Registered Nurse-administered Propofol Sedation for Endoscopy Christine A. Overley, RN, and Douglas K. Rex, MD Recent evidence indicates that appropriately trained registered nurses can safely administer propofol under the supervision of an endoscopist. This review summarizes advantages and disadvan- tages of nurse-administered propofol sedation (NAPS), the pro- cess of developing a NAPS program, and issues regarding the administration of propofol for endoscopy. © 2004 Elsevier Inc. All rights reserved. T his article deals with the rationale for use of propofol in the endoscopy suite, and our process in developing a program of Nurse Administered Propofol Sedation (NAPS). It is in- tended to provide only an overview, and we in no way intend this to be a manual for institution of a NAPS program in another facility. In our view, institution of a NAPS program involves many steps, including involvement of appropriate institutional authorities, investigation of state and local laws and statutes, development of a written protocol, mastery of written and prac- tical materials, observation of others with extensive experience, and strict continued quality improvement measures once the program is underway. Efficiency in the Endoscopy Suite There are increasing demands for endoscopic services. Screen- ing and surveillance for colorectal polyps and cancer, techno- logical advancements in endoscopic ultrasound, evaluation of patients with chronic gastroesophageal reflux disease and ob- scure gastrointestinal bleeding, and other factors have contrib- uted to continued growth in endoscopy. The increased de- mands have resulted in a desire to identify novel ways to increase productivity without compromising patient safety and satisfaction. We have reviewed the practices from 20 experi- enced endoscopists in the State of Indiana to determine if vari- ability exists in efficiency, and what factors might correlate with improved efficiency. 1 The overall mean procedure volume score (4 points for colonoscopy, 2 points for upper endoscopy) per hour was 6.5, with a range of 3.2 to 11.7. We furthermore found that there were several factors that correlated with in- creased procedure volume. The most important of these was room turnover time; there was a mean room turnover time of 27 minutes, with a range of 14 minutes to 66 minutes. Two other factors approached statistical significance: namely, the use of 2 rooms by the endoscopist, and the provision of sedation and analgesia by an individual other than the endoscopist. The use of two rooms by a gastroenterologist can be prob- lematic for units with space constraints. If there are several endoscopists all working at one time, the recovery room can become overrun with patients being checked in for procedures and/or recovering from sedation with opioid and benzodiaz- epine combinations. Recovery in the procedure room is often impractical, as a patient may still be in the procedure room when the gastroenterologist-nursing team is ready for the next patient to enter the room. Many gastroenterologists perform endoscopy in the presence of an anesthesiologist or nurse anesthetist. In many of these practice situations, the nurse anesthetist is in the employ of the gastroenterology group, and the provision of sedation and an- algesia is another source of revenue. In these settings, sedation and analgesia is typically provided not with combination opioid and benzodiazepine, but with propofol. However, it is clear that the routine presence of an anesthesiologist or nurse anesthetist increases overall endoscopy costs. In fact, a recent analysis of propofol administration for endoscopy showed that only if the gastroenterologist-RN team provided sedation would this seda- tion strategy be cost effective. 2 The Role of the Registered Nurse The gastrointestinal assistant has many roles in the perfor- mance of any endoscopic procedure. Many of these relate to the provision of sedation and analgesia, including initial patient assessment, completion of required documentation, establish- ing and maintaining intravenous access, drawing up sedative/ analgesic medications, patient monitoring, and patient recov- ery and discharge. For nearly 20 years, the practice of nurse- administered sedation under the supervision of the endoscopist has been routine in our unit. We have recently expanded this role to include RN administered propofol sedation. Advantages of Propofol Use There are several advantages to the use of propofol for gastro- intestinal endoscopy. It is an effective sedative/hypnotic, and associated with far shorter recovery times than conventional sedation/analgesia with opioid and benzodiazepine combina- tions. These characteristics make the use of propofol highly desirable for the busy endoscopy unit, as recovery room con- gestion would be significantly lessened. Furthermore, the en- doscopist-nurse team utilizing two procedure rooms simulta- neously may not utilize the recovery room at all, since the patient receiving propofol as a single sedative agent may be able to recover sufficiently to leave before the endoscopist is ready for the next patient in that room. From the IU Hospital, Indianapolis, IN. Address reprint requests to Christine A. Overley, RN, 550 N University Blvd, IU Hospital, Suite 4100, Indianapolis, IN 46202; e-mail: drex@iupui.edu. © 2004 Elsevier Inc. All rights reserved. 1096-2883/04/0602-0007$30.00/0 doi:10.1053/j.tgie.2004.03.010 Techniques in Gastrointestinal Endoscopy, Vol 6, No 2 (April), 2004: pp 75-77 75