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Joint Commission on Accreditation of Healthcare Organizations Requirements for Sedation
PAIN MANAGEMENT/CONCEPTS
Joint Commission on Accreditation of Heahhcare Organizations Requirements for Sedation From the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico. From the First International Symposium on Pain Researchin Emergency Medicine, Montreal, October 1994, Copyright © by the American College of Emergency Physicians.
4 12
David P Sklar, MD
[Skiar DP: Joint Commission on Accreditation of Healthcare Organizations requirements for sedation. Ann ErnergMedApril 1996;27:412-413.]
Recent changes in the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have implications for emergency department pain research. The JCAHO, in its manual for hospitals, specifies in section LD 1.6 "that leaders develop and implement mechanisms designed to assure the uniform performance of patient care processes throughout the organization." 1 LD 1.6 also states, "Patients with the same health problems and care needs have a right to receive the same level of care throughout the organization. ''2 Anesthesia is specifically cited, and an example of implementation is given in which anesthesiologists help develop policies and procedures for patients who "lose protective reflexes" in areas besides the operating room such as the cardiac catheterization laboratory, ED, and radiology department. 2 The idea is to have one standard in the hospital for patients who receive agents that cause them to lose protective airway reflexes. If a patient who would receive midazolam in the operating room would have monitoring with a pulse oximeter and an anesthesiologist controlling the airway, a similar standard should be met if the same agent is administered to a patient in the ED for sedation to perform a similar procedure. For the purposes of this regulation, anesthesia has been defined in a previous section (OP 1.2.3.) ~ as "the administration (in any setting, by any route, for any purpose) of a general, spinal or other major regional anesthesia or sedation (with or without analgesia) for which there is a reasonable expectation that, in the manner used, the sedation/analgesia will result in the loss of protective reflexes for a significant percentage of a group of patients." Taken together, the definition and LD 1.6 require scrutiny and documentation of whether specific sedation/anal-
ANNALS OF EMERGENCY MEDICINE
27:4 APRIL 1996
JCAHO
SkIar
gesic combinations in the ED cause "loss of protective reflexes in a significant percentage of a group of patients." If loss of reflexes does not occur, LD 1.6 does not apply. However, it is important to document that loss of reflexes does not occur. Terms such as "loss of protective reflexes" and "significant percentage" are not defined. However, it is likely that anyone requiring intubation, bag-valve-mask ventilation, deep suctioning, and cricothyroidotomy would be considered likely to have lost protective reflexes. Whether inability to converse normally is also considered evidence of loss of protective reflexes is not clear. If protective reflexes are lost, the LD 1.6 standard is triggered. The effect is that the ED staff would be responsible for documenting that equivalent anesthetic care is provided in the ED compared with that given in the operating room, for example. This might mean that an anesthesiologist must be present in both cases or that clear expertise in monitoring, preanesthesia evaluation, and postanesthesia discharge airway management be demonstrable. Forms for documentation similar to those used in the operating room might also be required in the ED. Such mechanisms hold implications for ED pain research. Documentation requirements of loss of protective reflexes may lead to fixed doses of agents and study of specified parameters such as respiratory rate, gag reflex, corneal reflex, and cognitive capability that will improve comparative knowledge about the agents in common use in the ED. These requirements will simplify data collection and encourage analysis. However, the diNcuhy of meeting LD 1.6 may lead to the ED use of agents with less likelihood of depressing "protective reflexes," even if the efficacy of performing the procedure in question is decreased. There may be increased reexamination of the usefulness of local anesthetics and nerve blocks if sedation/analgesia is restricted. Collaboration between departments of emergency medicine and anesthesiology will become increasingly important. Use of common terminology, agents, documentation, discharge instructions, and identification of complications will become necessary. Agents that may face increasing scrutiny because of their effects on protective reflexes include ketamine, narcotics, barbiturates, and benzodiazepines. The development of protocols for use of these agents may become so cumbersome that routine use is avoided. Designing clinical trials for their use may offer the advantage of fulfilling monitoring requirements and providing accurate information. In the short term, the JCAHO standards will improve the monitoring and documentation of ED analgesic use,
APRIL 1996
27:4
ANNALS 0E EMERGENCY MEDICINE
as well as limit the use of some agents. In the long term, the standards may cause changes in agent use, development of institutional protocols, and the monitoring of analgesia-associated complications and increasing coordination between anesthesiologists and others who use agents that depress protective reflexes. Research on pain management in the ED should receive more institutional support to ensure documentation of adverse events. In centers where political problems between anesthesiologists and emergency physicians cannot be resolved, the new standard may become a constant reminder of the unresolved conflict rather than the unifying tool it could be. REFERENCES 1. 1994Accreditation Manua/for Hospitals, vol 1.0akbrook Terrace, lllinois: Joint Commission on Accreditationof HealthcareOrganizations, 1993. 2. 1994Accreditation Manual for Hospitals, vet 2.0akbmok Terrace, Illinois: Joint Commission on Accreditationpf Healthcare Organizations, 1993.
