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The BEST way to prepare and use an Emergency Response Plan in a dental office


Patient emergencies occur, according to the ADA, in dental offices about 3000 times per year. It is not a question of if an emergency will occur, it is a question of when.


Dental office emergencies are inevitable.


Every dental office will, at the moment of truth, be either READY or NOT READY for the emergency they will experience.


The most effective offices - those that are READY - will respond to the patient emergency as a team, and the roles and responsibilities of each team member will be clearly designated in an office Emergency Response Plan. Each team member will be familiar with their specific roles and responsibilities and will have developed muscle memory in fulfilling those roles through routine and repetitive practice during mock medical emergency drills.


Failure to have and use an Emergency Response Plan is planning to fail during a patient emergency.


If your office does not have nor routinely use an Emergency Response Plan during mock medical emergency drills, you are NOT READY for a patient emergency. You have put your patients and your career at risk.


How to develop your Emergency Response Plan


Pre-assigning responsibilities fall into two broad categories, 1) full cardiac arrest, or 2) all other medical conditions.


Cardiac arrest is rare (although teams must prepare for it). You are far more likely to see anaphylaxis, an asthma attack, or someone experiencing low blood sugar.


For non-cardiac emergencies, there are four primary roles among the dental team. Most dental offices have at least four individuals on-site during patient care, a dentist, a clinical assistant, a dental hygienist, and a staff person, such as an office manager.


For the purposes of this discussion, we will use this core staff to meet the four primary duties. Later, I will discuss adapting this system if you have a dental team of a different size.


The four primary roles in an effective Emergency Response Plan:


  1. Reactor: the team leader, a diagnostician, and a decision maker, typically this is the dentist.

  2. Responder: the primary person supporting the Reactor; typically this is the assistant.

  3. Retriever/Recorder: retrieves equipment/meds and record keeper; typically this is the hygienist.

  4. Rover: calls EMS and manages all other office activities; typically this is the office manager.


The Reactor: As the team leader, diagnostician, and decision-maker, the dentist has three primary responsibilities.

  1. Identifying the problem based on the patient's symptoms.

  2. Directing the rest of the team.

  3. Delivering care to the patient.

Note that direct patient care is the last priority. Most physical tasks in patient care, like administering oxygen, can be delegated to other team members. There may be tasks, such as injecting a drug, which, legally, must be performed by the dentist, however, the dentist is best utilized as the Master Monitor and Manager of the emergency situation.


Focus on decisions, not tasks


The team leader, while never leaving the patient, should focus on decisions, not tasks. The Reactor should use the Quick Reference Checklist (QRC) containing the treatment algorithm for the emergency being experienced as a chair-side cognitive aid to assist in the recognition of the problem and to help map a strategic response.


The QRC is deliberately brief and should be used as a quick reference. It is a memory aid, and not intended to be a textbook on emergencies or as a substitute for periodic training. Instead, it is a tool to refresh your memory on material already learned in a potentially dangerous and stressful situation.


The Responder: In most cases, the Responder will be the dentist's clinical assistant. Since this person has worked many hours directly with the dentist and knows his or her working style.


First and foremost, the Responder is responsible for respiration. The protocols for many medical emergencies begin with supplemental oxygen. Although every member of the team needs to be familiar with the oxygen equipment, the clinical assistant should be highly competent, because he or she is the individual most likely to use it.


In addition, in cases where the patient is not breathing, the Responder should be comfortable holding open a patient's airway with a chin lift technique. He or she should be familiar with the purposes of the emergency medication in the office and able to load a medical syringe from either an ampule or a vial.


If advanced equipment is available, he or she should know how to set up and use it.


The Retriever/Recorder: Typically the dental hygienist fulfills this role. Upon hearing the office's signal that an emergency has occurred, the Retriever/Recorder should immediately note the time and head to the area of the emergency.


Paper, pen, stethoscope, and various sizes of blood pressure monitors should be retrieved if they are not already on site.


Immediately, and without waiting for the dentist's direction, the Retriever/Recorder should take a set of three basic vital signs:

  1. Pulse

  2. Blood pressure

  3. Respiratory rate

The pulse is composed of two components, the heart rate & the rhythm. The rate is the number of beats in one minute. It is usually measured for 30, 20, or 15 seconds and then multiplied by two, three, or four accordingly. The longer the interval of the measurement and the smaller the number used to multiply the raw number, the more accurate the heart rate.


