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Policy for Selecting Anesthesia Providers for the Delivery of Office-based Deep Sedation/General Anesthesia

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that it is the exclusive responsibility of dental practitioners, when employing anesthesia providers to administer office-based deep sedation/general anesthesia, to verify and carefully review the credentials and experience of those providers.1  An understanding of the educational and training requirements of the various anesthesia professions and candid discussions with potential anesthesia providers can assist in the vetting and selection of highly skilled licensed providers in order to help minimize risk to patients.

Methods

This policy is based on a review of current dental and medical literature pertaining to the education and training accreditation requirements of potential anesthesia providers.

Background

Historically, care necessitating deep sedation/general anesthesia was provided in a surgical center or hospital-based setting by an anesthesiologist selected and vetted by the facility or institution. The dental surgeon had little, if any, choice as to who would provide these services. Current trends find an increasing number of dental providers electing to complete such care in the confines of their office using the services of an anesthesia provider.2  Over the last decade, office-based deep sedation/ general anesthesia in the dental office has proven to be safe and effective when delivered by a highly competent and attentive individual.3  Substantial societal cost savings associated with the delivery of care outside of a surgical center or hospital setting have been well documented.4

With the use of office-based deep sedation/general anesthesia, the primary dental provider takes on the significant responsibility of creating a team of highly qualified professionals to deliver care in an optimal and safe fashion. Deep sedation/ general anesthesia techniques in the dental office require at least three individuals:

  • independently practicing and currently licensed anesthesia provider.
  • operating dentist.
  • support personnel.1

No other responsibility is more important than identifying an anesthesia provider who is highly competent. Significant pediatric training, including anesthesia care of the very young, and experience in a dental setting are important considerations, especially when caring for young pediatric and special needs populations. Advanced training in recognition and management of pediatric emergencies is critical in providing safe sedation and anesthetic care.1  Close collaboration between the dentist and the anesthesia providers can provide access to care, establish an enhanced level of patient cooperation, improve surgical quality, and offer an elevated level of patient safety during the delivery of dental care.

Federal, state, and local credentialing and licensure laws, regulations, and codes dictate who legally can provide officebased anesthesia services. Practitioners choosing to use these modalities must be familiar with the regulatory and professional requirements needed to provide this level of pharmacologic behavior management.1  The operating dentist must confirm any potential anesthesia provider’s compliance with all licensure and regulatory requirements. Additional considerations in anesthesia provider selection may include proof of liability insurance and recommendations from professional colleagues. Lastly, dentists must recognize potential liability issues associated with the delivery of deep sedation/general anesthesia within their office.

It is important to acknowledge that not all anesthesia providers have equal training and experience delivering care during procedures performed within and around the oral cavity, especially in the pediatric or special healthcare needs patient populations or on a mobile basis. The following table summarizes the educational requirements of various anesthesia professions.

Because of the diversity in anesthesia education among potential providers, operating dentists should further investigate an individual’s training and experience. A candid discussion with a potential anesthesia provider to establish the individual’s comfort and experience with unique patient populations (e.g., patients with development disabilities or medical comorbidities, infants and toddlers) is extremely important, especially if it is anticipated that this will represent a large portion of a dental practice’s deep sedation/general anesthesia focus. Selection of a skilled and knowledgeable anesthesia provider is paramount in providing patients with the safest and most effective care possible.

Policy statement

The AAPD encourages dental practitioners, when employing anesthesia providers to administer office-based deep sedation/ general anesthesia, to verify and carefully review the credentials and experience of those providers. In addition to the credentialing process, the AAPD encourages dentists to engage a potential anesthesia provider in a candid discussion to determine expectations, practices, and protocols to minimize risk for patients.

Sample questions to assist in this conversation appear below. Sample questions to ask a potential office-based anesthesia provider*

