Department of Health/Faculty of General Dental Practice (UK)s540821202.websitehome.co.uk/Wordpress2/wp-content/... · Document purpose Best practice guidance ROCR ref: Gateway ref:9102

Guidelines for the Appointment of Dentists with a Special Interest (DwSI) in Conscious Sedation

Department of Health/Facultyof General Dental Practice (UK)

Document purpose Best practice guidance

ROCR ref: Gateway ref: 9102

Title Guidelines for the Appointment of Dentists with a Special Interest (DwSI) in Conscious Sedation

Author DH/Dental and Eye Care Services and FGDP(UK), Royal College ofSurgeons of England

Publication date December 2007

Target audience PCT CEs, NHS Trust CEs, Care Trust CEs, Medical Directors, PCT PECChairs, Directors of HR, Consultants in Dental Public Health, Dental PracticeAdvisors, Directors of Commissioning, Clinical Directors of PCT SalariedDental Services

Circulation list SHA CEs, Directors of PH, GPs, Communications Leads

Description Guidance to PCTs on the appointment of DwSIs in Conscious Sedation,including a competency framework, contract requirements, assessmentstandards and the scope of treatment that can be undertaken. This will be of particular use when reviewing contracts for advanced mandatory servicesin sedation.

Cross ref Implementing a Scheme for Dentists with Special Interests (DwSIs):A Step by Step Guide to Setting Up a DwSI Service. DH/FGDP (UK), May 2004.NHS Primary Care Contracting, 2006

Superseded docs N/A

Action required N/A

Timing N/A

Contact details Tony Jenner, Deputy Chief Dental OfficerDental and Eye Care Services, Commissioning and System Management DirectorSection 11/035, New Kings Beam House22 Upper Ground London SE1 9BW020 7633 4247www.dh.gov.uk/cdo

For recipient’s use

DH INFORMATION READER BOX

Policy EstatesHR/Workforce CommissioningManagement IM&TPlanning FinanceClinical Social Care/Partnership Working

Guidelines for the Appointment of Dentists with a Special Interest (DwSI) in Conscious Sedation

Department of Health/Facultyof General Dental Practice (UK)

Members of DwSI Conscious Sedation Working Group

Christine Arnold – Salaried Primary Dental Care ServicesDavid Craig – King’s College London Dental Institute (Chair) Tom Cripps – Consultant AnaesthetistDerek Debuse – Society for the Advancement of Anaesthesia in Dentistry Sharon Drake – Project Manager, Faculty of General Dental Practice (UK)

and Department of Health Robert Elford – Lay memberRuth Gasser – Department of Health Andrea Goring – Southwark Primary Care TrustRichard Hayward – Faculty of General Dental Practice (UK)Tony Jenner – Department of Health John Lowry – Faculty of Dental Surgery, Royal College of Surgeons of

England Nigel Robb – Association of Dental AnaesthetistsMichael Wood – General Dental Practitioner

1Guidelines for the Appointment of Dentists with a Special Interest (DwSI) in Conscious Sedation

ContentsIntroduction 2

• Rationale for a DwSI in conscious sedation 2

• Definition of a DwSI in conscious sedation 3

• Contract requirements 4

• General requirements 5

Competency framework and assessment standards for a DwSI in conscious sedation 6

Competency framework for a DwSI in conscious sedation 7

• Evidence of maintenance of competencies 18

Accreditation of DwSIs in conscious sedation for PCTs 19

• Contract specification 19

• Appointment of DwSIs in conscious sedation with PCTs 19

• Monitoring of the conscious sedation service 21

• PCTs – needs assessment and delivery 22

• System of assessment and evidence required to demonstrate competence 23

• Sources of evidence 23

• Process 24

Appendices

1. Standard and alternative conscious sedation techniques 25

2. Conscious sedation practice requirements 26

3. Person specification for an experienced specialist in conscious sedation 27

References 28


Introduction1. Guidelines for the Appointment of Dentists with a Special Interest (DwSI) in

Conscious Sedation is one of a series of framework documents jointlydeveloped by the Department of Health and the Faculty of General DentalPractice (FGDP) (UK).

2. The frameworks aim to provide guidance to primary care trusts (PCTs) onthe development of local DwSI services, and include the competencies forthe scope of treatment that can be undertaken by DwSIs.

3. The conscious sedation guidance has been written in conjunction withrepresentatives from the Society for the Advancement of Anaesthesia inDentistry (SAAD), the Association of Dental Anaesthetists (ADA), theBritish Dental Association (BDA), primary care dentists, specialists,consultants, university departments, dental faculties, PCT managers,strategic dental health leads and patients. It acknowledges the work of theDental Sedation Teachers Group (DSTG) in developing a curriculum thatis the basis of the core competencies described in this document.

4. The guidelines apply to England and should be read in conjunction with a number of other documents.1–7

Rationale for a DwSI in conscious sedation

5. The General Dental Council (GDC) document The First Five Years – A Framework for Undergraduate Dental Education 8 states that all dentalgraduates should have a range of practical experience in the administrationof basic conscious sedation techniques.

