30 Miss. Code. R. 2301-1.30 - BOARD REGULATION NUMBER 30-ADMINISTRATION OF ANESTHESIA

Purpose: Pursuant to Miss. Code Ann. § 73-9-13, to promulgate rules for the administration of anesthesia in the dental office to allow dentists to provide patients with the benefits of anxiety and pain control in a safe and efficacious manner

1. Definitions of Terminology Used Herein:

a. ACLS - Advanced Cardiac Life Support endorsed by the American Heart Association or approved by the dental board.

b. Analgesia - the diminution or elimination of pain.

c. Anxiolysis - administration of an agent administered in a dosage intended to reduce anxiety without diminishing consciousness or protective reflexes.

d. Behavioral Guidance - the use of pharmacological or psychological techniques, singly or in combination, to modify behavior to a level that dental treatment can be performed effectively and safely.

e. BLS-HCP - Basic Life Support at the Health Care Provider Level endorsed by or equivalent to the American Heart Association.

f. Clinically Oriented Experiences - clinical patient cases which are presented outside a clinical environment and in an instructional setting, e.g., video presentations.

g. Combination Inhalation Enteral Anxiolysis (applies to Class 3 permit holders)- when nitrous-oxide is used in combination with an enteral agent with the intent of achieving anxiolysis only, and the appropriate dosage of agents is administered.

h. Competent - displaying special skill or knowledge derived from training and experience.

i. CRNA - Certified Registered Nurse Anesthetist.

j. Critical portion - the anesthesia provider must be present from induction until the patient is recovered to spontaneous ventilations without airway support, Sp02 on roomair >= 95%; pupils equal, round, central, and reactive to light; and awake, alert and responds to verbal commands.

k. Dental Facility - the office where a permit holder practices dentistry and provides anesthesia/sedation services.

I. Dental Facility Inspection - an on-site inspection to determine if a dental facility where the applicant proposes to provide anesthesia/sedation is supplied, equipped, staffed and maintained in a condition to support provision of anesthesia/sedation services that meet the minimum standard of care; may be required by the Board prior to the issuance of a sedation/anesthesia permit or any time during the term of the permit.

m. Direct Supervision - the anesthesia provider to be physically present in the operating room and continuously aware of the patient's physical status and well-being.

n. Enteral route - absorption of medication across enteric membranes which line the alimentary canal from the oral cavity, through the digestive tract, ending in the rectum. This route includes medications that are either swallowed, absorbed through the mucosa of the oral cavity, or inserted rectally.

o. Hospital Facility - a "hospital" or "ambulatory surgical facility" as those terms are defined in Miss. Code Ann. § 41-7-173(h).

p. Immediately Available - on-site in the dental facility and available for immediate use.

q. Live Patient Experiences - procedures involving live patients either performed or observed in a clinical environment and in an instructional setting.

r. Local Anesthesia - the elimination of sensations, especially pain, in one part of the body by the regional application or injection of a drug.

s. May - indicates freedom or liberty to follow a reasonable alternative.

t. Mobile anesthesia provider- a dentist anesthesiologist, physician anesthesiologist, CRNA or oral and maxillofacial surgeon who provides anesthesia services in a permitted office that he/she does not operate.

u. Must or Shall - indicates an imperative need or duty or both; an essential or indispensable item; mandatory.

v Nitrous-Oxide Inhalation Anxiolysis - the inhalational use of nitrous oxide for anxi-olysis and/or analgesia.

w. PALS - Pediatric Advanced Life Support endorsed by the American Heart Association or approved by the dental board.

x. Parenteral route - administration of a drug other than absorption across enteric membranes (outside of the alimentary canal). These methods include intravenous, intramuscular, intranasal, and submucosal administration, among others.

y. Pediatric - for the purposes of this regulation pediatric is defined as seven (7) years of age or under.

z. Protective Reflexes - includes the ability to swallow, cough, and protect the airway.

aa. Surgery Center- Ambulatory surgery center facility licensed by the Mississippi Department of Health

2. Levels of Anesthesia

a. Minimal Sedation - a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes and ventilatory and cardiovascular functions are unaffected.

b. Moderate Sedation (Conscious Sedation) - a drug-induced depression of consciousness during which patients respond purpose fully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

c. Deep sedation - a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

d. General Anesthesia - a drug-induced loss of consciousness during which patients caimot be aroused, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

