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Health Care Industry

What is in a name—sedation or anesthesia

AORN Journal, March, 2002 by Kathleen Catalano

Many in the perioperative area scoff at the involvement of anesthesia care providers or perioperative nurses in the development or implementation of sedation policies. Sedation generally is used outside the OR in such areas as the emergency department, the gastrointestinal laboratory, the radiology department for interventional procedures, the intensive care unit, and various clinics, so why should perioperative personnel be concerned? Perioperative personnel and anesthesia care providers are aware already of the risks and benefits of anesthesia, and they know what can happen if an anesthesia emergency occurs.

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The main controversy among hospital personnel and physicians about the difference between sedation and anesthesia revolves around the intent statement for standard TX.2 in the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) sedation standards. (1) This statement says that individuals who administer moderate or deep sedation and anesthesia must be qualified and have the requisite credentials to manage patients at what ever level of sedation or anesthesia is achieved. Sedation is to be considered anesthesia, which means that everything normally done for patients receiving anesthesia now must be done for patients receiving sedation.

WHAT THE STANDARDS SAY

The Joint Commission's new sedation and anesthesia standards are in the section on care of the patient, specifically TX.2 to TX.2.4.1. The overview of sedation and anesthesia standards contains written definitions for sedation and anesthesia (Table 1). The intent statement of standard TX.2 notes that if a practitioner is qualified to provide moderate sedation, he or she also must be able to rescue patients who unavoidably or unintentionally slip into deep sedation. These individuals must be competent to manage a compromised airway and provide adequate oxygenation and ventilation. Likewise, practitioners providing deep sedation must be qualified to rescue patients who unavoidably or unintentionally slip into general anesthesia. These practitioners must be competent to manage an unstable cardiovascular system, as well as a compromised airway and inadequate oxygenation and ventilation.

The words qualified and competent are distinguishing factors for granting clinical privileges to administer moderate or deep sedation and may be an area of review by JCAHO surveyors. Practitioners who administer moderate or deep sedation should be credentialed or competent and have requisite privileges to administer moderate or deep sedation. In addition, most facilities across the country require practitioners who administer moderate or deep sedation to be trained in basic cardiac life support (BCLS). Some facilities have made it necessary for practitioners to be trained in BCLS to administer moderate sedation and in advanced cardiac life support (ACLS) or pediatric advanced life support (PALS) to administer deep sedation. Airway management and an understanding of medication dosing regimens for sedation are an integral part of this process and also should be part of the privilege or competency requirements before a practitioner is allowed to administer sedation or monitor a patient who has received sedation.

Many hospitals require that any physician, dentist, or RN who administers sedation and any physician, dentist, RN, licensed vocational nurse, or respiratory care practitioner who monitors a patient after administration of sedation pass a sedation test. Most sedation examinations are given after the participant has read and understood a sedation module pertinent to the type of sedation administered at his or her facility. Some facilities require that practitioners spend time with the anesthesia care provider in the OR to learn the necessary skills needed to provide deep sedation. The bottom line is that these practitioners need to be able to safely rescue patients who slip from moderate sedation into deep sedation or from deep sedation into general anesthesia. In addition to the practitioner performing the procedure, the standards require a sufficient number of qualified personnel to

* appropriately access the patient before beginning moderate or deep sedation and anesthesia,

* provide moderate or deep sedation and anesthesia,

* perform the procedure,

* monitor and evaluate the patient, and

* recover and discharge the patient from the postanesthesia care unit (PACU) or the health care facility.

MONITORING AND PATIENT EVALUATION

Also noted under the intent statement of TX.2 is the need for appropriate equipment (ie, pulse oximetry for continuous measurement of heart rate and oxygenation, electrocardiogram monitoring for patients with significant cardiovascular disease or anticipated dysrhythmias, a sphygmomanometer to measure blood pressure at regular intervals). Respiratory frequency and pulmonary ventilation are to be monitored continuously as well, so the use of a capnograph also is recommended. It is likely that the capnograph would be used only for patients receiving deep sedation.

Health Care Industry

What is in a name—sedation or anesthesia

AORN Journal, March, 2002 by Kathleen Catalano

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