advancing a safety culture in the care of sedated children: nursing issues advancing a safety...
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Advancing a Safety Culture in Advancing a Safety Culture in the Care of Sedated Children:the Care of Sedated Children:
Nursing IssuesNursing Issues
Terri Voepel-Lewis, MSN, RNTerri Voepel-Lewis, MSN, RN
University of Michigan Health SystemsUniversity of Michigan Health Systems
Examples of High Risk/High SafetyExamples of High Risk/High Safety
Airline industryAirline industry FAA StandardsFAA Standards
AnesthesiologyAnesthesiology ASA StandardsASA Standards
Operating Room NursingOperating Room Nursing AORN StandardsAORN Standards
Sedation settings?Sedation settings? AAP Sedation GuidelinesAAP Sedation Guidelines
The Top Five Indications thatThe Top Five Indications that Things are Amiss. . . Things are Amiss. . .
5. The practitioner complains that the pulse 5. The practitioner complains that the pulse ox is an unnecessary stimulus that may ox is an unnecessary stimulus that may prevent completion of the procedure.prevent completion of the procedure.
4. An oximeter and its alarm are 4. An oximeter and its alarm are considered sufficient replacement coverage considered sufficient replacement coverage for competent, licensed personnel.for competent, licensed personnel.
The Top Five Indications thatThe Top Five Indications that Things are Amiss. . . Things are Amiss. . .
3. A “healthy” dose (i.e., a “little extra”) of 3. A “healthy” dose (i.e., a “little extra”) of chloral hydrate is considered a bonus in chloral hydrate is considered a bonus in the available repertoire to speed up the the available repertoire to speed up the start of the procedure.start of the procedure.
2. The nurse considers baby formula to 2. The nurse considers baby formula to be adjuvant sedative therapy to facilitate be adjuvant sedative therapy to facilitate completion of the procedure.completion of the procedure.
The Number One Indication thatThe Number One Indication that Things are Amiss. . . Things are Amiss. . .
1. A crash course in airway management 1. A crash course in airway management techniques is included in the discharge techniques is included in the discharge instructions to parents. instructions to parents.
Case Report 1Case Report 1
4 year old ASA 14 year old ASA 1 Presenting for MRI Presenting for MRI Chloral hydrate 75 mg/kgChloral hydrate 75 mg/kg Paradoxical reaction in 10-15 minsParadoxical reaction in 10-15 mins Procedure aborted at 30 mins Procedure aborted at 30 mins Child discharged to home 40 mins after CHChild discharged to home 40 mins after CH
Case Report 1Case Report 1
On arrival at home (30 mins), child difficult On arrival at home (30 mins), child difficult to arouse, unable to support his headto arouse, unable to support his head
Return to EDReturn to ED Monitored for 4 hours Monitored for 4 hours Discharged home without sequelaDischarged home without sequela
Case Report 1 - Factors Case Report 1 - Factors Contributing to Adverse EventContributing to Adverse Event
Discussion
Case Report 2Case Report 2
3 year old ASA 1 with hx of hematemesis3 year old ASA 1 with hx of hematemesis Sedated for esophagoscopySedated for esophagoscopy Propofol induction 2 mg/kg Propofol induction 2 mg/kg
Infusion 6-9 mg/kg/hrInfusion 6-9 mg/kg/hr Trained pediatric resident and RN in Trained pediatric resident and RN in
attendanceattendance
Case Report 2Case Report 2
Patient “deeply sedated”Patient “deeply sedated” No reflex withdrawalNo reflex withdrawal
Laryngospasm on insertion of endoscopeLaryngospasm on insertion of endoscope Emergency measures initiatedEmergency measures initiated
BVM with PAPBVM with PAP Deepened level of sedationDeepened level of sedation EpinephrineEpinephrine IV Corticosteroids IV Corticosteroids
Laryngospasm prolonged (>5 mins)Laryngospasm prolonged (>5 mins) Call to Emergency anesthesia backupCall to Emergency anesthesia backup
Case Report 2Case Report 2
Emergency backup arrivedEmergency backup arrived Symptoms “almost completely resolved by Symptoms “almost completely resolved by
the time emergency team arrived”the time emergency team arrived” Total duration of event 9 minutesTotal duration of event 9 minutes Outcome unknownOutcome unknown
Case Report 2 - Factors Case Report 2 - Factors Contributing to Adverse EventContributing to Adverse Event
