CLINICAL GUIDELINE FOR RCHT SAFE SEDATION PRACTICE: Adult Patients

V1.0

September 2017

Page 2 of 22

Table of Contents

Table of Contents ................................................................................................................ 2

1.Introduction ....................................................................................................................... 3

2.Purpose of this Policy/Procedure ...................................................................................... 3

3.Scope ................................................................................................................................ 3

4.Definitions / Glossary ........................................................................................................ 3

5.Ownership and Responsibilities ........................................................................................ 4

5.2.Role of the Managers ................................................................................................. 4

5.3.Role of the Safe Sedation Group/Committee ............................................................. 4

5.4.Role of Individual Staff ............................................................................................... 4

6.Standards and Practice ..................................................................................................... 5

7.Dissemination and Implementation ................................................................................. 14

8.Monitoring compliance and effectiveness ....................................................................... 14

9.Updating and Review ...................................................................................................... 16

10.Equality and Diversity ................................................................................................... 16

10.2.Equality Impact Assessment .................................................................................. 16

Appendix 1. Governance Information ................................................................................ 17

Appendix 2. Initial Equality Impact Assessment Form ....................................................... 19

Appendix 3. References ..................................................................................................... 22

Appendix 4. Sedation and pain scoring systems ............................................................... 23

Page 3 of 22

1. Introduction

1.1. Sedation techniques can enable patients to tolerate unpleasant healthcare procedures, but they also have the potential to cause life-threatening complications. Research [1] suggests that despite a positive response in improving patient monitoring and giving supplementary oxygen during sedative procedures, patient morbidity and mortality had not improved significantly.

1.2. This version supersedes any previous versions of this document.

2. Purpose of this Policy/Procedure 2.1. The purpose of these guidelines is to allow clinicians to provide their patients with the benefits of sedation and analgesia while minimising the risks for the patient. The emphasis of these guidelines is that good multidisciplinary practice, combined with continuing professional development will help improve patient safety and quality of care. There is published guidance that has been instrumental in constructing these RCHT guidelines [2,3,4]

3. Scope 3.1. These guidelines apply to all RCHT employees who are involved with the care of patients who require sedation. 3.2. The patient group is those patients over the age of 16 years.

4. Definitions / Glossary

ABG: Arterial blood gas ASA: American Society of Anaesthesiologists (assessment of pre procedure

co-morbidity) CO: Cardiac output CO2 Carbon dioxide COPD: Chronic obstructive pulmonary disease ECG: Electrocardiography (recording of the heart’s electrical activity) IABP: Invasive arterial blood pressure IM: Intramuscular IMCA: Independent medical capacity advocate IV: Intravenous NEWS: National early warning system MOF: Multi organ failure NIBP: Non invasive blood pressure PAC: Pulmonary artery catheter RR: Respiratory rate

Page 4 of 22

5. Ownership and Responsibilities 5.1. These guidelines have been written and revised by members of the Safe Sedation Group including: Mr Andrew Birnie, Consultant in Oral surgery

Dr, K Woolson, Consultant in Acute Medicine

Dr Desmond Creagh, Consultant in Haematology and Oncology

Mr K McCune, Consultant in Vascular Surgery

Dr John Hancock, Consultant in Interventional Radiology

Dr Rebecca Mawer (Chair), Consultant in Anaesthesia and Critical Care

Dr Paul Fortun, Consultant in Gastroenterology

Dr Jonathan Myers, Consultant in Respiratory Medicine

Dr Alastair Slade, Consultant in Cardiology

Drs Rob Taylor, Anna Shekhdar, Mark Jadev, Consultant Emergency Medicine

Mr Adam Widdison, Consultant in Gastrointestinal Surgery

5.2. Role of the Managers

Line managers are responsible for:

Enabling staff to undertake required training and ensuring that they have achieved the required level of competency

Ensuring that staff are aware of the location of guidelines Taking active role in audit of sedation practice in their clinical areas

5.3. Role of the Safe Sedation Group/Committee

The Safe Sedation Group/Committee is responsible for:

Ensuring that the RCHT guidance complies with national guidance Ensuring dissemination of the guidance Encouraging excellent clinical governance in the practice of sedation at RCHT Encouraging, analysing and presenting audit data from their clinical areas

5.4. Role of Individual Staff

All staff members are responsible for:

Ensuring that they are adequately trained to carry out their role in sedation Keeping clear, legible medical records and documentation Ensuring that they practice responsibly within the RCHT guidance Involving themselves in the audit of practice in their clinical areas

Page 5 of 22

AUDIT TARGET:

100% patients should have NIBP reading and weight recorded in clinic, on admission or on the ward in the case of inpatients. 100% of patients with treated hypertension, a history of ventricular failure, cardiac impairment or angina should have a pre-procedure baseline 12 lead ECG recording

6. Standards and Practice

The process below should be followed for patients who require sedation by a non-specialist anaesthetist, outside of the theatre environment. This is imperative to improve patient safety and quality of care. The process involves patient selection, pre-assessment and preparation, fasting guidance, premedication and documentation needed. It also provides guidance on patient monitoring, drug administration, staffing levels and competency, reporting of critical incidents, recovery and discharge criteria. Please see RCHT paediatric sedation guidelines for sedation practice for children

6.1. Patient selection, pre-assessment and preparation When appropriate the date of procedure should be given to our patients when they attend the clinic. Selection criteria for sedation should be determined by the specialist performing the procedure, by the proposed procedure and should be explored with the patient in advance to avoid cancellations. Where patients lack the capacity to understand the implications of the intervention, a meeting of Best Interests may need to be facilitated. When the patient does not have a next of kin available, the input of an IMCA may be required. Pre procedure investigations e.g. baseline ECG, chest X-ray, full blood count, urea & electrolytes, liver function tests or clotting should be decided upon in advance if there are risk factors or if the planned procedure may necessitate it, ideally on booking to aid patient preparation on the day of the procedure. Spirometry may be indicated if COPD is suspected and ABG if oxygen saturation in air is <93% or FEV1 is <40% expected. Patient information sheets explaining the procedure and sedation techniques available should be given to the patient on booking to give them time to digest the information. 6.2. Fasting All electively sedated patients should be fasted, in line with RCHT guidelines (see document library). Clinicians who are required to administer sedation in an emergency must choose the safest method appropriate for that particular patient bearing in mind their co-morbidity, injury and starvation status

Page 6 of 22

AUDIT TARGET 100% of elective sedation patients should be starved for 6 hours but not longer than 18 hours unless they are receiving IV fluids

6.3. Premedication: 1 hour pre-procedure, except glycopyrolate or hyoscine hydrobromide which can be given iv 5 mins before

• Patients receiving opiate premedication should receive supplementary oxygen and pulse oximetry from the time of administration. • Fentanyl is a derivative of pethidine and therefore patients who report sensitivity (but not anaphylaxis) to morphine may safely tolerate fentanyl. • Initial doses of opiates should be reduced to 50% and given in reduced incremental doses in patients who are > 70 years or who are acutely unwell.(10)

6.4. Documentation Each patient must have a full medical history taken by an individual who can recognise issues that can lead to increased risk for sedation and the procedure, and alert others to those risks, this should include a simple assessment of the airway. Patients must understand and accept the risks and benefits that sedation

Time before

procedure

Substance

2 hours

Non fizzy see through fluids (water, black tea/ coffee, diluted squash)

6 hours

Food and milky drinks

Anxiolytic: Oral Temazepam 0.2-0.4 mg/ kg (max 40 mg) PO

Diazepam 0.05-0.1 mg/ kg (max 10 mg) PO

Topical anaesthesia

Amethocaine gel (Ametop)

Anti-sylogogue Glycopyrolate 5 mcg/ kg (max 300 mcg) IV

Hyoscine hydrobromide 5 mcg/ kg (max 400 mcg) IM/ IV

Analgesics Papaveretum* 0.15-0.3 mg/ kg (max 15.4mg) IM/ IV

Pethidine* 0.5-1 mg/ kg (max 100 mg) IM/ IV

The patient’s usual medications should be taken with water on the day of the procedure

