HB 2479 Text

H. B. 2479

(By Delegates Morgan, Stephens, Hartman, Hatfield,

D. Poling, Martin, Staggers, Swartzmiller and Rowan)

[Introduced ; referred to the

Committee on Health and Human Resources then the Judiciary.]

A BILL to repeal §30-4A-6 of the Code of West Virginia, 1931, as amended; to amend and reenact §30-4A-4, §30-4A-5 and §30-4A-8 of said code; and to amend said code by adding thereto four new sections, designated §30-4A-6a, §30-4A-6b, §30-4A-6c and §30-4A-6d, all relating to anesthesia.

Be it enacted by the Legislature of West Virginia:

That §30-4A-6 of the Code of West Virginia, 1931, as amended, be repealed; that §30-4A-4, §30-4A-5 and §30-4A-8 of said code be amended and reenacted; and that said code be amended by adding thereto four new sections, designated §30-4A-6a, §30-4A-6b, §30-4A-6c and §30-4a-6d, all to read as follows:

ARTICLE 4A. ADMINISTRATION OF GENERAL ANESTHESIA AND PARENTERALCONSCIOUS SEDATION BY DENTISTS.

§30-4A-4. Requirement for anesthesia certificate or permit.

(1) No dentist may induce central nervous system anesthesia without first having obtained an anesthesia permit under these rules for the level of anesthesia being induced.

(2) The applicant for an anesthesia permit must pay the appropriate permit fees and renewal fees, designated in section six of this article, submit a completed board-approved application and consent to an office evaluation. The fees are to be set in accordance with section eighteen of this article.

(3) Permits shall be issued to coincide with the applicant's licensing period.

(4) Permit holders shall report the names and qualifications of each qualified monitor. A monitor qualified by PALS or ACLS shall maintain that certification to act as a qualified monitor.

(5) A dentist shall hold a permit class equivalent to or exceeding the anesthesia level being provided, unless the provider of anesthesia is a physician or dentist anesthesiologist.

§30-4A-5. Classes of anesthesia certificates and permits.

(a) The Board shall issue the following certificates and/or permits:

(1) Class 2 Certificate: A Class 2 Certificate authorizes a dentist to induce anxiolysis.

(2) Class 3 Permit: A Class 3 Permit authorizes a dentist to induce conscious sedation as limited enteral (3a) and/or comprehensive parenteral (3b), and anxiolysis.

(3) Class 4 Permit: A Class 4 Permit authorizes a dentist to induce general anesthesia/deep conscious sedation, conscious sedation, and anxiolysis.

(b) When anesthesia services are provided in dental facilities by medical personnel, the dental facility shall be inspected and approved for a Class 4 permit.

§30-4A-6a. Qualifications, standards applicable, and continuing education requirements for relative analgesia permit.

(a) The board shall allow administration of relative analgesia without a permit if the practitioner:

(1) Is a licensed dentist in the State of West Virginia;

(2) Holds valid and current documentation showing successful completion of a Health Care Provider BLS/CPR course; and

(3) Has completed a training course of instruction in dental school, continuing education or as a postgraduate in the administration of relative analgesia.

(b) A practitioner who administers relative analgesia shall have the following facilities, equipment and drugs available during the procedure and during recovery:

(1) An operating room large enough to adequately accommodate the patient on an operating table or in an operating chair and to allow delivery of age appropriate care in an emergency situation;

(2) An operating table or chair which permits the patient to be positioned so that the patient's airway can be maintained, quickly alter the patient's position in an emergency, and provide a firm platform for the administration of basic life support;

(3) A lighting system which permits evaluation of the patient's skin and mucosal color and a backup lighting system of sufficient intensity to permit completion of any operation underway in the event of a general power failure;

(4) Suction equipment which permits aspiration of the oral and pharyngeal cavities;

(5) An oxygen delivery system with adequate full face masks and appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, together with an adequate backup system; and

(6) A nitrous oxide delivery system with a fail-safe mechanism that will insure appropriate continuous oxygen delivery and a scavenger system.

