Category:
Number
Date Originated:
January 2000 / Effective Date:
January 2014
Last Review Date:
Definitions: The various degrees of sedation occur on a continuum. The patient may progress from one degree to another, based upon the patient’s medical condition and the way in which the medication is administered. The determination of patient monitoring and staffing requirements should be based upon the patient’s acuity and the potential response of the patient to the procedure and sedation.
Minimal Sedation (anxiolysis)
A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Qualified RNs, under the supervision of a physician/LIP (Licensed Independent Practitioner), performs minimal sedation. Any medical staff member with privileges at Sacred Heart Medical Center may prescribe minimal sedation.
Moderate sedation/analgesia ("conscious sedation")
A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either along or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Qualified RNs under the supervision of a physician/LIP who has moderate sedation privileges performs moderate sedation. The physician/LIP supervising moderate sedation must have SHMC moderate sedation privileges as defined in the Medical Staff Privilege delineation.
Deep sedation/analgesia
A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. Only physicians/LIP with deep sedation privileges may administer deep sedation.
We DO NOT PROVIDE DEEP SEDATION AT ANY OF THE Inland ImagingLOCATIONS !
PURPOSE:
The purpose of this policy is to establish minimum requirements for administering and monitoring light sedation used for diagnostic or therapeutic procedures and to establish “one standard of care” for all patients throughout the Medical Center.
POLICY:
The following standards are to be implemented whenever minimal sedation is used during a procedure or patient care event in which a stimulus is going to be applied and will be removed soon. If the minimal sedation is an appropriate amount when the stimulus is present, the patient may slip into deeper sedation when the stimulus is removed. These minimal sedation standards are designed to provide adequate assessment and monitoring to identify a deeper level of sedation allowing the nurse to provide appropriate care. (For example, if minimal sedation were used during dressing changes, these standards would be implemented. However, if a patient receives a minimal sedation because of anxiety related to news of their new diagnosis, or as a sleeping aid these standards do o need to be implemented.
Child: For purposes of sedation, this policy covers individuals 16 years of age or under.
MINIMAL SEDATION
Staff Competencies
a)The medical director of anesthesia will be responsible for ensuring that a minimal sedation policy exists within the Medical Center and is applicable to practice.
b)Minimal sedation is performed by qualified RNs, under the supervision of a physician.
The RN must have successfully completed the Minimal Sedation self-study and demonstrate Basic Life Support competency. Yearly competency is reflected in the RN's annual performance review
c)Any physician with privileges at Sacred Heart Medical Center may prescribe minimal sedation.
Pre-sedation Assessment:
1. A brief nursing assessment is completed and documented prior to the procedure. The assessment includes:
a) Vital Signs: Heart rate, blood pressure, quality and rate of respiration.
b) Allergies
c) Height and weight (actual or estimated).
a) Current medication list.
d) A brief medical history
e) Pregnancy
2. IV access is recommended, but not required.
3. Informed consent and a medical history and physical are not required prior to minimal sedation. However, they may be necessitated by the procedure the patient is undergoing. (See Administrative Manual for policies: History and Physical Examination, and Consent, Informed) H & P required for Inland Imaging at Holy Family
Monitoring:
Monitoring and assessment of the patient is to be done prior to the administration of sedation, at or before 30 minutes and every 4 hours or more frequently based on the patient's response and medication administered for the next 8 hours.
Recovery:
1. Patients will be assessed (as needed) until they are sufficiently alert and are physiologically stable or at pre-sedation level.
2. If the patient progresses to a deeper level of sedation, the RN is to follow monitoring criteria as defined by moderate sedation section. If the patient becomes unstable, the RN is to implement the SHMC Code 3/55 procedure.
3. If a reversal agent is administered, the patient must be monitored (See section under Moderate Sedation) a minimum of one hour before discharge/return to unit’s routine monitoring to insure that re-sedation does not occur. The recovery phase may be longer due to the patient's pre-existing condition and the amount of sedation medications administered.