For reference, a correct recording of a pulse would be 70, normal, and regular. The location of the pulse should also be noted. The wrist or radial pulse is the most common site. The brachial pulse is located inside the elbow. When the pulse is too weak, the carotid pulse, found in the neck, may be easier to locate.


A normal heart rate for a resting adult is around 70. A rapid heart rate is called tachycardia and is any rate over 100. A slower rate at or under 60 is called bradycardia.


Be aware, a rapid or a slow heart rate is not always a sign of a medical problem. Well-conditioned athletes routinely have resting heart rates under 60. Conversely, a poorly-conditioned patient running from the parking lot to your office to meet their appointment time may temporarily have a heart rate over 100.


Children, because of their smaller size, will have higher heart rates. A healthy newborn has an average heart rate of around 120, that number decreases as the child grows toward maturity.


In addition to the heart rate, the Retriever/Recorder should note the rhythm.

Is the intensity of the heartbeats normal, unusually strong, called bounding, or weaker than normal, called thread? Is the heartbeat occurring regularly or are there missed beats?


The second vital sign the Retriever/Recorder should note is the respiratory rate or the number of breaths per minute.


For respiratory rate, there are two important techniques:

  1. Observe the patient's respiratory rate discreetly without them being aware of what you are doing. If any person is aware their breathing is being observed, they will not breathe naturally and an artificially high rate will result. (A normal respiratory rate in a healthy adult is 14 to 18. Similar to a pulse, it is higher in children. Note, this is a much smaller number than the heart rate.

  2. Measure the respiratory rate for a full 30 seconds and then multiply by two. Taking the respiratory rate for a shorter period holds the potential of multiplying the magnitude of an error.


The third vital sign to record is blood pressure.


After taking the vital signs, write them down immediately along with the time that they were taken. This is important because the patient's vital signs may be taken several more times. In the stress and chaos of emergencies, it is easy to forget data that was hurriedly mentioned in passing only a few minutes before if no one writes it down.


If an unwanted outcome were to occur, it is not what you "say" happened to the patient that counts, only what you can document in writing that happened.


In addition to vital signs, the Retriever/Recorder should note the dosage and times of administration of all medications. This includes oxygen. It is easy to forget to note that oxygen was provided and the time it began.


Documentation of medications is also important because some emergency medications, like nitroglycerin and epinephrin, quickly lose their efficacy and need to be administered again. The dentist, processing many things, may not realize it is time for a second dose.


It is critical to record both the dosage and time of administration of any medication that is used. Doing so reduces the chance of a patient receiving too much medication or a drug's useful life expiring. This information is also helpful for the EMS team if one is eventually called.


The written record should also note the patient's level of consciousness, actions taken by the staff, and responses by the patient.


Comments, such as, "The dentist supported the airway," or, "The patient's color improved after oxygen," are invaluable. Remember, these entries need to have a time recorded.


Upon arrival of EMS, the record-keeper should quickly review his or her notes with the paramedics. After EMS has taken control of the situation, quickly make two copies of your notes, one for the paramedics and the other for the emergency room staff.


Always keep your original documentation notes for future reference!


The Rover: This position is normally filled by the office manager. The Rover's tasks are "collect, call, & control."


Collect: Gather the following items and deliver them to the area of the medical emergency:

  1. Quick Reference Checklists (if not already in the operatory)

  2. Portable oxygen tank and all airway devices

  3. Other medical supplies, including the drug kit and the AED (if this is a non-arrest emergency, the AED is a standby piece of equipment.)


Call: Stand by for direction from the dentist on whether EMS needs to be called.


The Rover follows the dentist's lead on calling EMS. Depending on the patient's demeanor, the dentist may be obvious or discrete in telling you to call. Sometimes the dentists may view that it is best that the patient not be explicitly told that the decision has been made to call EMS. If directed to call EMS, verbally acknowledge the order to ensure the dentist knows that you understood the directive. Once the call has been placed, verbally report its completion to the dentist.


Depending on the physical arrangement of the office, find an appropriate quiet area to quietly and discreetly call 911. In some offices, the business desk's phone calls can be overheard by the reception room or other treatment areas. To prevent alarming others in the office, make your call away from them.


Maximize the efficacy of the call by using a script or template for your call.


  1. Request an ambulance. For example, "Ambulance needed at the dental office of ..." and then insert your practice's name. It is important to state you need an ambulance at the beginning of the conversation, then the dispatcher knows this is not a police or a fire call.

