
•	The date in WAC 246-817-765(1) was changed from "January 1, 2024" to "January 1, 2025."
•	The word "and" was added to WAC 246-817-765 (3)(c)(ii)(B)(V).
•	The word "or" was removed from WAC 246-817-740 (1)(a) and (1)(b).

(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, 2025, 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; and

(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.