Outcome Measurement:
- All untoward outcomes that result from minimal sedation are reported to Risk Management via the Quality Improvement form. Electronic Patient Incident Report
MODERATE SEDATION
Staff Competencies:
- The medical director of anesthesia will be responsible for ensuring that sedation
policies exist for the Medical Center and are applicable to practice.
- Qualified RNs under the supervision of a physician who has moderate sedation
privileges performs moderate sedation.. The RN administering moderate sedation
must have successfully passed an arrhythmia test, the sedation cognitive test, and
is checked off on the sedation competency by a qualified observer. The RN must
also hold a current PALS provider card, and demonstrate the ability to identify high-
risk patients and age related care needs. Documentation of the yearly Sedation
Competency Review will be included as a part of the RN's annual performance
appraisal.
- The physician supervising moderate sedation must have SHMC moderate
sedation privileges as defined in the Medical Staff Privilege delineation.
Pediatricians have core privileges to order Chloral Hydrate within
established dosage guidelines (50 – 75 mg/kg up to 1 Gm in ages 2 and
under and 2 Gm if 3+ years of age).
Pre-sedation Assessment:
- NPO status is reviewed.
a.Clear liquids up to 2 hours prior to procedure (water, apple juice). NO milk.
b. Patient may have formula up to 6 hours and breast milk 4 hours pre-procedure.
c.Limit last feeding to 8 ounces
d.No solid food a minimum of 8 hours
e.Anesthesiologist or physicians credentialed for sedation may modify the above guidelines based on the procedure, patient characteristics or acuity of the clinical situation.
For sedation needed in an emergency:
a.Evaluate food intake carefully based on procedure planned.
b.Delay procedure if possible. If not possible, the patient may require an anesthesia provider to provide airway protection before sedation.
c.The lack of pre-sedation fasting should not be considered a contraindication to the use of sedation in an emergency.
d.Trauma: calculate NPO time from time of food until time of injury.
2. A nursing assessment is completed and documented prior to the sedation. The assessment includes:
a.Vital Signs: Heart rate, blood pressure, quality and rate of respiration
b.Baseline oxygen saturation.
c.Level of consciousness.
d.Airway assessment to include Mallampati classification, status of dentition, and any neck, jaw or craniofacial abnormalities.
e.Heart and Lung Exam
f.Movement and strength of extremities (if indicated).
g.Allergies.
h.Height/Weight - Actual or estimated.
i.Pregnancy
j.Current medication list.
k.Brief medical history
3. Assessment of the need for IV access is required by the physician ordering the sedation.
4. Moderate sedation Physician Guidelines:
a.Informed consent for sedation must be obtained prior to sedation. (See SHMC Administrative Policy “Consent, Informed”)
b.A medical history and physical examination must be documented in the patient’s medical record. (See SHMC Administrative Policy “History and Physical Examination”)
c.A pre-sedation assessment is performed for each patient before beginning moderate sedation. The assessment includes a predetermined ASA classification and airway assessment. Vital signs will be documented on the sedation sheet immediately prior to sedation. This set of vital signs will be evidence of the re-evaluation of the patient prior to sedation. If the RN performs the assessment, the RN will alert/inform the physician of any abnormality related to this assessment prior to the initiation of the sedation. The MD will then reassess the patient and decide and document if they will proceed with the sedation, or delay/cancel to do this assessment. The physician documents and signs this assessment on the procedure form.
Monitoring:
1. Physician
a. For procedures that are invasive and the physician /LIP is performing the
procedure:
The physician is in attendance during the procedure and will order moderate
sedation medication according to his/her assessment.
* Except for life-threatening emergency situations, a RN qualified to monitor
the patient must be present.
- For procedures that are non-invasive and the physician is not performing the
procedure, such as MRI, EEG etc).
The physician /LPI with moderate sedation privileges will assess and
document their need to be in attendance during sedation or immediately
available (in person, not by phone). A dosage range of medication to
achieve moderate sedation will be ordered by the physician after he/she has
assessed the patient.
c. For procedures where the same patient receives repeated moderate sedation and safe dosage patterns have been established by the physician/LIP ordering the moderate sedation (dressing changes, e.g.), the physician may write sedation guidelines for the moderate sedation nurse to implement. The physician does not need to be present, but immediately available by phone.