3. When anesthesia is administered in a hospital facility or surgery center, the following general guideline applies:

A licensed dentist with no advanced anesthesia permit may employ or work in conjunction with a qualified anesthesiologist or CRNA who is eligible to practice in a licensed hospital or ambulatory surgical facility pursuant to the provisions of the "Minimum Standards of Operation for Mississippi Hospitals" or "Minimum Standards of Operation for Ambulatory Surgical Facilities" as published by the Mississippi State Department of Health. The licensed ambulatory surgical facility or hospital's department of anesthesia, or in the absence thereof the department of surgery, has the responsibility for establishing general policies and procedures for the administration of anesthesia, including a collaborative agreement with the CRNA as specified by nursing board rules and regulations.

4. Advanced Anesthesia Provider Permit Classifications.

a. Class 1 Permit. Allows for administration of advanced anesthesia by a permit holder in the State of Mississippi with the intent to have the patient placed under deep sedation or general anesthesia. A pediatric endorsement must be obtained to provide anesthesia care for patients that are seven years of age or younger. A class 1 permit covers all levels of sedation permits.

b. Class 2 Permit. Allows for administration of advanced anesthesia by a permit holder in the State of Mississippi with the intent to have the patient placed under moderate sedation. A pediatric endorsement must be obtained to provide anesthesia care for patients that are seven years of age or younger. Moderate sedation for pediatric patients seven years of age and younger must be administered via an oral, intranasal or intramuscular route. An intravenous route of administration in patients seven years and younger is prohibited, except for class 1 permit holders.

c. Class 3 Permit. (same as Enteral Sedation) Allows for administration of advanced anesthesia by a permit holder in the State of Mississippi with the intent to have the patient placed under minimal sedation. Parenteral route of administration is not allowed. A pediatric endorsement must be obtained to provide anesthesia care for patients aged 8-12 years old. The dentist must use an anesthetic protocol in which he/she was trained.

5. Class 1 Provider Permit Requirements

a. Providers who are eligible for a Class 1 permit include:

(1) An oral and maxillofacial surgeon who has completed a CODA-accredited residency in oral and maxillofacial surgery.

(2) A dentist anesthesiologist who has completed a CODA-accredited residency in dental anesthesiology.

Note: For graduates of a dental anesthesiology residency program prior to CODA accreditation, the program must have met the requirements of the ADA Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in Dentistry at the Advanced Education Level, in effect at the time of residency completion.

(3) Maintain ACLS certification

b. Pediatric endorsement requirements - In order to provide anesthesia care for pediatric patients seven years of age and younger, a Class 1 permit holder must:

(1) Have completed a CODA-accredited residency that has a standard for pediatric anesthesia training and is in compliance with such a standard.

(2) Maintain PALS certification.

6. Class 2 Provider Permit Requirements

a. Providers who are eligible for a class 2 permit include:

(1) A dentist or dental specialist who has successfully completed a CODA-accredited dental residency that includes comprehensive training in administering moderate sedation.

(2) A dentist or dental specialist who has successfully completed a board-approved continuing education course in the administration and management of moderate sedation (including a parenteral route). The course shall be board approved, and include:

(a) Sixty (60) hours of didactic instruction including:

(i) Physical evaluation.

(ii) Management of sedation and medical emergencies.

(iii) The importance of, and techniques for, maintaining proper documentation.

(iv) Monitoring and the use of monitoring equipment.

(v) Rescuing patients from a deeper level of sedation than intended including managing the airway, intravascular or intraosseous access, and reversal medications.

(b) Individually-managed personal administration of moderate sedation to at least twenty (20) individuals.

(3) Maintain ACLS certification

b. Pediatric endorsement requirements- In order to provide anesthesia care to pediatric patients seven years of age and younger, a Class 2 permit holder must:

(1) Have completed a CODA-accredited residency that has a standard for pediatric anesthesia training and is in compliance with such a standard.

(2) OR - In addition to requirements as listed in 6 a (2) above, have completed a board approved level of training specific to sedation of pediatric patients which includes:

(a) Minimum of twenty-two (22) hours of didactic instruction hours on pediatric sedation including:

(i) Physical evaluation.

(ii) Management of sedation and medical emergencies.

(iii) The importance of, and techniques for, maintaining proper documentation.

(iv) Monitoring and the use of monitoring equipment.

(v) Rescuing patients from a deeper level of sedation than intended including managing the airway, intravascular or intraosseous access, and reversal medications.

