PRE-SEDATION EVALUATION FORM (DRAFT) - Mission Health

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Administrative Policy and Procedure Policy Number: 300.005Subject: Sedation Page: 1 Of: 9Effective: March 3, 1997Revised:Approved:.DRAFT 11/19/09after meetingDeleted: Signed by Kathy Guyette, VPand Chief Nursing Officer, 3/24/2009,and original filed in Administration.Deleted: March 24, 2009Deleted: Signed by Alan Baumgarten,Chief of Staff, 3/24/2009PURPOSE:This policy seeks to establish minimum requirements for administering and monitoring sedation forall patients throughout Mission Hospitals. This Administrative Policy of Mission Health System,Inc. ("Mission") is applicable to Mission Hospitals, Memorial and St. Joseph campuses, the AshevilleSurgery Center and other locations where services of the hospital are being provided. Site specificsedation guidelines may be more, but not less restrictive than the hospital guidelines, and mustconform to requirements that patients with the same health status receive a comparable level of carethroughout Mission Hospitals. These standards are intended for patients undergoing a diagnostic ortherapeutic procedure. This policy is applicable to all patients undergoing procedures with the intentto receive sedation.DEFINITIONS:1. Minimal Sedation (Anxiolysis)A drug-induced state during which patients respond normally to verbal commands. Althoughcognitive function and coordination may be impaired, ventilatory and cardiovascular functionsare unaffected.2. Moderate Sedation/Analgesia (Conscious Sedation)A drug-induced depression of consciousness during which patients respond purposefully toverbal commands, either alone or accompanied by light tactile stimulation. No interventions arerequired to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascularfunction is usually maintained.Deleted: Minimal Sedation (Deleted: )Deleted: Although cognitive functionand coordination may be impaired,ventilatory and cardiovascular functionsare unaffected.Minimal Sedation3. Deep Sedation/AnalgesiaA drug induced depression of consciousness during which patients cannot be easily arousedbut respond purposefully after repeated or painful stimulation. The ability to independentlymaintain ventilatory function may be impaired. Patients may require assistance in maintaininga patent airway and spontaneous ventilation may be inadequate. Cardiovascular function
Policy #300.005 – Sedation Page 2 of 7is usually maintained.4. AnesthesiaConsists of general anesthesia and spinal or major regional anesthesia. It does not includelocal anesthesia. General anesthesia is a drug induced loss of consciousness during whichpatients are not arousable, even by painful stimulation. The ability to independently maintainventilatory function is often impaired. Patients often require assistance in maintaining apatent airway, and positive pressure ventilation may be required because of depressedspontaneous ventilation or drug induced depression of neuromuscular function. Cardiovascularfunction may be impaired.5. ProceduralistThe person qualified to perform the procedure. This person may be a physician, midlevelprovider, or others privileged to perform an invasive procedure or may be a technologistor other personnel qualified to perform the procedure for noninvasive procedures such aschest radiographs, nuclear medicine scans, ultrasound examinations, or MRI’s.6. SedationistThe physician or advanced practitioner privileged to perform the sedation.7. MonitorA person qualified to monitor and respond appropriately to the patient's responseto medication and assist in any supportive or resuscitative measures required. Themonitor will not engage in any tasks that would compromise continuous patientmonitoring.SCOPE:1. This policy applies to patients who receive drugs with the intent of sedation/analgesiafor procedures. This policy does not apply to mediations given for anticonvulsant effects,minimal sedation (anxiolysis) without an intended procedure or pain control; however,should any such agents be given and followed by deeper levels of sedation (moderatesedation), appropriate monitoring/interventions in keeping with this policy should beimmediately instituted.2. This policy is not intended to address situations in which an anesthesiologist or nurseanesthetist is engaged in the administration of anesthesia/sedation.Deleted: EXCLUSIONSFormatted: Font: 12 ptFormatted: Font: 12 ptFormatted: Font: 12 ptFormatted: Font: 12 ptFormatted: Font: 12 ptFormatted: Font: 12 ptFormatted: Font: 12 ptFormatted: No underlineFormatted: Bullets and Numbering3 This policy does not apply to sedation used to secure an airway, for ventilatory management, forpain control, or when sedation is used as chemical restraint in the psychiatric patient.LOCATION:Moderate Sedation may be administered in the following primary locations: Emergency Department,Intensive Care Units, Operating Rooms, Asheville Surgery Center, Radiology Department, CardiacCath Lab, Echo Lab, Endoscopy Department including mobile endoscopy, and Pediatrics, PediatricOutpatient, Pediatric Adolescent Unit, Pediatric Intensive Care Unit, Neonatal Intensive Care Unit
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PRE-SEDATION EVALUATION FORM (DRAFT) - Mission Health

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