The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#155 Nitrous Oxide & Patient Safety - It's No Laughing Matter
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Nitrous Oxide (N2O) sedation relieves anxiety and makes dental visits relaxing, even enjoyable. If your practice isn’t utilizing N20 sedation, The Divas provides insights on the many benefits. And for those already using N2O, how confident are you in your maintenance protocols for delivery systems, tubing, and nasal masks?
The Compliance Divas are a trusted source for consistent, accurate information, based on guidelines, standards, science, and recommendations.
Resources:
- ADHA State requirements for hygienists and nitrous oxide https://bit.ly/3PLlf8v
- DANB Dental assistants functions by state: https://bit.ly/3PJtdit
- Accutron Nitrous Oxide/Oxygen Sedation Solutions https://www.hufriedygroup.com/en/accutron
- Accutron - Nasal Masks Samples https://bit.ly/3vzfXWQ
- Accutron - Reprocessing Instructions for Scavenging Circuits https://bit.ly/3VOqKH8
Welcome.
SPEAKER_04I'm Leslie Cannum. I'm Mary Gavoni.
SPEAKER_03I'm Linda Harvey. I'm Olivia Wan. And together we are the Compliance Divas.
SPEAKER_00Welcome to the Compliance Divas podcast. My name is Leslie Cannum, and I'll be your moderator today for our topic nitrous oxide and patient safety. It's no laughing matter. We are sponsored this podcast by the Hugh Freedy Group, a global leader in instrumentation, infection prevention, and instrument processing workflows that help dental professionals be best in practice with the highest quality products, services, and educational experiences in the industry. With Hugh Freedy Group, clinicians reduce risk, improve efficiencies, and drive compliance. They also enhance patient and team member safety and achieve superior clinical performance to continue to be the best in practice. At the compliance divas, we bring clarity and simplicity to compliance by navigating the regulatory environment to keep you on course. Subscribe to the ComplianceDivas podcast at our podcast website, thecompliancedevas.com, or subscribe on your favorite podcast channel. Also, we encourage you to enter your questions at our podcast website channel, thecompliancedevas.com, under support at thecompliancedivas.com. Well, for today's program, nitrous oxide has been a big game changer for many patients in dental practices for relieving anxiety, for making patient visits relaxing, even enjoyable. But not all dental practices offer nitrous oxide sedation. And this podcast we'll highlight how both pediatric and adult patients can benefit from the calming effects of nitrous oxide sedation. And then for those who are already utilizing nitrous oxide, we'll ask you to ask yourself how confident you are in your nitrous oxide maintenance protocols for the delivery system, tubing, hood, and mass. So to bring you confidence and clarity and to provide you with tips, our podcast guest expert on nitrous oxide is Jeff Hines. Jeff, you've been in the dental industry for 17 years, and you've been with Hugh Friedi Group as a director of corporate accounts and accuracy. I understand you're originally from Chicago. You now live in Arizona, and you're married with a five-year-old son, Lincoln, and a 12-year-old Corgi. Jeff, welcome. How long have you been with Hugh Friedi over the time that you have been their director of corporate accounts and Acroton?
SPEAKER_01Well, thanks for having me. First of all, I really appreciate it. Um, I've been with Hugh Freedy Group since before Hugh Freedy Group and Prostex came together in 2020. So six years total, but with the conscious sedation part with Accutron for about four years.
SPEAKER_00Wow. Well, you know, we have a lot of questions to ask you to help our listeners understand more about how to safely utilize nitrous in the dental setting. And I'm going to start out with our first Diva, Linda, who wants to address some questions surrounding misconceptions.
SPEAKER_02Linda? Thank you, Leslie. Jeff, I'm so happy that we're talking about this topic today. I think it's one that needs a lot more education in the dental industry. So thank you for joining us. Over the years, I've seen dental professionals all across the spectrum with how they feel about nitrous in their practice. Sometimes they're too lax, they start administering the nitrous, and everybody walks out of the room while the patient's relaxing. The macro gamut goes all the way to the other end when you see some offices that are just concerned, they're not sure, they're not comfortable with nitrous. So, can you talk about what some of the misperceptions or the perceived risk or that there thinkers there that maybe really isn't? And give us some ideas about what's what's going on with that, Jeff.