(b) Attendance of a Board approved course, which includes ten (10) live patient experiences for pediatric moderate enteral sedation.

(3) Maintain PALS certification

(4) Moderate sedation for pediatric patients seven years of age and younger must be administered via an oral, intranasal or intramuscular route. Patients must be AS AI or AS All. An intravenous route of administration is prohibited. This restriction does not apply to Class 1 providers.

7. Class 3 Permit Requirements

a. Providers who are eligible for a Class 3 permit include:

(1) A dentist or dental specialist who has successfully completed a CODA-ac-credited dental residency that includes comprehensive training in administering minimal sedation. This would include the use of combination agents for anxiolysis.

(2) A dentist or dental specialist who has successfully completed a board-approved continuing education training in the administration and management of minimal sedation using combination agents. The training should meet requirements for minimal sedation training which includes:

(a) Twenty-five (25) hours of didactic instruction including:

(i) Physical evaluation.

(ii) Management of sedation and medical emergencies.

(iii) The importance of, and techniques for, maintaining proper documentation.

(iv) Monitoring and the use of monitoring equipment.

(v) Rescuing patients from a deeper level of sedation than intended including managing the airway, intravascular or intraosseous access, and reversal medications.

(b) Twenty (20) clinically-oriented patient experiences.

(3) Maintain ACLS certification

b. Pediatric Endorsement requirements- hi order to provide anesthesia care to pediatric patients eight (8) to twelve (12) years of age, a Class 3 permit holder must:

(1) Have completed a CODA-accredited residency that has a standard for pediatric anesthesia training and is in compliance with such a standard.

(2) OR - hi addition to 7 a (2) above, have completed a board approved level of training specific to sedation of pediatric patients which includes;

(a) A minimum of Twenty-two (22) hours of didactic instruction hours on pediatric sedation, and includes:

(i) Physical evaluation.

(ii) Management of sedation and medical emergencies.

(iii) The importance of, and techniques for, maintaining proper documentation.

(iv) Monitoring and the use of monitoring equipment.

(v) Rescuing patients from a deeper level of sedation than intended including managing the airway, intravascular or intraosseous access, and reversal medications

(b) Attendance of a Board approved course, which includes ten (10) live patient experiences for pediatric moderate enteral sedation.

(3) Maintain ACLS certification.

(4) Class 3 permit will not allow sedation on any patient seven (7) years of age or younger. Also, patients age eight (8) to age twelve (12) must be ASA I or ASA II.

(5) The dentist must use an anesthetic protocol in which he/she was trained.

8. A licensed dentist may provide anxiolysis without an advanced anesthesia permit.

a. Permissible examples include:

(1) Nitrous-Oxide used with the intent for anxiolysis.

(2) A single enteral agent used with the intent for anxiolysis, not to exceed the MRD.

(3) Nitrous-oxide in combination with a single enteral agent with the intent for anxiolysis in patients 8 years and above.

b. A dentist without an advanced anesthesia permit is prohibited from:

(1) The administration of an enteral drug exceeding the maximum recommended dose (MRD) in FDA-approved labeling for unmonitored home use.

(2) The use of two or more enteral drugs during a single appointment.

(3) Administering any sedative drug to a pediatric patient (seven (7) years of age or under) other than nitrous oxide.

9. Utilization of Anesthesia Services by Non-Dentist Anesthesia Providers

a. The licensed dentist who wishes to utilize the services of a non-dentist anesthesia provider shall, (1) complete a non-dentist anesthesia provider application form and (2) notify the Board, hi addition, if a licensed dentist wishes to utilize the services of a CRNA, the parties must also enter into a collaboration agreement/protocol as required by the rules and regulations of the Mississippi Board of Nursing.

b. The application form as noted above, serves to provide the licensed dentist with a vet-ting/credentialing mechanism. At the same time, the notice to the Board serves to keep the Board advised of where non-dentist anesthesia providers are working and ensure that the licensed dentist is in full compliance with the regulations as promulgated herein.

c. The dentist who utilizes a physician anesthesiologist or CRNA must possess a Class 1 or Class 2 Anesthesia Permit and have his/her facility permitted to the Class 1 Level.

d. The licensed dentist shall participate through discussion of, and in agreement with, the anesthesia plan and shall remain physically present and available on the premises during the delivery of anesthesia services for consultation and treatment of emergency medical conditions.

