Update on controversy over ED nurses sedating patients
Appropriate training and competencies are key
It seems like a no-brainer: When ED nurses perform procedural sedation, patients get pain relief quicker. However, several organizations, including the American Society of Anesthesiologists and the American Association of Nurse Anesthetists, have approached state nursing regulators looking to put a stop to this practice.
"There is a movement to stop nurses from administering sedation to acutely ill and injured patients in our EDs," says Donna Mason, RN, MS, CEN, immediate past-present of the Emergency Nurses Association (ENA) and senior nurse consultant with Orlando, FL-based Blue Jay Consulting, specializing in ED processes. Mason is former nurse manager of adult emergency services at Vanderbilt University Medical Center in Nashville, TN. "The ENA has taken the lead to fight this absurd practice," she says.
The issue at hand is whether medications such as propofol and etomidate can be given safely by individuals, such as emergency nurses, who have not been trained in administration of general anesthesia. Mary M. Jagim, RN, BSN, CEN, FAEN, consultant for pandemic and emergency preparedness for MeritCare Health System in Fargo, ND, says, "The primary concern with those medications is the risk that the patient may slip into a deeper level of sedation than is intended, with a potential impact on the patient's airway."
However, there is an extremely low number of these incidents, and the patients required minimal support, says Jagim. "Propofol has a very short half-life and that is part of the reason it is so popular," she says.
Even so, some state boards of nursing don't allow ED nurses to administer the drugs, and some of those that do are taking a second look at the issue, says Jagim. "The issue may not have been previously discussed, but it is now coming to the board of nursing for a decision, and so the debate begins," she says.
Molly A. Evans, RN, BSN, CEN, ED manager at University of Colorado Hospital in Denver, says that if ED nurses were not able to give procedural sedation, "it certainly would be a disservice to patients involved in a traumatic painful injury. It is unusual to have a day in the ED that someone doesn't benefit by getting procedural sedation."
This means that ED nurses are able to do the procedure without coordinating with the OR and waiting for the on-call specialist to come in, says Evans. "We can take care of the situation right away. It makes it less expensive and much more timely for the patient's comfort," she says. "Also, sometimes the sooner you get something fixed, the less likely you will have neurovascular complications. For example, a dislocated joint could be injuring nerves or vessels. Quick treatment could minimize the damage."
If ED nurses aren't allowed to perform the procedure, then two ED physicians are required to be at the patient's bedside, which could leave the ED short-staffed. "Or if anesthesia staff are going to administer the propofol, they are often not available right away," says Jagim. "This causes delay in patient care and increases the patient's discomfort."
If a patient is acutely injured in the middle of the night, there is no time to wait for an anesthesiologist to come in from home to perform procedural sedation, argues Mason. "A patient could wait as long as an hour. If that is my loved one, it is way too long to watch them suffer."
Give appropriate training
Mason believes strongly that ED nurses should have the right to give procedural sedation. "With that being said, nurses have to be trained, experienced, and competent to give these drugs," she says.
At a minimum, ED nurses should receive training in basic airway management, recognition of complications, the combination of drugs and their actions, administration issues, side effects, and contraindications, says Mason. In addition, nurses should be certified in cardiopulmonary resuscitation (CPR), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS), in the event the patient needs to be resuscitated, she says.
In addition, the ED nurse has to be solely dedicated to administering the medications and monitoring the patient, says Evans. "They have to evaluate the patient before, during, and after the procedure," she says. "They can't leave their monitoring of the patient to get an item that may be needed or assist with the procedure."
Little room for error
Nurses must be very aware of appropriate dosages and the effects of medications, including special populations such as pediatric patients, because small dosages leave little room for error, says Evans. "Also, many times elderly patients do not require what is a usual dose, or they can react differently than predicted," she says.
There always is a possibility that your patient will require physiological support, whether that means intravenous fluids or respiratory support, so be prepared for "the worst-case scenario," says Evans. "It is infrequent that a patient undergoing procedural sedation will have a complication, but being fully prepared and competent is essential."
Sources/Resource
For more information on procedural sedation in the ED, contact:
- Molly A. Evans, RN, Manager, Emergency Department, University of Colorado Hospital, Denver. Telephone: (303) 372-6595. E-mail: [email protected].
- Mary Jagim, RN, BSN, CEN, FAEN, Internal Consultant for Pandemic and Emergency Preparedness, MeritCare Health System, Fargo, ND. Telephone: (701) 234-4893. E-mail: [email protected].
- Donna Mason, RN, MS, CEN, Senior Nurse Consultant, Blue Jay Consulting, Orlando, FL. Phone: (615) 973-4227. E-mail: [email protected].
A consensus statement from the Emergency Nurses Association and other organizations outlines the benefits of ED nurses using procedural sedation for patients undergoing invasive or painful procedures. To read the consensus statement, go to www.ena.org. Under the "About ENA" heading, click on "Position Statements," and "Procedural Sedation Consensus Statement."
It seems like a no-brainer: When ED nurses perform procedural sedation, patients get pain relief quicker. However, several organizations, including the American Society of Anesthesiologists and the American Association of Nurse Anesthetists, have approached state nursing regulators looking to put a stop to this practice.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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