adult moderate sedation policy

8/7/2019 Adult Moderate Sedation Policy

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The policy is designed to provide specific

recommendations for the safe care of patients

(15 years of age or older) during the delivery ofmedications(s) for sedation and analgesia,

known as moderate sedation, by non-

anesthesiologists during diagnostic, therapeutic,

or surgical procedures.


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` Endoscopic examinations

` Vascular and cardiac catheterizations

` Radiological procedures

` Other procedures performed in clinics, patient

care units, or in the emergency department


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Moderate sedation can be described as a state,

which allows patients to tolerate procedureswhile maintaining adequate cardiopulmonary

function and the ability to respond purposely toverbal commands or physical stimuli.


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` Preoperative medications` Patient controlled analgesia` Post operative or labor analgesia

` Pain Management (dressings, burns or angina)` Sedation in the intensive care unit` Sedation for treatment of insomnia` Anxiolysis` Pulmonary edema

` Drug or alcohol withdrawal or prophylaxis` Treatment of seizure disorders` Multiple trauma patients in the ER` Premedication with a standard dose


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Minimal

Sedation

(Anxiolysis)

Moderate

Sedation/Analge

sia (Conscious

Sedation)

Deep Sedation

/Analgesia

General

Anesthesia

Responsiveness Normal

Response to

verbalstimulation

Purposeful

response to

verbal or tactilestimulation

Purposeful

response

followingrepeated or

painful

stimulation

Unarousable

even with painful

stimulus

Airway Unaffected No intervention

required

Intervention may

be required

Intervention

often required

Spontaneous

Ventilation

Unaffected Adequate May be

inadequate

Frequently

inadequate

Cardiovascular

Function

Unaffected Usually

maintained

Usually

maintained

May be impaired


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`Age

`

Weight

` Preexisting medical condition

` Deep sedation or general anesthesia requiresskilled anesthesia personal


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` Request to Credentials Committee

` Completion of training

` Complete a written post test

` Proof of certification in ACLS


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`ACLS certification

`

Recredentialing follows procedures described inthe Medical Dental Staff Bylaws and is the

responsibility of the individual physician

` Successful completion of the sedation andanalgesia test is required


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` Airway management

`

Use of medication and dosages

` Pulse oximetry

`

Cardiac monitoring equipment

` Arrhythmia recognition


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`All personnel shall demonstrate understandingof the pharmacology and side effects ofmedications

` Training in basic monitoring techniques andbasic airway management

` The means for notifying additional support staffservices such as Respiratory Therapy and"Code Blue" pages should be posted inprocedure/sedation area


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` Bag valve device (Ambu) and other O2 deliverysystems such as nasal cannula and masks

` Suction catheter or cannula` Oral and nasal airways`Automatic BPmonitor` Pulse Oximeter` EKGmonitor` Emergency Code Cart

` Reversal agents`Atropine


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The American Society of Anesthesiologist (ASA)

risk classification is used in the selection ofpatients to receive moderate sedation.


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` Class I: A normally healthy patient

` Class II: A patient with mild systemic disease

` Class III:A patient with severe systemic disease

that limits but is not incapacitating` Class IV:A patient with severe systemic disease

that is a constant threat to life

` Class V: A morbid patient who is not expected

to survive with or without theoperation/procedure


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` Patients with an ASA classification greater than 3

` Patient has limited range of head/neck motion

` Abnormal craniofacial anatomy

` Morbid obesity

` History of sleep apnea

` During pregnancy


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Ambulatory patientsM

UST HAVE

a responsible,designated adult to escort them home.


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` The patient must be informed about the risks andalternatives of sedation as a component of the plannedprocedure

` The informed consent for any short term therapeutic,

diagnostic, or surgical procedure in which moderatesedation is to be employed will include the risks ofsedation and the alternatives to sedation

` Documentation of the consent for both the procedure

and the administration of moderate sedation must beincluded in the patient's chart


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` Patients undergoing moderate sedation forelective procedures should not drink fluids or eatsolid foods for a sufficient period of time to allowgastric emptying before their procedure

` Solids and Non-clear Liquids: NPO for 6 hoursClear Liquids: NPO for 2 hours

` Medications may be administered with a sip ofwater


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` Anxiety

` Abdominal Pain

` Autonomic Dysfunction

` Pregnancy

` Mechanical Obstruction

` NPO guidelines do not guarantee complete gastricemptying


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` When patient requires emergency procedure

and is not NPO, conscious sedation might be

dangerous

Delayed

Executed judiciously to avoid unconsciousness and

the suppression of airway reflexes

Not Administered


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` The patient's state of consciousness and medicalcondition appropriate for using moderate sedation