  1.   What is your experience with pediatric patient populations? …special healthcare needs populations? 
  2.   What is your background/experience in providing office-based deep sedation/general anesthesia care? … and specifically for pediatric dental patients?
  3.   How do you evaluate a dental facility and staff prior to initiating anesthesia services? What expectations and requirements do you have for the dentist, auxiliary staff and facility?
  4.   What equipment do you use to administer and montor deep sedation/general anesthesia in the office, and what is your maintenance protocol for this equipment?
  5.   What equipment and/or medications should be maintained by the dental facility?
  6.   What are some potential emergencies associated with the delivery of deep sedation/general anesthesia in the pediatric dental office, noting any that may be unique to these clinical
      circumstances?
  7.   What is your training/experience in recognition and management of pediatric anesthetic emergencies? 
  8.   In the event of a medical emergency, what is your plan of action? What are the roles of the dentist and auxiliary staff during a medical emergency?
  9.   Do you have an affiliation with any area hospitals in case a patient requires transfer?
  10.   What patient selection criteria (e.g., age, weight, comorbidities) do you use to identify potential candidates for office-based deep sedation/general anesthesia?
  11.   When a decision has been made that a patient is a candidate for office-based sedation/general anesthesia, what is the office’s role in preparing a patient for office-based deep sedation/general
      anesthesia? How and when do you prepare the patient for the procedure?
  12.   What is your protocol for monitoring a patient post-operatively?
  13.   What are your discharge criteria and your follow-up protocols for patients who receive office-based deep sedation/general anesthesia?
  14.   Would you describe a typical general anesthesia case from start to finish? 
  15.   What is your protocol for ordering, storing, and recording controlled substances for deep sedation/ general anesthesia cases?
  16.   What are the patient fees associated with office-based deep sedation/general anesthesia services?
  17.   How and where are patients records related to the office-based administration of and recovery from deep sedation/general anesthesia stored?

* The information included in the preceding sample questions, developed by the AAPD, is provided as a tool for pediatric dentists and other dentists treating children. It was developed by experts in pediatric dentistry and is offered to facilitate excellence in practice. However, these samples do not establish a standard of care. In issuing this information, the AAPD is not engaged in rendering legal or other professional advice. If such services are required, competent legal or other professional counsel should be sought.

References

  1. American Academy of Pediatric Dentistry. Use of anesthesia providers in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent 2018;40(6):317-20.
  2. Saxen MA, Urman RD, Yepes JF, Gabriel RA, Jones JE. Comparison of anesthesia for dental/oral surgery by office-based dentist anesthesiologists versus operating room-based physician anesthesiologists. Anesth Prog 2018;64(4):212-20.
  3. Spera AL, Saxen MA, Yepes JF, Jones JE, Sanders BJ. Office-based anesthesia: safety and outcomes in pediatric dental patients. Anesth Prog 2017;64(3):144-52.
  4. Rashewsky S, Parameswaran A, Sloane C, et al. Time and cost analysis: Pediatric dental rehabilitation with general anesthesia in the office and the hospital settings. Anesth Prog 2012;59(4):147-58.
  5. Commission on Accreditation of Allied Health Education Programs. Standards and Guidelines for the Accreditation of Educational Programs for the Anesthesiologist Assistant, Revised 2016. Available at: “https://www.caahep.org/CAAHEP/media/CAAHEP-Documents/StandardsAnesthesiologistAssistant.pdf ”. Accessed February 14, 2018. (Archived by WebCite® at: “http://www.webcitation.org/722mS5XuN”)
  6. Council on Accreditation of Nurse Anesthesia Educational Programs. Standards for Accreditation of Nurse Anesthesia Educational Programs, Revised January, 2018. Available at: “http://home.coa.us.com/accreditation/Documents/2004%20Standards%20for%20Accreditation%20of%20Nurse%20Anesthesia%20Educational%20Programs,
    %20revised%20January%202018.pdf”. Accessed February 14, 2018. (Archived by WebCite® at: “http://www.webcitation.org/722mNYvtX”)
  7. Commission on Dental Accreditation. Accreditation Standards for Advanced General Dentistry Education in Dental Anesthesiology, 2017. Available at: “https://www.ada.org/~/media/CODA/Files/2018_Dental_Anesthesiology_Standards.pdf?la=en”. Accessed February 14, 2018. (Archived by WebCite® at: “http://www.webcitation.org/722mCtzH0”)
  8. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Education in Anesthesiology, July 1, 2017. Available at: “https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/110_emergency_medicine_2017-07-01.pdf”. Accessed February 14, 2018. (Archived by WebCite® at: “http://www.webcitation.org/722m1xDAm”)
  9. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pediatric Anesthesiology. July 1, 2017. Available at: “https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/042_pediatric_anesthesiology_2017-07-01.pdf?ver=2017-06-28-085120-903”. Accessed June 13, 2018. (Archived by WebCite® at: “http://www.webcitation.org/722lp4RSQ”)
  10. American Board of Anesthesiology. Pediatric anesthesiology registration eligibility. Available at: “http://www.theaba.org/Exams/Pediatric-Anesthesiology/Registration-Eligibility”. Accessed June 13, 2018. (Archived by Web Cite® at: “http://www.webcitation.org/722lew6YX”)
  11. Commission on Dental Accreditation. Accreditation Standards for Advanced Specialty Educational Programs in Oral and Maxillofacial Surgery, 2017. Available at: “https://www.ada.org/~/media/CODA/Files/oms.pdf?la=en”. Accessed February 14, 2018. (Archived by Web Cite® at: “http://www.webcitation.org/722lTtH4K”)