fifteen minutes;)).

(((c)))(d) To complete dental procedures under general anesthesia, the anesthesia permit holder, the anesthesia monitor, and the dental assistant shall all be present in the operating or treatment room. During deep sedation or general anesthesia, the ((person administering the)) anesthesia provider and the ((person))provider monitoring the patient may not leave the immediate area((;)).

(((d)))(e) During the recovery phase, the patient must be continually observed by the anesthesia provider or credentialed personnel((;

(e)))acting within their scope of practice and trained in recovery phase of anesthesia.

(f) A discharge entry ((shall))must 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))(5) A licensed dentist who holds a valid general anesthesia permit shall document in the patient record appropriate medical history and patient evaluation. Anesthesia records ((shall))must be recorded during the procedure in a timely manner and must include:

(a) Blood pressure;

(b) Heart rate;

(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)))(6) A licensed dentist shall comply with the following recordkeeping, equipment, and emergency ((medications: All offices in which general anesthesia (including deep sedation) is administered must comply with the following equipment standards))medication requirements:

(a) Equipment used for monitoring patients must be calibrated or performance verified according to manufacturer's instructions;

(b) An operating theater must be 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)))(c) An operating table or chair ((which))must permit((s)) 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)))(d) A lighting system ((which is))must be 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))procedure underway at the time of general power failure;

(((d)))(e) Suction equipment capable of aspirating gastric contents from the mouth and pharyngeal cavities. A backup suction device must be available;

(((e)))(f) 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)))(g) A recovery area that has available oxygen, adequate lighting, suction, and electrical outlets. The recovery area can be the operating theater;

(((g)))(h) 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; and

(xi) AED or 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)))(i) Emergency drugs of the following types ((shall))must be maintained:

(i) Vasopressor or equivalent;

(ii) Corticosteroid or equivalent;

(iii) Bronchodilator including, but not limited to, albuterol;

(iv) Muscle relaxant;

(v) Intravenous medications for treatment of cardiac arrest;

(vi) Narcotic antagonist;

(vii) Benzodiazepine antagonist;

(viii) Antihistaminic including, but not limited to, diphenhydramine;

(ix) Anticholinergic;

(x) Antiarrhythmic;

(xi) Coronary artery vasodilator including, but not limited to, nitroglycerin;

(xii) Antihypertensive;

(xiii) Anticonvulsant; and

(xiv) ACLS or PALS emergency drugs.

(((6) Continuing education:

(a) A dentist granted a permit to administer))(7) A licensed dentist who holds a valid general anesthesia permit and administers general anesthesia in another licensed dentist office, must have a contract in place that contains the provisions required in WAC 246-817-778 (1)(a) through (c).

(8) A licensed dentist who holds a valid general anesthesia (((including deep sedation) under this chapter, must))permit shall complete ((eighteen))18 hours of continuing education every three years as required in WAC 246-817-773.

(9) A licensed dentist who holds a valid general anesthesia permit must hold a current and valid ACLS certification.

((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.))

AMENDATORY SECTION(Amending WSR 13-15-144, filed 7/23/13, effective 8/23/13)

WAC 246-817-771Dental anesthesia assistant.

(1) A dental anesthesia assistant ((must))shall be certified under chapter 18.350 RCW and WAC 246-817-205.

(2) A dental anesthesia assistant may only accept delegation from an oral and maxillofacial surgeon or dental anesthesiologist who holds a valid Washington state general anesthesia permit.

(3) Under close supervision, the dental anesthesia assistant may:

(a) Initiate and discontinue an intravenous line for a patient being prepared to receive intravenous medications, sedation, or general anesthesia; and

(b) Adjust the rate of intravenous fluids infusion only to maintain or keep the line patent or open.

(4) Under direct visual supervision, the dental anesthesia assistant may:

(a) Draw up and prepare medications;

(b) Follow instructions to deliver medications into an intravenous line upon verbal command;

(d) Adjust an electronic device to provide medications, such as an infusion pump;

(e) Administer emergency medications to a patient in order to assist the oral and maxillofacial surgeon or dental anesthesiologist in an emergency.

