SCOPE OF THE PROBLEM

Regulatory oversight of procedural sedation and analgesia (PSA) in the emergency department (ED) is multifaceted involving federal, state, institutional, and professional mandates (Figure 6-1). The stated goals of these regulatory bodies are patient safety, standardization of care, and clinical guidance.

Developing protocols can be challenging for organizations and practitioners when filtering recommendations from multiple regulatory agencies and practice disciplines. The reality for the ED practitioner is often an increased frustration owing to regulations that are often, simultaneously, restrictive yet general and broad. The ED is a unique setting that necessitates practice guidelines and procedures that are clear, yet flexible enough to meet the broad spectrum of situations encountered.

Although the need for consistency across organizations, practice disciplines, and departments may maximize patient safety, the square-peg-into-a-round-hole method of standardization will not work in the implementation of guidelines for sedation in emergency medicine. ED patients present with complex sedation needs, often complicated by concurrent diseases, hemodynamic instability, unpredictable NPO status, and untreated pain. Sedation in the ED is a specialized practice utilizing treatment approaches that are not common to other settings where procedural sedation is administered.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recently focused a great deal of attention on procedural sedation. Unfortunately, much of this attention had led to advisory materials that are not evidence based.