Digital Repository Doctoral Projects Spring 2021 Development of Protocols, Guidelines, and Processes for Adverse Anesthesia Events, Recovery, and Discharge in Pediatric Dental Offices Megan A. Barney, MS, CRNA Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Barney, M.A., (2021) Development of Protocols, Guidelines, and Processes for Adverse Anesthesia Events, Recovery, and Discharge in Pediatric Dental Offices Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Development of Protocols, Guidelines, and Processes for Adverse Anesthesia Events, Recovery, and Discharge in Pediatric Dental Offices by Megan A Barney A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 14, 2021 Ann Rocha PhD, APRN, FNP-BC Faculty Advisor/Committee Chair (Ann Rocha PhD, APRN, FNP-BC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director Running head: Pediatric Dental Offices Anesthesia 1 Development of Protocols, Guidelines, and Processes for Adverse Anesthesia Events, Recovery, and Discharge in Pediatric Dental Offices Megan A. Barney, MS, CRNA Annie Taylor Dee School of Nursing, Weber State University Pediatric Dental Offices Anesthesia 2 Abstract Utilizing education and simulation to improve knowledge and skills, this Doctor of Nursing Practice project established guidelines to facilitate appropriate responses to adverse anesthesia events in a pediatric dental office. Procedures to ensure safe recovery and timing of discharge were also taught and implemented. Six pediatric dental assistants and one pediatric dentist participated in two sixty-minute education and simulation events focusing on a coordinated response to adverse anesthesia events. Pre and posttests, including multiple choice and short answer questions, were used to evaluate participant knowledge, skills, and confidence levels. The mean scores on content knowledge improved from 92% to 98% for knowledge after the training. Initially, 14% were 'a little confident', 72% were 'confident,' and 14% were 'very confident' of their role during an emergent situation. Posttest, the self-assessed "confident' level stayed 72%, but the 'very confident' level increased to 28%. Simulation participants also reported higher confidence in their use of skills needed during adverse events. Pediatric dental sedation is a common practice in dental offices, and it is essential to have a plan that the professionals can use to address adverse anesthesia events. The plan should include directions on the appropriate emergent actions, ensuring a safe recovery, and preparing for discharge. This project addressed a gap in education and skills and demonstrated its feasibility in other dental offices to improve dental providers' knowledge and confidence. Keywords: office anesthesia, pediatric dental anesthesia, dental sedations, pediatric dental office protocols, rapid response Pediatric Dental Offices Anesthesia 3 Development of Protocols, Guidelines, and Processes for Adverse Anesthesia Events, Recovery, and Discharge in Pediatric Dental Offices The last few decades have seen a significant increase in the number of sedations done in office settings or out of hospital locations (Ramaiah & Bhananker, 2011). It is estimated that 100, 000 to 250,000 pediatric dental sedations are performed each year in dental offices (Nelson & Xu, 2015). These cases are challenging as children present the highest risk and lowest error of tolerance for anesthesia (Chicka, Dembo, Mathu-Muju, & Bush, 2012). Closed insurance claims found that 67% of adverse events involved general dentists as the anesthesia provider (Chicka et al., 2012). A high proportion of general dentists have never received any basic life support or pediatric life support training to be prepared for these adverse events (Cukovic-Bajic et al., 2017). To support patient safety in these out of hospital settings, protocols and guidelines need to be developed. Education of the staff working in these settings is of paramount importance to make office settings safe. Education and training need to include the actions to be taken during adverse anesthesia events, recovery skills and guidelines, and discharge criteria including parent education that need to be met prior to discharge of a patient. Devising a simulation education and training program with assessment of required skills can provide the foundation for the safest environment for anesthesia to be provided in office settings. This DNP project addressed the knowledge deficit and confidence level of pediatric dental personnel regarding their roles during office sedation, in the case of an adverse anesthesia event, and while recovering a sedated pediatric patient. Pediatric Dental Offices Anesthesia 4 Review of Literature Dental caries is the single most common chronic childhood disease (Lee et al., 2017) with an incidence in 2 to 5-year-old children of up to 25 % (Heard & Wanamaker, 2015). Sedation is needed primarily to provide anxiolysis, analgesia, and control of movement during painful or unpleasant procedures (Ramaiah & Bhananker, 2011). Approximately, 10-20% of all children who present for dental work require sedation because of age, behavior, anxiety, lack of coping skills, or disabilities (Heard & Wanamaker, 2015). Children are much less likely to be able to be calmed down and talked through a procedure than adults and they are not mature enough to understand why the procedure is necessary. Therefore, sedating the child becomes the answer when procedures must be done to improve dental health. Sedation/anesthesia for the children must also be “deeper” than that given to adults to achieve acceptable conditions for the procedure (Cravero et al., 2006). Although exceedingly rare, sedation of pediatric patients can have serious associated risks such as vomiting, hypoventilation, apnea, airway obstruction, and cardiopulmonary impairment (Chicka et al., 2012). Lee, Milgrom, Starks, Burke, and Cote (2013) reported 17 deaths in office sedation settings from 1980 to 2011 with 56% of those being children aged 2 to 5 years old. In total, 80 % of complications during sedation are due to adverse airway or respiratory events (Ramaiah & Bhananker, 2011). Review of closed case claims have identified several other causes for adverse anesthesia events during sedation as well: 46 % of severe outcomes had no physiological monitoring according to Chicka et al. (2012); inadequate monitoring was found to be a major theme by Saxen, Tom, and Mason (2019); and Ramaiah and Bhananker (2011) also noted a large percentage of patients not monitored with pulse oximetry. Other causes of adverse anesthesia events were lack of recognition of a problem, being sent Pediatric Dental Offices Anesthesia 5 home overly sedated, office staff and dentist lacking basic life support training, lack of an independent observer, and failure to rescue (Saxen, Tom, & Mason, 2019). The Pediatric Dental Association and the American Academy of Pediatrics responded to these adverse events with a guideline for office sedation. This guideline recommends that deep sedation/general anesthesia in dental office requires the presence of at least three persons to include a licensed anesthesia provider, an operating dentist, and a support person. (Use of Anesthesia Providers, 2018). The pediatric advanced life support (PALS) certified anesthesia provider is responsible for continuous monitoring of the pediatric patient, administration of medications, and has the ability to rescue the patient from a deeper than intended level of sedation (Use of Anesthesia Providers, 2018). Continuous monitoring is required for deep anesthesia including end-tidal carbon dioxide monitoring (ETCO2), oxygen saturation (SaO2), and access to positive pressure oxygen source. Other equipment required for adverse events include automated external defibrillator (AED), emergency rescue medications and suction (Use of Anesthesia Providers, 2018). Adherence to these guidelines greatly increases the safety of the pediatric dental patient. Pediatric dental office-based sedation requires considerations and preparations that are unique and unlike any other settings such as room set up, airway manipulation by dentist, and a young and vulnerable population (Saxen et al., 2019). Dentistry invades the airway and can cause respiratory distress and failure along with upper airway obstruction (Kim, 2016). Because various instruments are used, the possibility of foreign body aspiration is also increased (Heo et al., 2015). Anesthesia providers must be extremely diligent in airway management in pediatric dental office settings. Pediatric Dental Offices Anesthesia 6 Offices must be prepared for any emergent adverse anesthesia event. Primary care practices that provide care to pediatric patients were found to have emergencies occur 1 to 38 times a year, yet most were unprepared to deal with these emergencies (Bordley, Travers, Scanlon, Frush, & Hohenhaus, 2003). Deficiencies were documented in equipment, organization, and training (Bordley et al., 2003). Toback, Fiedor, Kelpela, and Reis (2006) described it as a “lackluster preparedness effort” for emergency situations (p. 415). Practices were shown to be deficient in life- saving skills and education, available emergency equipment, and planning to continue readiness efforts (Toback et al., 2017). It is estimated that 100,000 to 250,000 pediatric dental sedations are performed each year in the United States, and it is anticipated that a need for more pharmacological behavior management in the future will be needed (Nelson & Xu, 2015). Deep sedation and general anesthesia in the dental office is a cost-effective mechanism to deliver dental care to healthy children (Nelson & Xu, 2015). However, the inherent nature of children, compared with adults, can be a key source of anxiety and stress for healthcare providers during emergencies (Guise et al., 2017). To help alleviate this, mock resuscitation drills with appropriate office personnel are part of recommended emergency training for dental offices (Saxen et