Inhalation Sedation. Clarification for a Corporate.

  " I have looked at the RA proposal and it is not viable on a number of levels".

1) "Dr. X would need to be sedation trained on an approved SAAD course, and according to our conscious sedation policy he would need to evidence that he was regularly practicing and delivering this as outlined in the IACSD"

Incorrect on both points.

A) SAAD do not approve courses. As of April 2015, it was the IACSD, on which SAAD were just one of many stakeholders, who produced the latest gold-standard guidelines and who can accredit courses.  It was  Accreditation Sub-Committee, appointed by IACSD, who accredited my courses, giving them the equivalence of a university-based module in this subject.

The Accreditation Sub-Committee was made up of senior SAAD and DSTG committee members. In addition SAAD themselves cannot certify competence as they are not set up to provide the required work-based assessments. SAAD & DSTG support the IACSD guidelines.

Please see the recent website statements:

SAAD statement 

DSTG statement

B)  This is a misreading of the IACSD report. The only people for whom "regularly practising and delivering" apply, are those covered by "Transitional Arrangements". 

These allow those already involved in delivering sedation prior to April 22nd 2015, to carry on. That does not apply to those newly training to deliver sedation techniques and I am specifically accredited to teach those new to sedation to the point of certifying their competence to practice Inhalation sedation without further supervision.

2)  The practice would need to be compliant and pass a SAAD inspection (cost approx. £3k)

That is not so unless your organisation wishes it or has been required to undertake the SAAD safe Sedation Scheme. e.g. by NHS commissioners.  I have had this confirmed by SAAD Committee member.

The correct equipment set-up and other formative assessments that I make, during the 2 days of my Work-Based Assessments (WBAs) with each candidate at their practices, will include the suitability of the practice and equipment for carrying out safe Inhalation Sedation.  In the event that there are deficiency noted, these would be brought to your attention to be corrected by day 2. 

I reserve the right NOT to certify any candidate's competence, if in my opinion they are not ready to deliver the service safely and proficiently after my 3-day course. Thus far this has never happened.

Remember, Dr. X we will have discussed the details of the equipment required, including, for example, a recognised method for active scavenging and the correct venting of waste gases outside the building, a correctly constructed "hole" in the exterior building wall either from a free standing unit ( e.g. Mini-scav or similar) or if confirmed by the equipment manufacturer as being safe to do so, via your central suction system, vented to the outside.

3) If Dr. X was carrying out the sedation and the treatment he would need 2 nurses present, one with sedation training.

This is totally incorrect for inhalation Sedation. It shows a lack of understanding I am afraid.

This ONLY APPLIES TO INTRA-VENOUS SEDATION.

4) "The whole practice team involved in the delivery would need ILS training and current gold standard is that this is specifically paediatric, and we do not currently have this training as a business."

"Involved in the delivery" means you and your RDN.

ILS + PILS is correct, to comply with the guidelines.

ILS = BLS + AED + Deployable airway 

(Do you cover these 3 elements in your practice's standard Life Support training already?)

PILS must be "age-appropriate", which would be from, say for 4 years of age (no age is actually specified) and so will not need to include elements required by the Resus Council's PILS courses covering neo-nates and infants.

I have tried to arrange a 1-day ILS+PILS via independant resus trainers without success so far. I may try again soon.  This means that for now at least you and your nurse may have no option but to undertake a PILS course via the Resus Council even though much of this will be irrelevant.

I have attached the IACSD FAQs which may help several of the points raised too.

FAQs 4 Dec 2015 — Royal College of Surgeons

				FAQs 4 Dec 2015 — Royal College of Surgeons © 2016 The Royal College of Surgeons of England 35-43 Lincoln's Inn Fields, London WC2A 3PE Tel: +44 (0) 20 7405 3474 Registered Charity no: 212808
				View on www.rcseng.ac.uk	Preview by Yahoo

5) Currently the CDO’s have referred the IACSD guidance to SCDEP for review of guidance report regarding implementation in primary care.

