WhiteCoat

“Safer” Conscious Sedation

I’ve performed conscious sedation dozens of times. Never had a problem. Not once.

Until now.

For some unforeseen reason, our hospital has now decided that there are multiple additional hoops through which physicians must jump in order to be credentialed to perform conscious sedation. We have to be certified in ACLS. We have to sit through a course on conscious sedation so that we know the difference between light/moderate/heavy sedation and general anesthesia. Then we have to take a test on the medications we prescribe to make sure that we know that the medications may … make patients drowsy. There are several “pre-procedure” forms that we have to complete to determine how difficult a patient may be to intubate … if intubation is needed. And, while the patients are in their sedated state, there is a six page form that the physicians must complete – in addition to another several page form that the nurses must complete. Looking through all the additional proposed paperwork, I’m not really sure how there will be time to do the procedures when all of the paperwork is required to be filled out and medical care will obviously just get in the way.

Yup. Conscious sedation just became a whole lot “safer.”

I’m glad.

But I just don’t think that the paperwork is appropriate, and I think the overwhelming focus on paperwork is bad medicine. Because of that, I withdrew my privileges for performing conscious sedation. I’m not the only doctor who has done so, either.
Now, if patients need conscious sedation performed while I’m working, the hospital has decided that I am no longer competent to perform the procedure.
From this point forward, patients who need conscious sedation in the emergency department will get an anesthesiology consult and the anesthesiologist can deal with the hassles if every last one of the multitude of checkboxes hasn’t been completed make sure that the conscious sedation is performed properly. That will cost substantially more money be safer.
And from this point forward, if the anesthesiologist is busy in the operating room (which is likely during the day) or is gone for the day (which is likely at night) and can’t come to administer the same medications that emergency physicians administer all the time, the patient will have to be admitted and the procedure will need to be performed in the operating room. That will be even more expensive and time consuming safe.
Patients with dislocations or other painful conditions who need procedures performed will have to wait. I’m competent to give them IV pain medications (we’ll see how long that lasts), but just not IV sedation. Patients who need IV sedation will need to speak to the anesthesia specialists. I’d like to help and I’m able to help, but I’m just no longer certified to help. Everyone is just looking out for your safety.

Now the Medical Marijuana Advocates (nee “the Joint Commission”) has further justified its existence because it can now REVIEW the stack of charting required for every patient that has received conscious sedation and threaten the hospital with decredentialing if every last check box on every last form hasn’t been completed correctly make sure that things are safe. It might even be able to create a booklet to describe how to pass inspection for said paperwork which will cost $595 per year be made available to hospitals. Hospitals will then be able to hire advanced consultants to look over all the paperwork and make sure it is complete before JCAHO comes to visit.

But patients will be “safer” …

at least on paper.

Isn’t that all that matters?

 

26 Responses to ““Safer” Conscious Sedation”

  1. doc99 says:

    Conscious sedation aptly describes the AMA support for PPACA.

  2. 2005LJR says:

    Well put

  3. Second Thought says:

    One opinion is that legally as a physician, we get to the final say in treatment of a patient because of the physcian-patient relationship.

  4. ndenunz says:

    What was the impetus behind this initiative?

  5. xsurgerdoc says:

    Another roll of red tape for those of us who can give clot-busters after WE read and interpret the EKG’s and CT scans, do emergency thoracotomies in the ER, stop an exanguinating femoral artery, entubate anyone we feel is a candidate, push Heparin after WE diagnose a PE; all at 3 AM while one of our gas passing colleagues is home asleep, protecting his/her turf. If we are well trained, experienced,and ACLS certified, where is the supporting data saying that we are not competent to push Propofol, but we can use all the IV Versed and Demerol we want, a much more time-consuming and dangerous approach? I’d especially like to hear the Anesthesiology response: real risk versus $

    • Emily says:

      A to the MEN.

      I would love to hear the anesthesia folks chime in: where is the data on this?

      • SeaSpray says:

        Interesting. Crazy Overkill. It doesn’t make sense they regulate one area and not consider the dangers of the other. Wasn’t there something a few years back where ED docs also had to take a class to do a hemoccult test in ED. It was written about in MDOD blog. A test they had always done ..they now had to have a certification. I may be off slightly with the facts, but it was the gist of it. Seriously ..you ED docs are on the front lines when everything hits the fans and are the ones who initially save the lives and stabilize, etc. Don’t you come into your job *KNOWING* how to do all of it?

      • ER Jedi says:

        @Seapray

        Yes, there is still a certification. As a resident, we all had to pass it this year, be color blind tested and what not. It was about a 30 minute in service, but still annoying.

    • Safely says:

      The definition of moderate sedation states that the patient is able to respond to verbal or light touch stimulation. I am sorry, but you can not give adequate “sedation” to a patient and then try to relocate their hip, or do many of the other procedures that you are describing. This falls under MAC anesthesia and should not be documented as anything else.

