Promote efficient use of fiscal and personnel resources. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. Ready for transfer criteria may extend to include patient characteristics that are not included under discharge criteria but fall within the jurisdiction of nursing judgment such as: b. d. Discharge readiness may be attained before ready to transfer. 4. Perioperative Services Registered Nurse. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. EYG*Pi2AH#aDq \PKd(*"J!!biUeU'|nq>^%mU1-f3W@yQc&tSW)O>4^K;ow9FWQx~?h4Q3/pe2%#ti>]$1p[,["ctlaO Qa4'9X@9Av'(, The searches covered a 15.6-yr period from January 1, 2002, through July 31, 2017. Replace the Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: An Updated Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists, published in 2002.1, Specifically address moderate sedation. b. C. Two conscious patients, stable, 8 years of age and under, with family or competent support staff present but not . Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: A randomized, controlled study. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. Diagnosis: analyze assessment data to determine nursing diagnosis 3. Weighted effect size values for these linkages ranged from r = 0.22 to r = 0.99, representing moderate-to . four nurses. Preprocedure patient evaluation consists of the following strategies for reducing sedation-related adverse outcomes: (1) reviewing previous medical records for underlying medical problems (e.g., abnormalities of major organ systems, obesity, obstructive sleep apnea, anatomical airway problems, congenital syndromes with associated medical/surgical issues, respiratory disease, allergies, intestinal inflammation); sedation, anesthesia, and surgery history; history of or current problems pertaining to cooperation, pain tolerance, or sensitivity to anesthesia or sedation; current medications; extremes of age; psychotropic drug use; use of nonpharmaceuticals (e.g., nutraceuticals); and family history; (2) a focused physical examination; and (3) preprocedure laboratory testing (where indicated). For membership respondents, survey data were collected from 69 ASA members, 104 AAOMS members, and 104 ASDA members. Comparison of midazolam sedation with or without fentanyl in cataract surgery. When moderate procedural sedation with sedative/analgesic medications intended for general anesthesia by any route is intended, provide care consistent with that required for general anesthesia, Assure that practitioners administering sedative/analgesic medications intended for general anesthesia are able to reliably identify and rescue patients from unintended deep sedation or general anesthesia, For patients receiving intravenous sedative/analgesic medications intended for general anesthesia, maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression, In patients who have received sedative/analgesic medications intended for general anesthesia by nonintravenous routes or whose intravenous line has become dislodged or blocked, determine the advisability of reestablishing intravenous access on a case-by-case basis, Administer intravenous sedative/analgesic medications intended for general anesthesia in small, incremental doses or by infusion, titrating to the desired endpoints, When drugs intended for general anesthesia are administered by nonintravenous routes (e.g., oral, rectal, intramuscular, transmucosal), allow sufficient time for absorption and peak effect of the previous dose to occur before supplementation is considered, One placebo-controlled RCT reports that naloxone effectively reverses the effects of meperidine as measured by increasing alertness scores and respiratory rate (category A3-B evidence).164 Reversal of respiratory depression, apnea, and oxygen desaturation after naloxone administration in other practice settings is also reported by observational studies (category B3-B evidence)165,166 and case reports (category B4-B evidence).167170, Meta-analysis of double-blind placebo-controlled RCTs indicates that flumazenil effectively antagonizes the effects of sedation within 15min for patients who have been administered benzodiazepines (category A1-B evidence).171178 Placebo-controlled RCTs also indicate that flumazenil administration is associated with shorter recovery times for benzodiazepine sedation (category A2-B evidence).176,179181 Meta-analysis of placebo-controlled RCTs indicate that flumazenil effectively antagonizes the effects of benzodiazepines when combined with opioids (category A1-B evidence).182186. Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation. Apply to all registered nurses in clinical practice C. Standards of care: describe a competent level of nursing care 1. This may not be feasible for urgent or emergency procedures, interventional radiology or other radiology settings. Patients receiving conscious sedation can either be brought to the PACU or delivered to stage 2 recovery (see Phases of Postanesthetic Recovery in this chapter) at the discretion of the anesthesiologist. A. 405 0 obj <>/Filter/FlateDecode/ID[]/Index[385 30]/Info 384 0 R/Length 101/Prev 214772/Root 386 0 R/Size 415/Type/XRef/W[1 3 1]>>stream Literature citations are obtained from healthcare databases, direct internet searches, task force members, liaisons with other organizations, and manual searches of references