Improving the Quality of Procedural Sedation in the. Emergency Department.

Transcription

1 Tim Ayres Quality Improvement Project (QIP). POW Improving the Quality of Procedural Sedation in the Emergency Department. FRCEM Quality Improvement Project

2 Tim Ayres Quality Improvement Project (QIP). POW : Improving the Quality of Procedural Sedation in the Emergency Department. FRCEM Quality Improvement Project Executive Summary BACKGROUND AND AIM Procedural sedation is a key skill for the emergency medicine practitioner but not without potential risk to the patient. The Royal College of Emergency Medicine (RCEM) has published audit standards for procedural sedation. These were not always being followed in my department and so I felt this was a clear area for quality improvement. In particular I identified that capnography was infrequently used and the existing sedation proforma was out of date. METHODS I utilised a plan, do, study act methodology to identify the problem and implement change (1). I reviewed our prior sedation performance against the RCEM standards. I then performed a literature search to assess the evidence base for the chosen intervention (capnography). I delegated the design of a new ED proforma and had it signed off for use in the department. I obtained new nasal capnography equipment, and designed a series of education package. I analysed our departmental procedural sedation practice against the RCEM standards on a monthly basis and plotted the results on a run chart. After implementation I felt I needed still further impact and so designed and sent out an online survey/ education package on sedation and updated our online departmental handbook. RESULTS Procedural sedation practice prior to my QIP: capnography used in 2/15 (14%) and proforma used 14/15 (93%). Following QIP start in December 2016 through to March 2017: Overall both capnography and proforma use increased to 96% of all sedations (100% for the last 3 months). CONCLUSION My QIP has improved the consistency and quality of procedural sedation in the ED at the POW Hospital, Bridgend. For the last 3 months all procedural sedations have used the new sedation proforma and capnography monitoring. This therefore includes all the data required to complete the RCEM audit, but more 1

3 importantly potentially keeps patients safer by incorporating pre-and post-sedation checklists, monitoring and capnography use. By updating the online departmental handbook to include current RCEM recommendations on sedation and drug dosing these improvements will hopefully continue, and be accessible to new trainees or locum staff. This has been all my own work and I have been supervised during the process. Any references used have been stated and included in the references. Word Count:

4 Tim Ayres Quality Improvement Project. POW : Improving the Quality of Procedural Sedation in the Emergency Department. INTRODUCTION My Quality Improvement Project (QIP) revolves around the use of capnography for procedural sedation in the ED of the POW Hospital, Bridgend. I started my ST6 training here in August The choice of topic is a combination of an area of interest, my recent involvement in the 2015/2016 RCEM procedural sedation audit, and a patient story. This is the first time I have been involved in the quality improvement process and after completing the IQT bronze training available through NHS e-learning (2) I felt that it was best was to find a problem, and then try to work forwards over several cycles towards the solution. I knew I required a clear aim, needed objective measures, and then a change which could be implemented and reviewed as part of a Plan, Do, Study, Act cycle, using Model for Improvement methodology (1). I was therefore looking out for a potential patient problem. Fortuitously this happened quite organically early in my rotation, as on a weekend shift near the start of my new job I was asked to help manipulate a patient s broken ankle in the resus area of the department. She had already undergone procedural sedation, but there had been difficulty in reducing the fracture. I went in and found her moderately sedated, but not enough to enable an effective reduction, and she did not have capnography monitoring in-situ. There was also no record that a pre-sedation checklist had been used for her sedation. These two omissions in particular raised potential patient safety concerns for me and were to become the problem and aim of my QIP. She unfortunately required a second formal sedation which I performed, after a thorough pre-sedation assessment. I enlisted the help of the orthopaedic team to reduce her fracture. This was successful, but the need for a second sedation increased her risk of a potential complications as well as prolonging her time spent in pain. She did not specifically voice any concerns herself, but it made me feel uneasy from a patient safety point of view. It also highlighted to me a potential area for improvement as I was aware that we were not meeting RCEM standards on procedural sedation (3). I had been involved in completing the 2015/2016 RCEM 3

5 procedural sedation audit in my previous post, and so was aware that the RCEM standards for procedural sedation mandate capnography for all procedures (3). In my previous department I had used a comprehensive sedation checklist pre-sedation, and also continuous nasal prong capnography for all sedations. I felt this was an effective standard and one which would benefit my current department as part of my quality improvement project. The apparent deviation from an established RCEM standard struck me as an important area for potential improvement, and one which had clear patient safety benefits. I was keen to analyse current practice in the department and then suggest an intervention to meet the RCEM standards. This would require changes to the sedation process and offer the opportunity to create an educational package for the department about procedural sedation as a whole. Therefore my aim was to introduce a new proforma which would incorporate all aspects of a comprehensive pre-sedation assessment and establish compulsory and effective capnography for all sedations. This seemed the most effective way to implement change. The department like many in the country has a flexible workforce and so there is the potential that sedation in ED may be carried out by a locum doctor or a doctor from another specialty like anaesthetics. I wanted to ensure that whoever was carrying out the sedation, the same safe standards would be used. Timeline - October 2016 Data gathering, retrospective review of practice, Literature review. - November 2016 Presentation of evidence to department and develop plan to initiate new proforma / monitoring to the department. Business case for nasal capnography. - December 2016 Roll out new sedation proforma, procedural sedation log and monitoring program. - January, February, and March 2017 ED sedation in house teaching and ongoing analysis of sedation practice. - June 2017 present poster at AWSEM day. 4

6 IDENTIFICATION / ANALYSIS OF THE PROBLEM. The initial patient story had highlighted to me a potential patient safety issue regarding a lack of monitoring with capnography during sedation and to inadequate pre-sedation assessment. I wanted to establish the reason for this. I started looking at the existing sedation proforma. It was introduced in 2013 and did not include capnography on its equipment checklist. Likewise it was not formally documented during the procedure part of the form. Therefore in its current format it did not in my opinion reflect current sedation practice. Trainees and consultants who have completed ACCS training may be more comfortable with what were traditionally anaesthetic drugs and now deeper level of sedation. This however requires a higher level of monitoring and a comprehensive pre-sedation checklist, including an airway assessment, as if you were about to perform a rapid sequence induction. This was one problem to aim to improve. The department did not participate in the official RCEM 2015/ 206 procedural sedation audit although sedation is audited regularly in house. I obtained the prior audits of sedation from our yearly audit meetings. Only 2 were available: 2011 and In 2011 a sedation proforma was used 93% of the time and in 2015 it was used 91% of the time. This was vital background data as I felt that it proved the rationale for potential improvement proforma use was historically accepted and by updating the proforma I could update practice to include more comprehensive assessment and monitoring standards, with an aim of improving patient safety. As it had not been mandated on the prior proforma, if end tidal CO2 capnography was used or monitored during procedural sedation was entirely dependent on the doctor involved and their training / experience. I had always used it in previous departments and was aware of the discrepancy. I spent time asking my colleagues and the resus nurses about existing practice, in a small focus group. It became evident that if it was used during sedation the capnography sampling line was often simply tucked under the non re-breather mask (see Fig 1) as this was the only option available. It was not something I had done before and so I tried it in my next couple of sedations. It was better than 5