All equipment used must be appropriate for the height and weight of the patient.

(1) Evaluate the patient;

(2) Give instruction to the patient or, when appropriate due to age or psychological status of the patient, the patient's guardian; and

(3) Certify that the patient is an appropriate candidate for relative analgesia.

(d) A practitioner who administers relative analgesia shall see that the patient’s condition is visually monitored. At all times the patient shall be observed by trained personnel until discharge criteria have been met. Trained personnel shall be certified in both adult and pediatric CPR. Documentation of credentials and training must be maintained in the personnel records of the trained personnel. The patient shall be monitored as to response to verbal stimulation and oral mucosal color.

(e) The record must include documentation of all medications administered with dosages, time intervals and route of administration.

(f) A discharge entry shall be made in the patient's record indicating the patient's condition upon discharge.

(g) Hold valid and current documentation:

(1) Showing successful completion of a Health Care Provider BLS/CPR course; and

(2) Have received training and be competent in the recognition and treatment of medical emergencies, monitoring vital signs, the operation of nitrous oxide delivery systems and the use of the sphygmomanometer and stethoscope.

(h) The practitioner shall assess the patient's responsiveness using preoperative values as normal guidelines and discharge the patient only when the following criteria are met:

(1) The patient is alert and oriented to person, place and time as appropriate to age and preoperative neurological status;

(2) The patient can talk and respond coherently to verbal questioning or to preoperative neurological status;

(3) The patient can sit up unaided or without assistance or to preoperative neurological status;

(4) The patient can ambulate with minimal assistance or to preoperative neurological status; and

(5) The patient does not have nausea, vomiting or dizziness.

§30-4A-6b. Qualifications, standards applicable, and continuing education requirements for a Class II Certificate.

(a) The board shall issue a Class II Certificate to an applicant who:

(1) Is a licensed dentist in West Virginia;

(2) Holds valid and current documentation showing successful completion of a Health Care Provider BLS/CPR; and

(3) Has completed a board approved course of at least six hours didactic and clinical of either predoctoral dental school or postgraduate instruction.

(b) A dentist who induces anxiolysis shall have the following facilities, properly maintained equipment and appropriate drugs available during the procedures and during recovery:

(1) An operating room large enough to adequately accommodate the patient on an operating table or in an operating chair and to allow an operating team of at least two individuals to freely move about the patient;

(2) An operating table or chair which permits the patient to be positioned so the operating team can maintain the patient's airway, quickly alter the patient's position in an emergency, and provide a firm platform for the administration of basic life support;

(4) Suction equipment which permits aspiration of the oral and pharyngeal cavities;

(5) An oxygen delivery system with adequate full face mask and appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, together with an adequate backup system;

(6) A nitrous oxide delivery system with a fail-safe mechanism that will insure appropriate continuous oxygen delivery and a scavenger system;

(7) A recovery area that has available oxygen, adequate lighting, suction and electrical outlets. The recovery area can be the operating room;

(8) Sphygmomanometer, stethoscope, and pulse oximeter;

(9) Emergency drugs; and

(10) A defibrillator device is recommended.

(11) All equipment and medication dosages must be in accordance with the height and weight of the patient being treated.

(1) Evaluate the patient;

(2) Certify that the patient is an appropriate candidate for anxiolysis sedation; and

(3) Obtain written informed consent from the patient or patient's guardian for the anesthesia. The obtaining of the informed consent shall be documented in the patient's record.

(d) The dentist shall monitor and record the patient's condition or shall use trained personnel qualified as a monitor to monitor and record the patient's condition. The trained personnel must have a certificate showing successful completion in the last two years of BLS/CPR training. A Class II Certificate holder shall have no more than one person under anxiolysis at the same time.