  2. Explain the nature of your problem and your current status. For example, "We have a patient experiencing chest pains. The dentist is with him and the patient is on oxygen."

  3. Explain any particular services that you desire. Do you need a paramedic or is an EMT acceptable for this emergency situation? (Smaller communities rely on emergency medical technicians unless a paramedic is specifically requested.) For example, "I am requesting a paramedic."

  4. Be specific about where you want the ambulance to go. How easy is it for an EMS crew to find your building? Are you in a standalone building, a condo, or a strip mall? How has the address numbering system, is it straightforward or is it confusing? Would it be helpful to give more concrete directions? For example, "Go to the right side of the first building as you enter the north side of the parking lot. The address is 1005 Sycamore, Suite C."

  5. Be specific about which entrance is large enough to accommodate an EMS crew and their equipment. The ambulance is arriving with a cot of over seven feet in length. The main entrance of many dental offices contains a double set of doors called an airlock that may slow down an EMS team. Having an EMS crew pass through the treatment room can be another obstacle, especially if the team must navigate through another set of doors separating the reception from the treatment rooms. Furthermore, a person accommodating the patient being treated may become upset or anxious if an EMS crew rushes past them. What are some better options for an EMS crew? Perhaps there's a staff entrance at the side or back of the building that grants easier access to the treatment room. For example, "Use the staff entrance on the right side of the building. It is clearly marked and I will be standing at the door awaiting your arrival."

  6. Be specific about where the patient should be taken. Advanced therapies are available to heart attack and stroke victims if treatment is initiated within a certain period of time. However, not all hospitals are equipped or credentialed to provide these services. Dentists are wise to investigate in advance if any hospitals near their office are accredited chest pain centers or comprehensive stroke centers. If you suspect the patient is suffering a heart attack or a stroke, advise the dispatcher you want the patient directed to an appropriate facility. Do not assume your nearest hospital is accredited. For example, "The patient should be taken to General Hospital on Main Street."

Control: Control the environment. During a medical emergency, other patients, and possibly, family members may be present in the office. Patients may be in treatment rooms or the reception area, vendors and maintenance people may be present, and other office staff may be on-site.


Failure to manage these people can leave them feeling ignored, dissatisfied with the office, or anxious. At worst, they could become an interruption to the dental team's treatment of the primary patient.


The first step in managing other people in the office is to determine the severity of the medical event. A minor emergency, like fainting, means the dentist is going to run a few minutes behind schedule and you probably don't need to call EMS. On the other hand, a major event, like a heart attack, will require a lot of time and disruption.


Begin in the treatment rooms where patients are waiting in the dental chair. Say, for example, "A patient is experiencing a medical problem. Our doctor and our staff are addressing it." You should also let them know if you have called emergency services so they are not startled by the sound of an approaching siren.


In many instances, for those receiving routine treatments, like hygiene patients, you may want to ask the patient to leave. Let them know you'll call to reschedule them.


However, some patients, such as those getting a root canal, will need to remain so the doctor can stabilize them before they're dismissed. Ideally, spend no more than one minute per patient in the treatment room.


Next, move to the reception room. You should anticipate spending more time here. If patients are only waiting for appointments, dismiss them and tell them you'll call to reschedule. However, here you may encounter family members or caretakers of the patient experiencing the medical emergency. In a comforting manner, advise this person about the nature of the problem. Emphasize to them that the doctor and team are treating the problem and that EMS is en route.


Understandably, the family member or caregiver will want to see the person experiencing the medical emergency. Gently discourage this. Explain that the treatment room is small and the dentist and team are caring for the patient. Emphasize that the patient needs to rest and seeing them is going to cause the patient to want to talk. While it is important to comfort this person, there's still more work to do.


Return to the site of the medical emergency to check in with the dentist. Ask if there is anything the dentist needs. If there is not, remind the dentist that you're going outside of the office to meet EMS. Confirm this message was heard by asking for an acknowledgment if the dentist doesn't automatically provide one.


If you were in a multi-floor building call for the elevator when you hear EMS is close so time is not lost waiting. If you are on a first floor of a multi-tenant building, stand outside and direct EMS to the easiest point of entry. In most offices, this will not be the main entrance. In many offices, the staff entrance will be the easiest entry point. However, be aware that even if you ordered EMS to go to a specific entrance, do not assume they will find it. Help them.


