Propofol is part of a larger issue
Propofol is part of a larger issue
CMS ignores expertise of ED doctors?
While some publications have focused on the restriction of Propofol use by ED physicians and nurses under new rules issued in December 2009 by the Centers for Medicare and Medicaid Services (CMS), many observers say the issue is much larger, and that it deals with who can administer what ED providers consider procedural sedation and what CMS considers anesthesia. In a few cases, this issue has caused tension between hospital EDs and anesthesia departments something neither wanted.
"We used the term 'procedural sedation,' which is common in emergency medicine, and one of the CMS people had not even heard that term before," notes Kevin Klauer, DO, FACEP, chief medical officer of Emergency Medicine Physicians in Canton, OH, Klauer participated in a recent meeting that included CMS, several representatives of the American College of Emergency Physicians, and the Emergency Nurses Association. "They became acutely aware we have unique training that requires us to know all those things such as airway management and others that were written into their document," he says.
CMS' definition of a qualified physician "lumped us in with all non-anesthesiologists," Klauer explains, so he was pleased to have opportunity to explain that emergency physicians are different. Nonetheless, Klauer admits that he is not "incredibly optimistic" that CMS officials will change their position.
The issue goes beyond giving ED physicians credit for their expertise, he says. 'If they send us back to the Dark Ages and do not allow us to give what is most appropriate, we'll have a lower success rate and lengths of stay of over six hours instead of three," Klauer says.
Al Sacchetti, MD, FACEP, chief of emergency services at Our Lady of Lourdes Medical Center in Camden. NJ, says, "We've looked at all these sedations and found that Propofol was one of the two safest, and in one study where we looked at what happened when you introduced Propofol into the ED, complication rates went down and cure rates went up.1-4 There's no argument; Propofol is the safest way to go."
In addition, only anesthesiologists can administer Propofol, and then ED physicians who still wish to use it have to wait for an anesthesiologist to come to the ED. Therefore, the patient's length of stay will inevitably be extended, Sacchetti says.
This situation is not one that most anesthesiologists welcome, notes Sacchetti. "If you talked with anesthesiologists on an individual basis, most of them would tell you they do not want to be called down to the ED for a dislocated shoulder," he says. "Most hospitals have struck a deal, and most anesthesiologists are tickled to have it that way." (For more information on those "deals," see the story below.)
Finally, says Sacchetti, the focus on Propofol does not make sense in terms of potential complications. "If we're not safe for Propofol, we're not safe for other medications that we use on a routine basis that have identical complications," he says. The logical extension of the CMS stance would be to apply it to those other drugs as well, which would of course be impractical, he says.
"Do I have to call an anesthesiologist to give morphine? What about diazepam, lorazepam, or midazolam?" Sacchetti poses. (The timing of Propofol administration is critical, says Sacchetti. See the story, below.)
References
- Senula G, Sacchetti A. Impact of introduction of Propofol on ED procedural sedation. Ann Emerg Med 2008;52:S.
- Sacchetti A, Stander E, Ferguson N, et al. Pediatric procedural sedation in the community emergency department: Results from the ProSCED registry. Ped Emerg Care 2007; 23:218-222.
- Sacchetti A, Senula G, Strickland J, et al. Procedural sedation in the community emergency department: initial results of the ProSCED registry. Acad Emerg Med 2007;14:41-46.
- Hogan K, Sacchetti A, Aman L, et al. The safety of single-physician procedural sedation in the emergency department. Emerg Med J 2006;23:922-923.
Sources
For more information on the use of procedural sedation in the ED, contact:
- Kevin Klauer, DO, FACEP, Chief Medical Officer, Emergency Medicine Physicians, Canton, OH. Phone: (330) 705-9500.
- Al Sacchetti, MD, FACEP, Chief of Emergency Services, Our Lady of Lourdes Medical Center, Camden, NJ. Phone: (609) 519-8509.
Options exist on ED sedation There's a misconception among some hospital administrators and anesthesiologists that a Centers for Medicare and Medicaid Services (CMS) rule issued in December 2009 absolutely prohibits ED providers from administering Propofol. "As of today, it's hospital-specific, and the anesthesia department has to have input into procedural sedation in the hospital, but input does not mean absolute authority," notes Al Sacchetti, MD, FACEP, chief of emergency services at Our Lady of Lourdes Medical Center in Camden. NJ. "Most of the time there is a congenial relationship between anesthesia and emergency medicine. We have a spectacular relationship with our anesthesia department." In most cases that he's aware of, he says, leaders of anesthesia and the ED have sat down and worked out an agreement. "The problem is when anesthesia mistakenly says they'd love to let us use Propofol, but they're not allowed to," Sacchetti says. Kevin Klauer, DO, FACEP, chief medical officer of Emergency Medicine Physicians in Canton, OH, "You have to let administration know this is open for discussion, and that there has been ongoing discussion with CMS. Point out that the clarification is overbroad and there may be some unintended consequences, so we should keep things as they are." Finally, Klauer says, focus on the patient and ask the administrator how he or she would like to be treated. "If you had a dislocated shoulder, would you want me to give you a shot of fentanyl and see how it goes, or would you prefer small doses of Propofol which is very safe, and you won't remember anything?" he poses. |
Timing critical with Propofol Propofol has a relatively short duration of action, so it is important that when titrating Propofol to effect, not to wait too long before administering additional medication, advises Al Sacchetti, MD, FACEP, chief of emergency services at Our Lady of Lourdes Medical Center in Camden. NJ. "The initial bolus will begin to lose its effect after about 5-6 minutes, so if a physician waits 10 minutes or so before adding any additional drug, the first dose will be almost gone," he explains. This problem generally happens in patients in whom the initial dose was too small to begin with, says Sacchetti. By adding subsequent additional small doses at 10 minute intervals, the patient is never adequately sedated. "In general, Propofol will have effect at a maximum of three minutes, and usually less," he adds. "If you haven't achieved good sedation by then, consider a follow-up dose." |
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