Quality Standards: Primary dental care

Healthcare providers have an obligation to provide resuscitation skills in the event of a cardiorespiratory arrest and to ensure that staff are trained and updated regularly to a level of proficiency appropriate to each individual’s expected role. 

This document provides Quality Standards and supporting information for the aspects of cardiopulmonary resuscitation practice and training relevant to the setting of primary dental care. The document does not include the resuscitation standards expected when ‘Conscious Sedation’ techniques are undertaken by dental practitioners as there is existing guidance for this specific area of practice from the Academy of Medical Royal Colleges (see Supporting information). 

Furthermore, this document replaces the Resuscitation Council UK document ‘Medical Emergencies in General Dental Practice’ which will no longer be supported or available on the RCUK website. Those requiring information on medical emergencies encountered in dental practice (other than cardiorespiratory arrest) are referred to the relevant section in the British National Formulary (BNF). Further enquiries should be directed to the Dental Advisory Group of the BNF or the British Dental Association who contributed to the advice within the BNF. 

The core standards for the provision of cardiopulmonary resuscitation across all healthcare settings are described in the Introduction and overview page.

Alongside the Quality Standards, there is a primary dental care equipment list. Please refer to that by clicking here.

‘A patient could collapse on any premises at any time, whether they have received treatment or not. It is therefore essential that ALL registrants are trained in dealing with medical emergencies, including resuscitation, and possess up to date evidence of capability’. General Dental Council ‘Scope of Practice’ 2013 

• Cardiorespiratory arrest is rare in primary dental practice. 
• There is a public expectation that dental practitioners and all other dental care professionals should be competent in treating cardiorespiratory arrest. 
• All primary care dental facilities should have a process for medical risk-assessment of their patients. 
• Specific resuscitation equipment should be available immediately in all primary care dental premises. This equipment list should be standardised throughout the UK. 
• All clinical areas should have immediate access to an automated external defibrillator (AED). 
• Primary dental care providers, general dental practitioners and all other dental healthcare professionals should undergo training in cardiopulmonary resuscitation (CPR) including basic airway management and the use of an AED. 
• Each primary dental care facility should have a plan for summoning assistance in the event of a cardiorespiratory arrest. For most practices this will mean calling 999 immediately. 
• There should be regular practice and teaching using simulation-based cardiorespiratory arrest scenarios. 
• Dental staff’s knowledge and skills in resuscitation should be updated at least annually. 

Standards

There should be a standard list of equipment required for cardiopulmonary resuscitation within any primary dental care practice in the UK.      

Click here to view the equipment list for cardiopulmonary resuscitation in primary dental care. 

Standards

Accurate documentation of any patient’s medical history should allow most people at risk of certain medical emergencies and subsequent cardiorespiratory arrest to be identified in advance of any proposed treatment. 

1. Dental practitioners and other dental care professionals must be trained in cardiopulmonary resuscitation (CPR) so that in the event of cardiorespiratory arrest occurring they can:    
   • recognise cardiorespiratory arrest; 
   • summon help immediately (dial 999); 
   • start CPR, using chest compressions and providing ventilation with a pocket mask or bag-mask device and supplemental oxygen (evidence suggests that chest compressions can be performed effectively in a fully reclined dental chair); 
   • attempt defibrillation (if appropriate) within 3 minutes of collapse, using an AED; 
   • provide other advanced life support skills if appropriate and if trained to do so. 
2. Dental practitioners and other dental care professionals who work with children should learn the differences in between CPR for children and CPR for adults, and practice CPR for children on paediatric manikins. 
3. Dental practitioners and other dental healthcare staff should update their knowledge and skills in resuscitation at least annually. 
4. A system must be in place for identifying which equipment requires special training, (such as AEDs, bag-mask devices and oropharyngeal airway insertion) and for ensuring that such training takes place. 
5. All new members of dental staff should have resuscitation training as part of their induction programme. 
6. Training can be undertaken locally within the dental practice or within local or regional training centres. Qualified trainers in resuscitation from within the dental practice staff should be encouraged to deliver ‘cascade’ training to other staff members (e.g. in Basic Life Support). Training in more advanced techniques may require a more advanced trainer (e.g. Resuscitation Officer) or attendance at a designated course. 
7. For all staff, various methods to acquire, maintain and assess resuscitation skills and knowledge can be used for updates (e.g. life support courses, simulation training, mock-drills, ‘rolling refreshers’, e-learning, video-based training/self instruction). The appropriate methods should be determined locally. For example, the interactive film Lifesaver, developed by Resuscitation Council UK, or brief videos designed to be used by the general public may be appropriate for non-clinical staff. ‘Hands-on’ simulation training and assessment is recommended for clinical staff. 
8. Training in resuscitation must be a fundamental requirement for dental practitioners and other dental care professional qualifications. Undergraduate and postgraduate examinations for all dental practitioners and dental care professionals should include an evaluation of competency in resuscitation techniques appropriate to their role. 
9. All primary dental care providers should recognise the need for and make provision for dental staff to have sufficient time to train in resuscitation skills as part of their employment. 
10. All training should be recorded in a database. 
11. Training and retraining should be a mandatory requirement for Continuing Professional Development and maintenance on professional healthcare registers. It may be appropriate for some retraining to be undertaken using ‘e-learning’. 

