Sedation Analgesia: JCAHO Requirements and How to Fulfill Them

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Sedation Analgesia JCAHO Requirements and How to
Fulfill Them

• Norah N. Naughton, M.D.
• Associate Professor
• Department of Anesthesiology
• University of Michigan Health System

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• JCAHO standards for assessment and care of
  patients
• Credentialing physicians
• Nurse competency
• Continuous quality improvement program

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Early 1990s 83 deaths associated with Midazolam
in sedation analgesia settings. Joint
Commission took up patient safety
concerns. 1990-1993 Joint Commission regulated
anesthesiology departments to participate
with divisions to develop policy for
practice. 1994 Uniform conscious sedation
policy. Applicable across entire
institution. 1998 Moderate and deep sedation care
standards are incorporated into anesthesia care
standards.
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Sedation Analgesia
Sedation Analgesia is a clinical practice
whereby the administration of medication results
in a drug induced depression of consciousness to
allow for a diagnostic, therapeutic, or minor
surgical procedure.
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Continuum of Depth of Sedation Definition of
General Anesthesia and Levels of
Sedation/Analgesia(Approved by House of
Delegates on October 13, 1999)
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JCAHO Standards of Anesthesia Care Apply To

• 1. General, spinal, or major regional anesthesia
• 2. Sedation (with or without analgesia) that in
  the manner used may be reasonably expected to
  result in the loss of protective reflexes gt
• Meaning moderate and deep sedation

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JCAHO Standards Related to Moderate and Deep
Sedation and Anesthesia
Assessment of Patients

• PE 1.8.1 Any patient for whom moderate or deep
  sedation OR ANESTHESIA is contemplated
  receives a presedation OR PREANESTHESIA
  assessment.
• PE 1.8.2 Before anesthesia, the patient is
  determined to be an appropriate candidate for
  planned anesthesia.

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Assessment of Patients
JCAHO Standards Related to Moderate and Deep
Sedation and Anesthesia

• PE 1.8.3 The patient is reevaluated immediately
  before moderate or deep sedation use and
  before ANESTHESIA induction.
• PE 1.8.4 The patients postoperative status is
  assessed on admission to and discharge
  from the postanesthesia recovery area.

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Care of Patients

• TX 2 Moderate or deep sedation and
  ANESTHESIA are provided by qualified
  individuals.
• TX 2.1 A presedation or ANESTHESIA
  assessment is preferred for each patient
  before beginning moderate or deep sedation
  and before ANESTHESIA induction.
• TX 2.1.1 Each patients moderate or deep sedation
  and ANESTHESIA care is planned.
• TX 2.2 Sedation and ANESTHESIA options and
  risks are discussed with the patient and
  family prior to administration.

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Care of Patients

• TX 2.3 Each patients physiological status is
  monitored during sedation or ANESTHESIA
  administration.
• TX 2.4 The patients postprocedure status is
  assessed on admission to and before discharge
  from the postsedation or POSTANESTHESIA
  recovery area.
• TX 2.4.1 Patients are discharged from the
  postsedation or POSTANESTHESIA recovery area
  and the organization by a qualified licensed
  independent practitioner or according to
  criteria approved by the medical staff.

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Documentation

• Presedation
• Focused H P
• Airway
• Complications associated with anesthesia
• ASA status
• NPO status
• Baseline vital signs
• Pain score
• Informed consent
• Patient assessment immediately prior to sedation
• Physician signature

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Documentation

• Sedation
• Medications and time administered
• Physiologic monitoring
• BP
• Pulse
• Saturation
• Sedation level
• Intervention and outcome
• Respiratory
• Airway
• Antagonists
• End time

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Documentation

• Postsedation
• Recovery room entry time
• Physiologic monitoring
• BP
• Pulse
• Saturation
• Sedation level
• Pain score
• Discharge criteria met/physician signature
• Time of discharge or transfer
• Discharge instructions

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Physician Credentialing

• able to rescue from next level of sedation
• Moderate ? Deep
• Bag/mask ventilation
• Deep ? Anesthesia
• Bag/mask ventilation
• Immediate hemodynamic support

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Physician Credentialing

• Knowledge of physiology pharmacology of
  medications
• Knowledge of oxygen delivering devices
• Knowledge of required equipment and supplies
• Immediate resuscitation skills how to call for
  help

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UMHS Privileges

• Moderate
• BLS, ACLS, ATLS, PALS, NALS, or UMHS Sedation
  Workshop
• Online test
• OCA application (read guidelines)
• Deep
• ACLS, ATLS, PALS, NALS, or UHMS Sedation Workshop
• Online test
• OCA application (read guidelines)
• (minimum number of annual cases)

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UMHS Sedation WorkshopDepartments of
Anesthesiology and Cardiology

• Adult sedation
• Pediatric sedation
• Hemodynamic resuscitation
• Demonstration of bag/mask skills

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UMHS Nurse Competency

• Initial orientation
• Critical Care Course
• Online test
• Annual
• Online test
• Swat Team
• Bedside sedation in general care areas

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• Quality Indication Screen
• Individual physician tracking
• Division/institution trends
• Quarterly reports
• Sedation level intended/achieved OCA
• Sedation Analgesia QI Committee
• Interdisciplinary
• Reports to ECCA
• Reports to institution risk management
• CQI principles

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Morbidity and Mortality
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Sedation Activity by Location
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Sedation Depth of Sedation
Distribution of Reported Depth of Sedation
Not Reported
Deep
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Over 85 of deep sedations are pediatric patients.
Anesthesia
4
2
Mild
12
Moderate
73
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Sedation Critical Adverse Events
Overall incidence of critical adverse events
1.4
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Lessons Learned

• Support by physician and nursing leadership
• Time
• 30 FTE attending anesthesiologist
• 50 FTE administration
• 50 FTE administration assistant
• Money
• Capital equipment
• Pulse oximeters
• Personal
• 1-2 FTE nurses
• Computer support

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Lessons Learned

• Interdisciplinary effort and institutional
  program, NOT Anesthesiology rules
• Interdisciplinary Task Force
• Determine settings of sedation analgesia
• Survey site specific needs
• One institution guideline
• Anticipate modifications for some divisions
• Consider avoiding inclusion criteria by
  medications used

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Lessons Learned

• Precede clinical roll-out with intense
  educational program
• Staff physicians
• Nurses
• Residents
• Credentialing Program
• Support of physician and nursing leadership
• Expect resistance by staff
• Time and money
• Interdisciplinary effort
• Present as institution requirement

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Lessons Learned

• Quality Assurance Program
• Interdisciplinary
• DO NOT have Anesthesiology Department responsible
  for form routing or database management
• Program for Ongoing Competency Review
• Make this OCA responsibility
• Make this nursing department responsibility