Pediatric Moderate Sedation in the ED Survey

Transcription

1 Pediatric Mderate Sedatin in the ED Survey Jb Title f Survey Respndent(s) Check all that apply CQI Liaisn ED Medical Directr ED Nurse Manager ED Staff Nurse ED Physician ED Educatr Anesthesilgist Chief/staff Department f Anesthesia Chief f Staff Mderate Sedatin Definitin: A drug-induced depressin f cnsciusness during which patients respnd purpsefully t verbal cmmands, either alne r accmpanied by light tactile stimulatin. N interventins are required t maintain a patent airway, and spntaneus ventilatin is adequate. Cardivascular functin is usually maintained. Surce: American Sciety f Anesthesilgists, Task Frce n Sedatin and Analgesia by Nn- Anesthesilgists. Practice guidelines fr sedatin and analgesia by nn-anesthesilgists. Anesthesilgy. 2002;96: Hw des yur emergency department define the pediatric ppulatin? Check ne answer nly 0 thrugh 12 years ld 0 thrugh 18 years ld 0 thrugh 13 years ld 0 thrugh 19 years ld 0 thrugh 14 years ld 0 thrugh 20 years ld 0 thrugh 15 years ld 0 thrugh 21 years ld 0 thrugh 16 years ld Nt defined specifically 0 thrugh 17 years ld Other 2. What is the average vlume f pediatric (defined as 0 thrugh 15 years ld) ED visits per year in yur facility? Check ne answer nly 0-2,000/year 7,001 9,000/year 2,001 3,000/year 9,001 11,000/year 3,001 5,000/year 11,001 13,000/year 5,001 6,000/year 13,001 15,000/year 6,001 7,000/year 15,001+/year 3. What is the average vlume f ALL patient (adult and pediatric) ED visits per year in yur facility? Check ne answer nly /year 40,001-50,000/year ,000/year 50,001-60,000/year 10,001 20, 000/year 60,001-70,000/year 20,001-30,000/year 70,001-80,000/year 30,001-40,000/year 80,001+/year 1

2 4. Des yur hspital have a mderate sedatin plicy/clinical guideline? Yes (if yes, answer Q.4 a - c) N (skip t Q.5) 4a. Des yur hspital s mderate sedatin plicy/clinical guideline specifically address pediatrics? Yes N 4b. Are NPO status guidelines included in yur hspital s mderate sedatin plicy/clinical guideline? Yes N 4c. Hw recently has yur mderate sedatin plicy/clinical guideline been updated/reviewed? In the past 6 mnths In the past 12 mnths Has nt been updated/reviewed in the past year 5. Des yur hspital require an IV t be started n all pediatric patients underging mderate sedatin? Yes N 6. Des yur hspital require physicians t underg a credentialing prcess befre being allwed t administer/perfrm sedatin? Yes (if yes, answer Q.6a) N (skip t Q.7) 6a. What is included in yur hspital s sedatin credentialing prcess fr physicians? Check all that apply Minimal # years f experience Minimal # f supervised prcedures PALS/APLS/NRP training Pharmaclgy curse Practical cmpetency test Recmmendatin by Anesthesia department Self-assessment Self-study Written cmpetency test Other Nne 7. Des yur hspital require ther medical staff (e.g., RN, PA, APN) t underg a sedatin cmpetency curse/prcess befre being allwed t assist with sedatin? Yes N 2

3 8. Des yur hspital have a frmal pediatric sedatin service/team? Yes N 9. Des yur hspital cnduct mderate sedatin chart reviews fr QI purpses? Yes (if yes, answer 9a & b) N (skip t Q.10) 9a. What indicatrs are included in chart reviews? Check all that apply QI Indicatrs a. Airway assessment/mallampati Classificatin 0 b. Physical assessment 0 c. ASA Classificatin 0 d. Anesthetic plan 0 e. Immediate prir-t-sedatin physical assessment 0 f. Time ut/universal precautin 0 g. Site marking 0 h. Prcedure 0 i. Cnsent signed 0 j. Equipment checklist 0 k. Drug calculatins/preparatin/med wrksheet 0 l. Mnitring during/pst sedatin at apprpriate intervals 0 m. Vital signs 0 n. Pain scre 0. Pre-p meds 0 p. Aldrete scre 0 q. Mdified Ramsey scre 0 r. Dept/Unit prcedure was perfrmed 0 s. Staff names/rle in prcedure 0 t. Prcedure utcme 0 u. Cmplicatins (reversal agent given, recvery time > 90 min, 0 unplanned admissin, Oxygen desaturatin, etc) v. Discharge instructins 0 w. Patient/parent educatin (explanatin f prcedure) 0 x. Patient/parent educatin (explanatin f mderate sedatin) 0 0 9b. What is dne with that infrmatin? Check all that apply Implement staff educatin Review at staff meetings Review at ED QI meetings Review at hspital-wide QI meetings Nthing I Dn t Knw 3