e. When utilizing the services of a CRNA, the licensed dentist shall insure that the CRNA only sedates to the level of the anesthesia permit held by the licensed dentist. For those Class 2 Anesthesia Permit holders working with a CRNA, the intent of the sedation should be moderate sedation with the understanding that the patient could drift to a deeper level of sedation for a brief period of time. The CRNA will not be limited in type of sedative-hypnotic agent used in order to provide the appropriate level of sedation and analgesia during stimulating portions of the procedure or when there are relevant patient safety concerns. This provision is not intended to limit the CRNA's ability to select and administer medication, including controlled substances, or to apply appropriate medical devices for the delivery of anesthesia services under the anesthesia plan agreed upon in conjunction with the operating dentist as contemplated by Mississippi Code § 73-15-20.

10. Application for Advanced Anesthesia Permit

a. The first-time applicant must submit an application for a Class 1, Class 2 or Class 3 permit. The application must include:

(1) Certification of training.

(a) This will include a copy of the provider's residency/program certificate and a letter from the program director certifying that his/her training meets CODA anesthesia standards.

(b) OR evidence of successful passing of a board-approved continuing education course.

(2) United States Drug Enforcement Administration (DEA) permit to prescribe and administer controlled substances in the state of Mississippi.

(3) Evidence of ACLS and/or PALS certification

(4) Notification of any previous disciplinary action related to the practice of anesthesia by a dental or medical board, other regulatory agency or hospital.

b. An attestation statement must be signed that he/she will only provide sedation/anesthesia in a permitted facility to the level of the facility permit.

c. If more than two years out from a CODA-approved training program with sedation training standards and/or the clinical practice of anesthesia and wish to obtain a permit, the provider must obtain ten (10) sedation experiences, five (5) of which are personally administered under direct supervision of a board-appointed Class 1 or a Class 2 permit holder.

d. Grandfathering of existing permit holders:

(1) Curent general anesthesia permit holder:

(a) A provider who currently holds a general anesthesia permit qualifies for a Class 1 permit.

(b) A provider who currently holds a general anesthesia permit may acquire a Class 1 pediatric endorsement by attesting to administration of, or involvement in, deep sedation/general anesthesia for at least twenty (20) pediatric patients during the last two (2) years of clinical practice.

(2) Current parenteral conscious sedation permit holder:

(a) A provider who currently holds a parenteral conscious sedation permit qualifies for a Class 2 permit.

(b) A provider who currently holds a parenteral conscious sedation permit that fulfills the requirements for patients who are twelve (12) years of age or under qualifies for a Class 2 permit with a pediatric endorsement after completing a board-approved pediatric sedation course.

(c) A dentist who has completed a CODA approved pediatric residency and holds a parenteral or enteral sedation permit qualifies for a class 2 permit with a pediatric endorsement.

(3) Current enteral conscious sedation permit holders:

(a) A provider who currently holds an enteral conscious sedation permit qualifies for a Class 3 permit.

(b) A provider who currently holds an enteral conscious sedation permit that fulfills the requirements for patients who are twelve (12) years of age or under qualifies for a Class 3 permit with a pediatric endorsement.

(c) The dentist must use an anesthetic protocol in which he/she was trained.

11. Renewal of Advanced Anesthesia Permit

a. An advanced anesthesia permit must be renewed biennially.

b. The provider must demonstrate currency by providing:

(1) A copy of current ACLS and/or PALS certification.

(2) Continuing education training over the past two years.

(3) Attest to administration of, or involvement in, twenty (20) cases of deep sedation/general anesthesia (Class 1 permit) or moderate sedation (Class 2 permit) during the last two (2) years of clinical practice.

(4) If renewing a pediatric endorsement, attest to administration of, or involvement in, sedation/anesthesia consistent with the permit level for twenty (20) pediatric patients.

12. Continued Competency

a. To maintain an advanced anesthesia permit, an anesthesia provider shall participate in at least eight (8) hours of continuing education every two (2) years in any of the following areas (Class 1 permit holders must obtain a minimum of half of the required CE hours in general anesthesia):

(1) General anesthesia.

(2) Moderate sedation.

(3) Physical evaluation.

(4) Medical and sedation/general anesthesia emergencies or urgencies.

(5) Monitoring and use of monitoring equipment.

