适度镇静,俗称有意识的镇静,是一种药物引起的意识抑郁。当给予中等镇静时,患者有目的地响应口头命令,单独或伴随轻触触觉刺激。干预不需要维持专利通道;自发通风仍然是足够的;和心血管功能保持。

Moderate sedation can be performed throughout the organization by non-anesthesia providers, in accordance with law and regulation, in areas such as the Intensive Care Unit, Emergency Department, Catheterization Laboratory, Electrophysiology Laboratory, Interventional Radiology, Endoscopy Suite, and the Pain Clinic. All areas that perform moderate sedation will be reviewed by Centers for Medicare and Medicaid Services (CMS) and accrediting organizations, such as The Joint Commission, to ensure patient safety.

降低适度镇静计划中的可变性是患者安全的关键!让我们来看看TJC标准的要求和一些遵守策略。

员工要求

首先,我们将介绍员工要求。在开始温和的镇静计划之前,这些是关键。

员工要求

Component

TJC认证标准

EP

文本

合规策略

提供者已被授予适度的镇静权限

MS.03.01.01

2

从业人员在其特权范围内实践,根据有组织的医务人员定义的机制确定。

审计医疗人员特权,以确保所有提供商都有当前和适当的特权以及医务人员章程所需的任何额外培训,例如ACL。

FPPE是对请求的特定权限执行的

MS.08.01.01.

1

为所有最初要求的特权实施了一段焦以专业实践评估(FPPE)。

确保评审进行包括模式rate sedation for FPPE as defined by the Medical Staff.

对特定的特权进行了特定的oppe

MS.08.01.03

1

The process for the ongoing professional practice evaluation (OPPE) includes the following: There is a clearly defined process in place that facilitates the evaluation of each practitioner’s professional practice.

Ensure that there is a process in place for ongoing review of all providers that have been granted privileges for moderate sedation in accordance with the Medical Staff Bylaws.

工作人员完成适度镇静的初始培训和能力

HR.01.06.01

5.

Staff competence is initially assessed and documented as part of orientation.

医疗组织决定了员工的初始培训要求。这通常包括适度的镇静评论,动力学训练和ACL。确保在此培训中包含所需适度镇静的所有区域。

工作人员完成适度镇静的持续培训和能力

HR.01.06.01

6.

工作人员能力每三年进行一次评估和记录一次,或根据医院政策或根据法律和法规的要求更频繁地记录一次。

医疗组织决定了员工的持续培训要求。这通常包括适度的镇静评论,动力学训练和ACL。确保在此培训中包含所需适度镇静的所有区域。

Medical Staff

Members of the Medical Staff must have additional privileges granted to perform moderate sedation. The Medical Staff Bylaws define additional training that is needed and how often that training must occur. A period of Focused Professional Practice Evaluation (FPPE) for initial privileges and Ongoing Professional Practice Evaluation (OPPE) specific to moderate sedation care will ensure that quality care is being delivered.

护理人员

在需要适度镇静的程序期间施用药物的护士应具有初始和持续的能力。该培训由组织的政策定义。所提供的培训类型应基于护士(新手或专家)的技能水平以及技能将执行的频率。

适度镇静是一种高风险的程序。在这项技能最低使用的地区,组织应考虑更多的动手培训和培训方法,而不是员工倾听讲座或观看示范。

请记住,应评估高风险,低批量技能,应制定教育计划,以确保满足学习需求。

预过程,程序内和程序后要求

提供适度镇静的工作人员必须参与规划和向患者提供适度的镇静护理。以下是1)前的最低要求元素,2)例,程序内,3)术后。

请记住,您的医务人员章程/规则和法规中可能会发现其他要素,以及组织的政策和程序手册。

预级别要求

Component

TJC认证标准

EP

文本

合规策略

Properly executed Informed Consent

ri.01.03.01

1

该医院遵循书面政策,即描述以下内容:
- 需要知情同意的具体护理,治疗和服务
- 允许例外获得知情同意的情况
- 用于获取知情同意的过程
– How informed consent is documented in the patient record
注意:文档可以以表单,正在进行中的录制记录,或记录中的其他位置。
- 当代理决策者可以提供知情同意时

本组织的政策将根据法律和法规描述获取知情同意的过程。确保在确定的所有区域中正确执行此过程,并且该同意包括将执行的镇静类型。将其作为预先核查表的组件作为一个组成部分被视为领先的做法,以确保合规性。

记录有关风险,福利和替代方案的讨论

ri.01.03.01

2

知情同意进程包括关于以下内容的讨论:
– The patient’s proposed care, treatment, and services.
- 患者拟议的护理,治疗和服务的潜在利益,风险和副作用;患者实现他或她的目标的可能性;以及在恢复过程中可能发生的任何潜在问题。
- 患者提出的护理,治疗和服务的合理替代品。讨论包括与替代方案相关的风险,福利和副作用以及与未接收拟议的护理,治疗和服务相关的风险。

必须有证据表明患者发生讨论,以讨论程序的风险,福利和替代方案以及正在进行的镇静类型。这可能是关于知情同意书或进展笔记。

历史和物理(H&P)

PC.01.02.03.

