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PhaseLeading practiceReferenceRequired Sedation Policy Competency: All such practitioners must successfully complete aninstitutionally-approved education module on theorganization’s moderate sedation policy with a passingscore as approved by the institution’s anesthesiachairman.Patient Advocacy Responsibility: Nurses and others permitted to participate areempowered to stop the sedation process at any timeduring the procedure up to and including requestingconsultation with a credentialed anesthesia provider.Requirementsfor traineesFull moderate sedation LIP privileges may be granted toboard-eligible, post-residency fellowship trainees who meetall the above LIP requirements.All other non-fellow trainees must have direct, on-sitesupervision by an LIP with current, active moderate sedationprivileges. (Exempted providers: trainees in anesthesiology,emergency medicine, critical care medicine, and oralmaxillofacial surgery are not required to demonstratecompetency if their training program director hasdocumented that they have comparable knowledge of airwayassessment and rescue skills.)Renewal ofmoderatesedationprivileges forLIPs andadvancedpracticeproviders(APP’s)Moderate sedation privileges will be reevaluated at leastevery 2 years.Renewal of privileges requires: Ongoing maintenance of current, active BLS and ACLSqualifications Valid DEA registration number and unrestricted license Completion of at least 10 moderate sedation procedureswithin the previous 2 years with ongoing yearly sedationeducation as approved by the institution’s anesthesiachairman Ongoing monitoring/evaluation of moderate sedationoutcomes and process indicator compliance withinstitutional moderate sedation policy and currentregulatory guidelines at least every 2 years Supervising physicians for advanced practice providers(APP’s) must remain continuously privileged throughoutthe term of the APP’s moderate sedation privileges, andAPP’s must also complete the above 10 sedationprocedure volume requirement If an LIP does not meet all requirements for renewal ofmoderate sedation privileges, the LIP must reapply forPractice Guidelines forModerate ProceduralSedation and Analgesia2018: A Report by theAmerican Society ofAnesthesiologists TaskForce on ModerateProcedural Sedation andAnalgesia, the AmericanAssociation of Oral andMaxillofacial Surgeons,American College ofRadiology, American DentalAssociation, AmericanSociety of DentistAnesthesiologists, andSociety of InterventionalRadiology*. Anesthesiology2018; 128(3): 437-479. doi:10.1097/ALN.0000000000002043. Accessed April 4,2019 CMS CoP §482.52 2019, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational pur poses only and does not,itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.09/2019

PhaseRenewal ofmoderatesedationprivileges forLIPs e-sedationevaluationLeading practiceReferencesuch privileges and fully meet current institutionalmoderate sedation credentialing requirementsExcept for emergent procedures to limit morbidity andmortality, a comprehensive pre-sedation patient evaluationmust be performed prior to the procedure to allow time forpatient optimization. This focused history and physical mustbe performed immediately before the start of the procedureto confirm there has been no significant interval changes inthe patient’s underlying medical condition.The focused history and physical examination includesat a minimum: History (signed, dated and/or updated, and timed beforefirst sedation medication is administered) Medical conditions Cardiovascular e.g., coronary artery disease (CAD),congestive heart failure (CHF), arrhythmias, etc. Pulmonary e.g., congestive obstructive pulmonarydisease (COPD), asthma, recent upper respiratoryinfection (URI), etc. Renal e.g., chronic kidney disease (CKD), renalreplacement therapy, etc. Hepatic e.g., hepatitis, portal hypertension, etc. Endocrine e.g., diabetes, etc. Central Nervous System e.g., cerebral vascularaccident (CVA), seizures, cognitive disabilities, etc. Sleep apnea signs/symptoms and possiblecontinuous positive airway pressure (CPAP) use Current medication regimen, especially medicationtaken within the last 48 hours (including herbal agents,etc.) Allergies (including foods, herbal agents and/or latex) Pregnancy status or last menstrual period, whereapplicable Tobacco, alcohol, or substance use/abuse Prior anesthetic, sedation and/or airway issues Last oral intake, including tube feedings whereapplicablePractice Guidelines forModerate ProceduralSedation and Analgesia2018: A Report by theAmerican Society ofAnesthesiologists TaskForce on ModerateProcedural Sedation andAnalgesia, the AmericanAssociation of Oral andMaxillofacial Surgeons,American College ofRadiology, American DentalAssociation, AmericanSociety of Dentists,Anesthesiologists, andSociety of InterventionalRadiology*. Anesthesiology2018; 128(3): 437-479. doi:10.1097/ALN.0000000000002043. Accessed April 4,2019CAMH RI.01.03.01 EP 1,2 NPSG.03.05.01 EP 2, 3 PC.03.01.03 EP 1,4,8,18 PC.13.20 CMS CoP §482.51(b)(2) CMS CoP §482.52(b) (1) 2019, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational pur poses only and does not,itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.09/2019