(e) The patient shall be monitored as follows:

(1) Patients must have continuous monitoring using pulse oximetry. The patient's blood pressure, heart rate and respiration shall be recorded at least once before, during and after the procedure, and these recordings shall be documented in the patient record. At all times the patient shall be observed by trained personnel until discharge criteria have been met. If the dentist is unable to obtain this information, the reasons shall be documented in the patient's record. The record must also include documentation of all medications administered with dosages, time intervals and route of administration.

(2) A discharge entry shall be made by the dentist in the patient's record indicating the patient's condition upon discharge.

(f) A permit holder who uses anxiolysis shall see that the patient’s condition is visually monitored. The patient shall be monitored as to response to verbal stimulation, oral mucosal color and preoperative and postoperative vital signs.

(g) The dentist shall assess the patient's responsiveness using preoperative values as normal guidelines and discharge the patient only when the following criteria are met:

(1) Vital signs including blood pressure, pulse rate and respiratory rate are stable;

(2) The patient is alert and oriented to person, place and time as appropriate to age and preoperative neurological status;

(3) The patient can talk and respond coherently to verbal questioning, or to preoperative neurological status;

(4) The patient can sit up unaided, or to preoperative neurological status;

(5) The patient can ambulate with minimal assistance, or to preoperative neurological status; and

(6) The patient does not have uncontrollable nausea or vomiting and has minimal dizziness.

(7) A dentist may not release a patient who has undergone anxyolysis except to the care of a responsible adult third party.

§30-4A-6c. Qualifications, standards applicable, and continuing education requirements for Class III Anesthesia Certificate or permit.

(a) The board shall issue or renew a Class 3 Permit to an applicant who:

(1) Is a licensed dentist in West Virginia;

(2) Holds valid and current documentation showing successful completion of a Health Care Provider BLS/CPR course, ACLS and/or a PALS course if treating pediatric patients; and

(3) Satisfies one of the following criteria:

(A) Certificate of completion of a comprehensive training program in conscious sedation that satisfies the requirements described in Part III of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced.

(B) Certificate of completion of an ADA accredited postdoctoral training program which affords comprehensive and appropriate training necessary to administer and manage conscious sedation, commensurate with these guidelines.

(C) In lieu of these requirements, the board may accept documented evidence of equivalent training or experience in conscious sedation anesthesia:

(i) Limited (Enteral) Permit (3(a)) must have a board approved course of at least eighteen hours didactic and twenty mentored clinical cases (PALS or ACLS course).

(ii) Comprehensive (Parenteral) Permit (3(b)) must have a board approved course of at least sixty hours didactic and twenty mentored clinical cases (ACLS course).

(b) A dentist who induces conscious sedation shall have the following facilities, properly maintained age appropriate equipment and age appropriate medications available during the procedures and during recovery:

(4) Suction equipment which permits aspiration of the oral and pharyngeal cavities and a backup suction device which will function in the event of a general power failure;

(6) A nitrous oxide delivery system with a fail-safe mechanism that will insure appropriate continuous oxygen delivery and a scavenger system;

(7) A recovery area that has available oxygen, adequate lighting, suction and electrical outlets. The recovery area can be the operating room;

(8) Sphygmomanometer, pulse oximeter, oral and nasopharyngeal airways, intravenous fluid administration equipment;

(9) Emergency drugs including, but not limited to: Pharmacologic antagonists appropriate to the drugs used, vasopressors, corticosteroids, bronchodilators, antihistamines, antihypertensives and anticonvulsants; and

(10) A defibrillator device.

(1) Evaluate the patient and document, using the American Society of Anesthesiologists Patient Physical Status Classifications, that the patient is an appropriate candidate for conscious sedation;

(2) Give written preoperative and postoperative instructions to the patient or, when appropriate due to age or neurological status of the patient, the patient's guardian; and

(3) Obtain written informed consent from the patient or patient's guardian for the anesthesia.

(d) The dentist shall monitor and record the patient's condition or shall use an assistant qualified as a monitor to monitor and record the patient's condition. A qualified monitor shall be present to monitor the patient at all times.