SPEAKER_01Yeah, sure. Thanks for asking me. Um so a couple different things. One is just the clinicians sometimes get concerned about uh ambient nitrous in the in the room. Uh another sort of concern could be if if they run out of gas in the middle of a procedure. Uh and you know, another thing that that really is a misconception is that nitrous is is dangerous. Um, so a lot of times clinicians will just give you know a pill or something like that, value maybe. Uh and then I'd say probably the last thing would be really patient safety. First, I mentioned clinicians, and they're also concerned about the patient's safety. So those are really some of the things I would say are really a concern.
SPEAKER_02Well, those are some key topics, and I know we're going to go more into that with Diva Leslie, but as a risk manager, those really hit my hot buttons as well because it's all about patient safety. And of course, this with this case, it's the use of nitrous for comfort for the patient and for the relaxation, so they'll be more comfortable coming in and not be anxious about their dental care. So there's definitely a vital role that nitrous plays in our practices. Thanks, Jeff. Back to you, Leslie.
SPEAKER_00Thank you. A resident attorney has questions about mitigating risks. What would we do to best mitigate any kind of risk that could occur as a result of utilizing nitrous oxide in a dental setting?
SPEAKER_03We are curious, Jeff. You know, as compliance consultants, we are all about mitigating risk. So from your perspective and your industry experience, how would you suggest that dental practices mitigate risk as it relates to nitrous?
SPEAKER_01Yeah, that's a great question. You know, one of the first things that I think about is the initial installation and making sure that you have the proper medical gas plumber doing the installation and making sure that everything is certified properly and you have the proper inspector as well. So those are really the most critical things. The foundation that I would say is the utmost importance. A couple other things I would say would be, you know, I mentioned before how the ambient nitrous is a concern. Really, if you're checking all of the scavenging tubes and all of the reservoir bag, all the tubing that is associated with uh the mixed gas and the gas, the vacuum, for any leaks, any cracks, you really need to do that before every patient. As long as you're doing those sorts of things, uh you really mitigate a lot of risk for that ambient nitrous, like we mentioned. Another thing, too, that we've seen is you know, innovations in the industry have caused the nasal hoods that the patients wear to improve to where there's no assembly required on the newer nasal hoods. Some of the older ones, you have to put multiple pieces together on scavenging hub and you know, inner piece and outer piece, and that really, again, causes some risk if the clinician doesn't put them together 100%. If maybe there's a little bit of a seal that's not properly closed, then that could be concerned. So, you know, the innovations have really helped us in the industry uh in that sense. If I had to think of a few other things, probably just making sure that the equipment is kept maintained properly, that you know, if the equipment needs to be calibrated, you need to make sure that that's being checked. I know with uh with Acuchon, we recommend uh to check every two years for uh your equipment to be uh calibrated. Of course, uh local and and national codes may say otherwise, so you have to kind of check with your your particular area that you live. But uh that's really an important part that can help mitigate risk as well.
SPEAKER_03That's some good points to consider, Jeff, because a lot of times people may be misinformed that it's installed and that's it. So you made some very valid points of checking the tubing and making sure that it's calibrated correctly and ensuring the safe use of it. So thank you for pointing that out. I think those are good items for people to add to their checklists and make sure that it's being done, particularly now and during the labor shortage, where we may not have enough time to get through the day that we need to have some checklist and task in place to make sure nothing is overlooked. So thank you for those points, Leslie.
SPEAKER_01Actually, I had one other thing, Olivia, I'd like to mention. Um, in Linda's question, I had mentioned that uh uh changing gas can also kind of be of concern. One of the other things that that Accutron has done to sort of uh reduce that risk is we've actually just discontinued two-cylinder portable flow meters altogether. So that's going to prevent any need for a change during a patient procedure, a change of cylinders. So you can just we only sell the four-cylinder carts now, so you can just switch from one cylinder to another as you're doing the procedure. So again, staying away from any two-cylinder system is is really, I think, important and just keeping with the four-cylinder is the best way to go.
SPEAKER_03Thanks for that added information. Uh Leslie, back to you.
