Gloucestershire Hospitals

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1 Gloucestershire Hospitals TRUST POLICY NHS Foundation Trust CONSCIOUS SEDATION IN THE ORAL AND MAXILLOFACIAL OUTPATIENT DEPARTMENT AT GLOUCESTERSHIRE ROYAL HOSPITAL Any hard copy of this document is only assured to be accurate on the date printed. The most up to date version is available on the Trust Policy Site. All document profile details are recorded on the last page. All documents must be reviewed by the last day of the month shown under review date, or before this if changes occur in the meantime. FAST FIND: For details of patient assessment and selection criteria, see section 10. For information on preparation of patients, see section 11. For details of the conscious sedation protocol, see action card OMF1. DOCUMENT OVERVIEW: This operational policy describes the workflow for patients being treated under local anaesthetic and intra-venous (conscious) sedation in the Oral & Maxillofacial Outpatient Department at Gloucestershire Royal Hospital. The guidelines in this operational policy are taken from the General Dental Council, Standing Dental Advisory Committee Guidelines and other national standards documents as agreed and revised from time to time that GDC registrants are obliged to follow. It details the personnel, equipment, facilities and protocol used to treat patients requiring Oral & Maxillofacial Surgery under conscious sedation. This document may be made available to the public and persons outside of the Trust as part of the Trust's compliance with the Freedom of Information Act 2000 CONSCIOUS SEDATION IN OMF OPD V2 PAGE 1 OF 8

2 Gloucestershire Hospitals NHS Foundation Trust CONSCIOUS SEDATION IN THE ORAL & MAXILLOFACIAL OUTPATIENT DEPARTMENT AT GLOUCESTERSHIRE ROYAL HOSPITAL 1. INTRODUCTION 2. DEFINITIONS 3. PURPOSE 4. ROLES AND RESPONSIBILITIES 5. FACILITIES 6. COMPETENT STAFF 7. DRUGS AND TECHNIQUE 8. EQUIPMENT 9. INDICATIONS FOR CONSCIOUS SEDATION 10. PATIENT ASSESSMENT AND SELECTION 11. PREPARATION OF PATIENTS 12. CONSENT ISSUES 13. DOCUMENTATION AND RECORD KEEPING 14. CONSCIOUS SEDATION PROTOCOL 15. EMERGENCY PROCEDURES 16. TRAINING 17. DISSEMINATION 18. MONITORING OF COMPLIANCE 19. REFERENCES Action cards OMF1 Conscious Sedation Protocol CONSCIOUS SEDATION IN OMF OPD V2 PAGE 2 OF 8

3 Gloucestershire Hospitals NHS Foundation Trust CONSCIOUS SEDATION IN THE ORAL & MAXILLOFACIAL OUTPATIENT DEPARTMENT AT GLOUCESTERSHIRE ROYAL HOSPITAL 1. INTRODUCTION This operational policy describes the workflow for patients being treated under conscious sedation in the Oral & Maxillofacial Outpatient Department at Gloucestershire Royal Hospital. The guidelines in this operational policy are taken from the General Dental Council, Standing Dental Advisory Committee Guidelines and other national standards documents as agreed and revised from time to time that GDC registrants are obliged to follow. 2. DEFINITIONS Word/Term Intra-venous (conscious) sedation GDC Descriptor A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out but during which verbal contact with the patient can be maintained throughout the period of sedation. The drugs and techniques used to provide sedation for dental treatment should carry a margin of safety wide enough to render loss of unconsciousness unlikely. General Dental Council 3. PURPOSE The operational policy details the personnel, equipment, facilities and protocol used to treat patients requiring Oral & Maxillofacial Surgery under conscious sedation. 4. ROLES AND RESPONSIBILITIES Post/Group Associate Specialist, Oral Maxillofacial Sedationists Registered Staff General Nursing Staff Details Ultimate responsibility for this document and provision of conscious sedation service Provider of conscious sedation, OMF treatment & clinical lead Ensures appropriate equipment available Ensures correct patient selection Ensures fitness to discharge Maintains thorough knowledge of theoretical and practical aspects of conscious sedation Provider of conscious sedation, OMF treatment Ensure equipment available prior to list Ensure correct patient selection Ensure fitness to discharge Maintains thorough knowledge of theoretical and practical aspects of conscious sedation Patient observation & monitoring during and after sedation Ensure equipment checked, stocked & maintained 5. FACILITIES Conscious sedation is only performed in the purpose-built operating room/recovery facility in the outpatient department at Gloucestershire Royal Hospital. 6. COMPETENT STAFF Elective IV sedation will only be performed by the Associate Specialist and members of the Oral and Maxillofacial Surgery department who have full medical registration. CONSCIOUS SEDATION IN OMF OPD V2 PAGE 3 OF 8

