Patient Safety

3 Key Steps for Safe Moderate Sedation

In January 2016, the Association of periOperative Registered Nurses (AORN) released Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia.

As stated by AORN, the goal of moderate sedation is:

drug-induced, mild depression of consciousness achieved with the use of sedatives or a combination of sedatives and analgesic medications, most often administered intravenously, and titrated to achieve a desired effect … to reduce the patient’s anxiety and discomfort.

AORN in releasing this guideline warns that the “patient may slip into a deeper level of sedation than intended; therefore, practitioners who administer moderate sedation/analgesia should be able to rescue a patient who enters deep sedation/analgesia.”

There are three keys to AORN’s Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia:

#1 – At All Times, The Perioperative Nurse Should Have Immediate Visual and Physical Access to the Patient

As the AORN guideline states, the perioperative nurse must have constant vigilance on the patient to “monitor the patient, administer the sedation and analgesia medications, and continuously care for the patient throughout the procedure.”

This means that only brief interruptible tasks (such as tying a sterile gown or opening supplies) are permitted – and these brief interruptible tasks are only permitted if they are done within the room, and not if the patient is receiving propofol.

Ideally, a nurse should be at every patient’s bedside watching, observing, and caring for that patient on a continual basis. However, the reality of the current work environment is that a frenetic pace, high workload and numerous administrative demands reduce nursing time with patients.

As Lillee Gelinas, RN, MSN, FAAN (then vice-president and chief nursing officer, VHA Inc.; currently System Vice President and Chief Nursing Officer, CHRISTUS Health) says:

Too much of nurses’ time is spent in activities other than in actual patient care. The majority of nurses’ time is spent in ‘hunting’ and ‘gathering’ – types of activities, like finding the right supplies. In addition, they are documenting, coordinating care, and administering medications. Not enough time is actually being spent at the patient’s bedside, assessing, teaching and ‘caring’.

The AORN guideline is emphatic about the need for undivided nursing attention to the patient.

#2 – The Patient Must be Screened for Obstructive Sleep Apnea

The AORN guideline emphasizes the dangers of not assessing patients for obstructive sleep apnea (OSA) particularly given the rate of undiagnosed OSA:

The undiagnosed range of moderate to severe OSA is estimated at 82% for men and 92% for women. Surgical patients have a reported higher incidence than the general population. The number of patients with OSA is likely to increase as the population ages and becomes more obese.

Assessing for OSA and then ensuring that care is tailored to the OSA patient could prevent adverse events and death. Perhaps such assessment and care would have saved the life of John LaChance:

Patricia LaChance talks about the death of her husband, John.

Click on the image to watch a video of Patricia LaChance speaking about the death of her husband, John.

#3 – The Patient Must be Monitored with Pulse Oximetry and Capnography

The AORN guideline emphasizes that the patient must be monitored with pulse oximetry for oxygenation and capnography for adequacy of ventilation:

the perioperative RN should monitor exhaled CO2 (ie, end-tidal CO2 [EtCO2]) by capnography in addition to SpO2 by pulse oximetry during moderate sedation/analgesia procedures. Also, the perioperative RN should continuously observe the adequacy of the patient’s ventilation. Monitoring the patient’s EtCO2, SpO2, and performing visual assessments completes the cycle of respiratory monitoring of oxygenation and ventilation of patients undergoing moderate sedation/analgesia.

This call for monitoring with both pulse oximetry and capnography mirrors the paradigm shift in monitoring of patients called for by the Anesthesia Patient Safety Foundation (APSF). As Robert Stoelting, MD (President, APSF) stated:

It’s time for a change in how we monitor postoperative patients receiving opioids. We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.

The APSF released a video highlighting that continuous electronic monitoring of oxygenation and ventilation, when combined with traditional nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment.  To view the video, please click here.

For frequently asked questions and answers regarding AORN’s Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia, please click here.

 

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