A nurse is monitoring a client recovering from moderate sedation

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The challenge: keeping your patient safe while protecting your license in the practice and care of patients receiving sedation

By the MNA’s Congress on Nursing Practice with assistance from the Mass. Board of Registration in Nursing

setting. Responsibilities may include the administration and management of mild, moderate or deep sedation. Areas of practice for the nurse in this procedure often include the emergency room, intensive care areas, surgical and outpatient services. There are several challenges RN's face when administering sedation in the work setting. For example, consideration must be given to the following criteria:

The competency of the prescriber
The policies of the hospital
The effect of the medication ordered
he competence of the nurse experienced in airway management
Advanced life support skills to monitor the patient during and after administration

The American Society of Anesthesiologists (ASA) define the levels of sedation as follows: 1

“Minimal sedation is defined as a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilation and cardiovascular functions are unaffected.”

“Moderate sedation/analgesia is defined as a drug-induced depression of consciousness during which patients respond purposely to verbal commands, either alone or accompanied by light tactile stimulations; patients do not require intervention to maintain a patent airway, maintain adequate spontaneous ventilation, and usually do not require intervention to maintain cardiovascular function.”

“Deep sedation/analgesia is defined as a drug-induced depression of consciousness during which the patient cannot be easily aroused, but responds purposely following repeated or painful stimulation. The ability to maintain independent ventilator function may be impaired and may cause spontaneous ventilation to be inadequate. The patient may require assistance in maintaining a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.”

As nurses, we must consider multiple factors in caring for patients who receive sedating medications. It is not always possible to predict the potential for rapid or profound changes in sedative or anesthetic depth during sedation. Drugs such as Propofol or Etomidate (short acting hypnotics used for sedation) require delivery of care consistent with that required for deep sedation. Other considerations when caring for the sedated patient are the competency and availability of the practitioner who is proficient in airway management and advanced life support to correct the adverse physiologic
consequences that come with a deeper than intended level of sedation.

The American Association of Nurse Anesthetists has issued the following statement on Conscious Sedation, “Conscious Sedation is extremely safe when administered by qualified providers. Certified Registered Nurse Anesthetists (CRNA's), anesthesiologists, other physicians, dentists, and oral surgeons are qualified providers of conscious sedation. Specifically trained Registered Nurses may assist in the administration of conscious sedation. The AANA (American Association of Nurse Anesthetists) further states “that the provider who monitors the patient receiving conscious sedation should have no other responsibilities during the procedure and should remain with the patient at all times during the procedure.” 2

The Joint Commission Hospital Anesthesia Care Standards require that the individuals who are “permitted” to administer sedation are able to rescue patients at whatever level of sedation or anesthesia is achieved. Minimal to moderate sedation is a continuum and patient response can be unpredictable. 3

Laurie Talarico MS, RN, NP, Nursing Practice Coordinator Massachusetts Board of Registration
in Nursing was consulted regarding Conscious Sedation in May 2010. This advisory was updated on October 2013 and the title changed to Administration of Medications for Sedation/Analgesia.

The revised advisory dated 10/13 is as follows:

Advisory: The RN licensed by the Board will engage in the practice of nursing in accordance with accepted professional standards. The nurse must only assume those duties and responsibilities within the scope of practice for which necessary knowledge, skills, and abilities have been acquired and maintained.

Administration of Medications Intended for Mild to Moderate Sedation The RN who is duly educated and qualified may receive, accept and transcribe orders from duly authorized prescribers for medications capable of producing minimal to moderate sedation/analgesia.

The RN may administer medications intended for minimal to moderate sedation/analgesia when ordered by a duly authorized prescriber.

Professional standards recognize the nurse as responsible and accountable for possessing the knowledge and abilities to perform the activity safely, effectively and competently but not limited to:

patient selection and screening;
pharmacological selection, properties and mechanism of physiological response;
competent and safe administration of the medication by the specified route;
ability to anticipate and recognize potential complication of the medications being administered;
ability to recognize and appropriately react to emergency situations.