4 10. Which f the fllwing services/areas perfrm pediatric sedatin? Check all that apply Burn unit ED EEG GI lab Outpatient center PACU Pediatric unit PICU Radilgy/MRI/CT Urlgy Nne 11. Des yur ED perfrm mderate sedatin t pediatric patients in the ED? Yes (if yes, answer 11a) N (if n, end survey here) 11a. Des yur ED restrict perfrming mderate sedatin n any f the fllwing age grups? Check all that apply Nenate (< mnth) Infant Tddler Preschl Schl age Preadlescent Adlescent N age restrictins If yu answered YES t Questin #11, please cntinue t the Sedatin Scenari sectin f this survey. If yu answered NO t Questin #11, yu have cmpleted the survey. 4

5 Sedatin Scenaris Please respnd t the questins based n yur institutin s cmmn practices, standards, and guidelines Case #1 A 3-year-ld male is brught in by his mther after he fell playing in the park abut 2 hurs ag. He has a 2cm hematma n the right side f his head. The mther states he was unrespnsive fr abut 5 minutes and threw up 3 times initially, but has nt thrwn up in the last 90 minutes r during the car ride t the ED. There are n fcal findings. He will require mderate sedatin fr a CT f the brain. The child is very anxius and the mther states he will nt hld still during the head CT. Sedatin is discussed with the mther and she agrees t this. His vital signs are: Temp: 37.3/99.1 HR: 114 RR: 22 BP: 98/62 O 2 saturatin: 99% n RA Assuming he has n ther injuries r cntraindicatins t sedatin, please answer the 8 related questins. 1. What wuld be included in the pre-sedatin assessment f this patient? Check all that apply Aldrete scre Allergies Anesthetic plan ASA classificatin Bdy habitus Drug calculatins/preparatin/medicatin wrksheet Equipment checklist Histry f anesthesia Histry & Physical Mallampati classificatin/airway assessment Mdified Ramsey scre NPO Status Pain Scre Physician credential check Time ut/universal precautins Vital signs Nne 5

6 2. Fr the fllwing items, hw lng wuld yu rutinely wait befre sedating this patient? Apple Juice Full Lunch 0 hurs since cnsumptin 0 hurs since cnsumptin 1 hur 1 hur 2 hur 2 hur 4 hurs 4 hurs 6 hurs 6 hurs Nthing after midnight Nthing after midnight 3. In this scenari, where wuld yu rutinely sedate this patient? Check ne answer nly In the ED (using a prtable CT) In the ED, then transprt t Radilgy In Radilgy 3a. Based n where this patient wuld be sedated, what mnitring equipment, supplies & medicatins wuld be required at the bedside (r taken with yu during transprt)? Check all that apply Pulse ximeter 0 End-tidal CO 2 mnitr/detectr 0 BP mnitr 0 Thermmeter 0 Defibrillatr 0 IV equipment 0 IV access 0 Suctin equipment 0 Oxygen 0 Stethscpe 0 ETT (crrect patient size) 0 Bag valve mask (crrect size) 0 Nasal cannula 0 Nalxne (dse calculated) 0 Flumazenil (dse calculated) 0 Crash cart/respiratry bx 0 Cardiac mnitr 0 Other 0 Nne 0 6

7 4. In this scenari, is the persn respnsible fr mnitring the sedated patient allwed t perfrm r assist with the prcedure? Yes N 5. Which f the fllwing medicatin(s) wuld yu typically use t mderately sedate this patient? Check all that apply Ativan (Lrazepam) Brevital (Methhexital) Chlral Hydrate Clnidine Demerl (Meperidine) Diprivan (Prpfl) Drperidl Etmidate Fentanyl Haldl Ketamine Mrphine Nembutal (Pentbarbital) Nitrus Oxide Phenergan (Prmethazine) Precedex (Dexmedetmidine) Thrazine (Chlrprmazine) Valium (Diazepam) Versed (Midazlam) Other: 6. DURING the CT, what mnitring/charting wuld be required? Check all that apply Head psitin check/re-check Heart rate Respiratry rate Oxygen saturatin Bld pressure Temperature Skin clr Capngraphy Level f Cnsciusness (LOC) Mdified Ramsey scre Prtective reflexes Aldrete scre I&O Pain scre Med dsage/rute Nne 7

