(Exception - see below)
The New York State Education Department’s Board for Nursing has, within the last year, received numerous requests from health care facilities and licensees regarding the administration of intravenous (IV) anesthetic agents by Registered Nurses (RN) who are not trained anesthesia providers. Of particular concern is the administration of IV anesthetic (sedative-hypnotic) drugs such as propofol, ketamine, etomidate, methohexital, and thiopental for the purpose of sedation and anesthesia. We are pleased to provide you with this guidance memorandum on this critical issue. The role of RNs using IV anesthetic drugs in the treatment of intractable pain is not the subject of this memorandum.
At the onset, it is important to recognize that guidance memoranda such as this are not a substitute for or have the authority of Education Law, Regents Rules, or Commissioner's Regulations. A licensee can only be charged with professional misconduct if there is a violation of the Education Law or Regents Rules. Guidelines may be a resource in assessing conduct that underlies a violation, however, they may not be used as the basis for a charge of professional misconduct. Nor can conformance with guidelines be deemed to immunize a professional from potential charges of misconduct. Such determinations are made on a case-by-case basis by the Department. The purpose of this guidance memorandum is to provide general information to practitioners who will amplify that information with their individual practice skills, professional education and judgment.
In general, licensed professionals must only provide services that they are competent to perform. Therefore, any drug that is considered an anesthetic agent must be administered by a trained anesthesia provider who is competent to do so by virtue of licensure, education, training and experience, such that they are able to immediately recognize and treat the side effects and complications resulting from the administration of these drugs. Light sedation and analgesia may easily progress to deep sedation, loss of consciousness, loss of protective airway reflexes, and loss of respiratory effort as a result of the agents used as well as the physical status and various drug sensitivities of an individual patient. Generally, in order to assure adequate public safety, the use of IV anesthetic agents should be limited to anesthesia providers who possess competencies and have training in areas such as airway management, intubation of patient’s airways, pharmacology and use of these drugs, and are authorized to immediately recognize and treat their side effects and complications. We also recognize that providers will need to be deemed competent to provide such services by the institutions in which they practice.
Drugs such as propofol, ketamine, etomidate, methohexital, and thiopental for the purpose of sedation and anesthesia present specific safety concerns and may not be appropriate agents for administration by RNs unless they are qualified and competent to administer them. Some RNs gain such competence through the completion of a Certified Registered Nurse Anesthetist (CRNA) program. However, RNs who have not otherwise gained professional competence through a program such as one leading to CRNA recognition, but who otherwise are competent in the procedure through education and experience, may be deemed competent to administer propofol to intubated, ventilated patients in a critical care setting based on an appropriate medical order. The competence of a non-CRNA RN should be validated for the care of patients of the type and acuity commensurate with specific specialty areas, such as ER, OR, ICU, etc.
Generally, when an RN administers a drug such as propofol for an anesthesia provider in a crisis situation, the actual anesthesia provider must carefully consider all of the patient safety issues relating to monitoring and managing the patient. The RN may not choose the dose or monitor its effects. Specific concerns arise when an anesthesia provider is the only individual who is performing a procedure, such as inserting a central venous line or performing an endoscopic procedure. In such cases, care should be taken to chose anesthetic agents that can safely be administered and monitored by the non-anesthesia providing RN, within her/his competence. Such drugs may include midazolam (Versed) or a small dose of an opioid analgesic, for example, Demerol, Fentanyl, or Dilaudid.
When anesthesia drugs are administered outside of the OR in support of routine diagnostic or therapeutic procedures, additional concerns arise. We recognize that there are times when a procedure requires the full attention of the operating provider and the patient requires the use of IV anesthetic agents in order to tolerate the procedure. Such instances would require the services of a practitioner who is competent by virtue of licensure, education, training, and experience to administer IV anesthetic agents, immediately recognize their side effects and authorized to treat drug related complications and side effects. We are also aware of a variety of national standards that suggest that, ideally, there should be three appropriately credentialed individuals involved in any procedure requiring the use of IV anesthetic agents: the operating clinician, the anesthesia provider and an assistant to the operating clinician (who may or may not be the bedside RN). In all circumstances, the safety of the patient must be considered when assessing the need for staff appropriate to the procedure being performed. For example, if the authorized medical provider finds it necessary to use IV anesthesia drugs for moderate sedation in cases such as endoscopic or radiologic procedures, care should be taken to ensure that an appropriately trained and credentialed anesthesia provider assist with the sedation for these cases.
Administration of IV Anesthetic Agents - Exception
The New York State Board of Nursing has opined that, in situations calling for conscious sedation, Propofol (Diprivan) is not an appropriate agent for administration by Registered Nurses unless they are Certified Registered Nurse Anesthetists. There is one exception, however. Registered Nurses, who are competent in the procedure through education and experience, may administer Propofol to intubated, ventilated patients in a critical care setting based on an appropriate medical order.
We hope this clarification is helpful. If you have questions or need additional information, please contact the New York State Board for Nursing by phone 518-474-3817 ext. 120, or by e-mail firstname.lastname@example.org.