sedation policies vs practice where you are

[mosin46]

what is everyone's experience with the above issue? the big part of the nurse's responsibility in my department involves sedation of patients for GI procedures. the common daily practices in this unit are totally contrary to the hospitals written policies and my understanding of nationally accepted principals. the problem is many folded. we are daily expected to sedate patients that easily classifiable as ASA 3 and often class 4. we have some loose maximum drug (demerol,versed,fentanyl) limits and when they don't supply adequate sedation,we throw the kitchen sink at em in the form of benadryl,phenergan and droperdol. anything to knock em out. we also have a high percent of medically(legally)drug addicted patients who are not only pretty sick but very hard to sedate. we pretty much fly on our own with little input from the docs. the question at the end of the case is often"what'd you give em?" in patient sedation i think, and most literature i have seen, supports the concept that patient monitoring,airway management,and safety are paramount. our practice is contrary to most other units i have heard about. most have 2 personel in a procedure room. one monitoring and medicating the patient the other helping the doctor. we have 1 nurse doing sedation,monitoring,documenting,dealing with pathology and assisting in often complicated drawn out procedures. we have a pretty seasoned.skilled and rather aggressive staff and have of late been trying to get more physician input and support. that is working in most cases as our docs aren't blind or stupid. some others? weeell? propofol won't work. my state won't let us use it in this setting, anesthesia services are available maybe 1 day a week. management and administration have no interest in patient saftey for purely financial motives and refuse to admit a problem exists or to deal with it. what have the members seen in their areas? do these problems exist elsewhere? are they being dealt with? are reasonable guidelines laid down and followed? or, is all this stuff being blown off in the name of finance and expediency?

[patwil73]

what is everyone's experience with the above issue? the big part of the nurse's responsibility in my department involves sedation of patients for GI procedures. the common daily practices in this unit are totally contrary to the hospitals written policies and my understanding of nationally accepted principals. the problem is many folded. we are daily expected to sedate patients that easily classifiable as ASA 3 and often class 4. we have some loose maximum drug (demerol,versed,fentanyl) limits and when they don't supply adequate sedation,we throw the kitchen sink at em in the form of benadryl,phenergan and droperdol. anything to knock em out. we also have a high percent of medically(legally)drug addicted patients who are not only pretty sick but very hard to sedate. we pretty much fly on our own with little input from the docs. the question at the end of the case is often"what'd you give em?" in patient sedation i think, and most literature i have seen, supports the concept that patient monitoring,airway management,and safety are paramount. our practice is contrary to most other units i have heard about. most have 2 personel in a procedure room. one monitoring and medicating the patient the other helping the doctor. we have 1 nurse doing sedation,monitoring,documenting,dealing with pathology and assisting in often complicated drawn out procedures. we have a pretty seasoned.skilled and rather aggressive staff and have of late been trying to get more physician input and support. that is working in most cases as our docs aren't blind or stupid. some others? weeell? propofol won't work. my state won't let us use it in this setting, anesthesia services are available maybe 1 day a week. management and administration have no interest in patient saftey for purely financial motives and refuse to admit a problem exists or to deal with it. what have the members seen in their areas? do these problems exist elsewhere? are they being dealt with? are reasonable guidelines laid down and followed? or, is all this stuff being blown off in the name of finance and expediency?

At my facility we always have 2 people available and sometimes 3 (how can you do endo with only one person to assist and give the drugs?). When I did Cath Lab I was responsible for sedation. It was always done under strict doctor orders (give 50 mcg Fentynal now, give 2 mg versed now, etc). I was solely responsible for administration and monitoring. If patient looking bad I immediately reported it and we gave reversal as needed. Have rarely gone beyond Fentynal or Versed for sedation (atomidate a few times in ER). Propofol only in ICU for intubation.

