The Evaluation of 1-Physician Versus 2-Physician Deep Sedation with Propofol

Background: Emergency physicians routinely perform emergency department procedural sedation (EDPS) with propofol and its safety is well established. However, in 2009 the Centers for Medicare and Medicaid Services (CMS) enacted guidelines defining propofol as deep sedation and requiring administration by a physician. Common EDPS practice had been one-physician performing both the sedation and procedure. EDPS has proven safe under this 1-physician practice. However, the 2009 guidelines mandated separate physicians perform each. Objective: The study hypothesis was that 1-physician propofol sedation complication rates are similar to 2-physician. Methods: We performed an observational study of an a priori defined specific aims via secondary analysis of a prospectively collected database. Patients included were >17 years of age consenting to EDPS with propofol. EDPS completed with one physician were compared to those completed with two (separate physicians performing the sedation and the procedure). All data was prospectively collected. The study was completed at an urban Level 1 trauma center. Standard monitoring and procedures for EDPS were followed with physicians blind to the objectives of this research. The frequency and incremental dosing of medication was left to the discretion of the treating physicians. The study protocol required an ED nurse trained in data collection to be present to record vital signs and assess for any prospectively defined complications. We used Chi-square tests to compare the binary outcomes and ASA score across the time periods and two-sample T-tests to test for differences in age between the two time periods. Results: During the 2-year study period we enrolled 481 patients, 252 1-physician EDPS sedations and 229 2-physician. All patients meeting inclusion criteria were included in the study. Total adverse event rates were 4.4%, and 3.1%, respectively (p = 0.450). The most common complications were hypotension and O2 desaturation and they respectively showed a 1-physcian rate of 2.0% and 0.8% and 2-physician rate of 1.8% and 0.9% (p = 0.848 and 0.923.) The unsuccessful procedural rates were 4.0% vs 3.9% (p = 0.983). Conclusions: This study demonstrated no significant difference in complication rate for propofol EDPS completed by one physician as compared to two. established [1-7]. However, in 2009 the Centers for Medicare and Medicaid Services (CMS) enacted guidelines defining propofol as deep sedation and requiring administration by a physician [8]. This is similar to the anesthesia model for procedural sedation consisting of two physicians, one to perform sedation and monitor the patient and the other to perform the procedure. In theory, if one physician is dedicated to administer procedural sedation and analgesia (PSA) it should be possible to monitor the level of sedation and titrate medication carefully, and identify adverse effects earlier. However, despite such potential benefits, clinical observation indicates that one emergency physician-providing both the PSA and performing the procedure-may achieve safe sedation with a low risk of adverse events [9,10]. Such a practice of one-physician performing both the sedation and procedure had been a common emergency department approach to procedural sedation. The aforementioned 2009 guidelines mandated separate physicians perform each. To our knowledge, there has not been a previously published evaluation of EDPS administered by one physician as compared to that carried out by two physicians. The study hypothesis was that 1-physician propofol sedation complication rates are similar to 2-physician.