Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board
Clinical On-site Inspection Only
CLINICAL ON-SITE INSPECTION INSTRUCTIONS FOR THOSE DENTISTS THAT CONTRACT WITH AN ANESTHESIA PROVIDER THAT IS NOT SUBJECT TO THE RULES AND REGULATIONS OF THE COLORADO DENTAL BOARD LICENSEE(S): If you contract with a Colorado-licensed physician or certified registered nurse anesthetist (CRNA) to administer moderate sedation, deep sedation, and/or general anesthesia in your dental office (anesthesia provider), then prior to such administration taking place, you are required to complete a clinical on-site inspection. You must then submit an updated clinical on-site inspection every 5 years to continue having moderate sedation, deep sedation, and/or general anesthesia administered in your dental office by a non-licensed dentist authorized to do so (anesthesia provider). Provide these instructions, the attached Inspector Report Form, and a current copy of Board Rule XIV (available at www.colorado.gov/dora/Dental_Board) to the authorized person performing the clinical on-site anesthesia inspection (Inspector). Pursuant to Board Rule XIV(L)(9), the Inspector must be a Board-approved Colorado licensed: -
Physician or certified registered nurse anesthetist (CRNA) trained in dental outpatient deep sedation/general anesthesia and moderate sedation, or Dentist issued a Deep Sedation/General Anesthesia Permit.
The Inspector must also have actively and consistently administered general anesthesia and/or deep sedation for the last three years in the state of Colorado. INSPECTOR: Pursuant to Board Rule XIV(L)(10), you shall not have an unethical agreement or conflict of interest with any dentist(s) at this dental office. This means that you cannot have a vested interest in the outcome of the inspection and must be able to maintain complete impartiality throughout the process. Further, the dentist(s) and the anesthesia provider contracted by the dental office must be actively licensed in Colorado. PURPOSE: To allow an independent Inspector (who is not the anesthesia provider) to review the facility, office equipment, and emergency medications available to ensure they are in compliance with sections M, N, O, and P of Rule XIV, as applicable given the levels of anesthesia to be administered by the anesthesia provider at this dental office; and to do so with the dentist(s) and the anesthesia provider contracted by the dental practice with the goal of facilitating communications between the non-anesthetizing dentist(s) and dental staff in case of an anesthesia emergency. The dentist(s) should cover roles and responsibilities during an anesthesia emergency with every anesthesia provider contracted to provide anesthesia in the dental practice and applicable staff even though the inspection itself is only required to occur once every 5 years and involve only one contracted anesthesia provider. PAYMENT: Pursuant to Board Rule XIV(L)(7), the Inspector may charge the dental practice a reasonable fee up to $500, plus actual travel expenses for lodging, meals, and mileage for each clinical on-site inspection performed. The dental practice is responsible for paying all fees associated with the inspection. MULTIPLE LOCATIONS: Only one dental office is required to be part of the clinical on-site inspection. A separate clinical on-site inspection is not required if the anesthesia provider administers moderate sedation, deep sedation, and/or general anesthesia at more than one practice location. However, it is the responsibility of the licensed dentist(s) at each practice location to ensure that each dental office where moderate sedation, deep sedation, and/or general anesthesia is administered by a non-licensed dentist operating as an anesthesia provider meets the requirements of Rule XIV to ensure patient safety.
Applicant: Keep this page for your records.
06/2017
Clinical On-site Inspection Only
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board INSPECTOR CHECKLIST Review Rule XIV prior to conducting the clinical on-site anesthesia inspection.
Conduct the inspection of the dental office in compliance with Board Rule XIV. The inspection shall consist of the following three parts: PART I
Review of the office equipment, records, and emergency medications required in sections M, N, O, and P of Rule XIV, as applicable given the levels of anesthesia to be administered by the anesthesia provider at this dental practice.
PART II
Simulated Emergencies. The dentist(s), anesthesia provider, and dental team must be able to demonstrate their expertise in adequately managing a minimum of eight (8) emergencies.
PART III
Discussion Period. Make sure to facilitate communications between the non-anesthetizing dentist(s) and the dental staff in case of an anesthetic emergency.
Offer suggestions to the dentist(s) regarding improvements if you feel they are warranted. Report any concerns you have regarding the ability of this dental office to respond to an anesthetic emergency to the Board office immediately. Return the completed Inspector Report Form directly to the Board at the address at the top of this page. Please provide a copy to the dental office as well. If you have questions or concerns regarding this inspection process, contact the Colorado Dental Board at
[email protected].
Applicant: Keep this page for your records.
