Clayton P Josephy1, David R Vinson2. 1. Barton Health System and the Department of Emergency Medicine Barton Memorial Hospital, South Lake Tahoe, CA, United States. Electronic address: cjosephy@gmail.com. 2. The Permanente Medical Group, the Kaiser Permanente Division of Research, and the KP CREST Network, Oakland, CA, United States; Kaiser Permanente Sacramento Medical Center, Sacramento, CA, United States.
Abstract
OBJECTIVE: Sedation is commonly required for painful procedures in the emergency department (ED). Some facilities mandate two physicians be present for deep sedation cases. Evidence is lacking, however, that a two-physician approach improves safety outcomes. We report our experience on the feasibility of replacing a two-physician ED procedural sedation policy with a single-physician policy in a small, single-coverage community ED. METHODS: This is a retrospective, before/after, single-center observational study of prospectively collected data from January 2013 through December 2016. In September 2014, our medical center implemented a single-physician policy requiring only one emergency physician, accompanied by a sedation-trained ED registered nurse. The primary outcome was a sedation-related escalation of care that resulted in one of the following adverse events or interventions: dysrhythmia (symptomatic bradycardia or ventricular arrhythmias), cardiac arrest, endotracheal intubation, or unanticipated hospitalization. Secondary outcomes included hypoxemia (peripheral oxygen saturation less than 90% for greater than 1min), the use of bag-valve mask ventilation (BVM), use of a reversal agent, laryngospasm or pulmonary aspiration. RESULTS: We performed 381 sedations during the study period: 135 patients in the two-physician group (before) and 246 patients in the single-physician group (after). The two groups were comparable in age and gender. There was no occurrence of the primary outcome. Secondary outcomes were uncommon, and were similar in the two groups. CONCLUSIONS: In this small, single-coverage community ED, replacement of a two-physician policy with a single-physician policy for deep sedation in the ED was feasible and was not associated with an increase in adverse events.
OBJECTIVE: Sedation is commonly required for painful procedures in the emergency department (ED). Some facilities mandate two physicians be present for deep sedation cases. Evidence is lacking, however, that a two-physician approach improves safety outcomes. We report our experience on the feasibility of replacing a two-physician ED procedural sedation policy with a single-physician policy in a small, single-coverage community ED. METHODS: This is a retrospective, before/after, single-center observational study of prospectively collected data from January 2013 through December 2016. In September 2014, our medical center implemented a single-physician policy requiring only one emergency physician, accompanied by a sedation-trained ED registered nurse. The primary outcome was a sedation-related escalation of care that resulted in one of the following adverse events or interventions: dysrhythmia (symptomatic bradycardia or ventricular arrhythmias), cardiac arrest, endotracheal intubation, or unanticipated hospitalization. Secondary outcomes included hypoxemia (peripheral oxygen saturation less than 90% for greater than 1min), the use of bag-valve mask ventilation (BVM), use of a reversal agent, laryngospasm or pulmonary aspiration. RESULTS: We performed 381 sedations during the study period: 135 patients in the two-physician group (before) and 246 patients in the single-physician group (after). The two groups were comparable in age and gender. There was no occurrence of the primary outcome. Secondary outcomes were uncommon, and were similar in the two groups. CONCLUSIONS: In this small, single-coverage community ED, replacement of a two-physician policy with a single-physician policy for deep sedation in the ED was feasible and was not associated with an increase in adverse events.