6. This framework document acknowledges that basic (or ‘standard’)conscious sedation techniques can be carried out by all primary caredentists who are competent to do so, and is not designed to reduce thewidespread access to conscious sedation for dental patients. ‘Basic’conscious sedation techniques are defined as ‘standard’ techniques withinStandards for Conscious Sedation in Dentistry: Alternative Techniques.2

7. The standard conscious sedation techniques are:

• inhalational sedation using nitrous oxide/oxygen

• intravenous sedation using midazolam alone

• oral/transmucosal benzodiazepine (provided that adequate competencein intravenous techniques has been demonstrated – see Appendix 1)


8. In addition, it is expected that the DwSI in conscious sedation may be able to:

• accept referrals from other practices, clinics and hospitals

• offer more advanced or ‘alternative’ conscious sedation techniques

• provide conscious sedation for patients with more complex medicalhistories and/or dental treatment needs

• provide conscious sedation for patients under 12 years of age usingtechniques other than inhaled nitrous oxide and oxygen

Definition of a DwSI in conscious sedation

9. A DwSI in conscious sedation is a primary care dentist who:

• is able to demonstrate a continuing level of competence in theirgeneral dental activities

• is able to demonstrate a continuing level of competence instandard conscious sedation techniques, as well as demonstratingcompetence in some or all of the alternative techniques asdefined in Standards for Conscious Sedation in Dentistry:Alternative Techniques 2 as follows:

– any form of conscious sedation for patients under the age of 12 yearsother than nitrous oxide/oxygen inhalation sedation

– benzodiazepine plus any other intravenous agent, e.g. opioid,propofol or ketamine

– propofol either alone or with any other agent, e.g. benzodiazepine,opioid or ketamine

– inhalational sedation using any agent other than nitrousoxide/oxygen alone

– combined routes, e.g. inhalational plus intravenous agent (except forthe use of nitrous oxide/oxygen during cannulation)


10. While not offering the same breadth of activity, the DwSI in conscioussedation will be required to practise to a standard consistent with thatexpected from the established specialists who cover this area of clinicalexpertise.

11. It is not necessary for the DwSI in conscious sedation to be competent inall alternative conscious sedation techniques. The proposed activity willhave been identified and agreed by the PCT in consultation with allrelevant care agencies.

Contract requirements

12. NHS sedation services can be provided in the primary care setting by:

• primary dental care services managed directly by PCTs

• independent contractors under Personal Dental Services (PDS)agreements (which could be solely for the provision of sedation services)

• independent contractors under General Dental Services (GDS)contracts (provided that sedation is an agreed ‘additional service’)

13. From April 2006, the legislation has provided for two types of NHS dentalcontracts: GDS contracts and PDS agreements. Under a GDS contract, the dentist is required to provide a range of services set out in Regulation14 of the NHS (General Dental Services Contracts) Regulations 2005,4

known as ‘mandatory services’. In addition, a GDS contract can include,where agreed between the PCT and the contractor, other ‘additionalservices’ which include sedation services.

14. The contract between the PCT and the contractor will include the annualnumber of courses of treatment involving sedation.

15. Sedation services are provided as an entire course of treatment by onecontractor. The contractor is credited with units of dental activity for thebanded course of treatment. Dental charges are those appropriate to thebanded course of treatment and there is no charge for the administrationof sedation.


16. The number of courses of treatment that include sedation are reported tothe contractor and PCT on a monthly basis by the Dental ServicesDivision (DSD).

17. For courses of treatment involving the use of conscious sedation, mixing ofprivate and NHS treatment is not permissible under current NHSregulations. This regulation is designed to protect patient safety andmaintain quality assurance by ensuring that, where treatment is providedunder NHS arrangements, any conscious sedation provided in associationwith that treatment is provided in accordance with the recommendationsof the report1 of the Standard Dental Advisory Committee (SDAC).

General requirements

18. In order that PCTs might satisfactorily contract with a primary care dentistto carry out an agreed area of special interest work, the PCT should, firstand foremost, ensure that the primary care dentist is a competent andexperienced generalist.

19. In addition, it is recommended that a PCT satisfies itself that a primarycare dentist wishing to be contracted as a DwSI in conscious sedation isable to satisfactorily demonstrate that they:

a. are able to manage patients with specified indications for conscioussedation to a high standard as defined in the guidelines

b. recognise their limitations of knowledge and competence and are awareof the appropriate time to refer on for treatment

c. have the necessary knowledge and skills, reflecting an approved periodof training and experience as defined in the regulatory guidelines


Competency framework andassessment standards for aDwSI in conscious sedation

20. Some of the competencies may already have been assessed either at anundergraduate or postgraduate level, but it will be necessary to obtainconfirmation of competence.

21. The work of a DwSI in conscious sedation will be specified by the PCTbased upon the needs of the local community. Consequently, there maynot be a requirement for the practitioner to have developed competence inall conscious sedation techniques.

22. They will, however, be required to provide evidence of competence in allfields relevant to those conscious sedation techniques specified by the PCT.

23. This document is intended to assist PCTs in reviewing existing conscioussedation services and in assuring the quality of future services offering bothstandard and alternative conscious sedation techniques.