PhasePre-sedationevaluation(continued)Leading practiceReference Exposure to infectious diseases and/or need forisolation procedures Physical exam: Cardiac (regular versus irregular rate, murmurs, etc.) Pulmonary (rales, wheezing, etc.) Airway (Mallampati classification, difficult airwaystigmata, etc.) Habitus: Excessive facial hair, receding chin, orsignificant obesity especially involving the neck andfacial structures (body mass index 35) Head and Neck: Short neck, limited neckextension, decreased hyoid-mental distance ( 3 cmin an adult), neck mass, cervical spine disease ortrauma, tracheal deviation, dysmorphic facialfeatures (e.g., Pierre-Robin syndrome) Mouth: Small opening ( 3 cm in an adult);edentulous; protruding incisors; loose or cappedteeth; dental appliances; high, arched palate;macroglossia; tonsillar hypertrophy; nonvisibleuvula Jaw: Micrognathia, retrognathia, trismus, orsignificant malocclusion Examination(s) specific to the scheduled procedure(e.g., anatomic landmarks, ability to lie in requiredposition for the procedure, etc.) where applicableAdditional Evaluation: Documentation of an appropriate American Society ofAnesthesiologists (ASA) physical status classification Review of appropriate diagnostic or laboratory data anddetermination of need for/availability of blood and/orblood products Interpretation of cardiac rhythm if other than regular rateand rhythm Patients should be NPO (nothing by mouth) prior tosedation for a duration that is appropriate for theprocedure being performed and for the patientpopulation being served -please see Anesthesiology 32017, Vol.126, 376-393.doi:10.1097/ALN.0000000000001452, AccessedSeptember 29, 2019 Ensure there is a responsible adult (for a child less than18 years of age and not an emancipated minor, thismeans a parent, legal guardian, or their designee) toaccompany, monitor, and observe the post-sedationoutpatient for at least 6 hours after discharge. If such a 2019, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational pur poses only and does not,itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.09/2019

