Oral Moderate Sedation Facility Inspection Review Form

Transcription

1 6 Crescent Road, Toronto, O Canada M4W 1T1 T: F: Toll Free: TYPE A Oral Moderate Sedation Facility Inspection Review Form GEERAL IFORMATIO Inspection type: Initial Inspection Re-Inspection Facility Permit Holder: Facility Permit #: Facility Address: Facility Phone umber: Date of Inspection: Facility Address: Inspected By: Levels of sedation provided at this facility within the past 36 months: one Minimal Oral Moderate Sedation (OM) Parenteral Conscious Sedation (P) Deep Sedation/General Anesthesia (D/G) Practice Population At this facility, sedation and/or GA is/will be administered to: Pediatric patients (patients 12 years and under) Adult patients Both adult and pediatric patients A. SEDATIO/AESTHESIA TEAM REVIEW i. Sedation/GA Practitioners List all the sedation/ga practitioners who have administered sedation and/or GA at the facility in the course of the past 36 months. o sedation/ga has been administered at this facility in the past 36 months OR since the change in practice ownership. Please fill out the table below with respect to the intended provider (if known). PRACTITIOER 1 DDS MD GP SPECIALIST PRACTITIOER 2 DDS MD GP SPECIALIST Practitioner ame Provider type Visiting Member on-visiting Member Visiting Member on-visiting Member Current CPR (HCP or equivalent, ACLS, PALS) * ot required if practitioner is a visiting member Y A Y A Highest sedation/anesthesia modality provided within the past 36 months OM P DG OM P DG Do the intended documents comply with the Standard? Medical Out-of-facility Pre- Post- History sedation sedation Y Y /A Y Y Medical Out-of-facility Pre- Post- History sedation sedation Y Y /A Y Y All providers use the same set of instructions Y Frequency at facility (x/year) Provides dental services + sedation/ anesthesia? Y Y Responsibilities of the sedation/ga provider: Performs preoperative exam Administers sedation/general anesthesia Monitors the vitals and patient Recovers the patient Discharges the patient ORAL MODERATE SEDATIO FACILITY ISPECTIO REVIEW FORM 1

2 ii. Sedation/GA Team Members List all the members who are part of the sedation/ga team at the facility. MEMBER 1 DDS MD R RT DETAL ASSISTAT MEMBER 2 DDS MD R RT DETAL ASSISTAT MEMBER 3 DDS MD R RT DETAL ASSISTAT Facility-provided member Y Y Y If provided by the visiting provider, please skip to Responsibilities of the team member: Qualifications * Required only if member is facility-provided Current CPR (HCP or equivalent, ACLS, PALS) * Required only if member is facility-provided Responsibilities of the team member: Performs preoperative exam Administers sedation/general anesthesia Monitors the vitals and patient Recovers the patient Discharges the patient Maintains a clear operative field CO CRTO A CO CRTO A CO CRTO A Y A Y A Y A Designation Sedation Recovery Operative Assistant Supervisor Assistant Sedation Recovery Operative Assistant Supervisor Assistant Sedation Recovery Operative Assistant Supervisor Assistant iii. Adequacy of the Sedation Team Are sedation cases done concurrently*? Y If Yes, is the sedation team adequate to manage concurrent sedation cases*? Y A *Concurrent cases: An anesthetized patient is being worked upon while another patient is in recovery or pre-operatively sedated with the proper supervision. B. SEDATIO/AESTHESIA FACILITY REVIEW Building Codes/Facility Is there adequate lighting in the facility to conduct dental procedures under sedation? Y Is there adequate suction in the facility to conduct dental procedures under sedation? Y Is there appropriate access for the patient to be transferred to the hospital, if necessary, by ambulance? Y Electrical Does the facility have a back-up generator to provide emergency power to safely complete the procedure and recover the patient in the event of a power outage? Y ORAL MODERATE SEDATIO FACILITY ISPECTIO REVIEW FORM 2

3 Recovery Area Are patients recovered in the same operatory in which they are sedated or administered general anesthesia? Y Are there sufficient recovery areas to provide adequate recovery time for each case? Y Does the recovery area have the following items readily available? Oxygen Y Suction Y Lighting Y Pulse oximetry Y Sphygmomanometer Y C. SEDATIO/AESTHESIA EQUIPMET MAITEACE REVIEW MAITEACE DOCUMETATIO Equipment Invoice or Maintenance Date Maintenance Date Maintenance Date Present at facility Monitor Y Manufacturer, Model ame and S Second Monitor (Required if concurrent cases are performed) Y R Manufacturer, Model ame and S 2 delivery system Y R Manufacturer, Model ame and S Other: Y R Manufacturer, Model ame and S Was any sedation administered with equipment that was overdue for maintenance? [If yes, please attach maintenance records that are within the past 3 years.] Y Do the maintenance records correspond to the equipment reviewed in the facility? Y R D. SEDATIO/AESTHETIC EQUIPMET REVIEW Airway Management EQUIPMET REQUIRED YES O State sizes if missing Portable apparatus for intermittent positive pressure resuscitation Adult Pediatric Full face masks of appropriate sizes and connectors for the administration of positive pressure Sm Med Lrg ORAL MODERATE SEDATIO FACILITY ISPECTIO REVIEW FORM 3