4 6.1 Sedationist The responsible clinician should have a thorough knowledge of the theoretical and practical aspects of sedation. Skills should be continuously updated and practiced as demonstrated in their CME record. Training should include o theory and practical training in the use of emergency drugs and equipment o theory and practical training in life support and potential complications A log book of procedures, doses & complications will be kept for audit purposes The sedationist will be Advanced life support (ALS) qualified 6.2 Nursing Staff The operating list will only take place if there are 2 Registered General Nurses on duty, one to monitor the patient and one to recover the patient. Registered Dental Nurse Staff will be encouraged and supported to complete and pass the National Course for Sedation for Dental Nurses. 6.3 Emergency Scenario Training To comply with GDC guidelines, all members of the sedation team will undergo periodic training in management of simulated emergencies and use of the automated external defibrillator (AED). This is provided by the Trust resuscitation department. 7. DRUGS AND TECHNIQUE A single drug technique ONLY is practiced This drug will ONLY be midazolam This will ONLY be administered by the 2mg bolus and 1mg increment technique until a suitable end-point is reached (see action card OMF1) Reversal agent will be available at all times Midazolam will be administered by intravenous indwelling cannula according to existing Trust guidelines Sufficient amounts of sedative drug and reversal agent will be available at all times Oxygen will be available at all times see 8.3 below 8. EQUIPMENT All equipment must be readily available in the surgery or recovery area next door, and must be sufficiently portable/moveable to facilitate patient evacuation mid-treatment if necessary (e.g. fire). 8.1 Monitoring equipment Means for testing blood pressure, pulse rate and oxygen saturation Equipment to be calibrated & maintained in line with medical physics policy 8.2 Dental chair/recovery Trolley Must be able to be tilted head down Maintained in line with manufacturers policy 8.3 Oxygen Piped oxygen will be available for patient treatment, which will be administered via nasal cannulae A back-up supply to be immediately available in the case of any piped oxygen failure Bag-valve-mask system to be immediately available in the case of emergencies CONSCIOUS SEDATION IN OMF OPD V2 PAGE 4 OF 8

5 8.4 Emergency equipment The following are to be immediately available for emergency treatment, according to current Trust policy: Full range of emergency drugs Full range of airway adjuncts Automated External Defibrillator Back-up suction All of the above to be checked regularly and checklist signed as appropriate. Checklists are kept under last drawer on crash cart 9. INDICATIONS FOR CONSCIOUS SEDATION To facilitate the treatment of anxious patients requiring Oral & Maxillofacial Surgery To avoid the need for General Anaesthesia To minimise patient distress during a surgical or investigative procedure 10. PATIENT ASSESSMENT AND SELECTION All patients must meet the following criteria: 1) ASA Grade I 2) More than 16 years of age 3) Less than 65 years of age 4) BMI less than ) Readily accessible peripheral veins (please look/check) 6) Responsible adult escort (more than 18 years of age) for trip home, overnight stay and assistance 7) Able to have private transport home following procedure 8) Surgery not expected to exceed 40 minutes 9) Must be given Departmental pre-operative information leaflet 10) Nil by mouth - Water 2 hours - Everything else 6 hours (including sweets, chewing gum etc.) All patient management options should be considered and discussed with the patient at the initial consultation appointment. The relative merits and risks of local anaesthesia, sedation and general anaesthesia should be discussed as per GDC guidelines. Previous dental history is important to highlight any anxieties regarding treatment. A full medical history is mandatory in patient selection, including a comprehensive up-to-date list of medication and allergies. American Society of Anesthesiologists (ASA) group - only ASA group I patients will be routinely sedated in the outpatient department. Some fit and well ASA II patients MAY be suitable at the discretion of senior staff (e.g. well-controlled asthma). General fitness, blood pressure, pulse rate & oxygen saturation should be noted. Availability of an escort should be ensured. 11. PREPARATION OF PATIENTS The patient must be given the following pre- and post-operative instruction before the procedure Full verbal and written instructions regarding the sedation AND the operative procedure must be given to the patient at the initial consultation. (Patient info leaflets) An adult escort must be present and must be aware that they are responsible for the patient s welfare. No escort, no sedation. Fasting as per Trust guidelines, which are: Water -up until 2 hours pre-op. Food -up until 6 hours pre-op. Transport home must be by private car or taxi only. Public transport is NOT acceptable. CONSCIOUS SEDATION IN OMF OPD V2 PAGE 5 OF 8

