Joint Commission Resources CMS Consultant Karla Cason on CMS Conditions of Participation Regarding Sedation
Karla Cason, CMS Consultant
Joint Commission Resources (JCR) CMS consultant Karla Cason addresses the hot-button issue of moderate and deep sedation in an exclusive Q and A with Joint Commission: The Source. The Source is a monthly publication that offers readers a deeper look into accreditation requirements from various regulatory bodies, performance measurement processes, and patient safety measures.
The June issue of The Source covers the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) regarding both moderate and deep sedation, as these requirements can be challenging. Understanding the nuances of these CoPs can mean the difference between passing a CMS survey and facing Immediate Jeopardy.
Read through this sample of Cason’s interview, which covers those responsible for maintaining compliance with sedation-related CoPs, and the differences between moderate and deep sedation.
THE SOURCE: Which staff members should be involved in sedation processes? Does CMS specify particular disciplines, training, credentials, or privileges in these cases?
CASON:It is clear in the CoPs that the anesthesia department must oversee all anesthesia/analgesia provided throughout the facility—including the emergency department (ED). That is not to say ED physicians, for example, cannot provide sedation. Rather, the facility must identify all areas where sedation (deep or moderate) occurs and ensure the Medical Director of Anesthesia is involved in oversight for each area. Typically, after all areas that provide procedural sedation are identified, the facility brings involved providers together to review procedures. CMS clearly defines those practitioners (42 CFR 482.52 (a) and (c)) who may provide deep sedation. This includes MD/DO anesthesiologists, certified registered nurse anesthetists (CRNA), and anesthesia assistants (AA). A non–anesthesia trained MD/DO, dentist, or podiatrist may also provide deep sedation.
THE SOURCE: Moderate and deep sedation are distinct, yet organizations still struggle in differentiating them. Can you clearly distinguish between them?
CASON: CMS stays close to the American Society of Anesthesiologists (ASA) definitions for moderate and deep sedation.
The CMS State of Operations Manual Appendix A interpretive guidance defines deep sedation/analgesia as: a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
In the emergency department, deep sedation is used in situations in which a provider needs to expedite a procedure and also needs the patient to be still and not withdraw from painful/noxious stimulus. An example of a patient requiring deep sedation may be an adult with a traumatic head injury. This patient might not be cognitively capable of holding still enough to conduct an MRI.
The CMS definition for moderate sedation/analgesia, or conscious 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. Cardiovascular function is usually maintained. CMS, consistent with ASA guidelines, does not define moderate or conscious sedation as anesthesia.
Providing patients with moderate sedation allows them to tolerate unpleasant procedures by decreasing or relieving anxiety, discomfort, and/or pain. Many times in these procedures the provider conducting the procedure will need the patient to be awake enough to respond to questions but relaxed and comfortable enough that they are able to remain still voluntarily.
Look to your June 2015 issue of The Source for the complete interview, or sign up for a subscription.