(6) Pharmacology of drugs and non-drug substances used in general anesthesia or sedation.

b. The oral and maxillofacial surgeon auxiliary staff whose primary responsibility is to monitor the patient must complete a board approved CE course every two years.

c. BLS-HCP, ACLS, and PALS do NOT count toward the sedation/anesthesia continuing education requirements.

d. A facility must provide emergency management training in the form of drills or simulation for providers and their staff on a quarterly basis. This training must be documented and available for review at on-site evaluations.

e. Every six years, providers must complete a simulation continuing education course as approved by the board.

13. Class 1 Deep Sedation/General Anesthesia Staffing Requirements

a. For patients eight (8) years of age and older undergoing deep sedation/general anesthesia, a minimum of three (3) persons must be present with the patient during the critical portion of the procedure:

(1) The Class I anesthesia permit holder, OR a physician anesthesiologist OR CRNA who has a collaborative agreement with the operating dentist.

(2) The operating dentist with at least a class 2 permit and current certification in ACLS. However, the operating dentist must have a class 1 permit if utilizing a CRNA.

(3) A third person having current certification in BLS-HCP.

(4) If the operating dentist is also the Class 1 anesthesia permit holder (i.e. oral and maxillofacial surgeon), there must be a qualified auxiliary staff whose primary responsibility is to monitor the patient during the procedure. The auxiliary must have current certification in a board-approved training program for such a role and have current certification in ACLS.

b. For pediatric patients seven (7) years of age and younger, a minimum three (3) persons must be present with the patient during the critical portion of the procedure:

(1) The Class I anesthesia permit holder who has current certification in PALS OR a physician anesthesiologist OR CRNA who has a collaborative agreement with the operating dentist.

(2) The operating dentist with at least a class 2 permit with a pediatric endorsement and current certification in PALS. However, the operating dentist must have a class 1 permit if utilizing a CRNA.

(3) A third person having current certification in BLS-HCP.

(4) If the operating dentist is also the Class 1 anesthesia permit holder (i.e., oral and maxillofacial surgeon), there must be a qualified auxiliary staff whose primary responsibility is to monitor the patient during the procedure. The auxiliary must have current certification in a board-approved training program for such a role and have current certification in PALS.

c. For pediatric patients seven (7) years of age or under, a PALS-certified provider must recover the patient until he/she meets criteria for discharge using a recognized pediatric discharge scoring system, i.e. the Pediatric Post-Discharging Scoring System.

14. Class 2 Moderate Sedation Staffing Requirements

a. For patients eight (8) years of age and older, a minimum of two (2) persons must be present during the critical portion of the procedure:

(1) Class 2 anesthesia permit holder, OR a physician anesthesiologist OR CRNA who has a collaborative agreement with the operating dentist.

(2) The second person must have current certification in BLS-HCP.

b. For pediatric patients seven (7) years of age or under, a minimum of two (2) persons must be present during the critical portion of the procedure:

(1) Class 2 anesthesia permit holder who has a pediatric endorsement, OR a physician anesthesiologist OR CRNA who has a collaborative agreement with the operating dentist.

(2) The second person must have current certification in BLS-HCP.

c. For pediatric patients seven (7) years of age or under, a PALS-certified provider must recover the patient until he/she meets criteria for discharge using a recognized pediatric discharge scoring system, i.e. the Pediatric Post-Discharging Scoring System.

15. Class 3 Minimal Conscious Sedation Staffing Requirements

a. For adult patients thirteen (13) years of age and older, a minimum of two (2) persons must be present during the critical portion of the procedure:

(1) Class 3 anesthesia permit holder who has current certification in ACLS.

(2) the second person must have current certification in BLS-HCP.

b. For pediatric patients ages 8-12 a minimum of two (2) persons must be present during the critical portion of the procedure:

(1) Class 3 anesthesia permit holder who has a pediatric endorsement and current certification in ACLS.

(2) The second person must have current certification in BLS-HCP.

16. Facility Permitting

a. The dental office in which advanced anesthesia is being provided must be permitted by the board.

b. The facility must be adequately staffed and equipped for the provision of sedation and/or general anesthesia. The dentist who operates the facility and mobile anesthesia provider (if applicable) will be responsible for ensuring appropriate assistant staffing and training, monitoring equipment, emergency equipment and drugs, backup lighting, and electrical sources are in place.

c. The permit type an office obtains is based on the level of anesthesia the office has been certified to provide.

(1) Class 1 Deep Sedation/General Anesthesia Facility Permit.

(2) Class 2 Moderate Sedation Facility Permit.

