The Newest Threat to Emergency Department Procedural Sedation

Green, S M; Roback, Mark G.; Krauss, Baruch

doi:10.1016/j.annemergmed.2017.12.008

Cited by 9 publications

(33 citation statements)

References 24 publications

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“…They are not required or even encouraged by the Joint Commission or by CMS. They instead result from local sedation policies and protocols created by anesthesiologists or other hospital leaders based on local biases and unduly conservative visions of regulatory compliance . We found that such restrictions could not be predicted by hospital type, ED volume, or local population density, supporting an idiosyncratic impact of these local political forces.…”

Section: Discussionmentioning

confidence: 72%

“…In this statewide survey we found that 43% of responding EDs report limitations to their procedural sedation practice, in noncompliance with ACEP sedation guidelines and at variance with the CMS acknowledgement that emergency physicians “are uniquely qualified to provide all levels of analgesia/sedation.” Our surveyed ED medical directors report occurrences of adverse clinical consequences, with patients not receiving optimal alleviation of their procedural pain and anxiety in accordance with current and widely accepted standards of care …”

Section: Discussionmentioning

confidence: 99%

“…Most concerning is the prohibition of deep sedation at 18% of our responding EDs. Deep sedation is now a well‐established core skill in our specialty, is widely and safely practiced, and has a substantial supporting literature . It has permitted our patients to receive humane and effective relief of pain and anxiety during extremely painful emergency procedures for which moderate sedation alone is typically inadequate, e.g., cardioversion, fracture reduction, and joint dislocation reduction.…”

Section: Discussionmentioning

confidence: 99%

“…Emergency department (ED) patients frequently require procedures that are either extremely painful (e.g., fracture reduction, abscess drainage, cardioversion) or emotionally distressing (e.g., facial laceration repair in a young child), and humane care in such circumstances often requires pharmacologic sedation and analgesia. Such procedural sedation has been a daily occurrence in United States EDs now for decades, with well‐documented safety and efficacy …”

mentioning

confidence: 99%

“…Procedural sedation protocols and privileging are governed at the local hospital level based on standards from the Joint Commission and CMS, and hospitals frequently differ in how they specifically implement and regulate such sedation . Despite compelling existing evidence of safety and the above CMS verification of emergency physician credentials, there remain frequent reports of EDs in which either specific sedation practices (e.g., deep sedation) or drugs (e.g., propofol) are restricted or prohibited by anesthesia chiefs or other hospital leaders …”

mentioning

confidence: 99%

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Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey

Reibling

Green

Phan

et al. 2018

Academic Emergency Medicine

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Objectives:We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California.Methods: We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact.Results: We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control. Conclusions:In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care. E mergency department (ED) patients frequently require procedures that are either extremely painful (e.g., fracture reduction, abscess drainage, cardioversion) or emotionally distressing (e.g., facial laceration repair in a young child), and humane care in such circumstances often requires pharmacologic

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Section: Discussionmentioning

confidence: 72%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 3 more Smart Citations

Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey

Reibling

Green

Phan

et al. 2018

Academic Emergency Medicine

Self Cite

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Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children

et al. 2017

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IMPORTANCE Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes.OBJECTIVE To examine the incidence and risk factors associated with sedation-related SAEs.DESIGN, SETTING, AND PARTICIPANTS This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis.EXPOSURES The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type. MAIN OUTCOMES AND MEASURESFour outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting. RESULTSOf the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions. CONCLUSIONS AND RELEVANCEThe incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.

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Evolution of the Pediatric Intensivist Sedation Service

Lowrie

2019

Curr Pediatr Rep

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The Newest Threat to Emergency Department Procedural Sedation

Cited by 9 publications

References 24 publications

Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey

Emergency Department Procedural Sedation Practice Limitations: A Statewide California American College of Emergency Physicians Survey

Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children

Evolution of the Pediatric Intensivist Sedation Service

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