CONTINUING EDUCATION
Back to Basics: Procedural Sedation 0.8 www.aorn.org/CE
LISA SPRUCE, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #15509 Session: #0001 Fee: Members $6.40, Nonmembers $12.80 The contact hours for this article expire March 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to procedural sedation.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict of Interest Disclosures Lisa Spruce, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2014.09.011 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 345
Back to Basics: Procedural Sedation 0.8 www.aorn.org/CE
LISA SPRUCE, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR
ABSTRACT Patients undergoing surgery frequently receive procedural sedation from RNs in the perioperative setting. With appropriate training, perioperative RNs can administer procedural sedation safely and effectively, helping to eliminate the pain and anxiety often experienced by patients. Facility sedation protocols should provide guidance on training requirements, the RN’s role, the credentialing process, the medications the RN may use, and when anesthesia personnel should be consulted. Creating these protocols is guided by state scope of practice laws, Centers for Medicare & Medicaid Services Interpretive Guidelines, and accreditation requirements. Training, physician guidance, and appropriate protocols give the necessary support for perioperative nurses to provide safe and effective procedural sedation. AORN J 101 (March 2015) 346-350. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2014.09.011 Key words: procedural sedation, moderate sedation, anesthesia, analgesia.
http://dx.doi.org/10.1016/j.aorn.2014.09.011 ª AORN, Inc, 2015
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erioperative nurses frequently administer sedation to patients during surgical or other invasive procedures in which sedatives and analgesics are used to induce a state of relaxation that allows patients to tolerate procedures without losing consciousness or cardiac or respiratory function.1 This nursing role is defined by state scope of practice laws, the Centers for Medicare & Medicaid Services (CMS) Interpretive Guidelines,2 and a facility’s accreditation requirements. Perioperative nurses are ideal team members to administer procedural sedation because they free anesthesia professionals to administer deeper sedation and general anesthesia to other patients.
Perioperative nurses can administer procedural sedation effectively and safely. Conway et al3 conducted a survey in 2014 indicating that nurse-administered procedural sedation for percutaneous coronary interventions, pacemaker placement, vascular procedures, and pediatric procedures was routine in most hospitals in Australia and New Zealand. In this study, most nurses administered a combination of benzodiazepines (eg, diazepam, midazolam) and opioids (eg, morphine, fentanyl) but were not allowed to administer propofol. Additionally, most RNs surveyed indicated that when administering sedation, the nurses’ primary responsibility was monitoring the patient throughout the procedure. A study performed in the United States by Thompson et al4 investigated the safety and efficacy of nurse-administered sedation during procedures performed at a regional burn center. During a 12-month period, 328 patients who had experienced burns received nurse-administered procedural sedation 1,293 times. The majority of the patients received fentanyl and midazolam during the procedure. Ten adverse events occurred that involved respiratory complications, but no intubation was required. The researchers concluded that nurses who were competent in procedural sedation provided safe and effective sedation and management of pain during procedures in the burn center.4 Guidelines for sedation administration frequently recommend that nurses have no other duties while monitoring the patient, although there are no studies showing that performing other duties while also administering sedation results in poor outcomes for patients.3 When nurses have received the proper education and training in monitoring patients, they can identify early cardiac or pulmonary function impairment, prompting lifesaving rescue actions such as airway management and the use of sedation reversal medications.3 Ketcham et al5 conducted a literature review of patient outcomes related to nurse-administered sedation and concluded that the evidence
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Back to Basics: Procedural Sedation
supports the practice of RNs administering sedation after receiving appropriate education and training and with direct supervision by physicians. They concluded that nurses can administer sedation to patients safely and effectively with no evidence of adverse patient outcomes.5 A 2012 prospective study by Sayfo et al6 reviewed proceduralist-directed nurse administration of propofol during the placement of implantable cardioverterdefibrillators in a tertiary care facility in the United States. Didactic education, advanced cardiac life support training, and a video were used to educate nurses regarding procedural sedation techniques. After receiving training, the nurses administered propofol and monitored patients throughout their procedures. There were 582 instances of nurse-administered propofol, and the researchers determined that there were acceptable rates of adverse events and manageable nonserious events when nurses administered propofol and monitored the patients.5 In the United States, the ability of nurses to administer propofol is determined by state scope of practice laws A complete listing of state laws and nursing scope of practice laws regarding nurseadministered procedural sedation can be found at https:// www.ena.org/government/State/Documents/RNProceduralSedation Rules.pdf. As always, nurses should verify this scope of practice information with their individual state boards of nursing to confirm that it is current.
