Below is a narrative from January 2001, before hospitals adopted NAPS

NAPS: Nurse-Administered Propofol Sedation:  Propofol Oregon Protocol (POP) 

With the recent completion of over 7,000 cases of endoscopic sedation with nurse-administered Diprivan, Gastroenterology Consultants has unanimously agreed to pursue vigorously the introduction of propofol for endoscopic sedation into both local hospitals.  We've had no complications of endoscopic sedation, totally painless exams without exception, and extraordinarily fast recovery.  In all, we count 21 distinct advantages.  We feel our protocol provides more reliable and humane sedation, is actually safer than traditional sedation, and performs well in economic analysis.

Painlessness as a concept has certainly gained attention among national overseers, the media, and thought leaders, as well as a broad spectrum of our local community. 

More information on N.A.P.S.tm: A History of Propofol in GI Endoscopy Demographics of Over 7,000 Patients Dosage Information Potential Problems Our Safety Net Physician Opinion Poll Results

We have had patients come from as far away as the Bahamas, Mexico, Arizona, Alaska, Ojai (California), Los Angeles, and other locations up and down I-5.  We've had high-ranking medical teams visit from Indianapolis (the medical school), Cincinnati, and Delaware, and nurse or physician inquiries from Toronto, Tennessee, Louisiana, Portland, Roseburg, Orange County (California), Cody (Wyoming), the Cleveland Clinic, and the Mayo Clinic (Scottsdale).  More importantly, we have locally attracted high-ranking hospital personnel and over 200 physicians and spouses to have endoscopic tests with this sedation technique.  We’ve had nothing but happy patients.

Our endoscopic protocol has now been taught to 11 nurses, five of whom work outside the Rogue Valley.  Its exactitude is embodied in its very simplicity, and thus we feel it will continue to be fun to teach and easy to learn.  Encouraged by our huge numbers and with an envious eye toward our cardiology colleagues who have demystified nurse-administered propofol in the hospitals, we feel it is time to move forward.  It is becoming increasingly harder to answer the now commonly-posed question by many patients, "Why isn't this available in the hospitals?"

"We've had nothing but happy patients."

It has been suggested that our experience ahs SCSO has been skewed by our healthier patient population.  Though this is a factor to be considered, more than 5% of our patients are rank ASA-3.  We've had patients ranging from 80 to 340 pounds, ages 10 to 93, and a heavy load of various coincidental co-morbidities.  Several of the cardiologists have expressed at meetings and/or in writing their choice of Diprivan for upper endoscopy and colonoscopy over traditional sedation when the cardiac status is indeed at its very worst.  Diprivan may well be the drug of choice for ASA categories 4 and 5.

Our presentations at the American College of Gastroenterology, Phoenix, Arizona, in October 1999 and in Digestive Disease Week, San Diego, May 2000 were received very well by the academic and non-academic GI communities.  Dr. Gregory Zuccaro of the Cleveland Clinic, who gave the State-of-the-Art lecture following the POP (Propofol Oregon Protocol) sedation presentation said propofol sedation is the future of GI sedation.  At least last may the protocol at the Cleveland Clinic was to use a constant infusion and to follow the breath by capnography (not quantitative but merely showing the patient has expired; I mean breathe out); when apnea would occur, as it commonly did, it would last for 20 - 51 seconds, without any clinical importance.  They would simply turn down the drip or turn it off and the breath comes right back.

Our protocol, on the other hand, involves nurse decision-making, within the confines of the protocol, to administer a tiny, incremental dose when called for by patient adversive movement and only if the breath is robust, as determined by the nurse's constant palpation.  We have had no apnea, not do we expect this ever to happen.  Were it to happen, we think the length of the apnea would be in keeping with our colleagues at the Cleveland Clinic.  Since the nurse is palpating each breath and otherwise watching the patient like a hawk, and since propofol is white and opaque, one could envision a certain metaphor of a mother checking a baby's formula on her hand or wrist to make sure it is the proper temperature.  The nurse certainly exudes a loving presence to calm the patient, which is part of our protocol.  One local physician opened his eyes after his screening colonoscopy recently and told the nurse that he thought he had gone to heaven and was among the angels.

"Patients can be discharged in 15-20 minutes."

Our patients are able to sip juice within two to four minutes after the endoscopic procedure and can remember what the physician said in six to eight minutes.  They can be discharged in 15-20 minutes.  Quick turn-around is good for everyone: the health facility, the nurse, the patient, and the driver.  Though we emphasize caution, most people are able to return to full work or leisure in one to two hours.  When patients are alert so quickly and have no awareness of the test except a souvenir photograph and a kindly chat with the physician, a remarkable charismatic event takes place between doctor and patient.  It is not uncommon for the patient to turn to his or her spouse and say, "Honey, you’re next!" (in regards to screening colonoscopy).  With the knowledge that colon cancer can almost always be prevented, since the death rate of symptomatic colon cancer is 50%, in view of the invasiveness of the treatment of colon cancer, preventing colon cancer by way of POP sedation may be the greatest public health discovery yet to emanate from the State of Oregon.

Here is what we propose:  a study group consisting of endoscopy sedation nurses from RVMC, PMMC, and SCSO; interested physicians and pertinent administration and staff leaders from the hospitals.  The Diprivan utilizers from GI, one surgeon and several of the cardiologists will be invited.  Together we can explore the ways nurses could obtain training equal to or exceeding our six SCSO nurses and by what means we would select in the hospital setting which patients would be appropriate for the initial experience.  There would need to be case review and registry and ongoing CQI.  We envision the study group as a multiple points-of-view forum in an ongoing cohesive group so members can learn and evolve.  As time goes on, each one of Gastroenterology Consultants members expects palpable progress as we address the medical, legal, bureaucratic, and pragmatic issues.  We would like to reach consensus within the hospital walls and not have to resort to extrinsic remedies to extend this breakthrough technology to our appropriate hospital patients.

In conclusion, we would like to affirm our avowed dedication to the safety of the patient as being first and foremost.  We think that POP sedation will help to ensure this and is keeping with all the avowed mission statement principles of both hospitals displayed in the corridors.  We believe that propofol allows endoscopic titration which is easy to perform, precise, and will have profound public health implications and benefits.  We believe the Rogue Valley can continue the world leadership that was launched at 2798 East Barnett Road in October of 1998, after a study period of 17 months with the collaborate efforts at that time of anesthesiologist Dr. Robert McIntyre, Dr. Walker, and three nurses.  We can envision some day even greater levels of public recognition and perhaps, analogous to the cardiac surgery banner at Rogue Valley, a banner above the portals of the hospitals announcing "POP Sedation - We got there first!"

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