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Clinical Hub,References,Adult Moderate Sedation Topics

Pre-Procedure Care

Pre-Procedure Care - Clinical Hub, References, Adult Moderate Sedation Topics


1. Provide Physician Oversight and Direction 

A credentialed staff physician is ultimately responsible for ensuring that appropriate care is provided to the patient during all phases of sedation. When the physician ordering sedation is not on site at the time of sedation, a qualified physician will be designated to be on-site and responsible for the sedation including assessment and monitoring during the pre-, intra- and post-sedation phases. 

In the event that the physician responsible for the sedation is not available for any part of the sedation and procedural period, s/he shall delegate the care to another clearly identified qualified physician who has accepted the responsibility and is knowledgeable about the patient's condition. 

A credentialed physician will:

2. Perform and Record a Patient Assessment 

A collaborative patient assessment for sedation is essential for safe and effective care. Both the physician and the nurse have a role in patient selection and preparation for procedural sedation. It is mandatory that certain key elements of the physical assessment and patient interactions be documented before sedation is given, even if a full dictated note is to follow. These include:

Pre-procedure History and Physical 

Pre-procedure assessment for risk factors is the first step in providing safe and effective sedation. Cardiopulmonary compromise, prior history of difficulty with sedation, and risk for difficult intubation are a few of the assessment parameters to identify patients at risk for complications related to sedation. 

Pre-procedure assessments may be documented on a variety of forms in a variety of ways. Physicians may delegate part(s) of the assessment to qualified nursing staff but are ultimately responsible for assuring that the appropriate pre procedure assessment is completed. Pre procedure assessment includes (but may not be limited to):

Before any operative or invasive procedure, Universal Protocol must be followed. 

Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™ 

The following steps, taken together, comprise the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surgery: 

Pre-operative verification process

Marking the operative site

"Time out" immediately before starting the procedure

After reviewing the findings from the pre-procedure history and physical, the physician makes a determination as to the patient's appropriateness to receive sedation and the type of sedation to be used. 

Immediately prior to sedation administration the physician will re-evaluate the patient and will attest to their continued appropriateness to receive the planned procedure and sedation. This is evidenced by the physician signature on the sedation documentation form. Medical staff should collaborate with nursing staff regarding the documentation forms and process used for a particular procedure in their respective patient care areas. Documentation forms are available in both the inpatient and outpatient settings. These forms have helpful prompts for aiding in completion of the pre procedural work up, as well as, documentation of intra and post procedural monitoring and assessment requirements. 

* Airway Assessment 

Pre-procedure airway assessment aids in management of the airway if respiratory depression occurs, including identification of the need for increased expertise in airway management for patients at higher risk. 

Complete a visual airway inspection to identify potential risk factors in managing the patient's airway. This includes identifying the presence of loose teeth, dentures, assessing the patient's neck (chin to chest flexion and hyperextension) and jaw mobility (ability to open their mouth). Review the patient's history for factors contributing to the risk of airway maintenance such as head and neck surgery, obesity, cervical stenosis, arthritis, injury, etc. 

** NPO Status 

Gastric emptying is influenced by many factors including anxiety, pain, abnormal function (e.g., diabetes), pregnancy, and mechanical obstruction. Therefore, following an NPO protocol does not guarantee that complete gastric emptying has occurred. 

Adults must fast from solids and non-clear liquids for 6-8 hours prior to a scheduled procedure requiring sedation and from clear liquids for 2-3 hours. This includes enteral nutrition given by feeding tube. 

Procedure specific fasting protocols may exceed these recommendations and should be referred to for optimal patient care. 

Patients administered oral contrast for a diagnostic study should not be considered to have an empty stomach. Thus the risk of vomiting and aspiration in a sedated patient with oral contrast is higher than for patients with an empty stomach. All attempts must be made to perform these procedures under the "lightest" sedation possible. 

3. Education 

A qualified RN will educate the patient and/or family prior to administration of sedative medication regarding the risks/benefits/options of the recommended procedure, use of sedative drugs related to the procedure/treatment and any alternatives. Include information about what the patient can anticipate before, during and after sedation including symptoms and side effects to report.  When possible, work out a pre-established signaling system for pain.  Where applicable, pre-sedation instruction will be given to the patient, i.e., medication adjustments, NPO requirements, designated driver post procedure, etc. This will be performed by a qualified RN. 

4. Obtain Informed Consent 

Discuss the risks, benefits and alternatives to the procedure, with and without sedation, with the patient and/or family members as appropriate. Include post procedural expectations such as management of any post procedure pain and anticipated short and long term changes in activities of daily living. Ensure that patients or legal surrogates understand the proposed treatment and its potential complications. Ask each patient or legal surrogate to recount what he or she has been told during the informed consent. (Leapfrog) By providing pre-procedure patient education, the physician can allay patient fears and anxiety regarding the planned procedure. These measures can lead to a decrease in the dosage of medications needed for sedation (Yaney, 1998). 

Document consent as outlined in hospital policy 4.17 Informed Consent including date and time consent was obtained. The following outlines the various categories of medical care and the corresponding documentation required for each category, as it relates to sedation: 

Signed Consent 

Signed consent generally means a consent form or statement signed by the patient or representative. It is required for:

Documented Consent 

Documented consent includes signed consent (see above) or a note included in the patient chart outlining risks/benefits/alternatives to the plan of care. It should be signed by the responsible physician and note that the patient/representative understands and agrees to proceed with the plan as discussed. It includes:

In an emergency, when the patient is unable to give consent and delaying medical care until a patient's authorized representative can be found risks serious injury to health or significant pain, medical care may be given to the extent needed to respond to the emergency needs of the patient, provided there is no known advance directive to the contrary. In case of doubt concerning the validity or applicability of an advance directive directing withholding treatment, emergency medical care should be given. When possible, attempts to obtain consent of the patient or the patient's authorized representative should continue while care is given. The responsible physician determines the existence of an emergency. It is advisable to document in the medical record the nature of the emergency and the efforts made to obtain consent. 

No patient shall receive sedation until a pre-sedation assessment has been completed and documented by the physician responsible for the sedation. Documentation includes the patient's appropriateness to receive sedation.
The person administering the sedation medication (generally the qualified RN) is responsible for assuring the requirements are completed before administering medication. A procedure will be delayed or cancelled until all pre-procedure documentation is complete. This includes:

5. Establish Venous Access 

Establish venous access, if appropriate, for the administration of intravenous sedation and ready access should additional medications or IV fluids required during or after the procedure. The responsible physician determines the need for venous access. 

6. Obtain Necessary Equipment 

Because the potential for respiratory depression exists, resuscitative equipment needs to be readily available. Allow time for and coordinate equipment availability and set-up with nursing staff. A qualified RN will determine that the following resuscitative and monitoring equipment are available: