What is in a name—sedation or anesthesia

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.

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.

Before surgical and other procedures (eg, interventional procedures in radiology, procedures in the gastrointestinal laboratory) are performed on a patient, a history and physical examination must be completed. At least a short history and physical examination should be completed for patients undergoing moderate or deep sedation if this information is not on their charts already.

Standards TX.2.1 and PE.1.8.1 require a presedation assessment for each patient before initiation of moderate or deep sedation. Standards TX.2.1.1 and PE.1.8.2 pertain to the need to plan each patient's moderate or deep sedation, so many facilities have added a brief anesthesia portion to the bottom of their short history and physical examination forms. This allows for documentation of the American Society of Anesthesiologists (ASA) score and a place for the anesthesia assessment and plan.

PATIENT ASSESSMENT AND INFORMATION SHARING

As with anesthesia, the administration of moderate or deep sedation requires that sedation and anesthesia options and risks be discussed with the patient and his or her family members before administration (ie, TX.2.2). This should be documented by the practitioner in the progress notes or on the surgical or procedure report.

In addition, as with anesthesia, patients need to be reassessed (ie, vital signs checked, patient given a quick examination by the sedation provider) immediately before administration of moderate or deep sedation medication or anesthesia (ie, PE.1.8.3). This must be documented as well. The easiest way to capture this information is to place a small box above the graphic where vital signs will be documented. Next to the box write "patient reassessed immediately before administration of sedation."

After moderate or deep sedation medication has been administered, the patient's physiological status should be measured and assessed throughout the sedation period to ensure appropriate physiological support for the patient (ie, TX.2.3). A safe practice is to document a patient's vital signs and pulse oximetry every five minutes during moderate sedation. During deep sedation, it is safe practice to document the capnograph reading every five minutes. The person monitoring the patient has no other responsibilities during this time frame and thus can document these items adequately on the flow sheet. The patient should be monitored from the time the moderate or deep sedation is initialized through the time he or she has recovered fully from the moderate or deep sedation.

The patient's postoperative status must be assessed on admission to and before discharge from the postsedation recovery area or PACU (ie, TX.2.4, PE. 1.8.3). In most facilities, this is interpreted to mean until the patient has met his or her presedation Aldrete score and is able to be discharged home safely or returned to the inpatient unit. The patient is to be monitored during the postsedation recovery or PACU period (ie, TX.5.4). This monitoring will include airway management, documentation of vital signs, pulse oximetry, and any complications that may arise. Most sedation education programs include airway management and how to assess patients to determine the Aldrete score.

One issue to consider may be cross training staff members responsible for monitoring patients recovering from deep sedation with PACU staff members. This ensures the same level of care throughout the organization (ie, L.D. 1.6, M.S. 6.8). The reason for this is that patients receiving deep sedation may unintentionally or unavoidably slip into general anesthesia status. Staff members in the PACU generally are trained in ACLS or PALS. If this is the case, staff members monitoring patients recovering from deep sedation also should be trained in ACLS or PALS to provide the same level of care. Some organizations have PACU nurses or anesthesia care providers take into account the competencies of staff members monitoring patients recovering from deep sedation.

Lastly, patients are to be discharged from a postsedation recovery area or the PACU by a qualified licensed independent practitioner (ie, TX.2.4.1). Many organizations use medical staff member-approved discharge criteria when discharging patients from these areas. This is sufficient if use of this criteria is documented clearly in the patient's medical record. The reason medical staff member-approved criteria is used by many facilities is to relieve the anesthesia or sedation care provider from physically being present when a patient is discharged. Take care when using discharge criteria approved by medical staff members, however. There have been several reported sentinel events regarding patients being discharged too soon from presedation areas and the PACU because these areas experienced a sudden influx of patients or because of staffing issues. When the patient is discharged home, instructions must be provided regarding pain management, medications, diet, activities of daily living, complications of sedation, and where and whom to call in case of complications from the procedure or sedation.

POLICY DEVELOPMENT

Individual facilities must decide how best to achieve compliance with JCAHO standards. It is not a requirement that the anesthesia department be involved in the development and implementation of sedation policies; however, many medical and hospital staff members have far more confidence in sedation policies and processes when the champions of such policies are anesthesia care providers. They truly are the experts in the field when it comes to management of sedated patients and sedation medication dosage regimens. If your facility has no anesthesia department or the anesthesia department chooses not to be involved in developing policies and processes, take time to review practice parameters for nonanesthesiologists published by the ASA. (2)

Table 1
SEDATION AND ANALGESIA DEFINITIONS (1)

Minimal sedation (ie, anxiolysis)

Minimal sedation is defined as a medication-induced state during
which patients respond normally to verbal commands. Cognitive
function and coordination may be impaired, but ventilatory and
cardiovascular functions generally are unaffected.

Moderate sedation/analgesia (ie, conscious sedation)

Moderate sedation/analgesia is defined as a medication-induced
depression of consciousness during which patients respond
purposefully to verbal commands, either alone or accompanied by
light tactile stimulation. No interventions are required to
maintain the patients airway, and spontaneous ventilation
is adequate. Cardiovascular function usually is maintained.

Deep sedation/analgesia

Deep sedation/analgesia is a medication-induced depression of
consciousness during which patients cannot be aroused easily;
however, they do respond purposefully to repeated or painful
stimulation. Patients' ability to independently maintain
ventilatory function may be impaired. Patients may need
assistance to maintain an airway, and spontaneous ventilation
may be inadequate. Cardiovascular function usually is maintained.

Anesthesia

Anesthesia consists of general anesthesia and spinal or major
regional anesthesia. It does not include local anesthesia.
General anesthesia is a medication-induced loss of consciousness
during which patients are not arousable, even by painful
stimulation. Patients' ability to independently maintain
ventilatory function often is impaired. Patients often require
assistance in maintaining an airway, and positive pressure
ventilation may be required because of depressed spontaneous
ventilation or medication-induced depression of neuromuscular
function. Cardiovascular function may be impaired.

NOTE

(1.) Comprehensive Accreditation Manuel for Hospitals (Oakbrook
Terrace, Ill: Joint Commission on Accreditation of Healthcare
Organizations, 2001) TX.2-TX.2.4.1.

NOTES

(1.) Comprehensive Accreditation Manual for Hospitals (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 2001).

(2.) "Practice guidelines for sedation and anesthesia by non-anesthesiologists," American Society of Anesthesiologists, http://www.asahq.org/practice /sedation/sedation1017.pdf (accessed 16 Jan 2002).

Kathleen Catalano, RN, JD, is director of administrative projects at the Children's Medical Center of Dallas.

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