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Act

200

5O

btai

n ap

prop

riate

con

sent

s fr

om p

atie

nts/

rela

tives

/car

ers

for

the

prop

osed

tre

atm

ent

Eval

uate

the

eff

ectiv

enes

s of

con

scio

us s

edat

ion

Rec

ogni

se o

ppor

tuni

ties

for

prov

idin

g ca

re w

ithou

t co

nsci

ous

seda

tion

Mai

ntai

n le

gibl

e an

d co

ntem

pora

neou

s re

cord

sA

sses

s th

e su

itabi

lity

of s

taff

and

pre

mis

es f

or t

he p

rovi

sion

of

dent

al t

reat

men

tun

der

cons

ciou

s se

datio

n w

ith r

efer

ence

to

curr

ent

guid

elin

es.

The

abili

ty t

o:

Sele

ct t

he p

atie

nts

for

who

m t

his

is t

he m

ost

appr

opria

te s

edat

ion

tech

niqu

eSe

lect

an

appr

opria

te v

ein

and

perf

orm

intr

aven

ous

cann

ulat

ion

Rec

ogni

se s

igns

and

sym

ptom

s of

ext

rava

scul

ar in

ject

ion

Titr

ate

mid

azol

am t

o a

reco

gnis

ed c

onsc

ious

sed

atio

n en

d po

int

Adj

ust

the

titra

tion

regi

me

for

elde

rly p

atie

nts

Adm

inis

ter

supp

lem

enta

l oxy

gen

via

nasa

l can

nula

e w

hen

indi

cate

dR

ecog

nise

the

clin

ical

sig

ns o

f ea

rly a

irway

obs

truc

tion

and

have

airw

aym

anag

emen

t sk

ills

appr

opria

te t

o th

e ag

e of

the

pat

ient

bei

ng t

reat

ed

Rem

ove

intr

aven

ous

cann

ulae

saf

ely

and

at t

he a

ppro

pria

te t

ime

Ass

ess

whe

n a

patie

nt is

fit

to b

e di

scha

rged

Prov

ide

appr

opria

te p

ost-

oper

ativ

e in

stru

ctio

nsM

aint

ain

legi

ble

and

cont

empo

rane

ous

reco

rds

Intr

aven

ous

cons

ciou

sse

dati

on u

sing

mid

azol

am a

lone


MA

JOR

CO

MPE

TEN

CY

SUPP

OR

TIN

G C

OM

PETE

NC

IES

Add

itio

nal

skill

spe

rtai

ning

to

intr

aven

ous

cons

ciou

sse

dati

on u

sing

an a

lter

nati

vein

trav

enou

sse

dati

on a

gent

or c

ombi

nati

onof

age

nts

(inc

ludi

ngpa

tien

t an

dta

rget

-con

trol

led

cons

ciou

sse

dati

on)

Inha

lati

onal

cons

ciou

sse

dati

on u

sing

nitr

ous

oxid

e/ox

ygen

alo

ne

The

abili

ty t

o:

Prov

ide

intr

aven

ous

cons

ciou

s se

datio

n w

ith m

idaz

olam

com

pete

ntly

(in

clud

ing

the

inse

rtio

n of

an

intr

aven

ous

cann

ula)

Se

lect

the

mos

t ap

prop

riate

con

scio

us s

edat

ion

drug

/s a

ccor

ding

to

the

prin

cipl

e of

min

imum

inte

rven

tion,

i.e.

usi

ng t

he s

impl

est

cons

ciou

s se

datio

n te

chni

que

that

will

ena

ble

trea

tmen

t to

be

carr

ied

out

satis

fact

orily

C

ompl

y w

ith r

equi

rem

ents

for

a s

epar

ate

oper

ator

and

sed

atio

nist

(w

here

appr

opria

te),

incl

udin

g th

e se

lect

ion

of a

n ap

prop

riate

indi

vidu

al t

o pr

ovid

e th

eco

nsci

ous

seda

tion

whi

ch is

out

with

the

ope

rato

r’s c

ompe

tenc

e Se

lect

the

mos

t ap

prop

riate

rou

te o

r ro

utes

of

adm

inist

ratio

n fo

r an

indi

vidu

al p

atie

ntR

ecog

nise

sig

ns a

nd s

ympt

oms

that

mig

ht c

ompl

icat

e or

con

trai

ndic

ate

adm

inis

trat

ion

of s

peci

fic d

rugs

or

tech

niqu

es

Sele

ct a

ppro

pria

te d

rugs

and

dos

ages

for

an

indi

vidu

al p

atie

nt, a

dmin

iste

r th

ese

dativ

e ag

ents

in t

he c

orre

ct o

rder

and

rec

ogni

se t

he c

onsc

ious

sed

atio

n en

d po

int

Ope

rate

and

con

firm

cor

rect

fun

ctio

n of

the

equ

ipm

ent

used

for

inte

rmitt

ent/

cont

inuo

us in

trav

enou

s in

fusi

on, p

atie

nt-c

ontr

olle

d in

fusi

on o

r ta

rget

-con

trol

led

infu

sion

tec

hniq

ues

The

abili

ty t

o:

