Major liability risk with procedural sedation

There are two major liability risks associated with training requirements for procedural sedation: Failing to adhere to your organization's criteria, or having criteria inconsistent with accepted medical practice, says Vicki L. Searcy, CPMSM, practice director for credentialing and privileging at The Greeley Company, based in Marblehead, MA.

Research the literature to be sure your criteria for which practitioners are eligible to be granted privileges for procedural sedation are defensible, Searcy advises.

If specific training or monitoring of the amount of the practitioner's clinical activity in this area is required, your ED must have a system in place to collect this information. "Do this to avoid the situation of having an untoward occurrence and then finding out that the practitioner didn't meet the criteria to perform the privilege," says Searcy.

One major liability risk with procedural sedation involves failing to have proper preparation, with oxygen, suction, oral airway devices, and other supportive equipment readily available for rescue intervention in the case of prolonged apnea or laryngospasm, says John Burton, MD, residency program director of the Department of Emergency Medicine at Albany (NY) Medical Center. "Caregivers overseeing procedural sedation should be individuals who have had adequate rescue airway training for complications such as apnea, laryngospasm, and hypoxemia," he adds.

Another liability risk is failing to dedicate one-on-one nursing care for patient monitoring from the inception of an altered level of consciousness to the return of a pre-sedation level of consciousness. "While much attention is given to the current debate as to whether there should be two physicians in addition to the dedicated nurse, the cases I've seen in liability review have not focused on this question, but rather on the provision of one-on-one care throughout the period of impaired consciousness by any caregiver," says Burton.

The bottom line is that if a patient's level of consciousness is expected to be taken into levels of moderate or deep sedation during ED procedural sedation, there should be dedicated one-on-one monitoring until the patient returns to a pre-procedural level of alertness, he notes.

The known risks of procedural sedation include aspiration pneumonia, hypotension, hypoxia, and emergence phenomenae, says James R. Miner, MD, FACEP, associate professor of emergency medicine at University of Minnesota Medical School in Minnetrista and faculty physician in the ED at Hennepin County Medical Center in Minneapolis. "But they are so rare that the rates are not clear, and surrogate markers tend to be used in research," he says. Miner says he is not aware of any data showing that specific training requirements make any difference in outcomes.

In addition, complications in different settings are difficult to compare. For example, the sedation of trauma patients with displaced fractures for reduction is going to have a different complication rate than patients undergoing elective endoscopy in a gastrointestinal laboratory. "This makes the comparison of rates based on different training requirements difficult to do," says Miner.

Research on specific monitoring modalities continues to build, with a current area of debate involving the routine use of capnography during ED procedural sedation encounters, says Burton. However, the current science on rescue interventions and the training of caregivers for deep procedural sedation levels is "very clear and solid," he says. "We know what the risks of procedural sedation are in the ED setting, and the training and skills to address these risks is clear as well," he says.