4.

患者在后期或24小时内或在24小时内,登记或存入入院后,但在手术或需要麻醉服务的程序之前,患者在30天内接受病史和体检。

Ensure that a complete H&P is documented no more than 30 days prior to the procedure requiring moderate sedation. Medical Staff Bylaws will define all the components of a H&P. Ensure that both the providers and nurses understand the components that must be documented. Adding this as a component to the pre-procedure checklist is considered leading practice to ensure compliance.

历史和体力更新

PC.01.02.03.

5.

For a medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any changes in the patient’s condition is completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services.

如果在发生过程的同一天未执行H&P,则必须执行更新。如果H&P在30天前进行H&P,请记住更新不会取代完整的H&P.如果是这种情况,则必须执行新的H&P。将其添加为单独的组件,以预先进行检查列表被视为谨慎的做法,以确保合规性。

预镇静评估:ASA分类和航空考试

PC.03.01.03

1

Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered: The hospital conducts a pre-sedation or pre-anesthesia patient assessment

Before initiating sedation, the provider must document a pre-sedation evaluation. Medical Staff Bylaws will define the components of a pre-sedation evaluation. Minimally, the ASA classification must be documented, and an airway exam must be performed. The organization will determine which airway exam will be conducted (i.e., Mallampati).

Pre-Procedure Education

PC.03.01.03

4.

Before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered: The hospital provides the patient with preprocedural education, according to his or her plan for care.

举行预先教育的文件。如果给出了讲义,请确保有一个参考讲义中包含的信息。

内部内部要求

Component

TJC认证标准

EP

文本

合规策略

在镇静管理之前立即重新评估

PC.03.01.03

8.

在给药前或深镇静或麻醉前,医院立即重新评估患者。

Ensure that moderate sedation documentation includes that a reassessment was completed immediately before the sedation is administered when the patient is on the procedural table. This could be documented in the pre-sedation assessment or on the intra-procedure documentation. Ensure each area where moderate sedation is performed has a consistent place to document this component.

超时

UP.01.03.01

5.

记录超时的完成。
注意:医院确定文件的数量和类型。

确保每个区域都有一致的文件,以记录超出了满足组织政策要求的超时。

监测生命体征(VS),意识水平(LOC),波形表格端潮二氧化碳CO2监测(仅当医院政策所需时)

PC.03.01.05.

1

在手术期间或其他高风险程序中,包括需要施用中度或深镇静或麻醉,患者的氧合,通气和循环的那些。

组织的策略确定记录VS,LOC的频率,如果需要ETCO2。文档LOC(即Ramsey)的不同尺度不同。请参阅组织的策略以确定应使用哪个规模。领先的做法是在程序期间每五分钟记录这些项目。

记录镇静药物和事件

rc.02.01.03

1

The hospital documents in the patient’s medical record any operative or other high-risk procedure and/or the administration of moderate or deep sedation or anesthesia.

Document complications or the use of reversal agents in the patient’s medical record.

后期后要求

Component

TJC认证标准

EP

文本

合规策略

镇静后护理评估

PC.03.01.07.

1

医院在手术或其他高风险过程后立即评估患者的生理状态和/或患者从中度或深镇静或麻醉中恢复。

The organization’s policy defines the frequency of documentation and the required elements of the nursing assessment. Some hospitals decide to document an Aldrete score before the procedure, immediately after the procedure, and at intervals post-procedure to determine if the patient meets discharge criteria.

Monitoring of pain and level of consciousness after sedation

PC.03.01.07.

2

该医院监测患者的生理状态,精神状态和疼痛水平,频率和强度与手术或其他高风险手术和/或镇静或麻醉给药的潜在效果一致。

The organization’s policy defines the frequency of documentation. There are different scales to document LOC (i.e., Ramsey), refer to the organization’s policy to determine which scale should be used. Leading practice is to document these items in correlation with the time intervals for post-procedure vital signs.

直接程序后注意事项或简短操作

rc.02.01.03

7.

当操作或程序后无法立即进入患者的医疗记录时完全操作或其他高风险程序报告,在患者转移到下一个护理水平之前,在医疗记录中进入进度。此进度请注意包括主要外科医生的姓名及其助手,进行的程序,并描述每个程序的描述,估计失血,被移除的标本和术后诊断。

If the electronic medical record does not allow the full procedure report to be entered immediately after the procedure, an immediate post-procedure note must be written before the patient transfers to the next level of care and before the proceduralist leaves the immediate area. Remember that a dictated note may not be available immediately after the procedure because of the transcription process. Best practice is to create a template guided by Medical Staff Bylaws to ensure that all components are being documented. This note must include, at minimum, the name(s) of the primary surgeon(s) and his or her assistant(s), procedure performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis.

Post-procedure or operative report

rc.02.01.03

5.

An operative or other high-risk procedure report is written or dictated upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.

Even if an immediate post-procedure note is written, a full report must be written or dictated before the patient is transferred to the next level of care. Medical Staff Bylaws will guide providers on the required components of this post-procedure report. Ensure that the type of sedation used in included in this report.

程序报告要求

rc.02.01.03

6.

