OR Nurses Giving Conscious Sedation--WHY SHOULD WE?

[stevierae]

I posted this tonight on the operating room nursing section, and would much appreciate it if the anesthesia providers who post here would visit that section and post your thoughts, so that they can reach those OR nurses who don't ever visit your section.

I know we have discussed this topic here before.

I am getting more and more alarmed at the trend of OR nurses giving conscious sedation, and frankly, I think it is time we simply refuse to do it--too much risk, too much responsibility involved in doing something that OTHER people--those of YOUR group--are experts at doing--and are compensated accordingly for doing.

I would really like to see anesthesia providers lobby to have this practice changed--forever.

Of course, if there are anesthesia providers who DISAGREE--who feel that OR nurses SHOULD welcome this "expanded role as a perioperative nurse--" by all means please respond, as well. I would be very interested in hearing your rationales.

Thank you. My post is below.

Frankly, I have never understood why some operating room nurses feel honored to be able to sit up at the head of the bed and administer conscious sedation, especially during elective cosmetic surgery procedures (in which the patient could afford the services of a CRNA or anesthesiologist.)

I think it is a power trip for them--makes them feel oh-so-important.

OK, here come the flames from those who consider it "an expansion of their role as a perioperative nurse" and apparently aren't concerned about not being trained--or compensated--in the same way a CRNA or anesthesiologist would be for doing the same thing.

I truly believe that this is a classic example of the saying, "A little knowledge can be dangerous."

Yes, I am ACLS certified--I am good at starting IVs--I know the conscious sedation drugs and the drugs to reverse them---and hey, I have even had to do a stab trach or two with a jelco to ensure an adequate airway and prevent imminent death----but that was as a Vietnam era corpsman, when there was no other option.

There was no MD or CRNA to call on--as an independent duty corpsman, I was it. Oh, and the situation was trauma--NOT elective cosmetic surgery.

Today, there are plenty of other options--those include staff CRNAs and anesthesiologists who are PAID for their skills at airway management and conscious sedation (as well as far more complicated anesthesia situations.)

Yes, times have indeed changed.

Personally, I do not feel they pay me enough to take on this role and the extra responsibility it entails--especially when CRNAs or anesthesiologists are sitting around with nothing to do--simply because hospital management, or cosmetic surgery patients who are paying out of pocket, do not want to reimburse those providerd (or bill the insurance) accordingly.

This often happens in elective cosmetic surgery cases where insurance ISN'T picking up the tab. Rather than pay the person who is trained--and welll compensated--to do this job--we are supposed to do it.

Why are we allowing ourselves to be exploited as a source of cheap labor?

I actually worked registry a few times at a hospital where, in my opinion, the "queen bee" RNs who fought for the chance to give conscious sedation were waayyyyyyyy over their heads--they were allowed by certain plastic surgeons to simply give drugs in the increments and fashion they (the nurses) saw fit--usually Fentanyl and Versed--and more than once they got into trouble and had to slip in an oral airway, bag the patient, and reverse the Versed with Romazicon or the Fentanyl with Narcan to end up with (eventually!) a spontaneously breathing patient.

Forget about having anesthesia nearby to come bail them out--they had long since gone home--none covering OB, either, as this small hospital had no OB unit.

I expressed my concern to their supervisor about this--with some trepidation--I knew it would not be well received since I was not staff. Her answer? "We do it all the time--and anyway, if they run into trouble, they can call the ER doctor."

Right. Like he is going to drop whatever he is doing (perhaps handling his own code!) and rush right over to bail someone out of a situation they should not have been doing in the first place.

(When I voiced THIS, I was given a blank and hostile stare--and, not called to work there again, surprise--as if I would have wanted to return to this hotbed of sentinel events in the making.)

What do the rest of you think? Why are nurses taking on this role? If you have no other objection, just consider this one---they just do not pay us enough to do it.

__________________

[teeituptom, BSN, RN]

I dont know about OR

But we do it all the time in ER

For all sorts of procedures, We have guidelines we follow them, Been doing it for years. No Biggie.

I dont understand your concerns,

Now I must admit I hate all the paperwork that goes with it. Thats a major pain in the ass.

[loisane]

Stevierae, I am in complete agreement. Many anesthesia professionals are concerned about RNS being allowed/encouraged/coerced beyond their legitimate scope of practice in regard to so called "conscious sedation".

IMO, the central issue is conscious vs. deep sedation. By definition, during conscious sedation the patient should be conscious. That means the patient should be able to talk, and respond appropriately. Now, I ask you, if the patient is to be that "awake", what is the point of sedation? When patients request/expect sedation for a procedure, do they want to be awake? Heck, no. That is why they want sedation---DUH.

So it turns out (at least in my experience) that conscious sedation is very rarely achieved. Most of the times these procedures are actually deep sedation, in which the patient is not responsive, but still (hopefully) maintains his own airway.

And here is the rub. A provider should be educated/credentialed to handle one level deeper than the planned level of sedation. So what is the next level after deep sedation? Answer- general anesthesia. So if you plan to provide deep sedation, you are out of the scope of practice of RNs.

I could stand on this soapbox all day. There are other issues involved, but I think this is the central one.

I work in an outpatient center where we do a lot of GI cases. These used to be done in the main hospital with RNs giving sedation. Gradually, most are now being done at our place. The endoscopists love it because the procedure is more tolerable to the patient, and hence easier for them to perform. The patients love it because they are totally out when they need to be, but awaken very quickly and are on their way home in no time, feeling very well. Everybody is happy.

