William Flick - I Floss Presentation.ppt


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William Flick - I Floss Presentation.ppt

  1. 1. William G Flick DDS, MPH Clinical Associate Professor University of Illinois Chicago Oral Maxillofacial Surgery Public Health Implications of the Illinois Dental Anesthesia and Sedation Survey for 2006 Sponsored by the Illinois Dental Society of Anesthesiology, and the Illinois Society of Oral Maxillofacial Surgeons
  2. 2. Dental Anesthesia and Sedation The Lighting Rod for Public Attention ! <ul><li>Probably the single most scrutinized area of dental practice </li></ul><ul><li>Adverse outcomes create a disproportionate amount of media attention </li></ul><ul><li>Public concern regarding the, appropriateness, regulation and even the necessity of such services. </li></ul>
  3. 3. Example of Media Attention
  4. 4. The Challenge <ul><li>Sustain the Public’s confidence </li></ul><ul><li>Ensure public safety </li></ul><ul><li>Maintain availability of office based anesthesia and sedation services </li></ul><ul><li>Promote the cost effectiveness of office based anesthesia. </li></ul>
  5. 5. Multi Faceted Pro Active Response <ul><li>Governmental Sector, Regulatory Agencies </li></ul><ul><li>Input From Organized Dentistry </li></ul><ul><li>Research to Generate Data that Reflects the Scope, Utilization and Outcome </li></ul><ul><li>Continual reassessment of public health policy regarding services. </li></ul>
  6. 6. Illinois Dental Practice Acts Regulates Practice of Anesthesia by Dentists <ul><li>No permit required for Anxiolysis, Nitrous Oxide Analgesia </li></ul><ul><li>Permit A– Conscious Sedation, includes oral and parenteral </li></ul><ul><li>Permit B- Deep Sedation and General Anesthesia </li></ul>
  7. 7. Illinois Dental Anesthesia and Sedation Survey for 2006 <ul><li>A follow up survey of an earlier study conducted in 1996 among all dental practitioners in Illinois with a Type A permit for conscious sedation or a Type B permit for deep sedation/general anesthesia. </li></ul><ul><li>The survey describes the scope and many aspects about the sedation and anesthesia services offered in dental offices in Illinois. </li></ul><ul><li>The information is useful to the profession, public health policy advocates and regulatory agencies. </li></ul>
  8. 8. Issues addressed in the survey : <ul><li>age, years in practice </li></ul><ul><li>type of practice </li></ul><ul><li>ACLS training </li></ul><ul><li>peer review, accreditation </li></ul><ul><li>staffing </li></ul><ul><li>type of sedation drugs used </li></ul><ul><li>intubation in office </li></ul><ul><li>number of cases treated </li></ul><ul><li>morbidity, mortality </li></ul><ul><li>use of capnography </li></ul><ul><li>AED use </li></ul><ul><li>Dantrolene in emergency kit </li></ul>
  9. 9. Why an update of survey at this time? <ul><li>10 year anniversary </li></ul><ul><li>permit for oral sedation in Illinois </li></ul><ul><li>Anesthesia CE for license renewal </li></ul><ul><li>New inhalation agents, ie. Sevoflurane </li></ul><ul><li>Interruption of Brevital supply </li></ul><ul><li>Generic forms of Propofol and Versed </li></ul><ul><li>Mandatory AAOMS peer review </li></ul><ul><li>Dental anesthesiology specialty </li></ul><ul><li>Anecdotal reports of anesthesia related deaths in dental office </li></ul>
