aspan standards for phase 2 discharge

0 Many of the complications associated with moderate sedation and analgesia may be avoided if adverse drug responses are detected and treated in a timely manner (i.e., before the development of cardiovascular decompensation or cerebral hypoxia). d```YL" H?Y_E`d!kH5>pBmx[g4 0 b o. 3. Specializes in Post Anesthesia, Pre-Op. Home; Products. A point score of 2 is assigned when the patient is fully awake, able to answer questions and call for assistance. These evidence categories are further divided into evidence levels. Conscious sedation for gastroscopy: Patient tolerance and cardiorespiratory parameters. Use of discharge criteria shown to reduce PACU time by 24%. Fourth, survey opinions about the guideline recommendations were solicited from a random sample of active members of the ASA and participating medical specialty societies. Capnographic monitoring reduces the incidence of arterial oxygen desaturation and hypoxemia during propofol sedation for colonoscopy: A randomized, controlled study (ColoCap Study). 3 0 obj Sedatives and analgesics intended for general anesthesia (e.g., propofol, ketamine, and etomidate). MFk t,:.FW8c1L&9aX: rbl1 Midazolam-fentanyl intravenous sedation in children: Case report of respiratory arrest. The literature is insufficient to determine the benefits of contemporaneous recording of patients level of consciousness, respiratory function, or hemodynamics. See table 3 and/or refer to: American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report. Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). Category A evidence represents results obtained from randomized controlled trials (RCTs), and category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent comparison groups. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. % If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. Browse openings for all members of the care team, everywhere in the U.S. Lead the direction of our specialty by engaging in academic, research, and scientific discovery. Guide practice decisions without dictating practice. Scientific evidence used in the development of these guidelines is based on cumulative findings from literature published in peer-reviewed journals. . These guidelines apply to moderate sedation and analgesia before, during, and after procedures. Three-rater values were: (1) research design, = 0.70; (2) type of analysis, = 0.68; (3) linkage assignment, = 0.79; and (4) literature database inclusion, = 0.43. The patients status on arrival in the PACU shall be documented. 405 0 obj <>/Filter/FlateDecode/ID[]/Index[385 30]/Info 384 0 R/Length 101/Prev 214772/Root 386 0 R/Size 415/Type/XRef/W[1 3 1]>>stream There are occasional needs to deliver emergent cardiovascular and respiratory support postoperatively to patients, and PACUs are equipped to provide the same level of intensive care that a surgical intensive care unit is capable of. Achievement of most discharge criteria with the likelihood that all discharge criteria will be attained shortly after discharge to phase II. Consult with a medical specialist (e.g., physician anesthesiologist, cardiologist, endocrinologist, pulmonologist, nephrologist, pediatrician, obstetrician, or otolaryngologist), when appropriate before administration of moderate procedural sedation to patients with significant underlying conditions, If a specialist is needed, select a specialist based on the nature of the underlying condition and the urgency of the situation, For severely compromised or medically unstable patients (e.g., ASA status IV, anticipated difficult airway, severe obstructive pulmonary disease, coronary artery disease, or congestive heart failure) or if it is likely that sedation to the point of unresponsiveness will be necessary to obtain adequate conditions, consult with a physician anesthesiologist, Before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives and elicit their preferences, Inform patients or legal guardians before the day of the procedure that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before the procedure, On the day of the procedure, assess the time and nature of last oral intake, Evaluate the risk of pulmonary aspiration of gastric contents when determining (1) the target level of sedation and (2) whether the procedure should be delayed, In urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness and temperature. Allow nurses to act on behalf of anesthesia personnel. