POLICY: Conscious Sedation I. General Statement of Policy: University Hospitals and Clinics provides guidelines for monitoring conscious sedation administered to patients undergoing invasive, manipulative or constraining procedures. Definition of Conscious Sedation: Conscious sedation is defined as a medically controlled state that does not normally lead to a loss of* protective reflexes for the purpose of providing relaxation, amnesia and/or control of pain during a diagnostic and surgical procedures (especially endoscopy, closed reductions of fractures and many radiology procedures). *The ability to independently maintain a patent airway and respond appropriately to physical stimulation and verbal commands are important distinguishing features of conscious sedation. II. Scope: Medical Staff Registered Nurses III. Administration: Medical Faculty Director of Nursing Adults Pediatrics Head Nurses Adults Pediatrics Staff Registered Nurses I. Policy: A. Conscious sedation cannot be given without an order from the attending or consulting physician/dentist. B. Conscious sedation may be used outside of the OR in diagnostic and surgical procedures where general anesthesia is not required. C. The physician(s)/dentist(s) will review the need for conscious sedation using information gathered by the completion of a history and physical PE1 examination. D. The physician/dentist will review and discuss with the patient, guardian, and/or significant other about the risks, options and potential complications involved in the procedure and document that informed consent was obtained prior to the procedure. E. All patients receiving conscious sedation will be appropriately monitored by a RN/physician from the time of administration of sedation until discharge criteria has been met. F. All documentation for patients receiving conscious sedation will be done on the approved Conscious Sedation Record. Exceptions: SICU, PACU, MICU, CCU, NSICU, PICU, and NICU will document on the unit flow sheet. G. The department in which the patient receives conscious sedation as well as the department where the procedure is done shall have the following: EQUIPMENT LIST (Adult and Pediatric as appropriate) Emergency cart and Defibrillator Suction at bedside Positive pressure breathing device ( manual resuscitator) Oxygen and delivery devices (nasal cannula, face mask) Appropriate oral and nasal airways Cardiac monitor, including blood pressure measuring apparatus Pulse oximeter Incubation Equipment (with laryngoscope checked regularly) Reversal agents naloxone (Narcan) and flunazenil (Mazicon) IV supplies H. Minimum personnel during the procedure shall be two qualified professionals with one patient. The care of all patients receiving conscious sedation will be supervised by a physician/dentist accredited both for the specific procedure and conscious sedation. The RN (trained in conscious sedation) managing the care of the patient receiving conscious sedation shall have no other responsibilities that would leave the patient unattended or compromise continuous monitoring. I.The plans of care shall be developed and documented in the patient's medical record before the procedure is performed. There shall be written documentation of all aspects of care rendered to the patient inclusive of but not limited to teaching/education and referrals. J. Procedure: 1. Conscious sedation practices throughout University Hospitals and Clinics shall be monitored and evaluated by the Department of Anesthesiology according to the policy outline and performed in such a way as to assure optimal patient outcome. 2. The Chairperson of each department administering conscious sedation shall be responsible for ensuring that this policy and procedure is followed. 3. All conscious sedation will be ordered and supervised by a physician/dentist accredited for both the specific procedure and conscious sedation. 4. The professional/Unit responsible for monitoring/management of patients receiving conscious sedation will complete a post procedure monitoring form for each patient and forward to the Department of Anesthesia at the end of each month. Finding will be reported at the Perioperative Committee Meeting. SEE ATTACHMENT (A) CONSCIOUS SEDATION MONITOR FORM A. Preprocedure All patients receiving IV conscious sedation should have intravenous access. For patients who have received sedation by non-invasive route, determination of the need for intravenous access will be made on a case by case basis. Skilled personnel should be available if need arises. All patients requiring conscious sedation will have a preprocedure assessment, including, but not limited to: History an physical examination performed by a physician/dentist which should include past medical history, present medical history, drug history, previous anesthesia experience, (including any history of adverse or allergic drug reactions to anesthesia or sedation), current medications and assignment of American Society of Anesthesiologists Physical Status (ASA) and Aldrete Score. American Society of Anesthesiology Patient Classification Status ASA Classification Medical Description of