S c o p e o f Pr a c t i c e Is s u e sGuidelines for Equipment and Supplies forUse in Pediatric Patients in the ED, 2000;Alaska <strong>Board</strong> <strong>of</strong> <strong>Nursing</strong> Advisory Opinionon <strong>Nurse</strong> Administration <strong>of</strong> Sedating andAnesthetic Agents, 2007.)7. Written policies, procedures, clinicalguidelines, and protocols for proceduralsedation should be in place in the institution.These policies should be age appropriate andshould include, but not be limited to:➢Equipment and supplies➢Mandatory education and competencyvalidation➢Risk management➢Quality monitoring to include patientoutcomes➢ Required documentation********************************ADDENDUMProcedural Sedation Consensus <strong>State</strong>mentDefinitions:Advanced Practice Registered <strong>Nurse</strong> (APRN)is an umbrella term given to a RN whohas met advanced educational and clinicalpractice requirements beyond the two to fouryears <strong>of</strong> basic nursing education required <strong>of</strong>all RNs. APRNs include nurse practitioners,clinical nurse specialists, nurse anesthetists,and nurse midwives. <strong>Nurse</strong> practice acts varywidely among states. They define the scope<strong>of</strong> practice for APRNs within that particularstate. (American <strong>Nurse</strong>s Association [ANA]<strong>Nursing</strong> Facts, www.nursingworld.org)Certified Registered <strong>Nurse</strong> Anesthetists aremaster’s prepared advanced practice nurseswho provide anesthetics to patients in everypractice setting and for every type <strong>of</strong> surgeryor procedure. (http://www.aana.com)Credentialing is a term applied to processesused to designate that an individual, program,institution or product have met establishedstandards set by an agent (governmental ornon-governmental) recognized as qualifiedto carry out this task. The standards maybe minimal and mandatory or above theminimum and voluntary. Licensure, registration,accreditation, approval, certification,recognition or endorsement may be used todescribe different credentialing processes, butthis terminology is not applied consistentlyacross different settings and countries. Credentialsare marks or “stamps” <strong>of</strong> quality andachievement communicating to employers,payers, and consumers what to expect froma “credentialed” nurse, specialist, course orprogram <strong>of</strong> study, institution <strong>of</strong> higher education,hospital or health service, or healthcareproduct, technology, or device. Credentialsmay be periodically renewed as a means <strong>of</strong>assuring continued quality, and they may bewithdrawn when standards <strong>of</strong> competenceor behavior are no longer met. (Styles andAffara, 1997, International Council <strong>of</strong> <strong>Nurse</strong>sFact Sheet, http://www.icn.ch/matters_credentialing_print.htm)Deep sedation/Analgesia is a drug-induceddepression <strong>of</strong> consciousness during whichpatients cannot be easily aroused but respondpurposefully following repeated or painfulstimulation. The ability to independentlymaintain ventilatory function may be impaired.Patients may require assistance inmaintaining a patent airway, and spontaneousventilation may be inadequate. Cardiovascularfunction is usually maintained. (AmericanSociety <strong>of</strong> Anesthesiologists [ASA] policystatement on Continuum <strong>of</strong> Depth <strong>of</strong> SedationDefinition <strong>of</strong> General Anesthesia andLevels <strong>of</strong> Sedation/Analgesia, Approved byASA House <strong>of</strong> Delegates on October 13,1999, and amended on October 27, 2004.)Dissociative agents/dissociative sedation isdescribed as a “trancelike cataleptic statecharacterized by pr<strong>of</strong>ound analgesia andamnesia, with retention <strong>of</strong> protective airwayreflexes, spontaneous respirations, and cardiopulmonarystability. (American College<strong>of</strong> Emergency Physicians [ACEP] ClinicalPolicy for Procedural Sedation and Analgesiain the Emergency Department, Annals <strong>of</strong>Emergency Medicine 2005.)General anesthesia is a drug-induced loss <strong>of</strong>consciousness during which patients are notarousable, even by painful stimulation. Theability to independently maintain ventilatoryfunction is <strong>of</strong>ten