  10. 10. Methods <ul><li>a mail survey to all dentists in Illinois , registered with Illinois Dept. Professional Regulation with Anesthesia Permit ( n 471) </li></ul><ul><li>25 questions, 3 page, fill in, survey </li></ul><ul><li>second mailing after 6 weeks </li></ul><ul><li>respondents remained anonymous. </li></ul><ul><li>computer data base analysis </li></ul><ul><li>University of Illinois Chicago, Institutional Review Board, exemption granted </li></ul>
  11. 11. Initial Survey Results <ul><li>Initial mailing, list from IDPR, N 471 </li></ul><ul><li>Undeliverable, returned , n 27 </li></ul><ul><li>Responses, n 305 </li></ul><ul><li>Response rate 2006/ 69% </li></ul><ul><li>Response rate 1996 / 71% </li></ul>
  12. 12. Type of Permit <ul><li>1996 </li></ul><ul><li>14% Type A Conscious Sedation </li></ul><ul><li>86% Type B General Anesthesia/ Deep Sedation </li></ul><ul><li>2006 </li></ul><ul><li>34% Type A Conscious Sedation </li></ul><ul><li>64 % Type B General Anesthesia/ Deep Sedation </li></ul>
  13. 14. Type of Practice <ul><li>1996 </li></ul><ul><li>General Dentistry 11% </li></ul><ul><li>Oral Max Surg 84% </li></ul><ul><li>Periodontics 5% </li></ul><ul><li>Pedodontics 0% </li></ul><ul><li>Dent. Anesthesia <1% </li></ul><ul><li>2006 </li></ul><ul><li>General Dentistry 20% </li></ul><ul><li>Oral Max Surg 63% </li></ul><ul><li>Periodontics 6% </li></ul><ul><li>Pedodontics 9% </li></ul><ul><li>Dent. Anesthesia 1% </li></ul>
  14. 16. Years In Practice <ul><li>N 299 </li></ul><ul><li>Mean 20.7 (16.3 in 96) </li></ul><ul><li>Median 22.0 </li></ul><ul><li>Std. Deviation 10.5 </li></ul><ul><li>Minimum 1.0 </li></ul><ul><li>Maximum 50.0 </li></ul>
  15. 17. Age of Practitioners <ul><li>n 295 </li></ul><ul><li>Mean 49.8 </li></ul><ul><li>Median 51.0 </li></ul><ul><li>Std Deviation 9.7 </li></ul><ul><li>Minimum 30. </li></ul><ul><li>Maximum 78.0 </li></ul>
  16. 18. Practitioners With MD <ul><li>Practitioners reporting additional qualification of M.D. degree 2006, n 15 (5%) </li></ul><ul><li>Practitioners reporting additional qualification of M.D. degree 1996, n 10 (4%) </li></ul>
  17. 19. ACLS Training <ul><li>1996 </li></ul><ul><li>85% Initial Course </li></ul><ul><li>48% Recertification </li></ul><ul><li>2006 </li></ul><ul><li>90% Initial Course </li></ul><ul><li>80% Recertification </li></ul>
  18. 21. Peer Review/ Office Accreditation <ul><li>ISOMS/AAOMS office anesthesia review program n 159 (53%) </li></ul><ul><li>JCAHO or AAAHC office facility accreditation n 10 (4%) </li></ul><ul><li>None n 129 ( 43%) </li></ul>
  19. 22. Office Anesthesia Team Configuration <ul><li>Operator, one assistant </li></ul><ul><ul><li>11.5% (12%,96) </li></ul></ul><ul><li>Operator, two assistants </li></ul><ul><ul><li>66.5% (82%, 96) </li></ul></ul><ul><li>Operator, R.N or CRNA., assistant 13% ( 4%, 96) </li></ul><ul><li>Operator, MD /DDS anesthesiologist, assistant 8.8% (2%, 96) </li></ul>
  20. 23. Anesthesia Team Configuration
  21. 24. Practitioners Indicating Utilization of CRNA, MD or DDS Anesthesiologist <ul><li>CRNA n 29 (10%) </li></ul><ul><li>MD anesthesiologist n 28 (9%) </li></ul><ul><li>DDS anesthesiologist n 42 (15%) </li></ul>
  22. 25. Elective Intubations in Office <ul><li>1996 </li></ul><ul><li>Do not intubate 96% </li></ul><ul><li>2% intubate < 25% </li></ul><ul><li>1% intubate >51%< 75% </li></ul><ul><li>2006 </li></ul><ul><li>Do not intubate 94% </li></ul><ul><li>3% intubate <25% </li></ul><ul><li>2% intubate <25<75% </li></ul><ul><li>2% intubate <75% </li></ul>
  23. 26. Intubation in Office
  24. 28. Versed, Fentanyl, Propofol Practitioners’ Preference 2006
  25. 29. Practitioners’ Preference Sevoflurane
  26. 31. Reported Number of Patients Treated With I.V. Sedation/General Anesthesia <ul><li>For the year Jan 1, 05 thru Dec. 31, 05 </li></ul><ul><li>109,121 Total for all Dentists </li></ul><ul><li>100,269 ( 92%)by Oral Maxillofacial Surgeons </li></ul>
