The report published by the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD, originally published in 2015 and then updated in 2020) is the UK standard for the use of conscious sedation in the delivery of dental care. It was said that the report defined the standards for the provision of conscious sedation in the delivery of dental care and that “clinical provision is underpinned by the requirement for high standards of education and training for the entire clinical team”.
The standards apply to everyone involved in the delivery of conscious sedation, including dentists, doctors, nurses, and dental care professionals. It is essential to ensure that your visiting sedationist is thoroughly following these guidelines and consistently applying them throughout the entire sedation process to ensure patient safety and adherence to best practices.
It is recommended that a formal agreement be established between the dental practice and the sedation provider. This agreement should specify that the visiting sedationist will adhere to the IACSD sedation standards and ensure that their sedation practices comply with these guidelines.
Standard and advanced sedation
A variety of conscious sedation techniques are available, and the choice of method should be tailored to the specific needs of each patient. The selection must be based on clinical appropriateness rather than the convenience of the operator or sedationist, or pressure from third parties. The patient's safety, comfort, and individual circumstances are paramount when determining the most suitable sedation technique.
Standard sedation typically refers to the use of a single benzodiazepine drug, commonly midazolam, to achieve the desired level of sedation. This approach is favoured because single-drug benzodiazepine regimens are generally easier to titrate, offer a wide margin of safety, and benefit from the availability of a reversal agent if needed. In the UK, this method of titrated intravenous midazolam is used to manage the sedation of most patients – likely more than 95 per cent – due to its simplicity and effectiveness.
Advanced sedation technique (AST) refers to multi-drug sedation (which involves the use of two or more different types of sedative) or the use of anaesthetic drugs to achieve the desired level of sedation. Commonly, this may include the use of drugs such as propofol or fentanyl in combination with midazolam.
The most straightforward technique, which is likely to be effective based on a thorough patient assessment and clinical needs, is generally the best initial choice. Multiple drug/ anaesthetic drug techniques should only be considered where there is a clear clinical justification, having excluded simpler techniques. Irrespective of the setting, where multiple drug/anaesthetic drug techniques are used, the sedation team should have immediate access to the same range of skills and facilities as would be found in an acute NHS trust, for the prompt recognition and immediate management of adverse events.
Some visiting sedationists, particularly those with a medical background, may opt for advanced sedation techniques as their first choice. This practice is contrary to the IACSD guidelines. It is your responsibility to ensure that advanced sedation is not used as the initial treatment approach for your patients unless there is appropriate justification and a comprehensive patient assessment. Make sure that any use of advanced sedation is thoroughly justified and aligned with the IACSD recommendations.
The Care Quality Commission
The CQC offers guidance in the form of mythbusters. The 'Dental mythbusters 10: Safe and Effective Conscious Sedation' provides guidance on what the CQC will “explore” during the inspection. It states that if a provider employs a visiting sedationist, the CQC expect systems and processes to check that they are suitably qualified and competent to provide sedation services, the equipment and medicines used by the visiting sedationist are fit for purpose and that they comply with sedation standards.
Qualifications and competency
In addition to routine checks like indemnity, immunisation, and DBS certificates, keep detailed records of the sedationist’s qualifications and training, especially for IV sedation. This includes GMC or GDC registration and any relevant postgraduate training. For advanced techniques, ensure the sedationist has evidence of specialised qualifications or experience of this. Retaining these records ensures that all credentials are easily accessible and that the sedationist's expertise is properly verified and current.
Practitioners must provide a certificate of age-appropriate immediate life support (ILS), valid for one year, and ensure it is updated before expiry. Advanced life support (ALS) certificates are valid for four years, but life support skills should be refreshed annually. Include these requirements in agreements with sedationists. The sedation team must also complete at least 12 hours of continuing professional development (CPD) every five years, with records maintained for all team members directly involved in the care of the sedated patient.
Sedation guidelines for children
Understand the sedation options for different age groups in primary dental care and ensure your seditionist adheres to them. Children under the age of 12 cannot have treatment under intravenous sedation in a general dental practice in a primary care setting.
Patients aged 12-16 are classified as “young persons” and can be treated with intravenous sedation in a general dental practice, provided that only a standard technique (midazolam only) is used. When treating patients in this age group, it is crucial to ensure that the sedationist strictly adheres to the use of midazolam alone. Furthermore, all members of the clinical team involved in the care of the sedated patient must possess age-appropriate immediate life support (ILS) certification. This typically includes the sedationist, the operating dentist, and the assistant.
Although this protocol is generally followed, there are rare exceptions within the guidelines, and we refer the reader to the IACSD guidelines (pages 10-11) for more information. Patients who are 16 years of age or older are classified as adults for the purposes of sedation treatment.
Equipment
You should request evidence that all equipment is maintained and functioning as per the manufacturer's schedule. The provider should provide the practice with a compliance certificate for the calibration and testing of all medical devices. This certificate is valid for one year, and the latest, in-date version must be available for inspection.
Record-keeping
In primary dental care, thorough documentation is essential for safe and effective sedation. Key records include written patient consent for both sedation and the dental procedure, outlining the risks, benefits, and alternatives. Sedation assessments should also document a detailed review of the patient's medical history, including allergies, pre-existing conditions, and current medications, to ensure suitability and address any risks.
The sedation protocol and plan must be carefully documented. This includes specifying the justification for sedation, the type of sedation technique used, the sedative drugs administered, their dosages, and the method of administration. Pre-sedation information must be given to the patient or guardian, and this should also be recorded.
During sedation, document vital signs (heart rate, blood pressure, oxygen saturation, consciousness) and any sedation adjustments. After treatment, record details of the procedure, duration, and any complications. Include recovery and discharge information, post-op instructions, and signs of complications. Also, thoroughly document any incidents, including their management and corrective actions. These records are crucial for ensuring quality and improving future sedation practices.
All sedation-related records must be entered into the patient's notes by the sedationist at the time of the procedure. Ensuring that these records are made contemporaneously. From a dentolegal perspective, contemporaneous records are considered more reliable because they are less prone to errors and are less likely to be influenced by hindsight bias. Documenting information immediately after treatment ensures that the details accurately reflect the events as they occurred, thereby strengthening the credibility of the records in legal or regulatory reviews.
Summary
In conclusion, following IACSD guidelines and thorough documentation are key to safe sedation in dental care. Ensure visiting sedationists comply with these standards and keep detailed records of consent, assessments, and monitoring. Verify qualifications and maintain accurate equipment records to manage risks effectively.
By following these practices, dental practices can deliver sedation care that is patient-centred, safe, effective and aligned with current standards.
References available on request.