Vol. 14 •Issue 10 • Page 7
Will Your Conscious Sedation Training Meet JCAHO Codes?
By Margaret Clark, BS, RN, RRT
About 21.3 percent of all therapists participate in conscious sedation, with nearly half (46.8 percent) reporting involvement in bronchoscopy procedures, according to the AARC 2000 Human Resource Study. JCAHO requires practitioners administering conscious sedation to be competent and that proper policies, procedures and/or guidelines be established for patient safety.
Basically the question is how up to date on conscious sedation training are you?
By definition, conscious sedation is the induction of a minimally depressed level of consciousness that permits individuals to retain their protective reflexes, i.e. a patent airway and continuous and independent vital signs.
Individuals receiving conscious sedation should be able to respond to external stimuli including verbal commands and tactile stimulation. It is sometimes easier to say what conscious sedation is not. It is not pre-procedure medication, post operative pain analgesia, local anesthesia or deep sedation usually referred to as general anesthesia.
The American Society of Anesthesiology has published very specific practice guidelines for sedation and analgesia by non-anesthesiologists. These guidelines are a good resources when reviewing your policies and procedures.
Administration of conscious sedation is usually done by a nurse or a physician. However, depending on your state licensure law, a trained RCP may be permitted to give the medication under the direct supervision of a physician. Training programs vary from state-mandated certification courses to facility-specific competency evaluations. As a minimum, any practitioner administering conscious sedation should have a clear understanding of proper IV management, the medications involved and resuscitation procedures.
ACLS will not guarantee competency in this latter recommendation, but it is probably a good idea. The facility should also have a clear-cut policy and procedure under which the conscious sedation should be administered. This policy should state how the medication is to be accounted for, recommended routes of administration and dosages, indications, contraindications, interactions and side effects of the medications, patient monitoring and safety equipment that is required to be on hand.
Many facilities will not permit the administration of conscious sedation unless IV access has been established. As a minimum, there is usually a hep lock in place. This will provide access for a caregiver to administer the conscious sedation and will permit the rapid administration of reversing agents and resuscitation medication if necessary. IV access, however, is a matter of policy and patient need.
Most RCPs get involved in conscious sedation during a bronchoscopy. Generally therapists are not part of the decision-making process as to who should or shouldn’t be bronched. But there are contraindications for conscious sedation of which RCPs should be aware.
RCPs need to use caution when working with individuals who are hemodynamically, cardiovasculalry or in some way medically unstable; have a history of seizures; are pregnant; or may be under the influence of or have a history of alcohol and/or substance abuse. A complete pre-procedure assessment will usually uncover these contraindications.
While RCPs may not have any input into the decision process, they certainly can speak up and bring these conditions to the physician’s attention and determine whether additional monitoring or assistance to safely perform the procedure will be required.
RCPs usually leave the informed consent process to nursing, but we should be sure that consent is signed before any medications are administered. In the case of an outpatient bronchosopy, this can be tricky. Many times, we begin to administer an aerosol and prep the patient before the nurse arrives.
In a best-case scenario, the physician will have completed a pre-procedure history and physical as well as an examination and the informed consent form will be signed before the procedure is started. Pre-procedure assessment should include as a minimum the patient’s diagnosis, current medications, allergies, history of adverse reactions to anesthesia if any, vital signs including temperature, pulse, BP, respiratory rate, oxygen saturation, the individual’s level of consciousness and whether they are appropriate NPO status, pregnancy status and any history of alcohol or drug abuse. Laboratory values are nice to have on hand if available. Practitioners should note the individual’s hematocrit and clotting time in the event bleeding occurs.
Documentation is critical. If more than one record is being kept, caregivers should be careful to synchronize times. From both a patient safety and a legal perspective, it is essential that times on the patient’s flow sheet match the MAR, vital sign report, etc.
Vital signs should be documented prior to the administration of any medications and as a minimum every five to15 minutes after the administration as needed. In addition, caregivers should keep note of the medications administered, the dose, route, time of administration and patient response (became sleepy, pulse ox remained at 97 percent, etc.).
Many times RCPs forget to document the patent was using a nasal cannula prior to the bronchosopy. Remember oxygen is a drug too. It is also important to document the patient’s IV fluids infused. The subject of documentation brings up the point of responsibility.
One individual should be designated to monitor the patient throughout the procedure. It is difficult for a single practitioner to administer medication, assist with the procedure (biopsies, washes, etc) and adequately monitor the patients. For safety’s sake, adequate staffing is essential.
CATEGORIES OF DRUGS
There are basically two categories of medications likely to be used for conscious sedation: benzodiazepines and narcotics.
Drugs from either category can be effective, depending on the patient and the procedure. However, if classes are used together, practitioners should be aware that these medications could cause respiratory and/or cardiovascular depression and hemodynamic collapse.
Reversing agents for these medications should always be on hand. Flumazenil can reverse the effects of benzodiazepines. Naloxone hydrochloride and naltrexone are reversing agents for narcotics. In addition, emergency cardiovascular drugs should be available as should be a defibrillator, monitor and full resuscitation equipment.
Conscious sedation is always a hot topic with JCAHO, and it should be because caregivers are altering a person’s consciousness and usually undertaking an invasive procedure outside of a surgical setting. RCPs provide a vital active role in these procedures and should continue to do so. All it takes is training and good documentation. n
Margaret Clark is the clinical coodinator at Boston Medical Center.
Does Your Conscious Sedation Policy Meet JCAHO Requirements?
1. Do you have a written Policy and Procedure that clearly defines the roles and responsibilities of practitioners involved in the administration/monitoring of conscious sedation?
2. Have you provided training that addresses documentation, medications, monitoring, emergency procedures, patient safety and outcomes?
3. Have you assessed and documented the competency of all individuals administering these agents and monitoring these patients. Is this competency assessment ongoing?
4. Have you reviewed your documentation procedures to ensure the required patient and procedural data are being recorded? Is there a plan in place to address/correct documentation problems identified? (For example: are vital signs being documented every 5-15 minutes?)
5. Are there adequate safety equipment/supplies available and have all practitioners received training on safety equipment and emergency response techniques? Has this been documented?