COMPLIANCE WITH AND ATTITUDES TOWARDS THE MANAGEMENT OF MEDICAL EMERGENCIES IN GENERAL DENTAL PRACTICE T M JOHNSON1, C KURT-GABEL2
ABSTRACT Patient safety and risk management are increasing priorities in dental practice today. Ensuring that members of the dental team are prepared and equipped to adequately manage the common medical emergencies that might occur is an expectation of the public and increasingly demanded by the inspecting and regulatory bodies in healthcare. Prim Dent J. 2014;3(1)41-45
Guidance The General Dental Council document The First Five Years. A Framework for Undergraduate Dental Education, published in 2002, states that all dental practitioners should be able to diagnose and confidently manage medical emergencies and be competent in resuscitation techniques.1 Although there has always been this duty of care to patients, previously there had not been adopted guidance on the exact knowledge, equipment and training that dentists required to safely, ethically and legally fulfil their obligations. This is now no longer the case following publication by the Resuscitation Council (UK) of Medical Emergencies and Resuscitation: Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice.2 This document has been developed by a multidisciplinary working group with backgrounds in dentistry, resuscitation and anaesthesia. It provides
1
Trevor M Johnson
Civilian Dental Practitioner Defence Dental Services, Editor Cochrane Oral Health Group, Vice-Chair Research FGDP(UK) 2
Chris Kurt-Gabel
Chris Kurt Gabel, Managing Director A to E Training & Solutions Ltd, RGN, RN Child, MPA
VOL 3 NO 1 FEBRUARY 2014
clear details about areas such as medical risk assessment, assessment of the sick patient, specific emergency drugs and equipment that should be immediately available, and initial treatment of the sick patient. The main objectives of the standards are that: • All dental practices should have a process for medical risk assessment of their patients • All dental practitioners and dental care professionals should adopt the ‘ABCDE’ approach to assessing the acutely sick patient • Specific emergency drugs and items of emergency medical equipment should be immediately available in all dental surgery premises. These should be standardised throughout the UK • All clinical areas should have immediate access to an automated external defibrillator (AED) • Dental practitioners and dental care professionals should all undergo training in cardiopulmonary resuscitation (CPR), basic airway management and the use of an AED • There should be regular practice and scenario-based exercises using simulated emergencies • Dental practices should have a plan in place for summoning medical assistance in an emergency. For most
practices, this will mean phoning 999 • Staff skills should be updated annually • Audit of all medical emergencies should take place
Prevalence Medical emergencies in dental practice are an uncommon event: a reported emergency occurs every 4.5 practice years in England and Wales and every 3.6 years in Scotland.3 Other studies4,5 have also found that medical emergencies in dental practice are relatively rare events: the study by Broadbent and Thomson4 (1999) identified that two medical emergencies occurred every 10,000 patients treated under local anaesthesia while the study by Girdler and Smith5 (1999) found that 0.7 medical emergencies per dentist per year occurred. The study by Müller et al6 (2008) found that over the 12-month study period, 57% of dentists reported up to three emergencies and 36% up to ten emergencies; however, only 21% of dentists completed the questionnaire and it is possible that only those dentists that had experienced emergencies responded. These practices may have had a different practice profile, for example undertaking more oral surgery where the incidence of medical emergencies increases.7
41
COMPLIANCE WITH AND ATTITUDES TOWARDS THE MANAGEMENT OF MEDICAL EMERGENCIES IN GENERAL DENTAL PRACTICE
The study by Atherton et al8 (1999) reported variability in the provision of emergency drugs and equipment, although 90% of respondents had basic equipment and drugs available. This study predated the Resuscitation Council guidance on medical emergencies in dental practice,2 which has now been formally adopted by the GDC and is obligatory, therefore it is likely that this situation has improved. These studies are summarised in Table 1. Studies have also been undertaken in dental hospital settings, in the UK and worldwide. These studies are important, not only to compare the prevalence of medical emergencies in a specialist setting and how compliant staff are in dealing with them, but also because more medically compromised and elderly patients are being referred to dental hospitals for their treatment.9 These studies found that medical emergencies, when reported, were similarly infrequent to the studies in dental practice (with the exception of Müller et al’s6 2008 study). For example, Anders et al9 (2010) found that only 164 events per million patient visits occurred in the University at Buffalo School of Dental Medicine and Atherton et al7 (2000) found that per dentist, 1.8 events per year occurred in a survey carried out in the University Dental Hospital of Manchester. The most common medical emergency – vasovagal syncope – mirrored that in general practice. When data were available for reporting the incidence of myocardial
Date
Location
Muller
2008
Germany
Broadbent
2001
New Zealand
Girdler
1999
England
Atherton
1999
UK
42
Sample size
Training was identified as an important issue in most studies and there were regional differences identified, for example Adewole et al10 (2009) found that most dental respondents in a Lagos University Teaching Hospital felt that their departments needed to be better equipped to deal with medical emergencies and that staff training needed to be improved. In Udupi and Mangalore, India, Gupta et al11 (2008) found that less than half (42.1%) of dentists reported having received practical training in the management of medical emergencies during their undergraduate and postgraduate education. In Germany, Müller et al6 (2008) found that 92% of practitioners took part in emergency training following graduation (23% participated once and 68% more than once). Atherton et al12 (1999) identified that all GDPs (99.2%) in Great Britain had received training in the management of medical emergencies at some point, principally since graduation. The underlying message is that irrespective of location, almost all dentists feel that they need to have training in managing medical emergencies and that training should be undertaken at regular intervals.