The credentialed physician must provide written guidelines for subsequent moderate sedation dosing by the qualified moderate sedation RN. If the patient requires rescue from a deeper level of sedation, the RN will perform immediate rescue intervention and may summon using the established Code process. EMR process
2. The qualified Registered Nurse is present continuously throughout the sedation to administer the medication and monitor the patient.
3. Equipment:
The following equipment must be present, in working order, and be ready for use in the room where moderate sedation is being administered.
1. Oxygen and administration equipment (e.g. nasal cannula, masks)
2. Bag-mask-valve apparatus (e.g. Ambu bag)
3. Oral airways
4. Wall or machine suction, tubing, and suction catheters
5. Non-invasive blood pressure monitor or manual blood pressure cuff
6. Pulse Oximetry
7. Stethoscope
8. Reversal agents must be easily accessible in close proximity
9. Cardiac monitor HFIC ( Nurse Discretion in SC, SHIC, VC, Locations)
10. Emergency carts and Code Team at HFIC ( AED available at SC,
SHIC, VC Locations)
During the sedation:
1)Patients receive oxygen throughout the sedation unless contraindicated by medical condition and by diagnostic procedure.
- Monitoring of the patient is to be continuous and will include documentation of the following at least every 10 minutes and 5 minutes following each dose of medication.
- Vital Signs: Heart rate, blood pressure (prn patient status and condition), respiratory rate, and oxygen saturation.
- Level of consciousness on the Modified Ramsay Sedation Scale /level of pain and anxiety. The patient should be arousable, able to respond to verbal and tactile stimuli and able to cooperate throughout the sedation.
- Quality of respirations and airway.
- Color, capillary refill
- Cardiac rhythm (exception, MRI)
- The patient is monitored for potential complications continuously during the sedation.
- The physician is immediately notified of any significant changes in the patient’s condition.
Recovery:
1. The RN administering the moderate sedation will perform an assessment and make a decision concerning the disposition and level of recovery care that the patient requires.
Options:
a. Continue to monitor the patient in the room until stable.
b. Transfer the patient to an area where qualified staff deliver Phase I level of recovery
care.
c. Transfer the patient to an area where qualified staff monitor the patient post-moderate
sedation as defined below (e.g. inpatient or outpatient unit).
2. After receiving Moderate Sedation, the patient will be assessed on admission to the
recovery unit and at 30 minutes or until he/she has met the following criteria:
a. Stable vital signs X 2 (HR, RR, BP) +/- 20% of pre-procedures findings. If the patient arrives on O2 but is weaned to room air during recovery, SaO2 on Room Air is greater than or to 90% or same as pre-procedures level.
b. Capillary refill greater than or equal to 3 seconds or to pre-procedure level.
c. Patient has returned to pre-procedures level of consciousness or a maximum of
“2”on the Modified Ramsay Sedation Scale (MRSS).
d. Patient demonstrates that protective airway mechanisms have returned to pre-
procedure assessment findings.
e. Patient can ambulate without dizziness consistent with developmental age,
condition and the procedures
- Have minimal pain or pain controlled by analgesics
- Have no unusual bleeding for procedural site
3. If reversal medications were administered, monitor the patient q 15 minutes for a MIMIMUM
of One hour. Re-sedation can occur because the reversal drug does not have the same
half-life as the sedative/narcotic.
- Monitor vital signs (BP,RR,HR)
- Monitor LOC using the Modified Ramsay Sedation Scale
- If the patient arrives of O2 but is to be weaned to room air during recovery, titrate the O2 while maintaining a SaO2 of greater than or equal to 90%
- After a minimum of one hour from the time reversal medications were given, if the patient has met the criteria under #2 above, he/she can be discharged/returned to the unit’s routine monitoring.
4. If the patient is to be discharged to home, they must have a responsible adult to drive them. Verbal and written discharge instructions must be given to the patient and/or escort.
REVISION HISTORYDate of Revision / Revision Explanation / Author
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