Discussion
Case Report 3Case Report 3
4 year old ASA 1 boy4 year old ASA 1 boy MRI for benign tumor below kneeMRI for benign tumor below knee Previous uneventful sedation with Previous uneventful sedation with
midazolam and fentanylmidazolam and fentanyl Mom requested oral sedative for IV start Mom requested oral sedative for IV start
at current visitat current visit
Case Report 3Case Report 3
Sedation RegimenSedation Regimen
Versed PO – 0.5 mg/kgVersed PO – 0.5 mg/kg 30 minutes later 30 minutes later
Pentobarb IV – 3 mg/kgPentobarb IV – 3 mg/kg 4 minutes later4 minutes later
Fentanyl IV – 3 mcg/kgFentanyl IV – 3 mcg/kg No pulse oximeter until mother said child did No pulse oximeter until mother said child did
not look right!!not look right!! 11 minutes later – no respirations, no pulse11 minutes later – no respirations, no pulse
Case Report 3 - OutcomesCase Report 3 - Outcomes
Documented arrest time 10-12 minutesDocumented arrest time 10-12 minutes Decerebrate posturing on dischargeDecerebrate posturing on discharge 2 years following event2 years following event
standing with assistancestanding with assistance beginning to trackbeginning to track relearning to swallowrelearning to swallow no communicationno communication G-tubeG-tube
Case Report 3 – Factors Case Report 3 – Factors Contributing to Poor OutcomeContributing to Poor Outcome
DiscussionDiscussion
““Probability of an Accident is Probability of an Accident is never Absolutely Zero”never Absolutely Zero”
Complexity of Patient
+
High Technology
Multiple Teams/Personnel
Different Settings
+
+
>↑ Unpredictability
↑ Failure Modes
Promoting a Culture of SafetyPromoting a Culture of Safety
AAP Guidelines 1992
JCAHO Single standard of care 1994
ASA Practice Guidelines 1996
JCAHO Sedation/Anesthesia standards 2001
ASA Defines Sedation Continuum 1999
AAP & AAPD Guidelines 1985
AAP Addendum 2002
Promoting a Culture of SafetyPromoting a Culture of Safety
Improve system (leads to prevention of error)Improve system (leads to prevention of error) Identify care that works (safe & efficacious)Identify care that works (safe & efficacious)
• Standards of CareStandards of Care• ProtocolsProtocols
Ensure that the patient receives that careEnsure that the patient receives that care Deliver that care flawlesslyDeliver that care flawlessly
StandardizationStandardization• Equipment & monitorsEquipment & monitors• Techniques and proceduresTechniques and procedures• Use of protocols/checklistsUse of protocols/checklists
Promoting a Culture of SafetyPromoting a Culture of Safety
Simplification Simplification Remove unneeded dangerous alternativesRemove unneeded dangerous alternatives
Training and expertiseTraining and expertise Never violate the systems that have Never violate the systems that have
been put into place.been put into place.
Production PressureProduction Pressure
As the number of procedures increases, As the number of procedures increases, so does the likelihood of error.so does the likelihood of error.
Advanced Safety CultureAdvanced Safety Culture
Resolves conflict between production Resolves conflict between production pressure and safety.pressure and safety.
Advanced Safety CultureAdvanced Safety Culture
Informed at all levelsInformed at all levels Seeks out information (what helps to ensure that Seeks out information (what helps to ensure that
incidents do not turn into worse accidents)incidents do not turn into worse accidents) Exhibits trust by allExhibits trust by all Adaptable to change / FlexibleAdaptable to change / Flexible WorriesWorries
““Success does not engender complacency”Success does not engender complacency”
Assessment of QualityAssessment of Quality
Structure IndicatorsStructure Indicators• (i.e., numbers, preparation, qualifications of staff, patient (i.e., numbers, preparation, qualifications of staff, patient
population, settings)population, settings)• Provides the foundation of understanding process of careProvides the foundation of understanding process of care
Process indicatorsProcess indicators Way care is deliveredWay care is delivered
Outcome indicatorsOutcome indicators Results of workResults of work
Quality indicatorsQuality indicators Quantitative measures to monitor & evaluate Quantitative measures to monitor & evaluate
important clinical activities.important clinical activities.