SPEAKER_00Well, that's great information. I really think that uh people need to be focused on the fact that there is potential of state regulations that are separate from your every two-year calibration, that there should be a checklist for people to be able to inspect their nitrous oxide and oxygen tank units on how to make sure that everything is in good working order. And then also, I I love the idea that you're eliminating the two-cylinder. And that way it eliminates, as you said, the potential of running out of one or the other, which, you know, running out of oxygen certainly would mean only nitrous was going through unless there was some kind of bills fave. But then also having the less, I guess you could say, lost production to having to stop and then hook up new tanks. And I can imagine as a patient, I wouldn't want to have all that extra stuff going on while I'm having care, especially if I'm on nitrous oxide, which I've I've had as a dental patient once or twice. And it is a very nice and relaxing feeling, but I think I might also be worried if I saw the team doing something with my tanks and taking their time and focus away from my dental care. I'd like to bring our program over to Mary, who has several questions to ask, which are really kind of at the heart and soul of the compliance divas with regards to infection control and prevention and sterilization. And I know she's got several items to ask you that our listeners will certainly be interested in hearing about.
SPEAKER_04Mary? Thanks, Leslie. I've never heard so many questions about whether or not any of the equipment for nitrous oxide delivery needed to be sterilized until COVID. And then everyone was in a panic. What do I do? And COVID shouldn't have been the instigator of that. Because they should have been doing that all along. Jeff, can we talk about what is sterilizable and what is not?
SPEAKER_01Yeah, that's uh that's a great question. You know, it's funny because before COVID, you know, we nobody was really following the instructions for use uh to sterilize the tubing. It just kind of became the norm where you would, you know, wipe everything down uh after the patient and and then move on. What COVID helped us to really learn is that that you have to do that stuff. And that you actually have to make sure that you had some extra circuits on hand as you go through that sterilization cycle. Um what we also uh learned, we we needed to for us for Accutron at least, we needed to create a part code for just this the circuit that you needed to sterilize. So we quickly uh brought that to market and made sure that uh offices could mitigate costs, not having to buy the entire circuit, just the circuit that they needed to sterilize at a lower cost, uh, and just have a bunch of the office to cycle through. So uh that was good. And then for I can understand how it can certainly be confusing on what do I sterilize, what I what do I not sterilize with Accutron, it's great because everything that is a solid white tubing, solid white, opaque, it just needs to be sterilized. If it's not solid white, then it needs to be wiped down. Uh, I'll give you an example of our vacuum tubing is a white spiral, so it's clear in between the white spirals. So that's not solid white, so that's not sterilizable. The mixed gas tubing is a gray spiral tubing. So it's just really easy for the clinician to know that anything solid white that they have to sterilize uh after the patient.
SPEAKER_04That is so helpful, Jeff, especially with newer employees and perhaps some less experienced employees who may not know if they're breaking down the room. And so solid white, heat sterilizable. If it's not solid white, even though it's white, but the spirals in between are not opaque, needs to be wiped down. Now, there is, of course, a lot of concern on the part of a lot of practices about sustainability. What can I reuse? What can I heat sterilize? What should be a single use item? And obviously, we need to be paying attention to instructions for use and looking for that labeling of single use versus reusable. How can we talk to dental teams about this sustainability issue and convenience of single use and so forth? What would you say?
SPEAKER_01Well, you know, you know, at the beginning of COVID, the ADA did put out their guidance to use uh single use. And the single use is really just the nasal hood only being being thrown out. Uh in the industry uh that I'm aware of, there's nothing where the entire circuit is uh is disposable. Um so that really is where uh the market shifted to, which is great. It may again it mitigates the any kind of uh cross-contamination concerns. We saw um a lot of folks moving away from the multi-use masks over to the single-use. And we really think that's uh the future, that's where sort of everything is is going, it's safer for the patient, and there's not that much that is being thrown away. Uh, I think there may be a system out there where you throw a part of the scavenging circuit away, which you know goes to the landfill. But um, ideally, if it's just the nasal hood, uh then you know that's that's great.
SPEAKER_04So well, and I think since a lot of pediatric practices are heavily using nitrous oxide, and parents of those patients are concerned. And and I think that that's a big selling point, if you will, to parents that this is a single-use item. It hasn't been used on another patient, and especially now that we have these measles outbreaks all around the country, which are can be the measles can be spread through respiratory droplets. So we need to be very, very concerned about that and reassuring parents that these nasal hoods are single use. I think that's a great, great innovation.