HOW-TO GUIDE Caperelli-White and Urman7 published guidance on developing policies and protocols for facilities in which nurses administer procedural sedation and recommended forming a multidisciplinary team (eg, nurses, administrators, physicians, physician extenders, quality and patient safety officers, pharmacists) to contribute to policy and protocol development regarding nurses administering procedural sedation; outlining the RN’s role; defining the competency and education requirements for the clinical and administrative aspects of sedation; basing policy on published evidence; outlining essential elements, including o scope and purpose of the policy; o governance of the policy; o assignment of responsibility and roles; o state requirements for training, medication administration, and education; o competency and credentialing for practitioners; 8 o equipment needed for procedures ; AORN Journal j 347
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March 2015, Volume 101, No. 3
o
preprocedure patient evaluation requirements; o intraprocedural monitoring requirements; 8 o postprocedure patient evaluation and discharge criteria ; o postprocedure assessment of patient outcomes; and o documentation guidelines; identifying elements for education and training,9 including o knowledge of national guidelines such as the American Society of Anesthesiologists (ASA) Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists8 and AORN’s “Guidelines for managing the patient receiving moderate sedation/analgesia,”10 o informed consent for patients receiving sedation, o preprocedure patient assessment (eg, history and physical, lab work, and airway), 7 o ASA fasting guidelines, 7 o sedation levels, o pharmacology and safe administration of relevant sedatives and analgesics and reversal agents,7 o supplemental oxygen considerations, o airway assessment and management skills and oxygen delivery systems,8
“
either administer procedural sedation or supervise nurses and others who do. After the training was completed, all participants passed three of four modules on the first try and all but one passed the fourth module. All of the participants rated the simulation course as better than a course with lecture only.11 Checklists have been proven to be effective tools for patient safety and should be part of a procedural sedation policy.12,13 Checklists can be developed using templates and adjusted as needed based on the facility, types of procedures performed, and types of medications given.3 Nurses who administer sedation should have no other duties during the procedure and should ensure that the necessary equipment is present and working properly with audible alarms before the procedure. Examples of equipment14 include
cardiac monitor, pulse oximeter, oxygen, oral and nasal airways and endotracheal tubes,
Nurses who administer sedation should have no other duties during the procedure.
o
monitoring and documenting the patient’s physiologic vital signs (eg, blood pressure, respiratory rate, pulse oximetry reading, heart rate and rhythm, depth of sedation, capnography reading), o alarm recognition and significance, o common complications (hypoxemia) with interventions to counteract, o strong communication and skills in teamwork (ability to speak up), and o cardiopulmonary resuscitation (CPR) skills and advanced cardiovascular life support (ACLS); outlining the credentialing process; determining when there is a need for anesthesia consultation; and identifying medications that RNs are allowed to use during these procedures. Simulation coursework on sedation also should be considered. A 2013 report by Tobin et al11 described a successful course on moderate sedation and basic emergency procedures such as airway management for nonanesthesia physicians who
348 j AORN Journal
blood pressure monitor, capnography monitor, suction device, and emergency cart.
”
Capnography is an important aspect of patient monitoring, and nurses should be trained to monitor the patient’s end-tidal carbon dioxide (CO2). Capnography is a real-time measurement of the patient’s CO2 exhalation; it provides a better indication of how well the patient is oxygenated and could alert the nurse to respiratory compromise and hypoxemia sooner than a pulse oximetry reading.15 During the procedure, nurses should constantly monitor the patient for signs of complications, the most common being an obstructed airway or respiratory depression. At a minimum of every five minutes, the following should be documented13: medications administered; the patient’s o vital signs,
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March 2015, Volume 101, No. 3 o
capnography reading, pain level, o sedation level, o response to medication, and o amount of oxygen required; assessment of airway; and other observations (eg, IV fluids, communication with the patient). o
BENEFITS Patients who are undergoing minor procedures are often anxious and may be in pain. Administering procedural sedation helps to reduce patient anxiety and pain and allows the physician to complete the procedure with less difficulty. Nurse-administered sedation frees anesthesia professionals so they may attend to procedures requiring deep sedation or general anesthesia.
