Position Statements from different sources on moderate sedation:
- ACLS CE Update
- Emergency Med
- Joint Commission
- Board of Nurses
Considerations for Policy Guidelines for Registered Nurses Engaged in the Administration of Sedation and Analgesia Introduction. Although the safest care for the patient receiving sedation and analgesia is provided by a qualified anesthesia provider, a large number of registered nurses are involved in the administration of sedation and analgesia.
To promote safe care during sedation and analgesia and to address questions which have been raised by nursing organizations, and healthcare institutions with respect to the necessary qualifications of registered nurses involved in this care, the American Association of Nurse Anesthetists suggests the following policy considerations.
These considerations do not supersede or give the effect to more restrictive relevant laws, regulations, judicial and administrative decisions and interpretations, accepted standards and scopes of practice established by professional nursing organizations, or institutional policies applicable to registered nurses, which should be reviewed prior to the development of any sedation and analgesia policy.
Definition Sedation and analgesia describes a medically controlled state of depressed consciousness that allows protective reflexes to be maintained. The patient retains the ability to independently maintain his or her airway and to respond purposefully to verbal commands and/or tactile stimulation. The American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia has developed Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists which states “sedation and analgesia describes a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardio respiratory function and the ability to respond purposefully to verbal command and tactile stimulation.
The Task Force decided that the term sedation and analgesia more accurately defines this therapeutic goal than does the more commonly used but imprecise term of ‘conscious sedation.’ Those patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by sedation/analgesia.”
The Joint Commission on Accreditation for Healthcare Organizations has introduced to their standards definitions for four levels of sedation and anesthesia. Minimal sedation where the patient responds normally; moderate sedation/analgesia (conscious sedation), where an airway and cardiovascular function is maintained; deep sedation/analgesia, in which the patient is not easily aroused; and, anesthesia, in which patients require assisted ventilation.
Sedation and analgesia may easily be converted to deep sedation and the loss of consciousness because of the agents used and the physical status and drug sensitivities of the individual patient. The administration of sedation and analgesia requires constant monitoring of the patient and ability of the administrator to respond immediately to any adverse reaction or complication. Vigilance of the administrator and the ability to recognize and intervene in the event complications or undesired outcomes arise are essential requirements for individuals administering sedation and analgesia.
A. Qualifications The registered nurse is allowed by state law and institutional policy to administer sedation and analgesia. The health care facility shall have in place an educational/credentialing mechanism which includes a process for evaluating and documenting the individual’s competency relating to the management of patients receiving sedation and analgesia. Evaluation and documentation occur on a periodic basis. The registered nurse managing and monitoring the care of patients receiving sedation and analgesia is able to:
a) Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia recognition and complications related to sedation and analgesia sedation and medications.
b) Assess the total patient care requirements before and during the administration of sedation and analgesia, including the recovery phase.
c) Understand the principles of oxygen delivery, transport and uptake, respiratory physiology, as well as understand and use oxygen delivery devices.
d) Recognize potential complications of sedation and analgesia sedation for each type of agent being administered.
e) Posses the competency to assess, diagnose, and intervene in the event of complications and institute appropriate interventions in compliance with orders or institutional protocols.
f) Demonstrate competency, through ACLS or PCLS, in airway management and resuscitation appropriate to the age of the patient.
g) The registered nurse administering sedation and analgesia understands the legal ramifications of providing this care and maintains appropriate liability insurance.
Adopted By AANA Board of Directors, June 1996 Revised June 2003
B. Management and Monitoring Registered nurses who are not qualified anesthesia providers may be authorized to manage and monitor sedation and analgesia during therapeutic, diagnostic or surgical procedures if the following criteria are met. These criteria should be interpreted in a manner consistent with the remainder of this document. Guidelines for patient monitoring, drug administration, and protocols for dealing with potential complications or emergency situations, developed in accordance with accepted standards of anesthesia practice, are available.
A qualified anesthesia provider or attending physician selects and orders the agents to achieve sedation and analgesia. Registered nurses who are not qualified anesthesia providers should not administer agents classified as anesthetics, including but not limited to Ketamine, Propofol, Etomidate, Sodium Thiopental, Methohexital, Nitrous oxide and muscle relaxants. The registered nurse managing and monitoring the patient receiving and analgesia sedation shall have no other responsibilities during the procedure.