(e) The patient shall be monitored as follows:

(1) Patients must have continuous monitoring using pulse oximetry. At no time shall the patient be unobserved by trained personnel until discharge criteria have been met. The trained personnel must have a certificate showing successful completion in the last two years of BLS/CPR training and the American Association of Oral and Maxillofacial Surgeon Office Anesthesia Assistant certification or an equivalent. The patient's blood pressure, heart rate, and respiration shall be recorded every five minutes, and these recordings shall be documented in the patient record. The record must also include documentation of preoperative and postoperative vital signs, all medications administered with dosages, time intervals and route of administration. If the dentist is unable to obtain this information, the reasons shall be documented in the patient's record.

(2) During the recovery phase, the patient must be monitored by a qualified monitor.

(3) A discharge entry shall be made by the dentist in the patient's record indicating the patient's condition upon discharge and the name of the responsible party to whom the patient was discharged.

(f) A dentist may not release a patient who has undergone conscious sedation except to the care of a responsible adult third party.

(g) The dentist shall assess the patient's responsiveness using preoperative values as normal guidelines and discharge the patient only when the following criteria are met:

(1) Vital signs including blood pressure, pulse rate and respiratory rate are stable;

(2) The patient is alert and oriented to person, place and time as appropriate to age and preoperative neurological status;

(3) The patient can talk and respond coherently to verbal questioning, or to preoperative neurological status;

(4) The patient can sit up unaided, or to preoperative neurological status;

(5) The patient can ambulate with minimal assistance, or to preoperative neurological status; and

(6) The patient does not have uncontrollable nausea or vomiting and has minimal dizziness.

(h) A dentist who induces conscious sedation shall employ the services of an assistant at all times who holds a valid BLS/CPR certification and maintains such certification.

(i) A dentist granted a Class III Permit must hold a valid Health Care Provider BLS/CPR and ACLS certification for Comprehensive (3(a)) Permit and ACLS or PALS certification for Limited (3(b)) Permit and maintain such certification.

§30-4A-6d. Qualifications, standards applicable, and continuing education requirements for Class IV Anesthesia Permit.

(a) A Class IV Permit permits the use of general anesthesia/deep conscious sedation, conscious sedation, and anxiolysis.

(b) The board shall issue a Class IV Permit to an applicant who:

(1) Is a licensed dentist in West Virginia;

(2) Has a current Advanced Cardiac Life Support (ACLS) Certificate;

(3) Satisfies one of the following criteria:

(A) Completion of an advanced training program in anesthesia and related subjects beyond the undergraduate dental curriculum that satisfies the requirements described in Part II of the ADA Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry at the time training was commenced;

(B) Completion of an ADA or AMA accredited postdoctoral training program which affords comprehensive and appropriate training necessary to administer and manage general anesthesia, commensurate with these guidelines;

(C) In lieu of these requirements, the board may accept documented evidence of equivalent training or experience in general anesthesia.

(c) A dentist who induces general anesthesia/deep conscious sedation shall have the following facilities, properly maintained age appropriate equipment and age appropriate drugs available during the procedure and during recovery:

(1) An operating room large enough to adequately accommodate the patient on an operating table or in an operating chair and to allow an operating team of at least three individuals to freely move about the patient;

(4) Suction equipment which permits aspiration of the oral and pharyngeal cavities and a backup suction device which will function in the event of a general power failure;

(6) A nitrous oxide delivery system with a fail-safe mechanism that will insure appropriate continuous oxygen delivery and a scavenger system;

(7) A recovery area that has available oxygen, adequate lighting, suction and electrical outlets. The recovery area can be the operating room;

(8) Sphygmomanometer, pulse oximeter, electrocardiograph monitor, defibrillator or automated external defibrillator, laryngoscope with endotracheal tubes, oral and nasopharyngeal airways, intravenous fluid administration equipment;

(9) Emergency drugs including, but not limited to: Pharmacologic antagonists appropriate to the drugs used, vasopressors, corticosteroids, bronchodilators, intravenous medications for treatment of cardiac arrest, narcotic antagonist, antihistaminic, antiarrhythmics, antihypertensives and anticonvulsants; and

(10) A defibrillator device.

