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Guide to Policy and Procedure Development

1. Purpose

Include the general rationale for why the patient should be monitored. Example: “To ensure patients on PCA pumps are monitored for signs of opioid-induced respiratory depression.”

2. Policy

Describe who should be monitored and how (e.g., parameters to be monitored, continuous monitoring or frequency of intermittent checks, considerations for discontinuance, etc.) Example 1: “During moderate or deep sedation, the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.”

3. Scope

Define the clinicians responsible and accountable for set up and oversight of the monitoring.

4. Indications for Interventions

Though not a substitute for knowledgeable clinicians making informed decisions, it may be helpful to list general indications, based on monitoring measurements and trends, for when a clinician should intervene. Include potential interventions and escalations. This section may include default alarm settings for each parameter, indicating that alarm settings may need to be adjusted based on individual patient needs.

5. Procedure

List the steps involved in appropriately establishing and performing capnography monitoring as a general guide for those involved. Procedure may include, but is not limited to, sections covering patient preparation (educating the patient on the importance of capnography monitoring and encouraging compliance), monitor set-up, setting alarms, sampling line consumables required, infection control and monitor calibration.

6. Documentation

Define the clinician responsible for checking and documenting monitor values, the frequency of documentation required and any associated forms, data entry and method for communicating monitor values among clinical staff.

7. References and Resources

Cite the references and resources that were used to create the document so clinicians can review them.

View the Capnography Policy and Procedure PDF

  • All policy, procedure and protocol documents were provided with permission by the respective institutions.