Medical emergencies
TA B L E 1
STUDIES ON MEDICAL EMERGENCIES IN DENTAL PRACTICES Study
infarction and cardiac arrest, the incidences were very rare: an incidence of 0.003 and 0.002 cases per dentist per year, respectively.5 In their survey, Atherton et al3 (1999) found that 20 deaths resulting from medical emergencies were reported; four affected passers-by and none were associated with general anaesthesia (in 1999, general anaesthesia could still be carried out in dental practices).
Response (percentage)
Most common emergency
2998
21
Syncope
314
63
Syncope
887
34
Syncope
1500
74
Syncope
There are a number of common medical emergencies for which there is the expectation that any member of the dental practice team should be able to respond.13 These include chest pain and cardiac arrest, anaphylaxis, hypoglycaemia (low blood sugar), epileptic fitting and fainting, and asthma. There are common principles in the management of these medical emergencies as well as some specific measures. The signs and symptoms as
P R I M A R Y D E N TA L J O U R N A L
well as the specific management of these common medical emergencies will be discussed in subsequent articles.
Medical emergency drugs in the dental practice setting It is an accepted principle that dental practice settings should have a minimum level of emergency equipment and medications in order to respond effectively to potentially life-threatening medical emergency situations that may arise, in order to support patients until the arrival of the emergency services.14 The need for the ability to respond and ensuring that the correct medications are available was highlighted by the coroner’s findings in the 2011 death of a patient in a dental chair in Brighton, UK.15
Guidance and regulation Prior to 2006 the emergency drugs that were held in the dental practice setting were locally determined, with no standardisation or central guidance.16 In 2006, the Resuscitation Council (UK) published the first UK-wide guidance for dental care professionals as to the range of emergency medications that are required in dental practices to enable practitioners to respond appropriately to medical emergencies.2 The guidance was endorsed by the General Dental Council; however, it was only a recommendation and this guidance was not binding on dental practices.
oxygen should be available in the event of device failure. Guidance from the Resuscitation Council (UK), superseded in November 2013, recommends that the following common medical emergency drugs be available:2 • Aspirin 300mg (dispersible) • Glyceryl trinitrate (GTN) spray • Epinephrine 1mg/ml 1:1000 IM • Salbutamol aerosol inhaler 100mcg/actuation • Glucagon 1mg IM • Oral glucose gel/powder/tablets • Midazolam 5mg/ml or 10mg/ml (buccal or intranasal) • Oxygen cylinder (minimum D size) Clinicians should refer to the British National Formulary (BNF) for further guidance (see authors note on recent changes, right). These drugs should be checked regularly to ensure that they do not pass their expiry dates. All drugs must be kept in their original packaging, as dispensed or purchased. This is a legal requirement and drugs should never be decanted into alternative containers (Medicines Act 1968).17
The use of intravenous drugs in a dental practice setting is not encouraged. Intramuscular, inhalational, sublingual, buccal and intranasal routes are all much easier ways to administer drugs in an emergency. Wherever possible, drugs in solution form should be held in prefilled, ready-to-administer syringes.2
In April 2011, the Care Quality Commission commenced regulation of the dental healthcare sector and within its assessment framework general principles relating to the provision of medical emergency medication came into force. Standard 9H of the published guidance states that:18 “People who use services receive care, treatment and support that: ensures medicines required for resuscitation or other medical emergencies are accessible in tamper evident packaging that allows them to be administered as quickly as possible.”