Patients should be advised to NOT chew gum on the day of the procedure

Page 7 of 22

involves, and understand the conceptual difference between sedation and general anaesthesia. They must be informed of the possible side effects of drugs such as retrograde amnesia. Patients must sign a consent form agreeing to the proposed procedure and to the administration of sedative drugs. If the patient is unable to sign their own consent or lacks capacity to do so the reasons for this must be clearly documented, as must be the identity of the person taking this decision. For further reading (5,6,9). Full contemporaneous records should be kept of the procedure including monitored observations, respiratory rate, sedation score, drugs administered, problems or critical incidents encountered and NEWS score and/ or ASA rating for in-patients.

6.5. Staffing levels Adequate staffing levels during the procedure need to be agreed upon and be adhered to. This includes sufficient dedicated, appropriately trained staff to monitor the patient safely. 6.6. Monitor availability and monitoring for different risk patients There must be direct clinical monitoring by a nominated, member of staff who has completed the RCHT Sedation training and who has responsibility to record monitored observations. Sedation score (see appendix 4) should be recorded with the same frequency as other observations, initially each 5 minutes then each 10 minutes if the patient is stable. Pulse oximeters should have alarms set and an audible indication of reading. Pulse oximetry, ECG, NIBP and oxygen must be available for all patients if required.

Accepted monitoring standards

1:Fit patient Minor procedure +/- Oxygen During procedure: Pulse

oximetry, RR, sedation score Pre and post sedation NIBP

Recovery: NIBP, Pox recorded

2:Fit patient Major procedure Oxygen During procedure: Pulse

oximetry, ECG, NIBP, RR, sedation score

Recovery: NIBP, Pox recorded

AUDIT TARGET: 100% of patients should have legible contemporaneous records made peri-

procedure including observations and drugs received.

Page 8 of 22

3:Moderate co- morbidity: Cardiac history, neuro/

CVE, COPD, sepsis, liver disease, NEWS >5, ASA

III (Appendix 2)

Major or minor procedure

Oxygen During procedure: Pulse

oximetry, ECG, NIBP, RR, sedation score

Recovery: ECG, NIBP, Pox recorded, RR, sedation score

4:Severe co- morbidity: Unstable cardiac disease, MOF

Major or minor procedure

As above, also consider CO2, invasive IABP/ CVP/ PAC/ CO monitoring and/ or discussion with outreach team/ on call anaesthetist

6.7. Drugs When it is anticipated that a procedure will be painful it is appropriate to administer analgesia in addition to anxiolysis. Wherever possible the opiate used should be administered first with time to reach effect before the administration of the anxiolytic to reduce the frequency of synergistic side effects. It may be possible to administer the opiate as a premedication after the consent form has been signed (see premedication). If opiates are used either pulse oximetry and/ or oxygen should be administered from time of opiate administration. If required, reversal of benzodiazepines should be performed prior to reversal of analgesia.

Recommended drugs for parenteral sedation and analgesia

Drug Dose, total dose and route Notes

Midazolam 0.1 mg/kg, in 0.5 - 1 mg increments IV Max dose should not exceed 5 mg (or 2.5 mg in patients >70 years when also using an opiate)

Care if patient on anti- fungal medication or cimetidine

(Diazemuls)* (0.05- 0.1 mg/ kg, in 0.5 - 1 mg increments IV)

*Use recommended only in some paediatric inpatients or contraindication to midazolam

Fentanyl 25 mcg increments, 1 mcg/ kg IV Good short acting opiate

Alfentanyl 250 mcg increments, 10 mcg/ kg IV

Care needed as more respiratory depression than fentanyl

Lignocaine 10% topical metered spray, topical 4% or SC 1- 2% 4 mg/ kg Lignocaine gel 1%

Metered throat spray is 10 mg/ spray 4% is 40 mg/ml

N.B. Initial doses should be reduced to 50%, and given in reduced incremental doses in patients > 70 years or acutely unwell patients, especially when using more than one agent because of synergy of drug effects (8, 10)