Che

ck t

he f

unct

ion

and

safe

ty f

eatu

res

of t

he in

hala

tiona

l sed

atio

n m

achi

neSe

lect

the

app

ropr

iate

bre

athi

ng s

yste

m a

nd n

asal

mas

kA

djus

t th

e in

hala

tiona

l sed

atio

n m

achi

ne (

gas

mix

ture

and

flo

w, i

nclu

ding

obse

rvat

ion

of r

eser

voir

bag)

in p

repa

ratio

n fo

r ad

min

istr

atio

n of

sed

atio

nTi

trat

e ni

trou

s ox

ide

conc

entr

atio

n an

d re

cogn

ise

the

cons

ciou

s se

datio

n en

d po

int


MA

JOR

CO

MPE

TEN

CY

SUPP

OR

TIN

G C

OM

PETE

NC

IES

Add

itio

nal

skill

spe

rtai

ning

to

inha

lati

onal

cons

ciou

sse

dati

on u

sing

an a

lter

nati

veag

ent

Ensu

re t

he c

orre

ct f

unct

ioni

ng o

f an

ti-po

llutio

n m

easu

res

(gas

sca

veng

ing)

Ass

ess

whe

n a

patie

nt is

fit

to b

e di

scha

rged

Prov

ide

appr

opria

te p

ost-

oper

ativ

e in

stru

ctio

ns

Mai

ntai

n le

gibl

e an

d co

ntem

pora

neou

s re

cord

sR

ecog

nise

the

clin

ical

sig

ns o

f ea

rly a

irway

obs

truc

tion

and

have

airw

aym

anag

emen

t sk

ills

appr

opria

te t

o th

e ag

e of

the

pat

ient

bei

ng t

reat

ed

The

abili

ty t

o:

Prov

ide

inha

latio

nal c

onsc

ious

sed

atio

n w

ith n

itrou

s ox

ide

and

oxyg

en c

ompe

tent

lySe

lect

the

mos

t ap

prop

riate

con

scio

us s

edat

ion

agen

t/s

acco

rdin

g to

the

prin

cipl

eof

min

imum

inte

rven

tion,

i.e.

usi

ng t

he s

impl

est

seda

tion

tech

niqu

e th

at w

ill e

nabl

etr

eatm

ent

to b

e ca

rrie

d ou

t sa

tisfa

ctor

ily

Com

ply

with

req

uire

men

ts f

or a

sep

arat

e op

erat

or a

nd s

edat

ioni

st (

whe

reap

prop

riate

), in

clud

ing

the

sele

ctio

n of

an

appr

opria

te in

divi

dual

to

prov

ide

the

cons

ciou

s se

datio

n w

hich

is o

utw

ith t

he o

pera

tor’s

com

pete

nce

Sele

ct t

he m

ost

appr

opria

te e

quip

men

t fo

r ad

min

istr

atio

n of

the

age

ntR

ecog

nise

the

sig

ns a

nd s

ympt

oms

that

mig

ht c

ompl

icat

e or

con

trai

ndic

ate

adm

inis

trat

ion

of s

peci

fic d

rugs

or

tech

niqu

es

Sele

ct t

he a

ppro

pria

te d

rugs

and

dos

age

for

an in

divi

dual

pat

ient

and

rec

ogni

se t

heco

nsci

ous

seda

tion

end

poin

tO

pera

te a

nd c

onfir

m c

orre

ct f

unct

ion

of t

he e

quip

men

t us

ed f

or a

dmin

istr

atio

n(e

.g. a

naes

thet

ic m

achi

ne, v

apor

iser

)


MA

JOR

CO

MPE

TEN

CY

SUPP

OR

TIN

G C

OM

PETE

NC

IES

The

abili

ty t

o:

Com

pete

ntly

pro

vide

intr

aven

ous

cons

ciou

s se

datio

n w

ith m

idaz

olam

, inc

ludi

ngth

e in

sert

ion

of a

n in

trav

enou

s ca

nnul

aSe

lect

the

mos

t ap

prop

riate

con

scio

us s

edat

ion

drug

Se

lect

the

mos

t ap

prop

riate

rou

te o

f ad

min

istr

atio

n (e

.g. o

ral,

intr

anas

al,

tran

smuc

osal

) fo

r an

indi

vidu

al p

atie

nt, a

s de

fined

with

in S

tand

ards

for

Con

scio

usSe

dati

on in

Den

tist

ry: A

lter

nati

ve T

echn

ique

s2

Sele

ct t

he m

ost

appr

opria

te f

orm

ulat

ion

of t

he s

elec

ted

seda

tive

drug

and

the

equi

pmen

t re

quire

d fo

r its

adm

inis

trat

ion

Rec

ogni

se s

igns

and

sym

ptom

s th

at m

ight

com

plic

ate

or c

ontr

aind

icat

ead

min

istr

atio

n by

the

se r

oute

sSe

lect

an

appr

opria

te d

rug

and

dosa

ge f

or a

n in

divi

dual

pat

ient

and

rec

ogni

se t

heco

nsci

ous

seda

tion

end

poin

tA

dmin

iste

r su

pple

men

tal o

xyge

n vi

a na

sal c

annu

lae

whe

n in

dica

ted

Rec

ogni

se t

he c

linic

al s

igns

of

early

airw

ay o

bstr

uctio

n an

d ha

ve a

irway

man

agem

ent

skill

s ap

prop

riate

to

the

age

of t

he p

atie

nt b

eing

tre

ated

A

sses

s w

hen

a pa

tient

is f

it to

be

disc

harg

edPr

ovid

e ap

prop

riate

pos

t-op

erat

ive

inst

ruct

ions

Mai

ntai

n le

gibl

e an

d co

ntem

pora

neou

s re

cord

s

Ora

l an

dtr

ansm

ucos

alco

nsci

ous

seda

tion


MA

JOR

CO

MPE

TEN

CY

SUPP

OR

TIN

G C

OM

PETE

NC

IES

The

abili

ty t

o:

Sele

ct a

ppro

pria

te m

onito

ring

tech

niqu

es f

or in

divi

dual

pat

ient

s in

com

plia

nce

with

publ

ishe

d gu

idel

ines

Mea

sure

art

eria

l blo

od p

ress

ure

Perf

orm

clin

ical

mon

itorin

g of

res

pira

tion

(rat

e an

d de

pth)

, pul

se (

rate

and

rhy

thm

)an

d le

vel o

f co

nsci

ousn

ess

Use

a p

ulse

oxi

met

er, i

nter

pret

rea

ding

s an

d re

spon

d to

cha

nge

Rec

ogni

se e

quip

men

t ar

tefa

cts

and

mal

func

tions

The

abili

ty t

o:

Rec

ogni

se a

nd r

espo

nd t

o ov

er-s

edat

ion,

res

pira

tory

dep

ress

ion

and

airw

ayob

stru

ctio

n us

ing

appr

opria

te p

roce

dure

s in

a s

tep-

wis

e m

anne

r D

emon

stra

te t

he u

se o

f ai

rway

adj

unct

s (v

entil

atin

g ba

g, p

ocke

t m

ask

and

oral

airw

ays)