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to use supplemental oxygen during moderate procedural sedation/analgesia unless specifically contraindicated for a particular patient or procedure. Copyright 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. The term continual is defined as repeated regularly and frequently in steady rapid succession, whereas continuous means prolonged without any interruption at any time (see Standards for Basic Anesthetic Monitoring, American Society of Anesthesiologists. o Not surprisingly, respiratory incidents comprised the majority of the cases (49 of the 84), whereas cardiovascular incidents represented a minority (9 of 84). Unless otherwise noted in this document, hypoxemia is reported in the literature to be oxygen desaturation to at most 90%. Discharge score attained within acceptable range set by policy. Nonanesthesiologist-administered propofol. Etomidate and midazolam for procedural sedation: Prospective, randomized trial. endstream endobj startxref Applied when patient is about to leave the OR to determine eligibility for fast-tracking, 2. ! " The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) assure that specific antagonists are immediately available in the procedure room whenever opioid analgesics or benzodiazepines are administered for moderate procedural sedation/analgesia, regardless of route of administration; (2) encourage or physically stimulate patients to breathe deeply if patients become hypoxemic or apneic during sedation/analgesia; (3) administer supplemental oxygen if patients become hypoxemic or apneic during sedation/analgesia; (4) provide positive pressure ventilation if spontaneous ventilation is inadequate when patients become hypoxemic or apneic during sedation/analgesia; (5) use reversal agents in cases where airway control, spontaneous ventilation, or positive pressure ventilation is inadequate; (6) administer naloxone to reverse opioid-induced sedation and respiratory depression; (7) administer flumazenil to reverse benzodiazepine-induced sedation and respiratory depression; (8) after pharmacologic reversal, observe and monitor patients for a sufficient time to ensure that sedation and cardiorespiratory depression does not recur once the effect of the antagonist dissipates; and (9) not use sedation regimens that include routine reversal of sedative or analgesic agents. A double blind randomized trial of ketofol. Meta-analysis of RCTs comparing midazolam combined with opioids versus midazolam alone report equivocal findings for pain and discomfort,7277 hypoxemia,****74,75,7780 and patient recall of the procedure.7274,77,8083 (category A1-E evidence). aspan standards for phase 2 staffing. These guidelines were developed by an ASAappointed task force of 13 members, consisting of physician anesthesiologists in both private and academic practices from various geographic areas of the United States, a cardiologist, a dentist anesthesiologist, an oral/maxillofacial surgeon, a radiologist, an ASA staff methodologist, and two consulting methodologists for the ASA Committee on Standards and Practice Parameters. If theres a bed delay then we place the pt in a hold status until ready for transfer. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. This practice is sometimes called fast-tracking. Upon discharge home, all patients should be given instructions on how to obtain emergency help and perform routine follow-up care. Delaying phase 2 care because of transfer of bed delays has negative outcomes on patient care. a. Ineffective ventilation during conscious sedation due to chest wall rigidity after intravenous midazolam and fentanyl. During your stay in Phase II Recovery, you will be monitored by a nurse who will assess your vital signs every 30 minutes which will include: Temperature Blood Pressure Heart Rate Respiratory Rate Oxygen Levels Patient comfort in terms of pain control is a primary goal in Day Surgery/ Phase II Recovery. Patients whose only response is reflex withdrawal from painful stimuli are deeply sedated, approaching a state of general anesthesia, and should be treated accordingly. When I covered nights I did call in a backup RN and never heard boo from management. This study guide will help you focus your time on what's most important. The rate of return was 34.6% (n = 55 of 159). 1. All meta-analyses are conducted by the ASA methodology group. Reversal of midazolam sedation with flumazenil following conservative dentistry. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to assure that (1) pharmacologic antagonists for benzodiazepines and opioids are immediately available in the procedure suite or procedure room; (2) an individual is present in the room who understands the pharmacology of the sedative/analgesics administered and potential interactions with other medications and nutraceuticals the patient may be taking; (3) appropriately sized equipment for establishing a patent airway is available; (4) at least one individual capable of establishing a patent airway and providing positive pressure ventilation is present in the procedure room; (5) suction, advanced airway equipment, positive pressure ventilation, and supplemental oxygen are immediately available in the procedure room and in good working order; (6) a member of the procedural team is trained in the recognition and treatment of airway complications, opening the airway, suctioning secretions, and performing bag-valve-mask ventilation; (7) a member of the procedural team has the skills to establish intravascular access; (8) a member of the procedural team has the skills to provide chest compressions; (9) a functional defibrillator or automatic external defibrillator is immediately available in the procedure area; (10) an individual or service is immediately available with advanced life support skills; and (11) members of the procedural team are able to recognize the need for additional support and know how to access emergency services from the procedure room. Fast-tracking: an action bypassing PACU phase I recovery when phase I criteria have been met before leaving the operating room (OR). Developed By: Committee on Standards and Practice Parameters Has 16 years experience. Consultants were drawn from the following specialties where moderate procedural sedation/analgesia are commonly administered: anesthesiology, cardiology, dentistry, emergency medicine, gastroenterology, oral and maxillofacial surgery, pediatrics, radiology, and surgery. The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: A prospective, randomized study. This phase typically begins in the operating room and continues in the PACU. C. Two conscious patients, stable, 8 years of age and under, with family or competent support staff present but not . Evidence of discharge readiness includes: a. Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse oximetry. The following items are ASPAN 1 guidelines for discharge criteria assessment from Phase II recovery: 1. Outpatients will meet following criteria before home discharge. Comparison of alfentanil and ketamine infusions in combination with midazolam for outpatient lithotripsy. Body mass index (BMI) predicts the need for airway intervention and sedation related complications in anesthesiologist-directed propofol sedation for routine EGD and colonoscopy. Process Revision and additions to Phase II discharge criteria in the electronic medical record to include all the applicable ASPAN Standards. Discharge criteria must be applied consistently. Surgery Phase, PACU Phase I, Phase II and Extended Care PR 4 Recommended Competencies for the Perianesthesia Nurse PR 5 Competencies of Perianesthesia . St. Louis, MO: Saunders; 2016. Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these Guidelines. What Age Is Considered Elderly? A discharge criterion may be valid for one population of patients but not for another (e.g., discharge criterion of Sa, 1. Last Amended: October 23, 2019 (original approval: October 27, 2004) This is a real challenge for PACU RNs because when you have a mix of phase 1 and phase 2 patients, your attention is always going to be focused on the phase 1 patient who is "by definition" the most vunerable patient within the hospital setting. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). =yb 3. 2023 American Society of Anesthesiologists (ASA), All Rights Reserved. Conscious sedation for interventional neuroradiology: A comparison of midazolam and propofol infusion. /.uD6 n{M =-uSn}oq2~;.S;uX#eGFwhPz}4dO:~?#~$y`~`.PK >Bj Has 10 years experience. THE PATIENT SHALL BE CONTINUALLY EVALUATED AND TREATED DURING TRANSPORT WITH MONITORING AND SUPPORT APPROPRIATE TO THE PATIENTS CONDITION. These values represent moderate to high levels of agreement. Because minimal sedation (anxiolysis) may entail minimal risk, the guidelines specifically exclude it. Notably, all ambulatory surgery patients. Apparently, however, such units did not become commonplace in the hospitals of the developed world until the first half of the 20th century. Replace the Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: An Updated Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists, published in 2002.1, Specifically address moderate sedation. A Postanesthesia Care Unit (PACU) or an area which provides equivalent postanesthesia care (for example, a Surgical Intensive Care Unit) shall be available to receive patients after anesthesia care. On cumulative findings from literature published in peer-reviewed journals most 90 % EVALUATED and during... 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Y_E ` d! kH5 > pBmx [ g4 0 b o combination with midazolam for procedural:... Recovery when phase I recovery when phase I recovery when phase I criteria have been met before leaving operating...: 1 ASPAN Standards upon discharge home, all patients should be given to monitoring oxygenation, ventilation circulation!
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