Page 9 of 22

Not recommended are: Lorazepam (too long acting), propofol (general anaesthetic induction agent with very narrow therapeutic window only to be used by clinicians with initial anaesthetic competencies signed assessed and documented with local assessment by the Trust Sedation Lead/ another senior anaesthetist.) Though not necessarily recommended as analgesics to use with sedation, diamorphine 0.05 mg/ kg IV, morphine 0.1 mg/ kg IV and pethidine 1 mg/kg (max 100 mg) IV are still accepted as treatment in certain conditions. If reversal drugs i.e. naloxone or flumazenil are used they should also be titrated to effect to avoid unnecessary physiological and psychological problems associated with rapid uncontrolled reversal. Reversal of the benzodiazepine should be performed before reversing analgesic drugs.

Other routes for sedation-:

Drug Dose, total dose and route Notes

Midazolam 0.5 mg/kg to maximum of 20 mg PO or buccally Iv prep (1mg/ ml) Buccal prep (10 mg/ml)

Midazolam elixir is available from pharmacy. It is possible to give the iv preparation orally mixed with equal volumes of undiluted squash. They both taste very bitter.

Temazepam 1 mg/ kg maximum of 30 mg PO

Available as elixir or tablets from pharmacy. Elixir tastes very bitter.

Nitrous oxide/ oxygen mix

Entonox 50:50, Relative analgesia via quantiflex machine 30:70 – 70:30 Inhaled route via mouth or nose

See RCHT entonox guidelines

AUDIT TARGET: 100% of patients should have the drug doses recorded

contemporaneously with the monitored observations. 0% of patients should exceed the recommended dose of sedatives

without explanation on the monitoring chart. 90% of patients should have the opiate administered before the anxiolytic

agent. 0% of patients should receive drugs that are not recommended. 95% of patients should not require reversal of benzodiazepines

Page 10 of 22

6.8. Recovery areas Staffing levels need to be determined and adhered to. Staff must be trained so that they are competent in recognition and initial management of potential complications. Monitoring must be available for all patients who may require it. Oxygen, suction and means of ventilation must be available in all trolley spaces. Resuscitation equipment must be immediately available for all patients. Trolleys capable of height alteration with a functioning tipping mechanism must be used. Each recovery bay must be able to be sectioned off for privacy. Monitoring and oxygen must be continued in recovery and if appropriate continued on transfer to and on the ward until discharge criteria are met. The clinician performing the sedation is responsible for their patient until the patient is fit for discharge from the unit. If that responsibility is delegated to another clinician, they must be able to attend to the patient should a problem arise. Reversal medication when appropriate must be prescribed for all patients enabling the nurse responsible to administer reversal immediately should agree physiological parameters to be reached

6.9. Discharge criteria The patient’s airway must be patent and stable without support. They must be easily rousable and have an oxygen saturation no lower than 5% below their usual pre- procedure saturation level in room air. The patient must be haemodynamically stable, without bleeding, be adequately hydrated. The patient's conscious level and orientation should be within their normal limits and able to walk unaided as appropriate. Any pain, nausea or vomiting must be controlled. Sufficient time must have elapsed following the last administration of any reversal agent to ensure that patients do not become re-sedated after

AUDIT TARGET: 100% of patients have appropriate oxygen therapy in recovery. 0% of patients have an oxygen saturation >5% below their usual pre-

procedure saturation level. 100% of patients have NIBP and pulse oximetry recorded in recovery. 0% of patients are transferred back to a ward without oxygen if the

saturation is below 95%, or 5% below the patient's usual pre-procedure saturation, in room air.

0% of patients are transferred back to a ward with a sedation score > 2. 100% of patients on transfer or discharge have a full contemporaneous

record of observations, drugs administered, procedure carried out and critical incident form completed if appropriate.

Page 11 of 22

leaving the unit. Day case patients should be discharged to the community with a responsible adult escort. The patient and escort should be provided with written instructions regarding post-procedure diet, medications, activities to be avoided for 24 hours, such as driving and a phone number to be called in case of emergency. If the patient has received only analgesics e.g fentanyl or minimal sedation it is up to the responsible clinician to review the need for immediate supervision at home. Fentanyl does however impair driving and can be subject to a DVLA year ban from driving or given a prison sentence depending upon blood levels. Patients who have received reversal drugs should not be left alone. Any patient on their own post procedure must have immediate access to a telephone.

