Sedation and Anesthesia Visiting Provider Inspection Review Form

6 Crescent Road, Toronto, O Canada M4W 1T1 T: 416.961.6555 F: 416.961.5814 Toll Free: 1.800.565.4591 www.rcdso.org Sedation and Anesthesia Visiting Provider Inspection Review Form GEERAL IFORMATIO Inspection type: Initial Inspection Re-Inspection ame of Visiting Provider: Mobile Case #: Address Review Took Place: Provider Phone umber: of Inspection: Provider Email Address: Inspected By: Levels of sedation provided: Oral Moderate Sedation (OM) Parenteral Conscious Sedation (P) Deep Sedation/General Anesthesia (D/G) Practice Population The visiting provider administers/will administer sedation and/or GA to: Pediatric patients (patients 12 years and under) Adult patients Both adult and pediatric patients Storage and Use of Equipment Where are the sedation equipment and drugs stored when not in use? If stored at a dental facility, what is the facility s address? A If stored at a dental facility, are the equipment and drugs kept separate from the facility s equipment and drugs? Y A Are any items from the sedation/ga kit (equipment and/or drugs) used by anyone other than the visiting provider? Y A. SEDATIO/AESTHESIA TEAM REVIEW i. Sedation/GA Practitioners Practitioner ame Education DDS MD GP Specialist Highest sedation/anesthesia modality provided within the past 36 months OM P DG Current CPR (HCP or equivalent, ACLS, PALS) Y Provider documentation Do the intended documents comply with the Standard? Medical History Out-of-facility Pre-sedation Post-sedation Y Y /A Y Y Provides dental services + sedation/anesthesia? 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 SEDATIO AD AESTHESIA VISITIG PROVIDER ISPECTIO REVIEW FORM 1

ii. Sedation/GA Team Members List all the members who are part of the visiting provider s sedation/ga team. MEMBER 1 DDS MD R RT DETAL ASSISTAT MEMBER 2 DDS MD R RT DETAL ASSISTAT MEMBER 3 DDS MD R RT DETAL ASSISTAT Who provides the sedation/ anesthesia team? Visiting Facility Both Practitioner Visiting Facility Both Practitioner Visiting Facility Both Practitioner If provided by the visiting provider, please skip to Responsibilities of the team member: Qualifications CO CRTO A CO CRTO A CO CRTO A Current CPR (HCP or equivalent, ACLS, PALS) Y A Y A Y A 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 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 EQUIPMET MAITEACE REVIEW MAITEACE DOCUMETATIO Equipment Invoice or Present at facility Monitor (OM, P, D/G) Y Manufacturer, Model ame and S Second Monitor (Required if concurrent cases are performed) (OM, P, D/G) Y R Manufacturer, Model ame and S Defibrillator(s)/AED (D/G) Y R Manufacturer, Model ame and S SEDATIO AD AESTHESIA VISITIG PROVIDER ISPECTIO REVIEW FORM 2

MAITEACE DOCUMETATIO Equipment Invoice or Present at facility Vaporizer(s) (D/G) Y R Manufacturer, Model ame and S Anesthetic machine(s) (D/G) 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.] Do the maintenance records correspond to the equipment reviewed? Y Y C. 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 Tonsil suction (Yankauer) adaptable to the suction outlet (P, D/G) R Adequate selection of endotracheal tubes and/or laryngeal mask airways and appropriate connectors (P, D/G) Missing ETT: 4 5 6 7 8 9 Missing LMA: 2 2.5 3 4 5 Laryngoscope with an adequate selection of blades (P, D/G) 1 2 3 4 Laryngoscope spare batteries (P, D/G) R Laryngoscope spare bulbs (P, D/G) R Magill forceps (P, D/G) Adult Pediatric Adequate selection of oral airways (P, D/G) 6 7 8 9 10 11 Apparatus for emergency tracheotomy or cricothyroid membrane puncture (P, D/G) Auxiliary Systems Portable auxiliary system for light Portable auxiliary system for battery-powered suction Adult Pediatric SEDATIO AD AESTHESIA VISITIG PROVIDER ISPECTIO REVIEW FORM 3

