NEVADA STATE BOARD

of

DENTAL EXAMINERS

Public Board Meeting

Teleconference

May 7, 2015

6:00 p.m.

PUBLIC BOOK

Nevada State Board of Dental Examiners6010 S. Rainbow Blvd., Bldg. A, Ste. 1Las Vegas, NV 89118(702) 486-7044. (800) DOS-EXAM Fax (702) 486-7046

CONSCIOUS SEDATIONINSPECTION AND EVALUATION

~ON-SITE/ADMIMSTRATOR U SITE ONLY

Name ofPractitioner: Proposed Dates:a .

Location to beTnsnected: — Telephone Wmhber:

Date ofEvaluation: Time of Evaluation:

Evaluators

I)i. -—-S

2.

3.

INSTRUCTIONS FOR COMPLETING CONSCIOUS SEDATION ON-SITEINSPECTION AND EVALUATION FORM:

1. Prior to evaluation, review criteria and guidelines for Conscious Sedation (CS) On-Site/Administrator and SiteOnly Inspection and Evaluation in the Examiner Manual.

2. Each evaluator should complete a CS On-Site/Administrator or Site Only Inspection and Evaluation formindependently by checking the appropriate answer box to the corresponding question or by filling in a blankspace.

3. Answer each question. (For Site Only Inspections and Evaluations, complete sections A, B, and D)

4. After answering all questions, each evaluator should make a separate overall “pass” or “fail” recommendation tothe Board. “Fail” recommendations must be documented with a narrative explanation.

Sign the evaluation report and return to the Board office within ten (10) days after evaluation has been completed.

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A. OFFICE FACILITIES AND EQUIPMENT

~‘1. Operatiug Theater YES NOa. Is operating theater large enough to adequately accommodate the patient

on a table or in an operating chair?b. Does the operating theater permit an operating team consisting of at least

three individuals to_freely move about the patient?2. Operating Chair or Table

a. Does operating chair or table permit the patient to be positioned so theoperating team can maintain the airway?

b. Does operating chair or table permit the team to quickly alter the patient’s /position in an emergency?

c. Does operating chair or table provide a finn platform for the managementof cardiopulmonary resuscitation?

3. Lighting Systema. Does lighting system permit evaluation of the patient’s skin and mucosal

color?b. Is there a battery powered backup lighting system?

c. Is backup lighting system of sufficient intensity to permit completion of anyoperation underway at the time of general power failure?

4. Suction Equipment

I a. Does suction equipment permit aspiration of the oral and pharyngealCavities?b. Is there a backup suction device available which can operate at the time of

General power failure?5. Oxygen Delivery System

a. Does oxygen delivery system have adequate fill face masks and appropriateconnectors and is capable of delivering oxygen to the patient under positivepressure?

b. Is there an adequate backup oxygen delivery system which can operate at the .7Time of general power failure?

6. Recovery Area (Recovery area can be operating theater)a. Does recovery area have available oxygen? ~1z

b. Does recovery area have available adequate suction?

c. Does recovery area have adequate lighting? v’

d. Does recovery area have available adequate electrical outlets?

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)~. Ancillary Equipment in Good Operating Condition? YES NOa. Are there oral airways?

b. Is there a tonsilar or pharyngeal type suction tip adaptable to all officeoutlets?

c. Is there a sphygmomanometer and s~~~coe?

d. Is there adequate equipment for the establishment of an intravenousinfhsion?

e. Is there a pulse oximeter?

B. RECORDS — Are the following records maintained?

~ 1. An adequate medical history of the patient?

2. An adequate physical evaluation of the patient?

3. Sedation records show blood pressure reading?

I 4. Sedation records show pulse reading?5. Sedation records listing the drugs administered, amounts administered, and

time administered?6. Sedation records reflecting the length of the procedure?

7. Sedation records reflecting any complications of the procedure, if any?

8. Written informed consent of the patient or if the patient is a minor, his orher parent or guardian’s consent for sedation?

