Dear Ms Yeatts,

 The Virginia Association of Nurse Anesthetists (VANA) appreciates the opportunity to provide comment on the Petition for Rule-Making submitted by Mr. John Bitting on behalf of the Dental Organization for Conscious Sedation (DOCS).  The VANA was founded in 1934 and represents 90% of Virginia’s nurse anesthetists.

The VANA’s comments reflect the same priority order as presented by Mr. Bitting in the Petition.

1. Live Patients v. High-Fidelity Patient Simulator (HFPS)

VANA generally supports the use of HFPS and agrees that simulated patient technology will improve the quality of training in effective dentistry sedation techniques; however, VANA’s support is based on the assumption that HFPS training provides rescue and airway management practice, as well as practice in the recognition of patient deterioration.

2. Monitoring Requirements For a Moderate Sedation Dose  Resulting in a Minimal Sedation Level of Consciousness

Moderate Sedation Dose:  VANA does agree with the DOCS that a doctor should be allowed to check on other patients or attend to a dental emergency while an appropriately trained individual monitors the patient; however, VANA is concerned that the absence of the doctor is based on the dose administered, and not on the patient’s response to the medication administered.

DOCS comments reflect an assumption that, given the same relative dose of sedative medication, all patients will respond similarly.  Unfortunately, VANA’s experience indicates otherwise, and what for one patient could be a positive response to a particular dose, could result in death for another patient.

Additionally, VANA is concerned with the lack of uniformity among the varying health regulations related to anesthesia administration.  For instance, VANA notes the term “minimal conscious sedation” equals a level of anesthesia administration on par with what physicians call “light sedation.”  As defined in Virginia’s Board of Medicine Regulations for Office Based Anesthesia, the determination of the patient’s level of consciousness is based solely on that patient’s responses rather than on the doses of medications administered, a practice which differs greatly from what would be proposed for a minimally conscious sedation patient. 

Further, the standards for who may act as a qualified individual differ significantly between medical and dental practices.  Current office-based anesthesia regulations governing the Practice of Medicine, Osteopathy, Podiatry and Chiropractic require an MD who administers conscious sedation to be assisted by a licensed nurse.  This standard is significantly more stringent that the regulations Governing the Practice of Dentistry and Dental Hygiene which require the dentist have a “second person” who qualifies to assist as long as that person has certification in basic resuscitation techniques.

Uniformity among anesthesia safety regulations is a key factor to ensuring a patient’s safety expectations and sense of well being—Anesthesia patients expect the same safety standards in all practice settings, and regardless of whether a procedure is performed in a dental, oral surgeon, or physician’s office, the same anesthesia standards should apply.  VANA suggests that the definitions and rules related to anesthesia administration should be made uniform throughout Virginia’s regulatory and statutory laws.

Minimal Sedation Monitoring:  While VANA does not object to an appropriately trained individual or dentist monitoring a minimally sedated patient every five minutes, VANA’s support is based on the premise that the dentist’s absence is a result of the patient’s positive response to the medication, not the dose administered.

Patient safety is, and always has been, the number one priority of nurse anesthetists and VANA recognizes that each patient may have a different reaction and/or response to medication. Thus, VANA believes it is imperative that the monitoring of a patient by a qualified individual should occur only if the dentist’s absence is based on an evaluation of the patient’s response to the medication, and not upon the assumption that the dose administered allows the dentist’s absence.

3.  Fourteen Hours of Additional Training for Enteral Sedation of ASA III Patients

VANA supports the requirement of an additional fourteen hours of training, including actual practice in airway management as appropriate to the setting.  VANA agrees it is important that those administering oral sedation have the knowledge and skill to deal with medically complex patients, including airway management training, so as to better ensure patient safety.

4. Eighteen House of Training for the Dental Sedation Team

VANA supports the requirement of eighteen hours of training for an appropriately trained individual or a qualified auxiliary, as long as the training includes actual practice experience on an HFPS or live patient.

The VANA appreciates the opportunity to provide comment and if we can be of any further assistance, we ask that you do not hesitate to contact us.  Our telephone number is 804-754-4122.

Sincerely,

Paul Werbin, RN, MS, CRNA

VANA President

cc:  Ms. Sandra Reen, Executive Director, Virginia 

       Board of Dentistry