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Sedation Guideline at a Glance (Nursing Practice Guideline)

Sedation Guideline at a Glance (Nursing Practice Guideline) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines


Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
1
Guideline Title: Sedation
Effective Date: May, 2016
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council
I. Guideline Overview
Target Population
Adult and pediatric patients undergoing procedures receiving minimal, moderate and/or deep sedation; including
patients who become sedated beyond (or in excess of) original intent, as a result of sedative agents.
The scope of this guideline includes procedures requiring sedation in the ambulatory setting, on inpatient units, in
procedural areas, and in the emergency department.
Nursing Practice Guideline Objectives
The main objective is to provide an evidence-based guideline for inpatient and outpatient assessment and
monitoring of patients who receive sedation (minimal, moderate, deep).
Clinical Questions Considered
1. How do I prepare a patient and the environment for minimal, moderate and/or deep sedation?
2. What are the risk factors for adverse events such as over-sedation or airway compromise?
3. How should I assess and monitor my patient before, during, and after sedation?
For more information, please see the complete guideline.
DEFINITIONS
The following definitions are extracted from the America’s Society of Anesthesiologists’ Continuum of Depth of
Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia (click here for more details).
Minimal Sedation (anxiolysis): A drug induced state during which patients are quiet, drowsy and respond normally
to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular
functions are unaffected. Level of awareness for minimal sedation correlates with a Ramsey sedation score of 1, 2 or 3
on the adult sedation scale or Pediatric sedation score of 1, 2, 3.
Moderate Sedation/analgesia ("conscious sedation"): A drug-induced depressed level of consciousness during
which patients respond appropriately to verbal commands, either alone or accompanied by light tactile stimulation. The
ability to independently maintain ventilatory and cardiovascular function is retained. No interventions are required to
maintain an adequate airway and pulmonary ventilation. Level of awareness for moderate sedation correlates with a
Ramsey sedation score of 4 on the adult sedation scale or score on Pediatric sedation score of 4.
Deep sedation/analgesia: A drug-induced depressed level of consciousness during which patients cannot be easily
aroused but respond appropriately to painful stimulation. The ability to independently maintain ventilatory and
cardiovascular function may be impaired. Patients may require assistance in maintaining an adequate airway, but
ventilatory drive is usually sufficient to avoid the need for positive pressure ventilation. Level of awareness for deep
sedation correlates with a Ramsey sedation score of 5 on the adult sedation scale or score on Pediatric sedation score of
5.
General Anesthesia: A drug-induced loss of consciousness during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require
assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed
spontaneous ventilation or drug- induced depression of neuromuscular function. Cardiovascular function may be
impaired. This correlates with pediatric sedation score of 6 and Ramsey sedation score of 6.
Inadequate-sedation-analgesia: Increased arousal/change in level of consciousness as a response to stress and
may result in undue patient discomfort.
University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance

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Over-sedation: A level of sedation that is deeper or lasts longer than intended. It occurs as a result of accumulation
of sedative and analgesic medications and is associated with prolonged ventilatory monitoring and/or assistance.
II. Practice Recommendations
Use this active table of contents to directly link to individual sections of the practice recommendations.
I. General Recommendations for Procedure-Related Moderate and Deep Sedation
A. Nursing Considerations
B. Considerations for Specific Patient Populations
II. Assessment and Monitoring
A. Preparation
B. Pre-Sedation
C. Intra-Procedure
D. Post-Procedure Monitoring
III. Deep Sedation
A. General Considerations
B. Assessment and Monitoring
For more information about rating scheme used to describe strength of recommendations, see below.
I. General Recommendations for Procedure-Related Moderate and Deep Sedation (C IIa)
A. Nursing Considerations
1. Moderate and deep sedation procedures may cause cardiovascular and respiratory depression and
therefore require more frequent assessments.
2. Nurses should be able to recognize changes in the continuum of sedation and rescue the patient from
the various sedation levels.
3. Level of sedation goal should be based on clinical circumstances such as anticipated pain of
procedure, need for immobility, and patient anxiety.
4. Nurses administering moderate sedation should be trained to administer medications and monitor the
patient during intra-procedure, phase 1 and 2.
5. Nurses prepping the patient and recovering the patient should be knowledgeable regarding
medication side effects and potential complications of moderate sedation.
6. Nurses involved in moderate sedation need to have access to emergency equipment and personnel
with advanced airway skills.
7. Nurses should be knowledgeable about the risk factors for over-sedation such as:
a. patient is unable to handle secretions without aspiration
b. patient is unable to maintain a patent airway independently or independent ventilation
(excludes mechanically ventilated patients)
c. patient has severe systemic disturbance or disease which limits activity
d. patient has received opioids, benzodiazepines, or initiated therapy with any central nervous
system (CNS) depressant within the past 6 hours
e. patient has begun extended release opioids, received methadone, or intraspinal/epidural
opioids within the past 24 hours
f. patient has begun receiving opioids via an implantable pump within the past 72 hours
g. sedative drug is administered intravenously (regardless of drug or dose used)
h. two or more sedative drugs are administered concomitantly or sequentially such that there
is an overlap in the duration of action, which places the patient at increased risk for airway
compromise
8. Any complications or sudden change in condition should be reported immediately to the provider.
a. Conduct a rapid assessment of patient and equipment to determine possible cause(s)
b. Consider the use of reversal agents, if needed
c. Nurses should be knowledgeable about the special considerations when using reversal
agents:
i. Patients who receive reversal agents need to be recovered for minimum of 2 hours
after reversal agents are given to assure the patient doesn't become re-sedated
once the reversal agents wear off
ii. Initially, reversal medication should be intended to reverse the last dose of sedative
iii. Careful consideration should be given to reversal agents in patients with seizure
disorders, chronic opioid or benzodiazepine use, or complex medical history. The
reversal agent may have an impact on their condition and usually last shorter than
the benzodiazepine or opioid
iv. When reversal agents are administered to patients with respiratory depression,
abrupt reversal can cause pain, hypertension, tachycardia or pulmonary edema
v. Whenever a reversal agent is administered, organizational requirements specific to
safety reporting should be followed

