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A 32-year-old female patient is undergoing a minor gastroenterology procedure and her physician has prescribed moderate sedation with versed and fentanyl to keep her comfortable during the procedure.

The patient's pre-induction assessment has been obtained by the physician and reviewed by the perioperative staff, including what medications the patient is currently taking. Following AORN's Recommended Practices for Managing the Patient Receiving Moderate Sedation/Analgesia, a trained registered nurse working within their state board of nursing regulations is assigned to monitor the patient and administer medications during the procedural sedation.

However, five minutes into the procedure the patient begins to shows signs of discomfort and nausea. The physician requests more medication. The nursing staff questions the dose he requests and after an obvious moment of tension between the team, the nurse reluctantly gives more medication. The patient becomes increasingly nauseated and uncomfortable from the procedure. The physician is irritated because the patient is moving and he can't perform the procedure. The patient then vomits and the vital signs begin to show signs of distress. The team is irritated and frustrated, and the patient is miserable.

Luckily the patient is a simulation mannequin and the perioperative nurse monitoring the sedation is part of an AORN simulation training program designed to train perioperative nurses on safe procedural sedation practices.

In a debriefing after the scenario, the perioperative nurses involved with the simulation scenario review the patient's chart and note that the patient takes oxytocin** daily for chronic pain, making her tolerance for the sedation medication much higher than normal. They also discussed the possible use of different medications with this patient.

"This is not an uncommon situation. The key is preparing the non-anesthesia care providers monitoring procedural sedation to adequately prepare and respond to these types of scenarios," explained Pika Lynch, RN, MS, a perioperative nursing specialist in AORN's Center for Perioperative Education. She designed this and other simulation scenarios as part of the procedural sedation hands-on workshop AORN recently hosted at the Work, Education and Lifelong Learning Simulation (WELLS) Center in Aurora, Colo.

"Simulation creates a safe, non-threatening environment for healthcare professionals to learn how to support safe, effective procedural sedation with an emphasis on appropriate use of equipment and the necessary techniques required to support the patient, in an environment that allows the freedom to make mistakes and learn from them," Lynch said.

To prepare nurses to respond when problems arise during sedation, the training focused not only on the basics, such as physiology, pharmacology and emergency response, but also on planning, team communication and risk management, as well as proper documentation.

"Gaining these skills is empowering and enables the nurse to say 'I can support an airway or realize when my patient is in need of support and when to ask for help'," she added.

Necessary skills
AORN recommends that trained perioperative nurses working within their state boards of nursing guidelines can monitor and administer moderate sedation/analgesia, but must show competence in the different aspects of patient care associated with this level of sedation.

Recommendation IX of AORN's Recommended Practices for Managing the Patient Receiving Moderate Sedation/Analgesia states that "the perioperative nurse should be clinically competent, possessing the skills necessary to manage the nursing care of the patient receiving moderate sedation/analgesia." These competencies should include, but are not limited to:

• Patient selection and assessment criteria
• Selection, function, and proficiency in use of physiological monitoring equipment
• Pharmacology of the medications uses
• Airway management
• CPAP [what does CPAP stand for?] use
• Basic dysrhythmia recognition and management
• Emergency response and management
• Advanced cardiac life support (ACLS) and pediatric advanced life support (PALS) according to patients served
• Recognition of complications associated with sedation/analgesia
• Knowledge of anatomy and physiology

Protecting the patient
Procedural sedation is a relatively unique subject, in that it crosses so many specialties, types of medical facilities, types of procedures, and types of patients, acknowledged Mark Murphy, MD, staff anesthesiologist and chief of staff at Mercy Regional Medical Center in Durango, Colo. who co-taught the course with Lynch and Brian Davidson, MD.

Murphy has been involved in the continuing education field for 20 years and has developed and implemented programs to educate healthcare professionals on procedural sedation. "Today nurses are asked and expected to provide sedation for a wide variety of changing patient populations, and patients have more co-existing conditions, such as obesity, heart disease, diabetes and advanced age," he said.