(3) Class 3 Minimal Sedation Facility Permit.

d. The facility must successfully pass an onsite inspection in order to be permitted.

e. An onsite evaluation must be successfully completed every six (6) years for the advanced anesthesia permit to be renewed.

f. The inspection form used by examiners for the onsite evaluation will be available for the dentist(s) whose office is being evaluated to review beforehand. The facility must be continually maintained to the level of permitting for all procedures utilizing anesthesia (i.e. Class 1, Class 2 or Class 3) as listed in the Facility Inspection Form.

g. A mobile anesthesia provider may bring his/her own equipment and drugs necessary to provide anesthesia and emergency care into a permitted facility as long as it is maintained per manufacturer requirements. However, this must be in addition, not substitution, for facility required equipment and drugs.

h. A mobile anesthesia provider can only provide services for a Class 1 or Class 2 permit holder. The facility he/she provides care in has to have a class 1 permit.

i. A Class 3 permit holder can only have sedation provided to the level of Class 3 sedation.

j. An onsite review of the office by a Board representative can occur at any time to certify compliance with facility requirements. The Board shall consider such factors as it deems pertinent, including, but not limited to, patient complaints and reports of adverse occurrences.

k. The facility must continually meet standards of care set forth by organizations such as American Society of Dental Anesthesiologists (ASDA), American Academy of Pediatric Dentists (AAPD) or American Association of Oral and Maxillofacial Surgeons (AAOMS). The AAMOS Office Anesthesia Evaluation Manual, most current edition, serves as a resource.

l. Monitoring equipment must be checked and calibrated in accordance with the manufacturer's recommendations and documented on a yearly basis.

m. Controlled pharmaceuticals should be secured and maintained on site in accordance with state and federal guidelines.

(1) Medications utilized in the dental office for moderate sedation, deep sedation, and/or general anesthesia shall be utilized in accordance with the drug manufacturer's guidelines as set forth in either FDA-approved labeling, common protocols, or peer-reviewed scientific literature.

n. Grandfathering facilities-

(1) Current facilities in which sedation/anesthesia is provided must submit an attestation certifying compliance with staff credentials and continuing education, monitoring equipment, monitor calibration, emergency drugs and equipment, emergency preparedness training, and proper security and maintenance of controlled pharmaceuticals.

(2) Facilities have two (2) years to undergo the full initial evaluation.

17. Onsite Facility Inspection

a. The facility inspection is aimed at ensuring there is a safe environment for provision of minimal sedation, moderate sedation, deep sedation, and/or general anesthesia. The facility must demonstrate:

(1) Provision of equipment necessary to provide general anesthesia (Class 1), moderate sedation (Class 2), or minimal sedation (Class 3).

(2) Provision of emergency drugs and equipment necessary for general anesthesia (Class 1), moderate sedation (Class 2), or minimal sedation (Class 3).

(3) Provision of an appropriate back up suction and power source for operation of monitors, lighting, and visualization of the patient.

(4) Provision of adequate staffing and their training for the management of emergencies.

(5) Appropriate documentation of the anesthetic experience in patient records.

(6) Proper documentation of the use of controlled substances, including an inventory log that complies with state and federal requirements indicating the receipt, administration, dispensing, and destruction of controlled substances.

(7) Proper staff training and readiness for the management of anesthetic emergencies.

b. The onsite evaluation team shall consist of at least two (2) people for the initial facility evaluation and at least one (1) person for subsequent renewal evaluations as follows:

(1) Class 1 Facility will be evaluated by Class 1 permit holders only.

(2) Class 2 Facility and Class 3 Facility will be evaluated by Class 2 permit holders (except for the initial evaluation where there must be one Class 1 permit holder).

(3) The operator of a facility or the evaluator have the right to request re-assignment if there is a conflict of interest.

c. The onsite inspection shall include the following:

(1) Evaluation of the facility.

(2) Review of at least ten (10) charts in order to assess for proper documentation.

(3) Review of documentation of office staff emergency simulation training

d. If the board is unable to schedule a facility evaluation within 30 days of a provider being issued a provider permit, a provisional facility permit can be issued by the board if the permitted provider attests to the facility meeting regulation requirements for the level of anesthesia being provided.

e. The evaluation team selected by the Board shall recommend one of the following:

(1) Pass: Successful completion of the onsite evaluation.

(2) Conditional Approval: For failing to have appropriate drugs or equipment, proper documentation of controlled substances, or proper record keeping. The provider must submit proof of correcting the deficiencies before full approval is issued.