(5) The responsibility for monitoring a patient and determining the selection of the drug, dosage, and timing of all anesthetic medications rests solely with the supervising oral and maxillofacial surgeon or dental anesthesiologist.

(6) A certified dental anesthesia assistant shall notify the ((commission))DQAC in writing, on a form provided by the department, of any changes in his or her supervisor.

(a) The ((commission))DQAC must be notified of the change prior to the certified dental anesthesia assistant accepting delegation from another supervisor. The certified dental anesthesia assistant may not practice under the authority of this chapter unless he or she has on file with the ((commission))DQAC such form listing the current supervisor.

(b) A supervisor must be an oral and maxillofacial surgeon or dental anesthesiologist who holds a valid Washington state general anesthesia permit.

(i) "Any change" means the addition, substitution, or deletion of supervisor from whom the certified dental anesthesia assistant is authorized to accept delegation.

(ii) "Direct visual supervision" means supervision by an oral and maxillofacial surgeon or dental anesthesiologist by verbal command and under direct line of sight.

AMENDATORY SECTION(Amending WSR 16-06-106, filed 3/1/16, effective 4/1/16)

WAC 246-817-772((Requirements for))Anesthesia monitor requirements.

(1) When ((the))a licensed dentist is also administering ((the))moderate sedation with parenteral agents, deep sedation or general anesthesia, one additional appropriately trained team member must be designated for patient monitoring. The team member designated for patient monitoring when general anesthesia is being administered may not also perform dental assistant tasks.

(2) When moderate sedation with parenteral agents, deep sedation or general anesthesia is administered by a dedicated anesthesia provider who is not the operative dentist, the anesthesia provider may serve as the monitoring personnel.

(3) ((The))A licensed dentist cannot employ an individual to monitor patients receiving moderate sedation with parenteral agents, deep sedation or general anesthesia unless that individual has received a minimum of ((fourteen))14 hours of documented training,((())such as national certification American Association of Oral and Maxillofacial Surgeons (("AAOMS") in a course)), on-site or in-office training by a licensed dentist with a moderate sedation with parenteral agents or general anesthesia permit, or other education course specifically designed to include instruction and practical experience in use of equipment to include, but not be limited to, the following equipment:

(a) Sphygmomanometer((;)) or a device able to measure blood pressure;

(b) Pulse oximeter((;)) or other respiratory monitoring equipment;

(d) Bag-valve-mask resuscitation equipment;

(e) Oral and nasopharyngeal airways;

(f) Defibrillator((;))or automatic external defibrillator.

(4) The ((course))training referred to in subsection (3) of this section must also include instruction in:

(a) Basic sciences;

(b) Evaluation and preparation of patients with systemic diseases;

(d) Anesthesia equipment and monitoring; and

(e) Office anesthesia emergencies.

(5) A licensed dentist shall maintain training or certification documentation of the anesthesia monitor.

NEW SECTION

WAC 246-817-773Continuing education for dentists administering sedation.

Continuing education must contribute to the professional knowledge and development of the licensed dentist to enhance sedation services provided to patients.

(1) The continuing education reporting period for a licensed dentist that administers sedation in Washington before December 31, 2023, begins January 1, 2024.

(2) The five-year continuing education reporting period for a licensed dentist that administers minimal sedation with nitrous oxide or minimal sedation in Washington on January 1, 2024, or later begins the date of first administration of sedation.

(3) The three-year continuing education reporting period for a licensed dentist initially issued a moderate sedation with enteral agents, moderate sedation with parenteral agents, pediatric sedation endorsement, or general anesthesia permit in Washington on January 1, 2024, or later begins the date of permit issuance.

(4) A licensed dentist who holds a valid permit or endorsement shall complete required hours of continuing education in one or more of the subject categories as required in below table.

