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Patient Care Before, During and After Minimal Sedation For Adult Patients (2.3.25)

Patient Care Before, During and After Minimal Sedation For Adult Patients (2.3.25) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.25


UW HEALTH CLINICAL POLICY 1
Policy Title: Patient Care Before, During, and After Minimal Sedation For Adult
Patients
Policy Number: 2.3.25
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: May 26, 2017

I. PURPOSE

To ensure a consistent, safe approach to monitoring patients receiving pain and anxiolytic medications
resulting in a state of minimal sedation for inpatient or outpatient procedures or examinations. This policy is
intended to address sedation management for procedures or examinations only. This does not apply to the
treatment of pre-existing pain or anxiety.

II. DEFINITIONS

Minimal sedation: Minimal sedation is a drug-induced state during which patients respond normally to verbal
commands. Although cognitive function and physical coordination may be mildly impaired, airway reflexes,
ventilatory, and cardiovascular functions are unaffected.
Qualified staff: Qualified staff will be responsible for directing or administering sedative drugs for minimal
sedation. Qualified staff are as follows:
1. Attending Physician
2. Advanced Practice Providers
3. Graduate Medical Education (GME) trainees (interns, residents and fellows) - these trainees must
be working under the direction of an attending physician.
4. Registered Nurses

III. POLICY ELEMENTS

A. This policy addresses the care of patients receiving minimal sedation. According to UWHC policy #8.38,
Adult Sedation, this would correlate with a 1, 2, or 3 on the Ramsay Sedation Scale (Table 1). Patients
receiving only local anesthesia or therapeutic pain and or anxiolytic medications are not covered by this
policy.
B. If a patient is likely to require a higher level of sedation during a procedure, refer to UWHC policy #8.38 for
directions regarding Moderate Sedation.
C. No special privileges are required for prescribing medications for minimal sedation.

IV. PROCEDURE

A. Enteral medication for invasive or noninvasive procedures or examinations.
i. An evaluation of the patient will be completed and documented in the patient’s clinical record when
prescribing pain and anxiolytic medications. Minimal standards include reviewing at the time the
order is written the patient’s documented medications and allergies and response to past sedation
and anesthesia. Further assessment may be necessary depending on the patient, procedure being
performed, and/or procedure location.
ii. The effects and side effects of the minimal sedation medication will be discussed with the
patient/patient’s caregiver prior to administration of the medication. Patients should be cautioned
not to drive after sedation and offered assistance in finding alternate transportation if necessary.
iii. Procedure and examination rooms will have ready access to an Emergency Response cart.
iv. Patient will receive enteral medications as ordered. If these are administered within the institution
qualified staff will:
a. Review patient’s allergies and medication administration record prior to administration of
pain and anxiolytic medications.
b. Document all medications administered including dosage, time, route, and site.
v. If enteral sedation medication is prescribed for the procedure or examination and self-administered
outside of the institution, qualified staff will document the type and amount of sedation the patient
states that they took.
vi. Regardless of where the medications were administered:
a. Patients who have a documented diagnosis of Obstructive Sleep Apnea and who receive
minimal sedation will be observed with pulse oximetry during the procedure or



UW HEALTH CLINICAL POLICY 2
Policy Title: Patient Care Before, During, and After Minimal Sedation For Adult Patients
Policy Number: 2.3.25

