Intention (responsiveness) Responds normally to commands Responds purposefully to verbal commands/or light touch DEEP Responds to pain Reflex withdrawal No response Anticipated Outcomes (Airway, Cardiovascular) Examples GOAL: RASS score = 0 Airway maintained CV support not needed 1 mg ativan po before MRI GOAL: RASS score greater than - 4 Airway maintained CV support not needed Combination of opiates & benzos, typically GOAL: RASS score - 4 Airway may require support CV support may be needed Higher doses of opiates & benzos or anesthetic agents as needed to induce response only to painful stimuli GOAL: RASS score - 5 Airway requires support CV support may be necessary Induction doses of anesthetic agents:100 mg propofol & other anesthetic agents include: Line placement Chest tube insertion Bronchoscopy Cardiac Cath include: Endoscopy Colonoscopy include, surgical procedures done at bedside such as: Trachs/Perc trachs PEG placement 1
Who can administer RN * Excludes anesthetics/propofol boluses of any dose unless or certified MD (TBD), even if the patient is already on a continuous propofol drip and protocol. RN validated in moderate sedation or MD validated in Mod Sedation (list available) DEEP * Excludes anesthetics/propofol boluses of any dose unless or certified MD (TBD), even if the patient is already on a continuous propofol drip and protocol. Anesthesiologist, ED Attending or other credentialed MD (TBD) If a patient s LOC is already deeply sedated (from continuous medications or condition) prior to the procedure, and there is no intention to induce a deeper level of consciousness for a procedure, Anesthesia does not need to be present. Anesthesiologist In a life-threatening clinical situation such as Anesthesia STAT, if the is present & managing the airway, a nurse may give the anesthestic under the direct supervision of the /credentialed MD 2
Who must be at the bedside No one in particular A minimum of 2 clinicians: 2. assistant who monitors/documents. The assistant must be CPR certified and able to establish an airway if needed (using positioning, OPA, BVM) DEEP A minimum of 3 clinicians: 2. or credentialed MD (ED attending and others TBD) to administer medications and monitor 3. patient s nurse to assist with procedure A minimum of 3 clinicians: 2. or credentialed MD (ED attending and others TBD) to administer medications and monitor 3. patient s nurse to assist with procedure Equipment at bedside None Provisions must be available to institute should moderate sedation occur Oxygen (on during procedure) BVM available Oxygen or Ventilator with appropriate settings BVM at bedside Oxygen or Ventilator with appropriate settings BVM at bedside 3
DEEP Monitoring & Frequency None? ET CO2 (not currently in policy) Q 5-10 min LOC (change to RASS), rhythm, VS, O2 sat? ET CO2 Q 5-10 min, RASS, rhythm, VS, O2 sat? ET CO2 Q 5-10 min, RASS, rhythm, VS, O2 sat Documentation emar Mod sedation flowsheet Nurse-administered meds in emar If Anesthesia service is present, they will monitor & document on Anesthesia flowsheet up through Anesthesia service will monitor & document on Anesthesia flowsheet up through recovery. Nurse will 4
DEEP recovery. Nurse will indicate on flowsheet that VS are on another sheet. indicate on flowsheet that VS are on another sheet Other considerations Current patient condition Allergies and meds Co-morbidities Last PO intake Airway risk ( classification) Cardiac, pulmonary exam Consent Time-Out Use Mod Sedation documentation guidelines. Same as Mod Sedation guidelines. Use Mod Sedation documentation guidelines. Same as Mod Sedation guidelines. Authored/Approved: N. Bafundo, M. Davis, C. Ficara, M. Hanbury, L. Meisterling, L. Mahoney, C. Rooney, A. Russell, M. Scanlon, W. Waberski 5