Portable oxygen cylinders should be of sufficient size and also allow adequate flow. In a medical emergency, high-flow oxygen (>10L per minute) should be delivered through the correct oxygen mask until an ambulance arrives. A size ‘D’ cylinder holds 340L oxygen and therefore at 15L per minute will last approximately 25 minutes. Spare
An example of a high-impact situation used by the Care Quality Commission under the medicines management standards was out-of-date epinephrine for the use in anaphylaxis as a result of no clear checking and recording process.19 With regulation comes the increased need to ensure that dental practices are checking emergency medications on at
VOL 3 NO 1 FEBRUARY 2014
least a weekly basis to ensure both that they are present and also that they are in date. Processes should also be in place for a means of rapid replenishment should emergency medications be used up or for those that are coming close to their expiry. Responsibility for checking resuscitation equipment rests with the individual dental practice where the equipment is held. This process should be designated to named individuals and checking should be the subject of local audit.2
Recent changes In November 2013, the Resuscitation Council (UK) published a new document Quality Standards for Cardiopulmonary Resuscitation Practice and Training. Primary Dental Care.20 Importantly, this states that: “Furthermore, this document replaces the Resuscitation Council (UK) document ‘Medical Emergencies in General Dental Practice’ which will no longer be supported or available on the RC (UK) website. Those requiring information on medical emergencies encountered in dental practice (other than cardiorespiratory arrest) are referred to the relevant section in the British National Formulary (BNF). Further enquiries should be directed to the Dental Advisory Group of the BNF or the British Dental Association who contributed to the advice within the BNF.” At the same time, the Resuscitation Council (UK) published the Minimum Equipment List for Cardiopulmonary Resuscitation,21 which is to be read together with the Quality Standards document.20 Both of these documents and the relevant parts of the BNF should be referred to in future. Access to the online BNF is free through a simple registration process and the content relating to medical emergencies in dental practice is hyperlinked at the foot of its website ‘Prescribing in Dental Practice’.22
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COMPLIANCE WITH AND ATTITUDES TOWARDS THE MANAGEMENT OF MEDICAL EMERGENCIES IN GENERAL DENTAL PRACTICE
Training Traditionally the focus of emergency training has been very much on adult basic life support23 to the exclusion of other equally important elements; this is not in keeping with the evidence, which suggests that the emphasis should be on adequate management of medical emergencies and basic life support. Although it is vital that every member of the dental practice can commence adequate and appropriate resuscitation to a patient in cardiac arrest,24 it is also important that they can also manage common medical emergencies.13 Early correct intervention in a medical emergency can prevent further deterioration and possibly death. The rarity of medical emergencies in the dental setting makes it even more vital that all members of the team receive training relevant to their role in a medical emergency.12 The use of algorithms as an aidemémoire is often helpful for those clinical areas where the application of these skills and knowledge is infrequent. An additional method of reinforcing the skills and knowledge necessary to manage common medical emergencies is to undertake mock scenarios within the clinical setting.2 This allows staff to
REFERENCES 1
2
3.
44
General Dental Council. The First Five Years: A Framework for Undergraduate Dental Education. 2nd ed. London: GDC; 2002. Resuscitation Council (UK). Medical Emergencies and Resuscitation: Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice. London: Resuscitation Council; 2006 (rev 2012). Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. Br Dent J. 1999;186:72-9.
4
5
6
7
experience the complete process, including seeking help, retrieving relevant equipment and effective teamworking. Often it is only by recreating an emergency situation that risks and obstacles become apparent and steps can be taken to mitigate these should a real emergency arise.
Frequency of training It is generally accepted that those working in a healthcare environment where there is an expectation that staff can respond and manage medical emergencies should receive regular training; dental care professionals are no exception to this guideline. The Resuscitation Council (UK) guidance recommends that staff receive refresher training on an annual basis.2 Girdler and Smith5 (1999) found that approximately 59% of dentists underwent resuscitation training every 12 months; however, there were significant numbers that did not receive training so frequently and therefore fell outside the guidelines. The General Dental Council requires registered professionals to undergo ten hours of verifiable CPD in the management of medical emergencies in a cycle, ie five years. There is a
Broadbent JM, Thomson WM. The readiness of New Zealand general dental practitioners for medical emergencies. N Z Dent J. 2001;97:82-6. Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 1999;41:159-67. Müller MP, Hänsel M, Stehr SN, Weber S, Koch T. 2008 A statewide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J. 2008;25:296-300. Atherton GJ, Pemberton MN, Thornhill MH. Medical emergencies: the experience of staff
weight of evidence that supports training more frequently than annually; however, given the costs and resource requirements, the adoption of annual training appears to be a compromise to re-establishing emergency management skills of the dental team.
Skills retention There is a plethora of research aimed at determining the ideal length of time between refresher sessions for lifesupport skills and as yet there has not been a definitive answer. The retention of skills depends partly on the frequency with which they are deployed; in a dental practice setting this is likely to be rarely, indicating that more frequent training is required to ensure that the skills are retained for use in a genuine emergency. Einspruch et al25 (2007) suggest that CPR skills decay after just two months from the date of training.
Current research The authors of the present paper conducted a literature review. This identified that the most recent studies were reported in 1999. Girdler and Smith’s study5 centred on five counties in northern England and Atherton et al’s3 study included England, Scotland and Wales, although not Northern Ireland.
