Sedation Policy Research Articles

The use of seclusion in emergency medicine

Introduction Little is known about the use of seclusion in emergency departments (EDs) across the country. The primary purpose of this study was to determine the extent of the use of seclusion in EDs in the United States. The secondary purpose was to describe seclusion use in EDs. Methods A survey consisting of questions about the use of seclusion, hospital information, complication rate and related procedures was mailed to a random sample consisting of 20% of the US ED medical directors. The survey was re-mailed to the nonresponders who were also contacted by phone and faxed. The results of the survey were inputted into the SPSS program (SPSS, version 10, Chicago, IL). Results The survey was returned by 443 of the 1015, or 43.6% of the ED medical directors in the United States who had been selected. Of the valid 442, 123 (25.6%) use seclusion in their ED. The most frequent reason for not using seclusion was physical plant issues (212 of 422, 50.2%). Most used direct visualization (102 of 187, 54.5%) of seclusion rooms that were locked (54 of 120, 45.0%) and that were overwhelmingly located within the ED (112 of 117, 95.7%). The most frequent reason for placing a patient in seclusion was violence (122 of 126, 96.8%). Both adults (123 of 126, 97.6%) and children (41 of 126, 32.5%) were placed in seclusion rooms. The most frequently reported complication was the patient's getting out of the seclusion room (32 of 106, or 30.1%). Patients were also given chemical restraints (79 of 113, 69.9%). The physician almost always ordered the seclusion room (124 of 125 cases, 99.2%), but the patient was commonly placed in the room by a nurse (109 of 122, 89.3%); generally, the staff had formal training (99 of 122, 81.1%). The use of seclusion was correlated with the number of ED beds ( F=32.0, df=1, P=.003), ED volume ( F=37.7, df=1, P=.001), number of hospital beds ( F=22.6, df=1, P=.001), having a psychiatric unit ( F=24.7, df=1, P=.001) and teaching EDs ( F=10.8, df=1, P=.001). Conclusion Seclusion rooms are used in a minority of EDs across the country. It also identified many outstanding concerns with complications, use in children, addition of chemical sedation, training and seclusion policy.

Sedation in haemofiltered patients: a retrospective study of compliance with the sedation policy

Such patients are of particular concern as there is a danger of accumulation of sedatives. The UCLH sedation scale involves hourly assessment, -3 correlates with unrousable, -2 (roused by painful stimuli), -1 (roused by movement), 0 (roused by voice), 1 (aware but calm), 2 (aware and comfortable), 3 (agitated and restless). The sedation policy requires the following interventions: at +3 or +2 the dose is increased; at +1, 0 or -1 (i.e. the 'target range') no dose adjustment is attempted until three consecutive scores are achieved within the target range when dose reduction is attempted; at -2 or -3, sedation is stopped.

Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: Survey of fellowship training programs*

To survey current sedation, analgesia, and neuromuscular blockade practices in pediatric critical care fellowship training programs in the United States. Questionnaire survey sent by all program directors. The survey could be submitted either via a Web site, fax, or mail. University school of medicine. Fifty-nine pediatric critical care fellowship training program directors in the United States, listed on the Accreditation Council for Graduate Medical Education Web site. Survey. The response rate was 59.3% (35 questionnaires). Midazolam, lorazepam, morphine, and fentanyl are the most frequently used drugs in pediatric intensive care units for analgesia and sedation. Most pediatric intensive care units surveyed have a written sedation policy (66%). The majority of units responding to the survey (85.7%) routinely use a scoring system to assess agitation and pain in children, with the most common being the COMFORT score. All of the pediatric intensive care units surveyed reported weaning drugs slowly to try to prevent drug withdrawal. Movement disorders related to prolonged sedation and analgesia seem to be more common than is reported in the literature, with 65.7% of units reporting cases. There is good consensus on the indications for neuromuscular blockade, with vecuronium being the most popular drug. When compared with a similar survey from 1989, this survey suggests that pediatric critical care units with fellowship training programs have made some changes in their approach to sedation and analgesia over the past decade. More fellowship directors report the use of sedation protocols and better recognition, prevention, and management of drug withdrawal. Similar analgesic, sedative, and neuromuscular blocking drugs are being used but some more commonly than a decade ago.

Discharge Criteria for Children Sedated by Nonanesthesiologists: Is “Safe” Really Safe Enough?

Discharge Criteria for Children Sedated by Nonanesthesiologists: Is “Safe” Really Safe Enough?

Sedation and Analgesia for Diagnostic and Therapeutic Procedures.