(d) Before inducing general anesthesia/deep conscious sedation the dentist shall:

(1) Evaluate the patient and document, using the American Society of Anesthesiologists Patient Physical Status Classifications, that the patient is an appropriate candidate for general anesthesia or deep conscious sedation;

(2) Shall give written preoperative and postoperative instructions to the patient or, when appropriate due to age or neurological status of the patient, the patient's guardian; and

(3) Shall obtain written informed consent from the patient or patient's guardian for the anesthesia.

(e) A dentist who induces general anesthesia/deep conscious sedation shall monitor and record the patient's condition on a contemporaneous record or shall use an assistant qualified as a monitor to monitor and record the patient's condition on a contemporaneous record. The trained personnel must have a certificate showing successful completion in the last two years of BLS/CPR training and the American Association of Oral and Maxillofacial Surgeon Office Anesthesia Assistant certification or an equivalent. No permit holder shall have more than one patient under general anesthesia at the same time.

(f) The patient shall be monitored as follows:

(1) Patients must have continuous monitoring of their heart rate, oxygen saturation levels and respiration. At no time shall the patient be unobserved by trained personnel until discharge criteria have been met. The patient's blood pressure, heart rate and oxygen saturation shall be assessed every five minutes, and shall be contemporaneously documented in the patient record. The record must also include documentation of preoperative and postoperative vital signs, all medications administered with dosages, time intervals and route of administration. The person administering the anesthesia may not leave the patient while the patient is under general anesthesia;

(2) During the recovery phase, the patient must be monitored, including the use of pulse oximetry, by a qualified individual to monitor patients recovering from general anesthesia; and

(3) A dentist may not release a patient who has undergone general anesthesia/deep conscious sedation except to the care of a responsible adult third party.

(g) The dentist shall assess the patient's responsiveness using preoperative values as normal guidelines and discharge the patient only when the following criteria are met:

(1) Vital signs including blood pressure, pulse rate and respiratory rate are stable;

(2) The patient is alert and oriented to person, place and time as appropriate to age and preoperative neurological status;

(3) The patient can talk and respond coherently to verbal questioning, or to preoperative neurological status;

(4) The patient can sit up unaided, or to preoperative neurological status;

(5) The patient can ambulate with minimal assistance, or to preoperative neurological status; and

(6) The patient does not have nausea or vomiting and has minimal dizziness.

(7) A discharge entry shall be made in the patient's record by the dentist indicating the patient's condition upon discharge and the name of the responsible party to whom the patient was discharged.

(h) A dentist who induces general anesthesia shall employ the services of a qualified dental assistant who holds a valid BLS/CPR certification and maintains such certification.

(i) A Class IV permit holder must hold a valid Health Care Provider BLS/CPR and ACLS certification and maintain such certification.

§30-4A-8. Office evaluations.

(1) (a) The in-office evaluation shall include:

(a) (1) Observation of one or more cases of anesthesia to determine the appropriateness of technique and adequacy of patient evaluation and care;

(b) (2) Inspection of facilities, equipment, drugs and records; and

(2) (3) The evaluation shall be performed by a team appointed by the board and shall include:

(a) (A) A permit holder who has the same type of license as the licensee to be evaluated and who holds a current anesthesia permit in the same class or in a higher class than that held by the licensee being evaluated;

(b) (B) A member of the board's Anesthesia Committee;

(d) (D) Class III and IV permit holders shall be evaluated once every five years.

(b) A dentist utilizing a licensed dentist anesthesiologist shall have his or her office inspected to the level of permit by the dentist anesthesiologist. The office is only approved at that level when the dentist anesthesiologist is present and shall have the number of qualified monitors present as required by this article.

NOTE: The purpose of this bill is to clarify the certificate and permit requirements to administer anesthesia.

Strike-throughs indicate language that would be stricken from the present law, and underscoring indicates new language that would be added.

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