Transcript Sedation Analgesia: JCAHO Requirements and How to Fulfill Them

Sedation Analgesia: JCAHO
Requirements and How to Fulfill Them
Norah N. Naughton, M.D.
Associate Professor
Department of Anesthesiology
University of Michigan Health System
• JCAHO standards for assessment and care
of patients
• Credentialing physicians
• Nurse competency
• Continuous quality improvement program
Early 1990’s
83 deaths associated with Midazolam
in sedation analgesia settings. Joint
Commission took up patient safety
concerns.
1990-1993
Joint Commission regulated
anesthesiology departments to participate
with divisions to develop policy for
practice.
1994
Uniform conscious sedation policy.
Applicable across entire institution.
1998
Moderate and deep sedation care standards
are incorporated into anesthesia care
standards.
Sedation Analgesia
“Sedation Analgesia is a clinical practice
whereby the administration of medication
results in a drug induced depression of
consciousness to allow for a diagnostic,
therapeutic, or minor surgical procedure.”
Continuum of Depth of Sedation Definition of General
Anesthesia and Levels of Sedation/Analgesia
(Approved by House of Delegates on October 13, 1999)
Minimal
Sedation
(Anxiolysis)
Responsiveness Normal
response to
verbal
stimulation
Airway
Unaffected
Moderate
Sedation/
Analgesia
(“Conscious
Sedation”)
Purposeful
response to
verbal or tactile
stimulation
No intervention
required
Spontaneous
Ventilation
Unaffected
Adequate
Cardiovascular
Function
Unaffected
Usually
maintained
Deep Sedation/
Analgesia
General
Anesthesia
Purposeful
response following
repeated or painful
stimulation
Intervention may
be required
Unarousable
even with
painful
stimulus
Intervention
often
required
May be inadequate Frequently
inadequate
Usually
maintained
May be
impaired
JCAHO Standards of Anesthesia
Care Apply To:
1.General, spinal, or major regional
anesthesia
2.Sedation (with or without analgesia) that in
the manner used may be reasonably
expected to result in the loss of protective
reflexes =>
Meaning moderate and deep sedation
JCAHO Standards Related to Moderate and
Deep Sedation and Anesthesia
Assessment of Patients
PE 1.8.1
PE 1.8.2
Any patient for whom moderate or deep
sedation OR ANESTHESIA is contemplated
receives a presedation OR
PREANESTHESIA assessment.
Before anesthesia, the patient is determined
to be an appropriate candidate for planned
anesthesia.
JCAHO Standards Related to Moderate and
Deep Sedation and Anesthesia
Assessment of Patients
PE 1.8.3
PE 1.8.4
The patient is reevaluated immediately
before moderate or deep sedation use and
before ANESTHESIA induction.
The patient’s postoperative status is
assessed on admission to and discharge
from the postanesthesia recovery area.
Care of Patients
TX 2
TX 2.1
TX 2.1.1
TX 2.2
Moderate or deep sedation and
ANESTHESIA are provided by qualified
individuals.
A presedation or ANESTHESIA
assessment is preferred for each patient
before beginning moderate or deep sedation
and before ANESTHESIA induction.
Each patient’s moderate or deep sedation and
ANESTHESIA care is planned.
Sedation and ANESTHESIA options and
risks are discussed with the patient and
family prior to administration.
Care of Patients
Each patient’s physiological status is monitored
during sedation or ANESTHESIA administration.
TX 2.4 The patient’s postprocedure status is assessed
on admission to and before discharge from
the postsedation or POSTANESTHESIA
recovery area.
TX 2.4.1 Patients are discharged from the postsedation
or POSTANESTHESIA recovery area and the
organization by a qualified licensed independent
practitioner or according to criteria approved by
the medical staff.