Perf

orm

ora

l/ph

aryn

geal

suc

tion

Con

nect

and

adj

ust

oxyg

en s

uppl

yA

dmin

iste

r sp

ecifi

c an

tago

nist

and

/or

resu

scita

tion

drug

sC

ompl

y w

ith c

onte

mpo

rary

gui

delin

es o

n re

susc

itatio

n an

d th

e m

anag

emen

t of

med

ical

em

erge

ncie

s

Mon

itor

ing

Man

agem

ent

of c

onsc

ious

seda

tion

-rel

ated

com

plic

atio

ns


MA

JOR

AR

EAS

OF

SUG

GES

TED

SO

UR

CES

CO

MPE

TEN

CY

SUPP

OR

TIN

G C

OM

PETE

NC

IES

PER

FOR

MA

NC

EO

F EV

IDEN

CE

VER

BA

L A

ND

WR

ITTE

N C

OM

MU

NIC

ATI

ON

Wit

h pa

tien

ts/

care

rs

Wit

h re

ferr

ing

prac

titi

oner

s

Wit

h sp

ecia

list

serv

ices

Wit

h ot

her

heal

thca

re

prof

essi

onal

s

Wit

h th

e te

am

Be a

ble

to e

xpla

in b

enef

its, r

isks

and

alte

rnat

ives

to

trea

tmen

t un

der

seda

tion

to p

atie

nts/

care

rsIn

volv

e pa

tient

s (a

nd t

heir

care

rs, w

here

app

ropr

iate

) in

the

ir ca

re t

hrou

ghfe

edba

ck, m

otiv

atio

n an

d de

cisi

on m

akin

gEn

sure

tha

t pa

tient

s, c

arer

s an

d es

cort

s ar

e fu

lly a

war

e of

the

ir re

spon

sibi

litie

s in

rela

tion

to c

ompl

ianc

e w

ith p

ost-

oper

ativ

e in

stru

ctio

ns a

nd a

fter

care

Com

mun

icat

e pr

ogre

ss o

f tr

eatm

ent,

ver

bally

and

in w

ritin

g, w

here

app

ropr

iate

Whe

re t

here

is a

nee

d fo

r se

cond

ary

care

, be

able

to

writ

e an

app

ropr

iate

ref

erra

lle

tter

and

pro

vide

rel

evan

t do

cum

enta

tion

and

copi

es o

f re

leva

nt in

vest

igat

ions

Whe

re t

here

is a

nee

d fo

r lia

ison

with

oth

er p

rofe

ssio

nals

abo

ut t

he m

anag

emen

tof

the

pat

ient

, be

able

to

writ

e an

app

ropr

iate

lett

er, p

rovi

ding

rel

evan

tdo

cum

enta

tion

and

copi

es o

f re

leva

nt in

vest

igat

ions

Hav

e an

app

reci

atio

n of

the

con

cept

of

mul

tidis

cipl

inar

y ca

re w

ithin

the

cur

rent

regu

lato

ry f

ram

ewor

k

Com

mun

icat

ion

skill

sPo

rtfo

lio


MA

JOR

AR

EAS

OF

SUG

GES

TED

SO

UR

CES

CO

MPE

TEN

CY

SUPP

OR

TIN

G C

OM

PETE

NC

IES

PER

FOR

MA

NC

EO

F EV

IDEN

CE

Dem

onst

rate

an

appr

ecia

tion

of t

he im

port

ance

and

rol

e of

aud

it an

d th

e au

dit

cycl

e in

mon

itorin

g se

lf-pe

rfor

man

ce a

nd r

evie

win

g pr

actic

e

Ensu

re t

hat

all m

embe

rs o

f th

e se

datio

n te

am a

re a

ppro

pria

tely

tra

ined

and

com

mitt

ed t

o st

atut

ory

CPD

in r

elat

ion

to c

onsc

ious

sed

atio

nR

ecog

nise

the

des

irabi

lity

of s

uppo

rtin

g th

e te

am t

o ac

quire

for

mal

ly r

ecog

nise

dqu

alifi

catio

ns in

sed

atio

n

App

reci

ate

and

resp

ond

to h

ealth

and

saf

ety

issu

es r

elat

ing

to t

he p

ract

ice

of s

edat

ion

Dem

onst

rate

a c

omm

itmen

t to

kee

ping

up

to d

ate

with

dev

elop

men

ts in

con

scio

usse

datio

n te

chni

ques

and

the

ir ap

plic

atio

n to

den

tistr

y

Be a

ble

to c

ritic

ally

eva

luat

e th

e cu

rren

t lit

erat

ure

on c

onsc

ious

sed

atio

n dr

ugs

and

tech

niqu

es

Gov

erna

nce

and

self-

audi

t sk

ills

LEA

DER

SHIP

AN

D M

AN

AG

EMEN

T

Gov

erna

nce

Team

tra

inin

g

PRO

FESS

ION

ALI

SM

Ethi

cs/l

egis

lati

on

Cri

tica

l rea

ding

Port

folio

Peer

rev

iew



Evidence of maintenance of competencies

24. The DwSI in conscious sedation will be expected to maintain theircompetencies through CPD and education. It is recommended that theyundertake CPD relevant to their special interest area as part of the generaland verifiable CPD requirements laid down by the GDC.


Accreditation of DwSIs inconscious sedation for PCTs

Contract specification

25. The contract for a service provided by a DwSI in conscious sedationshould specify as appropriate:

• the core activities and the competencies required (see Competencyframework for a DwSI in conscious sedation on pages 7–17 andAppendix 1)

• the types of patient suitable to be treated by and referred to the service,including inclusion and exclusion criteria

• the minimum/maximum caseload

• the facilities, including the staffing, that must be present to deliver theservice (see Appendix 2)

• the clinical governance, accountability and monitoring arrangements,including links with other relevant disciplines working in primary care

• the agreed arrangements with the secondary care sector to facilitate themanagement of patients not able to be dealt with in the primary caresetting, including the provision of emergency cover where appropriate

• remuneration at an appropriate level

Appointment of DwSIs in conscious sedation with PCTs

26. In appointing a primary care DwSI in conscious sedation, the PCT shouldconsider:

• the development of a managed local clinical network appropriate forthe delivery of the necessary services and need for conscious sedation


• the views of key people in delivering the dental services locally,including clinicians and managers in other relevant acute trusts andPCTs, and local dental practitioners – it is important that the primarycare DwSI in conscious sedation commands the support and respect of others involved in delivering sedation services and of potential service users

• evidence of generalist primary dental care competencies. The DwSI inconscious sedation will be able to demonstrate a continuing level ofcompetence in their generalist skills. Evidence of training andexperience in generalist skills should be provided through a portfolioapproach and should demonstrate competence in the following areas:

– clinical record keeping

– infection control

– legislation and good practice guidelines

– medical emergencies

– radiography

– risk management and communication

– team training

The FGDP(UK)’s Key Skills in Primary Dental Care learning package is one means by which generalist skills can be demonstrated andindependently assessed. The Key Skills assessment is part of theDiploma of Membership of the Joint Dental Faculties’ (MJDF)portfolio of evidence, which provides a portfolio approach to thevalidation of general fitness to practise. The audit or research projectand evidence of clinical skills component of the MJDF portfolio can be met through the overall requirements for the assessment of specialinterest competencies. Other clinical governance packages such as the BDA’s Clinical Governance Kit and Smile-on.com ClinicalGovernance Package can assist in the demonstration of generalist skills.

