ACEP seeks resolution to limitations on procedural sedation in the ED, renews call to allow EM physicians to provide individualized sedation treatment for each patient

Emergency physicians are being forced by their hospitals to deliver substandard care when administering sedation to their patients. This in no way reflects a lack of training or experience on the part of emergency physicians but instead is the result of variable interpretation of rules and regulations. In the January issue of ACEP Now, ACEP Council respondents to a survey revealed that emergency physicians have been forced to provide substandard care 36.2 percent of the time due to limitations or restrictions placed on their ability to provide conscious or procedural sedation. These restrictions do not allow emergency physicians to practice as they would like 43.8 percent of the time and are promulgated by sources external to emergency medicine 53.9 percent of the time. For 85.5 percent of the respondents, limitations on nursing scope of practice prohibit emergency-department (ED) nursing from “pushing the plunger” when certain sedation drugs are ordered, thus requiring physicians, who are less qualified than nursing, to administer (draw up and push) medications. Restrictions on medication administration are under the purview of the nursing scope of practice; however, these restrictions clearly impact our practice. Having to push medications diverts physicians’ attention away from performing procedures and distracts them from monitoring patients.

I have heard from colleagues who are not allowed to use specific agents even if the specific agent is judged to offer the best option for their patients. In the survey, 15.2 percent of respondents cannot use propofol and 5.7 percent cannot use ketamine. This restriction is in direct conflict with the ACEP Policy “Sedation in the Emergency Department,” which states, “the decision to provide sedation and the selection of the specific pharmacologic agents should be individualized for each patient by the emergency physician and should not be otherwise restricted.”¹ In a 2014 paper, the ACEP Clinical Policies Committee recommended (Level A, the highest strength of evidence) that ketamine can be safely administered to children for procedural sedation and analgesia in the ED and that propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.² Given the strength of evidence regarding safety, it makes no sense that limitations are being placed on these agents. Furthermore, not using these agents results in the use of outdated medications, promoting substandard practices.

In 2011, the Centers for Medicare & Medicaid Services (CMS) issued its revised Interpretive Guidelines (IGs) pertaining to the hospital Conditions of Participation.³ The IGs have been widely used by health-care facilities to develop institutional and departmental guidelines related to the sedation of patients. The document attempts to distinguish analgesia from anesthesia but goes on to state, “anesthesia exists along a continuum. There is no bright line that distinguishes when their pharmacological properties bring about the physiologic transition from the analgesic to the anesthetic effects. Furthermore, each individual patient may respond differently to different types of medications.”

The CMS document goes on to state that hospitals “must establish policies and procedures, based on nationally recognized guidelines that address whether specific clinical situations involve anesthesia versus analgesia” and “address whether the sedation typically provided in the emergency department or procedure rooms involves anesthesia or analgesia.” Hospitals would be free to use ACEP guidelines and recognize them as authoritative. Furthermore, if sedation administered in the ED is termed “analgesia” (which it is), it would not fall under anesthesia-services oversight. The CMS document allows for this carve out for emergency medicine by stating that “it is important to note that anesthesia services are usually an integral part of surgery.” ED sedation is unique, and the credentialing and verification of competency of providers, selection and preparation of patients, informed consent protocols, equipment and monitoring requirements, staff training and competency verification, criteria for discharge, and continuous quality improvement should be overseen by emergency medicine.

In 2011, ACEP formed the sedation task force to address procedural sedation in the ED by working with ED nursing colleagues, anesthesiology, and other stakeholders. The sedation task force published its recommendations for physician credentialing, privileging, and practice related to procedural sedation and analgesia in the ED in 2011.⁴ This update is intended to be used to develop hospital policy for the administration of analgesia, sedation, and anesthesia by emergency physicians. From the paper, it is clear that sedation and analgesia in the ED represents a unique skill set and that policies and procedures that define the various uses of analgesia and anesthesia require an interdisciplinary effort on the part of ED physicians and nursing.

Resolution of these limitations to our practice will allow us to provide sedation in a manner conducive to patient safety by tailoring treatment to the individual patient. Emergency physicians are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general) and should be allowed to practice unencumbered.

Dr. O’Connor is professor, chair, and physician-in-chief of the department of emergency medicine at the University of Virginia Health System in Charlottesville, Va. He is also an emergency physician at the Culpeper Regional Hospital in Culpeper, Va., and is vice president of the ACEP Board of Directors.

References

1. Wendling P. CMS anesthesia policy altered after outcry. ACEP News. February 2011. Available at: http://www.acep.org/Content.aspx?id=79760. Accessed January 21, 2014.
2. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Procedural Sedation and Analgesia. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63:247-258.
3. Centers for Medicare & Medicaid Services. CMS Manual System pub. 100-07 state operations provider certification: revised appendix A, interpretive guidelines for hospitals. December 2, 2011. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R74SOMA.pdf. Accessed January 21, 2014.
4. O’Connor RE, Sama A, Burton JH, et al. Procedural sedation and analgesia in the emergency department: recommendations for physician credentialing, privileging and practice. Approved June 2011. Available at: http://www.acep.org/assets/0/16/898/904/95333/cdc72351-3f53-470a-8705-98a18ff53298.pdf. Accessed January 21, 2014.