SPEAKER_01Sure. And and just to clarify, so when I say circuit or scavenging circuit, it's essentially the the tubing that comes from the equipment to the patient and then from the patient out, right, to the vacuum system. So I tend to sometimes shorten it up and just say circuit. So just to clarify, scavenging circuit, that's what I'm referring to. Sure.
SPEAKER_04And I have seen some practices, especially during COVID, that did use disposable tubing for that purpose. But it's interesting now that we're past the COVID pandemic, people going back to not heat sterilizing those items that they should be. So we hope that this is a good reminder for our listeners.
SPEAKER_00Leslie? Thanks, Mary and Jeff. Well, I think another point that we need to bring up, Olivia wanted to chime in on what the fallout could be from reprocessing these single-use disposable items, particularly that are not heat resistant, with putting them in cold sterile. Olivia?
SPEAKER_03Leslie, some years back I was consulting with a client that utilized reusable nasal hoods, cost issue, budget concerns, what have you. And one of the patients had an allergic reaction because there was a residue of high-level disinfectant on the inside of the hood because it had not been rinsed properly. And so that definitely could be a patient safety issue. And I think Mary pointed that out that we have to follow the instructions for use. So anytime we can go disposable, of course, that's our preference. And then I also had an issue to come up where a dental office was cited that had to do with monitoring nitrous oxide. In most states, the dental assistant has to be certified to monitor nitrous oxide. So our listeners need to be familiar with their dental board requirements and also the issue of direct supervision. So when the board indicates that direct supervision is required, the dentist has to be in the building. I've addressed this multiple times with different dental offices that misconstrue what that supervision level means. So the dentist is not out to eat at a restaurant, the dentist is in the building. So this is really important for patient safety issues. Mary, you had something to add.
SPEAKER_04Olivia, that's a great point. Many cases, direct supervision also means that the dentist has to actually see that patient first before the dental assistant does anything like turn on the nitrous. So we will have two good resources in the show notes. One is to the dental assistant national board, or Dan B as we call it, that has a listing of functions for dental assistants state by state, and also the American Dental Hygienist Association, which also has a listing of what type of training or certifications that hygienists may need if they are administering nitrous as well.
SPEAKER_02Lynga, lastly, I'd like to piggyback off on, and I know we're not talking about specific state laws, but in Florida, direct supervision means the dentist is not only looking at the patient before the dental assistant does whatever delegable duty it is, but they're also checking after the fact. So it's that's why it's so important that we're sharing resources today and that we're stressing that our listeners check and know, not just check, but to know your state dental practice act so you can be practicing with nitrous very safely because of as Jeff mentioned, there's just there's a lot of misconceptions about the safe use of nitrous, and it can it can and is very safe. And it's something that officers should consider in their practice for patient safety and comfort because this is inhaled, it's not ingestible. So it's easier to monitor somebody on this on nitrous than to know did you give somebody somebody too much ingestable medication? And now you have to worry about a medical emergency that you have to really uh take that to care to the next level. It's such an easier process to use. And thanks for sharing.
SPEAKER_01Yeah, with with uh conscious sedation, it's great because the patient, five minutes with oxygen, can literally drive home and be perfectly fine, versus if they're ingesting, you know, volume or something like that, they have to have someone drive them home.
SPEAKER_00Well, that's a wonderful point. So we improve our patient's experience with nitrous oxide. Some for some patients it's a game changer due to apprehensiveness. And for children, I know my own grandson, when he goes to the pediatric dentist, the first thing they ask him when he walks in the door is is what flavor he wants, because they have apparently figured out a way to, I guess, flavor the the nitrous itself, if I'm not mistaken. So I think they said cotton candy. Is that right, Jeff? Do they have a way of making it more attractive for children? Or is that something that is just based on the the nasal, the call, the cannula, or yeah, that's that's a great question.
SPEAKER_01So a lot of our single-use nasal ads do have like a bubblegum mint. They do have the the scents, so that you know obviously it enhances getting to the conscious sedation point a little bit faster when you're trying to smell that that wonderful bubble gum smell. Uh and so that's yeah, that's always fun for the kids too.
SPEAKER_00So well, I would love it if they made it in chocolate.
SPEAKER_01Well, we I mean we do have a pina clear scent as well.