06/2017
Clinical On-site Inspection Only
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board
INSPECTOR REPORT FORM Reason for clinical on-site inspection (check all that apply): Administration of Moderate Sedation Administration of Deep Sedation/General Anesthesia
DENTIST RESPONSIBLE FOR ANESTHESIA PROVIDER Colorado License Number:
Expiration Date: First
Name: Last:
Middle:
Suffix:
E-mail Address: (This will be the primary communication method) PO Box, Street:
Mailing Address: This is a
Home
Business
Daytime Telephone Number: (
City, State, Zip:
)
Area of Practice:
Date of Inspection:
ANESTHESIA PROVIDER Colorado License Number:
Expiration Date: First
Name: Last:
Middle:
Suffix:
E-mail Address: (This will be the primary communication method) PO Box, Street:
Mailing Address: This is a
Home
Business
Daytime Telephone Number: (
Clinical On-site Inspection Only
City, State, Zip:
)
Area of Practice:
06/2017
Clinical On-site Inspection Only
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board
INSPECTOR First
Name: Last:
Middle:
Suffix:
E-mail Address: (This will be the primary communication method) PO Box, Street:
Mailing Address: This is a
Home
Business
Daytime Telephone Number: (
City, State, Zip:
)
I have confirmed that the anesthesia provider and the dentist(s) are actively licensed in Colorado.
I have confirmed that the anesthesia provider is authorized to administer moderate sedation, deep sedation, and/or general anesthesia. I swear or affirm that I am a Board-approved Colorado-licensed (check one):
Colorado License Number:
Physician trained in dental outpatient deep sedation/general anesthesia and moderate sedation Certified Registered Nurse Anesthetist (CRNA) trained in dental outpatient deep sedation/general anesthesia and moderate sedation
Expiration Date:
Dentist with an active Deep Sedation/General Sedation Permit Signature
Clinical On-site Inspection Only
Date:
06/2017
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board
Clinical On-site Inspection Only
PART I – REVIEW OF OFFICE EQUIPMENT, RECORDS, AND EMERGENCY MEDICATIONS (See Sections M, N, O, P, and Q of Rule XIV)
1. OFFICE FACILITIES AND EQUIPMENT (REQUIRED). The following office facilities and equipment must be present and functional: a. Emergency equipment and facilities, including: i. An appropriate size bag-valve-mask apparatus or equivalent with an oxygen hook-up; ii. Oral and nasopharyngeal airways; iii. Appropriate emergency medications; and iv. An external defibrillator – manual or automatic. b. Equipment to monitor vital signs and oxygenation/ventilation, including: i. A continuous pulse oximeter; and ii. A blood pressure cuff of appropriate size and stethoscope, or equivalent blood pressure monitoring devices. c.
Oxygen, suction, and a pulse oximeter must be immediately available during the recovery period.
d. Back-up suction equipment. e. Back-up lighting system. f.
Parenteral access or the ability to gain parenteral access, if clinically indicated.
g. Electrocardiograph (required for deep sedation and/or general anesthesia, but only if clinically indicated for moderate sedation). h. End-tidal carbon dioxide monitor (capnography). i.
Additional emergency equipment and facilities required if administering deep sedation and/or general anesthesia, including: i. Endotracheal tubes suitable for patients being treated; ii. A laryngoscope with reserve batteries and bulbs; iii. Endotracheal tube forceps (i.e. magill); and iv. At least one (1) additional airway device.
2. ANESTHESIA GAS DELIVERY SYSTEMS (REQUIRED): If present, must include the following: a. Capability to deliver oxygen to a patient under positive pressure, including a back-up oxygen system; b. Gas outlets that meet generally accepted safety standards preventing accidental administration of inappropriate gases or gas mixture; c.
Fail-safe mechanisms for inhalation of nitrous oxide analgesia;
d. The inhalation equipment must have an appropriate scavenging system if inhalation anesthetics are used; and e. Gas storage facilities, which meet generally accepted safety standards.
Clinical On-site Inspection Only
06/2017
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board
Clinical On-site Inspection Only
3. DOCUMENTATION (REQUIRED): Documentation of the administration of sedation/anesthesia shall include, but not be limited to the following: a. Medical History – current and comprehensive, to include current medications; b. Informed Consent – for the administration of anesthesia; c.
