Conscious sedation: Here’s how to comply with JCAHO
Conscious sedation: Here’s how to comply with JCAHO
By Sue Dill Calloway, RN, BA, BSN, MSN, JD
Several weeks ago I was working as a nurse in the ED. A patient came in with a "gunshot wound" and the usual trauma alert was called. He had been cleaning his gun as it leaned against the outer part of his shoulder and it went off. After the preliminary care was done and the wound was found to be superficial, he was transferred from trauma services to a regular bed in the ED. A physician had decided to debride and clean the wound under conscious sedation. I was assigned to be the patient’s nurse.
After getting a report from the other ED nurse, I assessed the patient myself. The patient was a healthy 23-year-old male who had no allergies, took no current medications, and had no medical problems. I then proceeded to prepare for providing intravenous conscious sedation.
Conscious sedation is a medically controlled state of depressed consciousness that allows protective reflexes to be maintained, retains the patient’s ability to maintain a patent airway, and continuously permits appropriate response by the patient to physical stimuli or verbal command, such as "open your eyes."
Our hospital has mandated that all nurses perfroming conscious sedation be qualified. A mandatory education packet had to be reviewed and a test taken to insure that a uniform level of care was being done, no matter what department in the hospital was involved, and that all persons doing conscious sedation have the skills necessary to provide quality care. This handout material included information on proper dosages, administration, adverse reactions, and interventions for adverse reactions and overdoses. It included information on how to recognize an airway obstruction.
All the ED nurses are ACLS certified. Information was provided on assessing the total patient care requirements, including oxygen saturation, respiratory rate, cardiac rate, blood pressure, and level of consciousness. We had stickers made up with the Aldrete score that could be placed right on the ED nursing notes.
Our hospital is accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), so I needed to ensure compliance with these standards. I first made sure the appropriate equipment was present (LD.1.3.2- this number is the corresponding section that shows the requirement in the JCAHO Comprehensive Manual for Hospitals—LD stands for the leadership standard and the section number follows it.)
The patient was placed on the cardiac monitor and I attached the pulse oximeter to his finger. We have all the emergency equipment nearby, such as the crash cart, medications with reversal agents, defibrillator, intubation equipment, airways, et al. Oxygen and suction are available at the bedside. The patient already had an IV, which I had assessed was patent. I was ready for my part and I wanted to check the cart.
The physician had privileges to do the procedure (MS.5.14). A history and physical was not on the chart and the physician said he could write one (PE.1.7 and see MS6.3). A presedation assessment was done (PE.1.7.1). The patient had no problems with analgesics or anesthesia before, he did not snore, had no chronic airway problems and no allergies. He was determined to be a candidate for conscious sedation by the physician as required ( PE1.7.2).
Next, I checked to be sure the informed consent was on the chart and it was. It discussed the procedure, risks, benefits, and alternatives as required in the Treatment of Patients section TX.5.2.1 and the sedation risks were discussed (TX.2.2). The physician affectionately referred to me as the "conscious sedation police" and asked if there was anything else to be done. I told him I thought we pretty much nailed the pre-conscious sedation standards and we could commence.
I administered the IV medication, and my job was to continuously monitor the patient’s vital signs and complete the Aldrete score after the Versed was given. One of the things I always carry in my pocket is a nice chart that lists each of the drugs commonly given during conscious sedation, the route, suggested usual sedation dose, when sedation monitoring is optional and when it is required, and the onset and duration of each drug. My list includes Midazolam (Versed), Lorazepam, Diazepam (Valium), Pentobarbital, Morphine, Meperidine (Demerol), and Fentanyl. We don’t do pediatrics, so we never use lollipops containing drugs.
The patient was monitored during conscious sedation (TX.2.3) and did fine. Post conscious sedation, the status was assessed (PE.1.7.4) and stable and fully awake. We did not have to worry about using discharge by criteria, as required by TX.2.4.1, since the physician determined the patient was stable and could now be transferred to his room since he was being admitted. My job was now over. I am not sure who collected the process and outcome data in our organization (PI.3.1.1) or what data was evaluated. Facilities doing conscious sedation generally review the medical records to ensure that quality care was given. A chart review is usually done to make sure that appropriate documentation is in the medical record, such as current medications; past medical problems; allergies; level of consciousness; appropriate monitoring devices used; dose; route and effect of medication; use of any interventions, such as oxygen; and untoward side effects of the procedure.
A quality improvement tool might include a check-off list to ensure there was continuous cardiac monitoring, pulse oximeter, respiratory rate, level of consciousness, whether medications were administered according to the policy, if informed consent was on the chart, and any undesirable effects from the medication. Any adverse event should be intensively evaluated as required by PI.4.3.
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