Many of you have had battles at your Credentials Committee meetings about who should be privileged to perform and/or supervise moderate sedation (aka conscious sedation). While your Department of Anesthesiology probably lays claim to the organizational oversight of moderate sedation, reality is that providers in multiple departments or services (the emergency department, radiology, orthopedics, surgery, cardiology, GI, and others) may need to participate in moderate sedation.
A new position paper from the American College of Emergency Physicians (O’Connor 2011) has recommendations on credentialing and privileging for procedural sedation in the emergency department. First and foremost they recommend that each organization should have a multidisciplinary committee that provides organizational oversight for procedural sedation. We think that’s a wise idea. We have some experience with that in other areas. For example, when vascular interventional procedures developed in the 1990’s we had physicians in multiple departments requesting privileges to perform these procedures. The only way to address the privileging issue and, more importantly, the quality improvement issues was to create such multidisciplinary committees for general oversight. So applying the same concept to procedural sedation has precedent and makes sense.
The ACEP paper has good recommendations on the performance of moderate sedation as well. It talks about the need for ED physicians to consider potentially competing tasks in the ED before they undertake a procedure requiring moderate sedation. It also discusses the pre-procedural needs, including assessment of the patient’s last oral intake and the performance of a timeout per Universal Protocol. It stresses the importance of interactive monitoring, with someone other than the proceduralist doing the monitoring, and recommends that use of continuous capnography also be considered during monitoring (see previous discussions on capnography in our Patient Safety Tips of the Week for June 10, 2008 “Monitoring the Postoperative COPD Patient”, March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue” and May 25, 2010 “Propofol Issues”). And though we often focus on high-tech monitoring, don’t forget good old-fashioned attention to physical findings such as eye movements (Tourtier 2011).
There are several good resources available for your moderate sedation educational programs. We recently mentioned the video on conscious sedation for minor procedures in adults (Jones 2011) in the new New England Journal of Medicine video series (see our August 2011 What’s New in the Patient Safety World column “NEJM Video on Conscious Sedation for Minor Procedures in Adults”). In addition, the most recent edition of the VA’s TIPS (Topics in Patient Safety) references the VA’s new moderate sedation toolkit for non-anesthesiologists (Murphy 2011). Though the full toolkit is not yet downloadable for anyone outside the VA system, you can view 2 very useful one-page aids for moderate sedation on the NPSC website. You’ll also find of interest a discussion with questions and answers on procedural sedation from an Annals of Emergency Medicine Journal Club (Menchine 2011).
See also our prior January 25, 2011 Patient Safety Tip of the Week “Procedural Sedation in Children” and our May 2011 What’s New in the Patient Safety World column “Update on Pediatric Procedural Sedation” for good discussions and resources on procedural sedation.
O'Connor RE, Sama A, Burton JH, et al. Procedural Sedation and Analgesia in the Emergency Department: Recommendations for Physician Credentialing, Privileging, and Practice. Ann Emerg Med 2011; 58: 365-370
Tourtier J-P, Diraison Y, Auroy Y. Conscious Sedation for Minor Procedures in Adults. N Engl J Med 2011; 365:1159-1160
Jones DR, Salgo P, Meltzer J. Conscious Sedation for Minor Procedures in Adults.
N Engl J Med 2011; 364: e54 June 23, 2011
Murphy J. New Moderate Sedation Toolkit for Non-Anesthesiologists. TIPS (Topics in Patient Safety) 2011; 11(2): 1,4
NPSC (VA National Patient Safety Center). Moderate Sedation Toolkit for Non-Anesthesiologists. Moderate Sedation Study Aid.
Menchine M, Arora S, Schriger D. Procedural Sedation: Is Two Better Than One? Answers to the May 2011 Journal Club Questions. Ann Emerg Med 2011; 58: 383-394