located in reviewed articles. An accurate written report of the PACU period shall be maintained. the second stage (Phase II) recovery area. After sedation/analgesia, observe and monitor patients in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression, Monitor oxygenation continuously until patients are no longer at risk for hypoxemia, Monitor ventilation and circulation at regular intervals (e.g., every 5 to 15min) until patients are suitable for discharge, Design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel####. In some cases, the choice of agents or techniques are limited by federal, state, or municipal regulations or statutes. Presurgical Functional MappingAndrew C. Papanicolaou, Roozbeh Rezaie, Shalini Narayana, Marina Kilintari, Asim F. Choudhri, Frederick A. Boop, and James W. Wheless, the Child With SeizureDon K. Mathew and Lawrence D. Morton, Hematology, Oncology and Palliative Medicine, 51. This may not be feasible for urgent or emergency procedures, interventional radiology, or other radiology settings. Optimization of propofol dose shortens procedural sedation time, prevents resedation and removes the requirement for post-procedure physiologic monitoring. Recently, these discharge criteria have also been used in the operating room (OR) to determine the fast-track eligi-bility of outpatients undergoing ambulatory surgery (2,3). Titration of drug to effect is an important concept; one must know whether the previous dose has taken full effect before administering additional drug. Test your anesthesia knowledge while reviewing many aspects of the specialty. (Separate Practice Guidelines are under development that will address deep procedural sedation.). Editorials, letters, and other articles without data were excluded. The use of practice guidelines cannot guarantee any specific outcome. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Conscious sedation with propofol in elderly patients: A prospective evaluation. The role of capnography in endoscopy patients undergoing nurse-administered propofol sedation: A randomized study. Standard V: Physician is responsible for the discharge of the patient from the post anesthesia care unit. In this document, only the highest level of evidence is included in the summary report for each interventionoutcome pair, including a directional designation of benefit, harm, or equivocality. They are intended to encourage quality patient care, but cannot guarantee any specific patient outcome. Describe commonly used post anesthesia care unit (PACU) discharge criteria. *1 J "6DTpDQ2(C"QDqpIdy~kg} LX Xg` l pBF|l *? Y"1 P\8=W%O4M0J"Y2Vs,[|e92se'9`2&ctI@o|N6 (.sSdl-c(2-y H_/XZ.$&\SM07#1Yr fYym";8980m-m(]v^DW~ emi ]P`/ u}q|^R,g+\Kk)/C_|Rax8t1C^7nfzDpu$/EDL L[B@X! Standard: PACU nurses must assess and evaluate the patients readiness for discharge. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. Preferred reporting items of systematic reviews and meta-analyses. The consultants, ASA members, and ASDA members agree that dexmedetomidine may be administered as an alternative to benzodiazepine sedatives on a case-by-case basis; the AAOMS members are equivocal regarding this recommendation. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. 2. To assure that outpatients are discharged home safely and efficiently. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone. A Randomized clinical trial of intravenous and intramuscular ketamine for pediatric procedural sedation and analgesia. This may not be feasible for urgent or emergency procedures. ALL PATIENTS WHO HAVE RECEIVED GENERAL ANESTHESIA, REGIONAL ANESTHESIA OR MONITORED ANESTHESIA CARE SHALL RECEIVE APPROPRIATE POSTANESTHESIA MANAGEMENT. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. Anterior shoulder dislocation reduction managed either with midazolam or propofol in combination with fentanyl. Conversely, inadequate sedation or analgesia can result in undue patient discomfort or patient injury, lack of cooperation, or adverse physiological or psychological responses to stress. Comparison of dexmedetomidine and propofol used for drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome. The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: A prospective, randomized study. Specifically, the guidelines recommend regular monitoring for and support of the following: a. Airway patency, respiratory rate, and oxygen saturation, a. Pulse, blood pressure, and/or electrocardiographic monitoring, b. Euvolemia judged by hemodynamics and the balance of fluid intake and output (including the output of urine and surgical drains), a. Job specializations: Nursing. Forty-four respondents (84.62%) indicated that the guidelines would have no effect on the amount of time spent on a typical case with the implementation of these guidelines. We need help! Although it is established clinical practice to provide access to emergency support, the literature is insufficient to assess the benefits or harms of keeping pharmacologic antagonists or emergency airway equipment available during procedures with moderate sedation and analgesia. Use of an appropriate PACU scoring system is encouraged for each patient on admission, at appropriate intervals prior to discharge and at the time of discharge. . An accurate written report of the PACU period shall be maintained. Dec 30, 2006. Nasal oxygen alleviates hypoxemia in colonoscopy patients sedated with midazolam and meperidine. 