Moderate Sedation Core Competency Course 2012

Moderate Sedation Core

Competency Course 2012

University of California San Diego Medical Center

Revised September 2011

Objectives

• State competency requirements for RNs & MDs assisting with Moderate Sedation as defined by MCP 370.1 & consent

requirements as defined by MCP 339.1 • Compare and contrast moderate sedation,

deep sedation, & anesthesia in terms of definition, monitoring requirements, areas of the hospital where it may be performed

Objectives continued…

• State documentation and patient monitoring requirements with moderate sedation

• Compare and contrast commonly used sedatives

• Compare and contrast common

complications of MS & appropriate clinical interventions

• Demonstrate difficult airway mgmt using patient positioning, BVM, oral, nasal airways

RN Competency Statement

• Moderate sedation competence is required for all RN’s who assist with moderate sedation in designated invasive procedure areas

• All RN’s who assist with moderate sedation will have current ACLS certification or UCSD evidence-based equivalency ART

• Competence is evaluated at least every two years.

Moderate Sedation Initial Competency

• Attend the Moderate Sedation Core

Competency

• Score 90% or greater on the Core Moderate Sedation Exam

Moderate Sedation Initial Competency

• Demonstrate competence by

assisting with moderate sedation by

one of the following:

– Actual observation of staff member during moderate sedation procedure – Successful performance during the

Moderate Sedation Annual Competence

• Score 90% or greater on the Annual Moderate Sedation Competency

• Demonstrate competence in assisting with moderate sedation by one of the following:

– Actual observation of staff member during a moderate sedation procedure

– Successful performance during mock moderate sedation check off

– Chart audit of moderate sedation procedure when RN was primary nurse delivering or assisting

Attending Physician Competence

• Medical Staff Attending Membership status from Med Staff Executive Committee & Credential Committee • ACLS or ART

• Granted privilege via credentialing process • Successful completion of MS course and

exam; Re-credential with exam every 2yrs

Exemptions

• Anesthesiologists, ED, Trauma & Pulmonary critical care MDs

• CRNAs

• Credentialed for MS and Deep Sedation • Exempt from credentialing process described

Fellow and Senior Residents

• 3rd_{year or above resident, in residency or}

fellowship with an active Ca Medical License • Endorsed by Training Program Director &

MSEC; Identify competency on intranet • ACLS or ART

• Complete Moderate Sedation Course and Test • First 3 procedures must be proctored by an

Attending privileged in Moderate Sedation • Attending of record must be privileged

Supervision of MD Trainees not

credentialed in Moderate Sedation

• Only under direct supervision of an attending who is certified in moderate sedation

• Supervising attending must be present for the entire duration of the

operation/procedure

• Residents in anesthesiology and Emergency Medicine, also Trauma Critical Care, Pulmonary Critical Care, and Neuro Critical Care who are competent defined by their training program, are exempt from process while under direct

supervision of credentialed attending physician in respective specialty

UCSD Healthcare Intranet

• Home Page:

• “Attending Physician Privileges” • Resident Physician Competencies

– Link and info to use “ New Innovations” site

• Web Ref: Physician Privileges

• Call House Supervisor

Designated area for Moderate Sedation at

UCSD Hillcrest

MCP 370.1 Attachment A

• Main Operating Room, PACU • Same Day Surgery Suites • GI Endoscopy Suite • Cardiac Catheterization Lab • Electrophysiology Lab

• Pulmonary Special Procedures Unit • Radiology: MRI (in-house), CT, IR • ICU SICU, CCU, MICU, BURN, IMU, NICU • ER

Designated areas for Moderate Sedation

UCSD Medical Center Thornton

• Main Operating Room • Same Day Surgery • PACU

• Intensive Care Unit and PCU • Special Procedure Suite • Emergency Department • Radiology: MRI,CT, IR

• Cardiac Cath Lab

• Moores Cancer Center: Procedural suites, MRI, Radiation Oncology

Designated areas for Moderate

Sedation UCSD Medical Center SCVC

• Main Operating Room • Same Day Surgery

• PACU and Procedural Treatment Unit (PTU) • Intensive Care Unit and PCU

• Special Procedure Suite • Emergency Department

LEVELS OF SEDATION

“The objective of intravenous sedation policies for diagnostic and surgical procedures is that within all locations within

the hospital, patients with the same health status can expect a comparable quality of

care” TJC

Implications

• In patients of any age, even if one

attempts moderate sedation, it can rapidly and easily become deep sedation or anesthesia

• Therefore, the practitioner who performs moderate sedation must assume that deep sedation or anesthesia can occur

– Level of vigilance must be maximal and – Area in which patient is sedated must be fully

equipped with monitoring equipment and appropriate personnel

• Level of consciousness, solely, determines level of sedation – not the drug or the route of administration.