  27. 32. Reported Number of Patients Treated with Oral Sedation <ul><li>For the year Jan. 1, 2005 thru Dec. 31, 2005 </li></ul><ul><li>By all dentists n 6,819 </li></ul><ul><li>By oral maxillofacial surgeons n 2,959 (43%) </li></ul>
  28. 33. Morbidity/ Mortality 10 year period Jan.1, 1996 thru December 31, 2006 <ul><li>Death associated with treatment n 2 </li></ul><ul><li>(Approximately one death/500,000) </li></ul><ul><li>Patients transferred to hospital with long term morbidity n 2 </li></ul><ul><li>Patient transferred to hospital with no long term morbidity n 30 </li></ul>
  29. 34. Controversial Practice Trends <ul><li>Capnograpy usage 9.0% </li></ul><ul><li>Automated Electronic Defibrillator 63% </li></ul><ul><li>Dantrolene stocked as emergency drug 21.6% </li></ul>
  30. 35. Summary and Conclusions Providers and Staffing <ul><li>The proportion of non-oral surgeon dentists providing sedation services has increased. </li></ul><ul><li>Based upon number of cases, oral maxillofacial surgeons continue to provide vast majority of sedation and anesthesia services in the dental setting </li></ul><ul><li>Utilization of CRNAs, DDS and MD anesthesiologists, although relatively low is increasing. </li></ul>
  31. 36. Summary and Conclusions Training and Airway <ul><li>90% of providers are ACLS trained </li></ul><ul><li>80% of providers report ACLS training is current (within 2 years) </li></ul><ul><li>The number of patients intubated in the dental office remains very low </li></ul><ul><li>Use of capnography monitoring remains low </li></ul>
  32. 37. Summary and Conclusions Regulation and Peer review <ul><li>The number of dentists providing sedation in an office accredited by the JCAHO or AAAHC is 4% </li></ul><ul><li>84 % of Oral Surgeons have participated with the AAOMS anesthesia evaluation program. </li></ul><ul><li>43% of providers do not participate in any peer review or accreditation program </li></ul><ul><li>Significant number of providers may not be staffing consistent with Illinois Dental Practice Act rules and regulations </li></ul>
  33. 38. Summary and Conclusions Medications <ul><li>Versed and Fentanyl are now the favored IV sedative agents. </li></ul><ul><li>Propofol has replaced Brevital as the favored short acting anesthesia inducing agent </li></ul><ul><li>Versed is the favored oral sedative agent </li></ul><ul><li>For inhalation agents, Sevoflurane is the favored agent. </li></ul>
  34. 39. Summary and Conclusions Morbidity and Mortality <ul><li>Two mortalities in 10 years were reported </li></ul><ul><li>(In excess of one million patients treated) </li></ul><ul><li>Two long term morbidities were reported </li></ul><ul><li>Thirty events required transfer to ER for management </li></ul>
  35. 40. Comparison of Mortality Rates <ul><li>Illinois Survey* </li></ul><ul><li>10 years, 2 deaths over one million patients. </li></ul><ul><li>1:500,000 </li></ul><ul><li>OMSNIC Claims* </li></ul><ul><li>1:900,000 </li></ul><ul><li>McCarthy* </li></ul><ul><li>1:400,000 U.S., California </li></ul><ul><li>1:300,000 U.K. Dental Offices </li></ul><ul><li>1:40,000 T and A’s U.S. </li></ul><ul><li>!:15,000 Teaching Hospital U.S. </li></ul>
