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200 Hoods Lane | P.O. Box 1168 | Marblehead, MA 01945 | www.greeley.com

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Sample Policy & Procedure

Sedation and Anesthesia

Policy

Moderate sedation/analgesia is produced by the administration of drugs to dull or reduce a patient’s pain and awareness. The drug and dose given is not intended to cause the patient to lose the ability to independently and continuously maintain a patient airway or respond appropriately to physical stimulation. However, since sedation is a continuum, this policy and procedure is designed to provide a safe level of care to patients who inadvertently lose their ability to independently maintain ventilatory function.

Procedure

Individuals administering moderate sedation are qualified and have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally. Included in the qualifications of individuals providing moderate sedation is a competency-based education, training and experience in

1.  Evaluating patients prior to performing moderate sedation,

2.  Performing the moderate sedation to include methods and techniques required to rescue those patients who unavoidably unintentionally slip into a deeper-than-desired level of sedation or analgesia. Specifically, practitioners who have appropriate credentials and are permitted to administer moderate sedation are qualified to rescue patients from deep sedation, meaning they are competent in managing a compromised airway to include providing adequate oxygenation and ventilation. (Note: The specific qualifications and privileging criteria to administer moderate sedation are to be determined by the medical staff.)

Sufficient numbers of qualified personnel (in addition to the individual performing the procedure) are present to:

1.  evaluate the patient

2.  provide the sedation and/or anesthesia

3.  assist with the procedure

4.  monitor the patient

5.  recover the patient at the appropriate level of postprocedure care

Appropriate equipment for care and resuscitation is available for monitoring vital signs including heart and respiratory rates and oxygenation using pulse oximetry equipment. A code cart with reversal agents must be available where the procedure will be performed. Heart rate and oxygenation are continuously monitored by pulse oximetry. Respiratory frequency and adequacy of pulmonary ventilation are continually monitored. Blood pressure is measured at regular intervals. Cardiac monitoring is used in patients with significant cardiovascular disease or when dysrhythmias are anticipated or detected.

The patient’s response to care provided throughout the sedation-supported procedure is documented in the patient’s record.

Before sedating or anesthetizing the patient, a licensed independent practitioner with appropriate clinical privileges either plans or agrees with the plan for sedation/anesthesia.

Pre-procedure Responsibilities

Physician

1.  A history and physical is to be record prior to the procedure on all patients receiving moderate sedation or anesthesia.

2.  A pre-sedation assessment, containing the following elements, is to be conducted prior to the procedure which addressed the anticipated needs of the patient to plan for the appropriate level of post procedure care. This will include but not necessarily be limited to ASA Classification and anesthesia/sedation plan.

3.  Obtains and documents appropriate informed consent for procedure and sedation/anesthesia

4.  Communicates the sedation/anesthesia plan to involved care providers

5.  Reassesses the patient immediately prior to administration of sedation/anesthesia

6.  Participates in the “time out” component of the universal protocol prior to the start of the procedure

RN

1.  Supervises the perioperative nursing care

2.  Verifies appropriate informed consent is documented in the medical record

3.  Gathers appropriate equipment to monitor the patient’s physiological status and to administer intravenous fluids, medications and blood products, if needed.

4.  Ensures resuscitation equipment is immediately available

5.  Establishes venous access prior to sedation and maintains through discharge

6.  Assesses the patient’s baseline vital signs: blood pressure, heart rate, respiratory rate, heart rhythm, oxygen saturation, level of consciousness, and Aldrete score.

7.  Participates in preprocedure patient education in accordance with the planned care and treatment

Intra-procedure Responsibilities

RN

1.  Monitors and documents the patient’s vital signs every five minutes or more frequently if necessary as physiological monitoring is often the only reliable source of assessment for patients who undergo sedation. Monitoring methods depend on the patient's preprocedure status, sedation or anesthesia choice, and the complexity of the procedure.

2.  Assesses the patient continuously for changes in condition and/or untoward responses or effects and reports any of the above to the responsible physician immediately.

Post-procedure Responsibilities

Physician

1.  Documents a post procedure/anesthesia note.

RN

1.  Monitors and documents the patient’s vital signs and mental status every five minutes until the patient’s Aldrete score is equal to nine or reaches his or her preprocedure score

2.  Monitors the patient’s pain level

3.  Notifies the responsible physician immediately if the patient doesn’t meet the criteria specified above after one hour postprocedure.

4.  Follows the procedure for post operative care of patients and arranges for discharge/transfer when a physician order is obtained or the patient meets the approved discharge criteria

5.  Ensures that patients being discharged in the outpatient setting following the administration of sedation/anesthesia are released to a responsible, designated adult

6.  Completes the necessary nursing documentation

Performance Improvement

Outcomes of patients undergoing moderate and deep sedation are collected and analyzed in the aggregate in order to identify opportunities to improve care. The following data are gathered following the administration of moderate sedation in all sites where sedation/anesthesia is provided:

·  Unplanned intubation

·  Unplanned admission or transfer to higher level of care

·  Administration of reversal agent

·  Chest pain

·  Drop in O² Sat. ↓ 92 for 7-5 minutes

Data collection forms are forwarded to the Performance Improvement Department for aggregation of data. Analysis and determination of interventions for improvement are the responsibility of a sub-group of anesthesia providers.