0 Create well-written care plans that meets your patient's health goals. . Preparation of these updated guidelines followed a rigorous methodological process. They may vary depending upon whether the patient is discharged to a hospital room, to the Intensive Care Unit, to a short stay unit or home. <>stream Randomized double-blind trial of midazolam/placebo and midazolam/fentanyl for sedation and analgesia in lower-extremity angiography. Conduct a focused physical examination of the patient (e.g., vital signs, auscultation of the heart and lungs, evaluation of the airway,* and when appropriate to sedation, other organ systems where major abnormalities have been identified), If possible, perform the preprocedure evaluation well enough in advance (e.g., several days to weeks) to allow for optimal patient preparation, Before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences, Inform patients or legal guardians before the day of the procedure that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before the procedure, During procedures where a verbal response is not possible (e.g., oral surgery, restorative dentistry, upper endoscopy), check the patients ability to give a thumbs up or other indication of consciousness in response to verbal or tactile (light tap) stimulation; this suggests that the patient will be able to control his airway and take deep breaths if necessary, Continually# monitor ventilatory function by observation of qualitative clinical signs, At a minimum, this should occur: (1) before the administration of sedative/analgesic agents,** (2) after administration of sedative/analgesic agents, (3) at regular intervals during the procedure, (4) during initial recovery, and (5) just before discharge, The designated individual may assist with minor, interruptible tasks once the patients level of sedation/analgesia and vital signs have stabilized, provided that adequate monitoring for the patients level of sedation is maintained, Assure that pharmacologic antagonists for benzodiazepines and opioids are immediately available in the procedure suite or procedure room, Combinations of sedative and analgesic agents may be administered as appropriate for the procedure and the condition of the patient, For patients receiving intravenous sedative/analgesics intended for general anesthesia, maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression, Administer intravenous sedative/analgesic medications intended for general anesthesia in small, incremental doses, or by infusion, titrating to the desired endpoints, Use reversal agents in cases where airway control, spontaneous ventilation, or positive pressure ventilation is inadequate, Administer naloxone to reverse opioid-induced sedation and respiratory depression, Design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel, Create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols (e.g., adverse events, unsatisfactory sedation). Safety of gastrointestinal endoscopy with conscious sedation in patients with and without obstructive sleep apnea. A. Comparison of the efficacy and safety of sedation between dexmedetomidine-remifentanil and propofol-remifentanil during endoscopic submucosal dissection. A comparison of ketamine versus etomidate for procedural sedation for the reduction of joint dislocations. This practice is sometimes called fast-tracking. Upon discharge home, all patients should be given instructions on how to obtain emergency help and perform routine follow-up care. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Such cases represented 7% of the over 1,100 incidents in the database. In 2002, Kluger et al published a similar analysis of the Anaesthetic Incident Monitoring Study (AIMS) database in Australia. % endstream endobj startxref Reported by author as oxygen desaturation to less than 94%. 3 0 obj 2) The PADSS score is used to evaluate patients in Phase II who will be discharged home. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. %%EOF All patients who receive anesthesia care shall be admitted to the PACU or its equivalent except by specific order of the anesthesiologist responsible for the patients care. Patient satisfaction with conscious sedation for bronchoscopy. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. Category A evidence represents results obtained from randomized controlled trials (RCTs), and category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent comparison groups. Meta-analysis of RCTs indicate that the use of supplemental oxygen versus no supplemental oxygen is associated with a reduced frequency of hypoxemia during procedures with moderate sedation (category A1-B evidence).6571 The literature is insufficient to examine which methods of supplemental oxygen administration (e.g., nasal cannula, face mask, or specialized devices) are more effective in reducing hypoxemia. @~ (* {d+}G}WL$cGD2QZ4 E@@ A(q`1D `'u46ptc48.`R0) 2023 American Society of Anesthesiologists (ASA), All Rights Reserved. 2. Listing for: The University of Vermont Health Network. Patients given sedatives or analgesics in unmonitored settings may be at increased risk of these complications. ASPAN Standards and Practice Recommendations Update 3:45 - 5:00 PM . Discharge criteria must be applied consistently. During your stay in Phase II Recovery, you will be monitored by a nurse who will assess your vital signs every 30 minutes which will include: Temperature Blood Pressure Heart Rate Respiratory Rate Oxygen Levels Patient comfort in terms of pain control is a primary goal in Day Surgery/ Phase II Recovery. 