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9. The nurse should be aware of and abide by organizational policies regarding provider credentialing to
perform sedation and to direct airway management and cardiopulmonary resuscitation.
B. Considerations for Specific Patient Populations
1. Additional considerations for patients receiving sedation: Some patient populations such as pediatrics,
pregnant and lactating women, patients with sleep diagnosis that require the use of CPAP, BiPAP, or
other forms of ventilation, elderly and/or those with previous problems with anesthesia or sedation,
as well as patients scored to be “at risk” for sleep apnea, with co-morbidities and anatomic variants,
may need special consideration related to their sedation plan.
2. Anesthesia should be consulted for severely compromised or medically unstable patients (difficult
airway, severe COPD, severe heart disease) or in situations where the patient will need to be sedated
past the point of responsiveness. Note that this list is not all inclusive for situations when anesthesia
might be needed.
II. Assessment and Monitoring (C IIb)
A. Preparation
1. Nurses should follow organizational policy requirements related to verification of provider credentials.
Refer to I.A.9 above.
2. Nurses should prepare the environment and ensure that appropriate equipment is in procedure room
with patient prior to the sedation initiation.
a. The following equipment will be available in the procedure setting: oxygen delivery
devices, suction apparatus (setup and ready to use), noninvasive blood pressure cuff, EKG
(if required), pulse oximetry, opioid and sedative reversal agents, and an Intravenous line.
b. Oxygen equipment should be immediately available.
3. The nurse should review patient’s pertinent history, laboratory values, NPO status and allergies.
Additional assessments include:
a. Pre-sedation assessment of patient’s current level of sedation
b. A baseline assessment of patient's ability to communicate with the nurse and develop a
plan during the procedure
c. Review all medications (including over-the-counter and herbal remedies) taken and the
time of the last dose
d. Review health history and systems assessment with special focus on abnormalities that
may alter expected responses to sedation and analgesic medications
i. Such concerns may include respiratory abnormalities, such as the use of CPAP or
BiPAP, sleep apnea, or screened “at risk” for sleep apnea
ii. Other concerns may include, facial deformities, increased intracranial pressure or
cardiac abnormalities
4. An approved tool for assessing level of sedation should be utilized for intra-procedure monitoring of
patient’s sedation level.
5. Pre-procedure fasting is necessary because of the risk of respiratory depression and possible
aspiration. If fasting was not done prior to procedure, may need to re-evaluate the urgency of the
procedure and possibly delay the procedure.
6. Ensure that patient meets NPO requirements; except in extenuating circumstances that should be
approved by the credentialed sedation provider (e.g. emergency department) and dependent on the
urgency of procedure.
a. For adults patients, use the following guidance:
i. Solids (including tube feeding) and non-clear liquids: 6-8 hours prior to procedure
schedule time
ii. Clear liquids minimum of 2 hours prior to procedure schedule time
b. For pediatric patients
i. Solids/milk/formula: NPO for 6 hours
ii. Breast milk all ages: 4 hours
B. Pre-Sedation (C I)
The nurse who is administering the sedation medications (the sedation nurse) and monitoring the patient
intra-procedure through Phase I should complete the assessments below.
Pre-sedation assessment increases the likelihood of satisfactory sedation and decreases the likelihood of
adverse outcomes for sedation.
1. The sedation nurse should verify procedural and emergency equipment availability.
2. Assess the patient’s history of receiving sedation for a procedure and the dose and medications
received. Assess patient’s tolerance of sedation and any adverse events.
3. Prior to beginning sedation, establish a system of responding to questions during the procedure for
the patient and/or family.

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a. Monitoring of patient's verbal response during sedation is important during the sedation,
except in procedures where movement could be detrimental or when patients are unable
to respond.
b. During procedures where verbal responses are not possible, an alternative method for
patient acknowledgment of verbal/tactile stimulation should be developed.
4. A “time out” will be done by all personnel in the room prior to sedation initiation and procedure. Final
verification to confirm the correct patient, correct procedure, correct site, correct position and correct
implants or equipment using a "time out” is carried out.
5. An organizationally approved sedation assessment tool will be used to assess any changes from pre-
sedation/procedure through Phase I.
C. Intra-Procedure (CII)
1. The frequency of assessment and documentation for the vital signs is determined by patient’s age,
level of sedation (deep vs. moderate) and any changes in the patient’s condition.
2. The sedation nurse should assess the patient’s respiratory effort including depth of respiration, use of
accessory muscles, signs of hypoxemia and any sign indicating that the patient is having difficulty
breathing.
a. Oxygen does not need to be placed on the patient at the time of the sedation procedure.
If signs of hypoxemia occur, oxygen may be administered according to physician orders.
3. The sedation nurse should assess the patient's ability to respond purposefully to verbal and/or tactile
stimulation.
4. The sedation nurse will monitor the patient’s tolerance to the procedure and sedation. Patient’s level
of sedation/analgesia is continuously monitored to maintain the desired level of sedation.
5. The sedation nurse should take into consideration the medication pharmacokinetics and the
individual’s response (or anticipated response) to the medication to prevent respiratory depression.
a. Each medication should be administered individually to allow each medication to achieve
desired effect. If medications are given in combination or in multiple doses, caution should
be taken to ensure doses are not given too close together (e.g. need to avoid “stacking”).
D. Post-Procedure Monitoring (CI)
1. Phase I post-procedure monitoring:
a. Only nurses who are considered competent in performing moderate sedation will monitor
the patient during this phase.
b. Patient’s blood pressure, heart rate, ventilatory function should be closely monitored;
oxygen can be administered as needed.
c. Phase I monitoring requires continuous monitoring by a moderate sedation competent
nurse and documentation at least every 15 minutes.
2. To discharge from Phase 1 criteria Aldrete Score should be greater than 8 and commensurate with
baseline Aldrete score.
3. Phase II monitoring should be a minimum of 30 minutes with assessment and documentation
occurring at least every 15 minutes by a nurse. This can be performed on any general care, IMC or
ICU area.
4. Patients should meet all Phase I and II criteria to discontinue sedation monitoring or be discharged
from sedation monitoring.
5. Discharge instructions should be provided to the patient and support person(s) both in writing and
verbally.
6. Ensure patient safety as patients receiving sedation are at higher risk for falls due to the procedure,
medications and potential co-morbidities.
7. Outpatients should be able to eat and drink prior to discharge. NPO status for hospitalized patients
will be evaluated by the primary team and revised when appropriate.
8. Patients should be discharged with a responsible adult who will provide transportation home.
III. Deep Sedation (C IIa)
A. General Considerations
1. Sedative drugs may result in deep sedation. When these drugs are used as intended or result in deep
sedation, additional requirements and precautions are necessary related to assessments, equipment,
monitoring, documentation, outcome evaluation, and staff competencies that are beyond those
required for moderate sedation.
2. Nurses require successful completion of ACLS and PALS courses (as applicable to their patient
populations) to care for patients under deep sedation.
3. The nurse should be aware of and abide by organizational policies regarding provider credentialing to
perform deep sedation and to direct airway management and cardiopulmonary resuscitation.
B. Assessment and Monitoring