• evidence of successful acquisition of the defined special interestcompetencies. It is important that the service provided meets localneeds and that the skills and competencies are appropriate to the servicerequirements. Applicants will be able to offer a range of evidence, as confirmation of competency, which will include both formalqualifications and/or experiential evidence (see paragraphs 20–22 and 32–35)


• ensuring that the following are in place before the service can bedelivered:

– support of the local population, primary care dentists and specialistdental practitioners, PCTs and acute trusts

– induction, support and CPD arrangements for the DwSI inconscious sedation and their team

– facilities and staffing to allow satisfactory delivery of dental treatmentunder conscious sedation

– local guidelines on the use of the service having been developed bythe PCT in consultation with the clinical network

– monitoring and clinical audit arrangements

– appropriate indemnity cover. If the primary care dentist is employeddirectly by the PCT or acute trust, they will be covered by theClinical Negligence Scheme for Trusts run by the NHS LitigationAuthority. The PCT should notify or discuss its proposed schemewith the NHS Litigation Authority and its own legal advisers. If theprimary care dentist is an independent contractor, they will normallybe covered by their professional indemnity provider. However, in allcircumstances the primary care dentist should notify their defenceorganisation

Monitoring of the conscious sedation service

27. In reviewing the service and the work of the DwSI in conscious sedation(through clinical governance, annual appraisal, annual review of thecontract and future revalidation requirements), the following should be sought:

• evidence that the guidelines for use of the service are being followed

• evidence that the caseload is appropriate


• evidence of relevant CPD in general and in their special interest area,clinical audit, exploration of the views of patients, carers and otherhealth professionals, peer observation and compliance with futurerevalidation requirements

• evidence of involvement in appropriate clinical governancearrangements, including when appropriate in the local acute trust(s)

• evidence of satisfactory process and outcomes of care

• evidence that the individual’s generalist service is not being adverselyaffected

PCTs – needs assessment and delivery

28. PCTs should identify their priorities in the context of key national policies(e.g. NHS Plan, National Service Frameworks), local needs and localservice delivery. In order to meet a priority, a service may requireconfiguration. PCTs in an area should work together, or singly, to considerthe options for service development. These options will include theappointment of a primary care DwSI in conscious sedation. In decidinghow to develop the service, the PCT may also wish to consider the viewsof other trusts and of the current service providers. Dental public healthcolleagues may provide an independent assessment of needs and demandsto determine whether the service is a priority for development.

29. If it is decided to appoint a primary care DwSI in conscious sedation aspart or all of a service development, then the PCT (acting singly or as a leadPCT for other local PCTs) should make an appointment, after due process,in line with this guidance and in collaboration with relevant stakeholders,including clinicians and providers.

30. Where there are no appropriately skilled candidates, the PCT (acting singlyor as a lead PCT for other local PCTs) could consider sponsoring asuitably motivated local primary care dentist on an appropriate programmeto acquire the necessary competencies. Where a PCT sponsors training itmight be appropriate to seek evidence of a continuing commitment by thepractitioner(s) to the commissioning PCT.


31. As in all commissioning decisions, the PCT should review theappointment regularly. Where the PCT is both commissioner and provider,there is a special responsibility to review service quality rigorously. In doingso, it will wish to take into account the views of the local healthcommunity and service users, clinical governance and audit data, and theoutcomes from appraisal.

System of assessment and evidence required to demonstratecompetence

32. Evidence of successful acquisition of the competencies is required. It isimportant that the service provided meets local needs and that the skillsand competencies are appropriate to the service requirements. Applicantswill be able to offer a range of evidence as confirmation of competency,which will include both formal qualifications and/or experiential evidence.

Sources of evidence

33. In the absence of an appropriate supporting testimonial from an experiencedspecialist in conscious sedation with whom the applicant has worked, therewill be an assessment of the applicant’s ability and competence by anappropriately trained and experienced specialist working in the secondarycare sector (for a suggested person specification see Appendix 3).

34. Alternatively, the applicant can provide evidence of either a formalqualification or experience.

• Formal qualification:

– The applicant must provide evidence of a formal qualification inconscious sedation (MSc, Diploma, etc.) relevant to the competencies(alternative conscious sedation techniques) required, accompanied byappropriate experiential evidence if the qualification was obtainedmore than three years prior to the application.

– Experiential evidence must be collected in a professional portfoliodemonstrating evidence of continuing experience.


• Experience:

– The applicant must provide evidence of having worked under directsupervision with an experienced specialist in conscious sedation inprimary or secondary care (minimum of one session per week for oneyear) or the equivalent.

– Experiential evidence offered, by way of clinical attachments, etc.,must be presented in a professional portfolio containing a detailedrecord of experience and must be accompanied by an appropriatereference from the supervising specialist.

– Experience gained post attachment, or its equivalent, must also bepresented in the professional portfolio.

35. In addition, the applicant must provide evidence of CPD and audit:

• Documented evidence of attendance at relevant courses must beincluded within the professional portfolio.

• Documented evidence of relevant audit, either carried out personallyor in association with others, must be included in the professionalportfolio.

Process

36. The process will usually be an evaluation of the evidence presented in the applicant’s professional portfolio together with the clinical assessment(see paragraph 20 and 34 above).

37. The evaluation should be carried out by a local accreditation panel, whichwould normally include an experienced specialist in conscious sedation (see Appendix 3), a member of the FGDP(UK), representing primary caredentistry, a local dental committee representative and a PCT representative.