Quality Indicators for SedationQuality Indicators for Sedation
ActivityActivity Possible indicatorsPossible indicators TypeType
Airway Airway assessmentassessment
▪ ▪ Assessment completedAssessment completed
▪ ▪ Anesthesia consult as appropriateAnesthesia consult as appropriate
ProcessProcess
Supplemental Supplemental oxygenoxygen
▪ ▪ Supplemental oxygen immediately Supplemental oxygen immediately availableavailable
StructureStructure
Pulse oximetryPulse oximetry ▪ ▪ Occurrence of O2 desaturation Occurrence of O2 desaturation >10%>10%
OutcomeOutcome
Adverse Events ReportingAdverse Events Reporting Reporting structure and process problemsReporting structure and process problems
Unsafe actsUnsafe acts Unsafe conditionsUnsafe conditions
Reporting outcomesReporting outcomes Sentinel EventsSentinel Events
• DeathDeath• Unexpected Hospital or ICU admissionUnexpected Hospital or ICU admission
““Near misses”Near misses”• Non-reportable by JCAHO standardsNon-reportable by JCAHO standards• ““Safety Net” – AORN national databaseSafety Net” – AORN national database
RespondingResponding Organized and systematic in managing hazardsOrganized and systematic in managing hazards
Current Nursing IssuesCurrent Nursing Issues Competency and trainingCompetency and training
BCLSBCLS PALS?PALS? Airway management techniquesAirway management techniques IV accessIV access
Pre-procedure assessment & Pre-procedure assessment & planningplanning OversightOversight Patient selection criteriaPatient selection criteria Use of medication guidelinesUse of medication guidelines
Current Nursing IssuesCurrent Nursing Issues
Monitoring and assessment Monitoring and assessment Depth of sedationDepth of sedation VS and BP monitoringVS and BP monitoring Pulse oximetryPulse oximetry End-tidal COEnd-tidal CO2 2 monitoring?monitoring?
Use of supplemental OUse of supplemental O22??
Current Nursing IssuesCurrent Nursing Issues
Children at risk for sedation failureChildren at risk for sedation failure Difficult sedationsDifficult sedations
Agitation & paradoxical reactionsAgitation & paradoxical reactions Supplemental sedatives (titration)Supplemental sedatives (titration) Sedation failuresSedation failures
• When to reschedule for sedationWhen to reschedule for sedation• When to schedule general anesthesiaWhen to schedule general anesthesia• When to discharge the patientWhen to discharge the patient
Use of reversal agentsUse of reversal agents
Current Nursing IssuesCurrent Nursing Issues
Sedation Program discussionSedation Program discussion Institutional support and directionInstitutional support and direction OversightOversight Available resourcesAvailable resources Recovery & dischargeRecovery & discharge
Current Nursing IssuesCurrent Nursing Issues
JCAHO ReviewJCAHO Review CitationsCitations
Quality AssuranceQuality Assurance Events reportingEvents reporting Adverse events follow-upAdverse events follow-up
““The COD has concluded that the The COD has concluded that the guidelines apply in guidelines apply in allall locations and to locations and to allall practitioners who care for children.”practitioners who care for children.”
““Regardless of the medications selected or Regardless of the medications selected or the route of administration, the potential the route of administration, the potential for serious adverse effects exists.”for serious adverse effects exists.”
• AAP Addendum Pediatrics 2002;110:836AAP Addendum Pediatrics 2002;110:836
Future Work to be DoneFuture Work to be Done
Newer sedation regimensNewer sedation regimens Drugs with increased margin of safetyDrugs with increased margin of safety Prevention/treatment of paradoxical reactionPrevention/treatment of paradoxical reaction Precise tests of discharge readinessPrecise tests of discharge readiness Consistent implementation of guidelinesConsistent implementation of guidelines Enhanced skill levels of sedation providersEnhanced skill levels of sedation providers