Sedation Analgesia: JCAHO Requirements and How to Fulfill Them

1. Sedation Analgesia: JCAHO Requirements and How to Fulfill Them Norah N. Naughton, M.D. Associate Professor Department of Anesthesiology University of Michigan Health System

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

3. Early 1990’s 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.

4. 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.”

5. Continuum of Depth of Sedation Definition of General Anesthesia and Levels of Sedation/Analgesia(Approved by House of Delegates on October 13, 1999)

6. 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 => Meaning moderate and deep sedation

7. 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.

8. JCAHO Standards Related to Moderate and Deep Sedation and Anesthesia Assessment of Patients PE 1.8.3 The patient is reevaluated immediately before moderate or deep sedation use and before ANESTHESIA induction. PE 1.8.4 The patient’s postoperative status is assessed on admission to and discharge from the postanesthesia recovery area.

9. 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 patient’s 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.

10. Care of Patients TX 2.3 Each patient’s physiological status is monitored during sedation or ANESTHESIA administration. TX 2.4 The patient’s 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.

12. 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

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

14. 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

15. Physician Credentialing “able to rescue from next level of sedation” Moderate  Deep • Bag/mask ventilation Deep  Anesthesia • Bag/mask ventilation • Immediate hemodynamic support

16. 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

17. 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)

18. UMHS Sedation WorkshopDepartments of Anesthesiology and Cardiology • Adult sedation • Pediatric sedation • Hemodynamic resuscitation • Demonstration of bag/mask skills

19. UMHS Nurse Competency • Initial orientation • Critical Care Course • Online test • Annual • Online test • Swat Team • Bedside sedation in general care areas

21. 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

22. Morbidity and Mortality

23. Sedation Activity by Location

24. Sedation: Depth of Sedation Distribution of Reported Depth of Sedation NotReported 9% Deep Over 85% of deep sedations are pediatric patients. Anesthesia 4% 2% Mild 12% Moderate 73%

25. Sedation: Critical Adverse Events Overall incidence of critical adverse events = 1.4 %

26. 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

27. 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

28. 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

29. 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