The Center for Medicare & Medicaid Services released an Interpretive Guideline on Anesthetic Use for Hospital Procedures. This guideline restricts injection of intravenous sedatives for procedures (including emergency intubation) to “qualified” practitioners, a definition that does not include critical care and emergency medicine nurses. The Critical Care Society Collaborative (CCSC) was concerned about this wording, as the intensivist may be the only qualified individual in the hospital at night. As such, he/she cannot delay intubation to wait for another practitioner and cannot effectively monitor sedation while preparing to perform the procedure.
The Critical Care Societies Collaborative sent a letter in August 2010 to the Centers for Medicare & Medicaid Services (CMS) to express concern about guidelines governing anesthesia service. The Collaborative is urging CMS to clarify these guidelines, as they have been broadly interpreted to include administration of sedatives for procedures such as emergent intubation for mechanical ventilation.
The letter notes that smaller hospitals may have only a single practitioner available at night. Drug administration by a qualified practitioner may be impossible to achieve if the only qualified practitioner is preparing for or performing the procedure. Placing individuals in a position that requires them to both administer an anesthetic drug and perform the procedure detracts from proper focus on both activities, and thus has the potential to unnecessarily increase the risk to an already compromised patient.
The Collaborative requested that CMS add a clause releasing qualified anesthesia practitioners from the requirement mandating that they personally administer sedating medications during an emergent procedure when two qualified practitioners are not present. Instead, the Collaborative requested that another individual with training in patient monitoring and rescue (e.g., advanced cardiac life support or pediatric advance life support) – likely a critical care or emergency medicine registered nurse – be designated to administer the anesthetic agent for an emergent procedure, pursuant to the scope of practice for the practitioner in that state.