7 nothing, but not ideal, and created the potential for many problems. Firstly the line could quite easily fall out, giving a false impression of apnea. It also renders the quantitative aspect of capnography unreliable as the sampling end can vary in position under the mask and so sample different CO2 concentrations. Lastly in situation where the patient is not wearing a mask (potentially if they are using Entonox) it s not possible to use capnography. This equipment problem may partially explain reluctance to capnography monitoring and so I felt there was definite room for improvement. It marked the first mini PDSA cycle I conducted. Fig 1. Current practice examples: Procedural Sedation Prior to QIP: I aimed to use the RCEM procedural sedation audit tool from the 2015/2016 national audit to retrospectively review 30 recent procedural sedations in this department. From the outset it was clear that we would not be meeting all the standards, as the most glaring deviation from the RCEM standards is that of capnography, which as discussed was not a feature of the existing proforma and so not always used. In some cases it may have been additionally documented, but effective data gathering is very much reduced by this omission in the form, and the validity of the results may be questioned. Potentially there may have been cases where it was used but not documented. 6

8 The data gathering of sedation practice pre and post intervention was and has been the most frustrating part of the QIP process. This was due to a lack of departmental coding for sedation, and difficulty obtaining the clinical records for the patients who have undergone procedural sedation. Our computer tracking system is sub optimal, and there was no sedation log. A record of the patients who have been admitted to our resus area is not kept, which is where all sedation should take place. This difficulty led me to introduce a change of practice and the integration of a new sedation log and collection of completed sedation proformas at reception. Initially I asked advice from our departmental secretary, the lead nurse for audit and education and several department consultants about the best way of obtaining the patient records for patients who had undergone sedation. The best way to obtain this appeared to be interrogating the Omnicell drug dispensing system, searching for the sedation drug use over the 2 months before I started (June / July 2016) and then cross referencing this with the patient details and looking to see the purpose of their use (sedation / intubation etc.). I used Fentanyl, Midazolam, Propofol and Ketamine as the search terms. I then checked their clinical records to see if a sedation checklist had been used, and pulled the data required to complete the RCEM audit standards from this or the patient notes. Pre QIP data: Proforma use: Sedation Proforma used? 14/15-93% 7

9 Table 1. Pre QIP data, June/ July 2016: Compliance with RCEM standards Standard Compliance Percentage 1 Patients undergoing procedural sedation in the ED should have documented evidence of preprocedural assessment, including: 1a ASA grading 1/ b Prediction of difficulty in airway management. 1/ c Pre-procedural fasting status 14/ There should be documented evidence of the patient s informed consent unless lack of mental capacity has been recorded 3 Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities. 13/ / Procedural sedation requires the presence of all of the below: 4a a doctor as sedationist 14/ b a second doctor, ENP or ANP as procedurist 7/ c a nurse 11/ Monitoring during procedural sedation must be documented to have included all of the below: 5a Non-invasive blood pressure 15/ b Pulse oximetry 15/ c Capnography 2/ d ECG 15/ Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area. 15/

10 7 Following procedural sedation, patients should only be discharged after documented formal assessment of suitability, including all of the below: 7a 7b Return to baseline level of consciousness Vital signs within normal limits for the patient 1/15 7 3/ c Absence of respiratory compromise 1/15 7 7d 7e Absence of significant pain and discomfort Written advice on discharge for all patients. 1/15 7 2/15 14 The most pertinent results to my QIP are that the existing sedation proforma use was 93%. This was very good as it highlighted the department already accepted proforma use as a standard and so an updated proforma would be likely to positively influence change. This standard needed to be maintained. Capnography use was only documented in 14% of cases. This was lower than I had expected and well short of the mandatory 100% from RCEM. There was much scope to improve with regard to my aim of improving patient safety during procedural sedation, as highlighted by my initial patient story, and introducing mandatory capnography with an updated proforma seemed the best way to achieve it. EVIDENCE BASE In order to bring about quality change it was important to me to review the evidence base for my intervention. I carried out a literature review of procedural sedation and capnography using these as the search terms on PubMed and the OVID Medline interface. I also reviewed the RCEM guidelines and RCOA guidelines. I then reviewed the RCEM e-learning resources on procedural sedation, and its evidence base, as well as searching FOAMED for any FOAM material / podcasts. 9

11 Table 2. Literature review: PubMed / OVID MEDLINE Author, date, Country Patient Group Study Type Outcomes Key Results Conclusion MacDougall M, Blackburn R, Lloyd G, Gray A. August 26 th UK (5) Adult emergency department patients undergoing procedural sedation. 7 studies met the eligibility criteria, representing a total of 662 patients Systematic review. Compared standard monitoring to capnography and defined and measured and adverse even rate. There was a lack of statistical evidence for a difference in the proportion of adverse events detected when capnography was used in addition to standard monitoring (48.8% (95% CI to 64.92)) compared with chance alone (50%). No firm evidence capnography provides additional safety compared with standard monitoring. Potentially related to reporting measures. However we advocate continued compliance with current professional recommendations for the use of capnography during PSA in adults in the ED. Godwin SA; Burton JH; Gerardo CJ; Hatten BW; Mace SE; Silvers SM; Fesmire FM; American College of Emergency Physicians America. (6) All emergency department patients requiring procedural sedation. 10 studies. Adults and paediatric patients. Systematic review and Clinical Policy Statement. Use of capnography to reduce the incidence of adverse respiratory events. Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. Level B recommendation. Routine use of capnography appears to decrease the incidence of hypoxia and respiratory events. Lack of evidence that capnography reduces the incidence of serious adverse events during procedural sedation and analgesia such as neurologic injury caused by hypoxia, aspiration, or 10

12 death. Burton F UK (7) Prospective studies of emergency department patients undergoing procedural sedations. Best Bet systematic review. Adverse events including hypoxia, hypercarbia, or apnea. 1 study demonstrated a statistically significant decrease in hypoxic events with the use of capnography. Most had methodological issues. Capnography may provide early warning of ventilatory changes that could result in hypoxia FOAM resources The Resus Room Podcasts Papers of the Month for October 2016 (8) discussed the Dewdney et al systematic review and also concluded that whilst there is no definitive evidence of reduced mortality with the use of capnography, it s still recommended in conjunction with monitoring other clinical signs. EMCRIT podcast 2 discusses the utility of capnography in a variety of emergency department situations and has hugely informed my practice since I first listened in 2009 (9). Interestingly capnography is NOT mentioned in the section on monitoring in the RCEM learning module on safe sedation published in (10). In conclusion it appears that there is clear evidence that capnography may decrease the incidence of hypoxia and allow earlier identification of hypoventilation. However this does not clearly correlate with reduced adverse outcomes. The papers reviewed have significant heterogeneity as to the definition of an adverse event and most authors concluded that early recognition of a potential respiratory problem may allow management before it has progressed to an adverse event. As ever it is suggested that more evidence is required, involving appropriately powered randomised clinical trials with accepted adverse incident definition and tools to give a definitive answer. I was aware that definitive evidence of capnography improving patient safety related clinical outcomes was lacking, but it seemed to me that by standardizing the quality of our sedation practice through the use of 11

