Frequently Asked Questions
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H. ESTABLISHING A SEDATION SERVICE
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1. I am setting up IVS services at my practice. Is there a list of equipment / regulations to help.
2. I attended the online presentation on peripatetic sedation however I still have a few questions and was wondering if you are able to help me with this. I don’t have a physical dental practice premises to order or store midazolam but would like to start offering a mobile sedation service.
- I am unsure how to buy midazolam via the CD requisition form as I don’t have a physical dental premises. How do you buy the drugs, where is the best place to get the drugs from?
- As a roaming sedationist, if you don’t have your own physical premises, can you keep and store the drugs yourself at home? Or is it mandatory for the drugs to be stored at a dental practice?
- Would you have a copy / template of a controlled drug policy and controlled drug standard operating procedure?
Thank you for your question and for tuning in to the webinar.
I have previously bought my midazolam from one of 3 places: Henry Schein, Medical World and my local pharmacy. It does not matter where you purchase the drugs from as the process is the same in that it requires you to fill out a controlled drugs requisition form specific to schedule 2 and 3 drugs (FP10CD form). The link for this is here:
On the second page of the form you will find guidance on how to fill it in.
When I order through Henry Schein, I use my account number as the individual prescriber code and my GDC number as the practice code. Pharmaceuticals are always sent to a dental practice and so I have 2 accounts with Henry Schein, one associated with a dental practice that I am close with and one associated with deliveries to my house which I use for non-pharmaceuticals. They both have my house as the billing address, so the practice does not receive or must deal with my bills. If you can form a relationship with a dental practice so they would accept your deliveries, then that would be ideal.
When ordering midazolam, you must fill out the form and sign it yourself and post it to whoever you are buying the drugs from and once they have received it then they will dispatch the midazolam to you. This is the same for anywhere. Medical world is also a good option, has a similar format and sells other drugs which are handy as a peripatetic sedationist, like dexamethasone.
If you really cannot connect with a practice then may I suggest connecting with your local pharmacist and you can take the forms to them and they can order it in for you to personally pick up. Whatever works for you.
On the form there is a section that asks, 'purpose for which the drugs are required' and I tick number 2: 'for use within practice / surgery'.
The midazolam can be stored in your house. Follow the same protocols that you have in a practice and taking all the reasonable steps to make sure the drugs are being stored with care.
Read and follow the CQC Myth Busters document entitled 'Management of controlled drugs' which you can find here.
I would recommend creating your own SOP as this would be personalised to you and your situation.
Controlled drugs must be denatured so whilst you are on the myth busters section of the CQC website, you will find a link to the site for you to apply for a T28 exemption from the environment agency to negate a need to obtain a licence to carry out this process.
3. I am joining a private practice in April alongside my current one and I am very keen to get a sedation service up and running but none of the nurses are currently sedation trained. I have advised that they will need to attend the training and directed them to the SAAD one which the practice manager is booking. However, they will then need to be observed for 20 cases. I was a STAC approved supervisor in community but suspect I will need to renew this. How do I go about this? My concern is that there is no sedation trained nurse so how do I supervise the cases with the nurses without one? I can't seem to work out a way round it.
For setting up a new service I would recommend SAAD's Safe Sedation Practice Validation.
Is it possible for you to find another clinician / practice for the 20 cases for your nurse to be observed? Another alternative may be for you to do the observation and training whilst doing a sedationist-only role i.e. not an operator sedationist. In this case, another dentist would do the dentistry whilst working with a dental nurse in addition to you doing the sedation and training the trainee sedation dental nurse - which involves 4 team members. I hope this helps.
4. I just wanted to ask if there’s any advice on starting a mobile sedation service
Thank you for your enquiry and I am pleased you have shown an interest in this incredible profession. Here is some advice on starting a peripatetic sedation service which hopefully you'll find useful. I would recommend getting prepared using the umbrellas that the IACSD furnishes us with.
1. Premises: Every practice you sedate at should be assessed by you and deemed conducive to providing safe sedation. I would recommend SAAD's Safe Sedation Practice Validation as a template to ensure quality control has been met.
2. Equipment: Acquire all the equipment you need and buy a lockable case with compartments so you can get organised with knowing your equipment. You would need to be affiliated with a practice for drug ordering. Have a list of all the equipment you carry as the practices may request this list for their records.
3. Training: Be at the forefront of staying updated and be affiliated with as many sedation establishments as you can. You would need to ensure that the practices / dentists that you sedate for are aware of guidelines and have ILS training. Offering 'Lunch and Learn' for local practices is a great way to promote your services and go through indications of sedation and what the practices need to have in place in order to offer sedation to their patients. They need to know what a great fulfilling service it is to offer. Train the dentists on how to assess the patients for sedation and what should be written in clinical notes at the appointment where sedation is offered as an option. Consider providing a template for the manager to place on the computer. Local BDA meetings and giving a lecture at the BDA locally also help with promoting your services.
4. Consent: Create a way to assess and consent your patients ideally by meeting them face to face or virtually. Have a way that you can get information about sedation to your patients and to the escorts. There are systems that allow for consent forms to be electronically signed and sent to the practice and included in notes. Be sure to check that all documents are in the patient's notes including your sedation notes. I would recommend you create a proforma for your sedation notes and one for the practices to send you when they book you for sedation. Be aware of GDPR and follow protocol and register with the ICO. Be sure the practice knows that they need to have written consent for any treatment they do under sedation even if it is treatment that they normally do not take written consent for e.g. scale and polish.
5. CQC: Ask the practices to familiarise themselves with CQC's Mythbuster 10 and what the requirements are for the practice and provide the practices you sedate at with your documents so they are compliant. This would include your qualifications, indemnity, equipment servicing and calibrating certificate, CPD and sedation practice protocol to name but few. Make the sedation team (the dentist and the second appropriate person) aware that they also need to have 12 hours of sedation-related CPD in every 5 year cycle. Suggest they become members of SAAD and read the Digest to help them gain this CPD.
6. Fees and Marketing: Decide on a fee scale for yourself and decide who would pay you and how you would invoice professionally.
7. Connection: Take time to get to know the practice managers and the reception staff. They will really help make sure your patients’ journey is smooth. They should be furnished with information about sedation so they can answer simple questions that patients have. They must know they cannot take payments from patients after sedation and have a system in place to take payments before or invoice after. Get to know the nurse at each session and take time to check that they have things in place e.g. the water is filled up, mouth prop is ready, equipment is checked (the infamous surgical hand piece has been checked and is working) and that they understand the importance of airway management etc. They are your eyes and are the holy grail of the procedure. Take time to talk to the dentist and see what they require from you. Everyone is different and they may work very differently to you and you will both be guided by each other. For example, it may be a good idea if they are taking two teeth out, that the LA is given for both teeth at the start of the appointment when the sedation and amnesia is most profound. Also, many dentists do not know that the reflexes are obtunded especially at the start of sedation so making them aware of flossing implant drivers and extra care when taking out the infamous upper 8s and if possible to not have the patient supine. Overall, you are the sedationist and it is very helpful for you to be able to direct the team on how best to provide care safely and efficiently for a sedated patient. Being a dentist yourself is key to this.
The rest you would already know and have in place because you are already sedating. The difference now is trying to make sure every place you go has the same set up, be able to help them be compliant and be clear about who has what responsibility. The success of this incredible career is being able to connect with both dentists, their patients and the practice staff and dovetail this with your skills and personality.