Sedation flowsheet facilitates compliance

Show JCAHO your hospitalwide policy

A flowsheet can help your ED comply with JCAHO standards for conscious sedation. "Everything is documented on the flowsheet, and on the patient’s chart, nurses write See conscious sedation flowsheet,’ which streamlines the process of documentation," says Sheryl Schroeder, RN, director of emergency and operative services at Fort Atkinson Memorial Health Services in Wisconsin.

A team of two ED nurses, a pediatric nurse, two physicians, and an anesthetist developed the form. "We developed the form because not all departments were using the same criteria when sedating patients, and physicians were not routinely filling out the pre-sedation form," Schroeder explains. (See Nursing Flowsheet, inserted in this issue.)

The form is based on all criteria established by JCAHO for conscious sedation. That includes physical status, current medications, drug allergies/sensitivities, concurrent medical conditions, history of substance abuse, chief complaint, baseline vital sign, LOC, communication ability and perceptions regarding the procedure, and sedation.

The flowsheet also addresses what needs to be checked during the procedure: respiratory rate (apnea monitor on pediatric patients), oxygen saturation, blood pressure, cardiac rhythm and rate, level of consciousness, and skin condition.

Documentation reflects time of dosage, route and effects of all medications, types and amounts of fluids, monitoring equipment needed, physiologic date, interventions, and patient responses.

The form includes a section for physician documentation. This includes a pre-procedure assessment, including a medical history and physical, review of systems, current medications being taken, allergies, vital signs, risks and benefits of the anesthesia, and plan of anesthesia.

The form guides the physician through the necessary pre- and post-assessment criteria. "This is all on the back of the conscious sedation form to make it easier for all users," says Schroeder. "Also, nurses are not to let the physician begin the procedure without documentation of pre-anesthesia assessment."

A scale is used for both adult and pediatric patients. "We looked at adult and pediatric documentation and came up with a scale to be used for both," says Schroeder. The scale is [a numerical] one used by anesthesia in post-anesthesia recovery phases called the Aldrete scale.

"The advantage is that the numerical scoring scale has been shown to correlate with the recovery of patients after anesthesia," Schroeder explains. "The advantages of a scoring system are reproducibility, standardization, and objectivity."

Help with documentation

JCAHO standards for conscious sedation are listed on the flowsheet. JCAHO surveyors want to see a hospitalwide policy for conscious sedation. "The form is used hospitalwide, in the ED and OR and [in test areas, including] endoscopy, MRI, and CT scan," says Schroeder. "JCAHO requires that the same level of care is given to all patients, regardless of where the care is given — therefore the standardized form."

Everyone giving and monitoring conscious sedation must be competent in the medications and side effects. "All nurses working with conscious sedation attend a yearly inservice given by anesthesia on both pediatric and adult conscious sedation, and the adult and pediatric pharmacological issues of conscious sedation drugs.

The form allows documentation to flow logically for nurses, anesthesiologists, and physicians, says Schroeder. "The form can be easily used to document, and a 100% QA (quality assurance) is done on all conscious sedation." JCAHO surveyors like the form and have taken copies to share with other hospitals, she reports.

Source

For more information on the conscious sedation flowsheet, contact:

Sheryl Schroeder, RN, Emergency Department, Fort Atkinson Memorial Health Services, 611 Sherman Ave., Fort Atkinson, WI 53538. Telephone: (920) 568-5336. E-mail: sheryl.schroeder@famhs.org.