~ 6%GP~S ?krC. DRUGS

DRUG NAME EXPIRES YES NO1. Vasopressor drug available? Si ~

2. Corticosteroid drug available? ~ (S

3. Bronchodilator drug available?At.4Stcn~toc

4. Appropriate drug antagonists F ~ (~ ~ available? -~A-’-a%co~.)t Ce €.—

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6. Anticholinergic drug available?

7. Coronary artery vasodilator drugavailable?

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Ir DRUG NAME EXPIRES YES NO5. Antihistaminic drug available? ~

8. Anticonvulsant drug available? /U646~ :4fl(4~ C—

9. Oxygen available? ....

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D. DEMONSTRATION OF CONSCIOUS SEDATION

1. Who administered conscious sedation?~ DentisVsName: c~Z.2. Was sedation case demonstrated within the definition of conscious

sedation?3. While sedated, was patient continuously monitored during the procedure

with a pulse oximeter?

Ifnot, what type ofmonitoring was utilized?4. Was the patient monitored while recovering from sedation?

Monitored by whom: ~ —

5. Is this person a licensed health professional experienced in the care andresuscitation ofpatients_recovering from_conscious_sedation?

6. Were personnel competent?

7. Are all personnel involved with the care of patients certified in basiccardiac life support?

8. Was dentist able to perform the procedure without any action or omissionthat_could have resulted in_a life threatening situation to_the patient?

9. What was the length of the case demonstrated?~)_O,.SW

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E. SIMULATED EMERGENCIES — Was dentist and staff able to demonstrate knowledgeand ability in recognition and treatment of:

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[YES NO1. Airway obstruction laryngospasm?

~ 2. Bronchospasm? I________

3. Emesis and aspiration of foreign material under anesthesia? ~—‘

4. Angina pectoris?

5. Myocardial infarction?

6. 1-lypotension?

F 7. Hypertension?

8. Cardiac arrest?

9. Allergic reaction?

10. Convulsions?

1 1, Hypoglycemia?

12. Asthma?

13. Respiratory depression?

14. Allergy to or overdose from local anesthesia?~

15. Hyperventilation syndrome?

16. Syncope?

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. I Evaluator Overall Recommendation

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6010 S. Rainbow Blvd., Bldg. A, Ste. 1Las Vegas, NV 89118(702) 486-7044. (800) DDS-EXAM. Fax (702) 486-7046

CONSCIOUS SEDATIONINSPECTION A1~D EVALUATION

[WbN-SITE/ADMIIqISTRATOR LI SITE ONLY

INSTRUCTIONS FOR COMPLETING CONSCIOUS SEDATION ON-SITEINSPECTION AND EVALUATION FORM:

1. Prior to evaluation, review criteria and guidelines for Conscious Sedation (CS) On-Site/Administrator and SiteOnly Inspection and Evaluation in the Examiner Manual.

2. Each evaluator should complete a CS On-Site/Administrator or Site Only Inspection and Evaluation formindependently by checking the appropriate answer box to the corresponding question or by filling in a blankspace.

3. Answer each question. (For Site Only Inspections complete sections A, B, and C)

4. After answering all questions, each evaluator should make a separate overall “pass” or “fail” recommendation tothe Board. “Fail” recommendations must be documented with a narrative explanation.

5. Sign the evaluation report and return to the Board office, within ten (10) days after evaluation has been completed.

Received

APR 2 ~ 2015

Proposed Dates:

Telephone Number:

Time of Evaluation:

Name of Practitioner:

Location to be Inspected:

Date ofEvaluation:

Evaluators

I

2.

~3.

NSBDE

A. OFFICE FACILITIES AN]) EQUIPMENT

1. Operating Theater YES NOa. Is operating theater large enough to adequately accommodate the patient

on a table or in an operating chair?b. Does the operating theater permit an operating team consisting of at least

three individuals to_freely move about the patient?2. Operating Chair or Table

a. Does operathg chair or table permit the patient to be positioned so theoperating team can maintain the airway?

b. Does operating chair or table permit the team to quickly alter the patient’sposition in an emergency?

c. Does operating chair or table provide a firm platform for the managementof cardiopulmonary resuscitation?