	WAC 246-817-740 Minimal sedation with nitrous oxide – 7 hours	WAC 246-817-745 Minimal sedation – 7 hours	WAC 246-817-755 Moderate sedation with enteral agents – 7 hours	WAC 246-817-760 Moderate sedation with parenteral agents – 14 hours	WAC 246-817-765 Pediatric sedation endorsement – 14 hours	WAC 246-817-770 General anesthesia and deep sedation – 18 hours
Appropriate use of immobilization devices					X
ACLS	X	X	X
Behavioral management						X
General anesthesia						X
Inhalation analgesia						X
Medical emergencies	X	X	X	X	X	X
Nitrous oxide analgesia	X	X	X	X	X
Oral or intravenous sedation				X
Oral sedation	X	X	X
PALS	X	X	X	X		X
Patient evaluation	X	X	X	X	X	X
Patient monitoring	X	X	X	X	X	X
Pediatric behavioral management					X
Pediatric pharmacology					X
Pediatric physiological					X
Pediatric sedation					X
Pharmacology				X		X
Physiology	X	X	X	X		X

(5) Verification of completion of continuing education hours will be due on the dentist's sedation permit renewal date beginning in 2027.

(6) Continuing education in subject categories identified in subsection (4) of this section may be completed using any of the activities or methods authorized in WAC 246-817-440(4).

(7) Proof of continuing education requirements are listed in WAC 246-817-440(5).

AMENDATORY SECTION(Amending WSR 09-04-042, filed 1/30/09, effective 3/2/09)

WAC 246-817-774Permitting((/))and renewal requirements.

(1) To administer moderate sedation (((oral and/or parenteral)))with enteral agents, moderate sedation with parenteral agents, or general anesthesia,((())including deep sedation((), dentist must first)), a licensed dentist shall:

(a) Meet the requirements of this chapter((,));

(b) Possess and maintain a ((current dental))valid dentist license pursuant to chapter 18.32 RCW; and

(c) Obtain a permit of authorization from the DQAC ((through the department of health)). ((Application forms for permits may be obtained online or from the department and must be fully completed and include the current))

(2) A pediatric sedation endorsement is required to administer moderate sedation with enteral agents or moderate sedation with parenteral agents to pediatric patients. A moderate sedation with enteral agents or moderate sedation with parenteral agents permit is required to obtain the pediatric sedation endorsement as described in WAC 246-817-765.

(3) An applicant for a permit or an endorsement as identified in this section shall complete and submit to the department an application as provided by the department and the applicable application fee.

(((2)))(4) A permit of authorization is valid for three years from the date of issuance ((and must be renewed prior to the expiration date)).

(((3) In addition to the renewal application form, the permit holder must))(5) The permit holder shall renew the permit prior to the expiration date by providing to the department:

(a) ((Demonstrate))Written declaration of continuing compliance with this chapter.

(b) ((Submit satisfactory evidence))For a licensed dentist with a moderate sedation with parenteral agents or general anesthesia permit a written declaration of an acceptable on-site inspection by a DQAC approved organization, as described in WAC 246-817-775, within the previous five years.

(i) The permit holder shall maintain on-site inspection documentation for five years.

(ii) The DQAC may randomly audit up to 25 percent of permit holders after the permit is renewed.

((The dentist must maintain records that can be audited and must submit course titles, instructors, dates of attendance, sponsors and number of hours for each course every three years as required by this chapter.

(c) Pay))(i) The permit holder shall maintain continuing education documentation for four years in compliance with WAC 246-12-170 through 246-12-240.

(ii) The DQAC may randomly audit up to 25 percent of permit holders as required in WAC 246-12-190.

(d) Written declaration that a minimum of 12 emergency drill scenarios were performed at least two times per year.

(i) The permit holder shall maintain emergency drill documentation for three years.

(ii) The DQAC may randomly audit up to 25 percent of permit holders after the permit is renewed.

(e) The applicable renewal fee.

(((4) Site visits may be conducted at the DQAC discretion. Site visits will be conducted by an anesthesia provider permitted at the same level, in conjunction with a department of health investigator. Site visits may include the evaluation of equipment, medications, patient records, documentation of training of personnel, and other items as determined necessary.))