6.10. Critical incident reporting

All incidents that occur in the peri-procedure period, be that clinical or management related which caused or could have resulted in morbidity or mortality of patients or staff must be recorded on DATIX and reviewed (E.g. loss of communication with the patient, significant oxygen desaturation, dysrhythmias, reversal required, loss of output). These critical incidents need to be reviewed in a non-blame culture to draw educational benefit for sedation teams and forwarding any risk management issues to the relevant parties. 6.11. Sedation team training and education

6.11.1. In order to maintain patient safety, all staff who treat and care for patients receiving sedation are required to possess a defined level of clinical competence. The tables below describe the training that staff must undertake in order to demonstrate clinical competence. There are 3 levels of training, appropriate for different staff for the role that they will perform for sedated patients. 6.11.2. Module 1 describes the required training for staff to prescribe and /or administer mild sedation.

Module 1 Prescribing and/ or administering mild sedation

Required training

Immediate Life Support (ILS) as a minimum

(if required)

Entonox- nitrous oxide:

oxygen 50:50 – Not 70:30

Have completed Entonox

training- available on the RCHT

Sedation Training site

Page 12 of 22

6.11.3.

Module 2 describes the training required for staff to prescribe and/or administer moderate sedation. At this level staff must be able to demonstrate a pre requisite skill of peripheral cannulation.

6.11.4. Module 3 describes the training required for the monitoring of moderately sedated patients for example the sedation level needed for an endoscopy, manipulation of a fracture or extracting a wisdom tooth

Module 3 Monitoring moderately sedated patients

Required training

Immediate Life Support (ILS)- minimum

Completion of F2F theory module for assistants

Active attendance at work based simulation training session

Observation of a minimum of 5 patients for whom the practice displays operator competency and completion of competency assessment

Optional training

Learning/ demonstration of clinical airway skills in theatre under supervision of senior anaesthetist

Module 2 Prescribing and/ or administering moderate sedation

Required

training

Completion of Advanced Life Support/ Immediate Life Support

(ALS/ ILS) for non medical staff or equivalent course

Completion of F2F theoretical knowledge, spanning pre-assessment consent, team working and human factors, physiology and pharmacology of sedation, contraindications to sedation

Active attendance at sedation based simulation training session Learning/ demonstration of clinical airway skills in theatre under supervision of specialty anaesthetist

Observation of a minimum of 5 patients for whom the practice displays operator competency and completion of competency assessment

Page 13 of 22

On completion of the appropriate module, evidence should be forwarded to the RCHT Employee support unit, retained by the department and the individual in their portfolio for evidence of compliance at appraisal. Competency will be recorded on ESR. There will be requirement for observation of 5 cases in the work place by their consultant lead or delegated senior clinician, and completion of a logbook, assessing competence and adherence to these guidelines. There may be need for on-going supervision

Equivalent training in sedation at another hospital must be confirmed in writing with the Line manager/ appropriate person. Directly observed assessment of at least one patient, by Consultant level clinician, at each module level must be undertaken at RCHT to confirm practical competency.

NB Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) set out very specific training guidelines in 2015 for those providing sedation in dentistry – this is primarily targeted at those providing sedation in primary care settings but the same principles apply

7. Dissemination and Implementation 7.1. A copy of the guidelines will be stored electronically in the ‘Clinical’ section of the Trust’s document library on the internet/intranet site.

7.2. Awareness of the guidelines will be promoted through a targeted approach to the departments where use of sedation is most frequent and more generally, through the trust updated policy and guidelines email.

7.3. A copy of the guidelines will be circulated to the safe sedation group members.

8. Monitoring compliance and effectiveness

Element to be monitored

Audit targets a r e i d e n t i f i e d in the body of the document. Departments need to conduct an annual audit of practice targets.

In addition clinical results of sedation, critical incidents, patient acceptability should also be conducted and presented at Sedation and clinical governance meetings.

Flumazenil usage must be conducted in each clinical area.