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1. Deep sedation for adult patients requires etCO2 monitoring, pulse oximetry, and EKG monitoring in
addition to blood pressure, heart rate, respiratory rate, level of consciousness, level of pain and any
signs of complications (respiratory depression, hypotension, aspiration and procedure specific).
2. Deep sedation for pediatric patients may use etCO2 monitoring or pre-tracheal stethoscope
monitoring, pulse oximetry, blood pressure, respiratory rate, pulse rate, level of consciousness, level
of pain and any signs of complications (respiratory depression, hypotension, aspiration and procedure
specific). Pediatric patients may have EKG monitoring.
3. Oxygen should be administered unless contraindicated.
4. The frequency of assessment and documentation for the vital signs is determined by patient’s age,
level of sedation (deep vs. moderate) and any changes in the patient’s condition.
5. Testing the patient's response to more profound stimuli is necessary, unless contraindicated, in order
to assure the patient has not become oversedated and is under general anesthesia.
6. The nurse monitoring the patient should not perform any tasks other than administering medications
and monitoring the patient's response.
III. Pertinent Resources
A. UWHC Policies
• UWHC Administrative Policy 8.38, UWHC Adult Sedation Policy
• ED Policy Manual 33.3, Deep Sedation for patients 13 years and older in the ED
• UWHC Clinical Policy 8.56, Pediatric Sedation Policy
• UWHC Administrative Policy 8.34, Performance of Procedures and Sedation in Clinics and Ambulatory
Settings
• UW Health Clinical Policy 2.3.2, Outpatient Discharge After Receiving Sedation
B. Patient Education Resources
• Health Facts for You 5821, Moderate Sedation for Adult and Pediatric Patients
C. Clinical Tools
• UW Health Clinical Practice Guideline: Assessment and Treatment of Pain, Agitation, and Delirium in the
Mechanically Ventilated Intensive Care Unit Patient
• UW Health Clinical Practice Guidelines: Neonatal Analgesia
• To search for Providers’ Sedation Privileges: Privilege List Search
• Educational Opportunities: search Learning and Development System Catalog for “Moderate Sedation” –
multiple computer-based training and in-class didactic course offerings.
IV. References
See full guideline document for list of references.
V. Rating Scheme For The Strength Of The Recommendations
Category Description
Class I Conditions for which there is evidence and/or general agreement that a given
procedure or treatment is beneficial, useful, and effective.
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion
about the usefulness/efficacy of a procedure or treatment
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb Usefulness/efficacy is less well established by evidence/opinion.
Class III Conditions for which there is evidence and/or general agreement that a
procedure/treatment is not useful/ effective and in some cases may be harmful.

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NURSING PRACTICE GUIDELINE SCOPE
Disease/Condition(s)
Patients may receive sedative drugs for short-term therapeutic indications (e.g. stabilization
of the intensive care patient, nausea, anxiety, pain relief, muscle spasticity, insomnia, and
agitation) in non-procedural settings, or as non-intravenous preoperative medications. This
guideline excludes sedation administered in surgical services and/or associated with alcohol
withdrawal.
The scope of this guideline includes procedures requiring sedation in the ambulatory setting,
on inpatient units, in procedural areas, and in the emergency department.
Clinical Specialty
Nursing
Intended Users
The intended users are nurses who provide sedation (minimal, moderate, deep) to adult and
pediatric patients in both the inpatient and outpatient settings.
Target Population
Adult and pediatric patients undergoing procedures receiving minimal, moderate and/or
deep sedation; including patients who become sedated beyond (or in excess of) original
intent, as a result of sedative agents.
Nursing Practice Guideline Objective(s)
The main objective is to provide an evidence-based guideline for inpatient and outpatient
assessment and monitoring of patients who receive sedation (minimal, moderate, deep).
Clinical Questions Considered
1. How do I prepare a patient and the environment for minimal, moderate and/or deep
sedation?
2. What are the risk factors for adverse events such as over-sedation or airway
compromise?
3. How should I assess and monitor my patient before, during, and after sedation?
Unive rsity o f Wisc onsin
Hospitals a nd C linic s
Nursing Practice Guidelines

