Intercollegiate advisory committee for sedation in dentistry: review of the guidelines published in april 2015

Background

The publication of A Conscious Decision: A Review of the Use of General Anaesthesia and Conscious Sedation in Primary Dental Care in 2000 resulted in the cessation of general anaesthesia for dentistry in the primary care setting.1 Up to this date, there had been an increased emphasis on the safe provision of conscious sedation for management of pain and anxiety in child and adult patients and this continued following the removal of general anaesthesia in primary care.

Several guidelines since 2001 have sought to provide advice and set standards for the provision of conscious sedation to children and young people and adults by general dental practitioners, community dentists and those in the hospital setting.

The Department of Health sponsored an independent working party of the Standing Dental Advisory Committee (SDAC) to develop guidelines which were published in 2003.2 These guidelines were endorsed by the General Dental Council (GDC) and dental professionals were expected to follow them. The SDAC report was considered as professional regulation in combination with the GDC's own Standards guidance of 2005, which has since been updated.3 The publication of the Scottish Dental Clinical Effectiveness Programme's Conscious Sedation in Dentistry (2006 updated 2012) and Standards for Conscious Sedation in Dentistry: Alternative Techniques (2007) extended the SDAC guidance.4^,5

The SDAC expanded, with several organizations joining it including the Department of Health. SDAC was renamed the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) in 2010 with the aim of updating the original guidelines of 2003 and the 2007 SCSD guidelines on ‘Alternative Techniques’.

Following reconfiguration in 2011, the committee comprised wide-ranging representation. This included all four Dental Faculties of the Royal Colleges, the Royal College of Anaesthetists, the Faculty of General Dental Practice, the Defence Organizations and the Specialist Advisory Committee for Special Care Dentistry. Additionally, the specialist sedation organizations: SAAD, Dental Sedation Teachers Group, National Examining Board for Dental Nurses, Health Education England, British Society of Paediatric Dentistry, Joint Committee for Postgraduate Training and a patient representative of the Joint Dental Faculties were all part of the committee, with observers from the Department of Health and the Ireland Royal College and correspondence with the General Dental Council.

The IACSD guidance on publication in April 2015 now replaces all other dental guidance to date and should be used in conjunction with the guidance produced by The Academy of Medical Royal College's Safe Sedation Practice for Healthcare Procedures (2013) and the National Institute for Health and Care Excellence (NICE) publication Sedation in Children and Young People (2010).6^,7 These latter publications advise standards for conscious sedation across many different medical procedures and disciplines and, although applicable in part to dentistry, the IACSD guidance differs as it applies only to dentistry.

IACSD has divided the standards document into several sections and appendices in order to provide a body of required standards and detailed supporting information.

The document provides standards for options for care, preparation for sedation, environment, team requirements, techniques and perioperative care. Requirements for audit, clinical governance and education and training are described.

A short summary of the guidance cannot adequately cover the detailed work put into the production of the guidance and readers who are involved with dental sedation are encouraged to read the full guidance carefully.8 However, this article will highlight some of the main aspects.

Options for care

The guideline describes conscious sedation as a part of the overall behaviour management strategy for adults and children that practitioners will need to be aware of in planning care for their patients. The guideline emphasizes the importance of having access to a range of supportive approaches to enable successful behaviour management and dental treatment outcomes.

The development of a care pathway is to encourage best practice. A specific care pathway for paediatric patients from primary care into a secondary care environment (p24 of the guideline) is described taking into account all behaviour management modalities, the skills of the team in dentally assessing and managing paediatric patients and the care environment.8

Inhalation sedation is suitable as a sedation technique that the general dental practitioner, or therapist with the relevant training, can give for all ages in primary care, including all children under 16 years. Sedation using midazolam is suitable for 12 to 16 year-olds in the primary care environment if the practitioner has suitable training, support and premises, as described elsewhere within the IACSD guideline.

Specifically below 12 years, those children who cannot be managed for dental care with non-pharmacological behaviour management (for example distraction, modelling) and local anaesthesia or local anaesthesia and inhalation sedation in primary care with their general dental practitioner or therapist, referral is required.

The team accepting the referral will have skills equivalent to those expected of a specialist or consultant in paediatric dentistry, where assessment of dental diagnosis and treatment need can take into account the range of behaviour management strategies available and most appropriate for the age of the patient, the complexity of the treatment, and arrange care accordingly. For advanced sedation techniques or general anaesthesia, the services would be in conjunction with a team having skills equivalent to those expected of a consultant in anaesthesia competent in sedation for dentistry in an environment equivalent to an NHS Acute Trust.

For inhalation sedation for all ages, or sedation with midazolam for 12–16 year-olds for children whose dental needs require specialist referral, this may be in a primary or secondary environment, such as the community dental services or a specialist hospital.