al., 2019). Use of mock codes for preparedness education increases the participants’ confidence to perform life- saving skills and provide comfort during emergency situations (Toback et al., 2006). Simulation has been shown to play an important role and should include all members of the team including the dentist, anesthesia provider, dental assistant, and front office personnel with each having clearly defined tasks (Saxen et al., 2019). In one mock simulation training, 91.7% of participants felt that the training was beneficial for crisis management skill development (Saxen et al., 2019). Chalwin et al. (2016) found that 64% of participants in a rapid response training course felt that Pediatric Dental Offices Anesthesia 7 their confidence and competence increased after simulation training. Simulation role play can successfully train personnel to respond to emergencies in environments where emergencies occur rarely but where the stakes are extremely high (Yager et al., 2016). Simulation fosters effective learning through active learner engagement, repetitive practice, the ability to vary difficulty and clinical complexity, as well as diagnostic performance measurement and intra-experience feedback (Okuda et al., 2009). The state of Utah does not require certification for dental assistants to practice (DANB, nd) and many just complete on the job training. The dental assistant scope of practice, for those who are certified, does include the requirement for basic life support training (BLS) (DANB, nd). Most dental assistants are not familiar with the advanced skills needed to assist in urgent anesthesia situations or with the recovery of sedated patients. These skills are not standard dental assistant roles (DANB, nd). However, after the sedation is completed, the dental assistant acts as a recovery person for the patient. Parents may experience this same apprehension taking their child home after a sedation procedure. Training and simulation for recovery as well as urgent anesthesia events increases confidence, speed of response, and improved outcomes. The World Health Organization (WHO) supports the use of checklists in improving safety and offers a comprehensive pediatric sedation checklist with discharge criteria (Kahlenberg, 2017). This allows decision making to be evidence – based and safer for the patient. A checklist for parent education for care at home is also essential and ensures a safe transition from the office to self-care at home (Gabriel et al., 2017). Theoretical Framework The Academic Center for Evidence-Based Practice (ACE) Star model of knowledge transformation was used to guide this project. This model has five steps represented by each Pediatric Dental Offices Anesthesia 8 point on the star. This interdisciplinary strategy transfers knowledge and implementation of knowledge gleaned from evidence- based process (Schaffer, Sandau, & Diedrick, 2013). The first step is knowledge discovery which refers to the statement of the problem and defining of the scope of the issue. Identifying the gap in knowledge and education in dental offices regarding roles, and responsibilities was this first step in the project. The second step is from the evidence summary and includes knowledge gained from the literature to support a solution. Information gathered for this project included sedation/adverse events, team roles, rapid response teams, pediatric dental sedations, protocols, discharge checklists, and simulation training for rapid response teams. The third step is a summary of the evidence synthesized into a single meaningful statement and action plan which may include protocols or guidelines. During this step, a pretest was administered to establish a benchmark level of skills and knowledge. This step incorporated the development of the education plan to include roles, responsibilities, and knowledge regarding action during, and recovery following, an adverse anesthesia event. The discharge checklist, parent education, and defined team roles during an adverse anesthesia event was taught and rehearsed through the creation of simulation scenarios. The fourth step is the implementation of the action plan. This was based on the development of a teaching plan for specific roles in monitoring, responding to adverse anesthesia events, and recovery of pediatric patients with pre- and post- surveys to ensure knowledge gained. Discharge criteria with parent education was provided based on a checklist for use by dental assistants. The final step and point on the star is the evaluation process to ensure outcomes are met. Surveys from step four were analyzed and used to guide the changes were needed in the teaching Pediatric Dental Offices Anesthesia 9 plan and simulation scenarios to ensure improved urgent event response time, increased confidence with roles during and recovery following an anesthesia emergency, address appropriate discharge criteria, and sustainability of the rapid response process. Project Implementation Plan Gap Most