Administrative Policies and Procedures

Transcription

1 Administrative Policies and Procedures Originating Venue: Provision of Care, Treatment and Services Policy No.: PC 2908 Title: Sedation and Anesthesia Policy Cross Reference: IC 2300 Date Issued: 05/09 Date Reviewed: 04/11, 8/16, 5/17, 04/18 Date: Revised: 04/14, 8/16, 5/17, 04/18 Attachment: None Page 1 of 7 PURPOSE: The purpose of this policy is to provide guidelines for patient management of all procedures requiring the use of sedation throughout the facility. DEFINITION: Sedation is produced by the administration of pharmacologic agents. The patient under sedation has a depressed level of consciousness, but retains the ability to maintain a patent airway independently and continuously, and respond purposefully to physical stimulation and/or command. The following are definitions of the sedation and anesthesia: 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. Deep sedation/analgesia:(monitored Anesthesia Care) A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. POLICY: Only anesthesiologists who are trained and proven competent in professional standards and techniques to administer pharmacologic agents to predictably achieve desired levels of sedation and to monitor patients carefully in order to maintain them at the desired level of sedation, and (when necessary) to rescue them from deeper than desired levels of sedation, will provide sedation. A pre-sedation assessment is performed and documented in the medical record for each patient before administering moderate or deep sedation.

2 Page 2 of 7 The patient will be re-evaluated immediately before receiving anesthesia. A sufficient number of qualified staff is present to evaluate the patient, to provide the sedation and/or anesthesia, to help with the procedure, and to monitor and recover the patient. The ordering anesthesiologist will review the risks, options and benefits of the selected agents with the patient or their representative, and document the patient, or representative s informed consent in the chart. Documentation may consist of a written note in the chart by the anesthesiologist. A pre-sedation plan of care will be documented by the anesthesiologist in the patient s medical record prior to administration of sedation. The organization assesses the patient s anticipated needs in order to plan for the post-procedure care. The anesthesiologist administering sedation must have privileges for clinical administration of this category of drugs, with these individuals at a minimum receiving competency-based education, training and experience in evaluating patients before performing moderate or deep sedation and anesthesia, and administering the sedation/anesthesia. The anesthesiologist administering moderate sedation must have the appropriate privileges and be qualified to rescue patients from deep sedation, and must be competent to manage a compromised airway and to provide adequate oxygenation and ventilation. Patients requiring moderate sedation and who meet the criteria for patient selection will be monitored by an anesthesiologist. Monitoring will include: Physical assessment Blood pressure Heart rate Respirations (frequency and volume) Oxygen saturation/co2 monitoring Cardiac monitoring Skin color The patient will be continuously monitored and reassessment will be documented every five (5) minutes until the procedure is completed. Emergency resuscitation equipment will be readily available. Patient Selection: Candidates for moderate sedation are those patients who must undergo painful or difficult procedures where cooperation and/or comfort will be difficult or impossible without pharmacologic support. Patients must be screened for potential risk factors for any pharmacologic agents selected. This decision on which agent to use must be based on the goals of sedation, type of procedure and condition and age of the patient.

3 Page 3 of 7 Patients will be screened by the ordering physician and anesthesiologist for risk factors utilizing the American Society of Anesthesiology (ASA) Physical Status Classification. For an EGD, BMI greater than 41 will be performed at the hospital. For a colonoscopy, BMI greater than 43 will be performed at the hospital. Any BMI outside these ranges will be discussed individually and reviewed by the Gastroenterologist and Anesthesiologist to make a determination on proceeding. For the Urology Division, patients with a BMI greater than 40 will be done at the hospital unless evaluated and approved by the Director of Anesthesia. ASA (American Society of Anesthesiology) PHYSICAL STATUS CLASSIFICATION: Class I No organic, physiologic, biochemical or psychiatric disturbance. Normal, healthy patient. Class II Mid-moderate systemic disturbance; may or may not be related to reason for surgery. (Examples: hypertension, diabetes mellitus) Class III Severe systemic disturbance. (Examples: heart disease, poorly controlled hypertension) Class IV Life threatening systemic disturbance. (Examples: congestive heart failure, persistent angina pectoris) Class V Moribund patient. Little chance for survival. Surgery is last resort. (Examples: uncontrolled bleeding, ruptured abdominal aortic aneurysm) Class E Patient requires emergency procedure. (Examples: appendectomy, D&C for uncontrolled bleeding) Equipment Needed: Oxygen and nasal cannula/co2 monitor Suction Emergency crash cart with defibrillator/aed Cardiac monitor Pulse oximeter Blood pressure monitor Pre-procedure Monitoring: Physical and baseline assessment parameters include, but are not limited to: Mental status Vital signs