NEW SECTION

WAC 246-817-775On-site inspections.

(1) A licensed dentist shall conduct a self-assessment of their office preparedness for emergencies, proper emergency equipment, and emergency drugs annually. The annual self-assessment attestation must be maintained for five years.

(2) A licensed dentist who holds a valid moderate sedation with parenteral agents or general anesthesia permit shall conduct a self-inspection using the appropriate DQAC's on-site inspection form annually. The annual self-inspection form shall be maintained for five years.

(3) A licensed dentist who holds a moderate sedation with parenteral agents or general anesthesia permit must:

(a) Obtain an on-site inspection every five years at the location where moderate sedation with parenteral agents or general anesthesia is provided by an approved organization or by a self-arranged inspection using the DQAC approved on-site inspection form.

(i) The self-arranged on-site inspection must be completed by at least two providers with the same or higher level permit as the licensed dentist being evaluated.

(ii) Volunteer evaluators may be a certified registered nurse anesthetist, licensed physician anesthesiologist, or a licensed dentist who holds an appropriate moderate sedation with parenteral agents or general anesthesia permit for at least five years.

(b) Choose one office to have inspected, if the permit holder provides sedation or anesthesia in more than one office. The permit holder must provide an attestation that all the same standards from the inspection are met in all offices where sedation or anesthesia is provided.

(4) On-site inspections by approved organizations include:

(a) The Washington state society of oral and maxillofacial surgeons;

(b) Accreditation Association for Ambulatory Health Care;

(d) Joint commission;

(e) American Association for Accreditation of Ambulatory Surgery Facilities;

(f) The Centers for Medicare and Medicaid Services; or

(g) Substantially equivalent organizations approved by the DQAC.

(5) On-site inspections for general anesthesia permit holders must begin by the end of the first full permit renewal period after June 30, 2023, or five years after initial permit issuance, whichever is later.

(6) On-site inspection for moderate sedation with parenteral agents permit holders must begin by the end of the first full permit renewal period after June 30, 2024, or five years after initial permit issuance, whichever is later.

(7) A licensed dentist who holds a moderate sedation with parenteral agents or general anesthesia permit shall maintain completed and signed on-site inspection forms for at least five years.

AMENDATORY SECTION(Amending WSR 09-04-042, filed 1/30/09, effective 3/2/09)

WAC 246-817-776Discharge criteria for all levels of sedation((/))or general anesthesia.

The licensed dentist shall ensure an anesthesia provider ((must assess))assesses patient responsiveness using preoperative values as normal guidelines and discharge the patient only when the following criteria are met, except when their prior baseline is below the noted criteria:

(1) Vital signs including blood pressure, pulse rate and respiratory rate are stable((;)). Vital signs are not required when:

(a) A pediatric ASA I or ASA II patient is undergoing a routine dental procedure using either local anesthetic, nitrous oxide, or both with no other sedating medications; or

(b) A pediatric patient is uncooperative or the emotional condition is such that obtaining vital signs is not possible.

(2) The patient is alert and oriented to person, place and time as appropriate to age and preoperative psychological status;

(3) The patient can talk and respond coherently to verbal questioning as appropriate to age and preoperative psychological status;

(4) The patient can sit up unassisted;

(5) The patient can walk with minimal assistance;

(6) The patient does not have uncontrollable nausea or vomiting and has minimal dizziness;

(7) The anesthesia provider has made a discharge entry ((must be made)) in the patient's record ((by the anesthesia provider indicating)). Discharge entries must include:

(a) The patient's condition upon discharge((,)); and

(b) The name of the responsible party to whom the patient is released,((())if a patient is required to be released to a responsible party(()));

(8) If the patient does not meet established discharge criteria, the anesthesia provider must evaluate the patient and determine if the patient has safely recovered to be discharged. The evaluation determining that the patient can be safely discharged must be noted in the patient's record.

AMENDATORY SECTION(Amending WSR 09-04-042, filed 1/30/09, effective 3/2/09)

WAC 246-817-778((Nondental))Nondentist anesthesia providers.