(3) Not pass: This category is reserved for deficiencies that are judged to potentially be a patient safety concern. The provider will be notified by the board of necessary corrective action. Until that corrective action is taken, the provider shall not allow the provision of any form of sedation or general anesthesia in his/her dental facility.

f. Should an anesthesia permit holder disagree with the evaluation team's recommendation of Conditional Approval or Not Pass, the permit holder can request a review by the Anesthesia Advisory Panel. If a positive resolution cannot be achieved, the aggrieved permit holder may then submit an appeal with the Board.

g. AH "Not Pass" recommendations will be reported to the Board.

18. Renewal of Facility Permit

a. The facility permit must be renewed by completing a biennial attestation form and by an on-site evaluation every six (6) years.

b. The biennial facility attestation must certify compliance with staff credentials and continuing education, monitoring equipment, monitor calibration, emergency drugs and equipment, emergency preparedness training, and proper security and maintenance of controlled pharmaceuticals.

c. Every facility will undergo an onsite inspection at least once every six (6) years beginning from the date of the initial permit to ensure the facility maintains appropriate practice standards.

d. An onsite inspection of the facility by a board representative can occur at any time to certify compliance with facility requirements. The Board shall consider such factors as it deems pertinent, including, but not limited to, patient complaints and reports of adverse occurrences.

e. If the facility gets a "Conditional Approval" for failing to have appropriate drugs or equipment, proper documentation of controlled substances, or proper record keeping, the provider must submit proof of correcting the deficiencies before full approval is issued.

f. If the facility gets a "Not Pass" for deficiencies that are judged to potentially be a patient safety concern, the provider must submit proof of correcting the deficiencies and may be subject to another on-site evaluation before full approval is issued.

19. Patient Selection Considerations

a. American Society of Anesthesiologists (ASA) classification should be considered in determining if a patient is appropriate to treat in an office setting. Providers should follow guidelines put forth by ASA and other governing bodies such as ADA, AA-OMS, ASDA, and AAPD.

b. Appropriate medical and dental indications must exist before placing a patient under a deep sedation or general anesthetic, especially pediatric patients.

20. Reports of Adverse Occurrence

a. If a death or adverse sedation/general anesthesia incident requiring an admission to a hospital occurs in a dental facility during the administration of or recovery from any level of sedation/general anesthesia, the permitted dentist anesthesia provider shall submit a complete report of the incident to the Board within ten (10) days of the occurrence including the name of the physician anesthesiologist or CRNA if applicable.

21. Penalty for Non-Compliance

a. Violation of the provisions of this regulation may subject the permitted dentist anesthesia provider to disciplinary action, after a hearing, as provided by the Mississippi laws pertaining to the practice of dentistry.

b. If a physician anesthesiologist or CRNA is involved, the Board will shall report noncompliance to the Medical or Nursing Board.

c. In addition to the above, if non-compliance with this regulation by any permitted dentist or facility is such that continued operation may result in immediate harm to the public, the Dental Board retains the right to issue a cease and desist letter to the permit holder and/or seek injunctive relief as provided by law.

22. Anesthesia Advisory Committee

a. The board will appoint permit holders to the anesthesia advisory committee whose responsibilities include:

(1) Review the content of Regulation 30, on-site evaluation forms, collaborate agreement forms and other documents pertaining to Regulation 30 annually for compliance with latest national standards (ASA, ADA, ASDA, etc.).

(2) Review and make recommendations to the board regarding training/educational programs for providers and staff.

(3) Make recommendations to the board regarding any changes necessary for compliance with Regulation 30.

(4) Upon request, answer questions from the board regarding standards of care.

b. The committee will consist of at least three (3) Class 1 permit holders, two (2) Class 2 permit holders and one (1) Class 3 permit holders. The committee should be broadly represented by specialty and general dentist permit holders and may include physician anesthesiologists and CRNAs. Members will commit to serve a two (2) year term and may be reappointed if eligible.

c. A chair will be appointed to oversee the activities of the committee. He/she will commit to serve a two (2) year term and may be reappointed if eligible. Responsibilities include:

(1) Overseeing activities of the committee.

(2) Act as a liaison between the committee, board, and executive director.

(3) Delegate responsibilities to committee members as appropriate.

Notes

30 Miss. Code. R. 2301-1.30

Adopted 5/10/2021