Getting off the soapbox now.

loisane crna

[stevierae]

Originally posted by teeituptom

I dont know about OR

But we do it all the time in ER

For all sorts of procedures, We have guidelines we follow them, Been doing it for years. No Biggie.

I dont understand your concerns,

Now I must admit I hate all the paperwork that goes with it. Thats a major pain in the ass.

Not our job; don't get paid enough. Simple as that.

[stevierae]

Originally posted by loisane

IMO, the central issue is conscious vs. deep sedation. By definition, during conscious sedation the patient should be conscious. That means the patient should be able to talk, and respond appropriately. Now, I ask you, if the patient is to be that "awake", what is the point of sedation? When patients request/expect sedation for a procedure, do they want to be awake? Heck, no. That is why they want sedation---DUH.

Exactly, Loisane. For the nurses that err on the conservative side--they don't give enough Fentanyl; they don't encourage the surgeon to give more local and be patient while it takes effect; instead, they load up on the Versed.

The patient is in pain throughout the entire case.

Rationale? "Well, he will feel pain, but he won't remember it."

Huh? WHAT? Excuse me, but the definition of anesthesia is WHAT again? This "technique" is unacceptable.

And here is the rub. A provider should be educated/credentialed to handle one level deeper than the planned level of sedation. So what is the next level after deep sedation? Answer- general anesthesia. So if you plan to provide deep sedation, you are out of the scope of practice of RNs.

loisane crna

This fact is NEVER--EVER--mentioned in the 2 hour (if that) "inservices" we get in preparation for being allowed--FORCED, rather-- to give conscious sedation.

I think that if more RNs were aware of this, they would be reluctant to even get involved in the first place.

Anesthesia is best left to anesthesia providers.

Why shouldn't patients know that the person in charge of their airways--their LIVES--is someone who does it day in, day out--not occasionally, and only as a cost-saving measure.

I urge anesthesia providers everywhere to write to AORN en masse and try to get this ever increasing practice repealed.

As I said--either the patient gets NO pain relief, just amnesia, or, more often he is given, as losiane said, deep sedation--something weas nurses have NO business providing. It's a sentinel event in the making.

Thank you.

[stevierae]

Originally posted by teeituptom

I dont know about OR

But we do it all the time in ER

For all sorts of procedures, We have guidelines we follow them, Been doing it for years. No Biggie.

I dont understand your concerns,

Now I must admit I hate all the paperwork that goes with it. Thats a major pain in the ass.

You do it all the time, and anyway, you can call the ER doc if you run into trouble (since you are, after all, doing it in the ER.)

Sounds just like the rationale used by that small hospital I mentioned--except you actually do have experienced help (an ER doc) nearby.

[Brenna's Dad]

I have also observed this practice and I just don't get it. If someone is going to pay for cosmetic surgery, then why wouldn't they pay for anestheisa. That just doesn't make sense.

When I had my wisdom teeth extracted, I had the option of either being awake with local, or receiving propofol, versed, and fentanyl. Guess what option I chose?

Mind you, the propofol was administered by an RN which probably thought just like I did, that she could handle an airway. But this was in Canada....

[Roland]

anesthesia? I always thought that the concept of "scope of practice" would keep this from occuring (and the litigation that violating said scope invites). To the extent that specific licensure is NOT required to administer anesthesia, I would think that this would be a high priority both for CRNA's and MDA's. Call me myopic, but I believe that society will always value legal license over education. Going back to my over used pharmacy analogy it doesn't matter how much advanced training you might give a pharmacy technician, NO drug can be dispensed without that federal, pharmacy license held by the primary pharmacist on site. To me this represents the ideal, professional paradigm for most health-care related professions.

[canoehead, BSN, RN]

Concious sedation is not general anesthesia. TPTB refer to light medium and deep sedation, deep being general anesthesia, midium is concious sedation, and light is just that Ativan that you give someone for anxiety.

Medium sedation means the pt can obey simple commands, like "take a deep breath" and can maintain their own airway. To be competent to give concious sedation you must be ready to deal with the airway issues that occur if you overshoot the mark and send the pt into a deeply sedated state. Nurses can administer the meds, but they don't have a license to prescribe, so the doc (in theory) is taking on a lot of the responsibility of sedating outside the OR.

RN's have been given a lot of tasks that MD's used to do and not gotten just compensation for them. Not so long ago we didn't even start IV's(!)

[Roland]

as general. My question involved the LEGAL line where the license of a CRNA or MDA would become necessary (if any). You point to a prescription for the drug, but CRNA's administer these agents on an implied basis (I think). I guess, I was saying that if a BRIGHT LINE legal requirement doesn't currently exist for anesthesia (of any level), that it would be in the interest of both CRNA's AND MDA's in creating one (via legislative advocacy). This is especially true now since it appears that the bounderies are starting to be pushed in this area.

[canoehead, BSN, RN]

CRNA's prescribe in my hospital...but only for anesthesia related needs.

Medium sedation becomes deep when the patient needs airway support. If you are not licensed to give deep sedation you perform "rescue" techniques like airway support, and reversing agents. You definitely would not give any more sedating med (as a CRNA would be licensed to do.

[meandragonbrett]

You point to a prescription for the drug, but CRNA's administer these agents on an implied basis (I think)

If I remember correctly, most CRNAs have "prescriptive authority" within the walls of the facility. Or something of this nature.

Brett