Preparation for sedation, information, consent, fasting

The guideline reviews the consent process, reinforcing that consent should not be taken on the day of procedure except when immediate treatment is in the patient's best interests, and that patient information in written form should be available for patients and carers and in age appropriate form where applicable. A full assessment, usually on a separate visit, should be employed to assess the dental need, medical history, determine the appropriate treatment plan and allow consent and information to be given to the patient/carer for consideration and reflection.

To encourage conformity, the guideline includes examples of patient information that meet the requirements of the Plain English Campaign and NHS information9 and practitioners may use these examples in their entirety, adding their own specific details, such as emergency telephone numbers. The full range of patient information documents for all aspects of sedation for adults and children are in Appendix 3 (p88 of the guideline).

Fasting is not required for conscious sedation techniques where verbal contact is maintained with the patient, but must be employed for more complex techniques where verbal contact may be lost. Advice for eating and drinking must be given verbally and in written form at the assessment visit.

For techniques other than inhalation sedation in adults, a suitable adult escort is required. The information available at assessment must include written advice to the escort on their responsibilities.

Recovery and discharge

Recovery of the patient remains the responsibility of the care team until the patient is fit for discharge. The care team require access to and training in the use of equipment and drugs to support recovery. For all techniques, this is immediate life support training (or paediatric immediate life support).

Following the sedation treatment episode, formal discharge from the clinical area must take place. This must conform to required criteria assessing the patient for orientation, normal vital signs and ensuring post-operative advice is given verbally and in writing (p19 of the guideline).8

Sedation techniques

The guideline provides a detailed analysis of the different sedation techniques available and describes the level of education and training expected, quantifying the number of supervised clinical cases required for those training in the technique, necessary life support skills, minimal monitoring, nature of the team and setting (p26 of the guideline).8

For example, for inhalation sedation which is suitable for use in primary care for all ages, training must log ten supervised clinical cases and the team must have immediate life support (ILS) or paediatric immediate life support (PILS) skills and employ clinical monitoring. For intravenous midazolam which is suitable for primary care for adults and young people between 12 and 16 years; 20 supervised clinical cases; ILS/PILS skills; non-invasive blood pressure monitoring and pulse oximetry are required.

For a more complex technique, such as an opioid followed by midazolam for adults, this is suitable for a primary or secondary care setting with an operator/sedationist; for paediatrics this must be a secondary care environment (facilities equivalent to an NHS Acute trust) and a separate sedationist. Twenty supervised clinical cases are required in addition to theoretical training, ILS/PILS and monitoring may additionally require capnography for certain groups of patients (p28 of the guideline).8

The full table describes a range of techniques and the reader is to note the comments in the form of notes attached.8

Environment

The guideline expects that the physical environment for sedation will be subject to inspection and that records of equipment maintenance will be kept and the environment allows access by the emergency services. Currently, inspection may be by the CQC, but this may change in the future. A checklist of requirements can be referenced at www.saad.org.uk/safepractice2015/10

Audit and governance

Regular audit of the sedation service provided and clinical outcomes is required. A log of all sedation cases, electronic or paper must be maintained. The guideline also suggests the mandatory reporting of adverse events by all doctors, dentists and healthcare providers in the same manner as anaesthetic incidents via the Safe Anaesthesia Liaison Group (SALG) should be developed.

The National Reporting and Learning System in England and Wales should be used to record over sedation or failure to monitor oxygen saturation when using midazolam, which is currently described as a ‘never event’ by the Department of Health.11

Education and training

This guideline provides detailed syllabuses for education of all members of the dental sedation team, that is dentists, doctors, nurses, therapists and, in so doing, for the first time sets a national standard. From the date of publication, all courses must conform to these requirements and only courses offering supervised clinical practice are recognized as suitable for novice sedationists intending to practise independently.

Those courses outwith universities and deaneries must apply to IACSD for accreditation.

All those involved with sedation are expected to undertake Continuing Professional Development in sedation, undergoing a minimum of 12 hours per 5-year cycle; this includes dentists, doctors, recovery nurses, the dental nursing team and therapists.

The guideline has detailed transitional arrangements (pp86–87) for experienced sedationists who may not have trained with a recognized course, such as a university Masters course, Diploma or the National Examining Board for Dental Nurses course in sedation.12 The maintenance of a personal log book of experience is required. Audit of current practice and reflection is mandatory; practitioners are required to have the appropriate rescue skills, namely ILS or PILS, according to the scope of sedation practice.

The environment, equipment and patient pathway checklist are required to meet the standards defined in the IACSD guideline.

Conclusion

For those providing dental sedation, the IACSD has provided definitive standards and guidance that will have an important impact in improving patient experience and the safe provision of dental care.

Since publication, the author has been aware of various queries regarding the guidance. Most concerns are answered by reading the guidance itself but further questions can be sent to the IACSD Committee Secretary13 who will arrange an individual reply.