4 Page 4 of 7 Skin color and condition Sensory defects Current medications and drug allergies Relevant medical surgical history including history of substance abuse Patient perceptions regarding procedure and moderate and deep sedation Pregnancy test/waiver status IV access is established for all patients anticipating sedation. Fluid type and rate as ordered. Equipment and supplies sufficient to meet the needs of the anticipated patient load at each procedural site shall be available at all times. Supplemental oxygen is administered as necessary. A time out will be verbally performed prior to the start of the procedure with the physician, nurse, and anesthesiologist while patient awake and all in agreement. Time out will consist of verifying: Patient Name Patient DOB Type of procedure Consents signed and witnessed (procedure consent and anesthesia consent) Allergies Pregnancy test/waiver status Intra-procedural Monitoring: Patient is continually reassessed throughout the procedure. Vital signs (EKG, oxygen saturation/co2, heart rate and blood pressure) are recorded every five (5) minutes. Respiratory frequency and adequacy of pulmonary ventilation are monitored throughout the procedure. Verbal reassurance to patient frequently throughout the procedure. Untoward reactions or sudden/significant changes in monitoring parameters should be immediately reported to the anesthesiologist and treating physician.

5 Page 5 of 7 Post procedure Monitoring and Discharge Criteria: Documentation of the Aldrete score will be completed prior to patient discharge. The score must return to the baseline assessment before the patient may be released from the procedure area. A baseline Aldrete score for complete recovery is needed before discharge. Evidence that patient has met discharge criteria must be clearly documented in the medical record. Aldrete scoring is as follows: Activity: Muscle activity is assessed by observing the ability of the patient to move his/her extremities spontaneously or on command. 2 - Able to move 4 extremities 1 - Able to move 2 extremities 0 - Not able to control any extremity Respiration: Respiratory efficiency evaluated in a form that permits accurate and objective assessment without complicated physical tests. 2 - Able to breathe deeply and cough 1 - Limited respiratory effort (dyspnea or splinting) 0 - No spontaneous respiratory effort Circulation: Use changes of arterial blood pressure from pre-anesthetic level. 2 - Systolic arterial pressure between plus or minus 20% of pre-anesthetic level (Riva- Rocci method) 1 - Systolic arterial pressure between plus or minus 20% to 50% of pre-anesthetic level 0 - Systolic arterial pressure between plus or minus 51% or more of pre-anesthetic level

6 Page 6 of 7 Consciousness: Determination of the patient's level of consciousness. 2 - Full alertness seen in patient's ability to answer questions and acknowledge his/her location 1 - Aroused when called by name 0 - Failure to elicit a response upon auditory stimulation Physical stimulation should not be considered reliable as even a decerebrated patient might react to it. Reflex withdrawal from a painful stimulus is not considered a purposeful response. Oxygen Saturation: This is an objective sign that is sometimes difficult to recognize, and includes confusion, decreased O 2 saturation noted on pulse oximeter. 2 Sp02 greater than 92% on room air 1 Supplemental O2 required to maintain Sp02 greater than 90% 0 Sp02 less than 92% with O2 supplementation All outpatients who receive sedation for any procedure must be observed and monitored for a minimum of 30 minutes prior to being discharged home. Vital signs (heart rate, respiratory rate and blood pressure) are recorded on admission to the recovery area, 15 minutes following and at discharge. Discharge Home: Medical staff approved discharge criteria includes: Meets baseline Aldrete score Anesthesiologist/Licensed Healthcare Provider will sign out patient for discharge Ability to ambulate consistent with baseline assessment Ability to retain oral fluid Pain assessed and physician notified if pain is present Ability of patient and home care provider to understand all home care instructions

7 Page 7 of 7 Written discharge instructions given to patient/family along with pertinent patient (family teaching.) Concurrence with prearrangements for safe transportation including discharge to the care of a responsible adult. The patient may not drive themselves home. Date Policy to be reviewed: 04/20