We will review this topic of conscious sedation when we review the 'safe' key question which relates to regulation 12 (safe care and treatment); regulation 11 (consent); regulation 18 (staffing) and regulation 15 (premises and equipment).

Sedation services are offered in primary care ‘high street’ dental settings, with community/salaried and hospital dental services providing additional care when required. They may be commissioned within NHS dental services or provided under private contract.

Types of sedation services usually provided in a ‘high street’ dental setting are

• inhalation sedation with nitrous oxide and oxygen
• intravenous sedation – usually administering a titrated dose of a single drug

Standards for Conscious Sedation in the Provision of Dental Care

In April 2015, the dental faculties of the Royal Colleges of Surgeons and the Royal College of Anaesthetists published:

• Standards for Conscious Sedation in the Provision of Dental Care

This created a national standard for conscious sedation in dentistry applying to all who practise conscious sedation techniques, whether they are dentists, doctors, nurses or dental care professionals. It replaces the previous documents:

• Conscious Sedation in the Provision of Dental Care (2003) Department of Health
• Standards for Conscious Sedation in Dentistry (2007) Department of Health
• Conscious Sedation in Dentistry (2012) Scottish Dental Clinical Effectiveness Programme (SDCEP).

The UK’s Chief Dental Officers have asked the Scottish Dental Clinical Effectiveness Programme (SDCEP) to apply their rigorous methodology to the guidance and consider how best it might be taken forward. This will take particular account of risks to patients, the practicalities of implementation, and potential impact on current services and training.

Many providers are providing care in accordance with these new guidelines or are working towards achieving them. However, until this process is complete our inspectors will use the pre-April 2015 SAAD check list criteria pertinent to a primary care dental setting to assess if providers are providing safe and effective care.

Mandatory requirements

To meet the basic requirements set out in:

• Conscious Sedation in the Provision of Dental Care (2003)

‘High street’ dental practices providing advanced techniques beyond those in these 2003 requirements need to meet the requirements set out in:

• Standards for Conscious Sedation in Dentistry: Alternative Techniques (2007).

Inspectors use the criteria in the Society for the Advancement of Anaesthesia in Dentistry (SAAD) April 2015 checklist pertinent to a primary dental care setting well as the normal key lines of enquiry to assess safe, responsive, caring, effective and well led care. The SAAD checklist includes:

• General - the type of sedation provided and to what group of patients.
• Facilities - ease of access for emergencies services, recovery area and functionality of the dental chair.
• Sedation practice and procedure - sedation protocol in place, patient assessment, discharge protocols, emergency contact details and ‘titrating to response’ approach.
• Documentation - pre and post-operative patient instructions, patient assessment, contemporaneous record of sedation procedure and consent process.
• Practices providing inhalation sedation (RA)-dedicated RA machine which is adequately serviced, maintained and checked and active scavenging system in place where appropriate.
• Other equipment - pulse oximeter, blood pressure monitoring machine, supplemental oxygen and emergency medicines in line with BNF guidelines and emergency equipment in line with Resuscitation Council UK recommendations.
• Sedative agents - standard operating procedures for sedative agents and reversal agents including labelled syringes, stock control, storage and disposal.
• Staffing - competency, maintaining competency, staffing ratios and emergency training.

Recommended practice

Professional guidelines:

• Standards for Conscious Sedation in the Provision of Dental Care
• Society for the Advancement of Anaesthesia (SAAD) checklist (2015)

Options for care

Practices should adopt a pathway approach in accordance with the guidelines.

Preparation for sedation

​Consent

• Patients, those with parental responsibility and carers need information provided in a way that can be understood before the process of valid consent can be completed.
• Patients who are already sedated cannot be regarded as competent to take valid decisions regarding consent for treatment; consent attempted under these circumstances is not valid.
• Consent obtained on the day of treatment is not appropriate except when immediate treatment is in the best interests of the patient.
• Consent obtained prior to the day of treatment must also be re-confirmed on the actual day of treatment.

Patient Information

• Appropriate written information for patients, those with parental responsibility, carers and escorts must be supplied:
  • use in conjunction with the clinical pre-operative assessment and face-to-face discussions and explanation.
  • include the range of techniques appropriate for both the relief of anxiety and the behaviour management appropriate for the dental treatment needs of the individual.
  • conform to the local health provider’s patient information policy.
• Give verbal and written advice on eating and drinking prior to the appointment for treatment under any form of conscious sedation and record this in the patient’s clinical records.

Clinical environment for sedation

• Use the correct equipment and facilities for the type of care required which conform to accepted standards for health and safety. All appropriate equipment must be available in working order when sedation is being provided and during recovery.
• Maintain equipment in accordance with the manufacturers schedule.
• Retain records of equipment maintenance which are available for formal inspections.

Staff training

Staff involved in sedation should be suitably trained and maintaining their competency in accordance with the guidelines. A practitioner must undergo a minimum of 12 hours of continuing professional development every 5 years that are relevant to the sedation techniques practised. This applies to dentists, medical practitioners, recovery nurses, dental care professionals and all members of the team providing conscious sedation.

Techniques - essential principles of safe sedation practice

Monitoring:

• Include the depth of sedation, patient comfort, clinical, electronic and mechanical monitoring appropriate to the technique and the medical status of the patient.
• A written contemporaneous record of the monitoring of the patient in accordance with the clinical sedation technique used.
• Clinical and instrumental monitoring relevant to the patient’s medical status and the clinical setting (see SAAD checklist); for inhalation sedation with nitrous oxide, clinical monitoring will usually suffice.
• For all other techniques, monitoring should include pulse oximetry as well as non-invasive blood pressure monitoring pre-operatively, at appropriate intervals during the procedure and post-operatively as a minimum.
• All members of the clinical team must be capable of monitoring the condition of the patient.

Complications:

Conscious sedation delivered appropriately by trained, competent individuals in a suitable environment can deliver benefits for patients. However, there can be risks, of which the patient should be made aware, and complications that the clinical team needs to manage:

• The sedationist (a dentist, doctor or dental hygienist and therapist) must be able to manage any complication arising from the sedation itself and from medical emergencies.
• The dentist, dental hygienist and therapist, sedationist and dental nurse must be competent in life support.
• There must be evidence of regular scenario-based team training in the management of potential complications associated with conscious sedation
• The provider of dental care and the provider of the sedation service must be able to maintain life support for a patient until emergency services are able to attend.
• Inspectors will assess emergency medicines and equipment in accordance with current BNF and Resuscitation Council UK recommendations.

Discharge:

• A suitable third party is required to take responsibility for the patient at the time of discharge is essential for sedation using anything other than inhalation sedation with nitrous oxide/oxygen in adults. Children under 16 years of age require an escort for inhalation sedation.
• Recovery from sedation remains the responsibility of the care team until the patient can be discharged into the care of the responsible adult escort.
• During recovery, the patient must be supervised; a trained member of the dental team must be responsible for the patient and monitor the individual throughout this period.
• The decision to discharge the patient is the responsibility of the sedationist, with each patient being assessed on an individual basis.
• Verbal and written instructions for the post-operative period must be provided for both the patient and the responsible adult escort.

Clinical governance and audit

The guidelines:

• State that records of the audit process and outcomes must be maintained and be available for inspection.
• Recommend using a national system for recording adverse clinical incidents by all dentists, doctors and healthcare professionals who provide or directly support sedation for the delivery of dental care (NHS and independent services), eg:
  • critical incidents that should be reported and investigated locally
  • ‘never events’ (Midazolam over-sedation and failure to monitor oxygen saturation during sedation (other than during inhalation sedation with nitrous oxide/oxygen).