HealthAlliance Hospital: Mary’s Avenue Campus
Margaretville Hospital
HealthAlliance Hospital: Broadway Campus
Woodland Pond
CONSCIOUS SEDATION PRIVILEGE REQUEST FORM
APPLICANT’S PRINTED NAME:
DATE:
If you do not want Conscious Sedation privileges, please do not fill out this form or return the test.
I am requesting Conscious Sedation privileges on:
 Initial Appointment
 Reappointment or as a new privileges
Unless otherwise requested in separate criteria, you do not need to send detailed information regarding the cases
documenting competence. Your signature attests that you have met all the requirements. The hospital and
Credentials Committee reserve the right at any time to request a specific listing of cases, which would include the
patient name, medical record number and institution.
Qualifications Minimum Training (Check one)
 Successful completion of an accredited three-year residency in Anesthesiology
 Certification by the American Board of Emergency Medicine
 Successful completion of a residency (with or without a subspecialty fellowship) wherein you
received education, training, and experience to administer and/or supervise conscious sedation.
 ACLS required unless residency completed in Anesthesiology or Emergency Medicine
Previous Experience (required)
 Performance of conscious sedation for at least 50 patients over the past 24 months.
 I attest that I have completed the required training and experience to perform Conscious Sedation at
a HealthAlliance facility and that I will comply with the policy on Conscious Sedation.
Applicant’s Signature: ________________________________________________________
Note: Any practitioner who feels that he/she has had adequate training or experience, yet does not meet the
minimum criteria, may submit documentation to the credentials committee and MEC for review. Documentation
should include training and experience, and other issues that you wish the committee to consider. Further training
or supervision may be required for approval of requested privileges.
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NAME:
DATE:
Conscious Sedation for the Non-Anesthesiologist
Assessment Test
Please write the correct answer to each question below. To receive a successful score on this Assessment
Test, you may not get more than two incorrect answers.
1) Objectives of Conscious Sedation include all of the following except:
a.
Alteration of mood
b.
Amnesia
c.
Cooperation during procedure
d.
Decreased pain threshold
e.
Stable vital signs
Answer:
2) Flumazenil (Romazicon) reverses the effects of Midazolam (Versed):
a.
True
b.
False
Answer:
3) The recommended initial dosage of Versed is:
a.
1 – 2.5 mg
b.
5 mg
c.
7 mg
d
10 mg
Answer:
4) Moderate Sedation:
Answer:
a.
Allows protective reflexes to be maintained by the patient
b.
Pertains to the patient that is unconscious or in a state of depressed consciousness
where the patient cannot respond purposefully to verbal or physical stimuli
c.
Requires mask ventilation to maintain respirations
d.
Requires the use of Naloxone at the end of the procedure
5) Monitoring parameters include:
Answer:
a.
Heart rate, blood pressure, respirations
b.
Heart rate, blood pressure, and oxygen saturation
c.
Heart rate and rhythm, blood pressure, respirations, oxygen saturation,
and level of consciousness
d.
Heart rate and rhythm, blood pressure, respirations, and oxygen saturation
e.
Heart rate, blood pressure, respirations, and oxygen saturation
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6) What information is needed in the history of a patient undergoing
conscious sedation:
a.
Allergies
b.
Past experiences with anesthetic drugs
c.
Last Meal
d.
Pregnancy or menstrual history
e.
All of the above
7) Moderate sedation, a medically controlled state of depressed consciousness
allows protective reflexes to be maintained:
a.
True
b.
False
Answer:
Answer :
8) If you have privileges to perform any endoscopic procedures, you automatically Answer:
have privileges to administer conscious sedation.
a.
True
b.
False
9) The most effective way to open the airway is the head-tilt jaw lift:
a.
True
b.
False
Answer:
10) The most common cause of airway obstruction is the tongue:
a.
True
b.
False
Answer:
11) Prior to administering sedation for any procedure, documentation
should include:
a.
History and Physical (H&P)
b.
Baseline vital signs
c.
Age and weight
d.
NPO status
e.
Evidence of informed consent
f.
Results of pregnancy test (if warranted)
g.
All of the above
Answer:
12) During the procedure the vital signs should be taken and documented:
a.
Pre and post procedure
b.
Every five (5) minutes
c.
Every ten (10) minutes
d.
Every fifteen (15) minutes
e.
As the physicians feels necessary.
Answer:
13) The RN monitoring the patient receiving conscious sedation:
a.
May be the charge nurse
b.
May also circulate in the room and get equipment
c.
May not apply oxygen if needed
d.
May not be engaged in any other activity during this period
e.
Should do the preoperative history and physical prior to the procedure
Answer:
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14) A patient currently undergoing bronchoscopy has received Versed for
sedation and within a few minutes, the oxygen saturation has begun to drop.
Answer:
You should:
a.
turn up the oxygen
b.
Check for respiration
c.
Arouse the patient
d.
All of the above
15) The scoring system for airway adequacy is the:
a.
Dooney and Bourke
b.
Mallampati
c.
Boone and Crockett
d.
Marietta
Answer:
Answer True or False
16) Guidelines for use of agents for conscious sedation are intended for diagnostic, therapeutic and surgical
procedures, as well as for sedation of patients on ventilators and in pain control.
Answer:
17) The goal of conscious sedation is to produce a depressed level of consciousness without the loss of
protective airway reflexes.
Answer:
18) The monitoring RN is permitted to leave the room at the discretion of the Physician.
Answer:
19) Post procedure monitoring must continue every five (5) minutes until vital signs have returned to the
pre-procedure range, protective reflexes are intact, O2 saturation is > 90% on room air (or at preprocedure level), there is age-appropriate verbalization response.
Answer:
20) An out-patient may be discharged to his own care if his mental status has returned to its baseline level.
(scheduled / planned out-patient procedure)
Answer:
21) Ketamine is restricted to Anesthesiologist and Emergency Department use ONLY.
Answer:
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22) Benzodiazepines will not amplify the respiratory depressant effects of narcotics.
Answer:
Match the ASA classification to each of the following patients. Place the corresponding letter on the line
provided below:
A)
B(
C)
D)
E)
23)
ASA Class I
ASA Class II
ASA Class III
ASA Class IV
ASA Class V
Answer:
A patient with marked signs of cardiac insufficiency
Answer:
A normal, healthy patient
Answer:
A patient not expected to survive twenty four (24) hours
Answer:
A patient with well-controlled essential hypertension
Answer:
A morbidly obese patient
Applicant’s Signature: __________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------*** INTERNAL USE ONLY *** DEPARTMENT CHAIR REVIEW ****
 I have reviewed the written competency test and the practitioner has demonstrated basic knowledge in the area
of Conscious Sedation.
 Airway Management – Not required
 Airway Management required to demonstrate the ability to rescue a patient whose level of sedation has
reached a deeper stage. Course provided by the Department of Anesthesia.
________________________________________________ Date: ___________________________________
Donald Louie, M.D., Chair, Department of Anesthesia
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