STRATEGIES FOR SUCCESS It is important to evaluate the patient before providing sedation. Recognized risk factors for patients undergoing sedation are advanced age and a high ASA classification score (https:// www.asahq.org/clinical/physicalstatus.htm). Patients who are older than 80 years of age require careful assessment and indepth informed consent discussions. One of the most important considerations in determining these patients’ pulmonary risks when receiving procedural sedation is their ASA score.16 The risk of developing a pulmonary complication is higher for patients with an ASA 2 classification compared with those with an ASA 1 classification.16 After an assessment and an informed consent discussion, a patient (or their family members or caregivers) must communicate that he or she understands what to expect, can tolerate the position required for the procedure, and understands the postprocedure instructions.15 Perioperative nurses who are administering procedural sedation must determine if a patient should undergo a consultation with an anesthesia professional. The nurse can use the following criteria when evaluating patients to determine if an anesthesia consultation is needed: a history of o opioid or other medication use that could interfere with sedative medications, o past inability to tolerate sedation, o allergic reactions to medications, and o limited neck motion; the inability of the patient to o tolerate the position required to complete the procedure, or o open his or her mouth widely; hemodynamic instability;
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Back to Basics: Procedural Sedation
a thick neck or reported difficulty with managing the patient’s airway; and significant comorbidities such as obstructive sleep apnea, cardiovascular disease, or obesity.
WRAP-UP Perioperative nurses are frequently called on to administer procedural sedation to patients undergoing surgical or other invasive procedures. With appropriate education and training, nurses can provide safe, effective sedation to alleviate patients’ pain and anxiety. Facilities that have a comprehensive procedural sedation policy for nurses help ensure that patients receive safe and effective sedation. Perioperative nurses should be educated and trained to administer procedural sedation until they are comfortable with this intervention, and they should be supported in this role by physicians and anesthesia professionals. When all of these factors are combined, patients will have good outcomes and procedural sedation experiences.
References 1. Jacques KG, Dewar A, Gray A, Kerslake D, Leal A, Lees F. Procedural sedation and analgesia in a large UK emergency department: factors associated with complications. Emerg Med J. 2011; 28(12):1036-1040. 2. Department of Health and Human Services Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-07 State Operations Provider Certification, Transmittal 74. Revised Appendix A, Interpretive Guidelines for Hospitals, 2011. http://www.cms.gov/ Regulations-and-Guidance/Guidance/Transmittals/downloads/R74 SOMA.pdf. Accessed October 23, 2014. 3. Conway A, Rolley J, Page K, Fulbrook P. Trends in nurseadministered procedural sedation and analgesia across cardiac catheterisation laboratories in Australia and New Zealand: results of an electronic survey. Aust Crit Care. 2014;27(1):4-10. 4. Thompson EM, Andrews DD, Christ-Libertin C. Efficacy and safety of procedural sedation and analgesia for burn wound care. J Burn Care Res. 2012;33(4):504-509. 5. Ketcham E, Ketcham C, Lopez Bushnell F. Patient safety and nurses’ role in procedural sedation. Emerg Nurse. 2013;21(6):20-24. 6. Sayfo S, Vakil KP, Alqaqa’a A, et al. A retrospective analysis of proceduralist-directed, nurse-administered propofol sedation for implantable cardioverter-defibrillator procedures. Heart Rhythm. 2012;9(3):342-346. 7. Caperelli-White L, Urman RD. Developing a moderate sedation policy: essential elements and evidence-based considerations. AORN J. 2014;99(3):416-430. 8. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017. http://journals.lww.com/anesthesiology/fulltext/ 2002/04000/practice_guidelines_for_sedation_and_analgesia_ by.31.aspx. Accessed October 1, 2014.