As EMS unloads equipment, give a brief summary of what you know. For example, "The doctor was treating a patient and the patient developed chest pains. When I last saw the patient, he was still conscious and oxygen was being administered." Then hold the door for EMS. Immediately, return to the reception room and if a family member or a caregiver is present, let them know that EMS is now on the scene.


Serve as a liaison between this person and the treatment area. If appropriate, as EMS is preparing to leave, bring the family member or caregiver to the patient before heading to the hospital. In most instances, EMS will instruct the family member or caregiver to drive separately to the hospital. Make sure the family member or caregiver knows to which hospital the patient's being taken.


Finally, remind the Retriever/Recorder to make a copy of the notes for EMS.


Summary of the Typical Emergency Response Plan


The pre-assignment of tasks is central to effective teamwork in times of stress. This emergency response plan frees the dentist to assess the patient's condition and make decisions about care delivered without being distracted by collecting equipment, taking vital signs, and managing others in the office.


Changes to the emergency response plan during a heart attack and cardiac arrest.


Heart Attack


During a heart attack, a blocked artery prevents blood rich in oxygen from reaching part of the heart. The patient may experience shortness of breath and discomfort among other symptoms. The heart typically does not stop beating and the patient will most likely remain conscious during the episode. However, treatment is still important because damage to the heart becomes more severe the longer the patient goes without treatment. In some cases, a heart attack might lead to cardiac arrest.


Cardiac Arrest


In a full cardiac arrest, the heart stops beating and it cannot pump blood to the body's vital organs. The victim loses consciousness and, with no heartbeat, is technically considered dead. Lifesaving measures must begin immediately after the onset of cardiac arrest to save the victim's life.


I consider cardiac arrest to be a "3-minutes-to-live" emergency. These 180 seconds may very well define the rest of your career, or, if handled poorly, end your career.


During a cardiac arrest, per American Heart Association guidelines, the Reactor should shout, "Call 911, cardiac arrest." Because this alert is verbal as opposed to a discreet message, the entire dental team immediately knows this is not a typical medical problem and they should immediately pursue a CPR protocol.


The Responder, usually the clinical dental assistant, begins chest compressions.


The Retriever/Recorder retrieves the AED and oxygen in that order.


The Rover (typically the office manager) immediately calls EMS, emphasizing this is a full cardiac arrest.


The Reactor (dentist) sets up the AED while the Responder continues with chest compressions.


The Retriever/Recorder (hygienist) begins setting up oxygen supplies by opening the tank and measuring the correct oral pharyngeal airway and unpacking the bag valve mask or BVM.


After administering the AED, the Reactor can focus on airway management while the Responder continues with chest compressions.


Within two-person CPR, the most challenging task is using the bag valve mask. Experienced paramedics, emergency room physicians, and anesthesiologists may be able to use one hand to seal the mask while elevating the mandible at the same time. For others, this skill requires training and practice. Therefore, the best use of the available team members is for the Reactor to use both hands to seal the mask and elevate the jaw. The Retriever/Recorder then squeezes the bag gently once every five seconds, as the Responder continues chest compressions.


By now, EMS should have been contacted by the Rover. The Rover should report to the team that EMS is en route, and then collect any other emergency equipment the Retriever/Recorder might not have secured, like the medication kit.


Presuming effective CPR is being administered, the Rover should then leave to meet EMS and facilitate quick entry to the site. Remember, it is the person doing chest compressions who will most likely become fatigued. The Retriever/Recorder, who is squeezing the BVM bag, will need to relieve the Responder.


The Reactor can then remain focused on addressing a patent airway and addressing the quality of chest compressions. The AED will automatically keep track of time and provide direction if shocks are indicated.


Clearly, full cardiac arrest is a special situation. With an office of only four persons, no records are kept. Other people in the office are not addressed. However, this approach best utilizes available personnel consistent with basic life support objectives. This approach for both cardiac arrest and all other emergencies relies on a four-person response because most dental offices have a doctor, a clinical assistant, a hygienist, and a business person/office manager.


If your office has a larger staff, you have the luxury of subdividing these assignments. For example, for a non-cardiac arrest emergency, the Rover has many duties, including "collect, call, and control." With more staff, you could delegate a separate person to each area. For example, you could assign a staff member to attend to a patient's family member or caregiver if one is waiting in the reception room. Or, you could have a person recording a time-based log during CPR.


However, base your emergency response plan assignments on the minimum number of staff that are always present. For example, if the dentist's clinical assistant is actually two part-time people working on different days, only one will be present when the emergency actually occurs. Perhaps you have different numbers of staff on different days. Maybe you have a second part-time hygienist two days a week. Determine how to best utilize this person that is not always present.