Standards 

1. In the event of cardiorespiratory arrest, emergency services should be summoned immediately by calling 999. A local protocol should include clear directions on how to find the dental care facility and whether there may be a difficult access point. Primary dental care practices should identify clearly all access points and patient removal routes. 
2. Ambulance personnel will provide equipment, expertise, practical help and a range of treatments supplementary to those available in the dental surgery. 
3. Written documentation containing details of the dental procedure (if any), medical emergency, any treatment given, and the name of the Dental Practitioner should all accompany the patient to hospital. 
4. Relatives or carers should be informed about the transfer of a patient but should not expect to travel with the patient in the ambulance. Contact details should be obtained by the ambulance personnel. 

Standards 

1. To ensure a high-quality service, primary care dental facilities should audit: 
   • weekly (as a minimum) checks of the resuscitation equipment; 
   • other elements of health and safety (e.g. manual handling). 
2. Audit should always include a full ‘debriefing’ of staff after any cardiorespiratory arrest. This allows them to reflect on the treatment given and permits discussion of whether anything might have been done differently. 
3. Where audit identifies deficiencies, steps must be taken to correct these. 

Standards 

Dental practitioners and other dental healthcare providers may treat patients who have a ‘Do Not Attempt Cardiopulmonary Resuscitation’ decision or who possess a legal document (Advance Decision to Refuse Treatment) specifying that they do not want CPR in the event of a cardiorespiratory arrest. Management of such patients must comply with the law and should follow the national guidance set out in ‘Decisions Relating to Cardiopulmonary Resuscitation - A Joint Statement by the British Medical Association, Resuscitation Council UK and the Royal College of Nursing’, and further guidance issued by the General Medical Council. 

1. Resuscitation Guidelines 2015, Resuscitation Council UK. 
2. Standards for the Dental Team. General Dental Council, London 2013 https://www.gdc-uk.org/information-standards-guidance/standards-and-guidance 
3. Scope of Practice. General Dental Council, London 2013. https://www.gdc-uk.org/information-standards-guidance/standards-and-guidance 
4. Preparing for Practice. General Dental Council, London 2011. http://www.gdc-uk.org/Newsandpublications/Publications/Publications/GDC%20Learning%20Outcomes.pdf. 
5. Poswillo DE. General anaesthesia, sedation and resuscitation in dentistry: Report of an Expert Working Party for the Standing Dental Advisory Committee, London. Department of Health 1990. 
6. Soar J, Perkins GD, Harris S, Nolan JP. The Immediate Life Support Course. Resuscitation 2003; 57:21-26. 
7. Girdler NM and Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation 1999: 41; 159-167. 
8. Atherton GJ et al. Medical Emergencies in General Dental Practice in Great Britain Part 1: their prevalence over a 10-year period. British Dental Journal 1999; 186:72-79. 
9. Müller MP, Hänsel M, Stehr SN, Weber S, Koch T. A state-wide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J. 2008; 25(5):296-300 
10. Lepere AJ, Finn J and Jacobs I. Efficacy of cardiopulmonary resuscitation performed in a dental chair. Australian Dental Journal 2003; 48; 244-247. 
11. Prescribing in Dental Practice, British National Formulary. https://www.evidence.nhs.uk/formulary/bnf/current/guidance-on-prescribing/prescribing-in-dental-practice 
12. Coulthard P, Bridgman CM, Larkin A et al. Appropriateness of a Resuscitation Council UK Advanced Life Support Course for primary care dentists. British Dental Journal 2000; 188: 507-512. 
13. Standards in Conscious Sedation for Dentistry. Report of an Independent Expert Working Group funded by the Society for the Advancement of Anaesthesia in Dentistry, 2000. 
14. Conscious Sedation for Dentistry: the Competent Graduate. Dental Sedation Teachers Group, 2000. 
15. Training in Conscious Sedation for Dentistry. Dental Sedation Teachers Group, 2005. 
16. Academy of Medical Royal Colleges - Safe Sedation Practice for Healthcare Procedures - Standards and Guidance. 2013. https://www.aomrc.org.uk/wp-content/uploads/2016/05/Safe_Sedation_Practice_1213.pdf 
17. UK Ambulance Services Clinical Practice Guidelines 2013. http://aaceguidelines.co.uk 
18. Emergency Oxygen Use in Adult Patients (2008). https://www.brit-thoracic.org.uk/quality-improvement/guidelines/emergency-oxygen/ 
19. Guidance from the British Medical Association, Resuscitation Council UK, and the Royal College of Nursing. 2016.   
20. Treatment and care towards the end of life: decision making. General Medical Council http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp 
21. Cardiovascular Disease Outcomes Strategy: Improving outcomes for people with or at risk of cardiovascular disease. Department of Health.  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/217118/9387-2900853-CVD-Outcomes_web1.pdf 
22. Standards for Conscious Sedation in the Provision of Dental Care.  Report of the Intercollegiate Advisory Committee for Sedation in Dentistry 2015 https://www.rcseng.ac.uk/dental-faculties/fds/publications-guidelines/standards-for-conscious-sedation-in-the-provision-of-dental-care-and-accreditation/ 

Resuscitation Council UK acknowledges the contribution made to this document by Dr Julie L Burke, PhD FDSRCS BChD( Lecturer and Specialist in Oral Surgery:School of Dentistry, Leeds) and Dr Kathryn H Taylor, PhD FDS.RCS (Oral Surg.) FDS.RCS BDS BSc (hons) (Lecturer and Specialist in Oral Surgery: School of Dentistry, Leeds).