13 capnography we would potentially reduce the chance of an adverse event occurring, although I could see there was no firm evidence base for this. The bottom line at present as echoed by the joint statement of the RCEM and RCOA is that capnography should be utilised for all ED procedural sedations. RCEM / RCOA Joint statement from Safe Sedation of Adults in the Emergency Department: Report and recommendations by The Royal College of Anaesthetists and The College of Emergency Medicine Working Party on Sedation, Anaesthesia and Airway Management in the Emergency Department,November 2012 (4): The use of continuous capnography is mandatory wherever deep sedation, dissociative sedation, general anaesthesia or RSI occurs (i.e. whenever it is anticipated that verbal contact with the patient will be lost), except in rare cases where it would substantially interfere with surgical access. Capnography is also recommended at lighter levels of sedation; this is an emerging area of practice, and the use of capnography is expected to become routine. RCEM procedural sedation audit standards section 5, monitoring: Monitoring during procedural sedation must be documented to have included all of the below a. Non-invasive blood pressure b. Pulse oximetry c. Capnography d. ECG Capnography - Sedation is a continuum. It is not always possible to predict the level of sedation in advance, therefore in this audit capnography is a standard for all sedation levels (4). By adhering to national and college guidelines and using capnography I felt we would be potentially improving patient safety, the main aim of my QIP. 12

14 STRUCTURE AND IMPLEMENTATION OF CHANGE My first step in the QIP process was to check with other members of the department that this was an appropriate area to consider and focus on. I discussed it with our QI lead Dr M Jones and my Educational Supervisor Dr S Shewring, as well as my registrar colleagues. This was very helpful as I had not been involved in the process before and I appreciated their support and endorsement. Dr Jones confirmed that anecdotally procedural sedation as a whole was an area identified as a potential patient safety issue, and that by updating the departments policy there would be departmental benefit. He explained that the department had not taken part in the national RCEM audit as the data collection system and lack of standardized approach was not felt to be robust enough. By focusing on the area as part of my QIP there were clear departmental benefits as well as the clear potential individual patient safety benefit. I hoped to enable the department to be able to take part in future national RCEM audit, which would then have a national benefit too. I then knew I needed to formally present the proposal at the department senior meeting when I had reviewed the evidence base, to get the approval of our clinical director and the consultant body. After reviewing the NHI website I knew I wanted to use a Model for Improvement Methodology to implement the changes I had proposed (2). The proposed changes related back to the problem I had identified with my initial patient in resus undergoing sedation lack of capnography and lack of a sedation proforma which I felt were below the required standards and a potential patient safety problem. In order to change this I wanted new equipment, a new proforma and then widespread teaching / education. Each happened iteratively, over several weeks then months, as when the equipment was finalized I realized I needed the proforma to highlight its use, and ongoing education about sedation in general to improve compliance and so hopefully patient safety. Equipment: I approached the relevant stakeholders regarding changing our capnography monitoring equipment. In my department this was Lead Nurse Mr K Randall and Clinical Director Dr S Spencer. They were very helpful and agreed that if a standard for monitoring patients existed we should be meeting this 13

15 standard. I therefore organised a meeting in mid-november 2016 with the man in charge of ordering our equipment Mr Jeremy Clare. I spoke to Mr Clare who put me in touch with a rep for the company Flexicare Medical who manufactured the capnography equipment we used currently. I ordered a copy of their catalogue and was able to see the required nasal capnography device. Fig 2. Proposed practice examples: After a series of s I arranged a face to face meeting whereby they agreed to provide samples of the potential nasal capnography monitoring set and get unit pricing. I trialed this over a 2 week period by showing it to the other senior doctors and getting their approval, as well as talking to the resus nursing staff. The feedback was almost universally positive and as the company agreed a competitive price and so I submitted a short a formal business case (in appendix) to get approval to stock the device. We ordered a run of 50 initially and then planned to re-order on a monthly basis dependent on demand. 14

16 Plan: Discuss current equipment options. Trial existing techniques Act: Equipment ordered and rolled out for use. Do: Under mask capnography trialled personally - flawed technique Study: Alternative equipment obtained and used. Feedback from colleagues sought. Proforma From my initial audit I was able to see that the departmental sedation proforma was no longer fit for purpose as it did not include much of the information required to complete the RCEM audit standard. In particular there was no mention of capnography in its monitoring requirements. I was aware that one of my registrar colleagues was also interested in sedation and had been meaning to update the sedation proforma. I therefore collaborated with him and the proforma we decided upon was a hybrid of a version used in the Royal Gwent Hospital where we had both worked (with their approval) and our own research into what was required. This proforma (included in the appendix) was presented at the department senior meeting on December 21 st along with a description of the QIP process and my project. It was attended by the CD of the department Dr S Spencer and the QI lead Dr M Jones. I discussed the results of my literature 15

17 review and audit findings, highlighting the potential for improvement. It was formally signed off without any required changes and agreed that we would use it in place of the previous proforma from then on. Plan: Review current proforma Act: Use new proforma for all ED sedations. Do: Design updated proforma including pre-assessment and capnography monitoring sections. Study: Take updated proforma to senior medical and nursing staff. Sedation Log / data capture One of the biggest difficulties I had initially with the project was the data gathering in terms of numbers of sedations carried out in the department and patient details. My plan to increase the capture was to introduce a sedation log in resus itself, whereby anytime a sedation proforma was taken from the sedation drawer a patient label was to be placed in the log in the same drawer. To further increase chances of successfully capturing all patients who were sedated and in whom a proforma was used I provided a clearly labelled folder to reception to collect the sedation forms in, and sent it to Lousie 16

18 Carver to add to the admin handbook as an official process. Education Once the equipment and proforma were in place I felt the main part of my QIP would in raising awareness of the changes. I wanted to achieve an intentional Hawthorne effect, as by knowing that our sedations were being reviewed the compliance with the basic standards may improve. I felt even these simple interventions would hopefully improve standards and therefore potentially increase patient safety. I would then adapt and modify the teaching as part of smaller PDSA cycles depending on uptake. Departmental teaching I designed a basic PowerPoint education package which I have presented monthly at junior and senior ED departmental teaching, encompassing information on the definitions of sedation, safe sedation practice, the RCEM standards and my QIP process. The slides are in the appendix. After presenting this at the weekly departmental teaching for the new junior doctors staff, senior teaching for the registrars, ENP ANP s and consultants I was reasonably happy I had been able to reach the majority of our long term medical / nurse practioner team. I struggled however to reach a lot of the nursing staff. I applied to teach at the protected nursing study days but unfortunately they were very infrequent. Also the much larger number of nursing staff made it difficult to reach them all. This was one of the biggest difficulties in the QIP and so it took me a little while to work out an appropriate strategy. 17

19 Plan: Disseminate information to ED Staff at initial departmental and induction teaching. Aim to teach at nursing study days. Act Develop online resource to target nursing education. Do: Junior and Senior departmental Dr teaching throughout December and January. Contact nursing education lead. Study Well recieved doctor teaching, unable to formally teach nursing staff.december compliance with capnography 82% Online Survey In order to maximise the number of people I could give formal procedural sedation teaching to and educate on the RCEM standards, I felt I needed an online or easily accessible resource that I could send out to all staff. In particular I wanted to target the nursing staff. I really felt I wanted to engage as many people from my department as possible in my QIP and by educating them about what I hoped to achieve would be able to improve standards and so quality. Therefore in mid-january (whilst the QIP process was ongoing) I designed and sent out a Survey monkey survey and educational package. The survey included the definitive standards or answers, and a picture of the new proforma and the new capnography nasal cannulae. It also highlighted the mandatory nature of the new proforma for all 18

