I have heard from colleagues who are not allowed to use specific agents even if the specific agent is judged to offer the best option for their patients. In the survey, 15.2 percent of respondents cannot use propofol and 5.7 percent cannot use ketamine. This restriction is in direct conflict with the ACEP Policy “Sedation in the Emergency Department,” which states, “the decision to provide sedation and the selection of the specific pharmacologic agents should be individualized for each patient by the emergency physician and should not be otherwise restricted.”¹ In a 2014 paper, the ACEP Clinical Policies Committee recommended (Level A, the highest strength of evidence) that ketamine can be safely administered to children for procedural sedation and analgesia in the ED and that propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.² Given the strength of evidence regarding safety, it makes no sense that limitations are being placed on these agents. Furthermore, not using these agents results in the use of outdated medications, promoting substandard practices.

In 2011, the Centers for Medicare & Medicaid Services (CMS) issued its revised Interpretive Guidelines (IGs) pertaining to the hospital Conditions of Participation.³ The IGs have been widely used by health-care facilities to develop institutional and departmental guidelines related to the sedation of patients. The document attempts to distinguish analgesia from anesthesia but goes on to state, “anesthesia exists along a continuum. There is no bright line that distinguishes when their pharmacological properties bring about the physiologic transition from the analgesic to the anesthetic effects. Furthermore, each individual patient may respond differently to different types of medications.”

The CMS document goes on to state that hospitals “must establish policies and procedures, based on nationally recognized guidelines that address whether specific clinical situations involve anesthesia versus analgesia” and “address whether the sedation typically provided in the emergency department or procedure rooms involves anesthesia or analgesia.” Hospitals would be free to use ACEP guidelines and recognize them as authoritative. Furthermore, if sedation administered in the ED is termed “analgesia” (which it is), it would not fall under anesthesia-services oversight. The CMS document allows for this carve out for emergency medicine by stating that “it is important to note that anesthesia services are usually an integral part of surgery.” ED sedation is unique, and the credentialing and verification of competency of providers, selection and preparation of patients, informed consent protocols, equipment and monitoring requirements, staff training and competency verification, criteria for discharge, and continuous quality improvement should be overseen by emergency medicine.