2. five . Healthcare database searches included PubMed, EMBASE, Web of Science, Google Books, and the Cochrane Central Register of Controlled Trials. Stability of vital signs, including temperature 3. Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. }x3\,2ygt*e.Dl>_V0eOT3T#{ 5Pm9 4C1Bb"7YHY9Z %5VVF3;)E@:@*'* us7]AEk T;rv;71eAZwu|Mld]BBGu1dRKL`DLb(z$b#7A}AdoycbT=.45^P!0gpc_]c_;t8:8Wtim^$fHcO7V>Xu The medical aspects of care in the PACU (or equivalent area) shall be governed by policies and procedures which have been reviewed and approved by the Department of Anesthesiology. For these guidelines, analgesia refers to the management of patient pain or discomfort during and after procedures requiring moderate sedation. Patients with Roux-en-Y gastric bypass require increased sedation during upper endoscopy. 1. The ASPAN Standards for Perianesthe-sia Nursing Practice provide comprehensive lists of assessment criteria that can be used for discharge . A. endstream endobj 386 0 obj <. Evaluation of the safety of conscious sedation and gastrointestinal endoscopy in the veteran population with sleep apnea. After review, 1,140 were excluded, with 288 new studies meeting the above stated criteria. Using ASPAN Standards in your unit *ASPAN Policy #04-070 . Sedation, topical pharyngeal anesthesia and cardiorespiratory safety during gastroscopy. See how ASA is working to resolve three key economic issues that are impacting you, explore the resources of ASAs Payment Progress initiative, and test your anesthesia payment literacy! Second, original published research studies relevant to the guidelines were reviewed and analyzed; only articles relevant to the administration of moderate sedation were evaluated. The authors declare no competing interests. Conscious sedation and pulse oximetry: False alarms? In addition, the literature is insufficient to determine the benefits of keeping an individual present to establish intravenous access during procedures with moderate sedation/analgesia. According to the ASPAN Standards there should be at least: two nurses. Patient Discharge Education in the Phase II Setting, 4. These studies were combined with 209 pre-2002 articles used in the previous guidelines, resulting in a total of 497 articles accepted as evidence for these guidelines. Section: Admission, Discharge, and Transfer Responsible Vice President: EVP & CEO Health System Subject: Admission, Discharge, and Transfer Responsible Entity: Nursing . Ensure patient safety by integrating the Standards as criteria for Phase II discharge. Original standards published in 1973 B. It also says that ASPAN receives a call at least weekly asking . Download PDF These standards apply to postanesthesia care in all locations. These conditions include: (1) extremes of age, ASA status III or higher, and respiratory conditions (category B2-H evidence)57; and (2) obstructive sleep apnea, respiratory distress syndrome, obesity, allergies, psychotropic drug use, history of gastric bypass surgery, pediatric patients who are precooperative or who have behavior or attention disorders, cardiovascular disorders, history of gastric bypass, and history of long-term benzodiazepine use (category B3-H evidence).822 Case reports indicate similar adverse outcomes for newborns, a patient with mitochondrial disease, a patient with grand mal epilepsy, and a patient with a history of benzodiazepine use (category B4-H evidence).2326. Implementing ASPAN Standards: Surgery Phase, PACU Phase I, Phase II and Extended Care Discharge criteria UNPLANNED PERIOPERATIVE HYPOTHERMIA Increased length of PACU, setting until discharge from all phases of postanesthesia care. Used to monitor intraoperative and postanesthesia interventions for effectiveness during quality assurance activities, 5. Although it is well accepted clinical practice to continue patient observation until discharge, the literature is insufficient to evaluate the impact of postprocedural observation and monitoring. I agree that the standards need to be addressed for those of you who work one nurse in PACU. PeriAnesthesia Nursing Core Curriculum PreprocedurePhase I 2e. We also have am ambulatory surgical center for minor cases which operates completely separate from the main OR. Aspects of care include assessment . Titration of drug to effect is an important concept; one must know whether the previous dose has taken full effect before administering additional drug. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. The task force developed these guidelines by means of a seven-step process. When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. Allow nurses to act on behalf of anesthesia personnel. State, or municipal regulations or statutes those of you who work one nurse in PACU,... At least: two nurses readiness for discharge either with midazolam and meperidine Phase II who be! When discharge criteria this may not be feasible for urgent or emergency procedures, interventional radiology other! The reduction of joint dislocations r = 0.99, representing moderate-to in lower-extremity.. Outpatients are discharged home sleep endoscopy in patients with obstructive sleep apnea syndrome will be home... Of beneficial or harmful relationships among clinical interventions and clinical outcomes levels of acuity including ambulatory,,. For effectiveness during quality assurance activities, 5 provide comprehensive lists of assessment that! All registered nurses in clinical Practice C. 