Mayo Medical School, Mayo Clinic, Rochester, Minnesota. warner.mary@mayo.edu.Sedation and Analgesia for Diagnostic and Therapeutic Procedures. Edited by Shobha Malviya, Norah Naughton, Kevin Tremper. Humana Press, Totowa, New Jersey, 2003. Pages: 310. ISBN: 0-89603-863-7. Price: $125.The proliferation of diagnostic and therapeutic procedures outside of the traditional operating room environment has brought many challenges to the medical profession. Chief among these is the dilemma of how to provide sedation and analgesia for these varied patients and procedures in a safe environment, often outside of the care of traditional anesthesia providers. Realizing the need for safe and uniform practices, many professional societies have developed guidelines specific for the care of the sedated patient during these procedures. Regulatory agencies have embraced these concepts and have demanded that patients receive the same standard of care, including uniformity of assessments, monitoring, documentation, outcomes measurements, and credentialing and competency of staff, regardless of where or by whom sedation is administered in an institution.In Sedation and Analgesia for Diagnostic and Therapeutic Procedures , the editors have recruited a variety of authors, including physicians, nurses, and scientists, to comprehensively review sedation and analgesia from all realms. The book begins with a short review of the basic physiology of the sedated state, progresses to various clinical guidelines for both the pediatric and adult patient population, and concludes with a very practical section on quality outcomes processes and measurements. Additional chapters included in this very concise and practical review of sedation and analgesia are devoted to pharmacology, assessments, monitoring, and recovery. Tables, graphs, and figures incorporated throughout the book highlight various protocols, regulatory requirements, guidelines, recommended drug dosages, monitoring requirements, and quality measurement tools. All of these will be valuable to a variety of professionals ranging from physicians, to nurses, to hospital administrators as they develop their own sedation and analgesia policies and guidelines.There are some inconsistencies in the book regarding the depth of details on certain subjects and lack of breadth on other matters. For example, an entire chapter is devoted to opioids in the management of acute pediatric pain, but discussion of analgesia for the adult population is noticeably lacking. I found myself searching for an expansion on patient assessments, medication use, and potential complications associated with sedation and analgesia and wishing that less time had been spent on the differences between the pediatric and adult population regarding various guidelines, procedures, and sites. One example of this lack of consistency is the discussion of monitoring for sedation care; approximately 10 pages of a 26-page chapter are devoted to the use of pulse oximetry, whereas all other methods of monitoring are discussed in 7 pages.Overall, editors Malviya, Naughton, and Tremper have produced a valuable, up-to-date, and practical resource for providers who deal with sedation care. Although the book is not intended to provide a thorough, in-depth scientific review of all the mechanisms of the sedated state or the obscure details of the different pharmacologic agents used in sedation and analgesia, it is an excellent reference. In the current medical environment in which sedation practices are increasing exponentially, this book is a very good resource for practitioners to ensure patient safety and high-quality outcomes when administering sedation and analgesia for this vast array of procedural practices. It is a must-read for anyone who is unfamiliar with the current sedation practices and guidelines promulgated by a number of national professional societies. The book contains sufficient information to help everyone ensure compliance with regulatory standards for sedation care.

Guiding and Managing the Child Dental Patient: A Fresh Look at Old Pedagogy

Society's approach to children during the past half-century has changed dramatically, and a transformation of medical and hospital pediatric care has followed. Dentistry has been slower to incorporate sound, child-friendly approaches to care. Nonetheless, much has changed in dental practice pertaining to children. The regular involvement of parents in the surgical/therapeutic suite is one such change. Expanded communication to ensure informed consent for treatment as well as consent for type of management approach to children is the standard of care. Since sedation policies are becoming more complex, enhancing the skills of all dentists and staff members in the best methods of nonpharmacological child management will be essential in the next decades. Biobehavioral methods will gain prominence, along with better communication skills of the dental team. These changes will occur only if more time and resources are positioned to teach dental students, dentists, and staff the necessary skills. Emphasis must be placed on early, timely intervention; parental involvement; effective communication; cultural competence; and the "medical/dental home" concept as methods to reduce negative dental attitudes and behaviors of children.

Intensive care sedation: a review of current British practice.