Anesthesia Record, which includes: i. Height and Weight of the patient to allow for the calculation of Body Mass Index (BMI) and dosage of emergency medications; ii. American Society of Anesthesiology (ASA) Classification; iii. NPO status; iv. Dental Procedure(s); v. Time anesthesia commenced and ended; vi. Parenteral access site and method, if utilized; vii. Medication(s) administered – medication (including oxygen), dosage, route, and time given; viii. Vital signs before and after anesthesia is utilized, to include heart rate, blood pressure, respiratory rate and oxygen saturation for all patients, and to include temperature for pediatric patients; ix. Intravenous fluids, if utilized (type and amount); x. Response to anesthesia, including any complications; and xi. Condition of patient at discharge. d. Airway Assessment (day of procedure for pediatric patients); and e. Anesthesia Record, which includes at least every: i. 5 minutes – oxygen saturation (SpO2), blood pressure, and heart rate. ii. 15 minutes – respiratory rate. iii. 15 minutes – End-tidal carbon dioxide (capnography). iv. 15 minutes – electrocardiograph (ECG) rhythm for the administration of deep sedation/general anesthesia (if clinically indicated by patient history, medical condition(s), or age for the administration of moderate sedation). v. 15 minutes – ventilatory status (spontaneous, assisted, controlled) for the administration of general anesthesia to a patient with an advanced airway in place (e.g. endotracheal tube or laryngeal mask airway). vi. 15 minutes – temperature for the administration of volatile anesthesia gases or medications which are known triggers of Malignant Hyperthermia (MH); otherwise the ability to measure temperature should be readily available. 4. PATIENT MONITORING (REQUIRED). Shall include, but is not limited to, the following for the administration of sedation/anesthesia: a. Continuous heart rate, respiratory status, and oxygen saturation; b. Continuous ventilatory status (spontaneous, assisted, controlled) for the administration of general anesthesia to a patient with an advanced airway in place (e.g. endotracheal tube or laryngeal mask airway); c.
Intermittent blood pressure every 5 minutes or more frequently;
d. Continuous electrocardiograph(required for deep sedation and/or general anesthesia, but only if clinically indicated by patient history, medical condition(s), or age for the administration of moderate sedation); e. Continuous temperature for the administration of volatile anesthesia gases or medications which are known triggers of Malignant Hyperthermia (MH); otherwise the ability to measure temperature should be readily available; f.
End-tidal carbon dioxide monitoring (capnography); and
g. Level of anesthesia on the continuum.
Clinical On-site Inspection Only
06/2017
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board
Clinical On-site Inspection Only
When the level of cooperation in the pediatric or special needs patient does not reasonably allow for full compliance with some monitoring requirements, the treating dentist shall use professional judgment and shall document available monitoring parameters to the best of his/her ability. 5. MISCELLANEOUS (REQUIRED). Do all dental personnel assisting in the utilization, administration, or monitoring of moderate sedation, deep sedation, and/or general anesthesia possess current certification of Basic Life Support (BLS) training for YES NO health care providers?
PART II – SIMULATED EMERGENCIES The type of emergencies selected should be based on the emergencies likely to be seen in the type of practice in which the dentist(s), anesthesia provider, and dental team are engaged in the administration of moderate sedation, deep sedation, and/or general anesthesia and should establish who is handling what and when. List all simulated emergencies the dentist(s), Anesthesia provider, and dental team demonstrated adequately managing (minimum of 8 required).
1. _______________________________________________________________________________ 2. _______________________________________________________________________________ 3. _______________________________________________________________________________ 4. _______________________________________________________________________________ 5. _______________________________________________________________________________ 6. _______________________________________________________________________________ 7. _______________________________________________________________________________ 8. _______________________________________________________________________________ 9. _______________________________________________________________________________ 10. _______________________________________________________________________________ 11. _______________________________________________________________________________ 12. _______________________________________________________________________________ 13. _______________________________________________________________________________ 14. _______________________________________________________________________________ 15. _______________________________________________________________________________ 16. _______________________________________________________________________________
Clinical On-site Inspection Only
06/2017
Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7764 www.colorado.gov/dora/Dental_Board
Clinical On-site Inspection Only
PART III – DISCUSSION PERIOD Comments or suggestions to improve: ______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
I state under penalty of perjury in the second degree, as defined in section 18-8-503, C.R.S., that the information contained in this report is true and correct to the best of my knowledge. In accordance with section 18-8501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute a violation of the Dental Practice Act.
______________________________________________________________________ Signature of Inspector
_______________________ Date
Upon completion of the inspection, return the Inspector Report Form to the Board at the following address: Division of Professions and Occupations Colorado Dental Board 1560 Broadway, Suite 1350 Denver, CO 80202 NOTE: The most current version of the Board’s Statutes, Rules and Policies is available online at: www.colorado.gov/dora/Dental_Board.
OFFICE USE ONLY: Approved: ____________________________________ Not Approved: ___________________________________ Clinical On-site Inspection Only
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