EQUIPMET REQUIRED Monitoring/Gas Delivery Systems Monitor(s) Stethoscope YES O State sizes if missing Sphygmomanometers of appropriate sizes Sm Med Lrg Electrocardioscope (D/G) R Anesthesia Gas Delivery System Review Is there an anesthesia gas delivery system as part of the visiting provider kit? (D/G) If Yes: R Does the system conform to CSA standards? R Are full face mask connectors, tubing, bag present for resuscitation? R Is a reserve supply of oxygen (E size tank as a minimum) present? R Is a scavenging system present? R Is a vaporizer fitted to the system? R Does the vaporizer have an agent-specific, keyed filling device? R Is the connection of the inlet and outlet ports such that an incorrect attachment cannot be made? Do all vaporizer control knobs open counterclockwise and indicate vapour concentration in volume percent? R R Is the vaporizer connected to the scavenging system? R Are cases intubated? (D/G) R If Yes, does the anesthetic machine have: Capnometer/Capnograph R Is an inhalation agent used? (D/G) R If Yes, does the anesthetic machine have an: Oxygen analyzer R Anesthetic agent analyzer R Other IV eedles (P, D/G) R Defibrillator/AED (DG) R Defibrillator/AED pads expired? (D/G) Y Adult Pediatric Defibrillator/AED battery expired? (D/G) R SEDATIO AD AESTHESIA VISITIG PROVIDER ISPECTIO REVIEW FORM 4

D. 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 Drug Acetylsalicylic Acid (non-enteric coated) Expiry : Y Epinephrine Expiry : Y Flumazenil Expiry : Y Are opioids used? Y If Yes - aloxone Expiry : Y A itroglycerin Expiry : Y Parenteral Diphenhydramine Expiry : Y Salbutamol Expiry : Y Intravenous fluids (P, D/G) Expiry : Y R Parenteral Atropine (P, D/G) Expiry : Y R Parenteral Corticosteroid (P, D/G) Expiry : Y R Parenteral Vasopressor [i.e. Ephedrine] (P, D/G) Expiry : Y R Parenteral Amiodarone (D/G) Expiry : Y R Parenteral Beta-blocker [i.e. Esmolol, Metoprolol, Propranolol] (D/G) Expiry : Y R Succinylcholine (D/G) Expiry : Y R Dantrolene (D/G), [umber of vials required is based on patient weight not age and is to be consistent with MHAUS Guidelines] Expiry : Y R ii. 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 locked bag/tackle box? Y Is the key to the bag/tackle box in a secure, separate location, with limited authorized access? Y SEDATIO AD AESTHESIA VISITIG PROVIDER ISPECTIO REVIEW FORM 5

Drug Register Does the visiting provider 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 drug received and dispensed Y Person who made the entry Y E. VISITIG PROVIDER RISK MITIGATIO Emergency Does the visiting provider have written protocols for emergency procedures? Y Are these procedures regularly reviewed with the staff if applicable or by the visiting provider? Y Within the last 36 months, has the visiting provider 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 SEDATIO AD AESTHESIA VISITIG PROVIDER ISPECTIO REVIEW FORM 6

RECOMMEDATIOS While not part of the current Standard, the following were suggestions to enhance the quality of sedation/anesthesia offered in your practice. 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 Drugs Adenosine (D/G) Equipment If only an automated blood pressure cuff is in the kit, ensure a second sphygmomanometer [manual or automated] with blood pressure cuffs of appropriate sizes [Sm, Med, Lrg] is present. Oral airways (OM) AED/Defibrillator (P) 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 SEDATIO AD AESTHESIA VISITIG PROVIDER ISPECTIO REVIEW FORM 7