Chairside qualified

WE ARE reviewing our practice policy on the provision of chairside assistance and are unsure whether it complies with the General Dental Council’s (GDC) requirements. I am a dental therapist and ordinarily a nurse is not assigned to assist me. However, there is generally a dentist and dental nurse working in the neighbouring surgery, except on Saturdays when the only other staff member is a receptionist. Is this an acceptable arrangement?

This type of query is a common feature of advice calls to MDDUS relating to chairside assistance, particularly from members who are hygienists and therapists. There is undoubtedly a tension between the benefits of working with a nurse and the additional practice costs that this level of cover entails. Unfortunately, the arrangement described above would be unlikely to satisfy the relevant GDC standards. In the first instance, the GDC standard 6.2.1 states:

You must not provide treatment if you feel that the circumstances make it unsafe for patients.

Attempting procedures without the assistance of a dental nurse may impact upon the safety (not to say efficiency) of treatment delivery. It also increases the risk to the clinician, both in terms of physical safety and complaints of improper conduct. Nevertheless, some practitioners feel content (or compelled) to work alone, perhaps believing that care can still be provided in a manner that is suitably safe and that, as a result, 6.2.1 has not been breached. However, GDC standard 6.2.2 sets a higher bar:

You should work with another appropriately trained member of the dental team at all times when treating patients in a dental setting (my emphasis).

Clearly, our dental therapist member is in breach of this standard during the Saturday sessions. However, it may be argued that, by having a dentist and nurse next door, she is “working with” another appropriately trained member of the dental team on weekdays. Unfortunately, the GDC tend to take the most restrictive interpretation of their standards when investigating complaints. So, there can be no guarantees whatsoever that an arrangement involving a therapist routinely working single-handed, but with other members of the team in the building, would be considered satisfactory. This view is supported by the fact that the GDC set down an exhaustive list of exemptions to the main stipulation of 6.2.2, including “exceptional circumstances”. These are described as “unavoidable circumstances which are not routine and could not have been foreseen. Absences due to leave or training are not exceptional circumstances”.

Therefore, if our member was a victim of circumstances (perhaps her nurse had called in sick) it may be possible to proceed with certain treatments, subject to a suitable risk assessment of each case. Even so, it would still be necessary to observe standard 6.2.6 which states that:

You must make sure that there is at least one other person available within the working environment to deal with medical emergencies when you are treating patients.

Ordinarily, the role of the second, life-support-trained person would be fulfilled by other GDC-registered members of the dental team (often the chairside nurse). However, logic and common sense dictate that this may not apply in unforeseen circumstances (as defined in 6.2.2). Therefore, the GDC accept that:

In exceptional circumstances the second person could be a receptionist or a person accompanying the patient.

Considering all these factors, in this scenario I would advise our member to have chairside assistance at all times. If her dental nurse is, for example, a recently recruited trainee, there must be someone else in the building who can properly assist with medical emergencies. If it is known in advance that chairside assistance will not be available then the patient should have their appointment rescheduled for a more suitable time. However, if our member is caught out on a one-off basis by, for example, last-minute staff illness, each patient should be risk assessed. Those with, for example, complex or non-urgent treatment needs should have appointments rescheduled. In other cases, treatment might proceed if this does not put patients at risk. However, in these circumstances, it would need to be established that the receptionist (or some other person) was present at all times and was trained in basic life support.

In short, the GDC’s concessions to the vagaries of in-hours staffing are limited and heavily caveated. Strict adherence to the relevant standards is the safest approach, both from the perspective of care delivery and the avoidance of regulatory criticism.

Doug Hamilton is a dental adviser at MDDUS and editor of SoundBite