That is true BUT SAAD & DSTG stand by the IACSD report. If despite their advice, you choose to be guided by the CDO, then currently you can choose to revert to the "Extant" guidelines of 2003. 

I have no idea when the SCDEP will report and when they do so what they will suggest. They may even reduce some requirements for "RA" but I have no evidence for that!

2003 guidelines would mean you would be OK to ignore the PILS requirements of IACSD and if you "felt competent", just go ahead to practice without the need for the WBAs!

6) Evidence base demonstrates that IV sedation is more effective for adult patients.

What evidence?

IVS has a higher morbidity and chance of complications. Over-sedation with IVS is potentially more serious, not least if it occurs in the middle of a surgical procedure. It has a much longer recovery period for patients and requires a competent adult escort. However when it is indicated OR Inhal. Sed. is contraindicated then yes, IVS would be the correct approach.

My evidence of 7-8000 patients over 38 years in a general practice setting says it is entirely a matter of patient selection.  I also have a library of testimonials from adults whose lives we have changed let alone treatment accomplished using inhalation Sedation.

In my private practice between 1999  (when I introduced IVS to add to my Inhalation Sedation service) and 2014, I found that I used IVS once per month and Inhalation Sedation 20 times per month on average.

In addition the latest guidelines requires us to use the least invasive procedure.

From Page 6:

"Optimal care is patient-centred and focuses on the needs of the individual". So not one-size fits all."

From page 15: para2

“No one technique is suitable for all patients. However, adopting the principle of minimum intervention, the simplest and safest technique based on robust patient assessment and clinical need, should be used. “

7) The practice would need to demonstrate to an outside body that the delivery of sedation is safe, compliant and in patient’s best interests.

Having been accredited, then I can act as that outside body.

As mentioned above, if in my opinion the practitioner/practice is not competent to provide Inhalation Sedation after the accredited 3-day course has been completed then I will not certify their competence.  A formative assessment report will be provided at the end of day 2 of the WBAs

In case of any doubts, please write to Neil Sutcliffe of the IACSD. He will answer your queries or refer them onto the appropriate IACSD committee member

Neil Sutcliffe

NACPDE Administrator & Committee Manager

Royal College of Surgeons
Faculty of Dental Surgery
35-43 Lincoln's Inn Fields
London WC2A 3PET: 020 7869 6804E: nsutcliffe@rcseng.ac.ukW: www.rcseng.ac.uk

I hope this has helped clarify many of the points raised.

A Spring Cantilver Bridge 1975 - Richard Charon

OK. Here we go. A little background. I made this as a final year student in Manchester. The patient was 21 y.o. and a rugby player (team mate).  

He had lost one upper central and damaged the adjacent lateral about 3 years earlier. The other central was chipped at the MI corner but otherwise sound. He attended having already had a spring cantilever bridge made 2-3 years before. My typed notes state that the original slice preps for the 3/4 GC retainers were too short and so provided inadequate mechanical retention.

Apart from possibly the cast gold post/core for the post crown (Little or no ferrule possible!), the rest of the casting and the PJCs were made by the Dental School Lab techs. 

Even in B&W we can see the shade match wasn't great. The images were taken on a day that the bridge was cemented with a temporary Zinc Oxide Eugenol + Vaseline temporary cement. 

Also note the state of the gingival tissues at the lateral incisor crown. I believe that TC had been in place for about a month and no doubt had faulty margins which caused gingival irritation and I almost certainly had just cauterised the bleeding tissue with a heated burnisher. 

Rem these scanned images are from B&W prints which are 40-odd years old, taken with my newly acquired 35mm Pentax camera with 135 mm Telephoto lens + extension tubes and an attached hot-shoe flash gun too.

The die for the lateral incisor would have been copper plated.

It is also worth noting that due to the high gold costs, students in that year were not permitted to undertake any bridgework unless it was part of an approved elective study - which it was together with some work on precision attachments!