Venous access shall be maintained for all patients having sedation and analgesia. Supplemental oxygen shall be available for any patient receiving sedation and analgesia, and where appropriate in the post procedure period. Documentation and monitoring of physiologic measurements including but not limited to blood pressure, respiratory rate, oxygen saturation, cardiac rate and rhythm, and level of consciousness should be recorded at least every 5 minutes. An emergency cart must be immediately accessible to every location where and analgesia sedation is administered. This cart must include emergency resuscitative drugs, airway and ventilatory adjunct equipment, defibrillator, and a source for administration of 100% oxygen.
A positive pressure breathing device, oxygen, suction and appropriate airways must be placed in each room where an analgesia sedation is administered. Back-up personnel who are experts in airway management, emergency intubations, and advanced cardiopulmonary resuscitation must be available.
A qualified professional capable of managing complications is present in the facility and remains in the facility until the patient is stable.
A qualified professional authorized under institutional guidelines to discharge the patient remains in the facility to discharge the patient in accordance with established criteria of the facility.
Bibliography American Academy of Pediatrics Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.
Pediatrics. 1992;89:6 1110-1114. Barr J, Donner A: Optimal Intravenous Dosing Strategies for Sedatives and Analgesics in the Intensive Care Unit. Critical Care Clinics. 1995;1 1:4:827-847. Finnie G: Conscious sedation and plastic surgery. Specialty Nursing Forum. 1990;2:8. Gunn IP: The many issues regarding IV conscious sedation. Specialty Nursing Forum. 1990;2:2. Harvard minimal monitoring standards. JAMA. 1986;256:8. Holzman RS, Cullen DJ, Eichhorn JK Philip JH: Guidelines for Sedation by Non-anesthesiologists during Diagnostic and Therapeutic Procedures. Journal of Clinical Anesthesia. 1994;6 Joint Commission on Accreditation of Health Care Organizations. Care of Patients-Examples for Use of Anesthesia and Conscious Sedation. Joint Commission Accreditation Manual for Hospitals. 1996; 194-201. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals, The Official Handbook. 2000; Kallar SK- Conscious sedation for outpatient surgery. Wellcome Trends in Anesthesiology. 1991;9:3-5, 8-9. Kingsbury JA: IV Conscious sedation: Joint Commission and hospital issues. Specialty Nursing Forum. 1990;2:7- 8. Nemiroff MS: IV Conscious Sedation: Essential Techniques of Monitoring. Trends in Health Care, Law & Ethics. 1993;8-1:87-94 Nursing Care of the Patient Receiving Conscious Sedation in the Gastrointestinal Endoscopy Setting. Society of Gastroenterology Nurses and Associates, Inc. Rochester, New York. 1991. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 1996; 84;459-71. Qualified Providers of Conscious Sedation. American Association of Nurse Anesthetists Position Statement. Park Ridge, IL: American Association of Nurse Anesthetists. 1996; 2.2 Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures. ANA Collaborative Statement. Washington, DC. American Nurses Association. 1991. Spry CC: Perioperative nurses should keep monitoring within their specialty. AORN Journal. 1990;51:1071-1072. Watson DS: Recommended practices for monitoring and administering IV conscious sedation. Specialty Nursing Forum. 1990;2:3. Council for Public Interest in Anesthesia See the state-by-state regulations governing RNs in regards to administering sedation and analgesia: http://www.ncsbn.org/news/stateupdates_state_sedation.asp Back to Top
Documents Joint Statement on Delegation American Nurses Association (ANA) and National Council of State Boards of Nursing Introduction: There is more nursing to do than there are nurses to do it.
Many nurses are stretched to the limit in the current chaotic healthcare environment. Increasing numbers of people needing healthcare combined with increasing complexity of therapies create a tremendous demand for nursing care. More than ever, nurses need to work effectively with assistive personnel. The abilities to delegate, assign, and supervise are critical competencies for the 21st century nurse.