Sedation
May 2016

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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2
Major Outcomes Considered
Provide evidence-based individualized, quality, standardized and safe care to our patients
receiving sedation.
METHODOLOGY
Description Of Methods Used To Collect/Select the Evidence
• Hand-searches of published literature (primary sources)
• Hand-searches of published literature (secondary sources)
• Hand searches of selected articles’ reference list
• Searches of electronic databases: Cochrane, National Guideline Clearinghouse,
Agency for Healthcare Research and Quality, Joanna Briggs Institute
Methods Used To Assess The Quality And Strength Of The Evidence
Weighting according to a rating scheme (scheme provided below)
Rating Scheme For The Strength Of The Evidence
Strongest (I) – Weakest (VII) as follows:
Level of Evidence A:
Data derived from multiple randomized clinical trials or meta-
analyses.
Level of Evidence B:
Data derived from a single randomized trial or nonrandomized
studies.
Level of Evidence C:
Only consensus opinion of experts, case studies, or standard-of-
care.
Description Of The Methods Used To Analyze The Evidence
The guideline recommendations were originally based on published guidelines specific to
the care of patients undergoing gastrointestinal procedures. Sparse research trial evidence
and expert opinion was used to develop practice recommendations for patients receiving
deep sedation. The best available evidence available on the care of the patient receiving
moderate sedation in the inpatient setting is expert opinion and regulatory standards.
Description Of Methods Used To Formulate The Recommendations
Review of the data from research literature. Review of nursing literature and its
recommendations.
• Expert consensus
• National guideline
• Meta-analyses
• Systematic review
• Literature review

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Rating Scheme For The Strength Of The Recommendations
Category Description
Class I Conditions for which there is evidence and/or general agreement that a given
procedure or treatment is beneficial, useful, and effective.
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion
about the usefulness/efficacy of a procedure or treatment
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb Usefulness/efficacy is less well established by evidence/opinion.
Class III Conditions for which there is evidence and/or general agreement that a
procedure/treatment is not useful/ effective and in some cases may be harmful.
Cost Analysis
None completed
Description Of Method Of Guideline Validation
The original version of this guideline included internal peer review by multiple
representatives of nursing units and clinics from University of Wisconsin Hospital and Clinics
and American Family Children’s Hospital.
Revision version (2016) was reviewed by the Sedation Committee.
DEFINITIONS
The following definitions are extracted from the America’s Society of Anesthesiologists’
Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of
Sedation/Analgesia (click here for more details).
Minimal Sedation (anxiolysis): A drug induced state during which patients are quiet,
drowsy and respond normally to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Level
of awareness for minimal sedation correlates with a Ramsey sedation score of 1, 2 or 3 on
the adult sedation scale or Pediatric sedation score of 1, 2, 3.
Moderate Sedation/analgesia ("conscious sedation"): A drug-induced depressed level of
consciousness during which patients respond appropriately to verbal commands, either
alone or accompanied by light tactile stimulation. The ability to independently maintain
ventilatory and cardiovascular function is retained. No interventions are required to maintain
an adequate airway and pulmonary ventilation. Level of awareness for moderate sedation
correlates with a Ramsey sedation score of 4 on the adult sedation scale or score on
Pediatric sedation score of 4.
Deep sedation/analgesia: A drug-induced depressed level of consciousness during which
patients cannot be easily aroused but respond appropriately to painful stimulation. The
ability to independently maintain ventilatory and cardiovascular function may be impaired.
Patients may require assistance in maintaining an adequate airway, but ventilatory drive is
usually sufficient to avoid the need for positive pressure ventilation. Level of awareness for
deep sedation correlates with a Ramsey sedation score of 5 on the adult sedation scale or
score on Pediatric sedation score of 5.

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General Anesthesia: A drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance in maintaining a patent airway,
and positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug- induced depression of neuromuscular function. Cardiovascular function
may be impaired. This correlates with pediatric sedation score of 6 and Ramsey sedation
score of 6.
Inadequate-sedation-analgesia: Increased arousal/change in level of consciousness as a
response to stress and may result in undue patient discomfort.
Over-sedation: A level of sedation that is deeper or lasts longer than intended. It occurs as
a result of accumulation of sedative and analgesic medications and is associated with
prolonged ventilatory monitoring and/or assistance.
INTRODUCTION
This guideline provides information for nurses who care for adult and/or pediatric patients
receiving minimal, moderate, or deep sedation as well as any patient who reaches a
sedation level after receiving medication.
The goals of sedation include:
• minimizing physical discomfort and pain,
• minimizing physical response to the procedure and sedation (intact protective
reflexes, relaxation, comfort, cooperation, appropriate level of consciousness, patent
airway with adequate ventilatory exchange and easy arousal from sleep),
• controlling behavior and/or movement to allow for the safe completion of the
procedure,
• maximizing the potential for amnesia,
• minimizing psychological trauma,
• controlling anxiety, and
• returning the patient to a state, as determined by recognized criteria, in which they are
deemed safe to be discharged from medical supervision.
Sedation and analgesia are on a continuum ranging from minimal sedation to general
anesthesia. Patients who have received minimal sedation generally require only
observation and intermittent assessment of their level of sedation.
RECOMMENDATIONS
I. General Recommendations for Procedure-Related Moderate and Deep Sedation
(C IIa)
A. Nursing Considerations
1. Moderate and deep sedation procedures may cause cardiovascular and respiratory
depression and therefore require more frequent assessments.
2. Nurses should be able to recognize changes in the continuum of sedation and
rescue the patient from the various sedation levels.
3. Level of sedation goal should be based on clinical circumstances such as anticipated
pain of procedure, need for immobility, and patient anxiety.
4. Nurses administering moderate sedation should be trained to administer medications
and monitor the patient during intra-procedure, phase 1 and 2.