Reprint no. 47/1/71805 Address for reprints: David P Sklar, MD Department of EmergencyMedicine Universityof New Mexico School of Medicine Albuquerque,New Mexico 87131-5246
413
Joint Commission on Accreditation of Heahhcare Organizations Requirements for Sedation From the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico. From the First International Symposium on Pain Researchin Emergency Medicine, Montreal, October 1994, Copyright © by the American College of Emergency Physicians.
4 12
David P Sklar, MD
[Skiar DP: Joint Commission on Accreditation of Healthcare Organizations requirements for sedation. Ann ErnergMedApril 1996;27:412-413.]
Recent changes in the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have implications for emergency department pain research. The JCAHO, in its manual for hospitals, specifies in section LD 1.6 "that leaders develop and implement mechanisms designed to assure the uniform performance of patient care processes throughout the organization." 1 LD 1.6 also states, "Patients with the same health problems and care needs have a right to receive the same level of care throughout the organization. ''2 Anesthesia is specifically cited, and an example of implementation is given in which anesthesiologists help develop policies and procedures for patients who "lose protective reflexes" in areas besides the operating room such as the cardiac catheterization laboratory, ED, and radiology department. 2 The idea is to have one standard in the hospital for patients who receive agents that cause them to lose protective airway reflexes. If a patient who would receive midazolam in the operating room would have monitoring with a pulse oximeter and an anesthesiologist controlling the airway, a similar standard should be met if the same agent is administered to a patient in the ED for sedation to perform a similar procedure. For the purposes of this regulation, anesthesia has been defined in a previous section (OP 1.2.3.) ~ as "the administration (in any setting, by any route, for any purpose) of a general, spinal or other major regional anesthesia or sedation (with or without analgesia) for which there is a reasonable expectation that, in the manner used, the sedation/analgesia will result in the loss of protective reflexes for a significant percentage of a group of patients." Taken together, the definition and LD 1.6 require scrutiny and documentation of whether specific sedation/anal-
ANNALS OF EMERGENCY MEDICINE
27:4 APRIL 1996
JCAHO
SkIar
gesic combinations in the ED cause "loss of protective reflexes in a significant percentage of a group of patients." If loss of reflexes does not occur, LD 1.6 does not apply. However, it is important to document that loss of reflexes does not occur. Terms such as "loss of protective reflexes" and "significant percentage" are not defined. However, it is likely that anyone requiring intubation, bag-valve-mask ventilation, deep suctioning, and cricothyroidotomy would be considered likely to have lost protective reflexes. Whether inability to converse normally is also considered evidence of loss of protective reflexes is not clear. If protective reflexes are lost, the LD 1.6 standard is triggered. The effect is that the ED staff would be responsible for documenting that equivalent anesthetic care is provided in the ED compared with that given in the operating room, for example. This might mean that an anesthesiologist must be present in both cases or that clear expertise in monitoring, preanesthesia evaluation, and postanesthesia discharge airway management be demonstrable. Forms for documentation similar to those used in the operating room might also be required in the ED. Such mechanisms hold implications for ED pain research. Documentation requirements of loss of protective reflexes may lead to fixed doses of agents and study of specified parameters such as respiratory rate, gag reflex, corneal reflex, and cognitive capability that will improve comparative knowledge about the agents in common use in the ED. These requirements will simplify data collection and encourage analysis. However, the diNcuhy of meeting LD 1.6 may lead to the ED use of agents with less likelihood of depressing "protective reflexes," even if the efficacy of performing the procedure in question is decreased. There may be increased reexamination of the usefulness of local anesthetics and nerve blocks if sedation/analgesia is restricted. Collaboration between departments of emergency medicine and anesthesiology will become increasingly important. Use of common terminology, agents, documentation, discharge instructions, and identification of complications will become necessary. Agents that may face increasing scrutiny because of their effects on protective reflexes include ketamine, narcotics, barbiturates, and benzodiazepines. The development of protocols for use of these agents may become so cumbersome that routine use is avoided. Designing clinical trials for their use may offer the advantage of fulfilling monitoring requirements and providing accurate information. In the short term, the JCAHO standards will improve the monitoring and documentation of ED analgesic use,
APRIL 1996
27:4
ANNALS 0E EMERGENCY MEDICINE
as well as limit the use of some agents. In the long term, the standards may cause changes in agent use, development of institutional protocols, and the monitoring of analgesia-associated complications and increasing coordination between anesthesiologists and others who use agents that depress protective reflexes. Research on pain management in the ED should receive more institutional support to ensure documentation of adverse events. In centers where political problems between anesthesiologists and emergency physicians cannot be resolved, the new standard may become a constant reminder of the unresolved conflict rather than the unifying tool it could be. REFERENCES 1. 1994Accreditation Manua/for Hospitals, vol 1.0akbrook Terrace, lllinois: Joint Commission on Accreditationof HealthcareOrganizations, 1993. 2. 1994Accreditation Manual for Hospitals, vet 2.0akbmok Terrace, Illinois: Joint Commission on Accreditationpf Healthcare Organizations, 1993.
Reprint no. 47/1/71805 Address for reprints: David P Sklar, MD Department of EmergencyMedicine Universityof New Mexico School of Medicine Albuquerque,New Mexico 87131-5246
413