of a UK dental teaching hospital. Br Dent J. 2000;188:320-4. 8 Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 2: Drugs and equipment possessed by GDPs and used in the management of emergencies. Br Dent J. 1999;186:125-30. 9 Anders PL, Comeau RL, Hatton M, Neiders ME. The nature and frequency of medical emergencies among patients in a dental school setting. J Dent Educ. 2010;74:392-6. 10 Adewole RA, Sote EO, Oke DA, Agbelusi AG. An assessment of the competence and experience of dentists with the management of medical emergencies in a Nigerian
teaching hospital. Nig Q J Hosp Med. 2009;19:190-4. 11 Gupta T, Aradhya MR, Nagaraj A. Preparedness for management of medical emergencies among dentists in Udupi and Mangalore, India. J Contemp Dent Pract. 2008;9(5):92-99. 12 Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 3: Perceptions of training and competence of GDPs in their management. Br Dent J. 1999;186:234-7. 13 Standing Dental Advisory Committee. Conscious Sedation in the Provision of Dental Care. Report of an Expert Group on Sedation for Dentistry. London:
P R I M A R Y D E N TA L J O U R N A L
Since then, there have been many changes in dental practice, for example the removal of general anaesthesia provision (however, since then the use of intravenous sedation has grown significantly). The Resuscitation Council (UK) guidelines2 and their mandatory use should have also improved the provision of recommended drugs and equipment for managing medical emergencies. Training (at least annually) in recognising medical emergencies and managing them appropriately, together with resuscitation techniques, should have had an impact on compliance with current standards. However, as identified by Anders et al10 (2010), there are now more medically compromised and elderly patients who are dentate and needing treatment: their numbers will continue to increase and there are greater risks associated with treating these patients who are medically compromised and older patients who have complex and ongoing medical issues.
New study into medical emergencies in dental practice Because the most recent studies took place in 1999, it was decided to undertake a new study into medical
Department of Health; 2003. 14 General Dental Council. Principles of Dental Team Working. London: GDC; 2006. 15 British Broadcasting Corporation. Mouthwash reaction killed Brighton dental patient. BBC Sussex News [online]. 2011 Sep 16 [cited 2012 Jan 12]. Available from: www.bbc.co.uk/news/uk-englandsussex-14951073 16 Joint Formulary Committee. Prescribing in dental practice. In: British National Formulary. London: BMJ Group and the Royal Pharmaceutical Society of Great Britain; 2005. 17 Great Britain. Medicines Act 1968. Chapter 67. London: HMSO; 1968.
emergencies in dental practice. The study is split into two phases: the pilot, which is currently being undertaken, and the main study. The pilot will identify any areas (eg question ambiguity, data entry) that need modification before the main study begins.26 The pilot phase of the study uses the Active Research Group of the FGDP(UK).
Methodology This study will be a cross-sectional, questionnaire-based study that will be sent to a randomised sample of dentists and dental care professionals, using the General Dental Council database (the GDC has agreed to allow the study team free access to the whole database). The research protocol has undergone ethical approval, with the final decision delivered by the Proportionate Review Service. A sample of all dentists, whether they work in primary or secondary care or in academic dentistry, will be taken. The questionnaire will be coded to allow data to be extracted.
Conclusion The adoption of guidance that informs dental practitioners of the level of skills and equipment necessary to respond to medical emergencies will ensure that the standard of care delivered to patients is of the highest level. In order for the guidance issued by the regulating bodies to be of value, it should be evidencebased. However, the scarcity of current research in this field prevents the best guidance to support the dental team from being issued. This proposed research project is intended to fill the gap in recent knowledge of this subject area.
As a prelude to this study, a number of the 13 ambulance services in the UK were asked under the Freedom of Information Act 2000 to identify the number and type of emergency calls to which they responded in a 12-month
18 Care Quality Commission (CQC). Guidance About Compliance: Essential Standards of Quality and Safety. London: CQC; 2010. 19 Care Quality Commission (CQC). A New System of Registration: A Judgement Framework, a Set of Examples for Primary Dental Care Services. London: CQC; 2010. 20 Resuscitation Council (UK). Quality Standards for Cardiopulmonary Resuscitation Practice and Training. Primary Dental Care. London: Resuscitation Council; 2013. Available from: www.resus.org.uk/pages/QSCPR_ PrimaryDentalCare__13_11_18.pdf 21 Resuscitation Council (UK). Minimum Equipment List for Cardiopulmonary Resuscitation.
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period. All answered; however, only three were able to provide helpful data because the other services did not record dental practice as a specific environment. The three that were able to provide data reported that they went to an average of one emergency call a day over the 12-month reporting period.
Primary Dental Care. London: Resuscitation Council; 2013. Available from: www.resus.org.uk/pages/QSCPR_ PrimaryDentalCare_EquipList__13_ 11_18.pdf 22 Joint Formulary Committee. British National Formulary. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2013. Accessed (2014 Jan 7) at: www.medicinescomplete.com/mc/ bnf/current/PHP144-prescribing-indental-practice.htm 23 Lepere AJ, Finn J, Jacobs I. Efficacy of cardiopulmonary resuscitation performed in a dental chair. Aust Dent J. 2003;48:244-7. 24 Macpherson LDM, Binnie VI.
A survey of general anaesthesia, sedation and resuscitation in general dental practice. Br Dent J. 1996;181:199-203. 25 Einspruch EL, Lynch B, Aufderheide TP, Nichol G, Becker L. Retention of CPR skills learned in a traditional AHA Heartsaver course versus 30min video self-training: a controlled randomized study. Resuscitation. 2007;74:476-86. 26 Suvan J. An introduction to research for primary dental care clinicians: Part 6. Stage 7: Piloting the methodology and project management. Prim Dent Care. 2011;18:181-5.
