I.  Description

Describes the bi-directional communication standards between Registered Nurses, Physicians, and Licensed Practitioners established to ensure best practice and facilitate adequate sedation levels during Interventional Radiology Procedures.

II. Considerations

Moderate sedation verbal orders require bi-directional and closed-loop communication, including drug names and drug doses with each administration.

III. Best Practice

A.   Indications

Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.

B. Patient Identification

1. Before the procedure and during time-out, confirm the patient’s identity using at least two patient identifiers, including the patient’s full name and date of birth.

2. Verify consent includes ‘moderate sedation’

C. Medication Order

1. The provider initiates a verbal order

2. RN may use SBAR or AR by first recommending each subsequent dose of moderate sedation

3. Provider initiates order by verbalizing drug name and dose

4. RN verbalizes a readback of the provider order

5. Provider confirms or amends the readback

6. RN enters the order in EPIC, then administers the medication

7. RN closes the loop by verbalizing that medication has been administered

8. Medication totals discussed in the debrief

9. Provider signs all verbal orders at the end of the procedure

IV. References

• • ps-physician-orders-communication-and-implementation.pdf (ncbon.com)

  • ps-procedural-sedation-analgesia.pdf (ncbon.com)

V. Related Policies

• Moderate Sedation (Adult) Policy/Guidelines for Non-Anesthesiologists

• Provider Orders

• Verbal/Telephone Orders Read Back

• Patient Identification - Medication Administration, Administering Blood Products, Taking Blood Samples Or Specimens, Or Providing Treatments Or Procedures

• Medication Administration in the Operating Room