Accreditation surveyors are looking at conscious sedation — Are you ready?
Ensure consistency of administration, monitoring
A warning is rumbling through the same-day surgery community: Expect surveyors to take a hard look at your conscious sedation policies and outcomes when you undergo accreditation. One contributor to the increased use of and focus on conscious sedation — cost containment."Because of cost-containment efforts in medicine, there’s a tendency to do minor procedures without anesthesiologists," says Isaac Azar, MD, vice chairman of department of anesthesiology at Beth Israel Medical Center and professor of anesthesiology at Albert Einstein College of Medicine, both in New York City. Some of those procedures require only sedation and analgesia and are performed in physicians’ offices without an anesthesiologist, an RN to monitor the patient, or a crash cart for emergencies.
The key issues are how your same-day surgery program can avoid problems and be prepared for the next accreditation survey. Here are some tips from conscious sedation experts:
• Know that the Joint Commission on Accreditation of Healthcare Organizations requires the same standard of care for all areas performing conscious sedation.
Read through the Joint Commission standards, suggests Robert P. Gordon, MD, attending anesthesiologist at Westchester County Medical Center and assistant professor of anesthesia at New York Medical College, both in Valhalla.
"The goal is to establish a consensus throughout any given institution," he says. "Endoscopists performing conscious sedation must maintain a standard of care comparable to anesthesiologists providing conscious sedation."
When creating a policy and procedure for conscious sedation, same-day surgery managers have several resources. The Joint Commission’s Comprehensive Accreditation Manual for Hospitals — The Official Handbook and the Comprehensive Accreditation Manual for Ambulatory Care — The Official Handbook have templates for conscious sedation policies. (For ordering information, see sources, p. 22.) Also, the Task Force on Sedation and Analgesia by Non-Anesthesiologists, established by the Park Ridge, IL-based American Society of Anesthesiologists, has published rec-ommendations to help devise a policy. (See reference at the end of the story and source box, p. 22.) Policies from your peers also can offer guidance. (See "Guidelines for Nursing Care of the Patient Receiving Conscious Sedation" and "Patient Care/Conscious Sedation," inserted in this issue.)
Check with your peers
When Westchester County Medical Center was establishing standards on conscious sedation, the staff examined the policies at comparable tertiary care academic centers in the area, asking how they educated practitioners. Did they include conscious sedation in the delineation of privileges at the hospital? Did they require training in basic life support (BLS) or acute cardiac life support (ACLS) for everyone involved with conscious sedation?"We found wide diversity," Gordon says. "Some institutions simply signed off from the chairman of the department: Yes, someone is doing conscious sedation. Nothing else is required.’ Other institutions required BLS and/or ACLS. They required re-education at fixed intervals — every one to two years. Some did internal reviews, QI reviews, which spoke to how the actual services were complying with standards they established. "
Westchester County chose to do "something in the middle" in terms of setting up a policy, he says. (See copy of policy, Care of the Patient Receiving Conscious Sedation, which includes emergency algorithm, pp. 19-20.) "We did include BLS. We felt everyone, every practitioner providing [and monitoring] conscious sedation, should be BLS trained and maintained, renewing it every two years."
• Select appropriate patients.
"Most places I know use the ASA classification system," says Jan Odom, MS, RN, CPAN, clinical nurse specialist at Forrest General Hospital in Hattiesburg, MS. Using such a classification system is recommended by insurance companies’ risk management departments, Odom says.
"We say that patients who are class I and II are always appropriate" for nurse-administered conscious sedation, she says. Class III patients "you can decide on an individual basis." Exceptions were written into her hospital’s policy.
For staff who might never have heard of the ASA system, Westchester County outlined it on the back of its preprocedure assessment form. (See story on documentation, p. 24, and copy of form, inserted in this issue.)
"No non-anesthesiologists should be dealing with class IV or V," Gordon says, adding that some hospitals specify that statement in their conscious sedation policies.
• Prepare patients adequately.
For patient satisfaction, ensure that patients know what to expect. "Patients should understand they’re not going to be totally anesthetized," Azar says. "They’re going to feel something. If it’s unbearable, more medication can be given."
Also, ensure that patients understand NPO requirements, he emphasizes.
• Determine who should perform the monitoring.
The Joint Commission doesn’t specify who should monitor the administration of conscious sedation, other than saying the person should be competent, properly qualified, and trained, Odom says. Have an anesthesiologist look over the training outline, some experts suggest.
The topic of monitoring is controversial, Odom says, because in some physicians’ and dentists’ offices, a technician or an assistant may monitor the patient. (For information on educating your staff, see story, p. 22.)
Before you administer conscious sedation or supervise someone who is monitoring it, check with your malpractice insurance carrier and, if you’re a nurse, with your state board of nursing, Odom suggests.
"My board of nursing says that I as an RN cannot supervise a non-RN [monitoring conscious sedation] except that it does allow me to supervise LPNs that have gone to IV medication class," she says.
• Work toward having a dedicated person for monitoring.
A qualified person should observe the patient and document the vital signs every five minutes, Gordon says. The crux of controversy centers on whether a staff position should be dedicated to monitoring the patient. The controversy was inflamed by a recommendation from the ASA Task Force on Sedation and Analgesia by Non-Anesthesiologists, which states: "A designated individual, other than the practitioner performing the procedure, should be present to monitor the patient throughout procedures performed with sedation/analgesia. This individual may assist with minor, interruptible tasks."1
Some physicians think that position is adequate because staff have monitoring equipment with an alarm if the patient’s vital signs slip.
Many nurses disagree. What constitutes "minor, interruptible tasks" to one physician may not to another, Odom points out.
Twenty-three health care organizations have endorsed a position statement from the Washing-ton, DC-based American Nurses Association that says: The nurse monitoring the patient can have no other responsibilities that would leave the patient unattended or compromise continuous monitoring. (For information on how to access that position statement, see source box, p. 22.) In addition, some state boards of nursing and facility policies spell out that the nurses can have no other duties, says Odom.
"There are some places that tell me, when I’m lecturing, that they’re not necessarily following that," she says. "That doesn’t make it right. The person monitoring the patient, even if they’re not administering conscious sedation, should have no other duties."
The Joint Commission supports the position that one person should be dedicated to monitoring, Gordon says. In an age of staff downsizing, providing such a person is a "monumental task," he acknowledges.
• Monitor conscious sedation outcomes.
If you’re in a hospital setting, the Joint Commission will be looking to see whether you are monitoring outcomes, Odom says. "We monitor for respiratory depression," she says.
Her facility also has monitored for patients who no longer fall within the definition of conscious sedation. For example, can they respond to a verbal means of stimulation or to tactile stimulation? Or have they slipped into deep sedation? Also consider monitoring for complications, such as hyper- or hypotension, Odom suggests. "You just make sure, one, that you’re actually doing conscious sedation and, two, that you’re not having adverse reactions," she says.
Reference
1. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 1996; 84:463.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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