PhasePre-sedationevaluation(continued)Leading practiceReferenceresponsible adult is not available, the team must developalternative arrangements for more prolonged postsedation clinical monitoring/observation prior todischarge Consent Explain risks, benefits, and alternatives to sedationwith the patient and/or legal guardian with appropriatedocumentation of sameRecommendedmedicalspecialistconsultation Consultation with an appropriate medical specialist isrecommended for patients with: Severe medical comorbidities e.g., NYHA class 4CHF, O2-dependent lung disease, etc. Known or suspected sleep apnea – Sleep apneapatients are at significantly increased risk for airwayobstruction and rapid oxygen desaturation duringsedation, and organizations should seriously considerhow such patients are cared for during and afterprocedures requiring non-anesthesia sedationadministration A consultation with an anesthesiologist should bevery strongly considered for: Severe known or suspected sleep apnea Patients with an ASA physical status of 4 or higher Patients with a history of airway problems duringsedation, analgesia, or general anesthesia Patients with a history of adverse reaction to sedation,analgesia, or general anesthesia Patients who demonstrate high risk airwaycharacteristics (e.g., Mallampati class 4)- Morbid or supermorbid obesityLife-threatening situations may warrant proceedingwithout an anesthesiologist; those cases should beretrospectively reviewed for appropriateness in a timelymanner.Practice Guidelines forModerate ProceduralSedation and Analgesia2018: A Report by theAmerican Society ofAnesthesiologists TaskForce on ModerateProcedural Sedation andAnalgesia, the AmericanAssociation of Oral andMaxillofacial Surgeons,American College ofRadiology, American DentalAssociation, AmericanSociety of DentistAnesthesiologists, andSociety of InterventionalRadiology*. Anesthesiology2018; 128(3): 437-479. doi:10.1097/ALN.0000000000002043. Accessed April 4,2019Practice Guidelines for thePerioperative Managementof Patients with ObstructiveSleep Apnea: A Report bythe American Society ofAnesthesiologists TaskForce on PerioperativeManagement of Patientswith Obstructive SleepApnea. Anesthesiology2006; 104:1081–93. OSAAnesthesiology AccessedSeptember 29, 2019 2019, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational pur poses only and does not,itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.09/2019

PhaseLeading practiceReferenceMedication useMeperidine (Demerol) is not recommended because ofthe availability of more suitable agents.Practice Guidelines forModerate ProceduralSedation and Analgesia2018: A Report by theAmerican Society ofAnesthesiologists TaskForce on ModerateProcedural Sedation andAnalgesia, the AmericanAssociation of Oral andMaxillofacial Surgeons,American College ofRadiology, American DentalAssociation, AmericanSociety of DentistAnesthesiologists, andSociety of InterventionalRadiology*. Anesthesiology2018; 128(3): 437-479. doi:10.1097/ALN.0000000000002043. Accessed April 4,2019Recommended Medications: Fentanyl (short-acting opioid) Midazolam (short-acting benzodiazepine) Dexmedetomidine has been recommended by somespecialty organizations. Closely monitor for hypotensionand bradycardia when loading dexmedetomidine, and itsslower onset of action may contribute to excess dosing.Providers should have specific education aboutdexmedetomidine’s pharmacology before its utilization Other agents may be used that are approved by theinstitution’s Pharmacy & Therapeutics Committee inconsultation with the anesthesia chairman. (Medicationsnot approved by the P&T Committee or other approvedinstitutional body must be approved by the institution’sanesthesia chairman prior to becoming available formoderate sedation use).Intra-proceduremonitoring The patient should be clinically reevaluated to ensuretheir clinical status is appropriate before beginningsedation administration Vigilant, continuous, uninterrupted clinical monitoringof the patient during which the nurse, LIP, or otherhealth care provider permitted by state law andinstitutional policy is in constant attendance and shallhave no other responsibilities that would compromiseprovision of close, focused, one-to-one patientobservation. The following parameters are monitored continuouslyand recorded every 5 minutes: Level of consciousness or responsiveness Electrocardiogram (EKG) rate and rhythm Noninvasive blood pressure (BP) measurement atleast every 5 minutes (unless indwelling arterialcatheter for continuous beat-to-beat measurement ispresent) Respiratory rate Continuous oxygen saturation monitoring Continuous end-tidal carbon dioxide (ETCO2)monitoringJoint Commission 2019Operative and InvasiveProceduresPC.03.01.01:EP 6, 8CMS §482.51(b)(3),§482.52(b)America Society ofAnesthesiologists (2018).Statement onnonoperating roomanesthetizing locations.(Approved by the ASAHouse of Delegates onOctober 19, 1994, lastamended on October 16,2013, and reaffirmed onOctober 17, ionsAccessed April 1, 2019 2019, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational pur poses only and does not,itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.09/2019

