Download AORN Guideline Gap Analysis Tool: Moderate Sedation

AORN Guideline Gap Analysis Tool: Moderate Sedation
Meets
Recommendation?
Yes
No
[Insert facility name or a header]
Comments/Actions
Recommendation 1: The perioperative RN administering
moderate sedation/analgesia must practice within the scope
of nursing practice as defined by his or her state board of
nursing and should comply with state advisory opinions,
declaratory rules, and other regulations that direct the
practice of the registered nurse.
Is a policy in place that describes who can administer moderate
sedation in your facility and what sedation medications can be
administered by the perioperative RN?
Is the RN scope of practice, as defined by your state board of nursing,
state practice act, state advisory opinions, or other regulations that
direct nursing practice, part of the perioperative RN job description?
Is there a formal training program in administering moderate sedation
in place for the perioperative nurse?
Are licensed independent practitioners who administer moderate
sedation qualified by education, training, and licensure to administer
moderate sedation?
Is a policy in place that includes supervision of a moderate sedation
RN by a licensed independent practitioner who is physically present
and immediately available in the surgical suite?
Recommendation 2: The perioperative RN should perform
and document a patient nursing assessment before
administering moderate sedation.
Is a policy and procedure in place that directs the perioperative RN to
perform a physical assessment on each patient who will receive
moderate sedation?
Does the patient record include a plan of care established by the
perioperative team (moderate sedation RN, licensed independent
practitioner)?
Does your moderate sedation policy and procedure indicate under
what circumstances an anesthesia professional should be consulted?
Recommendation 3: A perioperative RN administering
moderate sedation/analgesia should continuously care for the
patient throughout the procedure.
Are two RNs assigned to a patient receiving moderate sedation, one
to monitor the patient and the other to circulate?
When propofol is used and your state allows administration of
propofol by a perioperative RN, is the RN given no additional
responsibilities that compete with monitoring the patient?
Are age- and size-appropriate emergency equipment and supplies
available?
Copyright © 2015 AORN, Inc. All rights reserved.
Page 1 of 2
AORN Guideline Gap Analysis Tool: Moderate Sedation
Meets
Recommendation?
Yes
No
[Insert facility name or a header]
Comments/Actions
Recommendation 4: The perioperative RN should know the
recommended dose, recommended dilution, onset, duration,
effects, potential adverse reactions, drug compatibility, and
contraindications for each medication used during moderate
sedation.
Are medications for moderate sedation and their antagonists
administered under the direct supervision of a licensed independent
practitioner?
When computer-assisted personalized sedation (CAPS) is used, are
policies and procedures in place for having an anesthesia professional
immediately available?
Does your policy and procedure for using CAPS define “immediately
availability” for anesthesia professionals?
Does your policy and procedure for use of CAPS follow the
manufacturer's instructions for use and the US Food and Drug
Administration labeling?
Recommendation 5: The perioperative RN should evaluate
the patient for discharge readiness based on specific discharge
criteria.
Is the patient’s recovery after moderate sedation supervised by the
operating practitioner or licensed independent practitioner?
Has a multidisciplinary team developed discharge criteria for the
patient receiving moderate sedation?
Does your moderate sedation policy and procedure include a plan of
care for patients who should have a delayed discharge (eg, in cases of
obstructive sleep apnea, use of medications with a long half-life, use
of an opioid antagonist, prolonged nausea and vomiting)?
Is a policy and procedure in place for discharging patients who are
accompanied by a responsible adult and have safe transport from the
facility?
Are additional discharge instruction provided to adults caring for an
infant who has undergone moderate sedation/analgesia?
Are written instructions part of the patient record?
Copyright © 2015 AORN, Inc. All rights reserved.
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