In 2005, both the American Nurses Association and the National Council of State Boards of Nursing adopted papers on delegation. Both papers presented the same message: delegation is an essential nursing skill. This joint statement was developed to support the practicing nurse in using delegation safely and effectively.
Position Statement: Authentication in a Computer-Based Patient Record – 11/95 Summary: Every process in the health care delivery system must be evaluated to determine its value: to the patient, to the caregiver, and to the health of the nation. Retrospective signature, in either electronic or paper form, represents a substantial administrative cost burden and prolongs the risk of using potentially inaccurate information. Putting processes in place which assist the author in ensuring accurate data entry, and instituting appropriate quality improvement mechanisms are critical to achieving the computer-based patient record and, ultimately, health reform goals.
Quality and efficiency benefits can then be turned into increased access to health care for the nation’s populace.
Position Statement: On Access to Patient Data – 11/30/95 Introduction: As defined in the Institute of Medicine patient record study report (The Computerbased Patient Record: An Essential Technology for Health Care) the computer- based patient record is “an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other aids.
Position Statement: Computer-based Patient Record Standards – 11/95 Summary: Computerization of health information offers many opportunities to improve the nation’s health care and reduce its costs. Some savings may be achieved through electronic billing. But longer term efficiencies can only be achieved within the context of an evolving new health care delivery system which is supported by a solid foundation of information used during the care process and as a source of scientific data on which to base rational health care policies.
Position Statement: Services to Families Following a Sudden Infant DeathSyndrome – 4/94 Summary: Families who experience the death of an infant from SIDS are immediately faced with a multitude of severe reactions. From the moment the infant is found the family begins to adapt to their loss, a process that continues throughout their lives. This process is affected by the response of their extended family as well as the community in which they live. ANA supports the position that specially trained nurses can assist families by providing informational and supportive services to those affected by SIDS. Furthermore, ANA supports that the training and support for nurses should come from SIDS programs.
Position Statement: Association of Operating Room Nurses Official Statement on RN First Assistants – 4/94 Preamble: Perioperative nursing practice has historically included the role of the RN as assistant at surgery. As early as 1980, documents issued by the American College of Surgeons supported the appropriateness for qualified RNs to first assist. AORN officially recognized this role as a component of perioperative nursing in 1983 and adopted the first Official Statement of RN First Assistants (RNFA) in 1984. Acceptance of this official statement by many state boards of nursing has supported that RNFA behaviors are recognized within the scope of nursing practice. AORN’s official statement delineates the definition, scope of practice, qualifications, educational requirements, and clinical privileges that must be met by the perioperative nurse who practices as an RNFA. AORN further recognizes the need for appropriate compensation/reimbursement to RNs who fulfill this role in providing perioperative patient care.
Position Statement: Maintaining Professional and Legal Standards During a Shortage of Nursing Personnel – 8/92 Summary: The focus of this statement is to clarify the role of the regulatory mechanisms provided internally by the profession, and those provided externally by the state to assure public access to high quality nursing services. Further, the statement addresses the regulatory implications for nursing in labor market situations involving increased demands for nursing services and a resulting shortage of licensed nurses.
Position Statement: Role of the Registered Nurse in the Management of Patients Receiving IV Conscious Sedation – 9/91 Policy/Position: The Board of Directors endorsed the Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short- Term Therapeutic, Diagnostic, or Surgical Procedures. This was a result of the joint work of ANA and several specialty nursing organizations to develop position statements. Position Statement: Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques – 9/91 Policy/Position: The Board of Directors endorsed the Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short- Term Therapeutic, Diagnostic, or Surgical Procedures. This was a result of the joint work of ANA and several specialty nursing organizations to develop position statements. Back to Top
ACLS CE Update
FROM: Mary Moon Allison, MHSE, BSN, RN,CAE Director, ANCC Accreditation Program ANCC recently sent a notice of the interpretation of the COA [NOTE: The “COA” in this documents refers to the American Nurses Credentialing Center’s Commission on Accreditation, which has no relation to the Council on Accreditation of Nurse Anesthesia Educational Programs] regarding the practice of awarding contact hours for activities such as BLS, ACLS, PALS, etc.
(That message is repeated below.)