      • Steve says:

        Does it really matter if you call it “deep sedation” (which is acceptable per the ACEP procedural sedation guidelines) or MAC? Now it is just a quibble over the definitions…unless you are implying that anything more than “moderate sedation” needs to be done by a credentialed anesthesia provider. In that case, I would refer to my other posts on this thread as to why the levels of sedation are useless and why the ED is an appropriate place to do all levels of sedation.

  6. SeaSpray says:

    This post should be a mandatory read for administration. Why can’t you all unite and fight back?
    **********************

    “while the patients are in their sedated state, there is a six page form that the physicians must complete – in addition to another several page form that the nurses must complete. ”

    Wait! Are you saying that the patients will be kept in their sedated state *longer than necessary* BECAUSE the physicians now have to fill out forms BEFORE the patient is woken back up?? Potentially putting the patient at more risk?

  7. Ben Rush MD says:

    Soon you’ll need credentialling to play Pink Floyd’s “Comfortably Numb.”

  8. Julie Stephenson says:

    Thank God I am a veterinarian because, while there are specialties, currently, I am able to do my own sedations, surgeries, x-rays, cardiology, or refer as I see fit, which is quite often. But I do like the ability to do what I am comfortable and trained to do.

  9. Jason Timmy says:

    Nice input! Another precious sector of ‘Medicare’ what we generally don’t give more attention. Thanks for your notice and focus on it.
    http://er247plus.com/

  10. Nurse K says:

    I tweeted about this, but a doc in my ER wants to do conscious sedation (propofol, etc) whenever adults say they want to be “knocked out” for anything, whether it’s a boil I&D, a disimpaction (yes, true story), stitches, or whatever.

    Seriously, I think this must be for people like him who use it inappropriately, putting people at risk unnecessarily. A couple of our docs don’t know the doses for this stuff and ask me to look up the doses for Propofol or Etomidate or whatever for them.

    No offense, but there has to be some iteration of protecting people against the lowest common denominators.

    • immerly says:

      Propofol and etomidate are not conscious/moderate sedation — they are deep sedation/monitored anesthesia care (MAC). That is likely where all of this comes from. Too many providers (nurses and docs) talk about them like they’re the same thing, and they’re not. Where I work, we use etomidate and call it “moderate” sedation. As an RN, I’m completely comfortable monitoring either one. What I’m uncomfortable with is calling deep sedation “moderate” and applying the standards of moderate sedation to deep sedation. Why? Because it’s a legal nightmare. One adverse event and we’re screwed — we won’t have a legal leg to stand on once someone points out that we were using monitoring standards for “moderate” sedation while actually doing “deep” sedation.

      • Steve says:

        Propofol really blurs that line in between moderate and deep sedation and its one that we should probably ignore anyway. The definitions are so close together that it really doesn’t matter and you aren’t necessarily going to get worse outcomes with deeper sedation. With propofol, sometimes we get moderate sedation, sometimes its deep but it doesn’t matter. What matters is that you have the right equipment to deal with any complications- an airway cart at the bedside, an airway plan, end tidal CO2, constant cardiac and pulse ox monitoring, etc. Sometimes we need deep sedation- most of the time a dislocated hip isn’t going back in unless you get the patient a little deep.

        As far as the original post- talking about these issues is the fastest way to raise my blood pressure on a shift. It infuriates me that I have been trained to use these drugs and trained to deal with their consequences but that ability is being taken away for some arbitrary reason.

        These regulations shouldn’t really apply to an ED- where they should be applied is on medical floors and doctor’s office without the necessary monitoring equipment. The ED is a critical care setting- no different in capabilities compared to the OR when it comes to procedural sedation for appropriate sedations. That being said, we have turned down requests from ortho to do procedural sedation on 90 year olds with afib, COPD, and CAD all the time. You are safer taking that patient to the OR and probably just putting a tube in but the majority of cases we are talking about don’t come close to that situation. There is a mountain of literature to say that ED procedural sedation with any agent out there is safe and effective.

        Whitecoat- I hope more of your colleagues join and the complaints are so numerous that the hospital has no choice but to give it back.

    • Nurse K says:

      Yes, I mis-said conscious sedation; it would be moderate or deep sedation. We get the monitors and the RT with the bag and the dedicated nurse (who has two-three other patients they have to assign to someone else for a half hour, etc), but the procedures ARE used for inappropriate reasons by untrained people. No one who is properly trained would even consider propofol for a disimpaction!!!

      BELIEVE IT OR NOT, BUT NOT ALL DOCTORS WORKING IN AN ER WERE TRAINED IN EMERGENCY MEDICINE, AND, EVEN THOSE THAT WERE MIGHT HAVE BEEN TRAINED BEFORE PROPOFOL AND ALL THAT WERE INVENTED. I think only half of the doctors in my ER ever did an ER residency. Some of the older doctors are even throwbacks to the era where ER doctors were people whose licenses in internal medicine or surgery were taken away.

