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Policy Advocacy

Objectives

Describe the policy challenge and the nursing association identification

Describe the agenda

Key Stakeholders

Legislative Strategies used to inform/lobby legislators

Non-legislative strategies to support the initiative

Legislative Process

Policy Challenge

Nurse Administered Sedation

American Association of Nurse Anesthesiology

Section 2725 (b)(2) of the California Nurse Practice Act places no limits on the type of medication or route of administration

Brief description of the policy challenge and the nursing association that was identified.

Our policy challenge started with research after the RNs were advised that the oral surgeon would be ordering Propofol for administration during wisdom teeth extractions under conscious sedation. The current moderate conscious sedation program allows for administration of Fentanyl, Versed and Ketamine after moderate conscious sedation training and exam.

Research brought the RNs to discover AB 2235, aka Caleb’s Law.

The RNs consulted the Nurse Leader, Department Head, Main Operating Room, Lieutenant Commander Erin Gagliano, Certified Registered Nurse Anesthetist, member of the American Association of Nurse Anesthesiology

The Warnings section of the drug’s package insert (Diprivan®, AstraZeneca 02/14, accessed 02/19) states that propofol used for sedation or anesthesia “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”

Propofol

Procedural sedation is safe and effective when performed by appropriately trained, credentialed, and supported emergency nurses and physicians. We, the undersigned organizations, agree:

1. Medications including, but not limited to, etomidate, propofol, ketamine, fentanyl, and midazolam are utilized by healthcare professionals to facilitate management of a continuum of painful conditions. These extend from simple pain management and maintenance sedation to moderate-deep sedation for painful procedures. Because of the myriad ways these medications might be used, it is best to focus on the goal of the intervention rather than the medication itself.

No reversal for Propofol

Caleb’s Law

California AB 2235

Effective January 1, 2017

Describe the “agenda.” How the policy issue was identified

AB 2235, referred to as “Caleb’s Law”, amends the Dental Practice Act to require the Dental Board to:

Generate a report on whether current regulations for pediatric dental anesthesia provide adequate protection to the pediatric dental patient

Require dentists to report a pediatric death or transportation to a hospital related to general anesthesia

Require that written informed consent forms contain certain language

Lieutenant Commander Erin Gagliano Certified Registered Nurse Anesthetist

Nurse Leader

LCDR Gagliano is a nurse leader in Naval Medical Readiness Training Center Lemoore, CA. As the department head of the main operating room that oversees the conscious sedation program, she placed a hard stop on the oral surgeon’s request on having the registered nurses push IV propofol for conscious sedation during teeth extractions. She advocated for the safety of our patients and also helped protect our nursing licenses from potential malpractice. LCDR Gagliano recommended to have an established policy for the facility and have adequate training before proceeding with the new practice.

Key Stakeholders

*The California Dental Association

*American Academy of Pediatrics -

CA (Bill sponsor)

Opposition

*American Society of Dentist

Anesthesiologists

*California Society of

Anesthesiologists

Supporters

*The California Society of Pediatric Dentistry

*PDI Surgery Center

*Happy Bear Surgery Center

*The Family of Caleb Sears

(2008–2015)

*The California Association of Oral and Maxillofacial Surgeons

“Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures.”1 The purpose of this update, as stated by the authors and supported by the AAP and AAPD, was to “unify the guidelines for sedation used by medical and dental practitioners; to add clarifications regarding monitoring modalities…; to provide updated information from the medical and dental literature; and to suggest methods for further improvement in safety and outcomes.” They described the substantial differences between sedation for children and adults, and emphasized the subtlety and rapidity with which young children can pass from 1 level of sedation to another unintended level.

The Sears family has faced strong opposition from the state dental lobby. The California Dental Association and other dental groups argue the new restriction would be costly and that the system is safe the way it is. arguing that there are insufficient data to justify change and that a separate anesthesia provider would increase costs to patients and decrease access to care. This point is especially suspect, given that dentists and oral surgeons usually bill their patients separately for surgery and anesthesia. Caleb’s oral surgeon, for example, billed $670 for the procedure and $755 for the general anesthesia.

Legislative Strategies

Identify the Issue

Assemble a Team

Start Small with Legislative Advocacy

Keep the Momentum Going

Identify the Issue

There are many healthcare and quality of life issues affecting people with cerebral palsy (CP) – so which one to advocate? Before jumping in, Dr. Kaplan suggests deciding on what has the best chance of passing and bringing the most change in the least amount of time.

“Finding small things that you can win quickly makes the issue present in everyone’s mind,” said Dr. Kaplan. “A big advocacy push could be just writing policy guidelines for transitional CP care. This could be parlayed into legislation and grassroots action.”

Assemble a Team

Putting together a strong coalition is what can make or break a bill. There’s strength in numbers and everyone on the team should, ideally, be out to achieve the same goal. Coalitions are built from a wide-swath of people and organizations: there are lobbying groups, lawmakers, regulatory agencies, academia, and influential, public personalities. All of them are essential to shepherd the bill through numerous stages of the legislative process and make it a reality.

“For Caleb’s Law, we now have a huge coalition that is moving in all different directions,” said Dr. Kaplan. “Policy is being made. There’s a start-up that just started fulfilling needs for dental anesthesia. We’re making the change we want while the legislature is working it out as well. The change is there.”

While researching what issue to get behind, it’s advantageous to research any groups that may be interested in or may lobby against the bill. Even seemingly benign legislation could generate some controversy in certain sectors. There are ways of making oppositional interests work for the bill – either through chipping away at their coalition or talking with them.

“You should engage with the opposition and see how you can get to a place where everyone can treat their patients fairly,” said Dr. Kaplan.

Start Small with Legislative Advocacy

Once there’s solid groundwork, it’s time to make those small wins happen. That includes regularly engaging with lawmakers and public interests and pushing them to the finish line. The best way to do that is to break down what can be passed now and what can be passed later.

“Incremental change is more successful in the end,” said Dr. Kaplan. “When I started, I should’ve moved slower. I went for the big change right away and it brought on more opposition.”

One of the more challenging aspects of this step is building a persuasive argument that will convince key decision makers that this bill is the right thing to pass and this is the right time to do it. If you’re leading this advocacy push, Dr. Kaplan highly recommends that you should make yourself the expert on that issue and understand it inside and out. That way if anyone ever has a question, you’ll have the answer or know the right person who has the answer. It may also convince anyone on the fence to join your cause.

“A great way to convince policy makers is to have real life stories available, so they can see the problem that needs to be fixed, and how passing this legislation can make it better,” said Dr. Kaplan.

Keep the Momentum Going

Change rarely happens overnight. Progress will be slow for any legislative effort and, when or if it is passed, there may be other legislation required to strengthen the original bill. How do you keep your coalition engaged and your bill top of mind as days turn into months? Just keep moving.

“Don’t take your foot off the gas,” said Dr. Kaplan. “Keep advocating, keep the process moving, and you’ll see the smaller wins as you get to your end goal.”

https://www.weinberg.cuimc.columbia.edu/news/lessons-legislative-advocacy-effective-strategies-cp-community

Non-Legislative Strategies

Six-year-old boy dies getting tooth extracted

Media Headlines

Provide Testimony

Join a Professional Organization

Father pushes for new law after son dies during dental procedure

Dr. Kaplan and Caleb’s mother’s testimony

Legislative Process

80%

Group E

Dr. Anna Kaplan partnered with Assemblymember Tony Thurmond