Opposition to Board of Nursing’s Proposed Conscious Sedation Rules

Lisa Percy, J.D., Manager
State Legislative and Regulatory Affairs


ver the past few years, the Florida Board of Nursing has solicited comments on its proposed Conscious Sedation Rules. The proposal was drafted in response to petitions for declaratory statements from registered nurses regarding the scope of practice of a registered nurse who is not a nurse anesthetist. Specifically the question was whether the administration of propofol and ketamine were within their scope of practice. The nursing board concluded that an R.N. could administer propofol under certain conditions but rejected petitions to administer ketamine. The R.N. could administer propofol pursuant to an order (written or verbal) if the patient is monitored and intubated. The R.N. must be trained in advance cardiac life support (ACLS) and must follow the policies and procedures of the facility.

Once the petitions for declaratory statements were heard, the nursing board published the proposed rules. The Florida Society of Anesthesiologists (FSA) and Florida Medical Association (FMA) submitted comments to the nursing board and Joint Administrative Procedures Committee (JAPC) expressing concerns. JAPC reviews agency rules to ensure that such rules do not exceed or conflict with the statutory authority delegated by the legislature to an agency.

Under the proposal, a R.N. qualified by training and education could administer limited medications to achieve conscious sedation pursuant to the order of a qualified anesthesia provider or physician. “Anesthesia provider” includes an anesthesiologist, physician or certified registered nurse anesthetist as authorized in a protocol agreement. The R.N. would be authorized and obligated to question orders and decisions that are contrary to standards of nursing practice and could refuse to administer medications that may induce general anesthesia or loss of consciousness. The R.N. would be required to have met the knowledge, education and competency requirements set forth in the rule, such as competence in patient assessment and the ability to administer medication through a variety of routes and to identify responses that are deviations from the norm. The R.N. or institution-based emergency response team would demonstrate skill in age-specific airway management and emergency resuscitation through ACLS, pediatric advanced life support, neonatal resuscitation program or equivalent training. The R.N. would have completed a program in conscious sedation developed by the institution or an approved continuing education provider. “Institution” includes a hospital, ambulatory surgery center, physician office setting, clinic or any other setting in which conscious sedation is utilized. The program would be, at a minimum, four hours in length and would contain information on drugs used during conscious sedation, assessment and monitoring of the patient receiving conscious sedation and recognition of emergency measures.

JAPC opposed the inclusion of nurse anesthetists as qualified providers who would be authorized to execute an order to an R.N. to administer anesthesia medications. Existing law does not extend such authority to a nurse anesthetist; their authority is limited to the prescription of pre-anesthesia medications. Moreover JAPC objected that the rule would not require supervision of the R.N. unless the purpose is to control the patient’s airway, such as rapid sequence intubation. JAPC questioned the rationality of requiring supervision of a nurse anesthetist but not an R.N. Lastly JAPC opposed the training requirements of an R.N. The comments expressed reservation that a four-hour program would be sufficient due to the acknowledged the complexity of the subject matter and that the proposal should list criteria for successful completion. JAPC, FSA and FMA all objected to the possibility that the program could be developed by any institution where the conscious sedation is administered.

Although the nursing board has not amended the conscious sedation rules to accommodate JAPC’s comments, it is unlikely that the current proposal would survive judicial scrutiny based on JAPC’s assessment.

Kentucky — Anesthesiologist assistants (AAs) in Kentucky are currently classified as physician assistants (PAs) who hold dual certifications from a PA program and AA program. S.B. 175 would delete the PA requirement so that an individual would only be required to have graduated from an approved AA program.