We have specific guidelines on what we can give and what we monitor. We have portable monitoring equipment and reversal agents drawn up. And if what we can give them doesn't work we don't (or at least I have never) started giving multiple different meds to do the work (I'd be very leery of giving phenergan and benadryl along with fentynal and versed - actually I'd be downright scared).

Hope this helps,

Pat

[pickledpepperRN]

Our Board of Registered Nursingadvisory states:

In administering medications to induce conscious sedation, the RN is required to have the same knowledge and skills as for any other medication the nurse administers. This knowledge base includes but is not limited to: effects of medication; potential side effects of the medication; contraindications for the

administration of the medication; the amount of the medication to be administered.

The requisite skills include the ability to: competently and safely administer the medication by the specified route; anticipate and recognize potential complications of the medication; recognize emergency situations and institute emergency procedures. Thus the RN would be held accountable for knowledge of the medication and for ensuring that the proper safety measures are followed. National guidelines for administering conscious sedation should be consulted in establishing agency policies and procedures.

The registered nurse administering agents to render conscious sedation would conduct a nursing assessment to determine that administration of the drug is in the patient's best interest.

The RN would also ensure that all safety measures are in force, including back-up personnel skilled and trained in airway management, resuscitation, and emergency intubation, should complications occur.

RNs managing the care of patients receiving conscious sedation shall not leave the patient unattended or engage in tasks that would compromise continuous monitoring of the patient by the registered nurse.

Registered nurse functions as described in this policy may not be assigned to unlicensed assistive personnel.

The RN is held accountable for any act of nursing provided to a client. The RN has the right and obligation to act as the client's advocate by refusing to administer or continue to administer any medication not in the client's best interest; this includes medications which would render the client's level of sedation to deep

sedation and/or loss of consciousness.

The institution should have in place a process for evaluating and documenting the RNs demonstration of the knowledge, skills, and abilities for the management of clients receiving agents to render conscious sedation. Evaluation and documentation of competency should occur on a periodic basis.

http://www.rn.ca.gov/practice/pdf/npr-b-06.pdf

[RN1989]

You say that you have policies written but no one is following them? Does anyone have a clue that this is big lawsuit material?

Obviously you need to implement the policies immediately before someone dies. If the policies do not seem adequate after you actually use them, then you need to rewrite them so that they reflect best practice standards.

What have you done to rectify this? Often I have seen situations where no one followed the policy because a policy was written but the staff had "always done it this way" and they were not told that a new policy had been written. Or people started slacking off because it was easier than fighting the system. No matter - what you are describing is dangerous.

You are also practicing medicine without a license since the physicians are not giving you orders on what meds to give, you are simply giving the meds and telling the docs later. The docs and the nurses should have gone through moderate sedation classes with checkoffs. And no doctor should be allowed to order sedation without having been to the class.

You should never be giving sedation without another person present if the doctor requires assist. The person giving the meds is responsible for all ekg, spo2, vs, loc monitoring. They cannot help perform endo at the same time. This is a death waiting to happen.

Each of these patients must be evaluated for safety in having moderate sedation given by an RN. The doctor has to sign off that this person is stable enough not to have anesthesia by CRNA.

What you are reporting is simply scary. In the old days we did stuff because that was best practice at the time. But what you have described has never been best practice in sedation since I first starting doing it.

You have few choices - leave or get this thing fixed. Your license and that of the docs is hanging in the balance!

[dianah, ASN]

Your department is not in compliance with your hospital's policy (I know you know this).

Your current practice endangers patients as well as the nurses' license (I know you know this as well).

Advise the nurses show solidarity in going to your chief, outlining the issues (what is your BRN statement re: nurses and moderate sedation?) and push for change FOR THE PT AND THE DEPT BENEFIT.

BEFORE patient injury/death or a lawsuit happens.

BEFORE someone loses a license.

Next stop would be your chief's supervisor (perhaps the chief needs a push from above).

Or the Committee that collects the procedural/sedation data (not for tattling purposes, but for guidance for change).

Or RISK MANAGEMENT.

Good luck with this.