This practice was considered after receiving a request and information from a state board of nursing. We regret that the rationale for the Commission’s decision was not disseminated along with the decision. The discussion of the COA was: BLS is no longer an augment to the nurse’s basic knowledge. Therefore it doesn’t meet the definition of continuing nursing education. Universities now require the student to be certified in BLS before ever entering the academic program. BLS is not an augmentation of knowledge; it is a basic preparation for training.
The advanced life support activities meet the definition of CNE because they are not included in the nurse’s basic training and therefore augment that training. However, these courses do not change often or significantly. Therefore, renewal of certification is meant to validate that the knowledge previously obtained has been retained. It does not augment that knowledge.
Please note: The issue discussed was related to whether the courses meet the definition of continuing nursing education. It did not address the issue of these courses typically being “canned‟ courses.
The COA’s discussion did not even mention the issue of “canned‟ courses and that was not a relevant factor in the decision. The effective date of this interpretation is two years away. This was done in order to avoid necessitating any mid-stream changes. The COA understands that the courses sometimes see significant revisions based on new evidence. The COA has agreed to continually monitor the more common advanced courses for significant revisions. If significant revisions occur, then the COA may re-visit the current interpretation of whether the course meets the definition of continuing nursing education.
Original Message Subject:
BLS, ACLS, PALS and related courses sent on May 21, 2009: At their May 19, 2009 meeting, the Commission on Accreditation decided that contact hours for BLS and other basic “canned” courses may not be awarded. Any courses currently being presented (by either accredited providers or approved providers) must cease to award contact hours by June 1, 2011. The Commission also decided that contact hours for renewal of ACLS, PALS and other advanced “canned” courses may not be awarded. Any courses currently being presented (by either accredited providers or approved providers) must cease to award contact hours by June 1, 2011.
Awarding contact hours for initial ACLS, PALS and other advanced “canned” courses is still permitted. Barbara Feild Sr. Accreditation Specialist firstname.lastname@example.org American Nurses Credentialing Center 8515 Georgia Avenue Silver Spring, MD 20910 800-284-2378, ext 5263
American Society of Anesthesiologists http://www.asahq.org/ The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of patients.
Each state is different so check with your state, however, most follow the AANA and ASA guidelines for Propofol.
Many states Board of Nursing have an Exemption rule for ER & LifeFlight Nurses because these patients are already intubated.
ASGE Postion Statement on nonanesthesiologist administration of propofol for GI endoscopy Nonanesthesiologist administered propofol (NAAP) for GI endoscopy is issued jointly by The American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy.
A 4-member commision.
The Gastroenterology position statement on Propofol from the ASGE SGNA Postion Statement on the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting. Disclaimer: The Society of Gastroenterology Nurses and Associates, Inc. assumes no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and procedures of any practice setting. Nurses and associates function within the limitations of licensure, state nurse practice act, and/or institutional policy. 2010
Joint Commission is an independent, not-for-profit organization, The Joint Commission accredits and certifies more than 15,000 health care organizations and programs in the United States.
Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards Joint Commission Rationale for PC. 13. 20 Because the response to procedures is not always predictable and sedation to anesthesia is a continuum, it is not always possible to predict how an individual patient will respond. Therefore, qualified individuals are trained and professional standards and techniques to manage patients in the case of a potentially harmful event. Elements of performance for PC. 13. 20
1. Sufficient numbers of qualified staff are available to evaluate the patient, perform the procedure, monitor and recover the patient.
2. Individuals administering moderate or deep sedation and anesthesia are qualified and have the appropriate credentials to manage patients at what ever level of sedation or anesthesia is achieved, either intentionally or unintentionally.
3. A registered nurse supervises perioperative nursing care.
4. Appropriate equipment to monitor the patient’s physiologic status is available.
5. Appropriate equipment to administer intravenous fluids and drugs, including blood and blood components, is available as needed.
6. Resuscitation capabilities are available. Before operative and other procedures or the administration of moderate or deep sedation or anesthesia.
7. Patient acuity accessed to plan for the appropriate level of post procedure care
8. Pre-procedural education, treatments, and services are provided according to the plan for care, treatment, and services.