8 7. DURING the CT, hw ften wuld patient assessment be perfrmed? Check ne answer nly Cntinuusly Every 5 minutes Every 15 minutes Every 30 minutes Nt standardized 8. What discharge criteria wuld this patient need t meet befre dispsitin? Check all that apply Returned t pre-sedatin mental status (e.g., able t talk if age apprpriate) Returned t pre-sedatin activity level (e.g., awake, able t sit up unaided if ageapprpriate) After a specified length f stay Able t take fluids Stable vital signs Oxygen saturatin > 95% n rm air r at patient s baseline Cardivascular functin and airway patency are satisfactry and stable Easily arusable Pain adequately cntrlled Physician discretin After a specified length f stay when a reversal agent was given Able t be discharged t respnsible adult and/r secnd adult t mnitr child n trip hme Patient/parent discharge instructins given Patient is prvided a 24-hur emergency telephne cntact Nne 8

9 Case #2 A six-year-ld female has suffered a severely angulated wrist fracture in a fall. The child is very agitated and cries when any stranger cmes near her. The rthpedist will perfrm a fracture reductin, and the child will need mderate sedatin t underg the prcedure. Her vital signs are: Temp: 36.4/97.5 HR: 110 RR: 28 BP: 108/70 O 2 saturatin: 99% n RA Assuming n ther injuries r cntraindicatins t sedatin, please answer the 7 related questins. 1. What wuld be included in the pre-sedatin assessment f this patient? Check all that apply Aldrete scre Allergies Anesthetic plan ASA classificatin Bdy habitus Drug calculatins/preparatin/med wrksheet Equipment checklist Histry f anesthesia Histry & Physical Mallampati classificatin/airway assessment Mdified Ramsey scre NPO Status Pain Scre Physician credential check Time ut/universal precautins Vital signs Nne 9

10 2. What mnitring equipment, supplies & medicatin wuld be required at the bedside fr this patient? Check all that apply Pulse ximeter 0 End-tidal CO 2 mnitr/detectr 0 BP mnitr 0 Thermmeter 0 Defibrillatr 0 IV equipment 0 IV access 0 Suctin equipment 0 Oxygen 0 Stethscpe 0 ETT (crrect patient size) 0 Bag valve mask (crrect size) 0 Nasal cannula 0 Nalxne (dse calculated) 0 Flumazenil (dse calculated) 0 Crash cart/respiratry bx 0 Cardiac mnitr 0 Other 0 Nne 0 3. In this scenari, is the persn respnsible fr mnitring the sedated patient allwed t perfrm r assist with the prcedure? Yes N 4. Which f the fllwing medicatin(s) wuld yu typically use t mderately sedate this patient? Check all that apply Ativan (Lrazepam) Brevital (Methhexital) Chlral Hydrate Clnidine Demerl (Meperidine) Diprivan (Prpfl) Drperidl Etmidate Fentanyl Haldl Ketamine Mrphine Nembutal (Pentbarbital) Nitrus Oxide Phenergan (Prmethazine) Precedex (Dexmedetmidine) Thrazine (Chlrprmazine) Valium (Diazepam) Versed (Midazlam) Other: 10

11 5. DURING the prcedure, what mnitring/charting wuld be required? Check all that apply Head psitin check/re-check Heart rate Respiratry rate Oxygen saturatin Bld pressure Temperature Skin clr Capngraphy Level f Cnsciusness (LOC) Mdified Ramsey scre Prtective reflexes Aldrete scre I&O Pain scre Med dsage/rute Nne 6. DURING the prcedure, hw ften wuld patient assessment be perfrmed? Check ne answer nly Cntinuusly Every 5 minutes Every 15 minutes Every 30 minutes Nt standardized 7. What discharge criteria wuld this patient need t meet befre dispsitin? Check all that apply Returned t pre-sedatin mental status (e.g., able t talk if age apprpriate) Returned t pre-sedatin activity level (e.g., awake, able t sit up unaided if ageapprpriate) After a specified length f stay Able t take fluids Stable vital signs Oxygen saturatin > 95% n rm air r at patient s baseline Cardivascular functin and airway patency are satisfactry and stable Easily arusable Pain adequately cntrlled Physician discretin After a specified length f stay when a reversal agent was given Able t be discharged t respnsible adult and/r secnd adult t mnitr child n trip hme Patient/parent discharge instructins given Patient is prvided a 24-hur emergency telephne cntact Nne Thank yu fr yur participatin!! 11