Lead Clinical leads, or staff nominated by them, from each area

Tool Rolling audit a reas and Co l lege Spec i f i c aud i t

t op ics

Sedation group to agree on other appropriate audit

Page 14 of 22

loops.

Frequency Each audit goal should be monitored annually

A 6 monthly audit of flumazenil usage

A report should be returned annual ly to the Safe

Sedation Group.

Reporting arrangements

The completed r e p o r t mus t be sent to the Safe

Sedation Group.

The reports should be reviewed openly within the group to identify successes and failures, to allow features which, with intervention, will allow practice to develop and progress within areas.

This will be documented in the annual meeting minutes.

Acting on recommendations and Lead(s)

Required actions will be identified and completed in as rapid timeframe as possible. A lead member of the team will be identified to take each change forward where appropriate

The Safe Sedation Group will make initial recommendations to aid improvement of practice.

If there are governance issues these will need to be raised initially with the Clinical Governance Leads from the Appropriate a r e a . This may require subsequent action form the RCHT Lead for Clinical Governance

Investment requirements wi l l need to be addressed

with the Business managers for that area.

Failure to address issue via these routes will require the attention of the Medical Director

Change in practice and lessons to be shared

Good practice will be celebrated and plans to improve other areas will be presented at the annual Safe Sedation Meeting. These presentations will be made available to Clinical Governance Leads to present as appropriate in their clinical areas, allowing lessons to be shared with all the relevant stakeholders.

Required changes to practice will be identified and actioned when identified by audit. A lead member of the team will be identified to

take each change forward in their clinical area. Lessons will be shared with all the relevant stakeholders

9. Updating and Review Review of policy will be 2 years after the date of ratification, unless national or local guidance warrants an earlier review.

Page 15 of 22

10. Equality and Diversity

10.1.This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the or the .

Royal Cornwall Hospitals NHS Trust is committed to a Policy of Equal Opportunities in employment. The aim of this policy is to ensure that no job applicant or employee receives less favourable treatment because of their race, colour, nationality, ethnic or national origin, or on the grounds of their age, gender, gender reassignment, marital status, domestic circumstances, disability, HIV status, sexual orientation, religion, belief, political affiliation or trade union membership, social or employment status or is disadvantaged by conditions or requirements which are not justified by the job to be done. This policy concerns all aspects of employment for existing staff and potential employees.

10.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

Page 16 of 22

Appendix 1. Governance Information

Document Title

CLINICAL GUIDELINE FOR RCHT SAFE SEDATION PRACTICE: Adult Patients

Date Issued/Approved: October 2017

Date Valid From: October 2017

Date Valid To: 31 October 2019

Directorate / Department responsible (author/owner):

Dr Rebecca Mawer, Consultant Anaesthetist and RCHT lead for sedation

Contact details: 01872 258195

Brief summary of contents Provision of Safe Sedation for Adult patients by non-specialist anaesthetists/ other clinicians , outside of the theatre environment at RCHT

Suggested Keywords: Sedation, Conscious sedation, Sedation training

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised:

This document replaces (exact title of previous version):

Previous RCHT Safe Sedation guidelines for adult patients

Approval route (names of committees)/consultation:

Safe Sedation Group

Divisional Manager confirming approval processes

Ms V Peverelle

Name and Post Title of additional signatories

‘Not Required

Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Name:

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

Clinical/Anaesthetics

Page 17 of 22

Links to key external standards

Related Documents:

Training Need Identified? Yes. Learning and Development department have been informed.

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

Oct 2017 V1 Document created Dr Rebecca Mawer, Consultant Anaesthetist

All or part of this document can be released under the Freedom of Information Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.

Clinical Guideline Template Page 18 of 23

Appendix 2. Initial Equality Impact Assessment Form

Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description):

CLINICAL GUIDELINE FOR RCHT SAFE SEDATION PRACTICE: Adult Patients

Directorate and service area: Theatres and Anaesthesia

New

Name of individual completing assessment:

Dr Rebecca Mawer

Telephone: 01872 258195

1. Policy Aim*

Who is the strategy / policy / proposal /

service function aimed at?

