CMS and JCAHO have both supported ACEP's position that you can have one "policy" for the hosptial and a separate procedure in the ED.
The multi-hospital system policy requires a separate procedural physician and sedation provider.
For PICU and ED only
The procedural physician can do both IF there is a separate credentialed person (nurse with sedation training PALS etc) in the room with the patient whose only responsibility is to monitor the patient. Therefore there needs to be a third person a tech etc. to help. The rational used is that there are ample backup resources in the ED and PICU if there was a problem and that we are unlikely to do a procedure that cannot be stopped immediately.
We have periodically had to fight this battle when a new system policy is written. At the children's hospital procedural sedation (deep) privileges are only given to PICU, ED and Anesthesia attendings. On the adult side there are other issues, but the adult ED's have also won the fight.
We have been providing "deep' procedural sedation primarily Propofol for almost 20 years with a long track record of safety. We have successfully survived multiple JCAHO survey's during which the policy was questioned.
The biggest help has come from anesthesia. We enlisted them as allies from the very beginning and it remains a collaborative practice
Ted Walkley MD FAAP FACEP
Interim Medical Director
Mary Bridge Children's Hospital Emergency Department
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From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of MacPhee, Shannon
Sent: Wednesday, November 19, 2014 11:28 AM
To: [log in to unmask]
Subject: Re: Deep (Procedural) Sedation in the Pediatric ED, one vs two physician presence
Our institution requires:
2. Separate Physician to administer sedation 3. Provider to monitor/manage airway (could be RT or the physician providing sedation) 4. RN for documentation/monitoring
Sent from my iPhone
> On Nov 19, 2014, at 3:19 PM, "Meckler, Garth" <[log in to unmask]> wrote:
> Thanks for the important discussion. Our institution requires a separate sedation its and proceduralist as well, but we also require a dedicated RN AND a dedicated RT. I'm wondering if others have explored or feel it would be safe to have a single physician with RN and RT presence? Or if there is variability of staffing requirements depending on the procedure? Cognitive load and attention notwithstanding (though important), a fracture reduction could be abandoned more easily and readily than say an LP, for instance.
> Garth Meckler, MD, MSHS, FRCPC
> BC Children's / UBC
>> On Nov 19, 2014, at 09:53, Van der Jagt, Elise <[log in to unmask]> wrote:
>> In our institution, for deep sedation, the person doing the procedure cannot be the person providing deep sedation. Meticulous attention needs to be paid to airway/respiratory management at all times and this is best done by a physician who is expert in this so that subtle changes can be identified and managed before the patient deteriorates. This is particularly true in that the threshold between deep sedation and gen anesthesia can be crossed inadvertently.
>> We have a nurse also who primarily documents and does some monitoring and is there to help out in the event there is a significant event related to the sedation.
>> Elise W. van der Jagt, MD, MPH, FAAP, SFHM Professor of Pediatrics
>> and Critical Care Pediatric Sedation Officer Chief, Pediatric
>> Hospital Medicine University of Rochester Medical Center
>> 601 Elmwood Ave., Box 667
>> Rochester, NY 14642
>> Tele: 585-275-8138/585-276-4113
>> Fax: 585-276-1128
>> Golisano Children's Hospital
>> -----Original Message-----
>> From: Pediatric Emergency Medicine Discussion List
>> [mailto:[log in to unmask]] On Behalf Of Bernard Dannenberg
>> Sent: Tuesday, November 18, 2014 7:09 PM
>> To: [log in to unmask]
>> Subject: Deep (Procedural) Sedation in the Pediatric ED, one vs two
>> physician presence
>> A straw poll to all members
>> We have written a new policy for deep sedation in our Pediatric Emergency Department.
>> The following sentence has raised significant resistance by our anesthesia department:
>>> The physician administering deep sedation may also perform the procedure if a qualified ED registered nurse (RN) is present to continuously monitor the patient.
>> Their argument is that not one academic institution they contacted would permit this.
>> Naturally I am suspicious. CMS guidelines appear to allow that one provider can administer the sedation if a qualified nurse is present to monitor the patient.
>> The California Department of Public Health has issued the following
>> clarification in July 2013
>> Can you respond to me directly what your institution is allowing you to do.
>> A. 2 physicians need to be present: One performs the sedation, the
>> other performs the procedure
>> B. 1 physician can administer the sedation and perform the procedure
>> if a qualified RN is monitoring the patient
>> I will tabulate the answers and distribute them back to the group.
>> Thank you for your assistance
>> Bernard Dannenberg, MD, FAAP, FACEP
>> Clinical Associate Professor
>> Davies Family Director, Pediatric Emergency Medicine Division of
>> Emergency Medicine Department of Surgery Stanford University School
>> of Medicine Lucile Packard Children’s Hospital
>> 300 Pasteur Drive
>> Alway Building M-121
>> Stanford, CA 94305
>> (650) 721 2450 FAX: (650) 723-0121
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