Wyoming State Board of Dental Examiners Guidelines for Office Evaluations for Anesthesia Level 3 Enteral (Oral) Conscious Sedation PART I-Case Review
Three cases should be discussed and the records reviewed. It is suggested that two short
cases, including a child, and a longer one be discussed. The evaluators may request more records for review. No evaluation can be considered complete unless this part is included. PART II-Check Advanced Cardiac Life Support Certification for Operator and BLS Certification for Assistants.
PART III-Simulated Emergencies
The evaluators and the anesthesia/sedation team should not just talk about the emergency
situations and how they should be managed. The individual performing the anesthesia/sedation and his/her team must discuss their method of treatment for the following situations:
Management of foreign bodies in the airway
The simulated emergency procedures are to be demonstrated in the operating area with full
participation of the office staff. All emergency equipment should be present, including syringes, medications, etc. PART IV-Office equipment, Records and Emergency Medications
All office equipment and records related to patient care should be available for inspection by
the visiting doctors. Specific attention should be directed to the following areas:
The oxygen and supplemental gas-delivery system-backup system
Patient transportation equipment (if used)
Completeness of emergency anesthesia equipment and medications
PART V-Discussion Period
This final part of the evaluation should be conducted in private away from staff and patients.
The evaluators at this time may note deficiencies and make positive suggestions for improving the office facility and patient management. At the completion of the evaluation visit, one member of the evaluating team should complete, detach and mail pages labeled ANESTHESIA EVALUATION CHECKLIST.
EMERGENCY EQUIPMENT AND DRUGS I. Surgical and/or operating Anesthetic Team A.
Local anesthesia and conscious sedation--doctor and one assistant
All assistants must be BLS certified and capable of performing CPR
Required Equipment A.
Source of oxygen and equipment to deliver positive-pressure ventilation
McGill forceps or other suitable instruments
ECG or electocardioscope, with leads and electropaste
Equipment to establish intravenous infusion
SUGGESTED DRUGS
It is required that each office providing these Level 3 (Conscious Sedation) services be
prepared to treat emergencies outlined in Part III. Commonly accepted or ACLS approved pharmacological agents must be present in the office to treat these emergencies.
Water for injections and/or mixing or dilution of drugs
Hydrocortisone sodium sucinate (Solu-Cortef) 50 mg/ml either/or
ANESTHESIA EVALUATION CHECKLIST APPLICANT:_________________________________________________________________ FACILITY:___________________________________________________________________ Street Address PART I – ORAL SEDATION TECHNIQUE AND DRUGS PART II – REVIEW CPR PART III - SIMULATED EMERGENCIES 1.
Management of foreign bodies in the airway
COMMENTS: _________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ PART IV - OFFICE EQUIPMENT, RECORDS AND EMERGENCY MEDICATIONS
Oxygen and gas delivery system and backup _____________
COMMENTS: _________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ PART V - DISCUSSION PERIOD
Note To Attending Physician/Prescriber Personal Consult Physician: Physician, Unassigned This review is based on the information provided. Background Patient with dementia and behaviors and now non-responsive, will not talk, does not interact per family. Recent psych admission d/t behaviors likely related to her dementia. On Exelon Patch, Ativan prn, Seroquel prn, Trazadone, Namenda
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