To promote the practice of Safe sedation in Adult patients at RCHT

2. Policy Objectives*

To identify the standards required to be met to allow Safe Sedation practice

3. Policy – intended Outcomes*

To promote thought processes, back ground information and standards for training which will encourage Safe Sedation Practice

To develop training opportunities for employees

4. *How will you measure the

outcome?

To use the embedded audit standards to re-audit the current sedation practice at RCHT.

To re-audit the uptake of training.

5. Who is intended to benefit from the

policy?

All patients older than 16 years who require procedural sedation at RCHT. All staff who are involved with sedating patients will be aware of the standards expected of their practice.

6a) Is consultation required with the

workforce, equality groups, local interest groups etc. around

this policy?

b) If yes, have these *groups been

consulted?

C). Please list any groups who have

been consulted about this procedure.

Consultation with Safe Sedation Group (a multidisciplinary group of Consultants representing all the specialties who practice sedation at RCHT)

Yes

Consultation with Safe Sedation Group (a multidisciplinary group of Consultants representing all the specialties who practice sedation at RCHT)

Clinical Guideline Template Page 19 of 23

7. The Impact Please complete the following table.

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence

Age Consideration of older patients when administering sedation

Sex (male, female, trans-gender / gender reassignment)

Race / Ethnic communities /groups

Disability - learning disability, physical disability, sensory impairment and mental health problems

Considering MCA and consent issues

Religion / other beliefs

Marriage and civil partnership

Pregnancy and maternity

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major service redesign or development

8. Please indicate if a full equality analysis is recommended. No

9. If you are not recommending a Full Impact assessment please explain why.

Has positive impact for safety and quality of care for all patient groups

Signature of policy developer / lead manager / director Dr Rebecca Mawer

Date of completion and submission 11/09/2017

Names and signatures of members carrying out the Screening Assessment

1. 2.

Clinical Guideline Template Page 20 of 23

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed __ _____________ Date ________________

Clinical Guideline Template Page 21 of 23

Appendix 3. References

1. Bowles CJ, Leicester R, Romaya C, Swarbrick E, Williams CB, Epstein O. A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut 53: 277-83, 2004

2. Implementing and ensuring Safe Sedation Practice for healthcare procedures in adults Report of an intercollegiate Working Party chaired by the Royal College of Anaesthetists March 2002

3. Practice guidelines for sedation and analgesia by non-anesthesiologists An updated report by the American Society of Anesthesiologists task force on sedation and analgesia by non- anesthesiologists Anesthesiology 96: 1004- 1017, 2002

4. RCHT fasting guidelines 2016

5. RCHT Policy for obtaining consent for examination or treatment 2009

6. Reference guide to consent for examination or treatment, second edition 2009 Department of Health Publications August 2009tionsandstatistics/Publications/PublicationsPolicyAndG uidance/DH_103643

7. Reducing risk of overdose with midazolam injection in adults NPSA RRR/2008/011 8 December 2008

8. Reducing Dosing Errors with Opioid Medicines NPSA/2008/RRR05 July 2008

9. RCHT Mental Capacity Act Policy 2009

10. Elderly patients vulnerable because of excessive doses of sedatives g.uk/pdf/current/NPSA%20sedation%20article.pdf

Clinical Guideline Template Page 22 of 23

Appendix 4. Sedation and pain scoring systems

Though there are many sedation scoring systems, probably the most simple to apply is the 4 stage from 0 – 3 as follows.

Sedation score Observation Relation to sedation of

patient Corresponds

approximately to AVPU

0 Awake Before sedation or after when fit for

discharge

A

1 Dozing intermittently

Conscious sedation V

2 Mostly sleepy Conscious sedation progressing to

sedation that is too deep

P

3 Difficult to rouse, even with a

painful stimulus

Heading towards or actual

anaesthesia not sedation

U

One of the most simple scoring system is as follows.

Pain score Observation Acceptable pain scores for the

conscious sedated patient

S Sleeping Patient may be too sedated

0 No pain Ideal if possible

1 Mild pain Acceptable if possible

2 Moderate pain Acceptable for short periods only

3 Severe pain Not acceptable