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Spruce 9. Sedation and Analgesia by Non-Anesthesiologists. American Society of Anesthesiologists. https://www.asahq.org/For-Healthcare -Professionals/Education-and-Events/Guidelines-for-Sedation-and -Analgesia-by-Non-Anesthesiologists.aspx. Accessed October 1, 2014. 10. Guideline for managing the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:553-562. 11. Tobin CD, Clark CA, McEvoy MD, et al. An approach to moderate sedation simulation training. Simul Healthc. 2013;8(2): 114-123. 12. World Health Organization. WHO Anesthesia Safety Checklist. http://www.who.int/surgery/publications/s15980e.pdf. Accessed October 1, 2014. 13. Strayer R, Andrus P. Procedural sedation checklist. Emergency Medicine Updates. http://emupdates.com/perm/PSAChecklist v2emupdates.com_print.pdf. Accessed October 1, 2014. 14. Nursing considerations for sedation. In: Urman RD, Kaye A, eds. Moderate and Deep Sedation in Clinical Practice. Cambridge, England: Cambridge UP; 2012:102-109.
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March 2015, Volume 101, No. 3 15. Ogg M. Patient monitoring during moderate sedation administration [Clinical Issues]. AORN J. 2012;95(4):541-543. 16. Jaffer A, Grant P. Assessing and managing pulmonary risk. In: Perioperative Medicine: Medical Consultation and Co-management. Hoboken, NJ: John Wiley & Sons; 2012:117.
Lisa Spruce, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR is the director, evidence-based perioperative practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a conflict of interest in the publication of this article.
Check back in May 2015 for the next “Back to Basics” topic: Infection Prevention.
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EXAMINATION
Continuing Education: Back to Basics: Procedural Sedation 0.8
www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge of best practices related to procedural sedation.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
The ability of nurses to administer procedural sedation is defined by which regulatory agencies? 1. each state’s board of medicine 2. the Centers for Medicare & Medicaid Services (CMS) 3. each state’s scope of practice laws 4. a facility’s accreditation agency a. 1 and 3 b. 2 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
2.
When creating policy for nurse-administered procedural sedation, a multidisciplinary team should 1. outline the RN’s role. 2. define the competency, credentialing, and education requirements. 3. base policy on published evidence. 4. identify elements for education and training. 5. determine when there is a need for anesthesia consultation. 6. identify medications that RNs are allowed to use. a. 1, 3, and 5 b. 2, 4, and 6 c. 1, 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
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3.
Capnography is an important aspect of patient monitoring, and nurses should be trained to monitor the patient’s end-tidal carbon dioxide (CO2) because capnography 1. is a real-time measurement of the patient’s CO2 exhalation. 2. provides a better indication of how well the patient is oxygenated. 3. could alert the nurse to respiratory compromise and hypoxemia sooner than a pulse oximetry reading. 4. alerts the nurse to the level of the patient’s pain. a. 1 and 2 b. 1, 2, and 3 c. 2 and 3 d. 1, 2, 3, and 4
4.
Checklists have been proven to be effective tools for patient safety and should be part of a procedural sedation policy. They can be developed using templates that can be adjusted as needed based on the facility, types of procedures performed, and types of medications given. a. true b. false
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5.
Which of the following criteria can the nurse use to determine if an anesthesia professional’s consultation is needed? 1. a history of opioid or other medication use that could interfere with sedative medications 2. past inability to tolerate sedation 3. limited neck motion, a thick neck, or reported difficulty with managing the patient’s airway
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4. allergic reactions to medications 5. significant comorbidities 6. inability of the patient to tolerate the position required to complete the procedure 7. unwillingness to undergo procedural sedation a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, 6, and 7
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LEARNER EVALUATION
Continuing Education: Back to Basics: Procedural Sedation 0.8
www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
8.
Our accrediting body requires that we verify the time you needed to complete the 0.8 continuing education contact hour (48-minute) program ____________________________________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High
3.
Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
5.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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AORN Journal j 353
Back to Basics: Procedural Sedation 0.8 www.aorn.org/CE
LISA SPRUCE, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #15509 Session: #0001 Fee: Members $6.40, Nonmembers $12.80 The contact hours for this article expire March 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to procedural sedation.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict of Interest Disclosures Lisa Spruce, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2014.09.011 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 345
Back to Basics: Procedural Sedation 0.8 www.aorn.org/CE
LISA SPRUCE, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR
ABSTRACT Patients undergoing surgery frequently receive procedural sedation from RNs in the perioperative setting. With appropriate training, perioperative RNs can administer procedural sedation safely and effectively, helping to eliminate the pain and anxiety often experienced by patients. Facility sedation protocols should provide guidance on training requirements, the RN’s role, the credentialing process, the medications the RN may use, and when anesthesia personnel should be consulted. Creating these protocols is guided by state scope of practice laws, Centers for Medicare & Medicaid Services Interpretive Guidelines, and accreditation requirements. Training, physician guidance, and appropriate protocols give the necessary support for perioperative nurses to provide safe and effective procedural sedation. AORN J 101 (March 2015) 346-350. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2014.09.011 Key words: procedural sedation, moderate sedation, anesthesia, analgesia.
http://dx.doi.org/10.1016/j.aorn.2014.09.011 ª AORN, Inc, 2015
346 j AORN Journal
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March 2015, Volume 101, No. 3
P
erioperative nurses frequently administer sedation to patients during surgical or other invasive procedures in which sedatives and analgesics are used to induce a state of relaxation that allows patients to tolerate procedures without losing consciousness or cardiac or respiratory function.1 This nursing role is defined by state scope of practice laws, the Centers for Medicare & Medicaid Services (CMS) Interpretive Guidelines,2 and a facility’s accreditation requirements. Perioperative nurses are ideal team members to administer procedural sedation because they free anesthesia professionals to administer deeper sedation and general anesthesia to other patients.
Perioperative nurses can administer procedural sedation effectively and safely. Conway et al3 conducted a survey in 2014 indicating that nurse-administered procedural sedation for percutaneous coronary interventions, pacemaker placement, vascular procedures, and pediatric procedures was routine in most hospitals in Australia and New Zealand. In this study, most nurses administered a combination of benzodiazepines (eg, diazepam, midazolam) and opioids (eg, morphine, fentanyl) but were not allowed to administer propofol. Additionally, most RNs surveyed indicated that when administering sedation, the nurses’ primary responsibility was monitoring the patient throughout the procedure. A study performed in the United States by Thompson et al4 investigated the safety and efficacy of nurse-administered sedation during procedures performed at a regional burn center. During a 12-month period, 328 patients who had experienced burns received nurse-administered procedural sedation 1,293 times. The majority of the patients received fentanyl and midazolam during the procedure. Ten adverse events occurred that involved respiratory complications, but no intubation was required. The researchers concluded that nurses who were competent in procedural sedation provided safe and effective sedation and management of pain during procedures in the burn center.4 Guidelines for sedation administration frequently recommend that nurses have no other duties while monitoring the patient, although there are no studies showing that performing other duties while also administering sedation results in poor outcomes for patients.3 When nurses have received the proper education and training in monitoring patients, they can identify early cardiac or pulmonary function impairment, prompting lifesaving rescue actions such as airway management and the use of sedation reversal medications.3 Ketcham et al5 conducted a literature review of patient outcomes related to nurse-administered sedation and concluded that the evidence
www.aornjournal.org
Back to Basics: Procedural Sedation
supports the practice of RNs administering sedation after receiving appropriate education and training and with direct supervision by physicians. They concluded that nurses can administer sedation to patients safely and effectively with no evidence of adverse patient outcomes.5 A 2012 prospective study by Sayfo et al6 reviewed proceduralist-directed nurse administration of propofol during the placement of implantable cardioverterdefibrillators in a tertiary care facility in the United States. Didactic education, advanced cardiac life support training, and a video were used to educate nurses regarding procedural sedation techniques. After receiving training, the nurses administered propofol and monitored patients throughout their procedures. There were 582 instances of nurse-administered propofol, and the researchers determined that there were acceptable rates of adverse events and manageable nonserious events when nurses administered propofol and monitored the patients.5 In the United States, the ability of nurses to administer propofol is determined by state scope of practice laws A complete listing of state laws and nursing scope of practice laws regarding nurseadministered procedural sedation can be found at https:// www.ena.org/government/State/Documents/RNProceduralSedation Rules.pdf. As always, nurses should verify this scope of practice information with their individual state boards of nursing to confirm that it is current.
