Dental Update - A review of the available guidance regarding management of medical emergencies in primary dental care

Abstract

This article provides an overview of the recent changes in guidance relating to the management of medical emergencies in primary dental care in the UK. The guidance relating to automated external defibrillators is also presented. The expectations of our regulatory bodies are discussed, as are the requirements for continued professional development. The potential shortcomings of the changes to the guidance are also discussed, as well as proposed solutions, such as the development of algorithms to use in a dental practice setting.

CPD/Clinical Relevance: All dental practitioners should be able to deal with medical emergencies in their practice.

Article

Medical emergencies occur in general dental practice. Previous surveys suggested that the prevalence of emergency events occurring in dental practice was low, but these were undertaken over 16 years ago.^1,2 A more recent survey in Germany showed that, over 12 months, 57% of dentists reported up to three medical emergencies, and 36% up to 10 emergencies. The most common was vasovagal syncope, but 42 severe life-threatening events were also reported.³

As our population ages, dental practitioners will deal with more medically complex patients being treated with polypharmacy and it is likely, therefore, that the prevalence of medical emergency events occurring in dental practice will increase.

The General Dental Council (GDC) expect dental practitioners to be able to manage any emergency events should they arise in the surgery.^4,5 Additionally, it is worth noting that the Care Quality Commission (CQC) also sets out standards expected of dentists concerning medical emergencies⁶ and failure to comply with these can leave the dentist open to criminal prosecution. This is highlighted in a review of the law surrounding deaths in dentistry⁷ which states that:

‘…dental practitioners should be aware that other clinical situations could in theory result in legal proceedings. For example, if a patient was to have an anaphylactic reaction and the dental practice had an inadequate supply of emergency drugs to deal with this reaction, or perhaps no medical history had been taken from the patient, then it could be argued that the practice had acted negligently'.

The GDC has also recently revised its continuing professional development (CPD) requirements following a consultation process. It continues to recommend at least two hours annually devoted to medical emergencies, with at least ten hours over the five-year CPD cycle.⁸ The Committee of Postgraduate Dental Deans and Directors UK (COPDEND) has also recently published a framework for the planning and provision of CPD, with an aim to ensure that the courses available to practitioners are of a high quality and to enable them to make informed choices about which courses to undertake.⁹

Current updated UK guidance

The GDC refers dental practitioners to the Resuscitation Council UK (RC(UK)) for specific advice regarding dealing with medical emergencies in primary dental care. In November 2013 there was an alteration in the guidance that the RC(UK) provides for dental practitioners. Its document Medical Emergencies and Resuscitation Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice,¹⁰ last revised in December 2012 and previously described in the literature,¹¹ was superseded.

The new GDC endorsed document Quality Standards for Cardiopulmonary Resuscitation Practice and Training: Primary Dental Care¹² provides ‘…quality standards and supporting information for the aspects of cardiopulmonary resuscitation practice and training relevant to the setting of primary dental care'. This has recently been reviewed in November 2015.

In conjunction with this, a further document Minimum Equipment and Drug Lists for Cardiopulmonary Resuscitation: Primary Dental Care¹³ describes the minimum equipment required by dental practices for cardiopulmonary resuscitation, also recently reviewed in November 2015.

The RC(UK) and GDC do not now give specific recommendations for how medical emergencies should be managed, they instead recommend that dentists refer to the relevant part of the British National Formulary (BNF)¹⁴ to get further advice on dealing with other medical emergencies in primary dental care. The RC(UK) and BNF do not describe the management required when resuscitating patients being treated under conscious sedation as there is now separate guidance in this area.¹⁵

Resuscitation Council UK guidelines

The two documents described above are available to download free of charge from the RC(UK)'s website at www.resus.org.uk. They can be printed and stored with the emergency drug box as a reference guide as these should be easily accessible in the event of an emergency.

The core standards that the RC(UK)¹⁶ expects from healthcare professionals undertaking CPR in any setting include:

Early recognition of the deteriorating patient;

Early recognition of cardiopulmonary arrest;

If appropriate, early defibrillation (defined as within 3 minutes);

Safe transfer of patients and appropriate post-arrest care (for dentists this would involve calling 999);

Availability of appropriate equipment;

At least annual updates in training in CPR.