20 ED sedations. In this way I was able to assess background knowledge and impart the standards I hoped to improve. The survey was sent to all the POW nursing and medical staff. The data gathered has enabled me to more accurately structure my teaching sessions as it highlighted the areas of potential ignorance of the standards. In total there were 36 respondents out of approximately 80 total staff surveyed (45%). The poor response rate is likely to be multi-factorial but also maybe partly due to using peoples work . Table 3. Survey Results. RCEM Standard 1: Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment, including ASA grading, Prediction of difficulty in airway management and Pre-procedural fasting status. 2. There should be documented evidence of the patient s informed consent unless lack of mental capacity has been recorded. 3. Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities 4. Procedural Sedation requires the presence of all of the below:- Dr- Nurse- Proceduralist 5. Monitoring during procedural sedation must be documented to have included:- ECG- Oxygen saturation- Blood Pressure- End tidal Co2 6. Oxygen should be given from the start of sedation until discharge from recovery Correct responce to survey Yes, all of the above:89% Yes97% Yes 100% Yes, all of the above:100% Yes, all of the above:100% Yes80% 7. Following procedural sedation, patients Yes, all of the above:100% should only be discharged after documented formal assessment of suitability, including:- Return to baseline level of consciousness- Vital signs within normal limits for the patient- Absence of respiratory compromise- Absence of significant pain and discomfort- Written advice on discharge for all patients 19

21 Overall I think the responses were positive and hopefully show the multiple teaching sessions I have put on were successful. I was aware that I had potentially missed an important area of the ED workforce thus far the locum doctors or doctors from other specialties who visit the department. The new sedation proforma would help, but we are fortunate to have an online departmental handbook which sets out all the acceptable standards and is a fantastic resource. I knew that updating this would further provide 24/7 guidance on the standards we required. It would also provide long term continuity for the new starting medical team who rotate regularly through the ED. Departmental handbook. Having reviewed the RCEM guidance on Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department (11) I found that there was a summary of recommendations: 1. Every Emergency Department should have a procedural sedation policy that is regularly reviewed and audited. 2. The procedural sedation policy should provide guidelines for pharmacological agents that are routinely used in the Department. 3. A pro-forma should be used for procedural sedation and analgesia (PSA) as a checklist and as an auditable record of the procedure. 4. Adverse events should be reported using the SIVA reporting tool I decided I would aim to meet these recommendations as part of my QIP. Number 1 was met through my ongoing PDSA process looking at compliance with RCEM guidelines, and the departmental annual audit. To meet the second I decided to update out departmental ED handbook sedation section. This was already a comprehensive set of local guidelines but only included advice on the dosing and administration guidelines for Midazolam. To update this I used the table from the Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department (11) document, and 20

22 included advice about the adverse incident reporting tool. I am indebted to Dr M Jones who produces the handbook for his help with this document. Our new departmental proforma met the third and fourth recommendations, and a link in the departmental handbook goes to the SIVA tool. I have included my updated chapter in the appendix. Plan: Develop 24/7 available departmental guidelines for ED sedation Act: Handbook live and available 24/7 Do: ED online handbook adapted and updated using RCEM guidance on pharmacological agents and audit standards. Study: Audit of compliance with standards up to 100% 21

23 MEASURING OUTCOMES AND RESULTS I continuously analysed the same RCEM standards from initiation of the QIP. Despite my best efforts to ensure all sedation proformas were collected in a designated folder in reception and a sedation log was kept in resus I became aware I was missing data. I therefore also went back to my initial technique of cross referencing all the patients who received drugs signed out of the Omnicell each month. This is a more robust system, but much more time consuming, as it then involved reviewing the scanned results to look for the proforma and collate the data. I collected data on all the procedural sedations done in December 2016, and January to March Table 4. Post QIP proforma use Month Proforma use December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% Table 5. Post QIP RCEM Standard Results Standard Month Compliance Percentage 1 Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment, including: 1a ASA grading December 9/11 82% January 16/16 100% 22

24 1b Prediction of difficulty in airway management. February 13/13 100% March 13/13 100% December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 1c Pre-procedural fasting status December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 2 There should be documented evidence of the patient s informed consent unless lack of mental capacity has been recorded December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 3 Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities. December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 4 Procedural sedation requires the presence of all of the below: 4a a doctor as sedationist December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 4b a second doctor, ENP or ANP as procedurist December 8/11 73% January 11/16 69% February 9/13 69% March 7/13 54% 23

25 4c a nurse December 8/11 73% 5 Monitoring during procedural sedation must be documented to have included all of the below: January 9/16 56% February 7/13 54% March 9/13 69% 5a Non-invasive blood pressure December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 5b Pulse oximetry December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 5c Capnography December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 5d ECG December 9/11 82% January 16/16 100% February 13/13 100% March 13/13 100% 6 Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area. December 9/11 82% January 11/ February 13/13 100% March 13/13 100% 7 Following procedural sedation, patients should only be discharged after documented formal assessment of suitability, 24

26 7a 7b 7c 7d 7e including all of the below: Return to baseline level of consciousness Vital signs within normal limits for the patient Absence of respiratory compromise Absence of significant pain and discomfort Written advice on discharge for all patients December 3/11 28% January 3/16 19% February 3/13 23% March 7/13 54% December 3/11 28% January 3/16 19% February 3/13 23% March 7/13 54% December 3/11 28% January 3/16 19% February 3/13 23% March 7/13 54% December 3/11 28% January 3/16 19% February 3/13 23% March 7/13 54% December 3/11 28% January 3/16 19% February 3/13 23% March 7/13 54% The main outcome data I was focused on was sedation proforma use and capnography for all sedations. This goes back to my patient story and aim. Prior to my QIP proforma use was actually very good at 14/15 or 93%. However, capnography was only used in 2/15 or 14%. Following my intervention proforma use remained very high (averaged for December, January, February and March 96%) and most importantly capnography use went up to and stayed at 100 %. Therefore all ED sedations undertaken in our department used end-tidal CO2 monitoring and in my eyes were much safer because of it. This clearly demonstrates an improvement in quality as defined by the RCEM 25

27 sedation guidelines and audit. Table 6. Proforma use Pre QIP Proforma use Post QIP Proforma use 14/15-93% Average 51/53 96% December /11 82% January /16 100% February /13 100% March /13 100% Run chart 1. Proforma use Percentage 120 ED Procedural Sedation Proforma Use 100 Goal Median Pre-QIP Baseline Intervention 2. Intervention Intervention 1. Start QIP 0 Jul/Aug 2016 Dec-17 Jan-17 Feb-17 Mar-17 Intervention 1. Start QIP. New proforma, new capnography equipment. Induction teaching for junior medical staff and senior medical teaching. Intervention 2. Online Survey Intervention 3. ED Handbook updated. 26

28 Table 7. Capnography use Pre QIP Capnography use Post QIP Capnography use 2/15 (14%). Average 51/53 96% December /11 82% January /16 100% February /13 100% March /13 100% Run Chart 2. Capnography use. Percentage 120 ED Procedural Sedation Capnography Use. 100 Goal Median Intervention Intervention 1. Start QIP Intervention3. 0 Jul/Aug 2016 Dec-16 Jan-17 Feb-17 Mar-17 Intervention 1. Start QIP. New proforma, new capnography equipment. Induction teaching for junior medical staff and senior medical teaching. Intervention 2. Online Survey Intervention 3. ED Handbook updated. 27

