BILL ANALYSIS                                                                                                                                                                                                    Ó



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          CONCURRENCE IN SENATE AMENDMENTS


          AB  
          2235 (Thurmond)


          As Amended  August 16, 2016


          Majority vote


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          |ASSEMBLY:  |      |(April 28,     |SENATE: |38-0  |(August 18,      |
          |           |      |2016)          |        |      |2016)            |
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                 (vote not relevant)




          Original Committee Reference:  B. & P.




          SUMMARY:  Declares the Legislature's intent that the Dental  
          Board of California (DBC) encourage dental sedation providers in  
          this state to submit data regarding pediatric sedation events to  
          a research database in order to improve the quality of services  
          provided to pediatric dental anesthesia patients, as specified;  
          requires the DBC, on or before January 1, 2017, to provide a  
          report to the Legislature on whether current statutes and  
          regulations for the administration and monitoring of pediatric  
          anesthesia in dentistry provides adequate protection of  
          pediatric dental patients; specifies the minimum information  
          that a licensee must report to the DBC in the event of a death  
          of his or her patient or removal of a sedation or anesthesia  
          patient to a hospital or emergency center for medical treatment,  








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          except as specified, and defines the categories of providers  
          that are required to be specified; specifies that the  
          information provided in this report is not an admission of  
          guilt; authorizes the DBC to assess a fine on any licensee that  
          fails to report an adverse event within a seven-day period and  
          provides that the licensee may dispute a penalty within ten  
          days; and, specifies the minimum information that a licensee  
          include on the written informed consent in the case of a minor.   



          The Senate amendments delete the Assembly version of this bill,  
          and instead:


          1)Declare the Legislature's intent that the DBC encourage all  
            dental sedation providers in this state to submit data  
            regarding pediatric sedation events to a research database  
            maintained by a nonprofit organization to formulate a  
            systems-based approach to improve the quality of services  
            provided to pediatric dental anesthesia patients in outpatient  
            settings.


          2)Require the DBC, on or before January 1, 2017, to make provide  
            a report to the Legislature on whether current statutes and  
            regulations for the administration and monitoring of pediatric  
            anesthesia in dentistry provides adequate protection of  
            pediatric dental patients and requires that this report be  
            made available on the DBC's Internet Web site.


          3)Specify the minimum information that a licensee must report to  
            the DBC within a seven-day reporting period of an a death of  
            his or her patient or the removal of a sedation or anesthesia  
            patient to a hospital or emergency center for medical  
            treatment, except as specified, is required to include, but  
            not limited to:


             a)   The date of the procedure; the patient's age in years  
               and months, weight, and sex; the patient's American Society  








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               of Anesthesiologists (ASA) physical status; the patient's  
               primary diagnosis; the patient's coexisting diagnoses; the  
               procedures performed; the sedation setting; the medications  
               used; the monitoring equipment used; 


             b)   The category of the provider responsible for sedation  
               oversight; the category of the provider delivering  
               sedation; the category of the provider monitoring the  
               patient during sedation; whether the person supervising the  
               sedation performed one or more of the procedures;


             c)   The planned airway management; the planned depth of  
               sedation; the complications that occurred; a description of  
               what was unexpected about the airway management; whether  
               there was transportation of the patient during sedation;


             d)   The category of the provider conducting resuscitation  
               measures; and, the resuscitation equipment utilized.


          4)Provide that the disclosure of individually identifiable  
            patient included in this report is limited to applicable law.


          5)Provide that that this report is not admissible in any action  
            brought by a patient of the licensee providing the report.


          6)Define the categories of providers as General Dentist,  
            Pediatric Dentist, Oral Surgeon, Dentist Anesthesiologist,  
            Physician Anesthesiologist, Dental Assistant, Registered  
            Dental Assistant, Dental Sedation Assistant, Registered Nurse,  
            Certified Registered Nurse Anesthetist, or Other.


          7)Specify that the information provided in this report is not an  
            admission of guilt.










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          8)Authorize the DBC to assess a fine on any licensee that fails  
            to report an adverse event not reported after the initial  
            seven-day reporting period; provides that the licensee may  
            dispute the failure to file a penalty within 10 days of  
            receiving notice of the penalty.


