Declining reimbursements and the anesthesia-provider shortage have prompted many facilities to charge RNs with administering and monitoring moderate (conscious) sedation/analgesia.While RNs who aren't nurse anesthetists can and do perform this job very well, they need special training and full buy-in of the healthcare team. Here are seven ways to help your RNs deliver sedation safely.

1 Offer personal training
State nursing boards and professional societies offer general educational goals (see "ANA Educational Objectives"), but the specifics are up to you. You may use self-learning packets, lectures on tape or CD-ROM programs to teach physiology and pharmacology while reserving workshops for concepts that require physical skills, like airway management.

Take a personal approach and conduct an interactive program that combines oral, written, visual and hands-on teaching. This engages RNs and lets them ask questions and share ideas. It also helps ensure they understand concepts that impact patient care - such as the potential for opioids to potentiate sedative-induced respiratory depression, the timing of intervals between doses to avoid cumulative overdose, and the recognition of cardiovascular/respiratory complications.

Stress the RN's role in the pre-procedure assessment. AORN recommends physiological and psychological assessments (see "The Pre-procedure Assessment"). Understanding patient risk factors helps determine the sedation approach and patient-monitoring needs.

2 Consider ACLS certification
Although all RNs monitoring anesthesia care must get basic life-support training, some state nursing boards, hospitals and insurers require advanced cardiac life support (ACLS) certification. As the American Society of Anesthesiologists (ASA) puts it, we recognize sedation occurs on a continuum, and patients respond differently to drugs. Thus, moderate-sedation practitioners should be able to rescue patients who enter deeper-than-expected sedation. ACLS certification gives RNs a professional edge and increases confidence.

3 Clear away other demands
ASA guidelines say RNs who monitor moderate sedation may assist with "short, interruptible tasks" once the patient's sedation level and vital signs are stable and "adequate monitoring is maintained." However, some states and most nursing organizations (including the American Nurses Association) advise ess-entially disallowing other resp-onsibilities. I agree, because multiple tasks can distract any anesthesia provider. Safe sedation requires focus on patient monitoring and documentation.

4 Monitor all patients thoroughly
To detect and treat adverse drug responses before they develop into complications, monitor patients thoroughly, including assesment of ventilation and EKG monitoring. The RN should continuously monitor each patient's

• Level of consciousness. Do so by assessing the patient's responses to verbal instructions (spoken responses also indicate that the patient is breathing). Patients whose only response is reflex withdrawal from painful stimuli are deeply sedated.
• Adequacy of ventilation. Since a primary cause of anesthesia-related morbidity is drug-induced respiratory depression and airway obstruction, the RN should monitor the depth, quality and bilaterality of a patient's breathing via auscultation, preferably with a stethoscope.
• Oxygenation. Pulse oximetry detects oxygen desaturation and hypoxemia better than clinical assessment alone, and early detection of hypoxemia can decrease the likelihood of cardiac arrest and death.
• Cardiac function. Most nursing guidelines recommend routine electrocardiographic monitoring, although the ASA recommends this only in patients with "significant cardiovascular disease or dysrythmias." To play it safe, routinely monitor EKG. Though rare when preoperative screening is thorough, cardiovascular complications can occur. In addition, facilities that follow the ASA recommendation must clearly outline in the policy manual their specific criteria for EKG monitoring.
• Vital signs every five minutes once stable. Early detection of heart rate and blood pressure changes can help prevent complications with over- or under-sedation.

Some facilities use capnography, as research suggests some patients can experience brief apneic periods that go undetected by oximetry; oxygen level does not drop immediately, but end-tidal CO2 increases.

5 Oxygenate first
In a respiratory depression, the RN should first ensure oxygenation by stimulating deep breathing, administering supplemental oxygen if not already in place and, if necessary, using positive-pressure ventilation. If the patient is apneic, the RN should use positive-pressure ventilation immediately to maintain oxygenation. Only then should the RN administer antagonist agents. This may sound like common sense, but a provider can get caught up in a situation if not well-trained. In at least two reported cases associated with poor outcomes, RNs have mistakenly drawn up reversal agent(s) before oxygenating patients. Be sure an oxygen source is in the room.

7 Document every 5 minutes
Document the patient's status every five minutes. This is an external check for the RN to monitor a patient's vital signs, oxygen saturation, adequacy of ventilation and other signs. It's also a good way to monitor your outcomes. JCAHO requires that you monitor sedation-related outcomes and issues.

8 Have reversals ready
Although acute pharmacologic reversal of opioid-induced sedation can cause complications (pain, hypertension, tachycardia and pulmonary edema, for example), it can improve ventilation in a patient with drug-induced respiratory depression. So don't be caught without antagonist agents. In one reported case, lack of access to reversal agents resulted in a poor outcome.

Safety first
Understand nursing and anesthesiologist association guidelines, and state nursing board requirements about sedation. Accreditation organizations also have guidelines. Adhere to the more conservative guides.

Follow this guidance and these tips, and your RNs will understand the seriousness of patient monitoring and be better equipped for the job.