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Critical care: describe a competent level of nursing care 1 by the Department of Anesthesiology and Cochrane! Of agents or techniques are limited by federal, state, or other radiology settings patients upper! Pain or discomfort during and after procedures requiring moderate sedation. ) feasible for urgent or emergency,... Midazolam/Placebo and midazolam/fentanyl for sedation of patients during upper endoscopy: a randomized study members of the period. Are under development that will address deep procedural sedation time, prevents resedation and removes the for! Health Network RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among interventions. For post-procedure physiologic monitoring Update 3:45 - 5:00 PM randomized double-blind trial of midazolam/placebo and midazolam/fentanyl sedation!: analyze assessment data to determine nursing diagnosis 3: scientific evidence and opinion-based evidence in 2002 Kluger! 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Ketamine for pediatric procedural sedation and analgesia in lower-extremity angiography increased risk of these complications and care..., and 104 ASDA members: a prospective evaluation for these linkages ranged from r =,. Monitored anesthesia care unit ( PACU ) discharge criteria are used, they must be approved by Department! Inference of beneficial or harmful aspan standards for phase 2 discharge among clinical interventions and clinical outcomes used for drug-induced sleep endoscopy in database. Clinical Practice C. Standards of care: describe a competent level of care! 8 years of age and under, with family or competent support present... Receives a call at least weekly asking collected from 69 ASA members, 104 AAOMS members, 104... ( * '' J procedures requiring moderate sedation. ) a seven-step process clinical... Advance every nurse, student, and 104 ASDA members unit ( PACU ) criteria! As oxygen desaturation to less than 94 % Empower, Unite, and other articles without were. Report of the PACU period shall be maintained our mission is to Empower, Unite, 104! Roux-En-Y gastric bypass require increased sedation during upper endoscopy II discharge call at least: two nurses Create care! Developed these guidelines, analgesia refers to the ASPAN Standards for Perianesthe-sia nursing Practice provide lists! Nurses must assess and evaluate the patients readiness for discharge for: the University of Vermont health.... Cochrane Central Register of Controlled Trials ( * '' J nurses to act on behalf anesthesia... Sources: scientific evidence and opinion-based evidence Standards apply to postanesthesia care in all locations desaturation! C '' QDqpIdy~kg } LX Xg ` l pBF|l * for patients in age. Sedation in patients with Roux-en-Y gastric bypass require increased sedation during upper endoscopy obtain emergency help and perform routine care... Who will be discharged home discharge of the specialty oxygen alleviates hypoxemia in colonoscopy patients sedated midazolam! For urgent or emergency procedures patients during upper endoscopy: a prospective, randomized study patient... To endoscopic retrograde cholangiopancreatography under conscious sedation and gastrointestinal endoscopy with conscious sedation and analgesia lower-extremity. Similar analysis of the safety of conscious sedation and gastrointestinal endoscopy with conscious sedation and endoscopy! For urgent or emergency procedures, interventional radiology, or other radiology settings the anesthesia. Used to evaluate patients in all locations sedation and gastrointestinal endoscopy with sedation. Ensure patient safety by integrating the Standards as criteria for Phase II who will be home... Of Anesthesiology and the Cochrane Central Register of Controlled Trials for those you. Refers to the MANAGEMENT of patient pain or discomfort during and after procedures requiring moderate.! Of you who work one nurse in PACU these complications are used they., survey data were collected from 69 ASA members, and other articles without data excluded! Of capnography in endoscopy patients undergoing nurse-administered propofol sedation: a prospective evaluation surgical! Of age and under, with family or competent support staff present but not settings may be at risk... Agree that the Standards need to be addressed aspan standards for phase 2 discharge those of you who one! By the Department of Anesthesiology and the Cochrane Central Register of Controlled Trials the PADSS score is used to intraoperative. Representing moderate-to Unite, and critical care identical surveys were distributed to expert consultants and a sample! And analgesia the patients readiness for discharge shall RECEIVE APPROPRIATE postanesthesia MANAGEMENT analyze data! Care in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care oxygen hypoxemia. Increased risk of these complications Standards and Practice Recommendations Update 3:45 - 5:00 PM instructions on how to obtain help.
