Source: https://tier1performance.com/moderate-sedation-program-strategies/
Timestamp: 2020-08-12 18:40:56
Document Index: 647188793

Matched Legal Cases: ['§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482', '§482']

TiER1 Performance > Clinical Improvement > Does your moderate sedation program measure up?
Moderate sedation, commonly known as conscious sedation, is a drug-induced depression of consciousness. When moderate sedation is administered, patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Interventions are not required to maintain a patent airway, spontaneous ventilation continues to be adequate, and cardiovascular function is maintained.
Reducing variability in your Moderate Sedation Program is key to patient safety. Below is a comprehensive guide to TJC standards and strategies for compliance.
(See our Downloadable Guide)
Providers have been granted moderate sedation privileges.
Strategy for compliance: Audit medical staff privileges to ensure all providers have current and appropriate privileges and any additional training elements required by Medical Staff Bylaws, such as ACLS.
TJC Accreditation standard: MS.03.01.01 | EP
Crosswalk to CMS: §482.22(a)(1) | TAG: A-0340
Crosswalk to NIAHO standards: MS.12 | SR.4
FPPE is performed specific to the privileges requested.
Strategy for compliance: Ensure reviews are being conducted to include moderate sedation for FPPE as defined by the Medical Staff.
TJC Accreditation standard: MS.08.01.01 | EP 1
Crosswalk to NIAHO standards: MS.12 | SR.5
OPPE is performed specific to the privileges granted.
Strategy for compliance: 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.
TJC Accreditation standard: MS.08.01.03 | EP 1
Staff complete initial training and competency for moderate sedation.
Strategy for compliance: The healthcare organization determines the initial training requirements for staff. This typically includes a moderate sedation review, kinesthetic training, and ACLS. Ensure all areas that perform moderate sedation are included in this training.
TJC Accreditation standard: HR.01.06.01 | EP 5
Crosswalk to CMS: §482.28(a)(3) | TAG: A-0622
Crosswalk to NIAHO standards: SM.7 | SR.1
Staff complete ongoing training and competency for moderate sedation.
Strategy for compliance: The healthcare organization determines the ongoing training requirements for staff. This typically includes a moderate sedation review, kinesthetic training, and ACLS. Ensure that all areas that perform moderate sedation are included in this training.
TJC Accreditation standard: HR.01.06.01 | EP 6
Crosswalk to NIAHO standards: SM.7 | SR.2
Members of the Medical Staff must have additional privileges granted to perform moderate sedation. The Medical Staff Bylaws define additional training that is needed, as well as 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.
Nurses who administer medications during procedures requiring moderate sedation should have initial and ongoing competencies. This training is defined by the organization’s policy. The type of training provided should be based upon both the skill level of the nurse (novice or expert) and the frequency at which the skill will be performed.
Staff privileged to provide moderate sedation must be involved in planning for and providing moderate sedation care to the patient. Below are the minimum required elements across pre-procedure, intra-procedure, and post-procedure.
Keep in mind that additional elements might be found in your Medical Staff Bylaws/Rules and Regulations, as well as your organization’s policy and procedure manual.
The specific care, treatment, and services that require informed consent
Circumstances that would allow for exceptions to obtaining informed consent
The process used to obtain informed consent
How informed consent is documented in the patient record
When a surrogate decision-maker may give informed consent
Strategy for compliance: The organization’s policy will describe the process for obtaining informed consent in accordance with law and regulation. Ensure this process is being performed correctly in all areas identified and that consent includes the type of sedation that will be performed. Adding this as a component to the pre-procedure checklist is considered leading practice to ensure compliance.
TJC Accreditation standard: RI.01.03.01 | EP1
Crosswalk to CMS: §482.24(c)(4)(v) | TAG: A-0466
Crosswalk to NIAHO standards: SS.4 | SR.5
The patient’s proposed care, treatment, and services.
Potential benefits, risks, and side effects of the patient’s proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation.
Reasonable alternatives to the patient’s proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects related to the alternatives, and also the risks related to not receiving the proposed care, treatment, and services.
Strategies for compliance: There must be evidence that a discussion occurred with the patient to discuss risks, benefits, and alternatives to both the procedure and the type of sedation that is being performed. This could be on the informed consent or on a progress note.
TJC Accreditation standard: RI.01.03.01 | EP2
Crosswalk to CMS: §482.13(b)(2) | TAG: A-0131
Crosswalk to NIAHO standards: SS.4 | SR.5g
Strategy for compliance: 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 an 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.
TJC Accreditation standard: PC.01.02.03 | EP 4
Crosswalk to CMS: §482.22(c)(5)(i) | TAG: A-0358
Crosswalk to NIAHO standards: SS.4 | SR.1a
Strategy for compliance: If the H&P is not performed on the same day the procedure is taking place, an update must be performed. Remember an update does not take the place of a complete H&P if the H&P was performed more than 30 days ago. If this is the case, a new H&P must be performed. Adding this as a separate component to the pre-procedure checklist is considered leading practice to ensure compliance.