• 4 levels of sedation are defined, but distinctions may obscure in practice.

• Level of sedation may change with time, and variable patient response – all practitioners need to be prepared for patient that becomes sedated beyond expectations.

Procedure Goals

• Accomplish the procedure • Behavior control or immobility • Patient safety • Minimal physical discomfort and pain • Minimal psychological response to procedure • Rapid return to baseline state of consciousness

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.

Moderate Sedation

• A drug induced depression of

consciousness during which the patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain patent airway and

spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

• (UCSD Medial Center MCP 370.1 04/12)

Deep Sedation

• A drug induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. May have impaired ability to maintain airway & ventilation. Cardiovascular function is usually maintained

• (UCSD Medial Center MCP 370.1 04/12)

Anesthesia

• Consists of:

– General anesthesia

– Spinal or major regional anesthesia – Drug induced loss of consciousness; pt

not arousable

• Requires assistance to maintain

airway

• Cardiovascular function may be

impaired

ASA Classification

of Physical Status

• ASA 1 = normal healthy patient • ASA 2= mild systemic disease • ASA3 = severe systemic disease

• ASA 4 = severe systemic disease that is a constant threat to life

• ASA 5 = moribund, not expected to survive

Sedation in the ICU

• Policy covers settings where patients receive moderate sedation for procedures.

• Includes additional sedatives and analgesics given to ICU patients that may or may not be receiving ICU sedation

• Does not cover sedatives or analgesics given for ICU sedation.

• (UCSD MCP 370.1 04/12)

Indications for Moderate Sedation

• Administering sedative or narcotics for

Position Statement on the Role of the

Registered Nurse in the Management of

Patients Receiving Intravenous Moderate

Sedation for Short-term Therapeutic,

Diagnostic or Surgical procedures

Endorsed by: AACN, California BRN, ASPAN, AANA, ANA

• The RN who for any reason does not feel 

comfortable managing the care of a patient should  consult an anesthesia provider and/or attending  physician and/or the Charge RN

Indications for Moderate Sedation…

Anesthesia Provider or RN?

• Consider:

– Patient anxiety

– History of drug or ETOH abuse

– Pediatric patient

– High acuity level or ASA level

Resource Personnel for Moderate Sedation

at UCSDMC

• Physicians certified in Moderate Sedation per the Delineation of Privileges form in the specific department

• PACU Registered Nurses who have completed competency

Monitoring and Support Equipment

• Adequate lighting

• Adequate space • Adequate power outlets

• Reliable two way means of communication • Ability to provide immediate changes in

patient position including Trendelenburg

Monitoring and Support Equipment

• Resuscitation equipment (Code blue

cart/defibrillator)

• Oxygen source with at least 10 LPM flow and devices

• Functional BVM • Functional suction

• Functional cardiac monitoring equipment

ASA Pre-Procedure Fasting Guidelines

• Adults

– Solid food 6-8 hours – Liquids 2-3 hours

• Factors that decrease gastric emptying

– Anxiety – Opiods – Trauma – Pregnancy

Procedures Requiring Consent

• Requires general anesthesia, moderate

sedation or regional blocks • Are performed in the OR

• Involves placement of implantable devices • Involves tissue biopsy

• Listed in Attachment B of MCP 339.1

Consent MCP 339.1

• Decisional Capacity

– Patient must be able to understand the condition, the risks and benefits of the recommended treatments, available alternatives (including no treatment)

Who may consent?

• Adult patient with decision making capacity

• Decisionally incapacitated patients may have the following:

– Durable power of attorney for healthcare – Conservator or guardian

– Closest available relative

Closest Available Relative (in order)

• Spouse • Son or Daughter • Mother or Father • Brother or Sister • Grandmother or Grandfather • Aunt or Uncle • Nephew or Niece

Surrogate Decision Maker not Present?

