Moderate Monitoring and Documentation Requirements

V. Moderate Monitoring and Documentation Requirements 

How can you assure the patient receives the necessary level of assessment and monitoring required for safe administration of moderate sedation?

The Physician/LIP along with the Qualified Personnel managing the care of the patient receiving moderate sedation will assure that the patient is not left alone during moderate sedation and must have continuous monitoring and patient assessment to insure patient safety.

A. Moderate Monitoring Requirements - the following should be monitored:

1. Vital signs

a. Respiratory rate
b. Blood pressure
c. Heart rate
d. Cardiac rhythm monitoring is required for the following:

  • Patients who are ASA Class III, IV, or V
  • Patients who have a history of cardiac disease

2. Consider monitoring exhaled carbon dioxide (through capnography) for patients whose ventilation cannot be directly observed during MODERATE sedation 

3. Skin color

a. Pallor
b. Cyanosis

4. Oxygenation status

a. Pulse Oximetry
b. Amount of oxygen delivered, if applicable
c. Route of oxygen delivered, if applicable

5. For all patients with an intravenous catheter, monitor and maintain IV access.

6. Comfort level

a. Level of pain (use institution approved pain scale)
b. Patient response to analgesic, if analgesic administered
c. Nausea/vomiting
d. Patient response to antiemetic, if administered

7. Level of consciousness

a. Monitor level of sedation using Ramsay Sedation Scale 
b. Compare the current level of consciousness with the established sedation goal

B. Documentation

Moderate Sedation forms have been developed for documentation use by Physician/LIPs and qualified personnel during the procedure. These should be used to assure compliance with the required elements of the Moderate Sedation policy. Documentation of the moderate monitoring must be conducted according to the frequency below.

1. The following must be documented, including date and time, at a minimum of every five minutes during the moderate sedation:

  •  Heart rate
  • Oxygen saturation
  • Respiratory rate
  • Blood pressure

2. The following must be documented, including date and time, at a minimum of every 15 minutes during moderate sedation:

  • Level of sedation utilizing the Ramsay Sedation Scale
  • Level of pain

C. Post-moderate Monitoring and Documentation

When the moderate sedation is completed, the same parameters monitored during the procedure listed above AND the Modified Aldrete Score must be monitored by a Qualified Personnel during the recovery period and prior to discharge from the facility.

The following must be documented, including date and time, every 15 minutes throughout the recovery period until the patient returns to pre-procedure status:

  • Heart rate
  • Blood pressure
  • Oxygen saturation
  • Modified Aldrete score
  • Level of pain

Note: Patient may be eligible for discharge with a score of less than 10 if return to baseline score.

When a patient who has not recovered is transported from one department to another, a qualified staff member must accompany the patient to continue monitoring for potential delayed complications.

Assessments should be documented PRN (whenever necessary) if a change in the patient condition occurs, and until the patient has returned to pre procedure baseline or vitals are within acceptable norm.

D. Discharge Process and Criteria

All of the following criteria must be met prior to discontinuation of post-procedure monitoring. After meeting the criteria, the patient may be transferred to an inpatient floor or discharged form the facility with a responsible person.

1. Patient is easily awakened by normal or softly spoken verbal commands.

2. Patient is awake and alert to baseline level of consciousness, at his/her pre-procedure level.

3. Patient meets Modified Aldrete Score of 9-10.

4. There is no significant risk of losing protective reflexes.

5. Patient is able to maintain pre-procedure mobility with minimal assistance as appropriate for procedure.

6. Patient has minimal nausea and/or dizziness.

7. Patients receiving a reversal agent must stay a minimum of two hours and be monitored after the last administration of the reversal agent to ensure that patients do not become resedated after reversal effects have abated.