At the training, Murphy helped participants learn about physiology, monitoring and the sedation continuum, something that Lynch believes can't be stressed enough.

During the training Murphy used this slide to discuss the sedation continuum, from local to general anesthesia, and the patient responses and reflexes associated with each level.

Monitoring the patient under sedation was another important subject at the training. According to Recommendation IV in AORN's Recommended Practices for Managing the Patient Receiving Moderate Sedation/Analgesia, "the perioperative registered nurse monitoring the patient receiving moderate sedation/analgesia should have no other responsibilities that would require leaving the patient unattended or would compromise continuous monitoring during the procedure."

Using the monitors can help a perioperative nurse determine if a patient is moving into deep sedation, but nurses should be aware of the patient, too, Lynch said. "The best indicator can oftentimes be the patient, by observing their baseline behavior and noting if they can hold a conversation and communicate with you throughout the procedure, but if they are snoring, chances are you will begin to see changes in the patient before you see the changes in the monitoring equipment."

At the training, Brian Davidson MD, a faculty member in the department of anesthesiology at the University of Colorado School of Medicine in Aurora, Colo., presented information on patient evaluation, special populations, and pharmacology, including reversal agents.

Davidson and Murphy both emphasized the need for all sedation medications to be chosen on a case by case basis, rather than selecting common medication combinations, such as versed and fentanyl, simply because that is what is usually used, Lynch said.

Team communication
Lynch also said perioperative nurses need to be an active part of the sedation plan. "I would never give a medication just because someone told me to. As nurses we have the right and the responsibility to use our critical thinking skills and that includes providing input to ensure the patient is safe and has effective sedation during their procedure," she added. "The key is developing a plan, and the nurse should be an active part of the team effort to develop a sedation plan and gather as a group before the procedure to discuss the approach and expectations. This is all part of the team process to set yourself up for success."

Lynch, Davidson and Murphy agree that making a plan for each case and making sure every member of the team is educated and prepared are essential keys to making procedural sedation safe and effective.

"Communication has to be fostered among healthcare providers involved with procedural sedation, because all members of the team need to feel comfortable communicating back and forth," Lynch said, adding that simulation training is an excellent environment to develop and foster team communication.

Protecting healthcare professionals
The sedation simulation training also addressed the need for clear understanding of the nurses' scope of practice outlined by state boards of nursing, as well facility guidelines established for sedation, particularly as facilities are increasingly establishing more detailed policy and procedure guidelines for procedural sedation to document what can and can't be done.

"Previously there have been a lot of unwritten rules for sedation, but increased emphasis on documentation and risk management have led to a greater focus on increased education and established roles to ensure that healthcare professionals do not act outside of their scope of practice," Lynch explained.

She encourages all healthcare professionals to be familiar with what is endorsed by their professional association, such as AORN, or more specifically their surgical specialty association, such as the American College of Gastroenterology, because "if something goes wrong and ends up in a court of law, this is the first group litigators will go to in determining if a wrongful action has occurred."

Lynch also strongly encouraged perioperative nurses to be familiar with sedation guidelines established by The Joint Commission and the Centers for Medicare and Medicaid Services, as well as the nurses' scope of practice as outlined by their respective state boards of nursing.

Lynch, Murphy and Davidson will be hosting another sedation simulation training at the WELLS Center in August and Lynch will be leading a sedation simulation training in St. Louis during AORN's multispecialty conferences in October. To learn more about participating in these trainings contact Pika Lynch at plynch@aorn.org.

Additional Resources
AORN's Recommended Practices for Managing the Patient Receiving Moderate Sedation/Analgesia, pages 461-471 in Perioperative Standards and Recommended Practices, 2008 Edition
www.aornbookstore.org

AORN's legislative map with contact information for individual state boards of nursing
aorn.org/PublicPolicy/LegislativeMap/

**The correct medication used in this scenario is oxycontin.

Read more news in AORN Connections.