anesthesia providers in the office setting follow the guidelines recommended by the American Academy of Pediatric Dentistry (Use of anesthesia providers, 2018). These guidelines are unclear as to the responsibilities of dental office staff and dental assistants during sedation. Dental assistants and front office personnel are not able to state their roles in an adverse anesthesia event, in monitoring, in identifying discharge criteria, or in parent education. Roles and responsibilities for patient safety before, during, and after sedation must be clearly defined, stated, and acknowledged by dental assistants, office staff, and dentist through education and simulation training and debriefing sessions that were used to determine confidence levels. Goals and Expected Outcomes The overall goal of the DNP project was to improve pediatric safety in dental sedation outpatient dental offices. This was accomplished by providing education and training on the roles and responsibilities of dental office staff for adverse anesthesia events, monitoring of patients during recovery, and implementing a checklist for discharge criteria and parent education. Expected outcomes included decreased response time during anesthesia emergencies, identification of roles and responsibilities during sedation and recovery, increased confidence in support role, knowledge of discharge criteria, and provision of parent education for safe transport and follow up care at home. Pediatric Dental Offices Anesthesia 10 Population, Setting, and Organization Setting. The population for this project included pediatric dentist, dental assistants, anesthesia provider, and front office staff. Patients range in age from two to seventeen. Only patients with American Society of Anesthesiologist (ASA) physical status of I or II are seen in the office. A patient with an ASA I refers to a healthy patient with no disease process and non-smoker while an ASA II is mild disease process such as mild asthma (American Society of Anesthesiologists Standards and Guidelines, 2019). Pre-evaluation of the patient and the history is obtained and documented by the anesthesia provider. A team approach is a critical component for activities in which the risk to human life is high (Weinstock, & Halamek, 2008). The pediatric office has two front desk staff who check patients in, and initiate required paperwork. There are four dental assistants who bring the patient and family back to the preop area and assist the dentist during the procedure. The anesthesia provider assesses the patient, obtains, and documents the history, and escorts the child to the sedation area for provision and monitoring of anesthesia. Following completion of the procedure, the anesthesia provider takes the patient to recovery area where the patient is then monitored by a dental assistant for 30 minutes. Parents are brought back to recovery area after 30 minutes and remain with the patient until it is determined the patient is ready to go home. The anesthesia provider is always readily available to assist with any problems. The setting for this DNP project was at Jesse Low Pediatric Dentistry office in Brigham City, Utah. Office sedations are planned weekly with the number of patients each week varying from two to seven. All required equipment and medications are supplied by the anesthesia provider. Following completion of the procedure under sedation, the anesthesia provider takes the patient to the recovery area where the patient is monitored with SaO2 and ETCO2 by the Pediatric Dental Offices Anesthesia 11 dental assistant until discharge to home. Parents are brought back to the recovery area after the procedure and discharge plans are reviewed following established guidelines. At the location for this project, all dental assistants are certified in basic life support (BLS) and two of the six dental assistants are certified through the state of Utah. Barriers, Resources, and Ethical Issues Barriers experienced during the implementation in the project included that lack of precedent for utilizing a guideline for training in the dental office for adverse anesthesia events and recovery. A significant barrier was the time it took away from patients and that the staff had to stay after the office was closed to complete the simulation training. Another barrier was the cost to pay for the staff to participate in the guideline and simulation training. Payment of dental assistants was discussed with Dr. Low who felt the education, training and simulation was beneficial to the office. Ethical implications of the project was ensuring that the training provided was applicable to the scope of practice for everyone. To be effective, the simulation scenarios were developed to match the existing clinical skill levels to ensure that each learner was challenged appropriately. The training respected and engaged dental office staff, dental assistants, and dentists to foster a collaborative and cooperative patient care environment through a culture of