      • Steve says:

        Re: procedural sedation for disimpaction and I and D

        I have come around on this one after it being discussed on EM:RAP a few months ago (a very popular EM CME podcast). Every disimpaction I have done with just narcotics on board has had the patient howling. Even with a solid dose of fentanyl its still horrible for the patient. In correctly trained hands, why not use propofol? (I’ll get to that in a second). Its an immensely painful and uncomfortable procedure that we tell the patient to just suck it up. Why should we do that when we have an extremely safe drug that will take away the patient’s suffering while we are wrist deep in their rectum?

        I and Ds can be immensely painful- especially in the axilla- and local anesthesia doesn’t do squat when you have to explore and break up loculations (although that new loop abscess technique looks promising for not doing exploration but you can’t use it on the smaller abscesses). I wanted to do procedural sedation on an 11 year old with an abscess in the axilla but got shot down because “we don’t have enough staff, just use fentanyl, blah blah blah.” Never again. I caused a lot of unnecessary pain and suffering to a nice kid.

        I just got done a rotation at a Peds hospital. They don’t even have a papoose in their ED. Doesn’t exist. They use intranasal versed/fentanyl and its not even considered procedural sedation that requires a 1:1 nursing. (*Audible gasp from most people reading this*) No IV, no pain, a little stinging in the nose, and you have a child that will hold still for any lac repair anywhere on their body. Its beautiful, its fantastic. They are on monitors but they don’t desat. Even if you just give versed intranasal without the fentanyl most get relaxed enough to let you sew their face. No more kicking and screaming, no more holding kids down on a papoose board- its awesome. Ready for primetime at a small community ED?- maybe not but it could be done with the right motivations and procedures in place. I would also encourage people not to automatically shoot down this idea if you start hearing about it. Watch it one time and you will be a believer.

        I understand that not everyone has done an EM residency and while its the best way to learn things like procedural sedation, it’s not the only way. You can go to a course and do some cases with anesthesia in the OR. Just because you haven’t done EM training doesn’t mean that you can’t learn how to do this safely and effectively. Maybe you don’t work with the brightest bulbs at your shop and that will always be the case but you shouldn’t blindly bar all non-EM trained docs from doing something that they can be taught to do safely. Should that same non-EM trained doc not be allowed to use a glidescope just because they didn’t train on it during residency? How are you supposed to progress your knowledge and skills if you don’t keep up with the literature and newest skills?

        There’s nothing magical about learning how to use propofol- where people run into trouble is not having a plan and being prepared for a complication. The nurses sometimes roll their eyes when I ask for the RSI kit at the bedside for all of my procedural sedations. However, if something goes wrong (like severe masseter spasm and myoclonus from etomidate) and I need to intubate, I don’t want to wait for someone to grab the RSI kit so I’m always prepared.

        You seem to be very concerned with propofol. That’s fine- suggest ketamine instead. Since it preserves your respiratory drive people rarely get into trouble unless you push it too fast (causes apnea) and very rarely laryngospasm (usually transient and will respond to bagging). Its even used for general anesthesia in 3rd world countries. It won’t get you as deep as propofol to put a hip back in but it will work fine for most procedures. You could give ketamine to the most incompetent EM doc out there and even without using monitors they would probably go their entire career without having a problem.

        Alright- this is long enough. But its great to see a good discussion on these topics- its a good thing.

      • ThorMD says:

        Hey Steve – in most ED’s I’ve worked in, given intranasal versed is considered anxiolysis and not moderate sedation. So I often give either PO or intranasal versed to calm kids down. It works great for suturing and minor procedures. I’ve even used to prior to starting an IV in autistic kids. Kinda like giving an adult some Ativan. No moderate sedation paperwork or 1:1 nursing needed.

        OTOH, I can’t ever imagine sedating someone for a BM. That’s a little beyond the pale for me.

    • anonymous says:

      ACKKK!!!! Don’t waste etomidate for that!!!!!! It is in shortage.

  11. Xsurgerdoc says:

    Steve, well said. Even the rural level 3 and 4 ERs I work in have very well trained, competent RTs and very adequate monitoring equipment which makes the brief propofol anesthesia very safe. This is a COMMON SENSE issue. Don’t eat the daisies and take the chronically Ill eldly to the OR. Otherwise, what incidents, real or imagined started all this?

  12. Dan says:

    As a patient this horrifies me. I know that if I had a bad dislocation I’d be begging for concious — or hell, unconcious — sedation. I’m guessing the administrators who penned this wonderful program would feel the same. If this came about because of a lawsuit, I’m guessing the lawyer who filed would as well.

  13. This is what ObamaCare (PPACA) is really about. By burdening us with insane regulations, healthcare will ultimately be left to those who would be clock-punching government employees. This is just one example of the madness. Great piece. Demand reform in government!

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