Introduction
The number of diagnostic and surgical procedures performed by non-anesthetic practitioners is rising. The State Boards of Nursing issue directions on anesthesia methods that are adapted into hospital policies to avoid inconsistencies, ensure patient safety and promote regulatory compliance. The Board decisions are founded in practice principles and recommendations developed by expert healthcare organizations and federal/state regulatory authorities. Registered Nurses’ (RNs) role in conscious sedation is one area where institutional policy informed by the Board standards and guidelines can advance best practices and compliance. The realm of practice of specialized RNs must be within the regulatory standards of their state licensure and administrative policies (Crego, 2015). This paper proposes a regulatory requirement for the RN role in administering conscious sedation to patients undergoing radiological procedures in Florida hospitals.
Description of the Regulation
The purpose of this regulation is to ensure that the RN-administration of conscious sedation occurs within the RN scope of practice as determined by the training, knowledge, and skills. The definition recognized is that of The Joint Commission, i.e., conscious sedation is a “drug-induced suppression of consciousness” to promote patient tolerance of “diagnostic and invasive procedures” (Hurford & Staubach, 2013, p. 17).
In this view, it is recognized that the administration of non-anesthetic drugs for conscious sedation falls within the realm of RN practice. However, the RN must possess the requisite training/expertise, skills, and abilities to function. Further, the monitoring of the patient under conscious sedation falls within the RN realm of practice, irrespective of whether the medication used is anesthetic or not. However, the RN role must be within the hospital policy and involve the guidance of a physician performing conscious sedation.
The administration of anesthetics or the monitoring of sedated patients does not fall within the realm of RN practice as defined by The Joint Commission. Perioperative RNs eligible to perform conscious sedation shall have the following skills and competencies:
- A demonstrated understanding of sedatives, medication classification, dosage levels, drug-drug interactions, and contraindications
- Skills in cardiac life support, emergency protocols for respiratory complications, oxygen delivery devices, and physiologic assessments based on the American Society of Anesthesiologists (ASA) guidelines, etc.
- The registered nurse should not administer drugs excluded from use by licensure. However, he/she may monitor physician-administered anesthetic drugs
The Need for this Regulation
Florida’s Board of Nursing limits non-advanced RN’s use of medications for conscious sedation. This means that all RNs must operate within the practice scope defined by the licensure and institutional policies and guidelines (Crego, 2015). However, variability in institutional policies and physician/RN practices related to the administration and monitoring of conscious sedation increases the risk of sentinel events. Therefore, there is a need for a clear position statement to regulate and define the scope of non-CRNA RN practice with regard to the administration and monitoring of medications considered anesthetics to minimize sedation complications.
Besides, such regulation will outline drugs classified as anesthetics and the acute-care patients that should receive them. It will also define the requisite advanced skills and competencies for CRNA RNs to offer moderate/conscious sedation to promote patient safety and avoid sedation complications. Demonstrated skills in “oxygen delivery, anesthetic medications, airway management, rescue procedures, and risk assessment” would determine the scope of practice of non-advanced RNs (Caperelli-White & Urman, 2014, p. 421).
Communicating and Implementing this Regulation
The regulation will be presented to the conscious sedation committee of the Board for discussion with the aim that it will result in policy adaptations in hospitals across Florida. The discussion will also focus on the scope of RN practice, barriers, knowledge deficits, and TJC definition of conscious sedation. The regulatory requirement will be communicated to nurse administrators/managers through e-mail. The nurse managers will be notified of the new regulation and best practice recommendations for policy adaptations.
Implementation of this regulation will be a three-step process. In the first step, as Fencl (2016) recommends, the hospitals will be required to implement an Aldrete tool for “discharge scoring after anesthesia” outside PACU environments (p. 506). The RNs will be required to receive training on conscious sedation and the use of the Aldrete tool post-anesthesia. The training will promote compliance with this regulation among RNs. The second step will involve a hospital policy to utilize the capnography equipment to “monitor the partial pressure of carbon dioxide” in all conscious sedation cases (Ketcham, Ketcham, & Bushnell, 2013, p. 21). The aim is to promote patient safety by preventing respiratory complications during RN administration and monitoring of conscious sedation. The third step will involve collaborating with the Nursing Education Council to support training options that improve medication knowledge of RNs at the institutional level.
Determining Regulatory Compliance
The Board of Nursing will determine regulatory compliance based on facility tours to evaluate anesthetizing procedures and equipment, evaluation of the RN staff – credentials and conscious sedation techniques, and examining hospital policies. Further, the RN practice in this area must be consistent with the credentials/skills defined in this regulation.
Conclusion
Conscious sedation is a multi-faceted issue. State to state differences in RN training, practice guidelines, and acts cause confusion. The regulation proposed aims to regulate RN skills and competences in the administration and monitoring of anesthetic agents. It aims to promote compliance with guidelines provided by expert organizations through local adaptation of the regulation as part of hospital policy.
References
Caperelli-White, L., & Urman, D. (2014). Developing a moderate sedation policy: Essential elements and evidence-based considerations. Association of Peri-operative Registered Nurses Journal, 99(3), 416-430.
Crego, N. (2015). Procedural sedation practice: A review of current nursing standards. Journal of Nursing Regulation, 6(1), 50-56.
Fencl, J. (2016). Guideline implementation: Moderate sedation/analgesia. Association of Peri-operative Registered Nurses Journal, 103(5), 501-511.
Hurford, W., & Staubach, C. (2013). A hospital policy for procedural sedation in the nonintubated patient. International Anesthesiology Clinics, 51(2), 1-22.
Ketcham, E., Ketcham, C., & Bushnell, L. (2013). Patient safety and nurses’ role in procedural sedation. Emergency Nurse, 21(6), 20-24.