United States Department of Veterans Affairs
United States Department of Veterans Affairs

National Anesthesia Service

Moderate Sedation Directive Frequently Asked Questions

Get a copy of the Directive (VHA Directive 2006-023) http://www1.va.gov/vhapublications/publications.cfm?pub=1

Example of a Local Policy (load document )

Have a Question about the Directive?  E-Mail us your question.     

Uniform national training for moderate sedation is available on the EES intranet web site.  Please e-mail us if you need links to the intranet based training.

Frequently Asked Questions (FAQs):

Question 1. 
Is it mandatory that the EES based National training be completed by non-anesthesia participants in the moderate sedation process?

Answer 1: 
NO.  Training is mandatory and the national training is one way to accomplish this.  The IG, in their moderate sedation report, noted that they found differing levels of training around the VA system.  Offering a uniform national training gives the option to the local facility of not having to create its own training program.


Question 2. 
Does the EES based National training meet the requirement for "ACLS or equivalent" training in cardiopulmonary resuscitation, airway management, and management of cardiac arrhythmias?

Answer 2. 
NO.  The Directive's training requirement covers four areas
a.  Evaluating patients before performing moderate sedation.
b.  Performing moderate sedation, including rescuing patients who slip into deep sedation.
c.  Knowing the pharmacokinetics of the drugs typically used for moderate sedation, as well as the potential effects of the drugs on vital functions.
d.  Training in cardiopulmonary resuscitation (CPR), airway management, and management of cardiac arrhythmias (This requirement may be satisfied by successful completion of Advanced Cardiac Life Support (ACLS) training or equivalent training. Periodic re-training or renewal of this training must be obtained as recommended by the American Heart Association or other training entity).

The EES based National training covers the first three required areas.  While the national training provides information on airway management it does not cover CPR or cardiac arrhythmias and thus cannot be considered ACLS or equivalent.

A facility could provide “equivalent” training per the Directive by accomplishing documented training that covers:

-  Airway management.  Airway Management is intended to imply the ability to provide jaw thrust and bag and mask ventilation.  It does not require the definitive management (tracheal intubation) discussed in VHA Directive 2005-031,  Out-of-Operating Room Airway Management. 

- CPR training.  CPR training includes basic life support. 

- Arrhythmia recognition and management:  Arrhythmia recognition and management includes the immediate management of life threatening arrhythmias.

ACLS provides excellent training in these topics and many others.  However, VHA recognizes that not all facilities will have the resources to provide formal ACLS training to all persons involved with sedation.  The “equivalency” route may provide a practical and safe solution.


Question 3. 
Would an LPN present in a room where moderate sedation is in use need to have the national training?

Answer 3. 
The Directive requires that those individuals ordering, administering, and supervising moderate sedation in support of patient care must be qualified and have appropriate credentials.  Individuals administering, monitoring, and/or supervising moderate sedation must have had competency-based education, training, and experience.  If the LPN is administering, monitoring and/or supervising moderate sedation then training is required.  Otherwise training is not mandatory.


Question 4.
Does use of inhalational Nitrous Oxide/Oxygen in a dental clinic setting fall under the moderate sedation directive?

Answer 4.
No.  It should not be considered moderate sedation as there is no risk of deep sedation resulting as long as not combined with other agents.

 

Question 5.
What is the VA position on nurse administered Propofol for endoscopy?

Answer 5.
It is not permitted, per the Directive.  Propofol can be administered only by people trained to rescue the patient from general anesthesia.  This could include an oral surgeon, for instance, since their training requires 3-6 months of anesthesia training.  If your LIP practitioners can document training and competence in general anesthesia, then they can use it.  This must be specifically stated in your hospital policy. 

The VA policy on this is based on FDA approval--Propofol is approved only for those trained in general anesthesia or for patients who are already intubated (ICU sedation).  The links below will take you to additional discussion of this issue.

http://www.ismp.org/newsletters/acutecare/articles/20051103.asp 

http://www.medicalnewstoday.com/medicalnews.php?newsid=40846