Sedation is central to the management of intensive care patients. Many different techniques have been tried, all have potential side effects, and some have been associated with serious adverse effects. The aim of this work is to establish current sedation practice in British ICUs; the use of neuromuscular blocking drugs and the indications for their use, the use of sedation policies and scoring systems, the influence of cost on drug choice, and the use of propofol for sedation in paediatric patients. A postal survey sent to all units identified in the Directory of Emergency Services. Two hundred and fifty-five replies were received from 323 questionnaires (79% response rate). The replies show that alfentanil, morphine, midazolam, and propofol are the most widely used drugs for sedation, and that changes occur in sedation policy with the time a patient spends in intensive care. Atracurium is the most widely used neuromuscular blocking drug, but the number of patients who receive therapeutic paralysis is relatively small and the indications for its use in different units is consistent. Propofol is used by many ICUs for the sedation of children despite reports linking its use to mortality in children and the advice of the regulatory authorities. Drugs used for the sedation of patients in intensive care have changed since previous surveys. The sedation policy of most units relies on the combination of small numbers of drugs. Sedation policies now seem to concentrate on achieving a lightly sedated co-operative patient.

Propofol for sedation

In fact, we have used propofol for procedural sedation and as an induction agent for intubation since 1995. Among our emergency physicians it has become the agent of choice (in combination with appropriate analgesia), particularly for orthopedic procedures. Although we have not been tracking its use, we are unaware of any adverse outcomes. Due to its rapid onset, short duration, and ease of titration, we find it easier to employ when one physician performs the procedure while another manages the sedation. We have been performing policydriven conscious sedation since the mid-1980s. Our procedural sedation policy was written in consultation with our Anesthesia Department and has their approval. Although the policy does

Clinical Policy for Procedural Sedation and Analgesia in the Emergency Department

[American College of Emergency Physicians: Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med May 1998;31:663-677.]

Sedation for children undergoing magnetic resonance imaging: Efficacy and safety of rectal thiopental

The need to reappraise sedation policy is dictated by newer noninvasive imaging modalities. In this study we evaluate the safety and efficacy of rectally-administered thiopental in children undergoing MRI. Eighty-three consecutive patients with congenital heart disease (mean age 2.9 years, SD 2.5) undergoing MRI evaluation of the heart were given thiopental (25-50 mg/kg, 700 mg max) per rectum. In order to prevent leakage, a female urinary catheter was used. In 79 patients (95.2%) successful sedation was achieved and adequate MR imaging could be obtained. In 4 patients (4.8%) the sedation was inadequate. Respiratory depression was not encountered in any of the patients. The presence of cyanotic congenital heart disease in 26 patients had no influence on the safety and efficacy of thiopental. All successfully sedated children were asleep within 30 min and adequate sedation was maintained for at least 45 min. All patients could be aroused within 90 min, and sent home thereafter. Minor side-effects occurred in two patients. Rectally-administered thiopental is a safe and effective sedative drug with a duration of action tailored to performing MRI.

Improving the quality of health services organization structure by reengineering: circular design and clinical case impact in an academic medical center.

Innovation to improve the quality of structure and process in health care organization is reported in this case example of change in an academic medical center. Interactive planning and the circular organization design concept were the driving principles and methods. This report presents the needs for and initial obstructions to change, planning and project design work, a description of the change process, and illustrative accomplishments to date--two cases, one of conscious sedation policy and one of nuisance pages. Evaluative criteria for judging the progress and lessons of the project regarding key design characteristics also are included.

Development of a conscious sedation policy.

Conscious sedation (CS) is used in a variety of healthcare settings on a wide range of patients. The methods of monitoring patients during and after the administration of CS vary considerably from one setting to another. In an effort to provide continuity of care, a project was undertaken to establish an organization-wide policy for the care of patients receiving CS.

Conscious Sedation in the Electroneurodiagnostic Laboratory

.Since the publication in 1992 of guidelines for conscious sedation and the subsequent JCAHO requirements for monitoring and management of patients being sedated, there have been many questions about the role of the electroneurodiagnostic (END) technologist in administration of sedation. Practices vary widely nationally and have created a challenge for the technologist to comply with JCAHO and to maintain the common practice of using sedation to obtain sleep records in the END lab. This paper attempts to clarify the issues and challenges in developing a conscious sedation policy within standards of practice and JCAHO requirements.

Development of a sedation policy for upper GI endoscopy based on an audit of patients' perception of the procedure.

To assess patients' perception of upper GI endoscopy, both with and without sedation, and based on this information to propose a sedation policy for the procedure. A prospective audit of the experience of patients undergoing upper GI endoscopy both with and without sedation. Of the 500 patients in the study, 237 had endoscopy with sedation and 263 with local anaesthetic throat spray. Sedated patients found the procedure more tolerable, but most unsedated patients felt the extra discomfort was more than compensated for by other advantages. 87% of those patients sedated and 70% of those not sedated would choose to have the procedure repeated in the same way. Upper GI endoscopy using local anaesthetic throat spray alone is well tolerated by patients. We have developed a policy on sedation which we believe could result in many more patients electively choosing to have the procedure without sedation, resulting in potential savings on cost and manpower.

