1. Advancing a Safety Culture in the Care of Sedated Children: Nursing Issues 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 FAA Standards  Anesthesiology ASA Standards ASA Standards  Operating Room Nursing AORN Standards AORN Standards  Sedation settings? AAP Sedation Guidelines 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 Infusion 6-9 mg/kg/hr  Trained pediatric resident and RN in attendance

10. Case Report 2  Patient “deeply sedated” No reflex withdrawal No reflex withdrawal  Laryngospasm on insertion of endoscope  Emergency measures initiated BVM with PAP BVM with PAP Deepened level of sedation Deepened level of sedation Epinephrine Epinephrine IV Corticosteroids 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 + High Technology Multiple Teams/Personnel Different Settings + + > ↑ Unpredictability ↑ Failure Modes

18. Promoting 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 

19. Promoting a Culture of Safety  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 care Ensure that the patient receives that care Deliver that care flawlessly Deliver that care flawlessly  Standardization Equipment & monitors Equipment & monitors Techniques and proceduresTechniques and procedures Use of protocols/checklistsUse of protocols/checklists

20. Promoting a Culture of Safety  Simplification Remove unneeded dangerous alternatives 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)(i.e., numbers, preparation, qualifications of staff, patient population, settings) Provides the foundation of understanding process of careProvides the foundation of understanding process of care  Process indicators Way care is delivered Way care is delivered  Outcome indicators Results of work Results of work  Quality indicators Quantitative measures to monitor & evaluate important clinical activities. Quantitative measures to monitor & evaluate important clinical activities.

25. Quality Indicators for Sedation Activity Possible indicators Type Airway assessment ▪ Assessment completed ▪ Anesthesia consult as appropriate Process Supplemental oxygen ▪ Supplemental oxygen immediately available availableStructure Pulse oximetry ▪ Occurrence of O2 desaturation >10% Outcome

26. Adverse Events Reporting  Reporting structure and process problems Unsafe acts Unsafe acts Unsafe conditions Unsafe conditions  Reporting outcomes Sentinel Events Sentinel 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 database“Safety Net” – AORN national database  Responding Organized and systematic in managing hazards Organized and systematic in managing hazards

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

28. Current Nursing Issues  Monitoring and assessment Depth of sedation Depth of sedation VS and BP monitoring VS and BP monitoring Pulse oximetry Pulse oximetry End-tidal CO 2 monitoring? End-tidal CO 2 monitoring? Use of supplemental O 2 ? Use of supplemental O 2 ?

29. Current Nursing Issues  Children at risk for sedation failure  Difficult sedations Agitation & paradoxical reactions Agitation & paradoxical reactions Supplemental sedatives (titration) Supplemental sedatives (titration) Sedation failures Sedation 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 agents 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 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;110:836AAP 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