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Report of the DCHRP Expert Panel
November 8, 2005

The DC Health Resources Partnership (DCHRP) convened an expert panel on Tuesday Nov. 8, 2005, to provide policy clarification and introduce best practices on the topic of conscious sedation. The panel was the first of its kind and is among the strategies employed by the DCHRP to help expand the level of knowledge among consumers and providers serving the individuals with intellectual and other developmental disabilities. The results of this and future panels will be posted on the DCHRP web site and used to guide future activities with the goal of improving the quality of health care for individuals with intellectual and other developmental disabilities.

Conscious sedation was selected as the topic for the first expert panel because many clients, care givers and health care providers have requested clarification on this very important issue. Because of the apparent misunderstanding and confusion regarding policy and best practices, it was apparent that this would be an ideal area to explore. The DCHRP identified key individuals to participate and share their expertise with the panel. These included:

Richard Boesch, PhD Clinical Psychologist, MRDDA Clinical Team
DC MRDDA Sedation Policy Clarification

The practice of prescribing “as needed” or PRN dosages of sedatives, anti-anxiety agents or other psychotropic medications prior to medical or dental appointments is prohibited per DC DHS/MRDDA policy. A specific physician order for administration prior to a specific appointment is permitted; however, if no Behavior Support Plan exists which encompasses such administration, a Serious Reportable Incident form must be filed each time such medication is ordered. Dr. Boesch mentioned that this policy was developed to help qualify the “PRN” order in a manner that permits the use of restricted medications in clients who require them. MRDDA policy applies only to medications given prior to a medical appointment. Any medications provided as part of a diagnostic or therapeutic procedure is not covered under this policy. (MRDDA Sedation Policy)

Aruna Natarajan, MD, Assistant Professor, Critical Care Medicine, Pediatrics,
Georgetown University Medical Center
Conscious Sedation for the Adult with Developmental Disabilities

Dr. Natarajan presented an overview of agents available to use with patients who require conscious sedation for medical and/or dental procedures. In her review, she noted the following considerations that need to be accounted for by clinicians when preparing patients for invasive and non-invasive medical procedures:

• Adults with developmental disabilities have an elevated pain threshold (25% of 123 patients that were studied)
• The more severe the cognitive disability, the greater the insensitivity to pain
• Risks of avoidable death and physical disability due to unrecognized discomfort and pain
• Necessity of investigations/ routine outpatient procedures

The following chart summarizes indications and therapeutic agents that can be used as a guide for clinicians.
Adapated from Schechter, N.L., Berde, C.B. and Yaster, M. (Eds) 2003. Pain in Infants, Children and Adolescents, Second Edition. Lippincott Williams and Wilkins.

Kim Bullock, MD Assistant Professor, Department of Family Medicine,
Georgetown University Medical Center and Clinician, Emergency Department, Providence Hospital
Appropriate and Effective Pain Management

Dr. Bullock began with a review of the principles of pain management that includes:

• Assessment
• Multimodal therapy
• Re-assessment
• Client safety
• Client education

She reviewed the non-pharmacologic and pharmacologic methods of pain relief and then presented different frameworks and protocols for procedural sedation and analgesia. She noted that often, clients with intellectual and other developmental disabilities are treated with sub-optimal dosages or no analgesic drugs. This is often attributed to an inadequate clinical evaluation that can underestimate the stress experienced by clients. She completed her presentation with a review of issues related to dental preparation, including the importance of a sensitive medical history. She emphasized that a detailed psycho/social history can help to anticipate issues that may compromise the success of the procedure. Often this may be difficult because of the client’s inability to communicate or lack of knowledge by the personal attendant accompanying the patient to the procedure.

Recommendations

After the presentations were completed, the participants engaged in a brain storming session to develop recommendations based upon the information provided and experiences in the field. These included:

1. Develop proactive Individual Support Plans that anticipate the need for preparation for medical visits.
2. Develop strategies for disseminating information about patients to all parties that interface with patients for medical procedures e.g. healthcare passport and who is responsible for gathering the information, keeping it current, and insuring that it gets to the appropriate health care providers.
3. Include sedation issues related to individuals with intellectual disabilities in curricula of medical, physician assistant, nurse practitioner, etc. education.
4. Develop protocols for patients as needed for the following medical interactions:
   • Emergency Care
   • Routine Primary Care
   • Scheduled Specialty Care
5. Review transportation policy waiver reimbursement.
6. Enhance team communication.
7. Use the DC Health Resources Partnership web site to disseminate information needed by staff and providers.
8. Develop and implement a “grand rounds” presentation on topic of conscious sedation for individuals with intellectual and other developmental disabilities at local area hospitals and academic health centers.
9. Disseminate Health Care Decisions Act For the health care decision act, click here. For more information about guardianship issues, click here and here.
10. Engage hospital administrators in a forum to problem solve.
11. Training for provider nurses.
12. Develop and disseminate briefing paper.