4 EQUIPMET REQUIRED YES O State sizes if missing Auxiliary Systems Portable auxiliary system for light Portable auxiliary system for battery-powered suction Monitoring/Gas Delivery Systems Monitor(s)/Pulse oximeter Stethoscope Sphygmomanometers of appropriate sizes Sm Med Lrg 2 Delivery System Review Is 2 used in this facility? If Yes: Does the system conform to CSA standards? R Is the reserve supply of oxygen (E sized tank as a minimum) part of the 2 system? R Is a scavenging system present? R E. EMERGECY AD SEDATIO/AESTHESIA DRUG REVIEW i. General Medication Standards Storage Medications are stored in appropriately labeled bins/cupboards Y Multi-dose vials of medication are dated on opening and disposed of according to manufacturer s guidelines Y Medications are stored according to the manufacturer s recommendations (i.e. refrigerated if required) Y Replenishment Does the facility have a policy/system in place to maintain emergency drug: Quantity Y Viability [non-expired] Y ii. Drugs for the Management of Emergencies Oxygen Is a portable E cylinder of oxygen available and dedicated for emergencies only [i.e. not part of a nitrous delivery system or anesthesia machine]? Are the regulator/flowmeter/wrench and administration supplies Y Continuously connected or readily available? Y In working order? Y ORAL MODERATE SEDATIO FACILITY ISPECTIO REVIEW FORM 4

5 Drug Acetylsalicylic Acid (non-enteric coated) Expiry Date: Y Epinephrine Expiry Date: Y Flumazenil Expiry Date: Y Are opioids used? Y If Yes - aloxone Expiry Date: Y A itroglycerin Expiry Date: Y Parenteral Diphenhydramine Expiry Date: Y Salbutamol Expiry Date: Y iii. Controlled/Targeted Substances Standards Are qualified staff [i.e. R, dentist] assigned to manage the controlled substances? Y Are controlled substances stored in a designated fixed locked cabinet? Y Is the key to the cabinet in a secure, separate location, with limited authorized access? Y Drug Register Does the facility have a Drug Register? Y Does the Drug Register indicate, for each controlled/targeted substance, the ame of the patient Y ame of the drug Y Quantity of the drug dispensed Y Date drug received and dispensed Y Person who made the entry Y F. FACILITY RISK MITIGATIO Emergency Does the facility have written protocols for emergency procedures? Y Are these procedures regularly reviewed with the staff? Y Within the last 36 months, has the facility needed to Call 911 and utilize EMS? Y Transport a patient to the hospital regardless of whether the patient was admitted or not? Y Use a reversal agent? Y Utilize any emergency or resuscitative drugs? Y ORAL MODERATE SEDATIO FACILITY ISPECTIO REVIEW FORM 5

6 RECOMMEDATIOS While not part of the current Standard, the following were suggestions to enhance the quality and provision of sedation offered in the facility. The following recommendations were reviewed with (SURAME/GIVE AME) at the dental facility: Patient Assessment Perform an airway exam pre-operatively Level of Consciousness Assessment Assess the patient s level of consciousness at regular intervals and document this in the sedation/ga record. Communicate regularly with the patient during the period of sedation and recovery. Assess the patient s ability to respond to help determine the patient s level of sedation. Utilize the Ramsay Sedation Scale. Training Arrange for HCP or equivalent CPR for the operative assistant Arrange for ACLS for sedation/ga providers Arrange for PALS for providers sedating patients 12 and under Equipment Oral airways of adequate sizes If only an automated blood pressure cuff is present at the facility, ensure a second sphygmomanometer [manual or automated] with blood pressure cuffs of appropriate sizes [Sm, Med, Lrg] is present. Emergency Store all emergency apparatus in one place Review the emergency manual with staff regularly Documentation Maintain a binder with all relevant material for an inspection including: the sedation team s current HCP or equivalent CPR/ACLS/PALS, relevant regulatory authorization, maintenance/invoice records for sedation equipment, pre-sedation/post-sedation and out-of-facility prescriptions for sedatives for each sedation/ga provider and sedation/anesthesia records. Recordkeeping/Charting: use permanent ink, retain original records in the facility, maintain electronic records as per the RCDSO Guidelines: Dental Recordkeeping. Do an internal chart review the signing sedation/ga provider should ensure all boxes and information is legible, accurate and complete o recommendations were made ORAL MODERATE SEDATIO FACILITY ISPECTIO REVIEW FORM 6