29 DISCUSSION. My QIP has improved our ED procedural sedation practice with a significant increase in the use of capnography for procedural sedation. 100% of ED sedations in the last 3 months have used a sedation proforma and capnography. After appraising the available evidence I feel that this is an important improvement as the use of capnography, in conjunction with measuring other physiological parameters, may decrease the incidence of hypoxia, and allow earlier identification of hypoventilation, potentially reducing adverse outcomes. This related back to my patient story and I feel that now it would be very unlikely for me to go into resus and find a patient sedated without having undergone a comprehensive pre-sedation checklist and with no capnography monitoring in situ. I hope to have improved patient safety through the changes implemented and achieved my aim. The improvement is probably related to 2 main interventions the new sedation proforma and the repeated educational packages I carried out to inform staff of the RCEM sedation standards. Firstly the new sedation proforma includes capnography on the pre procedural checklist. This therefore ensures it is both considered and used for all sedations. The proforma also includes all the data required to complete the RCEM audit on procedural sedation, allowing us to audit our practice. The new nasal capnography devices are a more appropriate measuring device, providing more quantitative data which can be used to guide depth of sedation and highlight apnoea earlier than oxygen saturation alone. Secondly the series of educational packages and teaching I carried out, including an online survey and updating our departmental handbook have meant that the majority of staff (medical and nursing) involved with procedural sedation in our department are aware of the changes and are using the proforma and capnography for all sedations. This is important as given the nature of the ED there is the potential for locum staff or doctors from other specialties like anaesthetics carrying out sedation. Because the handbook is online and now updated to include the proforma and the RCEM monitoring and drug dosing guidelines it is always available as a resource. And as all the senior nurses are aware 28

30 that proforma use is mandatory this should occur irrespective of who is carrying out the sedation. In retrospect I would have liked to include a written feedback aspect to my online survey from the nursing staff, asking them if they felt there were any important areas to improve on from their point of view. It may have highlighted other things I have not considered. Reviewing the data I think the discrepancy in December (only 82% proforma and capnography use) was related to the fact that the QIP really only started on the 21 st of December. Therefore the first 2 weeks of data included the 2 sedations which took place without a proforma and so no capnography. It was very satisfying to see that following the new proforma being available its use and so subsequently capnography use went up to and stayed at 100%. Despite meeting my primary QIP objective this work has highlighted areas of our sedation practice to improve upon. In particular the documentation of the 3 staff required for sedation (doctor, nurse and procedurist) was not always completed fully. I think in the majority of cases this is likely to be an oversight but potentially at times of departmental pressure sedations may be taking place with less than the safe staffing ratio. I plan to further update the proforma to clarify this mandatory standard. Another area highlighted by the project is the post sedation assessment was poorly completed. Prior to the QIP it was only completed around 11% of the time and in March 2017 it was 54%. This was an increase but still an area for improvement. In many cases this may be because the patient was going to be admitted to the hospital and so it was felt to be somebody else s responsibility, however the RCEM standards are clear that all patients need a post sedation assessment and so I need to continue to highlight this to our staff. I have included a line on this in the handbook, and will highlight it in induction teaching. It s particularly important as it s an area to assess patient satisfaction, which is not something I have specifically focussed my QIP upon (potential patient safety being the problem I identified and aimed to change) but in terms of the patients experience of sedation they may be less aware of the safety implications and actually care more about subjective outcomes like pain and awareness, which are picked up post sedation. I have also asked this to be included in the ongoing departmental sedation audit. 29

31 A very satisfying part of the completion of the QIP is that our department is now in a position to participate in the national RCEM audit of procedural sedation for 2017/2018, and has signed up for data collection this year. This is a direct response to the project as we are now in a position to supply the data required and have a proforma that is fit for purpose. In a small way there have been both patient, departmental and national benefits although I am in no way trying to over exaggerate the projects significance! I became aware our post sedation written advice was out of date, and so I have been involved in the wording and ordering of more current written discharge advice for the department. These have not yet arrived, but are vital from a patient education and governance standpoint to explain what we have done and what to expect. In retrospect I would like to have carried out comprehensive review of any prior Datix or possible significant events that occurred in the department prior to my QIP. Since the evidence base has shown no clear patient safety outcome data to show that capnography improves mortality it would have been nice to have data supporting its use. However by the time I started to write this discussion and realised the omission I hadn t heard back from the governance department. Nothing had been specifically raised in the 2 prior audits I reviewed from 2011 and The QIP project was presented in poster format at the All Wales School of Emergency Medicine (AWSEM) annual education day and was well received as a concept and a demonstration of improvement. REFLECTION. The QIP process has made me far more appreciative of the difficulty in bringing about even small change in practice. I was entirely naive as to how long the process would take, and found things like waiting for s to be replied to or the limited availability of study days very frustrating! It was also interesting to appreciate that different people in the department wanted different kinds of evidence prior to adopting the new standards. Some wanted the literature base, some were interested in the practicalities of the equipment or cost, and so addressing all these points had to take place prior to 30

32 starting. It made me realise that all considerations must be addressed and relevant stakeholders consulted prior to simply changing something on my own. I now appreciate that larger projects will encounter far more roadblocks unless they can address multiple different concerns. Overall I think the QIP has been most beneficial for potential patient safety by improving monitoring standards and standardising sedation practice, but also beneficial to me in developing an understanding of the quality improvement process. I hope to take this on with other projects and potentially supervising them as I complete my training. It has made me appreciate that even when you think you have identified a small problem (no capnography during sedation) and a clear solution (start using capnography) the objective steps needed to get there and justify this change feel huge and things escalate quickly. I have found it difficult to maintain oversight in the writing up process of a piece of work that takes place over many months. I found it hard not to become repetitive and to remain focussed on a specific narrative. I can imagine the larger the project and the more people involved the harder this may be. I am also aware that I work in a cooperative department which was incredibly supportive and agreeable to change but this may not always be the case. Potentially there may be situations in which other stakeholders do not want things to change in the same manner and raise additional problems. I am confident the observed improvement will be maintained. This is because proforma use has been excellent (100% use in the last 3 months) and the handbook is available online for everyone. The only potential time for change would be if the RCEM guidelines changed or there was a significant event which prompted it. I believe this would be covered by the department s robust internal audit and governance structure. I aim to add a post sedation assessment aspect to the ongoing departmental audit to improve awareness of this area too. In conclusion I feel that my QIP has successfully raised the overall standard of procedural sedation in our department as measured against RCEM standards. Going back to my initial patient I believe she now would not require two sedations as the first would have been carried out successfully, and her 31

33 safety as measured by a pre-sedation assessment and intra-sedation monitoring with capnography would be improved. 32

34 Plan, Do, Study, Act (PDSA) Summary Aim: Improve Quality of Emergency Department Sedation Practice. Describe your first (or next) test of change: Person responsible When to be done Where to be done We aim to improve the Tim Ayres quality of sedation practice as measured by use of capnography for every sedation in the ED at the Princess of Wales Hospital, Bridgend. December 16 to March 17. POW ED Plan: Predict what will happen when the test is carried out I aim to increase compliance with capnography in particular to 95% of all sedations (ideally 100%), and ensure an up-to-date sedation proforma is used every time. Measures to determine if prediction succeeds Improvement in compliance with RCEM standards, in particular use of capnography. Proforma used for every sedation. List the tasks needed to set up this test of change Develop new proforma Tim Ayres / Nabeel Jemar Person responsible When to be done Where to be done November 16 POW ED Review previous performance Tim Ayres November 16 POW ED Order new equipment Tim Ayres November 16 POW ED Start education program Tim Ayres December 16 POW ED Continuously analyse Tim Ayres December 16 March POW ED 33