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5
5. Nurses prepping the patient and recovering the patient should be knowledgeable
regarding medication side effects and potential complications of moderate sedation.
6. Nurses involved in moderate sedation need to have access to emergency equipment
and personnel with advanced airway skills.
7. Nurses should be knowledgeable about the risk factors for over-sedation such as:
a. patient is unable to handle secretions without aspiration
b. patient is unable to maintain a patent airway independently or independent
ventilation (excludes mechanically ventilated patients)
c. patient has severe systemic disturbance or disease which limits activity
d. patient has received opioids, benzodiazepines, or initiated therapy with any
central nervous system (CNS) depressant within the past 6 hours
e. patient has begun extended release opioids, received methadone, or
intraspinal/epidural opioids within the past 24 hours
f. patient has begun receiving opioids via an implantable pump within the past
72 hours
g. sedative drug is administered intravenously (regardless of drug or dose
used)
h. two or more sedative drugs are administered concomitantly or sequentially
such that there is an overlap in the duration of action, which places the
patient at increased risk for airway compromise
8. Any complications or sudden change in condition should be reported immediately to
the provider.
a. Conduct a rapid assessment of patient and equipment to determine
possible cause(s)
b. Consider the use of reversal agents, if needed
c. Nurses should be knowledgeable about the special considerations when
using reversal agents:
i. Patients who receive reversal agents need to be recovered for
minimum of 2 hours after reversal agents are given to assure the
patient doesn't become re-sedated once the reversal agents wear off
ii. Initially, reversal medication should be intended to reverse the last
dose of sedative
iii. Careful consideration should be given to reversal agents in patients
with seizure disorders, chronic opioid or benzodiazepine use, or
complex medical history. The reversal agent may have an impact on
their condition and usually last shorter than the benzodiazepine or
opioid
iv. When reversal agents are administered to patients with respiratory
depression, abrupt reversal can cause pain, hypertension, tachycardia
or pulmonary edema
v. Whenever a reversal agent is administered, organizational
requirements specific to safety reporting should be followed
9. The nurse should be aware of and abide by organizational policies regarding
provider credentialing to perform sedation and to direct airway management and
cardiopulmonary resuscitation.
B. Considerations for Specific Patient Populations
1. Additional considerations for patients receiving sedation: Some patient populations
such as pediatrics, pregnant and lactating women, patients with sleep diagnosis that
require the use of CPAP, BiPAP, or other forms of ventilation, elderly and/or those
with previous problems with anesthesia or sedation, as well as patients scored to be

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Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
6
“at risk” for sleep apnea, with co-morbidities and anatomic variants, may need
special consideration related to their sedation plan.
2. Anesthesia should be consulted for severely compromised or medically unstable
patients (difficult airway, severe COPD, severe heart disease) or in situations where
the patient will need to be sedated past the point of responsiveness. Note that this
list is not all inclusive for situations when anesthesia might be needed.
II. Assessment and Monitoring (C IIb)
A. Preparation
1. Nurses should follow organizational policy requirements related to verification of
provider credentials. Refer to I.A.9 above.
2. Nurses should prepare the environment and ensure that appropriate equipment is in
procedure room with patient prior to the sedation initiation.
a. The following equipment will be available in the procedure setting: oxygen
delivery devices, suction apparatus (setup and ready to use), noninvasive
blood pressure cuff, EKG (if required), pulse oximetry, opioid and sedative
reversal agents, and an Intravenous line.
b. Oxygen equipment should be immediately available.
3. The nurse should review patient’s pertinent history, laboratory values, NPO status
and allergies. Additional assessments include:
a. Pre-sedation assessment of patient’s current level of sedation
b. A baseline assessment of patient's ability to communicate with the nurse
and develop a plan during the procedure
c. Review all medications (including over-the-counter and herbal remedies)
taken and the time of the last dose
d. Review health history and systems assessment with special focus on
abnormalities that may alter expected responses to sedation and analgesic
medications
i. Such concerns may include respiratory abnormalities, such as the use
of CPAP or BiPAP, sleep apnea, or screened “at risk” for sleep apnea
ii. Other concerns may include, facial deformities, increased intracranial
pressure or cardiac abnormalities
4. An approved tool for assessing level of sedation should be utilized for intra-
procedure monitoring of patient’s sedation level.
5. Pre-procedure fasting is necessary because of the risk of respiratory depression and
possible aspiration. If fasting was not done prior to procedure, may need to re-
evaluate the urgency of the procedure and possibly delay the procedure.
6. Ensure that patient meets NPO requirements; except in extenuating circumstances
that should be approved by the credentialed sedation provider (e.g. emergency
department) and dependent on the urgency of procedure.
a. For adults patients, use the following guidance:
i. Solids (including tube feeding) and non-clear liquids: 6-8 hours prior
to procedure schedule time
ii. Clear liquids minimum of 2 hours prior to procedure schedule time
b. For pediatric patients
i. Solids/milk/formula: NPO for 6 hours
ii. Breast milk all ages: 4 hours

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B. Pre-Sedation (C I)
The nurse who is administering the sedation medications (the sedation nurse) and
monitoring the patient intra-procedure through Phase I should complete the assessments
below.
Pre-sedation assessment increases the likelihood of satisfactory sedation and decreases
the likelihood of adverse outcomes for sedation.
1. The sedation nurse should verify procedural and emergency equipment availability.
2. Assess the patient’s history of receiving sedation for a procedure and the dose and
medications received. Assess patient’s tolerance of sedation and any adverse
events.
3. Prior to beginning sedation, establish a system of responding to questions during the
procedure for the patient and/or family.
a. Monitoring of patient's verbal response during sedation is important during
the sedation, except in procedures where movement could be detrimental
or when patients are unable to respond.
b. During procedures where verbal responses are not possible, an alternative
method for patient acknowledgment of verbal/tactile stimulation should be
developed.
4. A “time out” will be done by all personnel in the room prior to sedation initiation and
procedure. Final verification to confirm the correct patient, correct procedure,
correct site, correct position and correct implants or equipment using a "time out” is
carried out.
5. An organizationally approved sedation assessment tool will be used to assess any
changes from pre-sedation/procedure through Phase I.
C. Intra-Procedure (CII)
1. The frequency of assessment and documentation for the vital signs is determined by
patient’s age, level of sedation (deep vs. moderate) and any changes in the patient’s
condition.
2. The sedation nurse should assess the patient’s respiratory effort including depth of
respiration, use of accessory muscles, signs of hypoxemia and any sign indicating
that the patient is having difficulty breathing.
a. Oxygen does not need to be placed on the patient at the time of the
sedation procedure. If signs of hypoxemia occur, oxygen may be
administered according to physician orders.
3. The sedation nurse should assess the patient's ability to respond purposefully to
verbal and/or tactile stimulation.
4. The sedation nurse will monitor the patient’s tolerance to the procedure and
sedation. Patient’s level of sedation/analgesia is continuously monitored to maintain
the desired level of sedation.
5. The sedation nurse should take into consideration the medication pharmacokinetics
and the individual’s response (or anticipated response) to the medication to prevent
respiratory depression.
a. Each medication should be administered individually to allow each
medication to achieve desired effect. If medications are given in
combination or in multiple doses, caution should be taken to ensure doses
are not given too close together (e.g. need to avoid “stacking”).
D. Post-Procedure Monitoring (CI)
1. Phase I post-procedure monitoring:

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a. Only nurses who are considered competent in performing moderate
sedation will monitor the patient during this phase.
b. Patient’s blood pressure, heart rate, ventilatory function should be closely
monitored; oxygen can be administered as needed.
c. Phase I monitoring requires continuous monitoring by a moderate sedation
competent nurse and documentation at least every 15 minutes.
2. To discharge from Phase 1 criteria Aldrete Score should be greater than 8 and
commensurate with baseline Aldrete score.
3. Phase II monitoring should be a minimum of 30 minutes with assessment and
documentation occurring at least every 15 minutes by a nurse. This can be
performed on any general care, IMC or ICU area.
4. Patients should meet all Phase I and II criteria to discontinue sedation monitoring or
be discharged from sedation monitoring.
5. Discharge instructions should be provided to the patient and support person(s) both
in writing and verbally.
6. Ensure patient safety as patients receiving sedation are at higher risk for falls due to
the procedure, medications and potential co-morbidities.
7. Outpatients should be able to eat and drink prior to discharge. NPO status for
hospitalized patients will be evaluated by the primary team and revised when
appropriate.
8. Patients should be discharged with a responsible adult who will provide
transportation home.
III. Deep Sedation (C IIa)
A. General Considerations
1. Sedative drugs may result in deep sedation. When these drugs are used as intended
or result in deep sedation, additional requirements and precautions are necessary
related to assessments, equipment, monitoring, documentation, outcome evaluation,
and staff competencies that are beyond those required for moderate sedation.
2. Nurses require successful completion of ACLS and PALS courses (as applicable to
their patient populations) to care for patients under deep sedation.
3. The nurse should be aware of and abide by organizational policies regarding
provider credentialing to perform deep sedation and to direct airway management
and cardiopulmonary resuscitation.
B. Assessment and Monitoring
1. Deep sedation for adult patients requires etCO2 monitoring, pulse oximetry, and
EKG monitoring in addition to blood pressure, heart rate, respiratory rate, level of
consciousness, level of pain and any signs of complications (respiratory depression,
hypotension, aspiration and procedure specific).
2. Deep sedation for pediatric patients may use etCO2 monitoring or pre-tracheal
stethoscope monitoring, pulse oximetry, blood pressure, respiratory rate, pulse rate,
level of consciousness, level of pain and any signs of complications (respiratory
depression, hypotension, aspiration and procedure specific). Pediatric patients may
have EKG monitoring.
3. Oxygen should be administered unless contraindicated.
4. The frequency of assessment and documentation for the vital signs is determined by
patient’s age, level of sedation (deep vs. moderate) and any changes in the patient’s
condition.
5. Testing the patient's response to more profound stimuli is necessary, unless
contraindicated, in order to assure the patient has not become oversedated and is
under general anesthesia.

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6. The nurse monitoring the patient should not perform any tasks other than
administering medications and monitoring the patient's response.
Availability Of Companion Documents
Companion documents are available on the Nursing Practice Guidelines Webpage housed
in U-Connect.
Patient Resources
Health Facts for You:
• Moderate Sedation for Adult and Pediatric Patients: HFFY # 5821
References Supporting the Recommendations (Minimal, Moderate, Deep and
Continuous Sedation for Adults)
1. Abbott/ American Association of Critical Care Nurses/ Saint Thomas Health System
Sedation Expert Panel Members. Consensus Conference on Sedation Assessment: A
Collaborative Venture by Abbott Laboratories, American Association of Critical Care Nurses,
and Saint Thomas Health System. Critical Care Nurse 2004; 24(2): 33-41.
2. Aldrete, J.A. Post-anesthetic recovery score. Journal of College of American Surgeons,
2007 Nov;205(5):e3-4; author reply e4-5.
3. Aldrete, J.A. The post-anesthesia recovery score revisited. Journal of Clinical Anesthesia.
1995 Feb;7(1):89-91.
4. Aldrete JA, Kroulik D.A postanesthetic recovery score. Anesthesia Analgesia . 1970 Nov-
Dec;49(6):924-34.
5. American Society of Anesthesiologists Task Force on Sedation and Analgesia.
Society of Critical Care Medicine and American Society of Health-System Pharmacists. An
Updated Report by the American Society of Anesthesiologists Task Force on Sedation and
Analgesia by Non-Anesthesiologists. Anesthesiology, 2002, April; 96(4): 1004-1017.
6. Association of Operating Room Nurses. Recommended Practices for Patient Receiving
Moderate sedation/ analgesia. AORN Journal, 2002 March; 75(13) 642-8.
7. Australian College for Emergency Medicine, Australian and New Zealand College of
Anesthetists, Faculty of Pain Medicine and Joint Faculty of Intensive Care Medicine.
Statement on Clinical Principles for Procedural Sedation. Emergency Medicine, 2002: 15:
205-206.
8. Carrasco, G. Instruments for Monitoring Intensive Care Unit Sedation. Critical Care
Medicine: 2000 July 13, 4: 217-225.
9. Ead, H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery.,
Journal of Perianesthesia Nurse. 2006 Aug;21(4):259-67.
10. Davidson, J.E., Bloomberg, D., Burnell, Scope creep: when nursing practice moves beyond
traditional boundaries: an evidence-based example using procedural sedation. Critical Care
Quarterly. 2007 July-Sept; 30(13): 219-232.