HOW-TO GUIDE Caperelli-White and Urman7 published guidance on developing policies and protocols for facilities in which nurses administer procedural sedation and recommended forming a multidisciplinary team (eg, nurses, administrators, physicians, physician extenders, quality and patient safety officers, pharmacists) to contribute to policy and protocol development regarding nurses administering procedural sedation; outlining the RN’s role; defining the competency and education requirements for the clinical and administrative aspects of sedation; basing policy on published evidence; outlining essential elements, including o scope and purpose of the policy; o governance of the policy; o assignment of responsibility and roles; o state requirements for training, medication administration, and education; o competency and credentialing for practitioners; 8 o equipment needed for procedures ; AORN Journal j 347
Spruce
March 2015, Volume 101, No. 3
o
preprocedure patient evaluation requirements; o intraprocedural monitoring requirements; 8 o postprocedure patient evaluation and discharge criteria ; o postprocedure assessment of patient outcomes; and o documentation guidelines; identifying elements for education and training,9 including o knowledge of national guidelines such as the American Society of Anesthesiologists (ASA) Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists8 and AORN’s “Guidelines for managing the patient receiving moderate sedation/analgesia,”10 o informed consent for patients receiving sedation, o preprocedure patient assessment (eg, history and physical, lab work, and airway), 7 o ASA fasting guidelines, 7 o sedation levels, o pharmacology and safe administration of relevant sedatives and analgesics and reversal agents,7 o supplemental oxygen considerations, o airway assessment and management skills and oxygen delivery systems,8
“
either administer procedural sedation or supervise nurses and others who do. After the training was completed, all participants passed three of four modules on the first try and all but one passed the fourth module. All of the participants rated the simulation course as better than a course with lecture only.11 Checklists have been proven to be effective tools for patient safety and should be part of a procedural sedation policy.12,13 Checklists can be developed using templates and adjusted as needed based on the facility, types of procedures performed, and types of medications given.3 Nurses who administer sedation should have no other duties during the procedure and should ensure that the necessary equipment is present and working properly with audible alarms before the procedure. Examples of equipment14 include
cardiac monitor, pulse oximeter, oxygen, oral and nasal airways and endotracheal tubes,
Nurses who administer sedation should have no other duties during the procedure.
o
monitoring and documenting the patient’s physiologic vital signs (eg, blood pressure, respiratory rate, pulse oximetry reading, heart rate and rhythm, depth of sedation, capnography reading), o alarm recognition and significance, o common complications (hypoxemia) with interventions to counteract, o strong communication and skills in teamwork (ability to speak up), and o cardiopulmonary resuscitation (CPR) skills and advanced cardiovascular life support (ACLS); outlining the credentialing process; determining when there is a need for anesthesia consultation; and identifying medications that RNs are allowed to use during these procedures. Simulation coursework on sedation also should be considered. A 2013 report by Tobin et al11 described a successful course on moderate sedation and basic emergency procedures such as airway management for nonanesthesia physicians who
348 j AORN Journal
blood pressure monitor, capnography monitor, suction device, and emergency cart.
”
Capnography is an important aspect of patient monitoring, and nurses should be trained to monitor the patient’s end-tidal carbon dioxide (CO2). Capnography is a real-time measurement of the patient’s CO2 exhalation; it provides a better indication of how well the patient is oxygenated and could alert the nurse to respiratory compromise and hypoxemia sooner than a pulse oximetry reading.15 During the procedure, nurses should constantly monitor the patient for signs of complications, the most common being an obstructed airway or respiratory depression. At a minimum of every five minutes, the following should be documented13: medications administered; the patient’s o vital signs,
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capnography reading, pain level, o sedation level, o response to medication, and o amount of oxygen required; assessment of airway; and other observations (eg, IV fluids, communication with the patient). o
BENEFITS Patients who are undergoing minor procedures are often anxious and may be in pain. Administering procedural sedation helps to reduce patient anxiety and pain and allows the physician to complete the procedure with less difficulty. Nurse-administered sedation frees anesthesia professionals so they may attend to procedures requiring deep sedation or general anesthesia.