          9)Require a dentist who is permitted to administer general  
            anesthesia or deep sedation to obtain written informed consent  
            of a minor patient's parent or guardian on a form or forms  
            approved the DBC that contains the following information:


             a)   "The administration and monitoring of general anesthesia  
               may vary depending on the type of procedure, the type of  
               practitioner, the age and health of the patient, and the  
               setting in which anesthesia is provided.  Risks may vary  
               with each specific situation.  You are encouraged to  
               explore all the options available for your child's  
               anesthesia for his or her dental treatment, and consult  
               with your dentist or pediatrician as needed." 


             b)   Provides that the information listed in the informed  
               consent, in the case of a minor, is not to be construed as  
               reasonable standard of care administering general  
               anesthesia or deep sedation.


          FISCAL EFFECT:  According to the Senate Appropriations  
          Committee, pursuant to Senate Rule 28.8, this bill will result  
          in negligible state costs.



          COMMENTS:  Purpose.  According to the author, "Dentists,  
          including oral surgeons, are administering anesthesia, including  
          general anesthesia and sedation, more frequently to children and  
          are using more powerful drugs in their procedures.  Dentists are  
          also the only healthcare professionals allowed to perform  
          procedures while simultaneously administering anesthesia.  Other  
          healthcare professions require a separate person extensively  








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          trained in anesthesia, to administer anesthesia and to monitor  
          the patient.  Dentists are also less likely to use recommended  
          monitoring technologies, such as capnography or EKG, when  
          administering anesthesia.  As a result, there are a  
          disproportionate number of deaths and injuries, especially of  
          children, linked to dental anesthesia.

          "To date, data collection regarding the administration of  
          anesthesia while performing dental operations has been  
          unscientific, unreliable, and inaccessible.  Based on their  
          experience with medical professionals, parents do not understand  
          their children are being exposed to additional risks when  
          anesthesia is administered during a dental procedure."

          Background.  Use of Anesthesia.  Previous to 1980, state laws  
          described separate and distinct definitions for general  
          anesthesia and the state of consciousness.  Since then, the  
          Legislature has declared that there exists a continuum of  
          consciousness that may not be predictable in every case.   
          However, in most instances, the level of consciousness is  
          correlated with the level of sedation.  Currently, the state  
          does not delineate the minimum number of people involved in  
          administering general anesthesia during a dental procedure, only  
          that the operating room be large enough to accommodate at least  
          three people.  The author cites more than 20 states that require  
          a person to solely monitor the vital signs of a patient while a  
          separate person performs the dental procedure.  The author also  
          asserts that other health professions that administer general  
          anesthesia are required to have the same model.

          DBC Subcommittee.  On February 8, 2016, the Chair of the Senate  
          Committee on Business, Professions and Economic Development  
          (BPED) sent a letter to DBC requesting that the DBC form a  
          subcommittee to investigate pediatric anesthesia in dentistry,  
          and requested that information from that investigation be  
          reported back to the BPED Committee no later than January 1,  
          2017.  The DBC voluntarily created subcommittee, pursuant to the  
          request of the Chair of the BPED Committee.  The subcommittee is  
          charged with reviewing all incident reports related to pediatric  
          anesthesia in California for the years 2011 through 2016,  
          inclusive, and will also assess the policies used by other  
          states and dental associations to ensure that California is  








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          protecting young patients.


          According to the DBC, "Over the last several months, a  
          two-person subcommittee of the [DBC] has been doing a great deal  
          of research into whether or not California's present laws,  
          regulations, and policies are sufficient to provide protection  
          of pediatric patients during dental sedation; reviewing the  
          present laws, regulations, and policies in California and  
          comparing these findings not only with the information available  
          in other states, but also with dental associations' policies  
          related to sedation.  In addition, [the DBC] staff has been  
          compiling six years of statistics (January 1, 2010-December 31,  
          2015) related to incidents that have occurred where all methods  
          of sedation, including oral conscious sedation, conscious  
          sedation, and general anesthesia have been used for pediatric  
          patients 21 years of age and younger.  Board staff also included  
          incident reports related to the use of local anesthetic in the  
          statistical analysis."  The information is available to  
          interested parties in the form of a "working document"; however,  
          there are no recommendations for statutory and/or regulatory  
          changes from the subcommittee at this time.

          Stakeholders were invited to meet with the subcommittee on  
          Thursday, July 28, 2016, prior to its August board meeting to  
          discuss the working document.  Testimony was taken at this time  
          from interested parties.  Following the August meeting, the  
          subcommittee will continue to refine the "working document"  
          based on public comments.  A final draft of the report will be  
          submitted to the Board for discussion and possible action at the  
          December 1-2, 2016 board meeting.

          Analysis Prepared by:    Le Ondra Clark Harvey Ph.D. / B. & P. /  
                          (916) 319-3301                    FN: 0004598


                          Gabby  
          Nepomuceno












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