` Individual sedation plan indicating medication

` A sedation order is signed or cosigned by thePhysician

` No allergies or sensitivities to prescribed

medications


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` The Appropriate history and physical exam are documented in thepatient's chart prior to the procedure:

-Actual or estimated weight in lbs. or kg.-Allergies and previous allergic reaction-A list of concurrent medications

-Time of last oral intake-Pertinent medical history including history of tobacco,alcohol, or substance abuse

-History of sedation/anesthesia problems-Baseline vital signs including blood pressure, heart rate,respiratory rate, and O2 saturation

-P

hysicalE

xam- General neurological status- Examination of airway- Pulmonary and Cardiac status


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` Functioning IV line or saline lock

` Oxygen requirements evaluated: it should beconsidered when hemoglobin oxygen saturation


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OtherPre-Procedure Items (cont)

Report any problems associated with theprocedure

Confirm that the patient has reviewed andreceived written instructions

A time out is conducted before starting theprocedure


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` Monitor and document vital signs every

5-10 minutes: Heart Rate

EKGRhythm

Blood Pressure

Respiratory Rate

O2 Sat. (continuous)

Patients Responsiveness


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` Document IV fluids, including blood products, andmedications(s) administered, route, site, time, dosage,and initials of individual administering medication

` Record oxygen therapy in liters/minutes orFi02 andmeans of oxygen therapy

` The individual who monitors the patient shall inform theMD of any changes in the patient's physiological status

from his/her baseline assessment and record itsoccurrence, interventions and outcome


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` Patient's vital signs every 5-10 minutes for a minimum of 30 minutesfollowing the last dose of medication administered

` After 30 minutes vital signs recorded every 15 minutes, untildischarge criteria are met to end the recovery period. The patientmust be observed for a minimum of 30 minutes post procedure

` Recovery Score documented at end of procedure and every 15minutes until the target score met

` Patient's requiring reversal will require a recovery period of 2 hoursfollowing administration of the reversal agent

` Discharge orders and follow-up care must be written by thephysician


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Respiration Able to breath deeply and cough freely

Dyspnea or limited breathing

Apneic

2

1

0

Circulation BP 20% of pre-anesthetic level

BP 21-49% of pre-anesthetic level

BP 50% of pre-anesthetic

2

1

0

Level of

Consciousness

Fully awake

Arousable on calling/responds to stimuli

Not responding

2

1

0

Activity Moves all extremities

Moves 2 extremities

Unable to move extremities

2

1

0

O2 SAT Adult Only

O2 SAT>92% on room air

O2 supplement to maintain O2 SAT>90%

O2 SAT


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` Recovery Score greater or equal to 8. If the score isless than 10, a note will indicate reason

` Vital signs and O2 Sat stable

` Swallow, cough, and gag reflexes are present

` Nausea and dizziness are minimal

` Dressing and/or procedure site checked


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Recovery / Discharge (cont)

Minimal pain managed by appropriate analgesics

Patient alert

Patient can sit unaided if appropriate to baseline andprocedure

Discharge order written, if applicable

If patients are to be transferred for further recoverywithin the institution, they will be accompanied by aMD, PA, or RN to the designated recovery area


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` Recovery Score of 10 (or pre-procedure state)

` Hydration adequate/able to drink fluids

` Voided or unable to void but comfortable

` Patient and/or family given written dischargeinstructions which will include an explanation ofanticipated limitation on activities

` 24 hour emergency contact (person/service)


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For patients discharged from the recovery areaand the hospital, a discharge order is written bya qualified licensed independent practitioner

Ambulatory patients may not leave the hospitalunless accompanied by a responsible,designated adult

A follow-up phone call is recommended, within24 hours post procedure

Outpatient Discharge (cont)


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` Medications will not be administered without the directpresence of the credentialed physician

` Written and signed physician medication order

` A list of medications and dosages is provided in thewritten policy document to serve as a guide for a saferange of drug administration for moderate sedation

` Dosages should always be titrated for desired

therapeutic effect. Any drugs outside these guidelinesmust be approved by the Chief of AnesthesiaDepartment or designee


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Each department/division involved in moderate

sedation should participate in Performance

Improvement activities for its practice. TheDepartment of Anesthesia will assist

departments in developing mechanisms to

monitor their quality of moderate sedation

services. The Joint Commission recommendedsample size for quarterly review is detailed in

the written policy document.


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adult moderate sedation policy

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