Pediatric anesthesia legislation advances

Three bills that seek to improve safety in pediatric dental anesthesia are moving through the state Legislature, including CDA-supported Senate Bill 392 (Bates, R-Laguna Niguel) and Senate Bill 501 (Glazer, D-Orinda). The three pieces of legislation passed out of policy committees following robust discussion at the Capitol, April 24-25, with CDA and other medical and dental organizations as well as individual stakeholders presenting testimony on the bills.  

In separate letters addressed to Jerry Hill, chair of the Senate Business, Professions and Economic Development Committee, CDA credited SB 392 and SB 501 for “contributing to the significant work of the California Legislature and Dental Board of California to ensure that children have access to safe and effective pediatric general anesthesia services when needed.”

CDA further acknowledged that both bills considered the dental board’s substantial analysis of California law and regulations for pediatric general anesthesia, culminating in a report issued by the board as required by AB 2235 (Thurmond, D-Richmond), which passed last September. CDA came to support AB 2235 after working closely with Assemblymember Tony Thurmond to address CDA’s concerns about the legislation’s inaccurate portrayal of risk and the lack of an evidence base for changes it proposed.

SB 501 adopts all of the recommendations the dental board made in its December 2016 report with the exception of requiring an additional, separate anesthesia provider for children under age 7. Instead, the bill calls for a dentist with the general anesthesia permit to qualify for and receive pediatric endorsement for children under age 7 as well as for a study on how a requirement for an additional, separate anesthesia provider would impact access to and cost of dental care. CDA was pleased that SB 501 included this impact analysis and was mindful of the critical cautionary statement that accompanied the board’s report:

The effects of regulatory change on healthcare can be fraught with unintended consequences. Any proposal should, therefore, strike a balance between established practice and evidence based changes that provide greater patient safety. The Board therefore recommends that there be an analysis of the effects of any proposed new legislation or regulation on access to care for pediatric dental patients prior to the implementation of any changes.

Both Senate bills “strike this balance,” CDA says, by “providing for additional training, monitoring and permitting requirements targeted to ensure that during the provision of pediatric dental anesthesia, the right people are in the room with the right training and the ability to respond quickly and expertly to emergencies should they arise.” SB 501 will require three people present for the provision of general anesthesia to a child under 7 years of age, including one person who is solely dedicated to monitoring the patient and trained in pediatric advanced life support and airway management. In addition to asking for a study on cost and access, SB 392 recommends the development of a new course on pediatric life support.

AB 224 (Thurmond), also discussed at the Capitol in April, originally included the separate anesthesia requirement but the bill was amended to remove this language before it passed out of the Assembly Business and Professions Committee.

CDA supports the dental board’s recommendations to increase and improve the board’s data collection, expand the board’s enforcement authority, define anesthesia by level of sedation and restructure the permitting system to ensure the appropriate level of expertise is always in the room with a patient. However, CDA also has concerns about the lack of an evidence base for a separate provider, noting that an analysis of pediatric anesthesia deaths that occurred over six years in California found that there was no pattern in the circumstances, providers or settings surrounding the deaths. A recent analysis by the Texas Dental Board failed to find additional safety with a separate anesthesia provider, leading to the fear that a separate anesthesia provider requirement provides a false assurance of safety for families and may negatively impact access to this essential service.  

“There are several things that we can do that will increase safety and set new, higher standards to make all levels of sedation safer and we should be doing those,” said CDA Government Affairs Council Chair John Blake, DDS, during testimony in support of SB 501. “However, it is equally important to ensure that children can get care, and we cannot ignore the ramifications or pretend that changes will have no effect on the system,” he added. Blake, who is also the executive director and dental director of a nonprofit children’s dental health clinic in Long Beach, spoke of the six- to eight-month wait lists for clinic patients who need dental treatment under general anesthesia in a Long Beach hospital operating room.

Blake urged the committee to exercise caution when considering legislation that could further increase cost and limit access. “The dental health care delivery system is complex, and I fear that you will lose additional providers, and especially those who are served under Denti-Cal, if the regulatory changes do not also address reimbursement levels, payer sources and availability of the work force,” he said.

CDA has expressed throughout this process that the data confirms what is already known: The use of anesthesia, especially in pediatric patients, always carries some risk, although incredibly rare, and reaffirms that more must be done to prevent dental disease and reduce the need for sedation and anesthesia for children to receive care.

CDA will inform members about the status of this legislation on cda.org and in the CDA Update. Read analyses of the bills.

Related Items

Making its way through the state Capitol is a key piece of legislation that, if passed, would improve infection control safety in dentistry. Assembly Bill 1277 calls for the Dental Board of California to amend the regulations on the minimum standards for infection control for certain dental procedures that expose the dental pulp and may create an opportunity for infection. CDA has taken a “support” position on the bill.

Senate Bill 379 (Atkins, San Diego), co-sponsored by CDA, would amend the law to improve both the quantity and quality of the oral health data collected. The statutory updates in the bill will also facilitate the efficient collection of the data by ensuring it is reported to one entity — the Office of Oral Health within the Department of Public Health.

Under AB 2235, the pediatric anesthesia bill signed into law by Gov. Jerry Brown last September, dentists are required to obtain written informed consent from the parent or legal guardian of a minor patient prior to administration of general anesthesia or conscious sedation. As part of this requirement, the written informed consent form must contain new, specific language.