impaired. Patients <strong>of</strong>tenrequire assistance in maintaining a patentairway, and positive pressure ventilation maybe required because <strong>of</strong> depressed spontaneousventilation or drug-induced depression<strong>of</strong> neuromuscular function. Cardiovascularfunction may be impaired. (ASA policy statementon Continuum <strong>of</strong> Depth <strong>of</strong> SedationDefinition <strong>of</strong> General Anesthesia and Levels<strong>of</strong> Sedation/Analgesia, Approved by ASAHouse <strong>of</strong> Delegates on October 13, 1999, andamended on October 27, 2004.)Minimal sedation (Anxiolysis) is a druginducedstate during which patients respondnormally to verbal commands. Althoughcognitive function and coordination maybe impaired, ventilatory and cardiovascularfunctions are unaffected. (ASA policy statementon Continuum <strong>of</strong> Depth <strong>of</strong> SedationDefinition <strong>of</strong> General Anesthesia and Levels<strong>of</strong> Sedation/Analgesia, Approved by ASAHouse <strong>of</strong> Delegates on October 13, 1999, andamended on October 27, 2004.)Moderate sedation/Analgesia (ConsciousSedation) is a drug-induced depression<strong>of</strong> consciousness during which patientsrespond purposefully to verbal commands,either alone or accompanied by light tactilestimulation. No interventions are required tomaintain a patent airway, and spontaneousventilation is adequate. Cardiovascular functionis usually maintained. (ASA policy statementon Continuum <strong>of</strong> Depth <strong>of</strong> SedationDefinition <strong>of</strong> General Anesthesia and Levels<strong>of</strong> Sedation/Analgesia, Approved by ASAHouse <strong>of</strong> Delegates on October 13, 1999, andamended on October 27, 2004.)Presence as used in the statement “in thepresence <strong>of</strong> a physician, advanced practiceregistered nurse, or other health care pr<strong>of</strong>essionaldescribes the location <strong>of</strong> the healthcare pr<strong>of</strong>essional” as being physically presentat the patient’s bedside or within the confines<strong>of</strong> the patient’s immediate treatment space.Privilege is an exceptional or extraordinaryright, immunity or exemption belonging toa person in virtue <strong>of</strong> their <strong>of</strong>fice or status.Clinical privileges include, as appropriate tothe organization, privileges, membership onthe medical staff and other circumstancespertaining to the furnishing <strong>of</strong> medical careunder which a physician, dentist or otherlicensed health care practitioner is permittedto furnish such care by a health plan or by afederal or state agency that either administersor provides payment for the delivery <strong>of</strong> healthcare services. (http://www.oig.hhs.gov/authorities/docs/datacollection.pdf)Procedural sedation is defined as the technique<strong>of</strong> administering sedatives or dissociativeagents with or without analgesics toinduce a state that allows the patient to tolerateunpleasant procedures while maintainingcardiorespiratory function. (ACEP clinicalpolicy for procedural sedation and analgesiain the emergency department – Annals <strong>of</strong>Emergency Medicine 2005.)Six Quality Aims as defined by the Institute<strong>of</strong> Medicine are:• Safe: Avoiding injuries to patients fromthe care that is intended to help them.• Effective: Providing services based onscientific knowledge to all who could benefitand refraining from providing services tothose not likely to benefit, thereby avoidingunder use and overuse, respectively.• Patient-centered: Providing care that isrespectful <strong>of</strong> and responsive to individualpatient’s preferences, needs, and values andensuring that patient values guide all clinicaldecisions.• Timely: Reducing waits and sometimesharmful delays for both those who receiveand those who give care.• Efficient: Avoiding waste, including waste<strong>of</strong> equipment, supplies, ideas, and energy.• Equitable: Providing care that does notvary in quality because <strong>of</strong> personal characteristicssuch as gender, ethnicity, geographiclocation and socioeconomic status. (Crossingthe Quality Chasm, IOM Report. NationalAcademies Press, 2001.)Continued on page18
