PAIN MANAGEMENT AND SEDATION/POLICY STATEMENT Procedural Sedation and Analgesia in the Emergency Department: Recommendations for Physician Credentialing, Privileging, and Practice Robert E. O’Connor, MD, Andrew Sama, MD, John H. Burton, MD, Michael L. Callaham, MD, Hans R. House, MD, William P. Jaquis, MD, Patrick M. Tibbles, MD, Marilyn Bromley, RN, Steven M. Green, MD, for the American College of Emergency Physicians [Ann Emerg Med. 2011;58;365-370.] INTRODUCTION Procedural sedation refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate unpleasant procedures while preserving cardiorespiratory function. 1 Procedural sedation and analgesia is a core competency in emergency medicine and a daily part of emergency department (ED) practice. 2-4 As noted by the United States Centers for Medicare & Medicaid Services (CMS): “The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality.” The CMS guidelines also state that “. . . emergency medicine–trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).” 5 Emergency medicine residency and pediatric emergency medicine fellowship core curricula include all of the requisite procedural sedation skills, eg, advanced airway management, resuscitation, critical care, monitoring, sedation pharmacology, pain management. 2-4 Emergency physicians have a well- established track record of safe sedation and are important research and thought leaders in this multidisciplinary field. The American College of Emergency Physicians (ACEP) is an authoritative body that has established guidelines for the use of sedation, analgesia, and anesthesia by emergency physicians. 1 CMS guidelines support the use of the ACEP guideline: “A hospital could use multiple guidelines, for example, ACEP for sedation in the ED and American Society of Anesthesiologists (ASA) for anesthesia/sedation in surgical services, etc.” 5 ACEP convened this task force in 2011 to provide this update to guide hospital policy for the administration of analgesia, sedation, and anesthesia by emergency physicians. HOSPITAL SEDATION LEADERSHIP The Joint Commission and CMS each requires that hospitals maintain central leadership over the sedation practices of their various specialists and departments. 6,7 Accordingly, many institutions have a hospital-wide sedation committee that oversees each individual department’s sedation practices. Given that procedural sedation is a multidisciplinary field, ACEP strongly supports the principle that institutional oversight is best provided by a committee structure in which all of those providing sedation services have representation. This format best facilitates open interspecialty dialog on optimal sedation practice, collaboration, and innovation. 8 Interspecialty collaborative institutional sedation authority is necessary to ensure that sedation practices are in accordance with specialty- specific national standards and that sedation privileges are granted to all appropriate specialties, such as emergency medicine. 8,9 ACEP further believes that the statement in the CMS Guidelines specifying that “the anesthesia services must be under the direction of one individual who is a qualified doctor of medicine (MD) or doctor of osteopathy (DO)” may be counterproductive to their stated intent of developing “anesthesia policies and procedures in collaboration with several other hospital disciplines,” especially since the CMS guideline FAQs explicitly raise the possibility that “policies and procedures that define the various uses of analgesia and anesthesia . . . [may be] . . . too narrow (or broad) or based on the opinions of . . . [only] . . . one individual.” 5 SCOPE AND DEFINITIONS This policy encompasses all items classified as “anesthesia services” by CMS, 7 including analgesia, local anesthesia, regional anesthesia, sedation, and anesthesia. Analgesia: The full or partial relief of painful perception without affecting consciousness, whether by parenteral, topical, oral mucous membrane, or other routes. In the ED analgesia is commonly achieved with opioids (eg, morphine, hydromorphone, and fentanyl), acetaminophen, and/or nonsteroidal anti- inflammatory agents (eg, ibuprofen, ketorolac). Local anesthesia: The localized injection or topical application of anesthetic agents to render specific portions of the skin insensitive to pain without affecting consciousness. In the ED local anesthesia is commonly achieved with injected lidocaine or bupivacaine, administered to facilitate dermal procedures such as laceration repair and abscess incision and drainage. Volume , .  : October  Annals of Emergency Medicine 365