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Gastroenterology Societies Reach Consensus
on Recommendations for Sedation During Endoscopic Procedures
March 8, 2004 (Washington, DC) -- The American College
of Gastroenterology, American Gastroenterological Association
and American Society for Gastrointestinal Endoscopy today
issued a jointly sponsored statement on sedation for endoscopy.
The joint statement clarifies billing issues related to the
administration and/or supervision of sedation/anesthesia,
summarizes current data on sedative agents and makes recommendations
regarding the appropriate use of anesthesia specialists for
endoscopy and appropriate patient surveillance during sedation.
The statement, approved by the governing boards of the three
societies, is the product of a six member committee composed
of representatives from each of the three societies. The impetus
for the work of the committee was confusion regarding billing
issues and recent developments and trends in sedation practice,
including the use of propofol.
The group made several recommendations with important implications
for endoscopic practice:
- The joint society recommendations assert that: "Compared
to standard doses of benzodiazepines and narcotics, propofol
may provide faster onset and deeper sedation…More rapid
cognitive and functional recovery can be expected with the
use of propofol as a single agent."
- The joint society recommendations indicate that there
are data to support the use of propofol by adequately trained
non-anesthesiolgists: "Large case series indicate that with
adequate training, physician-supervised nurse administration
of propofol can be done safely and effectively."
- The joint society recommendations note that: "Reimbursement
for conscious sedation is included within the codes covering
endoscopic procedures."
The recommendations review key issues regarding proper billing
protocols, patient safety, the management of complications
and the importance of training and skills necessary to rescue
patients from severe respiratory depression.
Full text of the statement follows and it may be modified
as future developments occur.
RECOMMENDATIONS ON THE ADMINISTRATION OF
SEDATION FOR THE PERFORMANCE OF ENDOSCOPIC PROCEDURES
A Joint Statement of a Working Group from
the American College of Gastroenterology (ACG), the American
Gastroenterological Association (AGA) and the American Society
for Gastrointestinal Endoscopy (ASGE)
- In general, diagnostic and uncomplicated therapeutic
endoscopy and colonoscopy are successfully performed with
moderate (conscious) sedation.
- Compared to standard doses of benzodiazepines and narcotics,
propofol may provide faster onset and deeper sedation.
- More rapid cognitive and functional recovery can be expected
with the use of propofol as a single agent.
- Clinically important benefits over standard sedatives
have not been consistently demonstrated in average-risk
patients undergoing standard routine upper and lower endoscopy.
Further randomized clinical trials are needed in this setting.
- Propofol may have more clinically significant advantages
when used for prolonged and therapeutic procedures, including,
but not limited to, ERCP and EUS.
- There are data to support the use of propofol by adequately
trained non-anesthesiologists. Large case series indicate
that with adequate training physician-supervised nurse administration
of propofol can be done safely and effectively. The regulations
governing the administration of propofol by nursing personnel
vary from state to state.
- Patients receiving propofol should receive care consistent
with deep sedation. Personnel should be capable of rescuing
the patient from general anesthesia and/or severe respiratory
depression.
- A designated individual, other than the endoscopist,
should be present to monitor the patient throughout the
procedure and should be able to recognize and assist in
the management of complications.
- The routine assistance of an anesthesiologist/anesthetist
for average risk patients undergoing standard upper and
lower endoscopic procedures is not warranted
- Physician-nurse teams administering propofol should possess
the training and skills necessary to rescue patients from
severe respiratory depression.
- Complex procedures and procedures in high-risk patients
may justify the use of an anesthesiologist/anesthetist to
provide conscious and/or deep sedation. In such cases this
provider may bill separately for their professional services.
- The use of agents to achieve sedation for endoscopy must
conform to the policies of the individual institution.
- Reimbursement for conscious sedation is included within
the codes covering endoscopic procedures.
- Billing separately for conscious sedation has been targeted
by the OIG as a possible fraud and abuse violation, and
is not recommended.
The members of the working group were: Damian Augustyn, M.D.
(San Francisco, CA), Joel V. Brill, M.D. (Scottsdale, AZ),
Douglas Faigel, M.D. (Portland, OR), Bergein F. Overholt,
M.D. (Knoxville, TN), John W. Popp, Jr., M.D. (Columbia, SC),
Maurits Wiersema, M.D. (Fort Wayne, IN).
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