3. Lighting Systema. Does lighting system permit evaluation of the patient’s skin and mucosal

color? Vb. Is there a battery powered backup lighting system? ‘Vc. Is backup lighting system of sufficient intensity to permit completion of any

operation underway at the time of general power failure?4. Suction Equipment

a. Does suction equipment permit aspiration of the oral and pharyngealCavities?

b. Is there a backup suction device available which can operate at the time ofGeneral power failure?

5. Oxygen Delivery Systema. Does oxygen delivery system have adequate full face masks and appropriate

connectors and is capable of delivering oxygen to the patient under positive \_./pressure?

b. Is there an adequate backup oxygen delivery system which can operate at theTime of general power failure?

6. Recovery Area (Recovery area can be operating theater)a. Does recovery area have available oxygen?

b. Does recovery area have available adequate suction?

c. Does recovery area have adequate lighting?

d. Does recovery area have available adequate electrical outlets? V

2

7. Ancillary Equipment in Good Operating Condition? YES NOa. Are there oral airways? V

b. Is there a tonsilar or pharyngeal type suction tip adaptable to all officeoutlets?

c. Is there a sphygmomanometer and stethoscope? /

d. Is there adequate equipment for the establishment of an intravenous vinfusion?

e. Is there a pulse oximeter?VI

B. RECORDS — Are the following records maintained?

1. An adequate medical history of the patient?

2~ k~adequatephysicaIevaluationofth~p~fi0n~? --•--~------~-- - - - v3. Sedation records show blood pressure reading?

4. Sedation records show pulse reading?

5. Sedation records listing the drugs administered, amounts administered, andtime administered?

6. Sedation records reflecting the length of the procedure?

7. Sedation records reflecting any complications of the procedure, if any?

8. Written informed consent of the patient, or if the patient is a minor, his orher parent or guardian’s consent for sedation?

C. DRUGS

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- DRUG NAME EXPIRES YES NO

5. Antihistaminic drug available?. <i 2ei~,

6. Anticholinergic drug available?~ ~zr2oK

7. Coronary artery vasodilator drugavailable? s 2c~ fl

8. Anticonvulsant drug available?

9. Oxygen available? AUt

D. DEMONSTRATION OF CONSCIOUS SEDATION

1. Who administered conscious sedation?Dentist’s Name;

2. Was sedation case demonstrated within the definition of conscioussedation?

3. While sedated, was patient continuously monitored during the procedurewith a pulse oximeter?

If not what type of monitoring was utilized?4. Was the patient monitored while recovering from sedation?

VMonitored by whom:

~ 5. Is this person a licensed health professional experienced in the care andresuscitation of patients recovering from conscious sedation?

6. Were personnel competent? .

7. Are all personnel involved with the care ofpatients certified in basiccardiac life support?

8. Was dentist able to perform the procedure without any action or omissionthat could have resulted in a life threatening situation to the patient?

9. What was the length of the case demonstrated?...VEfl-1 ‘,nn

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E. SIMULATED EMERGENCIES — Was dentist and staff able to dembnstrate knowledgeand ability in recognition and treatment of:

YES NOI. Airway obstruction laryngospasm? /

2. Bronchospasm? /

3. Emesis and aspiration of foreign material under anesthesia?

4. Angina pectoris? I’,,,

5. Myocardial infarction? .

ft~ G’i~w~. U%6. Hypotension?

\7. Hypertension? v8. Cardiac arrest?

. c~n’.&u~, p4ss9. Allergic reaction? VI

10. Convulsions?

~ v12. Asthma?

13. Respiratory depression?tr,t ~-wt lc~w ~tw~zS~4

14. Allergy to or overdose from local anesthesia? c ~VVb~lnflt$ w~c.vT S~r,n

15. Hyperventilation syndrome?

16. Syncope?

5

Evaluator Overall Reco ndationD Pass

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