35 performance monthly 17 Do: Describe what actually happened when you ran the test In December 2016 I presented results showing our current sedation performance data and my plans to improve this. These included the new sedation proforma, new capnography equipment and an educational program. In December I did a teaching session for the junior and senior emergency medical staff, followed by a session for the emergency nursing staff. Initially the uptake was good, but due to the difficulty in getting all staff members to attend these sessions I then designed an online survey which allowed me to further disseminate the RCEM sedation standards. This went out in Feb I then also updated our departmental handbook, so there was an online reference for all staff. Finally in March 2017 I realized our post sedation advice sheets were not current so have ordered these, reflecting our current practice. Study: Describe the measured results and how they compared to the predictions Audit of procedural sedation practice prior to my QIP: 15 patients in June/July 2016: proforma used 14/15 (93%), and capnography used in 2/15 (14%). Following QIP start December 2016 to March 2017: Overall both proforma (51/53-96%) and capnography (96%) use increased to 96% of all sedations (100% for the last 3 months Jan March 2017). This was very satisfying and met my predicted improvement. With widespread education of the required standards all sedations carried out in the ED over the last 3 months have used capnography monitoring, and a proforma that guides good practice and allows meaningful data collection. Act: Describe what modifications to the plan will be made for the next cycle from what you learned? I plan to continue to give induction teaching to the new medical staff at the regular induction sessions, and then delegate the slide set to colleagues when I leave. This in collaboration with the online 34

36 handbook should continue to emphasize the required standards and ensure long term improvement / compliance. Ongoing departmental and national audit participation will continue and even start in the case of participation in the 2017/2018 national RCEM audit. The only further area to improve I have highlighted from my QIP is that the post sedation return to normal cognition / vital signs is poorly completed and so this area needs to be addressed. Also our departmental post sedation advice sheets were out of date and so new re-worded copies have been ordered. 35

37 PDSA SUMMARY. ACT: Continued use of nasal capnography and the new proforma for all sedations. Regular induction training. New post sedation discharge advice. Regular audit PLAN The quality of our sedation practice will improve. I aim to increase compliance with capnography in particular to 95% of all sedations (ideally 100%). - Audit previous performance - Develop new proforma - Order new equipment - Start education program - Re-audit performance monthly STUDY: 15 patients in June/July 2016: proforma used 14/15 (93%), and capnography only used in 2/15 (14%). Following QIP start December 2016 to March 2017: Overall both proforma and capnography use increased to 96% of all sedations (100% for the last 3 months). DO: New proforma and capnography introduced December Education to medical and nursing staff. -Online survey and education Feb 16 - Monthly audit ED handbook updated 36

38 REFERENCES 1. PDSA Methodology, How To Improve, Institute for Healthcare Improvement Improving Quality Together Bronze Level. NHS Wales. Occupational Knowledge and Skills The Royal College of Emergency Medicine Clinical Audits: Procedural Sedation in Adults, : bf57d94bba8d 4. Safe Sedation of Adults in the Emergency Department: Report and recommendations by The Royal College of Anaesthetists and The College of Emergency Medicine Working Party on Sedation, Anaesthesia and Airway Management in The Emergency Department,November ED2012.pdfR 5. Dewdney C, MacDougall M, Blackburn R, Lloyd G, Gray A. Capnography for procedural sedation in the ED: a systematic review. Emerg Med J Aug 26. pii: emermed doi: /emermed [Epub ahead of print] 6. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Procedural Sedation and Analgesia. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Annals of Emergency Medicine Volume 63, Issue 2, February 2014, Pages e18 7. Burton F. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: should capnography be routinely used during procedural sedation in the Emergency Department?. [Review] Emergency Medicine Journal. 29(2):164-6, 2012 Feb. 37

39 8. Simon Laing and Rob Fenwick. The Resus Room Podcast. October 2016 papers of the month. 9. Scott Weingart. The Emcrit podcast. Episode 2, May Duncan R, Thakore S. Safe sedation procedures in adults : Learning session. October The Royal College of Emergency Medicine Best Practice Guidelines: Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department. May %20Agents%20for%20Procedural%20Sedation%20and%20Analgesia%20(June% ).pdf 38

40 Appendix 1. New POW ED sedation proforma 39

41 40

42 2. Business case for capnography Proposal Summary This business case concerns the ordering of nasal capnography monitoring from Flexicare medical. These would be used to perform capnography monitoring on all sedated patients or patients whom ventilation requires monitoring (opiate overdoses etc). Existing Service / Facility Capnography monitoring is not always utilised currently and if it is a sampling line is placed under a non re-breather mask. This can potentially dislodge and often gives variable readings. Objectives To enhance the quality of patient care by capnography monitoring as per RCEM 2015/2016 standards. This may identify patients at risk of apnoea or airway complications earlier, enabling effective airway manoeuvres top prevent patient harm. Strategic Fit It is a RCEM and RCOA standard that patients undergoing procedural sedation should have capnography monitoring. Benefits Patient benefits early identification of oxygenation / ventilation problems. Reduced time to definitive intervention if required. Significant Factors in Support of the Case RCEM / RCOA guidelines mandate this. Financial Implications The line cost was approximately 3, depending on quantity. This in comparison to the financial implications of a sedation complication are seemingly small. Risks No risks to patients in addition to the current technique Support for the Case Emergency department, Anaesthetic Department. Project Sponsor Dr Tim Ayres ST6 Emergency Medicine, Dr Amanda Farrow, Consultant in Emergency Medicine 41

43 3. Powerpoint senior meeting slides December 2016 Procedural Sedation Quality Improvement Project. Tim Ayres ST6 EM Summary of recommendations 1. Every Emergency Department should have a procedural sedation policy that is regularly reviewed, and audited 2. The procedural sedation policy should provide guidelines for pharmacological agents that are routinely used in the Department 3. A pro-forma should be used for procedural sedation and analgesia (PSA) as a checklist and as an auditable record of the procedure 4. Adverse events should be reported using the SIVA reporting tool Procedural sedation QIP. My QIP is to improve our procedural sedation performance as defined by the RCEM standards, in particular focussing on the use of capnography which RCEM has defined as mandatory for all sedations. Standards Current Practice Change in Practice. Improve quality... RCEM Standards 1. Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment, including ASA grading Prediction of difficulty in airway management Pre-procedural fasting status 2. There should be documented evidence of the patient s informed consent unless lack of mental capacity has been recorded. RCEM guidelines published 2012 and audited 2015, pharmacological agents reviewed RCEM Standards 3. Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities. 4. Procedural sedation requires the presence of all of the below a doctor as sedationist a second doctor, ENP or ANP as procedurist a nurse 42

44 RCEM Standards Current proforma 5. Monitoring during procedural sedation must be documented to have included all of the below Non-invasive blood pressure Pulse oximetry Capnography ECG RCEM Standards Proposed proforma 6. Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area. 7. Following procedural sedation, patients should only be discharged after documented formal assessment of suitability and record of return to baseline. Audit 15 cases June Jul 2016 Very difficult to track sedations by coding. Compliance highly related to proforma... Importantly for my QIP only 2/15 cases had documented use of capnography. 43

