For many years, dentists have been providing anesthesia in office settings, the rules gave a competitive advantage to dentist anesthesiologists, and requirements for reporting of adverse events were limited. The Arizona Association of Nurse Anesthesiology (AZANA) has changed this through Arizona Senate Bill 1602 and committee work at the Arizona State Board of Dental Examiners, establishing a level playing field among anesthesia providers in dental offices.
Prior to this legislation, the Arizona Dental Board would oversee permits for dentist anesthesia providers, regulating dentists through four different permits, including one for general anesthesia, one for oral anesthesia, one for intravenous sedation, and one needed to employ a Certified Registered Nurse Anesthetist (CRNA), also known as nurse anesthesiologists or nurse anesthetists, or a physician anesthesiologist.
Ali Baghai, CRNA, is the state reimbursement specialist and past president (2015-2016) of AZANA and managing partner of Arizona Anesthesia Solutions by Guide Anesthesia. He has been instrumental in helping develop key components of this legislation, beginning with his work on a multidisciplinary anesthesia and sedation committee composed of medical and dental representatives established in 2019 to make recommendations to the Arizona Dental Board. Baghai and AZANA developed a working relationship with a key freshman Arizona senator that would soon make a considerable impact.
“It was difficult to come together to make changes until Arizona Senator Janae Shamp (R) approached the board regarding some news stories about patient deaths in dental offices,” said Baghai. “Senator Shamp helped make the way for substantial changes with Senate Bill 1602, with the appropriate oversight of those providing anesthesia in dental offices. Yet, even with the senator’s involvement, there were some sticking points in the legislation for the multidisciplinary board to work through.”
Senator Shamp sent a letter to the Arizona Dental Board demanding action, which prompted the Arizona Dental Board to come together for a special meeting. The anesthesia and sedation committee was charged with working out how the rules would be determined to diminish any barriers that still existed in practice.
According to the new rules, any dental office in Arizona that brings in a Qualified Anesthesia Provider (CRNA, dentist anesthesiologist, or physician anesthesiologist) is required to notify the Arizona Dental Board. At minimum, the dentist must have training in either Advanced Cardiovascular Life Support (ACLS), Pediatric Advanced Life Support (PALS), or an advanced airway course.
The dentist must also sign an affidavit that they understand the equipment, supplies, and medication necessary to safely provide anesthesia services in a dental office. Under the previous rules, dental offices were only required to do this to bring in a Non-dentist Anesthesia Provider (CRNA or physician). This change levels the playing field between the three anesthesia professions working in dental offices as well as improve patient safety.
In addition, the new law and rules require that any adverse event in a dental office, defined as an EMS transport or hospital admission within 24 hours of the procedure, is reported to the regulatory board. This adds an additional layer of safety for patients, allowing the boards to monitor and act upon poor outcomes.
One of the rules Baghai worked to change concerned the permit (Permit 1304) to employ a CRNA or physician anesthesiologist, which required an on-site evaluation.
“I argued against the on-site evaluation being necessary. The anesthesia provider brings in all the equipment, supplies, and emergency medications that are evaluated in the on-site evaluation. But the permit goes to the dentist. After receiving the permit, the dentist can bring in any anesthesia provider, so there is no control over the equipment, supplies, and medications after the on-site evaluation, “he said.
According to Baghai the only impact of the on-site evaluation was to delay the process in obtaining a permit. When AZANA first approached the dental board with this issue, the permit time was exceptionally long, on occasion taking up to a year to obtain. After the dental board recognized this time delay, the time from application to permit receipt was shortened to around 60 days. Under the new rules, the 1304 permit has been eliminated. Now the dentist is required to notify the board of any anesthesia provider (CRNA, physician or dentist) caring for patients at their office. This dramatically improves access to care.
The Arizona Dental Board approved removing the 1304 permit, something Baghai had been working to make happen for four years.
There are many gains through the impact of the rule changes for this legislation. All anesthesia providers, (CRNAs, dentist anesthesiologists ,and physician anesthesiologists), are now on equal footing. All need to be registered with their respective regulatory agencies (dental board, medical boards, nursing board) to provide anesthesia services in a dental office. This rule places appropriate oversight of professionals and removes any potential for the Arizona Dental Board to indirectly regulate non dentist anesthesia providers.
In addition, every office where the operating dentist provides anesthesia services will need further training and an understanding of the basic requirements for safe anesthesia care in a dental office. The Arizona Dental Board will now know every office where sedation and anesthesia are being performed.
Baghai and AZANA celebrate this win and look forward to continue building relationships with lawmakers and advocating on behalf of CRNAs in the next legislative session.
“Everything is about relationships. Working to build and engage with lawmakers is key to informing them about the issues that affect the lives of CRNAs and their patients,“ said Baghai. “Passing this legislation and helping to create a completely level playing field in the dental market among CRNAs, physician anesthesiologists, and dental anesthesiologists, took lots of determination to find common ground and keep the focus on what would do the most for patients who this will positively impact.”