‘ABCDE’ assessment of the patient

The RC(UK) guidance¹² does not include the ‘ABCDE’ approach to assessment of the deteriorating patient that was included in its previous document, nor is this available in the BNF.¹⁴ This should be covered in annual basic life support (BLS) training.

Algorithms

The BLS, adult and paediatric choking and AED algorithms can all still be accessed on the RC(UK) website (www.resus.org.uk). The anaphylaxis algorithm that is available in the RC(UK) document Emergency Treatment of Anaphylactic Reactions: Guidelines for Health Care Providers, however, is too complex for primary dental care and includes the use of intravenous (IV) fluids, chlorphenamine and hydrocortisone, which may not be accessible in dental practices for first line care.¹⁷ However, the algorithm could be used up to the point of administration of adrenaline intramuscularly.

British National Formulary guidelines

The BNF is now only distributed in print edition to eligible NHS prescribers once a year, in September. Practitioners are encouraged to access the BNF either online or through the mobile phone apps (available on Android and iPhone). The guidance available for dental practice covers the following medical emergencies (the same as the previous RC(UK) guidelines):

Adrenal insufficiency;

Anaphylaxis;

Asthma;

Cardiac emergencies including myocardial infarction;

Epileptic seizures;

Hypoglycaemia;

Syncope.

The adult 'Advanced Life Support' (ALS) algorithm is available in the final few pages of the BNF, which again has elements which are beyond the scope of primary dental care, such as the use of 12-lead electrocardiography (ECG) and IV adrenaline.¹⁴ The guidance does not include choking or aspiration, although again these should be covered in annual BLS training.

Automated external defibrillators (AEDs)

UK guidance

There are still some dental practices in the UK that have not equipped themselves with an automated external defibrillator. The clear benefit of the early use of an AED in an emergency situation was demonstrated by a study undertaken in Las Vegas casinos.¹⁸ A total of 1350 security guards were trained in CPR and the use of AEDs, which were placed within three minutes of any location in the casinos. During the study period, 148 people suffered a cardiac arrest; 105 of these people collapsed with a shockable rhythm, which means that a shock delivered by an AED had a chance of saving their life. Fifty-three (59%) subjects who were witnessed collapsing and were found to have a shockable rhythm survived to discharge from hospital. This survival rate increased to 74% if they received a shock from an AED within three minutes of collapsing, compared with only 49% who survived when the shock was delivered after three minutes. This was found to be a statistically significant difference.

The legalities of the provision of resuscitative care have been discussed by the RC(UK).¹⁹ Although there is currently no legal requirement for employers to provide an AED specifically in the workplace, they note that, under English law, failing to undertake appropriate safety precautions on your premises could result in a liability for negligence. With regards to provision of AEDs, they suggest that any judgement made following an incident would be based on the likelihood of harm. In the event of a cardiac arrest, this potential harm would obviously be very high. Therefore the type of people who attend the premises and the prospect of them suffering a cardiac arrest should be considered. They also note that ‘failing to adopt common practice can be strong evidence that appropriate precautions were not taken’.¹⁹

The RC(UK) Quality Standards document¹² clearly states that ‘all clinical areas should have immediate access to an automated external defibrillator', and that staff should be trained in using it. The second RC(UK) document for primary dental care¹³ not only suggests the immediate availability of an AED, but points out that the general public would expect a dental surgery to have access to one. This, combined with the evidence as to the benefit of an early shock with an AED, where appropriate, is a compelling argument to ensure that your practice and staff members have access to and are trained in the use of these devices. The BNF does not specifically mention AEDs in its guidance for dental practice, but does direct readers to the 'Advanced Life Support' (ALS) algorithm in its back pages, which involves the use of a defibrillator.¹⁴

The CQC recommendations⁶ also include relevant guidance. In Outcome 11: Safety, Availability and Suitability of Equipment, Prompt 11A it states that ‘equipment should be available in sufficient quantities to meet the needs of the people who use the service' and Prompt 11H outlines that the equipment required for resuscitation is available and can be accessed quickly.

