FAQs: Unscheduled Sedation Guidelines

In May 2010, the Centers for Medicare & Medicaid Services (CMS) established interpretive guidance1 on anesthesia within a hospital, including defining analgesia and anesthesia, and limiting anesthesia (and sedation) to specific providers. This guidance stated that if a hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. CMS did NOT specify that the physician needs to be an anesthesiologist. Because of significant concerns raised by the American College of Emergency Physicians (ACEP) and other specialty societies, as well as individual providers, CMS issued a clarifying document in 2011.2 In this clarifying guidance, CMS clearly states that hospitals may follow the guidelines of specialty organizations (specifically citing ACEP's clinical policies) and that emergency physicians are 'uniquely qualified' to administer all levels of sedation 'from moderate to deep to general'. The guidance does not dictate which guidelines hospitals must use. In summary, a hospital can have different policies for anesthesia and sedation services provided in the emergency department versus other areas of the hospital as well as different guidelines for scheduled versus unscheduled sedation, as long as these policies and guidelines fall under the domain of a single physician within the hospital.

Some procedures require urgent or emergent sedation that cannot be scheduled or delayed. In these situations, emergency medicine providers must act quickly to provide patient care that is safe and effective. Unscheduled procedures must often be performed while a patient is in a dynamic physiological state or prior to a definitive diagnosis. Furthermore, providers of sedation must manage not just the sedation encounter, but also the acute pain, anxiety, and associated circumstances of the precipitating injury or illness. Current standards focus primarily on elective procedural sedation, and extrapolation to unscheduled, time-sensitive procedures can confuse and impede patient care.

In October 2018, ACEP issued a multidisciplinary consensus practice guideline specific
to unscheduled, time-sensitive procedural sedation. The guideline serves as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. The document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Highlights of the guideline include:

• Collaborative guideline preparation by emergency physicians and several other specialty societies who regularly perform unscheduled procedural sedation, yielding multidisciplinary perspective and applicability.
• A greater emphasis than prior guidelines on patient-centered and family-centered care.
• Time is of the essence for urgent and emergent procedures—not just to minimize physical harm from the active condition, but to minimize distress for the patient and their family.
• The inclusion and full discussion of all applicable procedural sedation states. Guidelines from other societies are often incomplete and omit deep and/or dissociative sedation.
• Recommendations for procedural sedation staffing and the requisite skill sets for sedation personnel.
• Recommendations for procedural sedation practice customized to the needs of time-sensitive, unscheduled procedures, including risk-assessment for non-fasted patients, and including interactive and physiologic monitoring.