Pre-Sedation Assessment History & Physical for Non ... Assessment History & Physical for Non-Operative Procedure WITH Sedation History: Pertinent to Anesthesia • Previous problems

Pre-Sedation AssessmentHistory & Physical

forNon-Operative Procedure

WITH Sedation

History: Pertinent to Anesthesia

• Previous problems with sedation or anesthesia in past?– Significant nausea/vomiting?– Significant drug reactions/allergies?– MH or Psuedocholinesterase defiency should not be an issue since

Non-Anesthesia provider do not use triggering drugs

• Evidence of predisposition to Airway Obstruction?– Stridor, snoring, or sleep apnea?– History of difficult intubation?

Medication Reconciliation

• Allergies reviewed and listed• “I have reviewed the patient’s home and

current medications and consider the patient appropriate for the procedure indicated above”

Physical Examination

• Document the following:– Heart & Lung Exam– Vital Signs assessed– Airway Exam

• Neck extension – normal or limited extension• Dentition – intact, edentulous, or other (may note

changes such as loose, rotten or capped teeth)• Mallampati Scale (takes into account mouth

opening)

Mallampati ClassificationMP III or IV predicts a difficult airway

ASA Classification

• Class 1: Healthy patient, no medical problems• Class 2: Mild systemic disease• Class 3: Significant systemic disease, but not

incapacitating• Class 4: Severe systemic disease that is a constant

threat to life• Class 5: Moribund, not expected to live 24 hours

irrespective of procedure/operation

Within 15 minutes prior to initiating sedation must verify

with a simple check box:

•Pre-induction assessment performed

Post Procedure Note

9/29/2008 9.19.08

Universal ProtocolPart 2

Mac Whitehouse MDSuzette Bouchard-Isackson RN, MSN

Tom Shehab MD

Universal Protocolnon-operative invasive procedures

with or without sedation

Part 2Tom Shehab MD

Mac Whitehouse MD

Defined as any procedure that

•could do harm to the patient•requires a consent

•Involves an incision or•percutaneous puncture or •insertion of instrumentation

•can be done in settings other than the operating room

Invasive procedures

(non operating room setting)

•checklist elements must be met on the procedure documentation form or •an additional checklist•checklist is included as permanent part of the record

Minimum Documentation requirements

PROCEDURE DOCUMENTATION FORMATVersion 1

Not using the SEPARATE check list format

•Pre procedure phase includes documentation of the following:•Consent signed and on chart •Confirm special equipment is obtained and available for use•Pre procedure assessment complete•Physician assessment is complete•Indications for procedure documented•Nursing assessment complete

Mark the site

•Patient must participate in verification•Mark all cases/ sites involving incision or percutaneous instrumentation•Mark prior to moving the patient to the location where the procedure is performed•Use permanent marker, visible after prepping•Proceduralist’s initials at site•Emphasis on laterality, level of spine, specific digit

Sedation assessment

SJMHS MSP No. 200, Policy for Moderate and Deep Sedation and Analgesia for Non-anesthesiologists

•Cardiac •Respiratory•Airway Mallampati class •ASA score 1-5

•Class I: soft palate, fauces, uvula, pillars

•Class II: soft palate, fauces, portion of uvula

•Class III: soft palate, base of uvula

•Class IV: hard palate only

Airway Mallampati class

•Class 1 Healthy patient, no medical problems

•Class 2 Mild systemic disease

•Class 3 Severe systemic disease, but not incapacitating

•Class 4 Severe systemic disease that is a constant threat to life

•Class 5 Moribund, not expected to live 24 hours irrespective of operation

ASA score 1-5

Elements of universal protocol must be documented on procedure form

Universal protocol implemented prior to starting procedure•Patient identified (2 identifiers)•Correct procedure verified with patient•Correct site and side marked by person performing the procedure•Correct patient position•Relevant image studies reviewed immediately prior to procedure and available for reference•Any special medications or fluids for irrigation •Additional safety precautions individualized to patient history or medication use•Final time out verification step include personnel involved.•________________ date________time_____