Scotland, Wales and Northern Ireland

Dental professionals working in Northern Ireland, Wales and Scotland are governed by the GDC and are expected to follow their recommendations regarding CPD and managing medical emergencies.

In the updated Northern Irish Guidance for Dental Practitioners, the Department of Health, Social Services and Public Safety²⁰ does not specifically mention AEDs, but it does state that the ‘appropriate equipment and drugs for treating medical emergencies' should be available.

The Scottish Government recently published through its National Dental Advisory Committee the document Emergency Drugs and Equipment in Primary Dental Care.²¹ This has a list of recommended drugs and equipment, states that AEDs must be available in all dental practices, and also includes the ‘ABCDE’ approach to the sick patient. It also advises on training in medical emergencies and the storage and transport of medical gas cylinders. The Scottish Dental Clinical Effectiveness Programme has also included medical emergencies in the second edition of its Drug Prescribing for Dentistry document.²²

No other published guidance regarding the use of AEDs in dental practice in Wales could be found.

Discussion

The main difficulty with the changes to the available guidance regarding medical emergencies in dental practice that the authors anticipate is accessibility. This may be a particular problem if relying on the online editions of the BNF, which are more frequently updated. On logging onto the BNF website, the first page is the contents page, and it is not immediately clear where to access the emergency information required. Only by typing ‘dental’ into the search box, or by clicking through two links (‘Guidance on prescribing’ and then ‘Prescribing in dental practice’) is one able to find the ‘Medical emergencies in dental practice’ webpage.

One of the main advantages of the previous RC(UK) document¹⁰ was that it could be easily downloaded, printed and kept with the emergency drug box, but will the dental team be able to log on and access the online BNF content as easily in such a stressful situation? Even the print edition may be difficult to navigate in a high pressure scenario.

In addition, there is always the risk of relying on having online access in the event of an emergency; will the computer be portable if the emergency occurs in a waiting room or bathroom within the practice? Will practitioners' mobile telephones be immediately available? Will they remember their login details? The authors would suggest the most up-to-date print edition of the BNF is kept within the emergency drugs kit, with the relevant pages bookmarked.

The authors would also suggest that the algorithms that are still accessible through other documents on the RC(UK) website, as previously discussed, are printed and kept within the emergency drug box. Ideally, each dental practice should develop its own algorithms or aide-memoire for each of the more common medical emergencies; although time consuming initially, this could save crucial time in the event of an emergency.

Given the obvious anticipated difficulties with the new organization of this vital information, the authors are disappointed that the Resuscitation Council guidance was withdrawn. However, as it is actually the care provided pre-resuscitation that the profession needs guidance for, perhaps the best way forward is a working group. This group would provide updated guidance, updated regularly, on dealing with medical emergencies in primary dental care and consist of all the significant stakeholders, eg dentists, emergency medicine consultants, anaesthetic consultants and representatives from the Resuscitation Council. This would lead to the production of clear, concise and relevant guidance which would be deliverable in a user friendly format to the whole of the dental team.

Conclusions

General dental practitioners and their team should be capable of dealing with medical emergencies in practice. They should be aware of the changes in the guidance available to them and should ensure that they are up-to-date with training and CPD in this area. Scenario-based training should be carried out on a regular basis so that everyone in the practice is aware of his/her role should an emergency arise. It is likely, as previously stated, that medical emergencies in dental practice will continue to increase in prevalence and it is critical therefore that dental practitioners and their teams keep up-to-date and well prepared for such an event. The authors believe it is to the detriment of dental professionals that the clear and concise guidance previously provided has been lost.

Reflective Practitioner

Vicarious Liability and the Moving Target of Dental Litigation: A Wake-up Call for Practice Owners?

References

A review of the available guidance regarding management of medical emergencies in primary dental care

Authors

Suzanne Lello

Julie Burke

Kathryn Taylor