45
ABSTRACT Patient safety and risk management are increasing priorities in dental practice today. Ensuring that members of the dental team are prepared and equipped to adequately manage the common medical emergencies that might occur is an expectation of the public and increasingly demanded by the inspecting and regulatory bodies in healthcare. Prim Dent J. 2014;3(1)41-45
Guidance The General Dental Council document The First Five Years. A Framework for Undergraduate Dental Education, published in 2002, states that all dental practitioners should be able to diagnose and confidently manage medical emergencies and be competent in resuscitation techniques.1 Although there has always been this duty of care to patients, previously there had not been adopted guidance on the exact knowledge, equipment and training that dentists required to safely, ethically and legally fulfil their obligations. This is now no longer the case following publication by the Resuscitation Council (UK) of Medical Emergencies and Resuscitation: Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice.2 This document has been developed by a multidisciplinary working group with backgrounds in dentistry, resuscitation and anaesthesia. It provides
1
Trevor M Johnson
Civilian Dental Practitioner Defence Dental Services, Editor Cochrane Oral Health Group, Vice-Chair Research FGDP(UK) 2
Chris Kurt-Gabel
Chris Kurt Gabel, Managing Director A to E Training & Solutions Ltd, RGN, RN Child, MPA
VOL 3 NO 1 FEBRUARY 2014
clear details about areas such as medical risk assessment, assessment of the sick patient, specific emergency drugs and equipment that should be immediately available, and initial treatment of the sick patient. The main objectives of the standards are that: • All dental practices should have a process for medical risk assessment of their patients • All dental practitioners and dental care professionals should adopt the ‘ABCDE’ approach to assessing the acutely sick patient • Specific emergency drugs and items of emergency medical equipment should be immediately available in all dental surgery premises. These should be standardised throughout the UK • All clinical areas should have immediate access to an automated external defibrillator (AED) • Dental practitioners and dental care professionals should all undergo training in cardiopulmonary resuscitation (CPR), basic airway management and the use of an AED • There should be regular practice and scenario-based exercises using simulated emergencies • Dental practices should have a plan in place for summoning medical assistance in an emergency. For most
practices, this will mean phoning 999 • Staff skills should be updated annually • Audit of all medical emergencies should take place
Prevalence Medical emergencies in dental practice are an uncommon event: a reported emergency occurs every 4.5 practice years in England and Wales and every 3.6 years in Scotland.3 Other studies4,5 have also found that medical emergencies in dental practice are relatively rare events: the study by Broadbent and Thomson4 (1999) identified that two medical emergencies occurred every 10,000 patients treated under local anaesthesia while the study by Girdler and Smith5 (1999) found that 0.7 medical emergencies per dentist per year occurred. The study by Müller et al6 (2008) found that over the 12-month study period, 57% of dentists reported up to three emergencies and 36% up to ten emergencies; however, only 21% of dentists completed the questionnaire and it is possible that only those dentists that had experienced emergencies responded. These practices may have had a different practice profile, for example undertaking more oral surgery where the incidence of medical emergencies increases.7
41
COMPLIANCE WITH AND ATTITUDES TOWARDS THE MANAGEMENT OF MEDICAL EMERGENCIES IN GENERAL DENTAL PRACTICE
The study by Atherton et al8 (1999) reported variability in the provision of emergency drugs and equipment, although 90% of respondents had basic equipment and drugs available. This study predated the Resuscitation Council guidance on medical emergencies in dental practice,2 which has now been formally adopted by the GDC and is obligatory, therefore it is likely that this situation has improved. These studies are summarised in Table 1. Studies have also been undertaken in dental hospital settings, in the UK and worldwide. These studies are important, not only to compare the prevalence of medical emergencies in a specialist setting and how compliant staff are in dealing with them, but also because more medically compromised and elderly patients are being referred to dental hospitals for their treatment.9 These studies found that medical emergencies, when reported, were similarly infrequent to the studies in dental practice (with the exception of Müller et al’s6 2008 study). For example, Anders et al9 (2010) found that only 164 events per million patient visits occurred in the University at Buffalo School of Dental Medicine and Atherton et al7 (2000) found that per dentist, 1.8 events per year occurred in a survey carried out in the University Dental Hospital of Manchester. The most common medical emergency – vasovagal syncope – mirrored that in general practice. When data were available for reporting the incidence of myocardial
Date
Location
Muller
2008
Germany
Broadbent
2001
New Zealand
Girdler
1999
England
Atherton
1999
UK
42
Sample size
Training was identified as an important issue in most studies and there were regional differences identified, for example Adewole et al10 (2009) found that most dental respondents in a Lagos University Teaching Hospital felt that their departments needed to be better equipped to deal with medical emergencies and that staff training needed to be improved. In Udupi and Mangalore, India, Gupta et al11 (2008) found that less than half (42.1%) of dentists reported having received practical training in the management of medical emergencies during their undergraduate and postgraduate education. In Germany, Müller et al6 (2008) found that 92% of practitioners took part in emergency training following graduation (23% participated once and 68% more than once). Atherton et al12 (1999) identified that all GDPs (99.2%) in Great Britain had received training in the management of medical emergencies at some point, principally since graduation. The underlying message is that irrespective of location, almost all dentists feel that they need to have training in managing medical emergencies and that training should be undertaken at regular intervals.