Chloral hydrate sedation of children undergoing CT and MR imaging: safety as judged by American Academy of Pediatrics guidelines.

The purpose of this prospective study was to determine the frequency of adverse events associated with supplemented and unsupplemented chloral hydrate sedation in a select group of children undergoing CT or MR imaging using the revised American Academy of Pediatrics (AAP) monitoring and management guidelines for pediatric sedation. The AAP guidelines do not recommend drug selection or dosages but define patient selection, discharge criteria, and monitoring standards for sedating children. This prospective study included 410 children 4 years of age or younger who were scheduled for CT and MR imaging as outpatients. Selected children were physical status 1 or 2 as determined by the American Society of Anesthesiologists physical status classification and had no contraindications to sedation per our institutional sedation policy. Children younger than 1 year old received only oral incremental doses of chloral hydrate. Children 1-4 years old received hydroxyzine plus incremental doses of chloral hydrate. Children between 2 and 4 years old who were not satisfactorily sedated 30 min after hydroxyzine plus incremental chloral hydrate were given 2 mg/kg meperidine intramuscularly, with a maximum dose of 50 mg. All children were monitored according to the revised guidelines recommended by the committee on drugs of the AAP. Vital signs and arterial hemoglobin oxygen saturation (SpO2) were monitored continuously by registered nurses trained in pediatric advanced life support from the time of sedative drug administration until the recommended discharge criteria were met. Mild hypoxia (SpO2, 90-95%) that resolved spontaneously without any therapeutic intervention was seen in 9% of the chloral hydrate group and in 5% of the chloral hydrate-hydroxyzine group. One child in the chloral hydrate group had severe hypoxia (SpO2, 85-89%), and one child in the chloral hydrate-hydroxyzine group had moderate hypoxia (SpO2, < 85%). Both required therapeutic intervention. In both cases, the severity of the underlying medical disease was underestimated at the time of presedation medical screening. The success rate of sedation was 100% for all the children having CT. For those having MR imaging, success was 100% for children 1-4 years old and 97% for children less than 1 year old. Use of supplemented and unsupplemented chloral hydrate sedation provides effective and safe sedation in children if the AAP guidelines for patient selection, monitoring, and management are followed. Careful medical screening and patient selection by knowledgeable medical personnel is important to exclude patients at high risk for life-threatening hypoxia. Monitoring with AAP guidelines is essential for prompt detection and management of life-threatening hypoxia.

The applicability of a new sedation scale for intensive care.

Experience of the sedation scale, which was in use for the assessment of ventilated patients, in an intensive care unit revealed a number of deficiencies. Discussion suggested that an ideal scale should be more straightforward and easily understood by all levels of staff. It should also relate closely to the behaviour of the ventilated patient, and allow an optimal level of sedation; where the patient receives the minimum level of medication to allow pain and stress-free ventilation. A scale was devised with explanations of each level, and was incorporated in a revised sedation policy. In practice this was found to be an improvement over the scale that had been used previously.

Sedation of children for technical procedures: current standard of practice.

We sought to define the current standard of care for children undergoing sedation for painless diagnostic procedures by sending questionnaires to 284 pediatric residency program directors in North America. From the 89 responses, we determined that departments of pediatrics set sedation policies for children in most institutions, often with formal written guidelines for these procedures. Most require that children have some form of cardiorespiratory monitoring while under sedation and that they are attended by individuals trained in cardiorespiratory resuscitation until the child is fully recovered. The use of parents to transport and monitor the sedated child is uncommon, and total lack of monitoring is rare. Chloral hydrate in dosages of 25 mg/kg to 100 mg/kg is the most common drug used for sedation; DPT, a combination of parenteral Demerol (meperidine), Phenergan (promethazine), and Thorazine (chlorpromazine), at a maximum dose of 2 mg/1 mg/1 mg/kg is the second; and pentobarbital in a dosage of 5 mg/kg to 7 mg/kg is the third. These sedation regimens were associated with few serious side effects, except that two deaths were reported in infants with congenital heart disease who were sedated with DPT. We believe this survey may reflect the current standard of practice for sedation in North American infants and children undergoing diagnostic procedures.