6 12. CONSENT ISSUES Written, informed consent for the sedation AND operative procedure must be obtained prior to the administration of sedative drugs. The patient will be fully informed of all relevant options and freely agree or disagree. All patient questions should be answered prior to administration of sedative drugs. 13. DOCUMENTATION AND RECORD KEEPING Each separate procedure must be documented on the Trust Record of Conscious Sedation Proforma (Y0536) The following is regarded as a minimum data set for each procedure: At initial appointment Accurate and contemporaneous notes Written medical and dental history, checked and acted upon Previous sedation/general anaesthesia history noted and acted upon Pre & post operative written and verbal instructions given Presence of adult escort on day of surgery/sedation established On day of procedure Patient has complied with pre-treatment instructions Written consent obtained Record of Cannulation Record of oxygen administration Record of IV drugs given Record of monitoring techniques/observations Details of operative procedure provided Post-sedation assessment 14. CONSCIOUS SEDATION PROTOCOL The conscious sedation protocol is detailed in action card OMF EMERGENCY PROCEDURES The following emergency measures are in place to ensure patient safety: All staff receive emergency scenario training (see section 6.3 above) Emergency equipment is available in the department and is tested regularly (see section 8) Emergency assistance is summoned using the black cardiac arrest bell and an emergency call is made to 2222 to confirm the location of the emergency Reception staff are briefed on directing the medical emergency team to the appropriate room 16. TRAINING See Training Needs Analysis document. 17. MONITORING COMPLIANCE Via Clinical Director, Matron for Head & Neck services. 18. REFERENCES Standing Dental Advisory Committee (2003). Conscious Sedation in The Provision Of Dental Care. London: Department of Health. CONSCIOUS SEDATION IN OMF OPD V2 PAGE 6 OF 8

7 Department of Health (2000) A Conscious Decision: A review of the use of general anaesthesia and conscious sedation in primary dental care. London: Department of Health. Dental Sedation Teachers Group (2000). Standards in conscious sedation for dentistry: Report of an independent expert working group. London: DSTG. General Dental Council (2001). Maintaining standards. London: GDC. Maintaining Standards Society for advancement of anaesthesia in dentistry. Policy documents & evaluation procedures Dental sedation teachers group. Logbook. CONSCIOUS SEDATION IN OMF OPD V2 PAGE 7 OF 8

8 CONSCIOUS SEDATION IN OMF OPD DOCUMENT PROFILE DOCUMENT PROFILE REFERENCE NUMBER A0394 CATEGORY Clinical VERSION 2 SPONSOR Jerry Farrier, Consultant OMFS AUTHOR Thomas Lees, Associate Specialist OMF (technical authoring support, Kym Ypres-Smith) ISSUE DATE 01/03/2016 REVIEW DETAILS 01/03/2016 review by Consultant OMFS ASSURING GROUP Trust Policy Assurance Group APPROVING GROUP No formal group, Oral & Max Fax Dept working practice APPROVAL DETAILS Policy application: approved 12/12/2012 TPAG approval: 26/03/2013 EQUALITY IMPACT 09/01/2013 ASSESSMENT CONSULTEES Consultant in OMFS and CD in anaesthetics at time original policy drawn up. DISSEMINATION DETAILS Upload to Policy Site; copy kept in OMFS OPD GRH KEYWORDS RELATED TRUST DOCUMENTS OTHER RELEVANT DOCUMENTS EXTERNAL COMPLIANCE STANDARDS AND/OR LEGISLATION Conscious, intravenous, sedation, Oral & Maxillofacial Department, OMF, Outpatient. Action card OMF1; Record of Conscious Sedation Proforma (Y0536) None. Conscious sedation in the provision of dental care, Standing Dental Advisory Committee (DoH) 2003 Scottish Dental Clinical effectiveness programme. Conscious sedation in Dentistry Dental clinical guidance 2012 CONSCIOUS SEDATION IN OMF OPD V2 PAGE 8 OF 8