examination. If the observed saturation is <90% a qualified staff member will be alerted
who will assess the patient and treat as ordered.
b. The qualified staff member will immediately notify the responsible physician or advanced
practice provider (APP) of any adverse events. These will be treated as ordered and the
events and management will be documented in the patient’s medical record.
c. Activation of a higher level of care to assist with unexpected complications will be readily
available.
d. Patients will remain in the procedure area until they are no longer impaired by the
sedation.
vii. At the completion of recovery from a procedure or examination the patient’s status will be
documented.
viii. The provider performing the procedure or examination will be the first point of contact in case of an
emergency. That provider should be readily available until the patient is ready to leave the
procedural area.
B. Intravenous or intramuscular medication for invasive or noninvasive procedures or examinations.
i. Intravenous or intramuscular sedatives may be used as single agents for minimal sedation. Use of
multiple agents is treated as Moderate Sedation for the purposes of Policy and is covered by
UWHC policy #8.38, Adult Sedation, except for burn dressing changes as detailed in Section
IV.B.vi.
ii. Intravenous or intramuscular sedatives will only be administered for minimal sedation within the
confines of the Hospital buildings (University Hospital, American Family Children’s Hospital, or The
American Center).
iii. Patients who have a documented diagnosis of Obstructive Sleep Apnea and who receive minimal
sedation will be observed with pulse oximetry during the procedure or examination. If the observed
saturation is <90% a qualified staff member will be alerted who will assess the patient and treat as
ordered.
iv. Intravenous or intramuscular sedatives must be administered by a qualified staff person as listed in
Section II. This staff person must remain with the patient for at least 10 minutes and until the
patient’s sedation score is stable and is 1 or 2. At this point the patient may be accompanied by
appropriate non-qualified personnel (e.g. ED Tech, Radiology Tech, or MA) for at least one hour
after the administration of the sedative. If the patient remains physiologically stable and at a
sedation score of 1 or 2 for more than one hour after the administration of the medication, staff
presence is no longer required.
v. ED patients who have received an intravenous sedative for examinations or procedures outside of
the ED may receive a single additional dose of that IV agent during the procedure or examination
scan, if needed, per MD order. The ED RN will remain with the patient to observe them throughout
the remainder of the procedure if an IV agent is readministered. More extensive monitoring will be
initiated as appropriate. Pulse oximetry will be monitored following the IV administration.
vi. Patients undergoing burn dressing changes in the Burn Unit may receive intravenous fentanyl and /
or midazolam for minimal sedation as is detailed in Nursing Patient Care policy #4.16, Patient
Monitoring During Burn / Wound Care.
C. Audit data will not be submitted for minimal sedation. Unexpected events (cardiac or respiratory events,
progression to moderate sedation, and any other significant event) will be reported via the PSN system.

V. COORDINATION

Author: Co-Chairs, Sedation Steering Committee
Senior Management Sponsor: SVP/Chief Nurse Executive
Approval committees: Nursing Patient Care Policy and Procedure Committee; Sedation Steering Committee;
UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: April 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.




UW HEALTH CLINICAL POLICY 3
Policy Title: Patient Care Before, During, and After Minimal Sedation For Adult Patients
Policy Number: 2.3.25

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UWHC policy #8.16, Patient Care Orders
UWHC policy #8.17, Administration of Medications
UWHC policy #8.38, Adult Sedation
UWHC policy #8.56, Pediatric Sedation
Nursing Patient Care policy #4.16, Patient Monitoring During Burn/Wound Care

VIII. REVIEW DETAILS

Version: Original
Last Full Review: May 26, 2017
Next Revision Due: May 2020



Table 1: Assessing Level of Sedation

Level of sedation1 Level of Consciousness Approximate
Ramsey Score 2
Approximate
RASS 3
Cognitive
function
Ability to
protect airway
Cardiac
function
None Normal 1 or 2 0 Intact Intact Intact
Minimal Cooperative, oriented,
tranquil
2 -1 Minimally
impaired
Intact Intact
Minimal Sleepy, responds
appropriately to verbal
commands and/or tactile
stimulation
3 -1 or -2 Impaired Intact Intact
Moderate Sleeping, arouses easily
to stimulation
4 -3 Impaired Intact (should
NOT have to
intervene)
Intact
Deep Sleeping, arouses only to
painful stimulation
5 -4 Impaired Impaired Impaired
General Anesthesia
(Anesthesiologist only)
Not arousable even to
painful stimulation
6 -5 Impaired Absent Impaired

1. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, Anesthesiology 2002; 96:1004–17.
2. Controlled Sedation with Alphaxalone-Alphadolone, BMJ 1974; 2:656-659.
3. The Richmond Agitation Sedation Scale, Am J Respir Crit Care Med 2002; 166:1338–1344.