Procedure documentation formatVersion 2

Using a separate check list similar to the operating room

•Consider having the separate Universal Protocol check list in phases

•Pre procedure phase•Check in phase •Final verification (time out)•Sign out phase

See operating room checklist for an example

•Universal protocol implemented•Check list elements met (2009 patient safety goals)•See page Operating room check sheet•Time out completed________date and time

•Personnel involved___________________________________________

•Check list included in patient record

Procedure form documentation must have

Process flow

Pocket card in development

Universal Protocol Flow Process - Non-Operative Procedure with SedationC

heck

In P

hase

Tim

e O

ut P

hase

Sig

n O

ut P

hase

Pre

Pro

cedu

re P

hase Required by patient, nurse, and

anesthesia providerPt asked to state full

name & DOB, verified by matching ID band

Pt states procedure, site,and side and verified

by consent

Site is marked by theprovider initiating

procedure (physician) andverified by the patient

Pt asked when last ate,NPO status confirmed

All data in the medicalchart and consent is

consistent with patientresponse

Required by physician, nurse, scrubtech/nurse, physician assistant, and

anesthesia provider Team membersintroduced

Pt identity confirmed. Procedure

reviewed verbally with teammembers

Laterality confirmedwith team verbal

(correct side)

Imaging, specialimplants and

equipment available

If applicable, pre-procedure antibiotics

available andinitiated on time

Additional safety precautionsindividualized to patent

history or medication use

Any specialmedication or fluids

for irrigation

Medical record andimaging confirms

correct side and site

Patient positionconfirmed

Procedure reviewedverbally with team and

confirmed with consent

Laterality confirmedverbally with team

and marked sitevisible after prep

Patient identityconfirmed

If applicable, correctinstrument, sponge,

and needle count

Physician, anesthesia providerand nurse and/or tech review

key concerns forpost procedure care of patient

Name of correct procedureon record, all specimens

labeled correctly

Review any itemsneeding follow up

Nursing assessmentcomplete

Sedation assessment complete:cardiac, respiratory airway

Mallampati class, ASA score

Required by physician, nurse, scrubtech/nurse, physician assistant, and

anesthesia provider

Required by surgeon, nurse, scrubtech/nurse, physician assistant, and

anesthesia provider

2009

Universal Protocol Flow Process - Non-Operative Procedure without SedationC

heck

In P

hase

Tim

e O

ut P

hase

Sig

n O

ut P

hase

Pre

Pro

cedu

re P

hase Required by patient and nurse and/or

procedure techPt asked to state full

name & DOB, verified by matching ID band

Pt states procedure, site,and side and verified

by consent

Site is marked by theprovider initiating

procedure and verified bythe patient

If applicable, pt askedwhen last ate, NPOstatus confirmed,

All data in the medicalchart and consent is

consistent with patientresponse

Required by physician, nurse, scrubtech/nurse, procedure tech, and/or

physician assistant Team membersintroduced

Pt identity confirmed. Procedure

reviewed verbally with teammembers

Laterality confirmedwith team verbal

(correct side)

Imaging, specialequipment available

Additional safety precautionsindividualized to patienthistory or medication use

Any specialmedication or fluids

for irrigation

Medical record andimaging confirms

correct side and site

Patient positionconfirmed

Procedure reviewedverbally with team and

confirmed with consent

Laterality confirmedverbally with team

and marked sitevisible after prep

Patient identityconfirmed

If applicable, correctinstrument, sponge,

and needle count

Provider performing procedureand nurse and/or tech review

key concerns forpost procedure care of patient

Name of correct procedureon record, all specimens

labeled correctly

Review any itemsneeding follow up

Nursing assessmentcomplete

Required by physician, nurse, scrubtech/nurse, procedure tech, and/or

physician assistant

Required by physician, nurse, scrubtech/nurse, procedure tech, and/or

physician assistant

2009