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Feasibility of single- vs two-physician procedural sedation in a small community emergency department

  • Clayton P. Josephy
    Correspondence
    Corresponding author at: 2170 South Avenue, South Lake Tahoe, CA 96150, United States.
    Affiliations
    Barton Health System and the Department of Emergency Medicine Barton Memorial Hospital, South Lake Tahoe, CA, United States
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  • David R. Vinson
    Affiliations
    The Permanente Medical Group, the Kaiser Permanente Division of Research, and the KP CREST Network, Oakland, CA, United States

    Kaiser Permanente Sacramento Medical Center, Sacramento, CA, United States
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Published:November 03, 2017DOI:https://doi.org/10.1016/j.ajem.2017.11.003

      Abstract

      Objective

      Sedation is commonly required for painful procedures in the emergency department (ED). Some facilities mandate two physicians be present for deep sedation cases. Evidence is lacking, however, that a two-physician approach improves safety outcomes. We report our experience on the feasibility of replacing a two-physician ED procedural sedation policy with a single-physician policy in a small, single-coverage community ED.

      Methods

      This is a retrospective, before/after, single-center observational study of prospectively collected data from January 2013 through December 2016. In September 2014, our medical center implemented a single-physician policy requiring only one emergency physician, accompanied by a sedation-trained ED registered nurse. The primary outcome was a sedation-related escalation of care that resulted in one of the following adverse events or interventions: dysrhythmia (symptomatic bradycardia or ventricular arrhythmias), cardiac arrest, endotracheal intubation, or unanticipated hospitalization. Secondary outcomes included hypoxemia (peripheral oxygen saturation less than 90% for greater than 1 min), the use of bag-valve mask ventilation (BVM), use of a reversal agent, laryngospasm or pulmonary aspiration.

      Results

      We performed 381 sedations during the study period: 135 patients in the two-physician group (before) and 246 patients in the single-physician group (after). The two groups were comparable in age and gender. There was no occurrence of the primary outcome. Secondary outcomes were uncommon, and were similar in the two groups.

      Conclusions

      In this small, single-coverage community ED, replacement of a two-physician policy with a single-physician policy for deep sedation in the ED was feasible and was not associated with an increase in adverse events.

      Keywords

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