STRATEGIES FOR SUCCESS It is important to evaluate the patient before providing sedation. Recognized risk factors for patients undergoing sedation are advanced age and a high ASA classification score (https:// www.asahq.org/clinical/physicalstatus.htm). Patients who are older than 80 years of age require careful assessment and indepth informed consent discussions. One of the most important considerations in determining these patients’ pulmonary risks when receiving procedural sedation is their ASA score.16 The risk of developing a pulmonary complication is higher for patients with an ASA 2 classification compared with those with an ASA 1 classification.16 After an assessment and an informed consent discussion, a patient (or their family members or caregivers) must communicate that he or she understands what to expect, can tolerate the position required for the procedure, and understands the postprocedure instructions.15 Perioperative nurses who are administering procedural sedation must determine if a patient should undergo a consultation with an anesthesia professional. The nurse can use the following criteria when evaluating patients to determine if an anesthesia consultation is needed: a history of o opioid or other medication use that could interfere with sedative medications, o past inability to tolerate sedation, o allergic reactions to medications, and o limited neck motion; the inability of the patient to o tolerate the position required to complete the procedure, or o open his or her mouth widely; hemodynamic instability;
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Back to Basics: Procedural Sedation
a thick neck or reported difficulty with managing the patient’s airway; and significant comorbidities such as obstructive sleep apnea, cardiovascular disease, or obesity.
WRAP-UP Perioperative nurses are frequently called on to administer procedural sedation to patients undergoing surgical or other invasive procedures. With appropriate education and training, nurses can provide safe, effective sedation to alleviate patients’ pain and anxiety. Facilities that have a comprehensive procedural sedation policy for nurses help ensure that patients receive safe and effective sedation. Perioperative nurses should be educated and trained to administer procedural sedation until they are comfortable with this intervention, and they should be supported in this role by physicians and anesthesia professionals. When all of these factors are combined, patients will have good outcomes and procedural sedation experiences.
References 1. Jacques KG, Dewar A, Gray A, Kerslake D, Leal A, Lees F. Procedural sedation and analgesia in a large UK emergency department: factors associated with complications. Emerg Med J. 2011; 28(12):1036-1040. 2. Department of Health and Human Services Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-07 State Operations Provider Certification, Transmittal 74. Revised Appendix A, Interpretive Guidelines for Hospitals, 2011. http://www.cms.gov/ Regulations-and-Guidance/Guidance/Transmittals/downloads/R74 SOMA.pdf. Accessed October 23, 2014. 3. Conway A, Rolley J, Page K, Fulbrook P. Trends in nurseadministered procedural sedation and analgesia across cardiac catheterisation laboratories in Australia and New Zealand: results of an electronic survey. Aust Crit Care. 2014;27(1):4-10. 4. Thompson EM, Andrews DD, Christ-Libertin C. Efficacy and safety of procedural sedation and analgesia for burn wound care. J Burn Care Res. 2012;33(4):504-509. 5. Ketcham E, Ketcham C, Lopez Bushnell F. Patient safety and nurses’ role in procedural sedation. Emerg Nurse. 2013;21(6):20-24. 6. Sayfo S, Vakil KP, Alqaqa’a A, et al. A retrospective analysis of proceduralist-directed, nurse-administered propofol sedation for implantable cardioverter-defibrillator procedures. Heart Rhythm. 2012;9(3):342-346. 7. Caperelli-White L, Urman RD. Developing a moderate sedation policy: essential elements and evidence-based considerations. AORN J. 2014;99(3):416-430. 8. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017. http://journals.lww.com/anesthesiology/fulltext/ 2002/04000/practice_guidelines_for_sedation_and_analgesia_ by.31.aspx. Accessed October 1, 2014.