safety, confidence, and open communication (AANA code of ethics, 2020). The anesthesia provider fostered a safe and trusting environment for successful learning by all members of the pediatric dental sedation team. In all aspects the nurse anesthetist followed the American Association of Nurse Anesthetists (AANA, 2018) Code of Ethics. Regulatory implications with the DNP project ensured that the anesthesia provider was certified by the National Board of Certification and Recertification for Certified Registered Nurse Anesthetists (NBCRNA) and had appropriate state licensure. The anesthesia provider, if CRNA, followed the Pediatric Dental Offices Anesthesia 12 AANA Nurse Anesthesia Standard of Practice (AANA, 2019). Also, the anesthesia provider was BLS, advanced life care support (ACLS), and pediatric advanced life support (PALS) certified (Use of Anesthesia Provider, 2018). The dentist and dental assistants were also BLS certified. The anesthesia provider had and knew the use of all the appropriate monitoring devices and emergency equipment such as an AED (automated external defibrillator) as required in the AANA office anesthesia requirements (AANA, 2020). The AANA scope of practice was also rigorously followed by the CRNA providing care (AANA, 2020). Project Implementation Plan The dentist, Dr Jesse Low, and the dental assistants employed at his office agreed to participate in a two-hour training that focused on roles and responsibilities during sedation, recovery room airway skills, monitoring of patient and the introduction of a checklist to be met before patient is discharged to home. A pretest was given prior to the training and simulation role play (see appendix B). A pretest for need analysis is vital for training development and effectiveness as it is the mechanism for ensuring that training is focused upon the correct team competencies underlying effective team performance (Weaver et al., 2010). Based on the pretest finding, an education plan was developed including simulation scenarios addressing the roles and responsibilities of office staff during adverse anesthesia events, recovery, and discharge. The goal for recovery was to provide training with skills and a checklist (see appendix C) to follow for dental assistants for managing patient in recovery. Specifically, side lying position, continuous SaO2 monitoring, oxygen delivery until awake, watching color and breathing of patient, jaw thrust maneuver, immediate oral suctioning if patient vomiting, and alerting the nurse anesthetist immediately for concerns. Pediatric Dental Offices Anesthesia 13 A checklist was developed based on example in Pediatric Dentistry journal to address criteria to be met prior to the pediatric patient being discharged from office following sedation (Cote & Wilson, 2019). This discharge checklist specifically noted if the patient could hold his/her head up unassisted for the count of 20 seconds, spontaneous eye opening, if patient is verbal then answering questions, and SaO2 above 95 on room air. Providing education to parents before leaving the office is also important and the development of a checklist of discharge education for parents on behaviors to watch for including difficulty breathing, when to start clear liquids, and side lying position for sleeping patients was implemented. The staff training and education included adverse/urgent anesthesia simulation and role play, adverse airway event, and adverse cardiac event with debriefing sessions after each exercise to determine confidence levels and knowledge gained. Roles and responsibilities were clearly identified and defined with each scenario. Specifically, during an adverse urgent anesthesia event one person acted as recorder and marked the time of events, one-person managed suction and assembled other equipment as needed, and the dentist assisted the anesthesia provider with any drug and oxygen administration. These skills were practiced with simulation training so that actions were adequately performed with speed and confidence. Simulation-based training enhances the didactic intervention and therefore the quality of team behaviors (Weinstock, & Halamek, 2008). If there was an adverse event that needed increasing care or monitoring, the dental assistant would be instructed to call 911 immediately while the anesthesia provider continued care of the patient. The closest hospital is Brigham City Hospital which is three minutes away from the office and it would be anticipated that the patient could be transferred there via ambulance if needed. Pediatric Dental Offices Anesthesia 14 A posttest (appendix D) was given to evaluate if the outcomes of improved knowledge in recovery and understanding of specific discharge criteria, defined roles for urgent events, and increased confidence in dental assistants were improved. Both pre and posttest results were plotted on bar graphs which aided visualization of the effectiveness of education and simulation. The leadership role of the DNP student was