Objectives. Regulatory Agencies 8/30/2016. Joint Commission CMS (Center for Medicare & Medicaid Services) State Boards of Health

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1 Susan Nuccio, MSN, RN, ACNS BC, CGRN Objectives 1. List Current regulatory requirements related to moderate sedation 2. Identify specific patient populations that are at risk for complications during moderate sedation 3. Discuss various resources for you related to sedation and nursing practice. Regulatory Agencies Joint Commission CMS (Center for Medicare & Medicaid CMS (Center for Medicare & Medicaid Services) State Boards of Health 1

2 Joint Commission Standards Patient Care Chapter: Provision of Care, Treatment and Services PC The planning of the procedure Qualified individuals, sufficient number to provide the sedation, monitor and recover RN supervises perioperative care Proper equipment to monitor Equipment to administer IV, medications, blood and blood components Resuscitation equipment available Joint Commission Standards PC Care before initiating sedation Presedation patient assessment is completed Assessment of anticipated needs for post procedure care Preprocedural treatment and services are provided Preprocedural education A licensed independent practitioner plans or concurs with the plan for sedation Reevaluated the patient immediately before administering sedation Evaluation is completed and document by an individual qualified to administer sedation prior to a procedure Joint Commission Standards PC Monitoring Required monitoring of oxygenation, ventilation and circulation are monitored continuously 2

3 Joint Commission Standards PC Care provided after sedation Assesses physiological status immediately after the procedure Monitors physiological i l status, mental status and pain level at a frequency and intensity consistent with the potential risk LIP discharges the patient from the recovery area, or patients are discharge according to approved criteria Patients are discharge in the company of an individual who accepts responsibility for the patient CMS Standards Follow the Joint Commission standards and are concerned for patient safety but have financial implications for the organization as well State Boards of Health Govern the scope of practice Protect the health of the population Create policy Advise local communities 3

4 Professional Organizations Society of Gastrointestinal Nurses and Associates SGNA American Critical Care Nurse ACCN American Operating Room Nurses AORN American Nurses Association ANA American Society for Gastrointestinal Endoscopy ASGE SGNA Standards and Guidelines Standards of Clinical Nursing Practice and Role Delineation Statements (2014) Guidelines for Documentation in the Gastrointestinal Endoscopy Setting (2013) Statement on the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting (2013) Minimum Registered Nurse Staffing for Patient Care in the Gastrointestinal Endoscopy Unit (2012) Goals of Sedation Management Physiological stability Comfort Patient s safety 4

5 Changing Needs for Sedation Reduce pain and anxiety while awake Moving toward Pain free and inability to feel anything What we Want to Avoid Reference for cardiopulmonary Complications 5

6 Risk Reduction for Patients Assessment of the patient Medical history and physical exam Previous experience with sedation and analgesia Current medications i Potential drug interactions Time and nature of last oral intake Hx of tobacco, ETOH or substance abuse Air way evaluation ASA classification Herbs and Sedation Other effect: Interferes with liver metabolism Ehi Echinacea Cardiac Arrhythmias Ephedra sinica Hypertension Licorice Increases sedative effect Valerian St. Johns wart Kava May increase bleeding Garlic Gingko biloba Feverfew Identifying Risk Factors For Adverse Events Comprehensive literature done yielding 2000 articles 106 were relevant regarding risk factors Summary o f factors predictive of cardiopulmonary events Are: Age ASA Inpatient Setting (inpatient versus outpatient) Trainee involvement Supplemental oxygen Pulmonary Disease Cardia Disease Obesity 6

7 High Risk Patient Population Obese Elderly Sleep Apnea Elderly Considerations Aging is associated with progressive decreases (1 1.5%) in function of major organ systems after age 30 Reduced cardiac output requires more patience with administration of medication Arthritis may limit range of motion and difficult airway management Loss of bony structure in the aged may make it difficult to resuscitate Modifications in endoscopic practice for the elderly. Gastrointestinal Endoscopy. 2006;63(4): Increase in body fat, Decrease in lean body mass Prolonged effects of medication Medications will bind with the fat deposits Takes longer to eliminate from the system 7

8 Start low and Go slow Medications take effect more slowly, peak later, last longer and cause more respiratory and cardiovascular effects Other considerations Total body water content Lower water content in elderly Higher peak concentration than expected Changes in protein levels May lead to delayed onset on medication Exaggerating effects Waiting for effect before administering additional meds Respiratory and cardiovascular changes Weaker airway protective reflexes Decrease pulmonary and cardio reserve Higher risk for respiratory depression and arrhythmias Obstructive Sleep Apnea Disorder of the upper airway at the level of the pharynx Episodes of apnea Sensitive to the respiratory depressant effect associated itd with the administration of CNS depressants More common in obese patients Periods of 10 second or more of total cessation of air flow (confirmed with sleep study Floppy airway Fat deposition in lateral pharyngeal walls Inherent narrowing of airway 8