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11. Elliott, R., McKinley, S., Aitken, L. Adoption of a sedation scoring system and sedation
guideline in an intensive care unit. Journal of Advanced Nursing, 2006: 54(2): 208-216.

12. Society of Gastroenterology and American Society of Gastrointestinal Endoscopy (2004).
Joint Position Statement: Role of GI Registered Nurses in the Management of Patients
Undergoing Sedated Procedures.

13. Statement of Granting Privileges for Administration of Moderate Sedation to Practitioners
Who are Not Anesthesia Professionals- American Society of Anesthesiologists 2006.

14. UHC Deep Procedural Sedation in Patients without a Controlled Airway- Best Practice
Recommendation August 2006.

15. University of Wisconsin Hospital and Clinics and American Family Children’s Hospital Policy
8.56: Pediatric Sedation Policy

16. University of Wisconsin Hospital and Clinics Policy 8.38: University of Wisconsin Hospital
and Clinics Adult Sedation Policy.

17. Watson, B.D., Kane-Gill, S.L. Sedation Assessment in Critically Ill Adults: 2001-2004
Update. The Annals of Pharmacotherapy; 2004 Sept 14; 38: 1898-906.

18. Fullwood, D., Sargent, S. An overview of sedation for adult patients in the hospital. Nursing
Standard; 2010; 24(39): 48-56.


19. Sumonceau, JM, Riphaus, A, Beilenhoff, U, Vilmann, P, Hornslet, P, Aparicio, JR, Dinis-
Ribeiro, M, Giostra, E, Ortmann, M, Knape, JT, Ladas, S, Paspatis, G, Ponsioen, CY, Racz,
I, Wehrmann, R, Walder, B. European curriculum for sedation training in gastrointestinal
endoscopy: position statement of the European Society of Gastrointestinal Endoscopy
(ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates
(ESGENA). Endoscopy. 2013 Jun 45(6): 496-504.

20. Schilling D, Leicht K, Beilenhoff U, Waechter K, Kallinowski B, Labenz J, Weiss C, Buttner
S, Riphaus A. Impact of S3 training courses "Sedation and Emergency Management in
Endoscopy for Endoscopy Nurses and Assisting Personnel" on the process and structure
quality in gastroenterological endoscopy in practices and clinics - results of a nationwide
survey. Zeitschrift fur Gastroenterol. 2013 Jul. 5197: 619-627.

21. Ehrhardt BS, Staubach KC. A program for education, competency, and quality in procedural
sedation. Int Anesthesiol Clin. 2013 Spring. 51(2): 33-42.

22. Willens JS, Jungquist CR, Cohen A, Polomano R. ASPMN survey- nurses' practice patterns
related to monitoring and preventing respiratory depression. Pain Manag Nurs. 2013 Mar.
14(1): 60-5.

23. Conway A, Page K, Rolley J, Fulbrook P. Risk factors for impaired respiratory function
during nurse-administered procedural sedation and analgesia in the cardiac catheterization
laboratory: Eur J Cardiovasc Nurs. 2013 Aug. 12(4): 393-9.


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24. Dawson R, von Fintel, N, Nairn S. Sedation assessment using the Ramsay scale. Emerg
Nurse. 2010 Jun. 18(3): 18-20.

25. Antonelli, M. T., Seaver, D., & Urman, R. D. (2013). Procedural sedation and implications for
quality and risk management. Journal of Healthcare Risk Management : The Journal of the
American Society for Healthcare Risk Management, 33(2), 3–10. doi:10.1002/jhrm.21121

26. Chawla, S., Katz, A., Attar, B. M., & Go, B. (2013). Endoscopic retrograde
cholangiopancreatography under moderate sedation and factors predicting need for
anesthesiologist directed sedation: A county hospital experience. World Journal of
Gastrointestinal Endoscopy, 5(4), 160–4. doi:10.4253/wjge.v5.i4.160

27. Conway, A., Rolley, J., Page, K., & Fulbrook, P. (2014a). Clinical practice guidelines for
nurse-administered procedural sedation and analgesia in the cardiac catheterization
laboratory: a modified Delphi study. Journal of Advanced Nursing, 70(5), 1040–53.
doi:10.1111/jan.12337

28. Conway, A., Rolley, J., Page, K., & Fulbrook, P. (2014b). Issues and challenges associated
with nurse-administered procedural sedation and analgesia in the cardiac catheterisation
laboratory: a qualitative study. Journal of Clinical Nursing, 23(3-4), 374–84.
doi:10.1111/jocn.12147

29. Leech, C., & Chishti, A. (2014). Safe sedation for surgeons. Surgery (Oxford), 32(2), 89–92.
doi:10.1016/j.mpsur.2013.12.002

30. Newstead, B., Bradburn, S., Appelboam, A., Reuben, A., Harris, A., Hudson, A., … Lloyd, G.
(2013). Propofol for adult procedural sedation in a UK emergency department: safety profile
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31. American Academy of Pediatrics, & American Academy of Pediatric Dentistry. (2006,
reaffirmed 2011). Guideline for monitoring and management of pediatric patients during and
after sedation for diagnostic and therapeutic procedures. Elk Grove Village, IL, & Chicago,
IL: Authors.

32. American Society of Anesthesiologists. (2009a). Distinguishing monitored anesthesia care
(“MAC”) from moderate sedation/analgesia (conscious sedation). Retrieved from
https://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx

33. American Society of Anesthesiologists. (2009b). Continuum of depth of sedation: Definition
of general anesthesia and levels of sedation/analgesia. Retrieved from
https://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx

34. American Society of Anesthesiologists. (2010). Advisory on granting privileges for deep
sedation to non-anesthesiologist sedation practitioners. Retrieved from
https://www.asahq.org/For-Members/Practice-Management/Practice-Parameters.aspx

35. American Society of Anesthesiologists (ASA). (2006). Practice Guidelines for
Peri-operative Management of Patients with Obstructive Sleep Apnea. [Practice Guideline].
Park Ridge, Il: Author.