TX 2.3
Documentation
Presedation
• Focused H & P
– Airway
– Complications associated with anesthesia
• ASA status
• NPO status
• Baseline vital signs
• Pain score
• Informed consent
• Patient assessment immediately prior to sedation
• Physician signature
Documentation
Sedation
• Medications and time administered
• Physiologic monitoring
– BP
– Pulse
– Saturation
• Sedation level
• Intervention and outcome
– Respiratory
– Airway
– Antagonists
• End time
Documentation
Postsedation
• Recovery room entry time
• Physiologic monitoring
– BP
– Pulse
– Saturation
• Sedation level
• Pain score
• Discharge criteria met/physician signature
• Time of discharge or transfer
• Discharge instructions
Physician Credentialing
“able to rescue from next level of sedation”
Moderate  Deep
• Bag/mask ventilation
Deep  Anesthesia
• Bag/mask ventilation
• Immediate hemodynamic support
Physician Credentialing
• Knowledge of physiology & pharmacology
of medications
• Knowledge of oxygen delivering devices
• Knowledge of required equipment and
supplies
• Immediate resuscitation skills; how to call
for help
UMHS Privileges
• Moderate
– BLS, ACLS, ATLS, PALS, NALS, or UMHS
Sedation Workshop
– Online test
– OCA application (read guidelines)
• Deep
– ACLS, ATLS, PALS, NALS, or UHMS Sedation
Workshop
– Online test
– OCA application (read guidelines)
(minimum number of annual cases)
UMHS Sedation Workshop
Departments of Anesthesiology and
Cardiology
•
•
•
•
Adult sedation
Pediatric sedation
Hemodynamic resuscitation
Demonstration of bag/mask skills
UMHS Nurse Competency
• Initial orientation
– Critical Care Course
– Online test
• Annual
– Online test
• Swat Team
– Bedside sedation in general care areas
• Quality Indication Screen
–
–
–
–
Individual physician tracking
Division/institution trends
Quarterly reports
Sedation level intended/achieved OCA
• Sedation Analgesia QI Committee
–
–
–
–
Interdisciplinary
Reports to ECCA
Reports to institution risk management
CQI principles
Morbidity and Mortality
Associated
with:
Sedation
Anesthesia
(ASA I-III)
Death
Critical Events
.005-.03 %
.54-1.6 %
.02 %
_____
Sedation Activity by Location
Sedation Activity by Location
Cancer Center
Emergency Dept
3%
4%
All Other Locations
3%
Inpatient
Units
CPU-Mott
1%
5%
CPU-UH
16%
Radiology
13%
Med Proced Unit
55%
Sedation: Depth of Sedation
Distribution of Reported Depth of Sedation
Not Reported 9%
Anesthesia
Deep
4%
2%
Mild
12%
Moderate
73%
Over 85% of deep
sedations are
pediatric patients.
Sedation: Critical Adverse Events
Distribution of Adverse Events
90%
82%
80%
70%
60%
Overall incidence of
critical adverse events
= 1.4 %
50%
40%
30%
20%
15%
10%
0%
1%
0%
Aspiration
Cardiac Arrest
Death
2%
0%
Respiratory Arrest
> 10% Baseline
reversal Agent
Lessons Learned
• Support by physician and nursing leadership
– Time
• 30% FTE attending anesthesiologist
• 50% FTE administration
• 50% FTE administration assistant
– Money
• Capital equipment
– Pulse oximeters
• Personal
– 1-2 FTE nurses
• Computer support
Lessons Learned
• Interdisciplinary effort and institutional
program, NOT Anesthesiology “rules”
• Interdisciplinary Task Force
– Determine settings of sedation analgesia
– Survey site specific needs
• One institution guideline
– Anticipate modifications for some divisions
– Consider avoiding inclusion criteria by
medications used
Lessons Learned
• Precede clinical roll-out with intense educational
program
– Staff physicians
– Nurses
– Residents
• Credentialing Program
– Support of physician and nursing leadership
– Expect resistance by staff
– Time and money
– Interdisciplinary effort
– Present as institution requirement
Lessons Learned
• Quality Assurance Program
– Interdisciplinary
– DO NOT have Anesthesiology Department
responsible for form routing or database
management
• Program for Ongoing Competency Review
– Make this OCA responsibility
– Make this nursing department responsibility