Exploratory survey of procedural sedation and analgesia practice in sample of New Zealand rural hospitals: existing guidelines do not support current rural practice

Purpose: Rural hospitals in New Zealand provide broad generalist clinical services, including procedural sedation and analgesia (PSA). This study was designed to explore patterns of procedural sedation use including; indications, equipment, medications, logistical and medical staff support available by rural hospitals, and whether current professional guidelines support rural sedation practice.
Procedure: Through the New Zealand Rural Hospital Research Network, 17 rural hospitals were enrolled in an online survey during February 2018.  The electronic survey consisted of 31 questions, regarding general information, staffing level, and procedural sedation practice. Further questions sought information on clinical documentation and training guidelines.
Main findings: Most participating sites represented larger rural hospitals and were distributed equally throughout New Zealand. All performed procedural sedation. The distance of rural hospitals to their referral hospitals varied, with the closest being 65kms and the furthest at 326kms away. This study found that staffing and equipment available for rural procedural sedation varied with the majority of rural hospitals having access to only one doctor out of hours, and only half having access to two doctors within daytime hours. A majority of the respondents felt that a minimum safe level for procedural sedation in their rural hospital required only a single doctor. Procedural sedation is frequently performed in rural hospitals in NZ, with the majority of respondents performing PSA at least once a week or more.  Ketamine is the preferred PSA agent. A wide variety of procedures are undertaken including orthopaedic and injury treatments, abscess incision & drainage and cardioversions. Patient transfer to another centre for the purpose of PSA is infrequent, occurring a few times a month or less for all hospitals.
Main conclusions: This exploratory  survey of rural hospital procedural sedation and analgesia (PSA) practice demonstrated that PSA is a commonly performed procedure for a variety of indications. Staffing, equipment and techniques available for rural PSA vary according to institution. There is no current professional framework that suitably defines ‘minimum standards’ for rural PSA practice and specific training resources are limited.
Providing procedural sedation and analgesia is an essential rural hospital service which is patient and whanau centred, saves patient transfers, and should be supported by a safe, pragmatic and realistic framework of tools, recommendations, and training for rural practitioners.