c. A permitholder may not administer or employ any agents that have a narrow margin for

20-01-02-01. c. A permitholder may not administer or employ any agents that have a narrow margin for maintaining consciousness, including ultra-short acting barbiturates, propofol, ketamine, or similarly acting drugs, agents, or techniques, or any combination thereof that likely would render a patient deeply sedated, generally anesthetized, or otherwise not meeting the conditions of moderate sedation. d. During moderate sedation the adequacy of ventilation must be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment. e. An applicant successfully shall complete the moderate site evaluation required by this chapter. An initial site evaluation must be completed within sixty days of the approval of the initial permit application. f. Administering intranasal versed or fentanyl, or both, is considered deep sedation. Rules for deep sedation and general anesthesia site evaluations apply for administration of intranasal versed or fentanyl, or both. 4. Before administering deep sedation or general anesthesia, a dentist licensed under North Dakota Century Code chapter 43-28 shall obtain a permit issued by the board and renewable biennially thereafter. An applicant for an initial permit shall submit a completed application and application fee on a form provided by the board and: 10 a. Within the three years before submitting the permit application, shall provide evidence the applicant successfully has completed an advanced education program accredited by the commission on dental accreditation that provides training in deep sedation and general anesthesia and formal training in airway management, and completed a minimum of five months of advanced training in anesthesiology and related academic subjects beyond the undergraduate dental school level in a training program approved by the board; or b. Must be, within the three years before submitting the permit application, a diplomate of the American board of oral and maxillofacial surgeons or eligible for examination by the American board of oral and maxillofacial surgeons, a fellow of the American association of oral and maxillofacial surgeons, a fellow of the American dental society of anesthesiology, a diplomate of the national dental board of anesthesiology, or a diplomate of the American dental board of anesthesiology or eligible for examination by the American dental board of anesthesiology; c. For an applicant who completed the requirements of subdivision a or b more than three years before submitting the permit application, shall provide on a form provided by the board a written affidavit affirming the applicant has administered general anesthesia to a minimum of twenty-five patients within the year before submitting the permit application or seventy-five patients within the last five years before submitting the permit application and the following documentation: (1) A copy of the deep sedation and general anesthesia permit in effect in another jurisdiction or certification of military training in general anesthesia from the applicant's commanding officer; and (2) On a form provided by the board, a written affidavit affirming the completion of thirty-two hours of continuing education pertaining to oral and maxillofacial surgery or general anesthesia taken within three years before application. d. Successfully shall complete the general anesthesia and deep sedation site evaluation required by this chapter. An initial site evaluation must be completed within sixty days of the approval of the initial permit application. e. For a dentist utilizing deep sedation or general anesthesia, shall maintain current certification in basic life support, advanced cardiac life support if treating adult patients or patients that are ten years of age and older, and pediatric advanced life support if treating patients that are nine years of age or younger. f. For a dentist authorized to provide deep sedation and general anesthesia, shall utilize and have present a staff of supervised personnel capable of handling procedures, complications, and emergency incidents, including at least two trained dental sedation staff members as specified in section 20-01-02-01. 5. A licensed and permitted dentist or host dentist utilizing moderate sedation, deep sedation, or general anesthesia is required to undergo a site evaluation for each location where sedation or anesthesia services are rendered. Site evaluations must be conducted by a North Dakota licensed anesthesia or sedation provider approved by the board. Site evaluators shall review the credentials, facilities, equipment, personnel, and procedures of a permitholder or host dentist. Site evaluations must be scheduled by the dentist and must be conducted initially and within every three years thereafter. The purpose of the evaluation is to assess the patient's anesthetic risk and assess a site's ability to provide emergency care; therefore, the site evaluation emphasizes recognition and management of emergencies and complications associated with office administration of sedation and recordkeeping. Requirements of the site evaluation are as follows: 11 a. The applicant is responsible for scheduling a site evaluation with a board-appointed anesthesia site evaluator. Permitholders and host dentists must be present during the site evaluation and submit the site evaluation form to the site evaluator no less than two weeks before the scheduled site evaluation and must include the following: (1) Life support credentials of the dentist and any trained dental sedation staff member, medical