to provide the pre and posttest, develop the education plan, and arranged for simulation role play with debriefing. Institutional Review Board (IRB) requirements were submitted. The project was determined by Weber State University IRB to be Quality Improvement and no further review needed. The training took place on an afternoon in November 2020 for two hours. when the office closed an hour early and then the staff stayed an hour late to complete the training. Following the education and simulation, the discharge criteria checklist was implemented to improve parent education and patient safety. The timeline included DNP project approval which was obtained during summer semester 2020. After project approval was obtained, the fall semester of 2020 was spent preparing and administering the pretest, utilizing the pretest information for development of the education plan, simulation training scenarios, development of checklists for recovery, and parent education prior to patient discharge. The remainder of fall semester was the implementation of the education, simulations, and training and the gathering posttest scores. Spring semester 2021 was the analysis and evaluation of the data gathered. The training consisted of hands-on demonstrations of the equipment and monitoring devices, the use of continuous monitoring, and how to determine if discharge criteria had been met. The simulation role play took place on a rescue mannequin provided on loan from the Davis Hospital Education Department. Urgent anesthesia event scenarios were role played with Pediatric Dental Offices Anesthesia 15 team member roles identified and discussed, equipment demonstrations, and questions answered during debriefing. The Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) model was adapted for the simulation scenarios. The SMARTER approach outlines an event-based method for developing simulation scenarios in which critical trigger events are created underlying targeted teamwork competencies. The events in this project were urgent anesthesia events and were found within the simulation scenario as triggers designed to provide pediatric dental staff with the opportunity to exhibit targeted team behaviors. These were used to create an event-based checklist which was used to assess whether trainees exhibited desired observable, behavioral responses throughout the course of the simulation session. Performance criteria are simply marked as being either present (i.e., hit) or absent (i.e., miss) (Rosen, Salas, Silvestri, Wu, & Lazzara, 2008). (See Appendix A for fish bone diagram of project). Evaluation and Data Analysis Plan Data Analysis Techniques Data analysis techniques included the use of pre and posttests before and after education, and simulation training. A debriefing discussion log was used to evaluate simulation scenarios on adverse anesthesia events and the trigger points in the scenarios. Dental office staff, assistants and dentist satisfaction with the training, confidence levels, knowledge gained, and the ability to identify roles and responsibilities during sedation and recovery was determined by survey. Short answer opportunities were included in the survey to allow participants to share what worked and what did not in the training. Pediatric Dental Offices Anesthesia 16 Expected results will include increased knowledge of and confidence in the roles and responsibilities of dental office staff during an adverse anesthesia event, increased skills and confidence while monitoring patients in recovery, increased speed of response during urgent anesthesia event, and the use of defined criteria for discharge planning with parents. Follow up meetings will be held with the office staff to discuss results of training and to provide any further discussion or additional educational training needs. Evaluation The training and education of dental office staff was scheduled and attended after hours. Participants included seven staff members including two receptionists, three dental assistants, one dental assistant intern, and a dentist. A pretest had been given the week prior to the scheduled education followed by a post-test at the conclusion of the program. The pre and posttests measured knowledge, skill, and confidence levels. Knowledge was determined by test score results which included three multiple choice and two short answer questions. Points were awarded for correct answers based on the information given in the training. Confidence and skill levels were self-assessed on a Likert scale of no improvement, some improvement, moderate improvement, and a lot of improvement. Percentage of correct answers was determined for the pre- and post-test and compared and assessed for improvement. Self – assessed confidence levels were compared pre- and post- to determine improvement. The post-test contained a self-assessed skill improvement question after completion of the education program. The education program consisted of lecture, question and answer sessions, and participation