Advancing a Safety Culture in the Care of Sedated Children: Nursing Issues

1. Advancing a Safety Culture in the Care of Sedated Children:Nursing Issues Terri Voepel-Lewis, MSN, RN University of Michigan Health Systems

2. Examples of High Risk/High Safety • Airline industry • FAA Standards • Anesthesiology • ASA Standards • Operating Room Nursing • AORN Standards • Sedation settings? • AAP Sedation Guidelines

3. The Top Five Indications that Things are Amiss. . . • 5. The practitioner complains that the pulse ox is an unnecessary stimulus that may prevent completion of the procedure. • 4. An oximeter and its alarm are considered sufficient replacement coverage for competent, licensed personnel.

4. The Top Five Indications that Things are Amiss. . . • 3. A “healthy” dose (i.e., a “little extra”) of chloral hydrate is considered a bonus in the available repertoire to speed up the start of the procedure. • 2. The nurse considers baby formula to be adjuvant sedative therapy to facilitate completion of the procedure.

5. The Number One Indication that Things are Amiss. . . • 1. A crash course in airway management techniques is included in the discharge instructions to parents.

6. Case Report 1 • 4 year old ASA 1 • Presenting for MRI • Chloral hydrate 75 mg/kg • Paradoxical reaction in 10-15 mins • Procedure aborted at 30 mins • Child discharged to home 40 mins after CH

7. Case Report 1 • On arrival at home (30 mins), child difficult to arouse, unable to support his head • Return to ED • Monitored for 4 hours • Discharged home without sequela

8. Case Report 1 - Factors Contributing to Adverse Event Discussion

9. Case Report 2 • 3 year old ASA 1 with hx of hematemesis • Sedated for esophagoscopy • Propofol induction 2 mg/kg • Infusion 6-9 mg/kg/hr • Trained pediatric resident and RN in attendance

10. Case Report 2 • Patient “deeply sedated” • No reflex withdrawal • Laryngospasm on insertion of endoscope • Emergency measures initiated • BVM with PAP • Deepened level of sedation • Epinephrine • IV Corticosteroids • Laryngospasm prolonged (>5 mins) • Call to Emergency anesthesia backup

11. Case Report 2 • Emergency backup arrived • Symptoms “almost completely resolved by the time emergency team arrived” • Total duration of event 9 minutes • Outcome unknown

12. Case Report 2 - Factors Contributing to Adverse Event Discussion

13. Case Report 3 • 4 year old ASA 1 boy • MRI for benign tumor below knee • Previous uneventful sedation with midazolam and fentanyl • Mom requested oral sedative for IV start at current visit

14. Case Report 3 Sedation Regimen • Versed PO – 0.5 mg/kg • 30 minutes later • Pentobarb IV – 3 mg/kg • 4 minutes later • Fentanyl IV – 3 mcg/kg • No pulse oximeter until mother said child did not look right!! • 11 minutes later – no respirations, no pulse

15. Case Report 3 - Outcomes • Documented arrest time 10-12 minutes • Decerebrate posturing on discharge • 2 years following event • standing with assistance • beginning to track • relearning to swallow • no communication • G-tube

16. Case Report 3 – Factors Contributing to Poor Outcome Discussion

17. “Probability of an Accident is never Absolutely Zero” Complexity of Patient + ↑Unpredictability High Technology > + ↑ Failure Modes Multiple Teams/Personnel + Different Settings

18. Promoting a Culture of Safety AAP & AAPD Guidelines 1985  AAP Guidelines 1992  JCAHO Single standard of care 1994  ASA Practice Guidelines 1996  ASA Defines Sedation Continuum 1999  JCAHO Sedation/Anesthesia standards 2001  AAP Addendum 2002

19. Promoting a Culture of Safety • Improve system (leads to prevention of error) • Identify care that works (safe & efficacious) • Standards of Care • Protocols • Ensure that the patient receives that care • Deliver that care flawlessly • Standardization • Equipment & monitors • Techniques and procedures • Use of protocols/checklists

20. Promoting a Culture of Safety • Simplification • Remove unneeded dangerous alternatives • Training and expertise • Never violate the systems that have been put into place.

21. Production Pressure • As the number of procedures increases, so does the likelihood of error.

22. Advanced Safety Culture Resolves conflict between production pressure and safety.

23. Advanced Safety Culture • Informed at all levels • Seeks out information (what helps to ensure that incidents do not turn into worse accidents) • Exhibits trust by all • Adaptable to change / Flexible • Worries “Success does not engender complacency”

24. Assessment of Quality • Structure Indicators • (i.e., numbers, preparation, qualifications of staff, patient population, settings) • Provides the foundation of understanding process of care • Process indicators • Way care is delivered • Outcome indicators • Results of work • Quality indicators • Quantitative measures to monitor & evaluate important clinical activities.

25. Quality Indicators for Sedation

26. Adverse Events Reporting • Reporting structure and process problems • Unsafe acts • Unsafe conditions • Reporting outcomes • Sentinel Events • Death • Unexpected Hospital or ICU admission • “Near misses” • Non-reportable by JCAHO standards • “Safety Net” – AORN national database • Responding • Organized and systematic in managing hazards

27. Current Nursing Issues • Competency and training • BCLS • PALS? • Airway management techniques • IV access • Pre-procedure assessment & planning • Oversight • Patient selection criteria • Use of medication guidelines

28. Current Nursing Issues • Monitoring and assessment • Depth of sedation • VS and BP monitoring • Pulse oximetry • End-tidal CO2 monitoring? • Use of supplemental O2?

29. Current Nursing Issues • Children at risk for sedation failure • Difficult sedations • Agitation & paradoxical reactions • Supplemental sedatives (titration) • Sedation failures • When to reschedule for sedation • When to schedule general anesthesia • When to discharge the patient • Use of reversal agents

30. Current Nursing Issues • Sedation Program discussion • Institutional support and direction • Oversight • Available resources • Recovery & discharge

31. Current Nursing Issues • JCAHO Review • Citations • Quality Assurance • Events reporting • Adverse events follow-up

32. “The COD has concluded that the guidelines apply in all locations and to all practitioners who care for children.” • “Regardless of the medications selected or the route of administration, the potential for serious adverse effects exists.” • AAP Addendum Pediatrics 2002;110:836

33. Future Work to be Done • Newer sedation regimens • Drugs with increased margin of safety • Prevention/treatment of paradoxical reaction • Precise tests of discharge readiness • Consistent implementation of guidelines • Enhanced skill levels of sedation providers