staff, and anesthesia provider; (2) Copy of licenses that may be held by any trained dental sedation staff member, other attending medical staff, or both; (3) Copy of current permit to prescribe and administer controlled substances in this state issued by the United States drug enforcement administration; (4) Copy of patient consent agreement and health history forms; (5) Copy of a blank sedation monitoring form; (6) Preanesthesia sedation instructions; and (7) Post care instructions. b. The site evaluator shall submit a completed site evaluation form and documentation to the board. The dentist's facility where anesthesia and sedation are provided must meet the requirements of this chapter and maintain the following properly operating equipment and supplies appropriate for the age and relative size of the patient during the provision of anesthesia and sedation by the permitholder or physician anesthesiologist or certified registered nurse anesthetist or other qualified sedation provider: (1) Emergency drugs as required by the board, including: (a) Vasopressor; (b) Corticosteroid (only deep sedation or general anesthesia permitholders); (c) Bronchodilator; (d) Muscle relaxant; (e) Intravenous medication for treatment of cardiopulmonary arrest; (f) Narcotic antagonist; (g) Benzodiazepine antagonist; (h) Antihistamine; (i) Antiarrhythmic; (j) Anticholinergic; (k) Coronary artery vasodilator; (l) Antihypertensive (only deep sedation or general anesthesia permitholders); (m) Antihypoglycemic agent; (n) Antiemetic; 12 (o) Adenosine, for general anesthesia and deep sedation sites; (p) Dantrolene, for general anesthesia and deep sedation sites, if volatile gases are used; and (q) Anticonvulsant; (2) Positive pressure oxygen and supplemental oxygen delivery system; (3) Stethoscope; (4) Suction equipment, including tonsillar or pharyngeal and emergency backup medical suction device; (5) Oropharyngeal or nasopharyngeal airways, or both; (6) Pulse oximeter; (7) Auxiliary lighting; (8) Blood pressure monitor with an automated time determined capability and method for recording the data; (9) Cardiac defibrillator or automated external defibrillator (AED); (10) End-tidal carbon dioxide monitor; (11) Electrocardiograph monitor; (12) Laryngoscope multiple blades, backup batteries, and backup bulbs; (13) Endotracheal tubes and appropriate connectors; (14) Magill forceps; (15) Appropriate intravenous setup, including appropriate supplies and fluids; (16) Cricothyrotomy equipment; (17) Thermometer; and (18) Scale. c. The operatory where moderate sedation, deep sedation, or general anesthesia is to be administered must: (1) Be of adequate size and design to permit physical access of emergency equipment and personnel and to permit effective emergency management; (2) Be equipped with a chair or table adequate for emergency treatment, including a chair or cardiopulmonary resuscitation board suitable to administer cardiopulmonary resuscitation; (3) Be equipped with a lighting system to permit the evaluation of the patient's skin and mucosal color with a backup system to permit the completion of any operation underway at the time of a general power failure; (4) Be equipped with suction and backup suction equipment also including suction catheters and tonsil suction; and 13 (5) Be equipped with an oxygen delivery system and backup system complete with full- face masks and appropriate connectors, capable of delivering oxygen to the patient under positive pressure. d. An operatory may double as a recovery location. A recovery room must be equipped with the following: (1) Suction and backup suction equipment; (2) Positive pressure oxygen; (3) Sufficient light to provide emergency treatment; (4) Be of adequate size and design to allow emergency access and management; and (5) Be situated to allow the patient to be observed by the dentist or a trained dental sedation staff member at all times. e. The applicant or permitholder shall provide the site evaluator with documentation confirming that the applicant or permitholder maintains written emergency protocol and conducts staff training on all patient emergencies listed below. The written documentation must demonstrate that the applicant or permitholder conducted quarterly mock codes with staff. Not every emergency listed below needs to be included in each quarterly training. Instead, each of the following clinical emergencies must be included in a quarterly mock code training at least once every two years: (1) Laryngospasm; (2) Bronchospasm; (3) Emesis and aspiration; (4) Airway blockage by foreign body; (5) Angina pectoris; (6) Myocardial infarction; (7) Hypertension/hypotension; (8) Hypertensive crisis; (9) Hematoma; (10) Extravasation; (11) Phlebitis; (12) Intra-arterial injection; (13) Syncope; (14) Hyperventilation/hypoventilation; (15) Seizures; (16) Allergic and toxicity reactions; and (17) Malignant hypothermia, deep sedation and general anesthesia only. 14 f. The board may suspend a dentist's anesthesia and sedation privileges upon a dentist's failure to timely and successfully undergo a board-approved anesthesia site evaluation. The applicant shall have thirty days from the date of inspection to correct documented deficiencies. Once the deficiencies are corrected by the applicant and approved by the board, the board may reinstate the sedation and anesthesia privileges. g. Effective January 1, 2028, completion of a board-approved anesthesia simulation course within twelve months prior to or after that date and the completion of anesthesia simulation training successfully every five years thereafter as required by section