Audit of procedural sedation in the emergency department
BACKGROUND Procedural sedation is commonly used in Emergency Departments such that the delivery of safe
sedation is a key component of the skill set of an Emergency Physician. The aim of procedural sedation is to relieve patients’ anxiety
towards and facilitate their cooperation for a potentially painful procedure. This provides obvious benefit to the patient but is not
without risk and if not done to set standards can cause adverse outcomes in relation to morbidity and, rarely, mortality. For this
reason, the Royal College of Emergency Medicine (RCEM) composed guidelines with the aim of setting standards for the safe
practice of adult sedation in the Emergency Department (ED) with continuing audit to identify areas for improvement. It was against these
eight standards the previous audit was completed. This demonstrated that NSECH Emergency Department was not meeting the
standards. A local protocol was going to be developed and implemented with a pro-forma to be used during sedation. The aim of this
audit cycle was to assess whether or not NSECH Emergency Department A) is meeting the standards set out by RCEM in “Safe
Sedation of Adults in the Emergency Department” and B) has improved compliance with the introduction of a local protocol and pro-
forma compared with the previous cycle.
METHODOLOGY Caldicott approval was gained. An application was made to the Coding Department to identify those who had received sedation in the ED. Using
this data, a retrospective study of 50 cases between January 2017 and December 2017 was completed. Electronic case notes were
reviewed. This allowed input and analysis of data. Inclusion Criteria: Adult patients past their 16th birthday and patients undergoing
procedural sedation at all levels. Exclusion Criteria: patients aged 15 or under or patients receiving: entonox only, opiates only,
entonox and opiates in combination.
RESULTS Previous percentage compliance (average quoted due to multiple subsets) achieved for each Standard (1-8) followed by
new percentage achieved: 1. 6.6% to 37.3% 2. 26% to 50% 3. 82% to 74% 4. NA 5. 29% to 46.5% 6. 28% to 40% 7. NA 8. 1.2% to
44.6%.
CONCLUSION The results show that in every category, NSECH Emergency Department is not meeting the RCEM standards.
However, the results do show an improvement upon the previous cycle. Moving forward, there are still improvements to be made.
Anecdotally, not all members of staff were aware of the sedation protocol. Suggestions to improve practice are to have the pro-forma
introduced at teaching/training meetings and departmental inductions, further raising the profile of the guidance. This strategy could
also be incorporated into nursing sessions/teaching. Nursing staff don’t rotate in the way the junior medical staff do and are more
likely to be the ones drawing up sedation medications. They could highlight to medical staff the existence of the protocol therefore
increasing usage. Once these measures have been undertaken, another audit cycle will be undertaken. This should be done in early
2019.
