Children's hospitals tackle issue of failed sedation
Process improvements, new protocol boost efficiency
Performing imaging procedures on the very young often requires sedation, but when the child wakes up before the procedure is complete, it is not only a frightening experience for the patient and the parents, but it also usually means the procedure must be rescheduled. Consequently, in addition to inducing stress, such incidents are expensive and often cause a serious backlog in pending imaging procedures.
No one understands this problem better than the radiology staff at busy children's hospitals. For this precise reason, some of these centers have taken bold steps to reduce the rate of failed sedations, instituting clinical and process improvements which, in some cases, have gone a long way toward eliminating the problem.
Failed sedations became such a significant problem at Fort Lauderdale, FL-based Chris Evert Children's Hospital (CECH) that administrators developed a dedicated eight-bed sedation unit that specializes in preparing children for imaging and other procedures requiring sedation. The approach has dramatically lowered the failed sedation rate from 12.29% in 2003 to .28% in 2006.1
Key to the success of the new approach was development of pediatric sedation protocol that replaced pentobarbital with an a2-adrenergic agonist, dexmedetomidine (dex) as the drug of choice for pediatric sedation. The move followed an internal research project that began by studying a panel of about two dozen autistic children who were sedated with the blood pressure medication clonidine.
"It was working extremely well, except that it would take one or two hours to work," explains Nina Lubisch, MSN, BC, ARNP, program director of the Pediatric Sedation Unit. However, Lubisch adds that the children weren't experiencing any adverse reactions from the drug, and it didn't interfere with brain wave studies.
This led investigators to dex, which is a refined version of clonidine that works more quickly than pentobarbital and also does a much better of keeping children sedated through longer, more complex imaging procedures. In addition to the new pediatric sedation protocol, administrators also streamlined the process by which imaging procedures requiring sedation are carried out. Patients don't come through the regular registration process, Lubisch says.
"They come straight to our unit, and we register them in a very child-friendly environment," she says. "While the parent is handling registration, the child is playing in a playroom."
While children must be transported from the sedation unit to the imaging department for many procedures, Lubisch points out that the approach has nonetheless resulted in more efficient scheduling and reduced the waiting time for diagnostic procedures from six weeks to about five days. Further, the radiology department now handles more than twice the number of pediatric cases per day than it handled before improvements were made.1
Screening is critical
Prompted by a huge backlog in cases and a troubling failed sedation rate, the radiology department at Cincinnati Children's Hospital Medical Center (CCHMC) also implemented improvements. Rather than establish a dedicated pediatric sedation unit, it has opted for a different approach, according to Lois Curtwright, RN, MSN, CPN, clinical director of the Department of Radiology/Anesthesia at CCHMC.
"We don't have to send patients to a unit or have a unit come to us. The individuals that need to [perform sedation] are already in the department; they are part of the radiology group," says Curtwright. The team includes anesthesiologists and sedationists as well as ancillary staff, including child life experts who help to prepare children for imaging procedures by explaining to them in detail what the procedures will involve, showing them the imaging machines that will be used, and even letting them listen to recordings of the sounds the machines make in some cases.
Further, the department has instituted a more thorough screening process, designed to ensure that children are scheduled appropriately. There is a large group of patients who are not the best candidates for sedation, explains Jasleen Goel, MD, MCRP, a staff physician and sedationist within the Radiology Department. These include children with respiratory problems; children with severe behavioral problems; very large children; and children who are scheduled for very long, complex studies, says Goel. "The first goal is to screen them before getting scheduled so make sure that they get directed to general anesthesia [rather than sedation]."
Secondly, the day before an imaging procedure is supposed to take place, nurses go through the schedule to make sure that no child has been scheduled inappropriately and to uncover any issues that need to be resolved prior to the scan. Matthias Konig, MD, a staff anesthesiologist and assistant professor at CCHMC, says, "Sometimes kids get scheduled for scans, and there are still some uncertainties as to what specifically is supposed to get scanned. For example, for patients who have any kind of implanted devices, we try to make sure we know what they have implanted and how that will impact scan safety before they even come here so that we don't have to go through all [that] while they are here."
Going forward
By taking care of all of these issues in advance, staff can minimize the amount of time needed to work up the patients and have them undergo their scheduled procedures. Further, the approach has enabled the Radiology Department to pare down its waiting time from more than 60 days to two weeks, says Curtwright.
However, Goel acknowledges that the department still is struggling with how to determine when a child might not need sedation or anesthesia. "What we have done recently is we tell parents that we are going to try a child without sedation. However, if the child fails to complete the scan, they will be rescheduled unless we start with an IV, in which case regardless of whether they fail to complete the scan, we can go ahead and sedate them quickly," she says. "I have not had any parent refuse the IV because they find it too hard to reschedule, so they are OK with the IV even though we may not need it. We try to minimize wasted scanner time."
While CCHMC and CECH have made considerable progress in improving their sedation process, clinicians at both facilities acknowledge the need for a continuing focus on new and better techniques. John McAuliffe III, MD, an associate professor of anesthesia and pediatrics at CCHMC, says, "The level of complexity [in imaging] is increasing all the time. We are really looking at what sorts of patients we will be seeing more of than we are seeing now and thinking in terms of what level of medical complexity we are moving to for some of our patients, and then having everything in place we need to take care of them."
Reference
- Lubisch N, Roskos R, Sattler S. Improving outcomes in pediatric procedural sedation. Joint Comm J Qual Pat Safety 2008; 34:192-195.
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