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

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Advancing a Safety Culture in the Care of
Sedated ChildrenNursing Issues

• Terri Voepel-Lewis, MSN, RN
• University of Michigan Health Systems

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Examples of High Risk/High Safety

• Airline industry
• FAA Standards
• Anesthesiology
• ASA Standards
• Operating Room Nursing
• AORN Standards
• Sedation settings?
• AAP Sedation Guidelines

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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.

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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.

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The Number One Indication that Things
are Amiss. . .

• 1. A crash course in airway management
  techniques is included in the discharge
  instructions to parents.

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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

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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

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Case Report 1 - Factors Contributing to Adverse
Event
Discussion
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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

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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 (gt5 mins)
• Call to Emergency anesthesia backup

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Case Report 2

• Emergency backup arrived
• Symptoms almost completely resolved by the time
  emergency team arrived
• Total duration of event 9 minutes
• Outcome unknown

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Case Report 2 - Factors Contributing to Adverse
Event
Discussion
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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

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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

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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

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Case Report 3 Factors Contributing to Poor
Outcome

• Discussion

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Probability of an Accident is never Absolutely
Zero
Complexity of Patient

? Unpredictability
High Technology
gt

? Failure Modes
Multiple Teams/Personnel

Different Settings
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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
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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

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Promoting a Culture of Safety

• Simplification
• Remove unneeded dangerous alternatives
• Training and expertise
• Never violate the systems that have been put into
  place.

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Production Pressure

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

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Advanced Safety Culture

• Resolves conflict between production pressure and
  safety.

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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

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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.

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Quality Indicators for Sedation
Activity Possible indicators Type
Airway assessment ? Assessment completed ? Anesthesia consult as appropriate Process
Supplemental oxygen ? Supplemental oxygen immediately available Structure
Pulse oximetry ? Occurrence of O2 desaturation gt10 Outcome
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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

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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

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Current Nursing Issues

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

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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

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Current Nursing Issues

• Sedation Program discussion
• Institutional support and direction
• Oversight
• Available resources
• Recovery discharge

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Current Nursing Issues

• JCAHO Review
• Citations
• Quality Assurance
• Events reporting
• Adverse events follow-up

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• 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 2002110836

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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