45 4. ED and Induction teaching slides Slide 1 Slide 4 Tim Ayres Is a spectrum from mild reduction of anxiety to general anaesthesia and so the monitoring and pre sedation work up must reflect this. There is no one specific best sedation drug but all have recognised side effects, and dosing strategies. Unless in an emergency (life / limb) sedation should only be carried out or supervised by senior doctors with airway training. Slide 2 Slide 5 My QIP is to improve our procedural sedation performance as defined by the RCEM standards, in particular focussing on the use of capnography which RCEM has defined as mandatory for all sedations. Standards Current Practice Change in Practice. Improve quality... Slide 3 Procedural sedation and analgesia, previously referred to as conscious sedation, is defined as "a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardio-respiratory function." Slide 6 Summary of recommendations 1. Every Emergency Department should have a procedural sedation policy that is regularly reviewed, and audited 2. The procedural sedation policy should provide guidelines for pharmacological agents that are routinely used in the Department 3. A pro-forma should be used for procedural sedation and analgesia (PSA) as a checklist and as an auditable record of the procedure 4. Adverse events should be reported using the SIVA reporting tool 44

46 Slide 7 Slide Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment, including ASA grading Prediction of difficulty in airway management Pre-procedural fasting status 2. There should be documented evidence of the patient s informed consent unless lack of mental capacity has been recorded. 6. Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area. 7. Following procedural sedation, patients should only be discharged after documented formal assessment of suitability and record of return to baseline. Slide 8 Slide Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities. 4. Procedural sedation requires the presence of all of the below a doctor as sedationist a second doctor, ENP or ANP as procedurist a nurse 15 cases June Jul 2016 Very difficult to track sedations by coding. Compliance highly related to proforma... Importantly for my QIP only 2/15 cases had documented use of capnography. Slide 9 Slide Monitoring during procedural sedation must be documented to have included all of the below Non-invasive blood pressure Pulse oximetry Capnography ECG 45

47 Slide 13 Slide Only a doctor who has received training in sedation and basic life support can administer intravenous sedation. 2. There must be at least 2 doctors present within the department. 3. Adequate numbers of trained nursing staff must be present within the department to assist during the procedure and to recover the patient Patient in room with full resuscitation equipment. 11. Patient connected to pulse oximeter, ECG monitor & BP cuff. CAPNOGRAPHY 12. Patient connected to supplemental oxygen. 13. Intravenous cannulae inserted and checked. 14. Naloxone and flumazenil should be immediately available (out of cupboard, not drawn up). Slide 14 Slide After 12 midnight (or when ED middle grade leaves department), intravenous sedation should only be used for life or limb threatening situations, and if all other criteria are met. Simple fractures (eg Colles) should be given analgesia and a POP and asked to return for manipulation at 9am. Other urgent procedures requiring intravenous sedation must be undertaken in the operating theatres 15. Inject intravenous midazolam slowly 1mg at a time (no more than 10mg) until the patient is drowsy. Verbal contact should be maintained at all times and the patient able to respond to simple physical stimuli. 16. After procedure, as painful stimuli is reduced, level of sedation often deepens so the patient should be monitored closely. Slide 15 Slide Patient must be 14 years or older. 6. Patient should be starved for 4 hours. 7. Pre-sedation checklist (including signed informed consent) must be completed by doctor undertaking procedure. 8. Observations recorded as per sedation sheet. 9. Patient on tiltable trolley. 17. No patient is to receive a second dose of sedation in the emergency department (Speciality teams CAN NOT overrule this without agreement from the ED Consultant). 18. Ensure post procedure checklist followed including written discharge advice. 46

48 Slide 19 Slide 22 New sedation proforma compulsory for every sedation New end tidal carbon dioxide monitoring for every sedation The use of continuous capnography is mandatory wherever deep sedation, dissociative sedation, general anaesthesia or RSI occurs (i.e. whenever it is anticipated that verbal contact with the patient will be lost), except in rare cases where it would substantially interfere with surgical access. Capnography is also recommended at lighter levels of sedation; this is an emerging area of practice, and the use of capnography is expected to become routine. Slide 20 Slide 23 Measures expired carbon dioxide Important because it monitors ventilation not just oxygenation. The sats probe is a time machine and not safe to use alone for monitoring of sedated patients receiving supplementary oxygen. Pre-oxygenated patients may have sats of 100% despite not having breathed for minutes their carbon dioxide goes up making them acidotic and they can potentially arrest! Sedation is not analgesia Different drugs have different side effects Common practice to give iv analgesia first then sedation drug Historically morphine and midazolam now often fentanyl and propofol Ketamine is a dissociative sedative with analgesic and sedation properties. Slide 21 Slide 24 Propofol. Pros Quick acting, good deep sedation and amnesia Cons- Can cause hypotension and apnoea. Fentanyl Pros - Synthetic opiod. Quicker onset than morphine Cons - apnoea 47

49 Slide 25 Slide 26 Midazolam Pros- most people have experience with it. Reversible. Amnesic properties Cons slow onset time 5-10mins. Variable sedation. Long acting Ketamine Pros analgesia, amnesia, and sedation. Cons emergence phenomenon, vomiting, apnea. All ED sedations need a pre-sedation proforma completed please. All sedations need capnography monitoring no capnography - no sedation. Joint medical and nursing responsibility to maintain these standards and make it usual practice. Drugs used depend on level of training and competence. 48

50 5. Survey monkey slides Procedural Sedation in the Emergency Department. Introduction Procedural sedation is an important area of emergency medicine, enabling potentially painful or distressing conditions to be treated. There are potential risks though, and so it needs to be standardised and monitored effectively. The Royal College of Emergency Medicine has published standards for sedation and I would like to assess your knowledge of these standards. At the end of the survey I have included the answers so we all know the standard we are aiming for. We will be auditing our compliance with these standards by looking through every sedation proforma on a monthly basis. I would like to remind everyone (including visiting specialties like anaesthetics) that it is mandatory to use a sedation proforma for every sedation in the ED. 1. Standard 1. Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment, including: ASA grading Prediction of difficulty in airway management Pre-procedural fasting status All of the above 2. Standard 2. True or false: There should be documented evidence of the patient s informed consent unless lack of mental capacity has been recorded. True False 3. Standard 3. True or false: Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities. True False 4. Standard 4. Procedural sedation requires the presence of all of the below: A doctor as sedationist A second doctor, ENP or ANP as procedurist A nurse All of the above 5. Standard 5. Monitoring during procedural sedation must be documented to have included: Non-invasive blood pressure Pulse oximetry Capnography 49

51 ECG All of the above 6. Standard 6. True or false: Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area. True False 7. Standard 7.Following procedural sedation, patients should only be discharged after documented formal assessment of suitability, including: Return to baseline level of consciousness Vital signs within normal limits for the patient Absence of respiratory compromise Absence of significant pain and discomfort Written advice on discharge for all patients All of the above ANSWERS Thanks a lot for completing the survey. Here are the answers / college standards. Its important we try to complete each sedation proforma completely to make sure we meet these standards. : 1. Patients undergoing procedural sedation in the ED should have documented evidence of preprocedural assessment, including all of : a. ASA grading b. Prediction of difficulty in airway management c. Pre-procedural fasting status 2. There should be documented evidence of the patient s informed consent unless lack of mental capacity has been recorded. True 3. Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities. True 4. Procedural sedation requires the presence of all of the below: a. A doctor as sedationist b. A second doctor, ENP or ANP as procedurist c. A nurse 5.Monitoring during procedural sedation must be documented to have included all of the below: a. Non-invasive blood pressure b. Pulse oximetry 50

