Procedural Sedation — Recover Patient — Clinical Pathway: Emergency Department

Procedural Sedation Clinical Pathway — Emergency Department

Recover Patient

Below are the standards for monitoring a patient post-procedure through recovery.

The ED nurse must be present from induction through Phase 1 recovery and monitor patient as per the hospital sedation protocol. See Nursing Standard: Post Sedation and Post Anesthesia Care

Recovery assessment and documentation

  Vital Signs Recovery Score Assessments
Phase I Recovery
Job Aid: Immediate Recovery (Phase I) Assessment Criteria and Frequency
  • Vital signs documented every 15 minutes after completion of procedure:
    • Heart rate
    • Respiratory rate
    • Blood pressure
    • SpO2
    • ETCO2
  • Temperature at the end of the procedure & then hourly in Phase I
  • Assess after completion of the procedure and every 30 minutes until patient has met criteria for transition to Phase II Recovery
  • Nurse may transition patient from Phase I to Phase II when patient has a recovery score of 5 or greater or is at baseline status
  • Pain assessment every 15 minutes
  • IV site assessment when accessed or hourly if infusing
  • Procedure site assessment, if applicable
Phase II Recovery
Job Aid: Ongoing Recovery (Phase II) Assessment Criteria and Frequency
  • Vital signs documented every 30 minutes x2, then every 1 hour x2.
  • If patient’s recovery score is and/or the patient is back to baseline status prior to the completion of the every 1 hour vital signs x2, the patient can be discharged.
  • Temperature every 4 hours unless hypo/hyperthermic, then per FLOC orders
  • Assess with vital signs
  • Pain assessment with vital signs
  • IV site assessment when accessed or hourly if infusing
  • Procedure site assessment, if applicable