Physician Responsibilities

Physician Responsibilities

• 
  Responsibilities of the Physician include:
  
• 
  Completion of history and physical
  
• 
  Completion of informed consent
  
• 
  Ordering of the medication, dosage and route of administration
  
• 
  Directing and providing of emergency interventions as necessary
  
• 
  Dictation of operative note immediately after completion of procedure (as per hospital policy)
  

 Documentation

• 
  Dosages, route, time and effect of all drugs used
  
• 
  Type and amount of fluids administered, including blood and blood products, monitoring devices or equipment used
  
• 
  Heart rate, rhythm, blood pressure, respiratory rate, oxygen saturation, and level of consciousness.
  
• 
  Interventions and the patients response to the interventions
  
• 
  Untoward or significant patient reactions and their resolution or outcome
  

 Patient Monitoring

The patient must be continuously monitored from the start of Sedation Analgesia until the time discharge criteria are met. Baseline vital signs, oxygen saturation level, heart rate, rhythm, and level of consciousness are the minimum assessment parameters obtained and documented prior to sedation. The patient should be monitored at 5-minute intervals during the procedure, and at 5-15 minute intervals during the recovery phase, and at any significant event in either phase. THE RN MONITORING THE PATIENT MAY NOT BE ENGAGED IN ANY OTHER ACTIVITY DURING THE PERIOD OF SEDATION ANALGESIA! The nurse should immediately report any unexpected response by the patient to the physician. These include, but are not limited to variations from baseline +20 % in BP or pulse; cardiac dysrhythmias (continuous); > 5 % below baseline of oxygen saturation (continuous monitoring); dyspnea, apnea, or hypoventilation; diaphoresis (may signify myocardial ischemia); inability to arouse the patient; or the need to maintain the patients airway mechanically. Once the patient's vital signs are at pre-sedation levels or at least 30 minutes have passed since the last sedating medication, monitoring of physiological parameters may be increased to every 15 minutes until the patient returns to pre-sedation level of consciousness and stability.

Procedural Sedation Overview Intra-Conscious Sedation and Procedure Treatment, Monitoring and Documentation: Supplemental oxygen automatically given to prevent hypoxia B. The objective of monitoring the patient during conscious sedation is to ensure the adequacy of ventilation, oxygenation, and circulatory function. The following guidelines for monitoring are considered a minimum standard, which is required for any patient receiving conscious sedation. Departments may develop their own specific guidelines that delineate requirements for monitoring of special patient populations that exceed the minimum standards set below. 1. Cardiac rhythm will be monitored continuously and documented at least every fifteen (15) minutes. 2. Oxygen saturation will be monitored continuously and documented at least every fifteen (15) minutes. 3. Document vital signs, pain level, and level of consciousness every (5) minutes. When respirations cannot be monitored, the oxygen saturation will be used to evaluate. Oxygen saturation will be the only monitoring during an MRI. Procedural Documentation 1. Procedure performed (as relevant) 2. Start and end times 3. Personnel involved 4. Name and dose of all drugs used including oxygen (time, route, and patient response) 5. Type and amount of IV fluids administered 6. Record of all vital signs, including pain assessment 7. Patient status at the end of the procedure 8. Post-procedure diagnosis 9. Unusual events or interventions Significant changes to be reported immediately by the registered nurse to the attending practitioner: 1. Heart rate < 50 or > 120 beats per minute 2. Cardiac rhythm changes 3. Oxygen saturation changes: a. Adult – 10% drop or saturation < 90 b. Pediatric – 5% drop or saturation < 90 4. Level of consciousness changes: a. Change in which the patient cannot communicate verbally or appropriately for age Sedation score > 2 (Attachment B) 5. Tissue perfusion changes with cyanosis, mottled skin or clamminess.

PROCEDURE MONITORING
Baseline vital signs are obtained prior to the initiation of the procedure.
While monitoring is continuously performed during the procedure, it is required that vital signs be recorded with the frequency listed below:

• 
  BP monitored continuously and recorded at least every 5 minutes or more frequently if necessary.
  
• 
  RR monitored continuously and recorded at least every 5 minutes or more frequently if necessary
  
• 
  Pulse monitored continuously and recorded at least every 5 minutes or more frequently if necessary
  
• 
  Continuous oxygen saturation monitored continuously and recorded every 15 minutes
  
• 
  Continuous cardiac rhythm monitored continuously and recorded every 15 minutes
  
• 
  End tidal carbon dioxide monitored continuously and recorded every 15 minutes if the patient is intubated.
  

SaO2	PaO2
95%	80mm Hg
90%	60mm Hg
85%	50mm Hg

Pulse oximetry does have limitations. Clinical situations may reduce its accuracy. Measuring only oxygenation does not measure the patient's ventilation nor does it detect carbon dioxide accumulation or excretion. Additionally, supplemental O2, by delaying the onset of hypoxemia, may delay the detection of apnea by pulse oximetry.

EQUIPMENT FACTORS

Motion at sensor site Ambient light inaccurate SpO2 readings have been reported from surgical lamps, infrared lights and fiberoptic surgical units.

PATIENT FACTORS

Abnormal hemoglobin's to include Met Hemoglobin, Carboxyhemoglobin and possibly sickle cell anemia IV dyes - methylene blue, indocyanine green Vasoconstriction, e.g. with hypothermia or vasopressors Hypotension Rapid or erratic heart rates where the pulse pressure does not correlate with heart rate Anemia: Hematocrit is less than 10% may cause underestimation of oxygen saturation Nail polish: green, blue or maroon nail polish, artificial nails Skin pigments: In a few very deeply pigment individuals, pulse oximetry is not possible because red light cannot be transmitted.