Procedural sedation in the emergency department has been reported to be safe in university settings involving multiple physicians.^1–5 This study examines whether similar outcomes occur in procedures carried out by single emergency physicians with monitoring by the emergency nurse.

METHODS

The Procedural Sedation in the Community Emergency Department Registry is a prospective observational database of consecutive procedural sedation cases directed by emergency physicians. Fifteen categorical parameters including complications are recorded for each case, including whether the emergency physician directed the sedation and also performed the procedure with monitoring by the emergency nurse or directed and monitored the sedation for another physician. Nurses had input into patient management but required the physician’s direction for administration of the drug. Specifics of the Procedural Sedation in the Community Emergency Department Registry are available online at http://emjonline.com/supplemental. Data were analysed using the χ² test.

RESULTS

A total of 1028 procedural sedations were performed on 980 patients at 14 study sites. Light sedation was produced in 130 (12.6%) cases, moderate in 541 (52.6%), deep in 352 (34.2%) and general anaesthesia in 5 (0.01%) cases. Cases of general anaesthesia were unintended overly medicated patients. Patient characteristics were similar between patients monitored by the emergency nurses and emergency physicians. Complications occurred in 42 (4.1%) patients, 35 (4.0%) of EN monitored patients and 6 (4.2%) of EP monitored patients (p>0.7). Tables 1 summarises these findings.

Complications increased with increasing American Society of Anesthesiologists status (p<0.002), but no difference was noted between the monitoring groups (p>0.7). Summary tables are available online at http://emjonline.com/supplemental.

All complications were recognised and resolved, resulting in no change in patient disposition, and no patient was admitted as a result of any complication. Procedures were successfully completed in 863 (97.5%) of the cases monitored by the emergency nurses and 140 (97.9%) of the patients monitored by the emergency physicians (p>0.7). Complications occured in 42 (4.1%) patients, 35 (4.0%) emergency nurse monitored patients and 6 (4.2%) emergency physician monitored patients (p>0.7).

Drugs with the lowest complication rates were ketamine (0.69%) and propofol (0.79%), whereas hydromorphone (9.7%), fentanyl (9.5%) and midazolam (6.4%) showed the highest complication rates (p<0.01).

DISCUSSION

Procedural sedation in the emergency department remains controversial.^6–8 Apart from a report on nurses from the endoscopy department, ours is the only study to show sedation competence by nurses from non-anaesthesiology departments.⁹ The overall complication rate of about 4% for the patients supervised by the emergency nurses in this study compares well with complication rates of 1–23% in university settings.^1–5 The emergency nurse’s ability to recognise and initiate appropriate actions for complications was evident in the fact that no patient disposition was changed after a complication. The 97.5% success rate for procedures indicates appropriate patient sedation and implies the emergency physician’s comfort with monitoring by the emergency nurse.

Many emergency departments in the US are staffed by a single emergency physician with no immediate access to the department of anaesthesia.

Without the ability to delegate monitoring responsibilities to an emergency nurse, patients in these emergency departments may undergo inadequate sedation or endure prolonged delays while waiting for anaesthesia personnel.

CONCLUSION

Procedural sedation by a single emergency physician with monitoring by an emergency nurse is safe and effective in the emergency department.