PhaseLeading practiceIntra-proceduremonitoring(continued) Resuscitative Equipment Available At The Bedside: Appropriately sized, self-inflating bag-valve-mask(BVM) device capable of administering at least 90%oxygen and delivering positive pressure ventilation Nasal cannula and nonrebreather face mask Oxygen – A reliable source of oxygen adequate for thelength of the procedure and a back-up supply. Oxygenpiped from a central source, meeting applicable codes,is strongly encouraged. The back-up system shouldinclude the equivalent of at least a full ( 2200 psi) Ecylinder An adequate and reliable source of suction withassociated patient attachments/tubing. A suctionsystem meeting operating room standards is stronglyencouraged. Reversal agents must be located in close physicalproximity to the procedure area and immediatelyavailable/readily accessible for administration asclinically indicated Adequate monitoring equipment in adherence with theASA "Standards for Basic Anesthetic Monitoring”(continuous cardiac, blood pressure, continuous pulseoximetry, continuous capnography) Sufficient electrical outlets to satisfy monitoringequipment and procedure requirements, includingclearly labeled outlets connected to an emergencypower supply Adequate illumination of the patient and monitoringequipment should occur where feasible. In addition, afunctional, battery-powered illumination device otherthan a laryngoscope should be immediately available Sufficient space to accommodate necessaryprocedure equipment and/or personnel and allowexpeditious access to the patient and monitoringequipment A reliable means of two-way communication to requestassistance. Emergency phone numbers should beposted in a highly visible procedure area location Other equipment as mandated by state lawReference Advanced resuscitative equipment that must beimmediately available (i.e., able to be mobilized to thebedside in 5 minutes) within the procedure area Institutionally-approved, age-appropriate code cartwith advanced airway equipment, defibrillatorpacemaker, and appropriate resuscitation medications 2019, Vizient Inc. and Vizient PSO. Do not distribute outside of your institution without permission from Vizient. Disclaimer: For informational pur poses only and does not,itself, constitute medical or legal advice. This information does not replace careful medical judgments by qualified medical personnel.09/2019

PhaseLeading practice Age-appropriate back-up airway device(s) such as astandard sized adult laryngeal mask airway (LMA) Intubation equipment, including emergency surgicalairway st-proceduremonitoringReference The RN, LIP, or other health care provider permitted bystate law and institutional policy who is responsible forthe patient during the post-sedation recovery periodshall not have any assigned duties other than patientrecovery. The LIP shall remain readily available withinthe immediate procedure area to provide ongoing postprocedure medical management and supervisionthroughout the recovery period until the patient isformally discharged. At procedure conclusion and immediately uponbeginning the post-procedure recovery period, thepatient should undergo an immediate post-sedationreevaluation of vital signs, level of consciousness,Aldrete score, and any appropriate procedure-relatedassessments. The RN, LIP, or other health care provider aspermitted by state law and institutional policy, shallcontinuously monitor/observe the patient throughoutthe recovery period and document vital signsmeasurements and/or clinical observations at leastevery 15 minutes (or more frequently, if clinicallyindicated) until the patient has returned to their presedation baseline or meets clinical discharge criteriaapproved by institutional leadership. Level of consciousness Continuous oxygen saturation Continuous ETCO2 Blood pressure Cardiac rhythm, if the patient has significantcardiovascular disease or when arrhythmias areanticipated or detected Assessment of adequacy of ventilation (spontaneousairway patency, respiratory rate/depth/pattern) Pain assessment using an institutionally-approvedpain scale to monitor for adequate pain control Post-procedure temperature Patients must be discharged from the recovery phase ofcare by a credentialed LIP or upon meetinginstitutionally-approved clinical discharge cri

Required Sedation Policy Competency: All LIP's (both exempt and nonexempt) must successfully complete an appropriate education module on the organization's moderate sedation policy with a passing score as approved by the institution's anesthesia chairman. Requirements for registered nurses (RNs) or others permitted to participate by