38. PCTs may consider it appropriate to interview potential candidates foraccreditation as DwSIs in conscious sedation.


Appendix 1Standard conscious sedation techniques

• Inhalational sedation using nitrous oxide/oxygen.

• Intravenous sedation using midazolam alone.

• Oral/transmucosal benzodiazepine,* provided that adequatecompetence in intravenous techniques has been demonstrated.

Oral or intranasal sedation should only be used where it is not possible to useone of the titratable techniques. Oral and intranasal sedation must only beadministered by those who:

• are trained and experienced in intravenous sedation

• are competent at intravenous cannulation

• are competent in the management of sedation-related complications

• have evidence of training in these techniques

Alternative conscious sedation techniques

• Any form of conscious sedation for patients under the age of 12 years,†other than nitrous oxide/oxygen inhalation sedation.

• Benzodiazepine plus any other intravenous agent, e.g. opioid, propofolor ketamine.

• Propofol, either alone or with any other agent, e.g. benzodiazepine,opioid or ketamine.

• Inhalational sedation using any agent other than nitrous oxide/oxygenalone.

• Combined routes, e.g. inhalational plus intravenous agent (except forthe use of nitrous oxide/oxygen during cannulation).

* In this context, ‘sedation’ is defined as the attainment of the state described in ConsciousSedation in the Provision of Dental Care 1 by the oral or intranasal administration ofmidazolam. It is distinct from pre-medication, where the aim is to make the subsequentanxiety management technique easier. Oral and transmucosal sedation must beadministered in the dental surgery under the supervision of the sedationist.

† It is recognised that the physical and mental development of individuals varies and maynot necessarily correlate with chronological age.


Appendix 2Conscious sedation practice requirements

PCTs that place a contract for services with a DwSI in conscious sedation needto ensure that the service they commission is, in all its aspects, fit for purpose, as the commissioner, in the event of any untoward incident, has a vicariousliability. This includes ensuring that the standards of facilities and support staffavailable for a particular service at each site meet contemporary standards. SeeAnnex A of Commissioning Conscious Sedation Services in Primary Dental Carefor further details.3

Many of these standards will have been checked and met via the local generaldental practice inspection system. Additional requirements for the practice of a DwSI in conscious sedation are defined in guidelines 1–3 and need to bemonitored on an annual basis. It is suggested that this could be the responsibilityof the local consultant in dental public health and general dental practice adviserworking closely with the person who leads the local conscious sedation network(if set up) within which the DwSI would operate, or an experienced specialist inconscious sedation as defined in Appendix 3.

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References

1. Conscious Sedation in the Provision of Dental Care: Report of an ExpertGroup on Sedation for Dentistry. Standing Dental Advisory Committee,commissioned by Department of Health, 2003www.advisorybodies.doh.gov.uk/sdac/conscious_sedationdec03.PDF#search=’Conscious%20Sedation%20for%20the%20Provision%20of%20Dental%20Care

2. Standards for Conscious Sedation in Dentistry: Alternative Techniques. Facultyof Dental Surgery of the Royal College of Surgeons of England and theRoyal College of Anaesthetists, 2007www.rcseng.ac.uk/fds

3. Commissioning Conscious Sedation Services in Primary Dental Care.Department of Health, 2007www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075172

4. National Health Service (General Dental Services Contracts) Regulations2005www.opsi.gov.uk/si/si2005/20053361.htm

5. National Health Service (Personal Dental Services Agreements) Regulations2005www.opsi.gov.uk/si/si2005/20053373.htm

6. Implementing a Scheme for Dentists with Special Interests (DwSIs).Department of Health and Faculty of General Dental Practitioners (UK),2004 www.dh.gov.uk/cdo www.fgdp.org.uk/dwsi/docs/dwsi_orig_framework.pdf

7. Dentists with Special Interests (DwSIs): A Step by Step Guide to Setting Up a DwSI Service, NHS Primary Care Contracting, 2006www.dh.gov.uk/cdo www.fgdp.org.uk/dwsi/docs/dwsi_step_guide.pdf

8. The First Five Years – A Framework for Undergraduate Dental Education.General Dental Council, 2002www.gdc-uk.org/NR/rdonlyres/4B6221BD-6224-415A-A0C3-8AD241DE249D/15158/first_five_years_2002.pdf


Further reading

Competency Document, OMFS/SHO Working Group – Dr Linda Prescott,2001, Appendix 3 of Dentally Qualified Senior House Officers in Oral andMaxillofacial Surgery Units: Report on Requirements for Education, Training andClinical Supervision, NHS Scotland, 2003www.nes.scot.nhs.uk

Conscious Sedation: A Referral Guide for Dental Practitioners. Dental SedationTeachers’ Group in liaison with Society for the Advancement of Anaesthesia inDentistry, 2001www.dstg.co.uk/teaching/conc-sed/

Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures inAdults. UK Academy of Medical Royal Colleges, 2001www.rcoa.ac.uk/docs/safesedationpractice.pdf

A Step by Step Guide to Setting Up a Dentist with Special Interests (DwSI) Service,2006.www.dh.gov.uk/cdowww.fgdp.org.uk

© Crown copyright 2007

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