Moderate Sedation Core Competency Course 2012

Transcription

1 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 & consent requirements as defined by MCP 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 1

2 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 mock moderate sedation check off 2

3 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 3

4 Fellow and Senior Residents 3 rd 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 4

5 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 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 Shiley Surgical Suite: 3 rd floor 5

6 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 6

7 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. (UCSD Medial Center MCP /12) 7

8 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 /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 /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 8

9 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 /12) Indications for Moderate Sedation Administering sedative or narcotics for procedures 9

10 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 Clinical Nurse Specialist/Educators 10

11 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 Intestinal obstruction 11

12 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 Consent MCP 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 Court appointed surrogate decision maker 12

13 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 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 13

14 Witness for Consent per MCP 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 Same-day pre-procedure assessment 14

15 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 untoward event occurs. 15

16 Intra-Procedure Documentation Sedation Procedure Record EPIC Intra-Procedure and Recovery Vital Signs Continuous Cardiac monitoring (post strip) Every 5 minutes: HR RR BP Sp02 LOC every 15 minutes 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 16

17 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 LEAST 30 minutes after the last dose of intravenous medication Monitor for at LEAST 90 minutes after the last transmucosal or intramuscular medication If reversal agents used, must monitor for 90 minutes after last reversal agent administration 17

18 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 18

19 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 19

20 References UCSD Medical Center MCP (revised 04/2012) UCSD Medical Center MCP (Aug 2011) University HealthSystem Consortium (2005). Moderate Sedation Best Practice Recommendations. Oakbrook, IL. 20