In August of last year, the Sunset Advisory Commission requested a review by a blue ribbon panel of dental experts into dental anesthesia-related deaths in Texas as part of its review process of the State Board of Dental Examiners.
On January 4, that report was released and is available online in a PDF file from the SBDE website as well as below.
Conclusion and Recommendations (starting page 14)
The reasons patients die or become permanently disabled in connection with dental care are quite varied. In the BRP case reviews, only a minority of deaths appeared directly related to mishandled sedation/anesthesia. Each of the six major events in this review included at least one significant failure on the part of the sedation provider to follow traditionally accepted core concepts of proper sedation/anesthesia technique. Failures included: poor pre-operative evaluation, poor technique, poor monitoring, and poor emergency management. In fact, all six of the major events included at least two major failures.
In the six major events studied by BRP, if current rules had been closely followed and the failures avoided, there likely would have been no sedation related event. Every patient would have been thoroughly evaluated pre-operatively for the planned sedation/anesthetic, drugs would have been conservatively and cautiously administered, and keeping patients closely monitored both electronically and personally by the dentist throughout the procedure. For the minimal and moderate sedation providers, patients would never have become unresponsive. If a truly unpredictable emergency event had occurred, the well-trained and practiced team would have worked together to efficiently manage the situation, including a rapid call to 911 when appropriate.
Unfortunately, these events did occur and they appear related to failures by the sedation/anesthesia provider at a basic level: poor preparation, poor technique and poor performance when an emergency did occur. It is unclear why practitioners allow this to happen. Equally challenging is to know how to remedy the situation.
The challenge to this panel is to consider whether or not reasonable changes to laws, rules or enforcement will motivate dentists to not be lax, but be meticulously attentive to each step in the sedation/anesthesia process and maintain the highest standard of safety. Rules changes should not limit access to care and should create a regulatory structure to foster best practices in sedation/anesthesia.
The BRP discussed many possible recommendations and suggestions that might be helpful, some clinical in nature, some administrative.
- The SBDE should have the authority to conduct inspections of dentists administering sedation/anesthesia. Thirty-six states have some type of sedation/anesthesia office provider inspection. The BRP suggests any inspections emphasize evaluation of the competency of the dentist.
- The SBDE have the authority to review sedation records of level 2, 3 and 4 providers. Determination that the records did not meet the standard of care would be used as an indicator for an on-site office inspection. In the 19 major events/mishaps, there was a strong correlation between poor documentation and poor performance during an office emergency.
- The SBDE mandate that sedation providers have written emergency protocols and that they be required to practice these protocols six times per year. Of the cases where an emergency occurred in the office, 11 of 13 mishaps were managed poorly. Literature clearly supports not only the use of emergency protocols (checklists) but also the use of pre-operative checklists. This should include a mechanism to encourage rapid activation of EMS when an emergency occurs and assure adequate access for EMS services.
- The SBDE mandate that at least one support staff assisting with a sedation procedure (level 2, 3, 4) receive training in the recognition and management of sedation/anesthesia related emergencies. Literature clearly documents that emergency management improves as the entire team is trained as opposed to only the doctor.
- The SBDE require level 2, 3, 4 providers who desire to sedate/anesthetize children under 8 years of age to document specific training in the management of this age group of patients.
- The SBDE require level 2, 3, 4 providers who desire to sedate/anesthetize high risk adults (75 years of age and older, ASA 3 or 4, obese – BMI greater than or equal to 30) to document specific training in the management of this group of patients. Each of the major events in this case series involved a child less than 8 years or a high-risk adult.
- The SBDE mandate that offices where portable providers function have basic ventilation equipment on-site. Two of the six major events involved a portable provider who attempted to manage an emergency without ventilation equipment.
- The SBDE mandate the use of capnography and a precordial stethoscope for level 2, 3 and 4 sedation. Of all the potential recommendations discussed by the BRP, this was the only one that did not garner almost immediate and unanimous support. The recommendation passed but with clear reservation by several members. Valid concerns were raised regarding applicability in level 2 and 3 sedation. Literature support for the use of capnography or a precordial stethoscope in deep sedation is well accepted, but is controversial in moderate sedation. Further consideration and study of the issue is needed by an ongoing committee of the board.
- The SBDE continue to utilize an independent panel of expert sedation/anesthesia providers to advise the Board. This BRP was given only a short period of time to accomplish their assigned task. An ongoing group can continue to discuss and more fully evaluate ideas based on evolving scientific literature that may allow improved patient safety.
- The SBDE make public de-identified sedation related major events and mishaps. If other state dental boards would do the same, a much larger pooi of information would be available with which to draw better conclusions.
- The Texas Legislature make an effort to encourage other state legislatures to share de-identified sedation/anesthesia data publicly. If a majority of states would participate, a much more scientifically valid pool of data would be available for study. This would include both accident data and non-accident data.
- The SBDE collect data regarding sedations performed by Texas dentists. (nonaccident data)
- The SBDE create a system to evaluate and approve sedation/anesthesia continuing education programs.
- The SBDE mandate that the sedation record for a dental procedure be a required part of the dental record, even if the sedation provider is a non-dentist.
- The SBDE consider creation of a required online sedation/anesthesia rules examination.
- The SBDE consider encouraging or mandating that dentists use a preoperative sedation checklist.
- The SBDE consider including more detail in the SBDE rules regarding appropriate pre-operative evaluation and an acceptable sedation/anesthesia record.