  36. 42. ER and discharged Patient developed atypical tachycardia Arrhythmia ER discharged without complications Unstable blood pressure, hpotensive and hypertensive. Bood Pressure ER, discharged without complications 48 y/o had vasovagal reaction, 15 minutes after completion of procedure Prolonged Recovery ER for management Sustained seizure activity, did not respond to anti-convulsives. Previous history of epilepsy and had therapeutic levels of anti-seizure meds. Seizures ER, monitored and discharged Slow recovery from I.V. sedation Prolonged Recovery ER, tooth retrieved with endoscopy Aspiration of tooth crown under sedation Aspiration Object ER , discharged without complications. 45y/o developed post op chest pain Chest Pain ER, discharged, no cardiac dysfunction was uncovered. Patient had multiple dental extractions under general anesthesia. Slow recovery. Pulse dropped from 80 to 12 to 7. Treated with atropine. Prolonged Recovery ER, hospitalized for three days, patient developed mild stroke 62y/o undisclosed labile hypertension, non-compliant with medications. Under IV sedation developed unstable hypertension Blood Pressure ER transfer, pacemaker inserted one month later General anesthesia for multiple dental extractions. Patient complained of chest pain and feeling faint. EkG revealed atrial fibrillation Arrhythmia ER transfer. MI diagnosis, died five days later. Patient had full mouth extractions under general anesthesia. Patient stopped breathing 50 minutes into procedure. Patient intubated Myocardial Infarction ER transfer, died 50 y/o suffered MI on way to post anesthesia recovery following multiple dental extractions under general anesthesia. Never regained consciousness, patient had a non-disclosed history of MI at age 48 with sever cardiac muscle damage. Myocardial Infarction OUTCOME SCENARIO EVENT Emergency Event Summary
  37. 43. ER, antibiotics 45 y/o aspiration of vomitus post op Aspiration Vomitus ER, hospital to manage airway edema Laryngospasm, intubated in office Airway Management ER, monitored and discharged Asthma during anesthesia Airway Management ER, monitored and discharged Seizures under IV sedation Seizures ER, monitored and discharged Undisclosed cocaine us, dropped BP Drug Abuse ER, monitored and discharged Ventricular arrhythmia Arrhythmia ER, monitored and discharged Arrived and discharged with new onset atrial fibrillation Arrhythmia ER, diagnosed as pinched intercostal nerve 26 y/o chest pain following IV sedation Chest Pain ER, monitored and discharged Apnea, airway loss, unable to ventilate, intubated in office Airway Management ER, gauze retrieved 4x4 gauze loged in airway under IV sedation Aspiration Object ER, monitored and discharged Allergic reaction to Brevital Allegric Reaction
  38. 44. ER, hospital two days 40 y/o diabetic vomited under general anesthesia, aspirated. Aspiration Vomitus ER, thought to be related to h/o psychiatric problems Unresponsive post-op, normal breathing, stable vital signs Prolonged Recovery ER, monitored and discharged Hypeertensive episode Blood Pressure ER, hospital, mangement of bronchospasm 19 y/o undisclosed drug abuse, laryngospasm, intubated, excessive secretions Airway Management ER, monitored and discharged, non-cardiac 30 y/o post-op chest pain Chest Pain ER, monitored and discharged Delirium, hypertension post-op, no intraoperative hypertension, resolved with narcan Prolonged Recovery ER, monitored and discharged, non-cardiac Post-op chest pain Chest Pain ER, monitored and discharged, non-cardiac Post-op chest pain Chest Pain ER, monitored and discharged, non-cardiac Post-op chest pain Chest Pain ER, monitored and discharged Slow recovery from versed Prolonged Recovery ER, monitored and discharged 18 y/o developed tachycardia under sedation Arrhythmia
  39. 45. Illinois Dental Practice Act Chart