36. American Society for Gastrointestinal Endoscopy. (2008a). Sedation and anesthesia in GI
endoscopy. Gastrointestinal Endoscopy, 68(5), 815-826.

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37. American Society for Gastrointestinal Endoscopy. (2008b). Modifications in endoscopic
practice for pediatric patients. Gastrointestinal Endoscopy, 67(1), 1-9.

38. American Society for Gastrointestinal Endoscopy. (2009). Position statement: Non-
anesthesiologist administration of propofol for GI endoscopy. Gastrointestinal Endoscopy,
70(6), 1053-1059.

39. American Society for Gastrointestinal Endoscopy. (2012). Guidelines for endoscopy in
pregnant and lactating women. Gastrointestinal Endoscopy, 76(1), 18-24.

40. American Society for Gastrointestinal Endoscopy. (2013). Modifications in endoscopic
practice for the elderly. Gastrointestinal Endoscopy, 78(1), 1-7.

41. American Society for Gastrointestinal Endoscopy & Society of Gastroenterology Nurses and
Associates, Inc. (2004). Joint position statement: Role of GI registered nurses in the
management of patients undergoing sedated procedures. Retrieved from
http://www.sgna.org/issues/sedationfactsorg/patientcare_safety/patientmonitoring.aspx

42. Amornyotin, S. (2013). Sedation and monitoring for gastrointestinal endoscopy. World
Journal of Gastrointestinal Endoscopy, 5(2), 47-55.

43. Centers for Medicare and Medicaid Services (CMS). (2011). Revised Hospital Anesthesia
Services Interpretive Guidelines-State Operations Manual (SOM) Appendix A. Retrieved
from www.asahq.org/For-Members/Advocacy/Federal-Legislative-and-Regulatory-
Activities/Interpretive-Guidelines.aspx

44. Cohen, L. B., Delegge, M. H., Aisenberg, J., Brills, J. V., Inadomi, J. M., Kochman, M. L., &
Piorkowski, J. D., Jr. (2007). AGA Institute review of endoscopic sedation. Gastroenterology,
133(2), 675–701.

45. Fanti, L., & Testoni, P. A. (2010). Sedation and analgesia in gastrointestinal endoscopy:
What’s new? World Journal of Gastroenterology, 16(20), 2451-2457.

46. Heuss, L. T., Schnieper, P., Drewe, J., Pflimlin, E., & Beglinger, C. (2003). Risk stratification
and safe administration of propofol by registered nurses supervised by the
gastroenterologist: A prospective observational study of more than 2000 cases.
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47. Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J. S., Nisbet, A., Oakes, L., Dempsey, S.
J., Santangelo, D., & Polomano, R. C. (2011). American Society for Pain Management
Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression.
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48. Krauss, B., & Green, S. M. (2006). Procedural sedation and analgesia in children. Lancet,
367(9512), 766-780.

49. Regula, J., & Sokol-Kobielska, E. (2008). Sedation in endoscopy: When and how. Best
Practice & Research. Clinical Gastroenterology, 22(5), 945-957.

50. Rex, D. K., Overley, C., Kinser, K., Coates, M., Lee, A., Goodwine, B. W., Strahl, E., Lemler,
S., Sipe, B., Rahmani, E., & Helper, D. (2002). Safety of propofol administered by registered

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nurses with gastroenterologist supervision in 2000 endoscopic cases. The American Journal
of Gastroenterology, 97(5), 1159-1163.

51. Rex, D. K., Heuss, L. T., Walker, J. A., & Qi, R. (2005). Trained registered
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52. Slagelse, C., Vilmann, P., Hornslet, P., Hammering, A., & Mantoni, T. (2011). Nurse-
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53. Society of Gastroenterology Nurses and Associates, Inc. (2012). Position statement:
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54. Vargo, J. J., DeLegge, M. H., Feld, A. D., Gerstenberger, P. D., Kwo, P. Y., Lightdale, J. R.,
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55. Society of Gastroenterology Nurses and Associates, Inc. (2013). Position statement:
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doi:10.1097/PEC.0b013e318280d824
POTENTIAL BENEFITS/HARMS OF IMPLEMENTATION
Potential Benefits
The benefit of implementing this guideline is to establish consistent evidence-based practice
recommendations for pre-, intra-and post- sedation care for patients of all ages receiving sedation.
When nurses follow these guidelines it is anticipated that fewer sedation related complications will
occur and/or will be optimally managed.
Potential Harms
There are no potential harms associated with implementing this guideline.
IMPLEMENTATION OF THE GUIDELINE
Description Of Implementation Strategy
The hospital based policies and procedures are aligned with this nursing practice guideline.
Ongoing implementation is completed through onboarding training of new employees and
through periodic sedation courses. In the Spring of 2016, all nurses at University Hospital
received updated information about the process for moderate sedation via computer based
training.

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20
Implementation Tools
Utilization of the Evidence-Based Practice Implementation Model copyright by Laura Cullen
and The University of Iowa Hospital & Clinics; see full article: Cullen, L. & Adams, S. (2012).
Planning for implementation of evidence-based practice. Journal of Nursing Administration,
42(4), 222-230. doi: 10.1097/NNA.0b013e31824ccd0a
IDENTIFYING INFORMATION AND AVAILABILITY
Date Released (Revised)
2009; revised 2009; revised 2016
Guideline Sponsor
UWHC Nursing
Guideline Authors
Clinical Nurse Specialist, Cardiac Surgery
Clinical Nurse Specialist, Trauma Life Support Center
Clinical Nurse Specialist, Pain
Clinical Nurse Manager, Nursing Diagnostic/Therapy Center
Clinic Manager, Gastro/Bronchoscopy Procedures
Nursing Education Specialist, ED, Psychiatry, Med Flight/CHETA
Guideline Status
May, 2016
DISCLAIMER:
Guidelines are designed to assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood
that some patients will not fit the clinical condition contemplated by a guideline and that a guideline
will rarely establish the only appropriate approach to a problem.