52 c. Capnography d. ECG 6. Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area: True 7. Following procedural sedation, patients should only be discharged after documented formal assessment of suitability, including all of the below: a. Return to baseline level of consciousness b. Vital signs within normal limits for the patient c. Absence of respiratory compromise d. Absence of significant pain and discomfort e. Written advice on discharge for all patient 51

53 6. Departmental Handbook SEDATION KEY DATA When sedating a patient always have a senior doctor present, full resuscitation equipment, pulse oximetry, end tidal CO2 monitoring and supplemental oxygen. A combination of two respiratory depressants (opiates and benzodiazepines) can result in respiratory arrest. Give opiate analgesia prior to the x-ray that way, when giving sedation prior to manipulation, titrating the sedation is easier, and may reduce the sedation requirements. Effective procedural sedation requires: Analgesia: Pain experienced by the patient should be treated with analgesia rather than sedation. Pain should be assessed and managed prior to starting sedation using the WHO pain ladder principles and the need for ongoing pain relief post-procedure considered. Where opiate pain relief has been given prior to PSA, doses of sedatives should be adjusted accordingly. Anxiolysis: Non-pharmacological methods of reducing anxiety are often the most effective and include consideration of the environment and patient comfort. Environment is particularly important for children and patients with dementia or learning difficulties. Family members often provide invaluable support and distraction. Most painful procedures are best performed with the patient supine. Sedation: For most procedures in the ED, the level of required sedation will be moderate to deep, this should be determined in advance. Amnesia: A degree of amnesia will minimise unpleasant memories associated with the procedure. In most circumstances a combination of short acting analgesics and sedatives are required to achieve this. RULES FOR INTRAVENOUS SEDATION IN THE ED No patient is to receive intravenous sedation in the Emergency Department outside of the following rules. Consider whether the patient needs sedation could the procedure be done under local anaesthetic block or with entonox? 52

54 Midazolam and propofol are not analgesics therefore the patient should receive iv opiates titrated to response prior to x-ray. 1. Only a doctor who has received training in conscious or procedural sedation and basic life support can administer intravenous sedation. 2. There must be at least 2 doctors present within the department. 3. Adequate numbers of trained nursing staff must be present within the department to assist during the procedure and to recover the patient. 4. After 12 midnight (or when ED middle grade leaves department), intravenous sedation should only be used for life or limb threatening situations, and if all other criteria are met. Simple fractures (e.g. Colles) should be given analgesia and a POP and asked to return for manipulation at 9am. Other urgent procedures requiring intravenous sedation must be undertaken in the operating theatres. 5. Patient must be 14 years or older. 6. Patient should be starved for 4 hours, unless life or limb threatening indication. 7. Pre-sedation checklist (including signed informed consent) must be completed by doctor undertaking procedure. 8. Observations recorded as per sedation sheet. 9. Patient on tiltable trolley. 10. Patient in room with full resuscitation equipment. 11. Patient connected to pulse oximeter, ET CO2 (nasal prongs available in resus cupboard), ECG monitor & BP cuff. 12. Patient connected to supplemental oxygen. 13. Intravenous cannulae inserted and checked. Consider fluid bolus prior to sedation with propofol. 14. Naloxone and flumazenil should be immediately available (out of cupboard, not drawn up). 15. Choice of intravenous sedation medication is dependent on level of training and familiarity. Refer to RCEM dosing guidelines below and remember onset / offset times. Err on the side of lighter rather than deeper sedation and remember to use opiate analgesic prior to the sedation. If little prior experience and sedation is definitely required then use midazolam, slowly 1mg at a time (no more than 10mg) until the patient is drowsy. Verbal contact should be maintained at all times and the patient able to respond to simple physical stimuli. 53

55 16. After the procedure, as painful stimuli is reduced, level of sedation often deepens so the patient should be monitored closely. 17. No patient is to receive a second dose of sedation in the emergency department (Speciality teams CAN NOT overrule this without agreement from the ED Consultant). 18. Ensure post procedure checklist followed including written discharge advice. 19. Any adverse events identified during the procedure should be reported. The World Society for Intravenous Anaesthesia (World SIVA) International Sedation Task force has developed an event reporting tool for sedation-related adverse events. This tool is available as a web page below IV sedation form There is a form kept in resus which must be completed each time procedural sedation is used. Alternatively print a copy here. Its use is compulsory for all sedations Choice of Sedation Agents The appropriate choice of pharmacological agents for PSA depends on: 1) The nature of the procedure 2) The planned level of sedation 3) Training and familiarity of the sedating practitioner with potential pharmacological agents 4) Patient factors 5) The local environment. Table 1: Adult: Pharmacological Agents for Procedural Sedation and Analgesia. Agent Role Route Initial dose Elderly Repeat dose Initial dose Adult Repeat dose Initial onset time (min) Peak effect time (min) Propofol Sedation/amnesia IV mg (given slowly) mg (given slowly) mg/ kg 0.5mg/kg every 3-5mins ½ Midazolam Sedation/amnesia IV (over 0.5mg 0.5mg 1-2 mg After

56 1-2mins) (max single dose 2.5mg) 5mins Ketamine Sedation/Amnesia/ Analgesia IV (give over 30-60secs) mg 1 mg/kg mg/kg every 5-10 ½ mins Ketamine Sedation/Amnesia/ Analgesia IM 4-5 mg/kg 2-2.5mg/kg every 5-10 ½ mins Ketamine Analgesia (sub dissociative dose) IV 0.3mg/kg ½ Fentanyl Analgesia with other sedatives IV 0.5μg/kg Up to 0.5μg/kg every 2 mins Fentanyl Sedation / analgesia IV 0.5mg/kg mg/kg of both agents HYPERLINKS Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department. May RCEM. Agents%20for%20Procedural%20Sedation%20and%20Analgesia%20(June%202016).pdf Safe Sedation of Adults in The Emergency Department. Nov secure.rcem.ac.uk/code/document.asp?id=6691 Adverse event reporting 55

57 7. AWSEM poster Procedural Sedation Quality Improvement Project Tim Ayres ST6EM Aim: Improve the quality of procedural sedation in POW ED. Plan: The quality of our sedation practice will improve. I aim to increase compliance with capnography in particular to 95% of all sedations (ideally 100%). Tasks: - Audit previous performance - Develop new proforma - Order new equipment - Start education program - Re-audit performance monthly Percenta ED Procedural Sedation Capnography Use. Goal Median Intervention 1. Start QIP Intervention 2. Intervention 3. Do: -New proforma and capnography introduced December Education to medical and nursing staff. -Online survey and education Feb 16 - Monthly audit 0 Jul/ Aug Dec -16 Jan- 17 Feb- 17 Mar Start QIP. New proforma, new capnography equipment. Induction teaching for medical staff and senior medical teaching. 2. Online Survey 3. ED Handbook updated. Act: Continued use of nasal capnography and the new proforma for all sedations. Regular induction training. New post sedation discharge advice. Regular audit. Study: See run diagram - 15 patients in June/July 2016: proforma used 14/15 (93%), and capnography only used in 2/15 (14%). Following QIP start December 2016 to March 2017: Overall both proforma and capnography use increased to 96% of all sedations (100% for the last 3 months). 56