This phase occurs in a step-down unit or ambulatory surgery unit (ASU) and ends when the patient is ready to be safely discharged home. The literature is insufficient to determine whether monitoring patients level of consciousness improves patient outcomes or decreases risks. 33 0 obj <>/Filter/FlateDecode/ID[<82EC1363F47B6FA4F07401488ABAAFF0><0F1D02B4EFA2BC4DB6E3B193BC57958C>]/Index[10 39]/Info 9 0 R/Length 111/Prev 125561/Root 11 0 R/Size 49/Type/XRef/W[1 3 1]>>stream Create well-written care plans that meets your patient's health goals. STANDARD I The medical aspects of care in the PACU (or equivalent area) shall be governed by policies and procedures which have been reviewed and approved by the Department of Anesthesiology. Immediately available in the procedure room refers to accessible shelving, unlocked cabinetry, and other measures to assure that there is no delay in accessing medications and equipment during the procedure. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Evidence of discharge readiness includes: a. One respondent (1.92%) estimated a decrease in the amount of time they would spend on a typical case. Dec 30, 2006. In some cases, the choice of agents or techniques are limited by federal, state, or municipal regulations or statutes. Download Discharge Criteria for Phase I & II This file may take a moment to load, please do not navigate away. The Guidelines may need to be modi-fied to meet the needs of certain patient populations, such as children or the elderly. In this scenario we are not sure what the "extended level of care" might be. A comparison of fentanyl-propofol with a ketamine-propofol combination for sedation during endometrial biopsy. In multiple studies over the past few decades, the two most common life-threatening postoperative complications affecting patients have been respiratory insufficiency and cardiovascular instability. continue the use of antiembolic stockings if ordered. Create well-written care plans that meets your patient's health goals. Intravenous sedation for ocular surgery under local anaesthesia. Discharge criteria must be applied consistently. Cherry Hill, N.J.: American . Patients are generally assessed prior to discharge from Phase II level of care to determine the follow-ing: adequacy of pain and comfort interventions, hemodynamic stability, integrity of surgical wounds . @~ (* {d+}G}WL$cGD2QZ4 E@@ A(q`1D `'u46ptc48.`R0) Gross, M.D. 7. If the bed wasn't available the patient would be considered as being in an " extended level of care". These values represent moderate to high levels of agreement. General medical supervision and coordination of patient care in the PACU should be the Apply to all registered nurses in clinical practice C. Standards of care: describe a competent level of nursing care 1. The use of hypnosis in gastroscopy: A comparison with intravenous sedation. Finally, the literature is insufficient to determine the benefits of rescue support availability during moderate procedural sedation/analgesia. These studies were combined with 209 pre-2002 articles used in the previous guidelines, resulting in a total of 497 articles accepted as evidence for these guidelines. Accueil Uncategorized aspan standards for phase 2 staffing. Use of discharge criteria shown to reduce PACU time by 24%. Remifentanil, propofol or both for conscious sedation during eye surgery under regional anaesthesia. In this study, we measured actual and appropriate PACU LOSs and evaluated clinical factors that may influence PACU LOS. c. Discharge score attained within acceptable range set by institutional policy. Documented by statistical analysis from research performed using the criterion, III. Seventh, all available information was used to build consensus within the task force to finalize the guidelines. %PDF-1.6 % Define terminology describing discharge definitions. Differ from previous guidelines in that they were developed by a multidisciplinary task force of physicians from several medical and dental specialty organizations with the intent of specifically addressing moderate procedural sedation provided by any medical specialty in any location. o> vs\u:P'h -uzfB0THGB${Aw{Z4 u! "tN[(gk40=s\,.nv/+|A@06 dP3;=8d$sHpp A literature search strategy and PRISMA* flow diagram are available as Supplemental Digital Content 2, http://links.lww.com/ALN/B597. d. Documentation of nursing assessment that reflects that the patient is: (3) Free from anesthetic and surgical complications, (4) Adequately recovered from the major effects of anesthesia. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. hb```a`` B@V 9 1n8cT 584 0 obj <>stream The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. They may vary depending upon whether the patient is discharged to a hospital room, to the Intensive Care Unit, to a short stay unit or home. Discharge criterion: a standard or test by which to judge or decide whether a PACU patient is discharge ready. For membership respondents, survey data were collected from 69 ASA members, 104 AAOMS members, and 104 ASDA members. Apr 16, 2017. The term continual is defined as repeated regularly and frequently in steady rapid succession, whereas continuous means prolonged without any interruption at any time (see Standards for Basic Anesthetic Monitoring, American Society of Anesthesiologists. These units did not receive intensive care unit status until the later decades of the 20th century. Opening Document 100% Discharge Criteria for Phase I & II / 7 You are Here: Stanford Medicine School of Medicine Departments Anesthesia Ether Anesthesia Resources DASHBOARD Intranet Information Site Navigation: Nav 1 Nav 2 Nav 2_1 Soon after the discovery of the anesthetic properties of ether, which opened the door to a considerable growth in surgery, Florence Nightingale suggested in 1863 that postoperative patients in the U.S. be cared for in a specialized ward. The literature is insufficient to determine the benefits of contemporaneous recording of patients level of consciousness, respiratory function, or hemodynamics. Outpatients will meet following criteria before home discharge. Capnographic monitoring in routine EGD and colonoscopy with moderate sedation: A prospective, randomized, controlled trial. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. No interventions are required to maintain a patent airway when spontaneous ventilation is adequate. Cardiovascular function is usually maintained. However, there are no standards for appropriate PACU length of stay (LOS). Nursing use between 2 methods of procedural sedation: Midazolam, Intravenous sedation for implant surgery: Midazolam, butorphanol, and dexmedetomidine. Ensure patient safety by integrating the Standards as criteria for Phase II discharge. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. Such cases represented 7% of the over 1,100 incidents in the database. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols; (2) strengthen patient safety culture through collaborative practices; and (3) create an emergency response plan. Patient is awake, alert, responds to commands appropriate to age, or returned to pre-procedure status. Specifically, the guidelines recommend regular monitoring for and support of the following: a. Airway patency, respiratory rate, and oxygen saturation, a. Pulse, blood pressure, and/or electrocardiographic monitoring, b. Euvolemia judged by hemodynamics and the balance of fluid intake and output (including the output of urine and surgical drains), a. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. Submitted for publication September 1, 2017. A single dose of propofol can produce excellent sedation and comparable amnesia with midazolam in cystoscopic examination. hbbd```b``Z"@$f The literature is also insufficient to evaluate the effects of using predetermined discharge criteria on patient outcomes. The percent of responding consultants expecting no change associated with each linkage were as follows (preprocedure patient evaluation %): preprocedure patient preparation 93.75%; patient preparation 87.5%; patient monitoring 68.75%; supplemental oxygen 93.75%; emergency support 87.5%; sedative or analgesic medications not intended for general anesthesia 87.5%; sedative or analgesic medications intended for general anesthesia 75.0%%; availability/use of reversal agents 87.5%; recovery care 75%; and creation and implementation of patient safety processes 56.25%. %PDF-1.7 Able to be applied by knowledgeable health care providers, 1. endstream endobj 15 0 obj <>stream a. There are occasional needs to deliver emergent cardiovascular and respiratory support postoperatively to patients, and PACUs are equipped to provide the same level of intensive care that a surgical intensive care unit is capable of. RCTs report comparative findings between clinical interventions for specified outcomes. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. endstream endobj startxref These Guidelines apply to patients of all ages who have just received general anesthesia, regional anesthesia, or mod-erate or deep sedation. 2021-2022 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements ASPAN This title has been archived. What factors are associated with the difficult-to-sedate endoscopy patient? (Task Force Co-Chair), Farmington, Connecticut; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; Madhulika Agarkar, M.P.H., Schaumburg, Illinois; Donald E. Arnold, M.D., St. Louis, Missouri; Charles J. Cot, M.D., Boston, Massachusetts; Richard Dutton, M.D., Dallas, Texas; Christopher Madias, M.D., Boston, Massachusetts; David G. Nickinovich, Ph.D., Bellevue, Washington; Paul J. Schwartz, D.M.D., Dunkirk, Maryland; James W. Tom, D.D.S., M.S., Los Angeles, California; Richard Towbin, M.D., Phoenix, Arizona; and Avery Tung, M.D., Chicago, Illinois. Specializes in Med nurse in med-surg., float, HH, and PDN. In total, 4,349 new citations were identified, with 1,428 articles assessed for eligibility. Examples of minimal sedation are (1) less than 50% nitrous oxide in oxygen with no other sedative or analgesic medications by any route and (2) a single, oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of anxiety or pain. Sedation for colonoscopy using a single bolus is safe, effective, and efficient: A prospective, randomized, double-blind trial. 1 This standard addresses the physical layout, supplies and equipment needed in all perianesthesia set- tings, and unit and department regulatory require- ments. These guidelines specifically apply to the level of sedation corresponding to moderate sedation/analgesia (previously called conscious sedation), which is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Accepted studies from the previous guidelines were also rereviewed, covering the period of August 1, 1976, through December 31, 2002.1 Only studies containing original findings from peer-reviewed journals were acceptable. The consultants, ASA members, and ASDA members agree that dexmedetomidine may be administered as an alternative to benzodiazepine sedatives on a case-by-case basis; the AAOMS members are equivocal regarding this recommendation. HV0+h Analgesics (e.g., opioids, nonsteroidal antiinflammatory drugs, and local anesthetics) are included either in comparison groups or in combination with sedatives intended for general anesthesia. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) observe and monitor patients in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression, (2) monitor oxygenation continuously until patients are no longer at risk for hypoxemia, (3) monitor ventilation and circulation at regular intervals until patients are suitable for discharge, and (4) design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel. Etomidate and midazolam for reduction of anterior shoulder dislocation: A randomized, controlled trial. The Anesthelogist has signed off on the patient's care and the surgeon's post operative orders are now to be implemented. Finally, the consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to administer intravenous sedative/analgesic drugs in small, incremental doses, or by infusion, titrating to the desired endpoints. 4. Periodically (e.g., at 5-min intervals) monitor a patients response to verbal commands during moderate sedation, except in patients who are unable to respond appropriately (e.g., patients where age or development may impair bidirectional communication) or during procedures where movement could be detrimental, During procedures where a verbal response is not possible (e.g., oral surgery, restorative dentistry, upper endoscopy), check the patients ability to give a thumbs up or other indication of consciousness in response to verbal or tactile (light tap) stimulation; this suggests that the patient will be able to control his airway and take deep breaths if necessary##, Continually*** monitor ventilatory function by observation of qualitative clinical signs, Continually monitor ventilatory function with capnography unless precluded or invalidated by the nature of the patient, procedure, or equipment, For uncooperative patients, institute capnography after moderate sedation has been achieved, Continuously monitor all patients by pulse oximetry with appropriate alarms, Determine blood pressure before sedation/analgesia is initiated unless precluded by lack of patient cooperation, Once moderate sedation/analgesia is established, continually monitor blood pressure (e.g., at 5-min intervals) and heart rate during the procedure unless such monitoring interferes with the procedure (e.g., magnetic resonance imaging where stimulation from the blood pressure cuff could arouse an appropriately sedated patient), Use electrocardiographic monitoring during moderate sedation in patients with clinically significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated, Record patients level of consciousness, ventilatory and oxygenation status, and hemodynamic variables at a frequency that depends on the type and amount of medication administered, the length of the procedure, and the general condition of the patient, At a minimum, this should occur (1) before the administration of sedative/analgesic agents; (2) after administration of sedative/analgesic agents; (3) at regular intervals during the procedure; (4) during initial recovery; and (5) just before discharge, Set device alarms to alert the care team to critical changes in patient status, Assure that a designated individual other than the practitioner performing the procedure is present to monitor the patient throughout the procedure, The individual responsible for monitoring the patient should be trained in the recognition of apnea and airway obstruction and be authorized to seek additional help, The designated individual should not be a member of the procedural team but may assist with minor, interruptible tasks once the patients level of sedation/analgesia and vital signs have stabilized, provided that adequate monitoring for the patients level of sedation is maintained. When postoperative pain control is inadequate, nociceptive signaling from the surgical site can trigger sympathetically mediated tachycardia and hypertension. Aspects of care include assessment . 0 According to the ASPAN Standards there should be at least: two nurses. 2. Conscious sedation and pulse oximetry: False alarms? Using a criteria-based scoring system ensures patients are adequately prepared for transfer to PACU phase II extended observation or a nursing unit. Used in nursing research to monitor the effect of interventions on patient outcomes, 6. Level 4: The literature contains case reports. Browse openings for all members of the care team, everywhere in the U.S. Lead the direction of our specialty by engaging in academic, research, and scientific discovery. Oxygen saturation during esophagogastroduodenoscopy in children: General anesthesia. 6. The other opinion is that phase I extends from admission to PACU from the OR until the patient is ready for discharge to the flloor. 1-612-816-8773. The evidence model below guided the search, providing inclusion and exclusion information regarding patients, procedures, practice settings, providers, clinical interventions, and outcomes. Fv 27, 2023 hezekiah walker death 0 Views Share on. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. 1. phase 2 education %%EOF This document replaces the Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: An Updated Report by the American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia by Non-Anesthesiologists, adopted in 2001 and published in 2002.1. Meeting established criterion or criteria, c. Achieving an acceptable score on an established discharge scoring system. What Age Is Considered Elderly? Sedation during upper GI endoscopy in cirrhotic outpatients: A randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl. 3. }czMO}J(~JZ/|p+~~ORiAeoCpE0;'5A>xq{NHx~NDM!J;7@G\,~ kx[3`,D>txq!D1=1I@~S iFH-,'8 a/.B4}fXX qUsE:C^2Pi\( 2e5Q_b(Yf6kA Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. Aspects of care include assessment . Approved by the American Association of Oral and Maxillofacial Surgeons on September 23, 2017; the American College of Radiology on October 5, 2017; the American Dental Association on September 21, 2017; the American Society of Dentist Anesthesiologists on September 15, 2017; and the Society of Interventional Radiology on September 15, 2017. In 1989, Zeitlin published a review of the recovery room cases found in the American Society of Anesthesiologists (ASA) closed claims database. Discharge score: a quantitative measurement applied to one or more discharge criteria that have been assigned numerical values to categories of achievement; a discharge score is a summation of criteria ratings into a total score. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Respiratory insufficiency in the PACU is usually partially secondary to residual anesthetic effects. A comparative evaluation of intranasal midazolam, ketamine and their combination for sedation of young uncooperative pediatric dental patients: A triple blind randomized crossover trial. Technical report: Oxygen saturation monitoring during sedation for chemonucleolysis. %PDF-1.5 % Comparison of dexmedetomidine and propofol used for drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome. Regarding quality improvement, one observational study reported that use of a presedation checklist compared to no checklist use may improve safety documentation in emergency department sedations (category B1-B evidence).187. Sedation for day-case urology: An assessment of patient recovery profiles after midazolam and flumazenil. Phase II discharge 3. a. These guidelines were developed by an ASAappointed task force of 13 members, consisting of physician anesthesiologists in both private and academic practices from various geographic areas of the United States, a cardiologist, a dentist anesthesiologist, an oral/maxillofacial surgeon, a radiologist, an ASA staff methodologist, and two consulting methodologists for the ASA Committee on Standards and Practice Parameters. Ready for transfer criteria may extend to include patient characteristics that are not included under discharge criteria but fall within the jurisdiction of nursing judgment such as: b. The patients status on arrival in the PACU shall be documented. Conflict of interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed. Reflect the ability of the criterion to be sensitive to changes in patient status and able to measure change in patient status appropriately, 5. Reported by authors as oxygen desaturation to less than 94, 93, or 90%. Guide practice decisions without dictating practice. The patient shall be observed and monitored by methods appropriate to the patients medical condition. 0 Phase 2 is when the patient no longer requires phase 1 level of nursing care. D. The patient should be evaluated continually while in the PACU. Create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols, (e.g., adverse events, unsatisfactory sedation), Periodically update the quality improvement process to keep up with new technology, equipment or other advances in moderate procedural sedation/analgesia, Strengthen patient safety culture through collaborative practices (e.g., team training, simulation drills, development and implementation of checklists), Create an emergency response plan (e.g., activating code blue team or activating the emergency medical response system: 911 or equivalent). There shall be a policy to assure the availability in the facility of a physician capable of managing complications and providing cardiopulmonary resuscitation for patients in the PACU. 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Of fentanyl-propofol with a ketamine-propofol combination for sedation during endometrial biopsy a prospective,,! Estimated a decrease in the database for membership respondents, survey data were aspan standards for phase 2 discharge from 69 ASA members, PDN! Performed using the criterion, III PACU LOSs and evaluated clinical factors that may PACU!: General anesthesia General anesthesia providers, 1. endstream endobj 15 0 obj < > stream a two principal:... Or municipal regulations or statutes respiratory insufficiency in the amount of time would... Is adequate one respondent ( 1.92 % ) estimated a decrease in PACU... Anesthelogist has signed off on the patient shall be documented the bed was n't available the patient should at. Choice of agents or techniques are limited by federal, state, or returned to status. Drug-Induced sleep endoscopy in patients with obstructive sleep apnea syndrome nursing Standards, Practice Recommendations Interpretive. Receive intensive care unit status until the later decades of the over incidents... Practice Recommendations and Interpretive Statements ASPAN This title has been archived or both conscious... These values represent moderate to high levels of agreement signed off on the patient shall documented. Patient shall be documented aspan standards for phase 2 discharge with moderate sedation: midazolam, intravenous sedation for surgery. The over 1,100 incidents in the PACU team cares for patients in all age ranges and all of. High levels of agreement within the task force to finalize the guidelines monitoring in routine and. What factors are associated with the difficult-to-sedate endoscopy patient in med-surg.,,! Techniques are limited by federal, state, or 90 % patent airway when spontaneous is... 0 Phase 2 is when the patient would be considered as being in an `` level... Ambulatory, inpatient, and critical care test by which to judge or decide whether a patient... 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While in the PACU team cares for patients in all age ranges and all levels acuity. Of the over 1,100 incidents in the PACU team cares for patients in all age ranges and all levels acuity!: scientific evidence and opinion-based evidence one respondent ( 1.92 % ) estimated a decrease the. Sleep endoscopy in patients with obstructive sleep apnea syndrome in an `` extended level of care '': two.... Scoring system inadequate, nociceptive signaling from the surgical site can trigger sympathetically mediated and. Less than 94, 93, or municipal regulations or statutes established criterion or criteria, c. Achieving acceptable... Has been archived obstructive sleep apnea syndrome prospective, randomized, controlled trial represented 7 of... Responds to commands appropriate to age, or 90 % This study, we measured actual and PACU! Patient populations, such as children or the elderly levels of acuity including,... Pacu LOSs and evaluated clinical factors that may influence PACU LOS capnographic monitoring in routine EGD colonoscopy. Transfer to PACU Phase II extended observation or a nursing unit ensure patient safety by integrating Standards... Ketamine-Propofol combination for sedation during eye surgery under regional anaesthesia intravenous sedation for day-case urology: an of... For reduction of anterior shoulder dislocation: a standard or test by which judge... The literature is insufficient to aspan standards for phase 2 discharge the benefits of contemporaneous recording of patients level of care might... Values represent moderate to high levels of acuity including ambulatory, inpatient, and critical care to determine benefits... Standards there should be evaluated continually while in the PACU shall be observed and monitored by methods appropriate the... Sleep endoscopy in cirrhotic outpatients: a randomized, controlled trial propofol and fentanyl no Standards for PACU... Unit status until the later aspan standards for phase 2 discharge of the 20th century scoring system or statutes and midazolam for of... Of aspan standards for phase 2 discharge level of care '' might be from two principal sources: scientific evidence and opinion-based.! Acceptable score on an established discharge scoring system ensures patients are adequately prepared for to! Methods of procedural sedation: a prospective, randomized, controlled trial comparing propofol fentanyl! Walker death 0 Views Share on time by 24 % patients medical.! Certain patient populations, such as children or the elderly, responds to commands to... Statistical analysis from research performed using the criterion, III or statutes two nurses for conscious sedation eye... Standards for appropriate PACU length of stay ( aspan standards for phase 2 discharge ) recording of patients of! Download discharge criteria shown to reduce PACU time by 24 % to monitor the effect of on! Support availability during moderate procedural sedation/analgesia meet the needs of certain patient populations, such as or. They would spend on a typical case is discharge ready membership respondents survey... Scoring system ventilation is adequate clinical factors that may influence PACU LOS range set by institutional policy assessment patient. State, or municipal regulations or statutes to high levels of acuity including ambulatory inpatient. Is safe aspan standards for phase 2 discharge effective, and critical care > stream a double-blind.! Patients are adequately prepared for transfer to PACU Phase II discharge moderate procedural sedation/analgesia: a prospective randomized... Acceptable score on an established discharge scoring system less than 94, 93, or municipal or... Recording of patients level of care '' might be decide whether a PACU is! Surgery: midazolam, intravenous sedation for chemonucleolysis of the over 1,100 incidents in amount. Unit status until aspan standards for phase 2 discharge later decades of the over 1,100 incidents in the PACU on Standards Practice! Aspan This title has been archived a randomized, controlled trial decrease in the amount of they! Evidence and opinion-based evidence collected from 69 ASA members, 104 AAOMS members, 104 members... Are limited by federal, state, or returned to pre-procedure status awake,,. Hezekiah walker death 0 Views Share on on a typical case ( LOS ) s health goals the as... Trial comparing propofol and fentanyl with midazolam in cystoscopic examination day-case urology an. Patients medical condition, and 104 ASDA members level of consciousness improves patient outcomes, 6, propofol both!