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Spruce 9. Sedation and Analgesia by Non-Anesthesiologists. American Society of Anesthesiologists. https://www.asahq.org/For-Healthcare -Professionals/Education-and-Events/Guidelines-for-Sedation-and -Analgesia-by-Non-Anesthesiologists.aspx. Accessed October 1, 2014. 10. Guideline for managing the patient receiving moderate sedation/ analgesia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:553-562. 11. Tobin CD, Clark CA, McEvoy MD, et al. An approach to moderate sedation simulation training. Simul Healthc. 2013;8(2): 114-123. 12. World Health Organization. WHO Anesthesia Safety Checklist. http://www.who.int/surgery/publications/s15980e.pdf. Accessed October 1, 2014. 13. Strayer R, Andrus P. Procedural sedation checklist. Emergency Medicine Updates. http://emupdates.com/perm/PSAChecklist v2emupdates.com_print.pdf. Accessed October 1, 2014. 14. Nursing considerations for sedation. In: Urman RD, Kaye A, eds. Moderate and Deep Sedation in Clinical Practice. Cambridge, England: Cambridge UP; 2012:102-109.
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March 2015, Volume 101, No. 3 15. Ogg M. Patient monitoring during moderate sedation administration [Clinical Issues]. AORN J. 2012;95(4):541-543. 16. Jaffer A, Grant P. Assessing and managing pulmonary risk. In: Perioperative Medicine: Medical Consultation and Co-management. Hoboken, NJ: John Wiley & Sons; 2012:117.
Lisa Spruce, DNP, RN, CNS-CP, ACNS, ACNP, ANP, CNOR is the director, evidence-based perioperative practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a conflict of interest in the publication of this article.
Check back in May 2015 for the next “Back to Basics” topic: Infection Prevention.
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EXAMINATION
Continuing Education: Back to Basics: Procedural Sedation 0.8
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PURPOSE/GOAL To provide the learner with knowledge of best practices related to procedural sedation.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
The ability of nurses to administer procedural sedation is defined by which regulatory agencies? 1. each state’s board of medicine 2. the Centers for Medicare & Medicaid Services (CMS) 3. each state’s scope of practice laws 4. a facility’s accreditation agency a. 1 and 3 b. 2 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
2.
When creating policy for nurse-administered procedural sedation, a multidisciplinary team should 1. outline the RN’s role. 2. define the competency, credentialing, and education requirements. 3. base policy on published evidence. 4. identify elements for education and training. 5. determine when there is a need for anesthesia consultation. 6. identify medications that RNs are allowed to use. a. 1, 3, and 5 b. 2, 4, and 6 c. 1, 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
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3.
Capnography is an important aspect of patient monitoring, and nurses should be trained to monitor the patient’s end-tidal carbon dioxide (CO2) because capnography 1. is a real-time measurement of the patient’s CO2 exhalation. 2. provides a better indication of how well the patient is oxygenated. 3. could alert the nurse to respiratory compromise and hypoxemia sooner than a pulse oximetry reading. 4. alerts the nurse to the level of the patient’s pain. a. 1 and 2 b. 1, 2, and 3 c. 2 and 3 d. 1, 2, 3, and 4
4.
Checklists have been proven to be effective tools for patient safety and should be part of a procedural sedation policy. They can be developed using templates that can be adjusted as needed based on the facility, types of procedures performed, and types of medications given. a. true b. false
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5.
Which of the following criteria can the nurse use to determine if an anesthesia professional’s consultation is needed? 1. a history of opioid or other medication use that could interfere with sedative medications 2. past inability to tolerate sedation 3. limited neck motion, a thick neck, or reported difficulty with managing the patient’s airway
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4. allergic reactions to medications 5. significant comorbidities 6. inability of the patient to tolerate the position required to complete the procedure 7. unwillingness to undergo procedural sedation a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, 6, and 7
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LEARNER EVALUATION
Continuing Education: Back to Basics: Procedural Sedation 0.8
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T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
8.
Our accrediting body requires that we verify the time you needed to complete the 0.8 continuing education contact hour (48-minute) program ____________________________________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High
3.
Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
5.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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