SPEAKER_00So and so again, to recap, it's very important that installation is done properly with the right kind of plumbing inspection and following all the local guidelines and making sure that we stay abreast of any other uh regulations and maintenance, always following the manufacturer's directions, uh, making sure that calibration is done at least every two years. And then more often, if your states required that, we also want to be mindful of how we are setting up our nitrust for success. Uh, we're those of You who are working with two cylinders may want to consider moving on over to the four-cylinder system so that you have that extra safety of not running out and make sure that we have our scavenging units properly hooked up and that we make sure that we have understanding of whether we're using a single-use type of tubing or a multi-use. We want to make sure that we understand the processing, reprocessing for the nasal hoods that are multi-use. And we also want to understand that obviously patient safety is key. We need to make sure that we're following all the proper protocols for that. And then employee safety, as was mentioned in the podcast, that monitors are required in some states for those who are utilizing nitrous. And there may be other certifications you can check with your state dental board surrounding how we will be able to assure that a dental assistant would be able to properly administer the nitrous oxide and under what circumstances. So I know we have lots and lots of resources that are available. There's some uh reprocessing instructions that will be available in the show notes, as well as a state map, Mary had mentioned, that gives information about hygienists and nitrous oxide, and we'll have some information from Danby, the Dental Assisting National Board. And to help provide a little bit more incentive for you to check our show notes, we're also going to have a link that you can get some nasal mass samples from Hugh Freedy. And we would appreciate, of course, if you would take a look at the show notes when you're there and either leave us a comment or ask questions. Uh, we'd love to have some reviews. We'd love for you to go to the Compliance Diva's website. And we want to thank Jeff for taking so much time with us today to help us understand more about nitrous oxide. Again, for those who are considering using it and for those who are using it or seasoned team members who have been using nitrous oxide forever to strengthen our safety and protocols surrounding our own safety and inpatient safety. And Jeff, did you have any other comments, anything else that you wanted to share with us before we close this podcast for today?
SPEAKER_01Leslie, there is one more thing I wanted to circle back on on a question that Linda had regarding misconceptions. And that was that patient safety. Uh one of the things that I'd really like to make sure that the audience knows is that there really have been no known allergic reactions recorded of nitrous oxide oxygen sedation. So it's a very, very safe method for conscious sedation. Uh, and when uh selecting a nasal hood that goes over the nose, uh, ours are free of most allergic concerns. They're silicone blend. Uh, and if a patient does have any uh sensitivity to scents, we do have an unscented version available for those patients. So it's safety is absolutely important and critical, and wanted to make sure that the clinicians and patients know that.
SPEAKER_00Jeff, you also mentioned something about the four-cylinder tank and the two-cylinder tank. Can you tell us what the hazard would be if, let's say, the oxygen ran out?
SPEAKER_01Yeah, if if either cylinder runs out, essentially the flow stops on a portable system, and the the clinician then has to run and go get uh a spare cylinder while the patient is sitting in the chair, hopefully not starting to feel something, until that clinician is able to get another cylinder, put it back on the system, and get going again. So there are fail-safe measures in in all equipment uh that prevent anyone from uh getting, you know, only nitrous, for example, instead of oxygen. So those fail-safes are are in the equipment uh and they're they're checked over quality-wise and all of that. So it's just the prevention of having to stop in the middle of the procedure and getting that cylinder is the reason why we just felt that selling a two-cylinder system is really not great for the clinician, it's not great for the patient. So we moved to only selling the the offering the four-cylinder uh portables for clinicians to use.
SPEAKER_00Yeah, you wanted to chime in.
SPEAKER_02Leslie, to Jeff's point, I'd like to point out that when you think about the whole world of patient safety, Jeff, what you're describing is putting on all these additional uh patient safety barriers, if you will, or stop gaps to help any kind of error or mistake or mishap or unsafe condition reaching the patient. So I want our listeners to really appreciate that because the fact that if you run out of gas in either tank, it shuts off altogether. The fact that you're addressing any allergic concerns by having no sense and that the material that the products are made out of or silicone, those are all important safety things when it comes to quality care for our patients. So I'm glad to hear that Pew Friday's got this top-notch system. Thank you, Jeff.
SPEAKER_01You bet.
SPEAKER_00Thank you. That's it. That's a wrap at the Compliance Divas. We bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please feel free to submit your questions to us as well at support at the compliance divas.com and check the show notes for the resources and our website. This concludes the podcast for today.