One technique is to make the extra team member responsible to the Rover since the Rover has the largest and most diverse list of assignments.


Emergency Response Plan for teams smaller than four


A three-person team with Dentist: The most common option is to consolidate the Retriever/Recorder and Rover into one position. This team member would record vital signs, then periodically leave to perform selected duties of the Rover, such as calling 911.


A three-person team without a dentist: Some states permit staff to provide limited dental treatment without the dentist on the premises. Most commonly, this is a hygienist performing prophylaxis. In some states, designated dental assistants may re-cement temporary crowns. If your office provides such services, have a backup emergency response plan for this situation.


General Emergency Response Plan Guidelines


Never allow a staff person to practice alone. At least one other person should be in the office. In addition to addressing a medical event, this is wise from legal and safety perspectives.


Communicate effectively: Use quick, quiet, and assertive communication with each other regardless of where they are in the office.


  • Quick: Each office should have a mechanism to alert the entire team that assistance is needed as swiftly as possible. Everyone on the team is alerted because everyone has a role in assisting the dentist.

    • Some dental software programs include an emergency messaging system. Other doctors favor a dedicated paging system. If you use a paging system, develop a simple "codeword" such as "Code Blue, Room 2" that when heard will alert the team to a medical emergency. Other offices use a simple doorbell system with a specified tone.


  • Quiet: All emergency communications between team members must be conveyed discreetly. Screaming or yelling implies panic. Panic on the part of the team is distressing to the individual being treated. Moreover, it encourages others, such as other patients or people in the reception room, to become involved in the event.

    • Few emergencies are serious enough to require a "lights-and-siren" response from the EMTs. We alert the staff simply because the dentist needs assistance.

    • Patients and others in the office should not be alarmed by the team's reaction to a possible emergency. Be mindful of HIPAA rules. Disclosing health information about a patient is a HIPAA violation, even if it's unintentional and revealed in the midst of an emergency. Quiet discretion is key to maintaining a calm environment, as well as protecting the privacy of the person who is experiencing a medical emergency.


  • Assertive: Speak up when you perceive a problem with patient care. Team members MUST advise dentists of observations that they may have missed.

    • Aviation has studied this phenomenon extensively. Airline crashes have occurred because a copilot observed something that was critical to the safety of the flight but was reluctant to question the decision of the senior captain. Don't be afraid to speak up.

    • No team will provide truly safe, high-performing care if they are not willing to speak up when a problem with patient care is perceived.


All communications must be acknowledged: For the dentist, it is not enough to issue a verbal directive. The Reactor must know that the order was properly understood and followed,


To ensure comprehension and clarity between everyone, the person receiving the instruction should:

  • Confirm they heard the order properly by verbally repeating the order (e.g., "Retrieve the AED.")

  • Report the result of the order (e.g., "Here is the AED.")

Orders not acknowledged are orders that did not happen.


Until the Reactor hears "sounds come out of the mouth" of the assigned team member, they have no assurance their order has been carried out.


Use cognitive aids: Remember that emergencies are very stressful and studies show that cognitive recall will be affected. Emergencies are "high consequence - low frequency" events that benefit from the use of cognitive aids to stimulate recall when it is needed the most.

Therefore, print and laminate your emergency response plans. You should have at least two versions of your emergency response plan:

  1. Emergency Response Plan for cardiac arrest

  2. Emergency Response Plan for other emergencies.

You may have a third emergency response plan for times when the dentist is not present.


Post these laminated plans in various areas throughout the office with Velcro. Keep them near the front desk in the hygiene area and inside the cover of the response manual. Inside a cabinet door is ideal. When an emergency occurs, grab the nearest laminated emergency response plan appropriate to the type of emergency the patient is experiencing, carry it with you, and begin your assigned tasks.


Next, you should have laminated copies of the Quick Reference Checklists for the 24 most common dental office medical emergencies. These QRCs should be present in every operatory for ready reference.


Summary


The most effective offices - those that are READY to competently manage a medical emergency - respond to patient emergencies as a team, with clearly designated roles and responsibilities for each team member as established by their Emergency Response Plan.


Each person in this high-performing team will be completely familiar with their specific roles and responsibilities and will have developed muscle memory in fulfilling their roles in the Emergency Response Plan through routine and repetitive practice during mock medical emergency drills.





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