9 Incidence of Risk for Sleep Obstructed Apnea Research published in Journal of the American Board of Family Medicine, March April 2011 Multiple findings: 30 40% have risk 20% report sleep symptoms 1/3 or reported symptoms get documented Multisystem Effects of Obesity Pulmonary Cardiovascular Gastrointestinal Increased chest wall mass Increased cardiac output Increased intraabdominal pressure Increased CO2 production Hypertension Increased intragastric pressure Decreased functional residual capacity Decreased pulmonary compliance Increased total oxygen consumption Increased work of breathing Pulmonary hypertension Increased stroke volume Increased risk of aspiration Risks of Aspiration Obesity Ascites Nausea/vomiting Food or fluid intake Dysphagia Mechanical disruption of usual defense barriers N/G tube Tracheostomy ET tube Upper endoscopy Bronchoscopy 9

10 Caregiver Risks Competency Expectation Policy Adherence Professional Standards Knowledge Competency Considerations Documentation of orientation and competency Annual education/competency is ideal Continuing education for staff Communication between ordering provider and nurse Recognition of a compromised airway Titration of medications Policy Adherence Knowledge of your organization s policy Documentation requirements Adherence to reportable events steps 10

11 Mistakes to avoid Performing sedation on a patient that is a poor candidate due to co morbidities Not checking the medication concentration Not labeling bli syringes Not having necessary airway equipment at the bedside Pushing medications too quickly Mistakes to avoid Continuing to give sedation despite some evidence of respiratory compromise Not knowing when to stop Not fully monitoring i the patient post procedures Not monitoring a patient sufficient time after use of a reversal agent Professional Standards Knowledge Resources Society of Gastrointestinal Nurses and Associates (SGNA) American Society of Anesthesiologists (ASA) American Association of Critical Care Nurses (AACN) Emergency Nurses Association (ENA) American society of Gastrointestinal Endoscopy (ASGE) American Association of Operating room Nurses (AORN) 11

12 Professional Resources Society of Gastrointestianl Nurses and Associates (SGNA) American Society of Anesthesiologists (ASA) American Association i of Critical ii Care Nurses (AACN) Emergency Nurses Association (ENA) American society of Gastrointestianl Endoscopy (ASGE) American Association of Operating room Nurses (AORN) Web Resources Sedationcertification.com Nationalsedationcenter.com Sedationresouce.com Netce.com These resources may have a cost associated with them and some are not backed by a professional organization SGNA S SEDATION WEBSITE 12

13 References Sharma V, Nguyen CC, Crowell MD, et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc. 2007;66(1):27 34 American Society for Gastrointestinal Endoscopy, American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association Institute, Society for Gastroenterology Nurses and Associates. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc. 2012;76(1):e1 e25. Cohen L, Delegge MH, Aisenberg J, et al. AGA Institute review of endoscopic sedation. Gastroenterology. 2007;133(2): References Odom Forren J, Watson D. Practical Guide to Moderate Sedation/Analgesia. 2nd ed. St Louis, MO: Mosby Elsevier; McQuaid K, Laine L. A systematic review and metaanalysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc. 2008;67(6): New references Practice patterns of sedation for colonoscopy Ryan E. Childers MD, J. Lucas Williams BAand Amnon Sonnenberg MD, MSc Gastrointestinal Endoscopy, , Volume 82, Issue 3, Pages , Sedation related complications in gastrointestinal endoscopy. Vargo J. J. Gastrointestinal Endoscopy Clinics of North America. 25(1):147 58, 2015 Jan Sedation in gastrointestinal endoscopy: current issues. Triantafillidis JK; Merikas E; Nikolakis D; Papalois AE. World Journal of Gastroenterology. 19(4):463 81, 2013 Jan 28 Indicators of safety compromise in gastrointestinal endoscopy. Borgaonkar MR; Hookey L; Hollingworth R; Kuipers EJ; Forster A; Armstrong D; Barkun A; Bridges R; Carter R; de Gara C; Dube C; Enns R; Macintosh D; Forget S; Leontiadis G; Meddings J; Cotton P; Valori R; Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group. Canadian Journal of Gastroenterology. 26(2):71 8, 2012 Feb. 13