(1) A licensed dentist((, certified registered nurse anesthetist (CRNA) or physician anesthesiologist may provide anesthesia services in dental offices where dentists do not have an anesthesia permit when the anesthesia provider ensures that all equipment, facility, monitoring and assistant training requirements as established within this chapter related to anesthesia have been met. The anesthesia provider is exclusively responsible for the pre, intra, and post operative anesthetic management of the patient.

(2) The dentist without a general anesthesia permit must establish a written contract with the anesthesia provider to guarantee that when anesthesia is provided, all facility, equipment, monitoring and training requirements, for all personnel, as established by DQAC related to anesthesia, have been met.

(a) The dentist and the anesthesia provider may agree upon and arrange for the provision of items such as facility, equipment, monitoring and training requirements to be met by either party, provided the delineation of such responsibilities is written into the contract.

(b) Any contract under this section must state that the anesthesia provider must ensure anesthesia related requirements as set forth in this chapter have been met.))shall have a contract in place when working with a nondentist anesthesia provider. The contract must include:

(a) That all facility, equipment, monitoring, and training requirements, for all personnel required in WAC 246-817-701 through 246-817-790 have been met.

(b) That the anesthesia provider is responsible for the pre, intra, postoperative, and discharge anesthetic management of the patient.

(c) Delineation of responsibilities. The dentist and the anesthesia provider shall agree upon and arrange for the provision of items such as facility, equipment, monitoring, and training requirements to be met by either party. The dentist and the anesthesia provider shall establish written emergency protocols, as required in WAC 246-817-724, and all clinical staff must be trained.

(2) A nondentist anesthesia provider may be a certified registered nurse anesthetist or licensed physician anesthesiologist.

(3) Sedation or general anesthesia must be provided by a competent and qualified certified registered nurse anesthetist, licensed physician anesthesiologist, or a licensed dentist with an appropriate sedation or general anesthesia permit.

(4) A licensed dentist must ensure compliance with WAC 246-817-701 through 246-817-790 whenever sedation or general anesthesia is administered in their dental facility.

(5) A licensed dentist with a moderate sedation, moderate sedation with parenteral agents, or general anesthesia permit must ensure compliance with WAC 246-817-701 through 246-817-790 everywhere they administer sedation or general anesthesia.

AMENDATORY SECTION(Amending WSR 09-04-042, filed 1/30/09, effective 3/2/09)

WAC 246-817-780Mandatory reporting ((of death or significant complication as a result of any dental procedure)).

((All licensees engaged in the practice of dentistry must))A licensed dentist shall submit a report of any patient death or other life-threatening incident or complication, permanent injury or admission to a hospital that results in a stay at the hospital for more than ((twenty-four))24 hours, which is or may be a result of a dental procedure caused by a dentist or dental treatment.

(1) ((The dentist involved must))A licensed dentist shall notify the ((department of health/DQAC))DQAC, by telephone, email, or ((fax))facsimile within ((seventy-two))72 hours of discovery and must submit a complete written report to the DQAC within ((thirty))30 days of the incident.

(2) When a patient comes into an office with an existing condition, and hospital admission is the result of that condition and not the dental procedure, it is not reportable.

(3) The written report must include the following:

(a) Name, age, and address of the patient.

(b) Name of the dentist and other personnel present during the incident.

(d) Description of the type of sedation or anesthetic being utilized at the time of the incident.

(e) Dosages, if any, of drugs administered to the patient.

(f) A narrative description of the incident including approximate times and evolution of symptoms.

(g) Hospital discharge records if available.

(h) Additional information which the DQAC may require or request.

AMENDATORY SECTION(Amending WSR 95-21-041, filed 10/10/95, effective 11/10/95)

WAC 246-817-790Application of chapter 18.130 RCW.

The provisions of the Uniform Disciplinary Act, chapter 18.130 RCW, apply to the permits and endorsements of authorization that may be issued and renewed under this chapter.

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