Medical emergencies
TA B L E 1
STUDIES ON MEDICAL EMERGENCIES IN DENTAL PRACTICES Study
infarction and cardiac arrest, the incidences were very rare: an incidence of 0.003 and 0.002 cases per dentist per year, respectively.5 In their survey, Atherton et al3 (1999) found that 20 deaths resulting from medical emergencies were reported; four affected passers-by and none were associated with general anaesthesia (in 1999, general anaesthesia could still be carried out in dental practices).
Response (percentage)
Most common emergency
2998
21
Syncope
314
63
Syncope
887
34
Syncope
1500
74
Syncope
There are a number of common medical emergencies for which there is the expectation that any member of the dental practice team should be able to respond.13 These include chest pain and cardiac arrest, anaphylaxis, hypoglycaemia (low blood sugar), epileptic fitting and fainting, and asthma. There are common principles in the management of these medical emergencies as well as some specific measures. The signs and symptoms as
P R I M A R Y D E N TA L J O U R N A L
well as the specific management of these common medical emergencies will be discussed in subsequent articles.
Medical emergency drugs in the dental practice setting It is an accepted principle that dental practice settings should have a minimum level of emergency equipment and medications in order to respond effectively to potentially life-threatening medical emergency situations that may arise, in order to support patients until the arrival of the emergency services.14 The need for the ability to respond and ensuring that the correct medications are available was highlighted by the coroner’s findings in the 2011 death of a patient in a dental chair in Brighton, UK.15
Guidance and regulation Prior to 2006 the emergency drugs that were held in the dental practice setting were locally determined, with no standardisation or central guidance.16 In 2006, the Resuscitation Council (UK) published the first UK-wide guidance for dental care professionals as to the range of emergency medications that are required in dental practices to enable practitioners to respond appropriately to medical emergencies.2 The guidance was endorsed by the General Dental Council; however, it was only a recommendation and this guidance was not binding on dental practices.
oxygen should be available in the event of device failure. Guidance from the Resuscitation Council (UK), superseded in November 2013, recommends that the following common medical emergency drugs be available:2 • Aspirin 300mg (dispersible) • Glyceryl trinitrate (GTN) spray • Epinephrine 1mg/ml 1:1000 IM • Salbutamol aerosol inhaler 100mcg/actuation • Glucagon 1mg IM • Oral glucose gel/powder/tablets • Midazolam 5mg/ml or 10mg/ml (buccal or intranasal) • Oxygen cylinder (minimum D size) Clinicians should refer to the British National Formulary (BNF) for further guidance (see authors note on recent changes, right). These drugs should be checked regularly to ensure that they do not pass their expiry dates. All drugs must be kept in their original packaging, as dispensed or purchased. This is a legal requirement and drugs should never be decanted into alternative containers (Medicines Act 1968).17
The use of intravenous drugs in a dental practice setting is not encouraged. Intramuscular, inhalational, sublingual, buccal and intranasal routes are all much easier ways to administer drugs in an emergency. Wherever possible, drugs in solution form should be held in prefilled, ready-to-administer syringes.2
In April 2011, the Care Quality Commission commenced regulation of the dental healthcare sector and within its assessment framework general principles relating to the provision of medical emergency medication came into force. Standard 9H of the published guidance states that:18 “People who use services receive care, treatment and support that: ensures medicines required for resuscitation or other medical emergencies are accessible in tamper evident packaging that allows them to be administered as quickly as possible.”