Organizational policies must include but are not limited to:

Listing the specific medication to be used for sedation/analgesia including the purpose, goals, techniques, desired outcomes of administration, and the recommended dose per kilogram of body weight that may be safely administered by a RN taking into account the patient's age and co-morbidities;
Nursing care responsibilities, including, but not limited to patient assessment, monitoring, medication administration, potential complications and documentation criteria;
Emergency protocol(s) including, but not limited to, immediate, on site availability of resuscitative equipment, medications and personnel
Protocols for assessing and documenting the education and validation for RN initial competency and continued competency; and
Protocols for provision of clear, complete and culturally informed consent.

Administration of Medications Intended for Deep Sedation 4

A RN who is duly educated and qualified may receive, accept and transcribe orders from duly authorized prescribers for medications capable of producing deep sedation.

The RN may administer medications intended for deep sedation when ordered by a duly authorized prescriber to a patient who is intubated.

The RN may administer medications for deep sedation when ordered by a duly authorized prescriber to a non-intubated patient when in addition to those listed above, organizational policies must require:

The registered nurse whose sole responsibility is to manage the patient's airway does so in the presence of a provider trained in anesthesia or expert in airway management; and
Uninterrupted monitoring of patient consciousness and the early detection of adverse signs of deep sedation is provided by an individual with no other significant responsibilities that would compromise or compete with his/her ability to continually monitor the work.

The Massachusetts Board of Nursing also reissued an Advisory Ruling on Verification of Orders on
December 9, 2009. This advisory was formerly titled Verification of Medication Orders. It once again emphasizes the nurse's role in the delivery of safe patient care with accepted standards of care to minimize error.

In reviewing the nurses' role in mild to deep sedation, the criteria are specific. The workplace will have an infrastructure to ensure the safety of the patient, defining policy, nursing practice and competency.

The MNA reminds nurses that RN's are accountable for ensuring that the orders executed are consistent with current standards of care and should ask themselves the following questions to ensure patient safety and to protect his (her) nursing license;

Does the workplace have a policy/procedure to ensure the prescriber has the education and training to manage the potential complications of sedation/anesthesia?
Will the anesthesia provider be present throughout the entire sedation period, be ACLS
trained and have the management of the patient's airway as their sole responsibility?
Does the nurse administering the medication possess the knowledge, skills and abilities to perform the activity safely, effectively and competently?

If the answer is no to any of the above questions, the nurse should reject the assignment because nurses are accountable for all of the care they deliver. If a situation is deemed unsafe or you lack knowledge, skills and abilities to care for patients receiving conscious sedation, you should report this to your supervisor and reject the assignment. As licensed nurses, you have the obligation to practice safely, guided by the policies in your workplace, the Massachusetts Board of Registration in Nursing Nurse Practice Act, and the Advisory Ruling on Administration of Medications for Sedation/Analgesia Advisory ruling 9101,

September 11, 2013.

References

1 American Society of Anesthesiologists. ASA Standards, Guidelines and Statements October 2007. 2 AANA/ASA Joint Statement Regarding Propofol Administration. Available at www.aana.com. Sept. 12, 2005. 3 CAMH Refreshed Core, January 2007 Provision of Care, Treatment and Services, Standards for Additional Special Procedures pc 41-42

4 Mass Board of Nursing Advisory, ruling number 9101, September 11, 2013.

Approved: BOD Sept. 16, 2010

Congress on Nursing Practice

Linda Barton, RN, BS, CCRN Susan Marston, RN, MS Linda Winslow, RN, BS Marianne Chisholm, RN, BSN Peg Taylor Careau, MEd, MS, RN Beth Piknick, RN, BS Mary Keohane, RN LeAnn Tibets, RN, BSN, CMSRN

Staff: Dorothy McCabe, RN, MS, MEd

Massachusetts Nurses Association

Since its founding in 1903, the Massachusetts Nurses Association (MNA) has been the most powerful and effective voice on nursing and health care in the Commonwealth.

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