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Despite its impact on emergency medicine, the CMS guidelines seemed to have been aimed at another area of the hospital: endoscopy suites. One part of the guidelines reads as follows:
“An example of deep sedation would be a screening colonoscopy when there is a decision to use propofol, so as to decrease movement and improve visualization for this type of invasive procedure. Because of the potential for the inadvertent progression to general anesthesia in certain procedures, it is necessary that the administration of deep sedation/analgesia be delivered or supervised by a practitioner as specified in 42 CFR 482.52(a).”
EPs are happy to be counted among those that may administer deep sedation/analgesia, but are frustrated at being lumped in with many other “non-anesthesiologists” such as dentists and podiatrists. While no one contends that EPs are anesthesiologists, emergency medicine specialty training, from board certification to daily practice, does provide for knowledge and skill that others might not possess.
How each hospital will implement the guidelines is yet to be determined. But taking a wait-and-see attitude would appear to be a recipe for exclusion from the process. EPs need to consider approaching their hospital leadership – including the anesthesiology department – to drive this process. Some EPs will find their leadership completely supportive of the ED and collaboration with anesthesia an easy solution. Others will not.
From a credentialing perspective, EPs will be well advised to make certain that moderate sedation is accepted as part of their core privileges and attempt to include deep sedation in the same package. Failing that, EPs will need to develop a mechanism to apply for this procedure, even if that means swallowing a little pride and consenting to testing of your knowledge of anesthetic agents. In the short run, this may be a reasonable interim step. If you don’t have access to deep sedation, kiss propofol goodbye, except for mechanically ventilated patients.
EPs also need to develop plans for the safe delivery of deep sedative agents, such as propofol. This includes development of an appropriate “anesthesia record” to monitor quality, including the use of capnography on all patients receiving procedural sedation. A formal performance improvement program is required under these regulations. As EPs monitor quality, verifying their practice is safe, it will become increasingly difficult for anyone to justify blocking their access to such agents.
Although not specifically addressed in this CMS “clarification,” a logical interpretation of past guidelines is that the qualified provider will not be allowed to perform the procedure as well as provide the deep sedation. In double-covered departments, this will present no problem. However, single coverage EDs will struggle to meet this standard.
First used for post intubation sedation for those on mechanical ventilation and more recently for procedural sedation, propofol has done for deep sedation what etomidate accomplished for rapid-sequence intubation. These two medications have revolutionized the way we care for patients, making RSI easier and safer, and allowing us to address many painful procedures safely with predictable patient comfort. Many might wonder how they would function if either of these become unavailable.