Patient Comments ASA I No known systemic disease May have conscious sedation without other consultation ASA II Mild or well controlled systemic disease(s) ASA III Multiple or moderate systemic Consider Medical systemic disease(s) Consultation ASA IV Poorly controlled systemic Consider Medical Disease(s) Anesthesiology Department ASA V Moribund Patient E Connotes emergency SEE ATTACHMENT (B) CONSCIOUS SEDATION RECORD Vital Signs: Heart rate, blood pressure, respiratory rate, oxygen saturation and temperature. Level of consciousness and responsiveness. NPO Status for 4 hours unless otherwise instructed by physician/dentist. Proper documentation of informed consent prior to conscious sedation/procedure. Pregnancy test (if question of pregnancy). Relevant pre-procedure laboratory/radiology assessment, as well as assessment of emotional, developmental age, psychological and safety needs of the patient. F. Intraprocedure All patients will have continuous monitoring and data recording from initiation of conscious sedation to the completion of procedure including, but not limited to: 1. Vital Signs: Heart rate, blood pressure, respirations; a minimum of every 15 minutes. 2. Level of consciousness and responsiveness. 3. EKG (If hx of hypertension, cardiovascular disease of dysrrhythmia). 4. Oxygenation: continuous oxygen saturation, a minimum of every 15 minutes. 5. Medications given (note - site, time, drug, and dose), including oxygen therapy in 1/min. and means of delivery. FOR APPROVED MEDICATIONS AND REVERSAL AGENTS FOR CONSCIOUS SEDATION, SEE ATTACHMENT (c) MEDICATION CHART If an adverse drug reaction occurs the RN will notify the attending physician and implement orders. An adverse reaction form will be sent to the Pharmacy. F. Postprocedure 1. Inpatients a. Admission and Transfer Orders Must Be Written. b. Staffing is based on patient acuity, census and physical facility. c. The physician/dentist will write a transfer order according to numerical scale if used of discharge criteria. d. Monitoring and documentation in the recovery unit. 1. Pulse oximetry, continuously until discharge. 2. Vital signs monitored and recorded at least every 15 minutes X 4, or until discharge criteria has been met. 3. Blood pressure 4. Heart rate 5. Respiration rate and airway patency 6. Level of consciousness and responsiveness 7. Body temperature (as appropriate) e. If the patient receives a reversal agent. 1. The patient should be continually observed for 1.5 hours longer for return of respiratory depression prior to transfer. 2. The patient may be transferred to the receiving unit when the following discharge criteria have been met. 3. Temperature above 97(ax) or below 100(ax) and approaching normal. 4. Blood Pressure within 15% of normal or pre-sedation value. 5. Pulse not below 60 or above 100 (except where pre-sedation values are below 60 or above 100). 6. Respirations not below 12 or above 30. 7. Patient is awake, can call for assistance, and is oriented if so disposed prior to sedation. Post Sedation Aldrete score of 7-10 (considering baseline). An RN or LPN may assume care of the patient with a normal patient load when discharge criteria have been met. A report will be given to the receiving nurse or unit consisting of: 1. Preprocedure history 2. Intraprocedure factors, including total medication given. 3. Postprocedure instructions. 4. Any additional and special care needs. 1. Outpatients a. Staffing is based on patient acuity, census and physical facility. b. A report will be given to the nurse or unit consisting of: 1. Preprocedure history 2. Intraprocedure factors, as above 3. Postprocedure recovery factors 4. Postprocedure instructions 5. Any additional test and special care needs a. Monitoring and documentation 1. Vital signs and oxygen saturations initially every 30 minutes until discharge to a responsible adult. 2. Monitor surgical site, if applicable 3. Administer medication as ordered, record results 4. Level of consciousness 5. Provide for safety 6. Provide for confidentially of information and records 7. Encourage fluids by mouth, if not contraindicated 8. Ambulate with assistance, if not contraindicated 9. Position patient gradually from supine to Fowler's position, if not contraindicated a. Discharge The patient may be discharged home when the following discharge criteria have been met: 1. Discharge orders must be written 2. Vital signs are stable for 30 minutes within 20% of preprocedure value 3. Patient is awake, and is oriented if so disposed prior to sedation 4. Able to ambulate unless inappropriate for age or condition 5. No signs or symptoms that may jeopardize the safety of recovery (e.g., bleeding, swelling, extreme pain) 6. No evidence of nausea, vomiting or dizziness 7. Void as indicated by procedure (gynecologic, urologic) 8. Tolerating clear liquids unless otherwise indicated 9. Review discharge planning with patient, family/accompanying responsible adult as appropriate; providing written home care instructions 10.Provide follow-up for extended care as indicated: Next day follow-up phone call is recommended to evaluate status. Provide 24-hour call back number.