Representing the Public as a Consumer on the<strong>State</strong> <strong>Board</strong> <strong>of</strong> <strong>Nursing</strong>Marguerite HermanI represent the consumer on the <strong>Wyoming</strong><strong>Board</strong> <strong>of</strong> <strong>Nursing</strong> and am constantlyimpressed with the commitment <strong>of</strong> theboard to the goal <strong>of</strong> assuring public healthand safety through regulation <strong>of</strong> the nursingpr<strong>of</strong>ession.I came to the board with a high regardfor nurses, derived from my work withthem on breastfeeding issues (I am astrong advocate), and that regard hasonly been enhanced during my 1 ½ yearson the board. I continue to admire boardmembers, the new and past executive <strong>of</strong>ficersand staff.What I bring to the board is a backgroundin journalism, education, lobbyingand other advocacy work. I bring theviewpoint <strong>of</strong> the consumer who may notknow all the technical details <strong>of</strong> medicalcare but who appreciates nurses’ pride intheir pr<strong>of</strong>ession and in giving quality care.I have an undergraduate degree in Englishfrom Colorado College and masters’degrees in journalism (University <strong>of</strong> SouthCarolina) and education (University <strong>of</strong>Chicago).After six board meetings, I am becomingfamiliar with the vocabulary, acronymsand abbreviations that are specific to theworld <strong>of</strong> medicine, nursing and nursingschool. I am on the education committee,and it is a relief to no longer have to stopand mentally translate when I hear NCLXor ADN or CNA or APN – and so on. Ido occasionally have to interrupt the discussionfor explanations <strong>of</strong> practice terms,but everyone is patient and understanding.Working on creation <strong>of</strong> new rules togovern CNA IIs helped me understand theextent to which nurses are very concernedabout competence to perform certain tasksand their own accountability for what isdone under their delegated authority. Therules approval process also was revealingabout the political nature <strong>of</strong> regulatingthe practice <strong>of</strong> nursing – not by the nursesor even necessarily by their patients butby those who employ nurses. Everyone isinterested in the practice <strong>of</strong> nursing, andrightly so.The pressure to contain medical costs isin a constant tension with the insistenceon high standards, and the political realityinvolves more negotiation on the point <strong>of</strong>standards than I had suspected. As a consumer,I am sympathetic to the desire tocontain expenses, especially as that affectsthe accessibility and affordability <strong>of</strong> healthcare in <strong>Wyoming</strong>. However, I never wantthat pressure to compromise the quality<strong>of</strong> nursing care <strong>Wyoming</strong> citizens receive.Decisions made by the <strong>Board</strong> <strong>of</strong> <strong>Nursing</strong>to license, discipline and define scope <strong>of</strong>practice are ultimately guided by the goal<strong>of</strong> quality care for <strong>Wyoming</strong> citizens.Availability <strong>of</strong> nursing educationdirectly affects the accessible/affordable issue.It also is a concern when you consider<strong>Wyoming</strong>’s obligation to provide as muchopportunity as possible for residents to getthe education and skills to earn a licenseor certificate. The current shortage <strong>of</strong>skilled nurses turns up the pressure evenmore. The board relies on the <strong>Nurse</strong> PracticeAct, rules and regulations to ensurethe success <strong>of</strong> nursing programs and theirstudents in <strong>Wyoming</strong>.I enjoy my role on the <strong>Board</strong> <strong>of</strong> <strong>Nursing</strong>and hope it makes a difference to residents<strong>of</strong> <strong>Wyoming</strong>.Beautiful Phoenix, AZUp To $8,000 Relo BonusHouston Available also! Join A Medical Center rated “Best in the Nation”-Teaching Campus, Magnet Status! $3,000 additional Relo Bonus Comprehensive Benefits w/401k Ask about Free Medical Plan! Base up to $38.90 per hour Plus 20% ShiftDiffs!, Double time!! Full-Time RN Positions-not travel Day Shiftsavailable…Call now! Phoenix, Glendale, Mesa, more 300 + SunnyDays per yearJeff Martin 800.304.3095 Ext-16jmartin@beck-field.com
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