November 17, 2017
ED Policy Manual
Title: Deep Sedation for patients 13
years and older in the ED
To establish safe practice for procedures requiring deep sedation in the emergency department
(ED). The transition from moderate sedation to deep sedation and from deep sedation to
general anesthesia is a continuum. Each patient’s progression along the continuum can be
difficult to predict and entering a level of deeper sedation than planned must be anticipated
when sedation is administered. Close monitoring and frequent reassessment of the patient will
facilitate prompt determination of when the desired level of sedation is achieved and
Deep Sedation/analgesia is a drug-induced 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 score of 5 on the adult sedation scale.
Sedation Score (Ramsay Scale)
Minimal Moderate Deep General
Sedation Sedation Sedation Anesthesia
Score: 1,2 or 3 4 5 6
B. Authorization to Administer, Monitor, or Supervise Deep Sedation
Deep Sedation may be administered in the ED. Physician medical staff members administering,
monitoring or supervising deep sedation must have clinical privileges.
1. The provider administering the deep sedation must be credentialed in adult deep
2. The provider administering deep sedation to pediatric patients 1 year old to less than 13
years old must be credentialed in pediatric deep sedation.
3. Resident staff may assist in the monitoring and administering of deep sedation under the
supervision of a physician with deep sedation privileges.
4. Medical staff members and nurse practitioners, outside of the Department of
Anesthesiology must pass a written pharmacology exam and a written exam on the
organization’s deep sedation policy before being authorized monitor or administer deep
sedation in the ED.
Registered nurses (RN) may assist in monitoring and administering deep sedation under the
supervision of a physician with deep sedation privileges provided the RN has
successfully completed the UWHC core competency education for this activity and passed the
applicable test. Other staff may not be assigned the responsibility to administer or monitor
C. The goals of all procedural sedation are to:
1. Maintain patient safety,
2. Provide effective pain control,
3. Reduce anxiety and psychological stress, and
4. Promote conditions conducive to successful performance of the procedure.
1. Any sedating medication may have the potential for inducing a deep
sedation for the patient. Thus, careful administration and patient monitoring is
essential during the sedation experience.
1. Before the administration of sedation and procedure, the Intent
of the sedation (Moderate or Deep) will be identified.
2. The physician performing the procedure and the physician
supervising the administration of the sedation will determine the
3. Most commonly propofol and etomidate are utilized for deep
2. The procedure for deep sedation in the ED:
a. Deep Sedation in the ED should only be undertaken for procedures that require less
than 20 minutes of deep sedation. Procedures that are expected to take longer
than 20 minutes may be completed under a combination of deep and moderate
sedation, with no more than 20 minutes under deep sedation. If more time is
anticipated for deep sedation, the care team should discuss the possible need for
completing the procedure in the OR.
b. All patients will have end tidal CO2 (ETC02) monitoring in addition to the standard
monitors as outlined in UWHC policies 8.38 and 8.56 (pulse oximetry, cardiac
monitoring, vital signs)
c. A medical staff member with deep sedation privileges must be continuously present
in the patient room, or proximate to the patient room in the Emergency
Department. The staff member must be present from the initiation of sedation and
throughout the course of the deep sedation.
d. The physician performing the deep sedation should not be the proceduralist. A
medical staff member, however, can oversee the sedation and supervise a resident
doing a procedure.
e. In addition, the following policies will be adhered to:
ξ University of Wisconsin Hospital & Clinics Sedation Polity (8.38)
ξ University of Wisconsin Hospital & Clinics Sedation Care of Pediatric Patients
3. Key Points
a. No patient shall receive sedation until a pre-sedation assessment has been completed
and documented by the physician ordering the sedation. Documentation includes the
patient’s appropriateness to receive sedation and that the patient was re-assessed just
prior to the sedative administration. In addition, all non-emergency procedures require
b. The person administering the sedation medication (RN) is responsible for assuring the
requirements are completed before administering medication. A procedure will not
begin until all pre-procedure documentation is complete.
c. The Universal Protocol must be performed prior to the sedation and includes 3 steps:
1) Pre-procedure verification (consent obtained; images displayed; necessary
2) Site marking (must be done by person performing the procedure; required when
right/left, multiple structures or multiple levels (spine) involved).
3) Time-out (all members of the team present and verify correct pt; side/site;
procedure; pt position; availability of equipment).
2. QUALITY REVIEW.
Sedation audits will be audited and reviewed quarterly. At least 30 cases per quarter or 5% of
all cases (whichever is greater): Consent for sedation, physical and airway exam done, presence
of high risk factors identified, adherence to required monitoring
i. 100% review of deaths
ii. 100% review of pulmonary aspirations
iii. 100% review of reversal agents
iv. 100% review of unplanned transfer to higher level of care
v. 100% review or cardiac or respiratory arrests
vi. 100% review of agents other than those approved
vii. 100% review of inability to complete the procedure as planned
a. UWHC Policy 31.1-- Ketamine: Low Dose IV Ketamine with Pain Management for Adult
Patients in the ED
b. UWHC Policy 2.3.30 -- Pediatric Procedural Sedation Policy
c. UWHC Policy 2.3.29 – Adult Procedural Sedation Policy
d. Emergency Nurses Association-- (2009). Clinical Practice Guideline: The Use of Capnography
During Procedural Sedation/Analgesia in the Emergency Department. Des Plains: ENA.
Accessed 7/25/2014 www.ena.org
ED Clinical Operations Committee
UW Health Sedation Steering Committee
ξ Anne Rifleman, MS, RN, Emergency Service Director
ξ Joshua Ross, MD, Clinical Vice Chair, Emergency Medicine
ξ Nick Kuehnel, MD, Medical Director, Pediatric Emergency Medicine