Portable oxygen cylinders should be of sufficient size and also allow adequate flow. In a medical emergency, high-flow oxygen (>10L per minute) should be delivered through the correct oxygen mask until an ambulance arrives. A size ‘D’ cylinder holds 340L oxygen and therefore at 15L per minute will last approximately 25 minutes. Spare
An example of a high-impact situation used by the Care Quality Commission under the medicines management standards was out-of-date epinephrine for the use in anaphylaxis as a result of no clear checking and recording process.19 With regulation comes the increased need to ensure that dental practices are checking emergency medications on at
VOL 3 NO 1 FEBRUARY 2014
least a weekly basis to ensure both that they are present and also that they are in date. Processes should also be in place for a means of rapid replenishment should emergency medications be used up or for those that are coming close to their expiry. Responsibility for checking resuscitation equipment rests with the individual dental practice where the equipment is held. This process should be designated to named individuals and checking should be the subject of local audit.2
Recent changes In November 2013, the Resuscitation Council (UK) published a new document Quality Standards for Cardiopulmonary Resuscitation Practice and Training. Primary Dental Care.20 Importantly, this states that: “Furthermore, this document replaces the Resuscitation Council (UK) document ‘Medical Emergencies in General Dental Practice’ which will no longer be supported or available on the RC (UK) website. Those requiring information on medical emergencies encountered in dental practice (other than cardiorespiratory arrest) are referred to the relevant section in the British National Formulary (BNF). Further enquiries should be directed to the Dental Advisory Group of the BNF or the British Dental Association who contributed to the advice within the BNF.” At the same time, the Resuscitation Council (UK) published the Minimum Equipment List for Cardiopulmonary Resuscitation,21 which is to be read together with the Quality Standards document.20 Both of these documents and the relevant parts of the BNF should be referred to in future. Access to the online BNF is free through a simple registration process and the content relating to medical emergencies in dental practice is hyperlinked at the foot of its website ‘Prescribing in Dental Practice’.22
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COMPLIANCE WITH AND ATTITUDES TOWARDS THE MANAGEMENT OF MEDICAL EMERGENCIES IN GENERAL DENTAL PRACTICE
Training Traditionally the focus of emergency training has been very much on adult basic life support23 to the exclusion of other equally important elements; this is not in keeping with the evidence, which suggests that the emphasis should be on adequate management of medical emergencies and basic life support. Although it is vital that every member of the dental practice can commence adequate and appropriate resuscitation to a patient in cardiac arrest,24 it is also important that they can also manage common medical emergencies.13 Early correct intervention in a medical emergency can prevent further deterioration and possibly death. The rarity of medical emergencies in the dental setting makes it even more vital that all members of the team receive training relevant to their role in a medical emergency.12 The use of algorithms as an aidemémoire is often helpful for those clinical areas where the application of these skills and knowledge is infrequent. An additional method of reinforcing the skills and knowledge necessary to manage common medical emergencies is to undertake mock scenarios within the clinical setting.2 This allows staff to
REFERENCES 1
2
3.
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General Dental Council. The First Five Years: A Framework for Undergraduate Dental Education. 2nd ed. London: GDC; 2002. Resuscitation Council (UK). Medical Emergencies and Resuscitation: Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice. London: Resuscitation Council; 2006 (rev 2012). Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. Br Dent J. 1999;186:72-9.
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5
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experience the complete process, including seeking help, retrieving relevant equipment and effective teamworking. Often it is only by recreating an emergency situation that risks and obstacles become apparent and steps can be taken to mitigate these should a real emergency arise.
Frequency of training It is generally accepted that those working in a healthcare environment where there is an expectation that staff can respond and manage medical emergencies should receive regular training; dental care professionals are no exception to this guideline. The Resuscitation Council (UK) guidance recommends that staff receive refresher training on an annual basis.2 Girdler and Smith5 (1999) found that approximately 59% of dentists underwent resuscitation training every 12 months; however, there were significant numbers that did not receive training so frequently and therefore fell outside the guidelines. The General Dental Council requires registered professionals to undergo ten hours of verifiable CPD in the management of medical emergencies in a cycle, ie five years. There is a
Broadbent JM, Thomson WM. The readiness of New Zealand general dental practitioners for medical emergencies. N Z Dent J. 2001;97:82-6. Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 1999;41:159-67. Müller MP, Hänsel M, Stehr SN, Weber S, Koch T. 2008 A statewide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J. 2008;25:296-300. Atherton GJ, Pemberton MN, Thornhill MH. Medical emergencies: the experience of staff
weight of evidence that supports training more frequently than annually; however, given the costs and resource requirements, the adoption of annual training appears to be a compromise to re-establishing emergency management skills of the dental team.
Skills retention There is a plethora of research aimed at determining the ideal length of time between refresher sessions for lifesupport skills and as yet there has not been a definitive answer. The retention of skills depends partly on the frequency with which they are deployed; in a dental practice setting this is likely to be rarely, indicating that more frequent training is required to ensure that the skills are retained for use in a genuine emergency. Einspruch et al25 (2007) suggest that CPR skills decay after just two months from the date of training.
Current research The authors of the present paper conducted a literature review. This identified that the most recent studies were reported in 1999. Girdler and Smith’s study5 centred on five counties in northern England and Atherton et al’s3 study included England, Scotland and Wales, although not Northern Ireland.
of a UK dental teaching hospital. Br Dent J. 2000;188:320-4. 8 Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 2: Drugs and equipment possessed by GDPs and used in the management of emergencies. Br Dent J. 1999;186:125-30. 9 Anders PL, Comeau RL, Hatton M, Neiders ME. The nature and frequency of medical emergencies among patients in a dental school setting. J Dent Educ. 2010;74:392-6. 10 Adewole RA, Sote EO, Oke DA, Agbelusi AG. An assessment of the competence and experience of dentists with the management of medical emergencies in a Nigerian
teaching hospital. Nig Q J Hosp Med. 2009;19:190-4. 11 Gupta T, Aradhya MR, Nagaraj A. Preparedness for management of medical emergencies among dentists in Udupi and Mangalore, India. J Contemp Dent Pract. 2008;9(5):92-99. 12 Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 3: Perceptions of training and competence of GDPs in their management. Br Dent J. 1999;186:234-7. 13 Standing Dental Advisory Committee. Conscious Sedation in the Provision of Dental Care. Report of an Expert Group on Sedation for Dentistry. London:
P R I M A R Y D E N TA L J O U R N A L
Since then, there have been many changes in dental practice, for example the removal of general anaesthesia provision (however, since then the use of intravenous sedation has grown significantly). The Resuscitation Council (UK) guidelines2 and their mandatory use should have also improved the provision of recommended drugs and equipment for managing medical emergencies. Training (at least annually) in recognising medical emergencies and managing them appropriately, together with resuscitation techniques, should have had an impact on compliance with current standards. However, as identified by Anders et al10 (2010), there are now more medically compromised and elderly patients who are dentate and needing treatment: their numbers will continue to increase and there are greater risks associated with treating these patients who are medically compromised and older patients who have complex and ongoing medical issues.
New study into medical emergencies in dental practice Because the most recent studies took place in 1999, it was decided to undertake a new study into medical
Department of Health; 2003. 14 General Dental Council. Principles of Dental Team Working. London: GDC; 2006. 15 British Broadcasting Corporation. Mouthwash reaction killed Brighton dental patient. BBC Sussex News [online]. 2011 Sep 16 [cited 2012 Jan 12]. Available from: www.bbc.co.uk/news/uk-englandsussex-14951073 16 Joint Formulary Committee. Prescribing in dental practice. In: British National Formulary. London: BMJ Group and the Royal Pharmaceutical Society of Great Britain; 2005. 17 Great Britain. Medicines Act 1968. Chapter 67. London: HMSO; 1968.
emergencies in dental practice. The study is split into two phases: the pilot, which is currently being undertaken, and the main study. The pilot will identify any areas (eg question ambiguity, data entry) that need modification before the main study begins.26 The pilot phase of the study uses the Active Research Group of the FGDP(UK).
Methodology This study will be a cross-sectional, questionnaire-based study that will be sent to a randomised sample of dentists and dental care professionals, using the General Dental Council database (the GDC has agreed to allow the study team free access to the whole database). The research protocol has undergone ethical approval, with the final decision delivered by the Proportionate Review Service. A sample of all dentists, whether they work in primary or secondary care or in academic dentistry, will be taken. The questionnaire will be coded to allow data to be extracted.
Conclusion The adoption of guidance that informs dental practitioners of the level of skills and equipment necessary to respond to medical emergencies will ensure that the standard of care delivered to patients is of the highest level. In order for the guidance issued by the regulating bodies to be of value, it should be evidencebased. However, the scarcity of current research in this field prevents the best guidance to support the dental team from being issued. This proposed research project is intended to fill the gap in recent knowledge of this subject area.
As a prelude to this study, a number of the 13 ambulance services in the UK were asked under the Freedom of Information Act 2000 to identify the number and type of emergency calls to which they responded in a 12-month
18 Care Quality Commission (CQC). Guidance About Compliance: Essential Standards of Quality and Safety. London: CQC; 2010. 19 Care Quality Commission (CQC). A New System of Registration: A Judgement Framework, a Set of Examples for Primary Dental Care Services. London: CQC; 2010. 20 Resuscitation Council (UK). Quality Standards for Cardiopulmonary Resuscitation Practice and Training. Primary Dental Care. London: Resuscitation Council; 2013. Available from: www.resus.org.uk/pages/QSCPR_ PrimaryDentalCare__13_11_18.pdf 21 Resuscitation Council (UK). Minimum Equipment List for Cardiopulmonary Resuscitation.
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period. All answered; however, only three were able to provide helpful data because the other services did not record dental practice as a specific environment. The three that were able to provide data reported that they went to an average of one emergency call a day over the 12-month reporting period.
Primary Dental Care. London: Resuscitation Council; 2013. Available from: www.resus.org.uk/pages/QSCPR_ PrimaryDentalCare_EquipList__13_ 11_18.pdf 22 Joint Formulary Committee. British National Formulary. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2013. Accessed (2014 Jan 7) at: www.medicinescomplete.com/mc/ bnf/current/PHP144-prescribing-indental-practice.htm 23 Lepere AJ, Finn J, Jacobs I. Efficacy of cardiopulmonary resuscitation performed in a dental chair. Aust Dent J. 2003;48:244-7. 24 Macpherson LDM, Binnie VI.
A survey of general anaesthesia, sedation and resuscitation in general dental practice. Br Dent J. 1996;181:199-203. 25 Einspruch EL, Lynch B, Aufderheide TP, Nichol G, Becker L. Retention of CPR skills learned in a traditional AHA Heartsaver course versus 30min video self-training: a controlled randomized study. Resuscitation. 2007;74:476-86. 26 Suvan J. An introduction to research for primary dental care clinicians: Part 6. Stage 7: Piloting the methodology and project management. Prim Dent Care. 2011;18:181-5.
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