Cardioversion Sedation goes Beyond Moderate-Help

[taj09]

I need some sound advise from experienced nurses regarding IV Conscious Sedation in the setting of elective cardioversion. In our Texas cath lab we perform these with the cardiologist at the bedside. We are administering the med-usually midazolam and mepheridine concurrently (never propofol). We are ACLS/BLS current, and have the reversal drugs at hand full monitoring equipment, etc. Problem enters with Texas BON position statement that "it is beyond the RN's scope of practice if the patient goes beyond the concept of moderate sedation" yet they admit that sedation is on a continuum and it is not always possible to predict how an individual will respond.

We are actually rendering the patient unresponsive (deep sedation) to give up to 3 stacked shocks.

So I ask the facility risk manager- her response was "as long as the physician is qualified to rescue an airway"... and is current in his qualifications we are "okay". So I ask who's responsibility is it to make certain the cardiologist is qualified (assuming it is the facility) and I haven't received a response. It's been 2 months now.

Now I have been a critical care nurse for 16 years, a cath lab nurse for 7 years and know the docs. We haven't had any bad outcomes and I feel confident in rescue and sometimes feel like I can handle the situation better than the doc.

So what are your thoughts on this?

[netglow, ASN, RN]

I have seen two at two separate hospitals (not TX) as a student. Anesthesia was bedside.

[taj09]

Yes, I forgot to mention- we aren't a teaching facility and don't have the luxury of anesthesia standby.

I just want input on the Boards Position Statement and the response from Risk Management.

[PICURN74, ASN, RN]

Can't speak for Texas or give legal advice but in my opinion you are right to have some concern. I think you bring up a good point of the level of consciousness being deeper than traditionally considered "moderate" but also concerning is that many of the recommendations for "best practices" related to sedation include having the person responsible for providing sedation be separate from the person performing the procedure. I couldn't tell what the practice at your location is. I agree with you that nurses can often handle situations that arise but make sure that you are supported by your hospital if things go bad. Keep questioning until you get your answers, preferably in writing.

[PostOpPrincess, BSN, RN]

Yes. You should be concerned. You have to be very, very adept at airway management should you go into the deep/general anesthesia continuum.

You are asking for trouble if that cardiologist isn't able to do it. I hope you have a good Code Rescue/Code Blue team always on standby.

Suggest you get studies to prove this as what you do is no longer standard of practice.

[canoehead, BSN, RN]

If a cardiologist cannot rescue, especially if they are routinely doing sedations, I think they make a very poor cardiologist. Any physician at bedside is responsible, and the hospital is responsible to know thy can perform the procedure safely. It's not the nurse in charge of the doc's practice- you cannot be blamed for his mistakes. You must be competent within your scope, of course. Have everything tested and ready x3, document meticulously, and know your stuff.

[luvRNs, BSN, MSN, RN]

Re: cardioversion sedation

As someone who has worked in multiple hospitals, several questions come to mind. First, is the cardiologist ACLS certified? Many 'say' they are, but don't have the credentials to prove it in a court of law. Second, has the hospital medical staff 'credentialled' the physicians in the use of propofol? If not, they need to get this done before you participate. Third, what is nursing adniistrations position on it? If they don't have a position, they need to develoip one, so that there is consistent safe care. Finally, is there an anesthesiologist on call if needed? This can make a difference if a difficult airway. finally, are statistic kept and analyzed on sedation level? These metrics will tell you how well your practices are working....

[BrnEyedGirl, BSN, MSN, RN, APRN]

How do you handle the sedation during a cath?? I work ER so we do the cardioversion sedation just like we would for a relocation of a hip any ortho procedure,.and of course we can intubate if needed. When I worked in cath lab we used the same sedation for our caths. Check your hospital policy regarding sedation and airway management,....we are having a bit of an issue right now with docs coming into the ER to do procedures,..they want the ER nursing staff to give meds and care for the pt but don't want the ER doc to actually see the pt,....come to find out only some of the docs on staff are "qualified" per policy to manage an airway,...go figure.

[classicdame, MSN, EdD]

my copy of the Texas NPA has annotations which seem to indicate that, regardless of the MD's license and experience, the nurse is never to act outside their own scope of practice. If you are are member of Texas Nurses Asso you can get free advice (limited, of course). Otherwise, you might call the ins co that has your malpractice insurance. BTW, certifications in ACLS, etc do not automatically qualify you for delivering deep sedation, per position statement of NPA.

[luvRNs, BSN, MSN, RN]

First, I agree with the above statement on the nurse practice act. Know your state's sedation constraints. Some states really do not adress this well, and are vague, leaving you to seek other options. As for RN cardiac, if you are assisting in a cath, you are NOT functioning as an ED nurse, and therefore not legally protected by ED policy. Many smaller hospitals have staff do 'double duty' and cross-cover . If this is the case, the manager of the cath lab needs to clearly outline in policy and procedure your scope of practice for sedation. This needs to include the other things I mentioned above. :)

[classicdame, MSN, EdD]

Usually it comes down to this concept: If you do not feel safe in the situation, regardless of your licensure status or certifications you hold - then DO NOT do it.

[BrnEyedGirl, BSN, MSN, RN, APRN]

First, I agree with the above statement on the nurse practice act. Know your state's sedation constraints. Some states really do not adress this well, and are vague, leaving you to seek other options. As for RN cardiac, if you are assisting in a cath, you are NOT functioning as an ED nurse, and therefore not legally protected by ED policy. Many smaller hospitals have staff do 'double duty' and cross-cover . If this is the case, the manager of the cath lab needs to clearly outline in policy and procedure your scope of practice for sedation. This needs to include the other things I mentioned above. :)

I didn't mean that I assist in cath lab as an ER RN,..I used to work in cath lab as a cath lab RN,..the sedation we used for caths was the same as we would use for a cardioversion,.so was wonder why the OP was having an issue with cardioversion sedation but not with cath sedation,....sorry about the confusion.