For Our Physicians
Sutter Medical Center, Sacramento

Procedural Sedation

On December 11, 2009, The Centers for Medicare and Medicaid Services (CMS) issued a memorandum addressing the revisions to the Anesthesia Services Conditions of Participation.

What is the key change required by CMS that impacts your practice? Agents of deep sedation (propofol, etomidate, ketamine, barbiturates) cannot be administered/injected by an RN, NP or PA. These agents must be administered/injected by a physician with current moderate and deep sedation privileges.

The RN may prepare these medications and infusions and connect them to the patient's IV; however, the sedation credentialed physician must be the one who initiates the infusion and/or injects these sedation medications.

• For short procedures, such as cardioversion, Anesthesia recommends a single dose of Propofol 0.5 mg/kg IV over 1-2 minutes using a syringe. An additional 20-40 mg IV may be needed for some patients. The physician will have to give that dose.
• For longer, more complex procedures, or procedures that require the physician to be gloved, Anesthesia recommends combined narcotic/hypnotic therapy:
  • Have the RN administer Versed 1 mg IV and Fentanyl 50 mcg IV to provide baseline moderate sedation while preparing for the procedure.
  • Have the RN set up a Propofol drip on an infusion pump and connect to the patient's IV. The physician will start the infusion pump.
  • Determine the dosing of Propofol you wish to administer for your procedure. Anesthesia recommends a continuous dose of Propofol 25 to 75µg/kg/min, with a dose of 50µg/kg/min working well for most patients. Stop the Propofol at the end of the procedure.
• Current standards of care for the patient receiving deep sedation for the purposes of performing a procedure include cardiac monitoring, non-invasive blood pressure, continuous oxygen saturation, and continuous end-tidal CO2 monitoring. A respiratory therapist or a 2nd RN is present to assist with airway management as needed.

Your assistance in following this CMS requirement for deep sedation is appreciated.

• Sedation Flyer
• Procedural Sedation Administered by Non-Anesthesiologist Providers, Moderate and/or Deep Sedation Patient Care Standard
• Sedation Power Point
• Sedation Power Point in PDF Format

2012 Core Measures

As you know, the Centers for Medicare and Medicaid Services require hospitals to participate in core measures for various clinical and disease states. For several years now, we have looked at the surgical care improvement project (SCIP), which includes elements such as selecting the correct prophylactic antibiotic, giving it within an hour of surgery, providing post operative DVT prophylaxis, etc. We have also measured processes of care for acute myocardial infarction, heart failure and community-acquired pneumonia. These requirements are all part of the value-based purchasing initiative from CMS. For 2012, there have been some additions:

The hospital is working on processes to ensure compliance to these measures. As you know, the immunization process for influenza for children and adults has been in place for some time. Pneumococcal vaccination has been in place for adults - it will be new to our Pediatric patients. Obviously if the patient has a contraindication as specified by CMS, they will not be vaccinated.

As you can see from this list, the Emergency Department throughput is an area of considerable focus for 2012. For the door to troponins in less than 60 minutes, the lab is working feverishly on their end to come up with a rapid TAT for the test, and the ED is working on the specimen acquisition process on the front end. The other metrics for ED involve the time it takes to see a physician as well as measuring the length of time from decision to admit to actual admission. We will need everyone’s help with this metric -efficient ED throughput is dependent on having beds to which the patient can be admitted, timely response to the ED for admissions and moving the patient as quickly as possible to the appropriate level of inpatient care.

I appreciate your interest in these new core measures. For more detailed information, please click on the measure below:

• Acute Myocardial Infarction (AMI)
• Emergency Department (ED)
• Heart Failure (HF)
• Hospital Outpatient (HOP)
• Immunization (IMM)
• Pneumonia (PNEU)
• Surgical Care Improvement Project (SCIP)