• Telephone consent with surrogate,

responsible physician and witness

• Consent form completed by MD or witness & signed by MD and Witness

• Include date, “telephone consent” and surrogate’s name on the consent form

Witness for Consent

per MCP 339.1

• Professional employee who verifies with the pt. that the MD discussed the risks, benefits & alternatives & that consent was voluntary

• It is NOT necessary for the witness to be present when the informed consent discussion takes place

Witness for Consent

per MCP 339.1

• After verifying the informed consent process, RN witnesses the patient’s signature on the consent form and signs the witness’ verification

Language Barrier?

• Translator

• ATT Translator Service (MCP 301.9)

Documentation Requirements

• Pre-Procedure:

– Patient identification using two forms of identification (name and MR)

– Informed consent for the procedure documented by a physician

– Signed consent form for the procedure – History and Physical Assessment

• > 24 hours but < 30 days needs Interval Assessment • > 30 days, must complete new H&P

Documentation Requirements:

Pre-Procedure

• Physician signature on the Pre-Procedure Sedation Assessment

• Immediate pre-sedation vital signs & assessment by the RN

– Notify MD of abnormalities

• Time Out Verification - in procedure location and with entire team

– Site of the procedure and the patient are actively and clearly communicated

Know your Resources!

• Be Proactive!

• Let Charge RN know that moderate sedation procedure is planned

• Know anesthesia's phone # and/or when to call Code Blue/give reversal agent

Monitoring Requirement

• RN, PA or NP credentialed/competent in MS will continuously monitor the patient & will be available from the time of first drug administration until recovery is judged adequate per MCP.

• MS credentialed MD and personnel will be available to direct pt care if

Intra-Procedure Documentation

• Sedation Procedure Record

• EPIC

Intra-Procedure and Recovery

Vital Signs

• Continuous Cardiac monitoring (post strip) • Every 5minutes:

– HR – RR – BP – Sp02

• LOC every 15minutes

• If patient goes into Deep Sedation, documents VS every 3 minutes!

Intra-Procedure

• Verbal order read back

• Sedative drug name, dose, administering personnel & time given

• Patient monitoring • Communication with MD

Sedative Administration

• Personnel that meet MS requirements, may administer sedative drug under direction of the MS credentialed physician.

• Consult with anesthesia required for Deep Sedation.

• Medications should be easily titrated for procedure, and those with specific reversal agents are preferred – rapid onset anesthetics are NOT appropriate.

Intra-Procedure Monitoring

• Have reversal agents for opiods and

benzodiazepines readily available • Anticipate procedural needs • Monitor patient safety and comfort

Patient Monitoring Post-Procedure

• Monitor for at LEAST30minutes after the

last dose of intravenous medication • Monitor for at LEAST90minutes after the

last transmucosal or intramuscular medication

• If reversal agents used, must monitor for 90 minutes after last reversal agent administration

Recovery & Discharge Invasive Procedure

Areas

• Use scoring criterion from discharge scoring assessment

• Modified Aldrete Score of at least 15 AND 30 min since IV or 90 min since IM or transmucosal medication

• MS MD will approve discharge once criteria met • If total score is < 15 or if there is a score of zero

in any category, then pt must be assessed & released by a physician

Recovery & Discharge

• Patients who require transport will be assessed for stability prior to transport • Supplemental oxygen will be used if Sp02

< 90% on room air

• Patients will be accompanied by licensed clinical personnel during transport

Discharge Criteria

• Patient must meet criteria for discharge • Record the mode of transportation home • Give both verbal and

written instructions • Discharge Instructions

• Discharge Instructions for the Parent

Recovery

• Patients sedated in the ICU or ED may be recovered in their respective areas • If pt does not meet recovery criteria,

must be transported to PACU

Potential Complications

• Airway Obstruction • Laryngospasm • Bronchospasm

• Noncardiogenic Pulmonary Edema • Aspiration

• Cardiovascular complications

Adverse Event Documentation

• Note in medical record, and eQVR:

– Use of reversal agent – Unplanned intubation

– Unplanned admission or transfer to higher level of care

– Chest pain during procedure

– Drop in oxygen saturation - <92 for >5 minutes – Unintended interuption of procedure due to med use – Hypotension and use of pressor

– Aspiration – RRT/Code Blue – Death

References

• UCSD Medical Center MCP 370.1 (revised 04/2012)

• UCSD Medical Center MCP 339.1 (Aug 2011) • University HealthSystem Consortium (2005).

Moderate Sedation Best Practice Recommendations. Oakbrook, IL .