premedication vs. conscious sedation

[SWAT_RN]

Help please! I'm new to the whole rad nurse thing (old to everything else and need some insight. Our radiologists thankfully medicate with fentanyl with some of the more invasive biopsy pts. My managers are calling this conscious sedation and want them to complete an H&P and the ASA form prior to the procedure. They are hacked off. From what I have read, some places differentiate between premedicating and conscious sedation and treat the two as separate uses of the same drugs. I guess like the old time "pre op". How can we meet JACHO standards while not pissing off the docs?

[Nesher, BSN, RN]

Fill out the H&P and ASA form - there is a difference between c. sedation and premeding especially when a preocedure is to be performed. Doesn' t your hospital have a policy regarding this? If they don't they need one pronto...

[dianah, ASN]

If the pt is an inpt, there should be an H&P on the chart. Does your hospital have a form where the Rad. can just check "no change " from the initial H&P, if the procedure is being done more than 30 days from it?

Agree w/nesher, check your policy. IV meds, esp when titrated during a procedure, ARE moderate (or "conscious") sedation. We were even monitored for the H&P from ER, for traumas (just reminded to check and be sure one is in the chart before we began the stat procedure we'd been called in for!)!!

If the pt is an out-pt, either the Rad. will have to do the H&P or delegate it to the ordering MD (to be done while the pt is in his/her office, when he/she orders the procedure).

Or you could have the clinic/MD's office fax the last visit, hoping it contains all that is required for the H&P (which is iffy). Perhaps you could develop a pre-sedation H&P form, with check boxes or charting by exception, or something that covers the requisite areas -- don't need a 6-pager. Quick and dirty (but accurate! again, check your policy).

Or you could schedule the pts to come in to the Rad Dept within a month of the procdure, for the Rads to do a brief H&P.

Our Rads filled out the ASA form, which is appropriate since they'll be the ones ordering the meds for the sedation.

It took us a lot of reminding and inservice and cooperation from the Rads to reinforce what was needed, in order to facilitate changes in the ordering doc's habits.

Wouldn't a dept PA be a blessing in this circumstance???!!

Good luck! :)

[SWAT_RN]

Fill out the H&P and ASA form - there is a difference between c. sedation and premeding especially when a preocedure is to be performed. Doesn' t your hospital have a policy regarding this? If they don't they need one pronto...

Yes, I know there is a difference, and so far anyway all the Rads have asked for in my opinion is premedication, but the managment ppl are requiring all the c. sedation paperwork be done including the H&P and ASA form. So I feel their frustration, but ultimately want to do what is best for the pts. I spoke with our DON and risk person asking for clarification re: this whole deal, so I hope that it clears up soon.

[dianah, ASN]

Glad you spoke with your DON and risk mgmt. It's best for issues like this, if the big guns decide this, "mano a mano," if you will, and work it out amongst themselves, making the necessary clarifications. Hopefully your Radiologists and mgr and DON and risk will work out the kinks.

Are you giving the fentanyl IV or IM? And is it only given pre-procedure? No versed? What if the pt is anxious - do you give versed also? Or, if the procedure goes longer than anticipated, or the pt has a high tolerance to the premed: do you then give additional doses during the procedure? As Fentanyl can cause muscular rigidity if administered too quickly, and has the potential for resp depression, I tend to consider it in the moderate sedation category. . . especially when given in conjunction w/Versed.

Let us know how it turns out. :)

[jewelcutt]

Especially when it comes to situations where there is use of sedation and risk of respiratory depression, conscious sedation should only be administered by those qualified. Docs never want this because it takes more time and more people get paid, it is very common for docs to get frustrated with anything that takes time because they want things done their way right then. They're probably asking your advice because they want more people on their side. I would definitely have a policy in place, save your license and review your scope of practice.

[rad rn]

Hello .. I'm a Rad RN in NJ .. according to our p/p manual .. Fent alone is not con sed. its a narc .. With the Versed if we are only giving ONE dose without any follow up it is not con sed..(although we rns treat it as such) Any way the way we work all our Outpatients they go thru our PAT unit and a chart is generated H/P is done by the ordering doc and has to be within 30 days.. or have a no changes statement within 30 days if H/P is outdated. we get the charts for pre calls the day before and can call the office for something that may be missing H/P, labs etc.. .. I hope this helps