Practice guidelines for sedation & analgesia by non-anesthesiologists have recently been reported by the ASA task force.  We conducted a telephone survey study of ER sedation practices in a large metropolitan area to determine if sedation guidelines were in place & if these guidelines were consistent with published guidelines. 
METHODS: The study involved both university & community based ER's. The ER director or person in charge was surveyed. The visits per year, percent pediatrics, & total daily attending coverage was noted. Questions were asked concerning the presence of a sedation policy or guidelines, reasons for formulating said policy, & persons involved in policy formulation. The common sedatives used for painful & non-painful procedures were noted. Specific inquiry was made regarding NPO guidelines & whether these guidelines were altered with different levels of sedation.
RESULTS: There were a total of 32 ER's surveyed, 10 university and 22 community based. The average visits per year were approximately 30 thousand with 20-30 percent pediatric cases. The duration of attending coverage was 16-24 hrs. 28 (88%) of the hospitals contacted had a sedation policy or guidelines. The most common reasons for policy formulation were JCAHO requirement (44%) & patient safety concerns (38%). The persons most often involved with policy formulation were emergency medicine (63%) and anesthesia (47%). The most frequently used sedatives for painful procedures were midazolam and fentanyl, with chloral hydrate and midazolam used commonly for non-painful procedures. Ketamine was used by 7 (22%) of the ER's surveyed. 13 (40%) of the ER's surveyed did not have NPO guidelines & those with NPO guidelines did not strictly enforce them. The most common NPO time was 3-4 hrs (31%), with 16% less than 2 hrs, & only 1 ER stated that their NPO guideline was 6 hrs.
DISCUSSION: Although several limitations are inherent in a study such as this, the results raise some important issues. Sedation guidelines are widely published, especially when pediatric patients are involved, [1,2] but our data suggest that these guidelines often are not followed in the high-risk emergent patient. Even though most of the ER's surveyed had a sedation policy in place, many either did not include NPO guidelines, or the NPO guidelines were not always followed. Sedation disasters have recently been documented.  We should continue to work towards the institution of safe sedation practices in ER's and other out-patient settings.
1. Anesthesiology 84:459, 1996
2. Pediatrics 89:1110, 1992
3. Anesthesiology 83:A1193, 1995.