The operative or other high-risk procedure report includes the following information:
– The name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s)
- 执行程序的名称
– A description of the procedure
- 该程序的结果
- 任何估计的失血
- 删除的任何标本
- 术后诊断

Best practice is to create a template guided by Medical Staff Bylaws to ensure that all components are being documented. This note must include, at minimum, the name(s) of the primary surgeon(s) and his or her assistant(s), procedure performed and a description of each procedure finding, any estimated blood loss, specimens removed, and postoperative diagnosis.

排放订单

PC.03.01.07.

4.

合格的许可独立从业者将患者从恢复区域或医院排放。在没有合格的许可独立从业者的情况下,患者根据临床领导者批准的标准进行排放。m88.com网址

确保放电订单在图表上,或者批准的协议用于确定放电的准备情况。本协议必须经医务人员批准,应定义卸货标准,并在政策/程序中规定。

Discharge Education: Procedure and Sedation education

PC.04.01.05.

7.

该医院教育患者,以及患者的家人参与决策或持续关怀,了解如何获得患者需要的任何不断的护理,治疗和服务。

确保患者的医疗记录中包含患者放电说明,并包含有关程序和镇静药物的教育。成人镇静教育的例子包括不驾驶,经营重型机械,或制造24小时的生命决定。如果在儿科患者上使用镇静,则指示包括在成人监督下剩余,直到患者从镇静的效果完全回收。

Program Requirements

必须监测结果,包括与使用中等镇静相关的报告和趋势不良事件。必须报告,审核,培训和分析数据以提高组织内的绩效。

领导力应促进患者安全,并确保通过持有人员对成功的中度镇静计划的要求负责来提供高质量的护理。

我们如何收集程序上的数据?考虑以下:

Program Requirements

Component

TJC认证标准

EP

文本

合规策略

Performance Improvement Data

PI.01.01.01

5.

The hospital collects data on the following: Adverse events related to using moderate or deep sedation or anesthesia.

Each area that performs moderate sedation should report data to the quality department on adverse events. These events should be tracked, trended, and analyzed to ensure there is not a pattern. These events should be reported up through committee to the governing body as defined by the organization.

工作人员对计划要求的责任

LD.04.01.05

4.

工作人员对他们的职责表示负责。

工作人员将对医务人员章程和本组织的政策负责。请记住减少文档之间的可变性,因为认证机构将审查从中镇静的每个区域的记录。

适度镇静:常见问题

指南针临床咨询从m88.com网址我们的客户接收各种问题,了解中度镇静。以下是一些最常见的问题:

问:我们的政策是必须要求特权进行适度镇静,麻醉主任最终负责这一点。我们的ED医生认为他们应该被排除在此政策之外,因为它们是ed。你能向我们提供方向吗?

A: The American Society of Anesthesiologists (ASA) has a position statement on granting privileges for administration of moderate sedation to practitioners who are not anesthesia professionals. Leading practice would be to consider these guidelines in your privileging process. They have sections describing their recommendations for training, licensure, privileging process, performance criteria, etc.

如你所知,这是医生的责任al Staff to determine which privileges are considered part of the core and which must be requested separately. It would be very unusual to list moderate sedation as a core privilege and state that by training that a physician group (e.g., ED) was exempt from supplying information about training or requiring any performance data to be collected, limiting the length of time that the privilege was granted, and then require another group who performs the procedure with similar training, e.g., gastroenterologists to request this as a privilege.

TJC标准没有特别引用中等镇静作为必须要求的特权。因此,由医务人员决定这一点,然后他们的建议必须得到理事机构的批准(MS.06.01.05,EP。2)。此外,MS.06.01.03表示,“所使用的所有标准都是持有那个特权的所有从业者评估。”

问:什么时候moderate sedation is performed by non-anesthesia providers, are a pre-anesthesia evaluation, intraoperative anesthesia record, and a post-anesthesia evaluation required?

答:根据CMS标签A-1004,虽然目前的实践指示接受患者接受中度镇静的患者在培训的从业者,术前和术前麻醉记录和职位的过程之前,期间和之后监测和评估。- 由于适度的镇静是所指的,因此不需要有资格给予§482.52(a)中规定的麻醉的人进行的评估not被认为是“麻醉”,因此在这条规则下不受该要求。

下载:您的中度镇静计划是否测量?

We have provided the above standards and strategies for compliance as a download for you to use in your organization:

We have also provided a tool you can use to conduct a risk assessment within your organization.

如果您担心您的计划不符合标准,请联系指南针(513)241.0142,通过m88.com手机网址电子邮件, 要么通过联系页面m88.com手机网址讨论我们如何帮助构建或加强您的中度镇静计划。


About Tabitha Garbart, DNP, RN

Fresh from the Joint Commission as a hospital nurse surveyor, Tabitha brings to Compass more than 19 years of experience in the industry and a commitment to helping healthcare organizations connect the dots and understand the “why” behind their work toward a goal of using evidence-based practices to reduce harm and improve quality of care. She previously served as the Chief Quality Officer at Mary Black Health System and has served as a consultant on a continuous survey readiness team assisting Veterans Affairs medical centers to prepare for accreditation visits.

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