Florida hospital cuts failed pediatric sedation rate 98%
Parents are involved in quality improvements
During an October 2003 survey conducted at Fort Lauderdale, FL-based Broward General Medical Center by The Joint Commission, surveyors recommended improvements with the organization's pediatric sedation process. In particular, they found fault with the administration of sedation for outpatient diagnostic procedures.
"It was noted that the pre-procedure assessment was not complete," says Suzan M. Sattler, RN, BSN, the hospital's performance improvement regional manager.
Compliance with history and physicals, the American Society of Anesthesiology's (ASA) classification system, and Mallampati scores were not meeting the standard, surveyors found.
"Sedating children for diagnostic or therapeutic procedures is a complex process," says Sattler. "At the time, the sedatives used, techniques employed, the personnel provided, and safety standards varied greatly from one location to another, even within any given institution."
The organization's goal was to increase the efficiency and safety associated with the delivery of pediatric sedation. A standard protocol was needed to reduce the failed sedation rate and create a child-friendly, welcoming atmosphere to ease apprehension among young children as they prepare for exams. A decision was made to invite parents to participate in the quality initiative.
First, protocols from nationally recognized children's hospitals were examined. A root cause analysis was conducted to determine underlying factors for failed sedations, and parents were surveyed to obtain input for needed changes.
The assessment, root cause analysis, and parent survey revealed the following areas in need of improvement:
- Chloral hydrate and nembutal were ineffective sedatives with a high rate of undesirable side effects, such as delirium and failed sedations.
- Scheduling was not taking into consideration parents' work hours and the length of time children went without eating or drinking.
- The sedation area, located in the radiology department, was not child-friendly.
- Continuity of care was fragmented.
- Staff education was needed.
- Procedures required process improvement methodologies.
The following performance improvement changes were implemented between October 2003 and April 2006:
- Sedation privileges were created. These defined minimum education and training requirements for staff performing pre-sedation assessments.
- Staff received certification in advanced cardiac life support (ACLS) and pediatric advanced life support (PALS).
- The organization's sedation policy and procedure criteria were revised to comply with Joint Commission standards and guidelines from the ASA and the American Academy of Pediatrics.
- A standalone eight-bed sedation unit was created to accommodate the registration process, pre-assessment, and post-procedure monitoring.
- A pediatric physician champion was designated.
- An a2-adrenergic agonist, dexmedetomidine, was selected to decrease the need for opioids and eliminate sedative narcotics.
- A requirement was established for all children to receive 4% topical lidocaine analgesia before intravenous insertion.
The results of the parent survey were used to redesign the sedation area and change the scheduling process. Instead of not eating or drinking the night before the procedure, children are now allowed to have clear liquids or breast milk two hours before the procedure and solids six to eight hours before the procedure.
Quality professionals worked with a statistician to implement a database, and collaborated with anesthesiologists to develop performance measurement tools to accurately measure the data. "Since the inception of this program, these tools have been proven reliable," says Sattler.
To evaluate safety and efficacy on an ongoing basis, the Chris Evert Children's Hospital at Broward General Medical Center participates with the Pediatric Sedation Research Consortium, a collaboration of 26 institutions with a database of procedural sedation practices.
"Since our initiative has demonstrated exceptional outcomes, children's hospitals throughout the nation have requested we share best practices through site visits and lectures, to assist with protocol development," says Sattler.
The organization has presented at meetings for the National Association of Children's Hospitals, the Florida Society of Anesthesiology, the Society of Pediatric Anesthesia and the American Academy of Pediatrics, where the initiative was presented with the "Outstanding Abstract Award" in October 2006.
Overall, the initiative eliminated rescheduled exams and failed procedures by 98%. After the new protocol was implemented in 2003, the failed pediatric sedation rate decreased to 1.63% in 2004, 0.19% in 2005, and 0.28% in 2006. "In 2007, our rate was 0.72%, still well below the national benchmark of 2%," says Sattler.
[For more information, contact:
Suzan M. Sattler, RN, BSN, Performance Improvement Regional Manager, Broward General Medical Center, 1600 South Andrews Avenue, Fort Lauderdale, FL 33316. Phone: (954) 355-5499. Fax: (954) 459-2080. E-mail: [email protected].]
During an October 2003 survey conducted at Fort Lauderdale, FL-based Broward General Medical Center by The Joint Commission, surveyors recommended improvements with the organization's pediatric sedation process.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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