in scenarios utilizing mannequins. Participants were involved in several scenarios and demonstrated knowledge and use of emergency equipment. Four scenarios were offered with participants taking on various roles in each situation. Scenarios included actions required during Pediatric Dental Offices Anesthesia 17 procedures as well as recovery of patients. Each participant was given the opportunity to demonstrate skills previously taught during the education program. Results The mean score of the pretest on the knowledge-based section was 92%. The mean of the posttest on the knowledge-based section was 98.9% which indicates an increase in knowledge after completing the training (see Table One). Table One The self-assessed pre and post confidence levels also showed an increase. Before the training, the mean was a three which indicates a moderate confidence in dealing with an emergent situation. The post training mean increased to over 3.25 which shows improved confidence in dealing with an emergent situation after the training (see Table Two). 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Pre and Post Test Scores PreTest Class Averages Post Test Class Averages Pediatric Dental Offices Anesthesia 18 Table Two The posttest self-assessed improvement of skills also showed an increase. One person scored a moderate improvement in skills after the training, and six people scored a lot of improvement after the training as shown in Table Three. Table Three 0 1 2 3 4 5 6 7 Not Confident A Little Confident Confident Very Confident Self - Assessed Pre and Post Confidence Levels Q8 Pre Q8 Post 0 1 2 3 4 5 6 7 No Improvement Some Improvement Moderate Improvement A lot of Improvement Self Assessed Skill Improvement Post Training Pediatric Dental Offices Anesthesia 19 Discussion The purpose of this training was to increase knowledge, skills and confidence in dental assistants who care for patients in post sedation setting in dental office. The data showed an increase in all these areas showing that the training was successful. The starting pretest mean score was high at 92% because this office works with the training instructor on a weekly basis and has already provided much of the information used in the formal training process. This would indicate that the training was even more successful if dental assistants already somewhat familiar with the areas of training still improved their knowledge, skills, and confidence. This also explains why most of the assistants started out with a confidence level of moderately confident. confident; however, the confidence level did increase following completion of the training. Verbal feedback from participants stated that the hands-on portion was “the most beneficial” and practicing scenarios and having “to think about the actions needed before they happened” helped them to feel much more confident. This DNP project is important to practice because it indicates that knowledge, skill, and confidence levels can be increased through a training program that improves patient care and patient outcomes in a dental office. Some dental offices do not have an assistant in attendance during recovery which places sedated patients at a higher risk of experiencing untoward events. Dental staff who have received education on adverse anesthesia events and appropriate recovery of patients reduces risks and enhances outcomes. While the anesthesia provider is ultimately responsible for the patient during sedation, having support staff with the knowledge, skills, and confidence to act appropriately in emergencies and recovery improves patient safety. Utilizing the skills and knowledge of a DNP-prepared nurse leader is beneficial for patients and communities. Pediatric Dental Offices Anesthesia 20 Recommendations Despite being somewhat familiar with the content of the training program, this formal education opportunity proved to be greatly beneficial for staff employed in a dental office offering sedation. Training was enhanced with the use of a mannequin during scenarios and the liaison with a local hospital willing to provide this equipment was beneficial and much appreciated. The DNP nurse leader is in an excellent position to network with hospitals and dental offices to provide an ongoing program to safeguard patients undergoing sedation proved greatly beneficial, even to a group that was familiar with the content. It would be even more beneficial to those unfamiliar with sedation in dental office settings. All dental offices that do in office sedations would benefit. For future trainings, it would be more advantageous to have a realistic mannequin with responses. However, this requires special expensive equipment. The participants were still able to demonstrate knowledge of all the equipment in the office that is needed for emergent situations. That was indicated to be a valuable learning experience by several participants. Because some things did not apply to everyone, it may be beneficial to split groups and teach parts