9. The side, procedure, and patient are accurate accurately identified and clearly communicated, using active communication techniques, during the final verification process, such as “timeout,” prior to the start of any surgical invasive procedure.
10. A pre sedation or anesthesia assessment is conducted.
11. Before sedating or anesthetizing the patient, and LIP with appropriate clinical privileges plans or concurs with the planned anesthesia.
12. The patient is re-evaluated immediately before moderate or deep sedation and before anesthesia induction.
A 2000 Revision to Anesthesia Care Standards in the Comprehensive Accreditation Manual for Hospitals states that: “Qualified individuals” conducting sedations must possess education, training and experience in:
1. Evaluating patients prior to moderate or deep sedation
2. Rescuing patients who slip into a “deeper than desired” level of sedation or anesthesia.
3. Managing a compromised airway during a procedure.
4. Handling a compromised cardiovascular system during a procedure.
Medicare on Propofol Sedation Medicare now requires that deep sedation with propofol in the operator setting requires the involvement of an anesthesia professional such as a CRNA. With respect to deep sedation using propofol fall fall, the new guidelines state: “An example of deep sedation would be a screening colonoscopy when there is a decision to use propofol, so as to decrease movement and improve visualization for this type of invasive procedure.
Because of the potential for the inadvertent progress into general anesthesia in certain procedures, it is necessary that the administration of deep sedation/analgesia be delivered or supervised by a practitioner as specified in 42 CFR.52 (a).” The agency’s previous guidelines did not make distinctions between general anesthesia, moderate sedation, monitored anesthesia care (MAC) and analgesia, as the new guidelines do.
The American Association Pediatric (AAP) suggest that all patients through 17 years of age be considered pediatric patients. Intravenous conscious sedation may be performed on pediatric patients greater than 9 months of age who are assessed Class I or Class II using the Physical Status Classification of the American Society of Anesthesiologists (ASA) System.
Procedural Sedation “A technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows patients to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia is intended to result in a depressed level of consciousness, but one that allows the patient to maintain airway control independently and continuously,” Reference: American College of Emergency Physicians) ACE
|Age||Respiration Rate||Heart Rate||Systolic Arterial BP||Diastolic Arterial BP|
|12 yrs 20 80 110 60||20||80||110||60|
|*Moderate Sedation Certification|
American Association of Pediatrics NPO Guidelines for elective cases For children 0-5 months: no milk or solids for four hours No breast milk for 4 hours before scheduled procedure 5-36 months: no milk or solids for six hours > 3 years: 8 hours for milk or solids Clear liquids up to two hours beforehand.
Who is qualified to do sedation? One practitioner – at least BLS, preferably PALS, and familiarity with drugs One assistant – primary responsibility is monitoring For deep sedation – practitioner must have advanced airway skills. (Anesthesia provider, Pediatric intensivists, ED physician)
Recommendations for moderate sedation in radiology. The nurse assumes no other concurrent responsibilities during the procedure. The imaging registered nurse is allowed within the limits of state licensure, state nurse practice act, and institutional policy to administer sedation and analgesia.
The healthcare facility should have in place an educational/credentialing mechanism that includes a process for evaluating and documenting the nurse’s competency relating to the management of patients receiving sedation and analgesia; evaluation and documentation should occur on a periodic basis. The registered nurse managing and monitoring the care of patients receiving sedation and Association for Radiologic & Imaging Nursing POSITION STATEMENT on Role of the Imaging Registered Nurse in Patients Undergoing Sedated Procedures analgesia must be able to do the following:
Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia recognition, and complications related to sedation and analgesia sedation and medications. Assess the total patient care requirements before, during, and post administration of sedation and analgesia.
Understand the principles of oxygen delivery, transport and uptake, respiratory physiology, as well as understand and use oxygen delivery devices. Recognize potential complications of sedation and analgesia sedation for each type of agent being administered.
Possess the competency to assess, diagnose, and intervene in the event of complications and institute appropriate interventions in compliance with orders or institutional protocols.
Demonstrate competency, through ACLS or PALS, in airway management and resuscitation appropriate to the age of the patient. The Association for Radiologic & Imaging Nursing https://www.arinursing.org/