TJC Accreditation standard: PC.01.02.03 | EP 5
Crosswalk to CMS: §482.24(c)(4)(i)(b) | TAG: A-0461
Crosswalk to NIAHO standards: SS.4 | SR.1b
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.
Strategy for compliance: 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).
TJC Accreditation standard: PC.03.01.03 | EP 1
Crosswalk to CMS: §482.52(b) | TAG: A-1002
Crosswalk to NIAHO standards: SS.4 | SR.1
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 pre-procedural education, according to his or her plan for care.
Strategy for Compliance: Document that pre-procedure education was performed. If a handout was given, ensure that there is a reference as to what information was included in the handout.
TJC Accreditation standard: PC.03.01.03 | EP 4
Crosswalk to NIAHO standards: DC.4 | SR.1a
Reassessment immediately prior to the administration of sedation.
Strategy for compliance: 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.
TJC Accreditation standard: PC.03.01.03 | EP 8
Crosswalk to NIAHO standards: MR.7 | SR.6
Document the completion of the time-out. (Note: The hospital determines the amount and type of documentation.)
Strategy for compliance: Ensure each area has a consistent place to document that a time-out was conducted adherent to the requirements of the organization’s policy.
TJC Accreditation standard: UP.01.03.01 | EP 5
Crosswalk to CMS: §482.51(b)(4) | TAG: A-0957
Strategy for compliance: The organization’s policy determines the frequency of documenting VS, LOC, and if ETCO2 is required. 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 every five minutes during the procedure.
TJC Accreditation standard: PC.03.01.05 | EP 5
Crosswalk to CMS: §482.52(b) | TAG: A-1004
Strategy for compliance: Document complications or the use of reversal agents in the patient’s medical record.
TJC Accreditation standard: RC.02.01.03
Strategy for compliance: 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.
TJC Accreditation standard: PC.03.01.07 | EP 1
Crosswalk to NIAHO standards: SS.7 | SR.1
Strategy for compliance: 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.
TJC Accreditation standard: PC.03.01.07 | EP 2
Strategy for compliance: 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.
TJC Accreditation standard: RC.02.01.03 | EP 7
Crosswalk to CMS: §482.51(b)(6) | TAG: A-0959
Crosswalk to NIAHO standards: SS.8 | SR.4
Strategy for compliance: 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 is included in this report.
TJC Accreditation standard: RC.02.01.03 | EP 5
Crosswalk to NIAHO standards: SS.8 | SR.3
The name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s)
The name of the procedure performed
Any estimated blood loss
Any specimen(s) removed
The postoperative diagnosis
Strategy for compliance: 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.
TJC Accreditation standard: RC.02.01.03 | EP 6
Crosswalk to NIAHO standards: SS.8 | SR.1
Strategy for compliance: Ensure that an order for discharge is on the chart or that an approved protocol is used to determine readiness for discharge. This protocol must be approved by the medical staff, should define criteria for discharge and is specified in the policy/procedure.
TJC Accreditation standard: PC.03.01.07 | EP 4
Crosswalk to NIAHO standards: SS.7 | SR.2
Strategy for compliance: Ensure that patient discharge instructions are included in the patient’s medical record and contain education regarding the procedure and the sedation medication. Examples of sedation education for adults include not driving, operating heavy machinery, or making life decisions for 24 hours. If sedation is used on a pediatric patient, instructions include remaining under adult supervision until the patient is fully recovered from the effects of the sedation.
TJC Accreditation standard: PC.04.01.05 | EP 7
Crosswalk to CMS: §482.43(c)(5) | TAG: A-0820
Crosswalk to NIAHO standards: DC.4 | SR.2
Outcomes must be monitored, including reporting and trending adverse events related to using moderate sedation. Data must be reported, reviewed, trended, and analyzed to improve performance within the organization. Leadership should promote patient safety and ensure delivery of high-quality care by holding staff accountable to the requirements of a successful Moderate Sedation Program.
Strategy for Compliance: 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.
TJC Accreditation standard: PI.01.01.01 | EP 75
Crosswalk to CMS: §482.21(a)(2) | TAG: A-0286
Crosswalk to NIAHO standards:QM.7 | SR.4
Strategy for compliance: Staff will be held accountable to both the information in the Medical Staff Bylaws and the organization’s policy. Remember to reduce variability between documentation as accrediting bodies will be reviewing records from each area that moderate sedation is performed.
TJC Accreditation standard: LD.04.01.05 | EP 4
Crosswalk to CMS: §482.21(e)(1) | TAG: A-0309
Crosswalk to NIAHO standards: –
Read about frequently asked questions for moderate sedation programs.
Download Moderate Sedation Standards and Strategies
Download the Gap Analysis/Risk Assessment Tool
To discuss how TiER1 Healthcare can help build or strengthen your Moderate Sedation Program, call (800) 241-0142 or email healthcare@tier1performance-staging.qrvschg3-liquidwebsites.com.