that apply to each group separately. The two front office dental assistants that only work the front desk stated that the training was more information than they needed, as their part would be calling 911 and directing paramedics to the back room in the event of an extreme emergency. Conclusion Pediatric dental office anesthesia guidelines have improved over the last ten years, yet there are still areas lacking clear parameters for pediatric dental offices. Proven techniques in improving anesthesia safety include identifying specific threats to patient safety and correcting Pediatric Dental Offices Anesthesia 21 problems in equipment, standards, and training (Cravero et al., 2006). Mechanisms to enhance patient safety during sedation include the need for dental assistants, anesthesia providers, and dentists, to be aware of their roles in urgent anesthesia events, recovery from sedation, and safe discharge to home with parents. Improved skills through simulation scenarios will enhance the speed and confidence during these events and promote better outcomes. Development of specific checklists for patient discharge criteria and parent education will also provide continuation of safe care once the patient returns home. Although this is a single office, the goal is that this training can be applied to all pediatric offices so that all can benefit and increase patient safety. Pediatric Dental Offices Anesthesia 22 References American Society of Anesthesiologist Standards and Guidelines, (2019, October 23). Retrieved from https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system American Association of Nurse Anesthetists, (2018). Code of ethics. Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/code-of- ethics-for-the-crna.pdf?sfvrsn=d70049b1_ American Association of Nurse Anesthetists, (2020). Office anesthesia guidelines. 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Pediatric Dental Offices Anesthesia 27 Appendix A Pediatric Dental Office Develop Training Program Recovery Room Area Pre- Post Testing Surgery Area Provide Training Pre-Post Test Simulation Equipment Simulation Training Suction, Oxygen, Ambu Bag Question/Answer s Figure 1. Fishbone Diagram of Project . Manpower Environment Method Materials Improved Pediatric Dental Anesthesia Adverse Event Training Pediatric Dental Offices Anesthesia 28 Appendix B Pretest 1. Which equipment does not need to be in the recovery room? a. Oxygen saturation monitor b. Oxygen positive pressure c. Scaler d. Suction 2. What position should patient be placed in recovery area? a. On stomach b. Two pillows behind head c. Laying on side d. On back 3. Which of the following is most important to be watching during recovery? a. Oxygen saturation b. Lip color c. Chest movement d. All of the above 4. List two factors that must be present for a patient be allowed to go home after sedation. a. One b. Two 5. In your words, what is your role in recovery? a. 6. What is one important job of first assistant during a sedation? a. 7. What is your role in an emergency situation during a sedation? a. 8. On a scale from 1-4, how confident do you feel about your role during an emergent situation? a. 1 – not confident b. 2- a little confident c. 3- confident d. 4- very confident Pediatric Dental Offices Anesthesia 29 Appendix C Posttest 1. Which equipment does not need to be in the recovery room? a. Oxygen saturation monitor b. Oxygen positive pressure c. Scaler d. Suction 2. What position should patient be placed in recovery area? a. On stomach b. Two pillows behind head c. Laying on side d. On back 3. Which of the following is most important to be watching during recovery? a. Oxygen saturation b. Lip color c. Chest movement d. All of the above 4. List two factors that must be present for a patient be allowed to go home after sedation. a. One b. Two 5. In your words, what is your role in recovery? 6. What is one important job of first assistant during a sedation? 7. What is your role in an emergency situation during a sedation? 8. On a scale from 1-4, how confident do you feel about your role during an emergent situation? a. 1 – not confident b. 2- a little confident b. 3- confident d. 4- very confident 9. On a scale from 1-4, how much do you feel your skills improved from this training? a. 1 – no improvement b. 2- some improvement b. 3- moderate improvement d. 4- a lot of improvement Pediatric Dental Offices Anesthesia 30 Pediatric Dental Offices Anesthesia 31 Appendix D Discharge Checklist Criteria 1. Eye opening – a. Spontaneous b. With stimulation c. Not opening 2. Movement a. Squeezes fingers (or other movement on command) b. With stimulation c. Not moving 3. Head Movement a. Holds head up unassisted to the count of 20 b. Holds head less then the count of 20 c. Not holding head up 4. If verbal, Talking a. Answers questions b. Some talking but not answering questions c. Not talking 5. Oxygen saturation on room air a. Above 95 % b. Not above 95% Patient must reach all five criteria to be discharged to home.