Objectives. Conflict of Interest Disclosure

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1 Developing a pediatric RN administered nitrous oxide/oxygen program for a multi state hospital system: Challenges and Lessons Teri Reyburn Orne, RN BC, MSN, CCPNP, CPNP AC Banner Children s Conflict of Interest Disclosure Authors Conflicts of Interest; Teri Reyburn Orne, no conflict Objectives Describe the DMAIC method of process improvement Identify the structures included in a clinical practice guideline Predict at least two potential challenges when creating a multi state practice guideline. 1

2 OVERVIEW OF NITROUS OXIDE What is Nitrous Oxide (N 2 O)? Colorless gas at room temperature Liquefies under pressure Sweet smelling Classified as an anesthetic Very weak anesthetic compared to other inhaled anesthetics It is always mixed with oxygen during delivery It is NOT nitric oxide Uptake & Distribution Inhaled weak anesthetic agent Highly insoluble Moves quickly across the alveolar membrane Does not bind with any blood elements Remains unchanged in the blood Uptake by the body is minimal thus equilibrium (amount needed to cross the blood brain barrier and give effect) is rapidly achieved 2

3 Mechanism of Nitrous Oxide Possible mechanism of action Acts on brain and spinal cord opioid and NMDA receptors Related to release of endogenous neurotransmitters Neurotransmitters activate descending pain pathways to inhibit transmission Analgesia involves a direct intraspinal antinociceptive action rather than depression of limbic function Outcomes of Actions Analgesic Decreases sensation of pain Anxiolytic Increases relaxation and sense of well being Amnestic May be difficult to recall procedure Onset & Elimination Onset of action Peak effect within 3 to 5 minutes Elimination Almost completely through the lungs Due to insolubility, it is cleared within minutes Must be followed by oxygen administration for at least 3 5 minutes 3

4 Our Motivation Safe and effective minimal sedation agent Quick recovery Helps with throughput Minimal side effects Limited NPO requirements Specific contraindications Decreases pain and suffering STRUCTURE Process Improvement Structure Clinical Consensus Group (CCG) All process improvement projects that involve the electronic medical record and physician Multidisciplinary group Use DMAIC (Define, Measure, Analyze, Improve, Control) Determine need for clinical practice guideline (CPG) Provide oversight 4

5 Clinic Practice Guideline Improve portion of DMAIC Define scope Design the tools Implement the process Control phase returns to CCG CPG responsible for data collection DMAIC Define RN administration of nitrous oxide/oxygen for minimal sedation safe and effective per literature review Patients suffering and traumatized by mildly painful and frightening procedures Two independent programs developed within the Banner system No system standard for training and administration GOING THROUGH THE PROCESS 5

6 DMAIC Measure Facility One: Training done by outside experts from dentistry for entire group (RNs/MDs) No quality or safety data being collected No standardized charting Facility Two: Training done at outside N2O/O2 leading children s hospital for super user RNs Super users developed training for RNs/MDs Quality and safety data collected Developed standardized charting DMAIC Analyze No standardization Current users want to expand to other departments Other facilities wanting to introduce modality Opportunities Explore the strengths and weakness of current state at each facility Agreement of what the standard should be Alignment of practice Accountability to follow new guidelines 6

7 DMAIC Improve Clinical practice guideline workgroup formed Identify best practice Standardize training Standardize documentation Standardize safety Standardize data collection CPG WG Membership Multidisciplinary MDs RNs Regulatory IT Multi facility Both facilities currently using N2O/O2 Future users Multi departmental Medical Imaging Emergency Department Intensive Care Anesthesiology THE CLINICAL PRACTICE 7

8 The Clinical Practice Guideline Overview Practice Statement Clinical approach The CPG Overview For pediatric inpatients and outpatients requiring minor procedures that cause anxiety and/or pain, nitrous oxide/ oxygen (N 2 O/O 2 )sedation can be used to provide minimal or procedural sedation. Evidence supports the use of nitrous oxide in children due to its rapid onset and rapid recovery. Nitrous oxide moves quickly across the alveolar membrane and does not bind with any blood elements, and remains unchanged in the blood. Also, due to its relative insolubility uptake by the body is minimal so equilibrium is rapidly achieved. Nitrous oxide acts on brain and spinal cord opioid and NMDA receptors thus decreasing the sensation of pain, increasing relaxation resulting in a sense of well being. Nitrous oxide/oxygen is an analgesic, amnestic and anxiolytic. Practice Statement Defines the population covered by the CPG States the rationale Summarizes the research support 8

9 Practice Statement and Rationale Practice statement restates the overview Rationale: Pediatric patients continue to have under treated pain as recognized by the American Academy of Pediatrics, American Pain Society and American Pain Management Nursing Society. Nitrous oxide/oxygen sedation via a nitrous oxide/oxygen blender has been shown to provide adequate pain and anxiety relief in children, 8, 10, 11, 16, 19, 23 with minimal adverse events, 3, 13, 16, 24, 25 for the procedures such as those listed in Appendix B. 6, 8, 10, 11, 16, 18, 19, 22 It has also been shown to be more time efficient due to its rapid onset and rapid recovery than other sedation medications used for minimal and procedural sedation. 11, 17 Clinical Approach Overview Uses Exclusion criteria Safety monitoring Required training for physicians, nurse practitioners and physician assistants (LIP) Does not define nursing scope of practice Does not give specifics of how to administer Approval Process Committee approval Pediatrics Anesthesia Emergency Department Clinical Consensus Group Peri op Emergency Pediatric Care management Oversees all CCGs and CPGs All CPGs require their approval 9

10 MAKING IT A REALITY Design Phase Process flow Equipment to be used Blender Mask or nasal hood Scavenging Dosimetry testing Nursing Policy Nursing education LIP education Credentialing requirements for LIPs (recommendation only) Patient education 10

11 Challenge C suite approval Approval from committees Availability of scavenging systems Funding Construction Purchase of equipment Fear of the unknown/unfamiliar Equipment Porter blender system Sedation system mask vs nasal mask Scavenging Dosimetry 11

12 Nursing Policy Training for nurses Scope of practice Administration step by step Patient monitoring Documentation Appendix Contraindications Appropriate procedures for use Education Nurses 6 hours total education (standard set by AZBN) 1 hour moderate sedation training 2hours of didactic and 2 hands on training Post test Three completed cases observed and checked off LIPs Receive Banner CME Complete assigned reading 2 hours of hand on training Post test Or Provide proof of training and competency from outside program Implementation Facility leads are identified Responsible for roll out, oversight and compliance Tool kit posted on SharePoint Meeting held with facility leads 12

13 Challenges Scope of RN practice varies by state Arizona within RN scope Colorado within RN scope Alaska not within RN scope Alaska presented to board of nursing Approved use at 60% maximum (CPG states 70%) Nursing policy addendums needed Challenges Each facility must get approvals from medical committees Colorado approved but no LIP on site at all times (CPG required physician readily available) Alaska approved with difficulty Challenges Training Monies to support training Send nurses to AZ for initial training Send trainer to outside facility Hourly pay for nurses to provide and complete training Nurses must have AZ license to get patient hands on competencies completed Trainer must have in state RN license to demonstrate giving to patients Physicians must be available for training when out of state trainer is present 13

14 DMAIC Control Identify outcomes Number of patients Age of patients Maximum concentration of nitrous oxide Side effects Serious complications Parent/patient satisfaction Challenges Data collection Manual vs digital Need EMR report to run Not a priority for IT Reporting is mandatory part of CPG Our Outcomes 14

15 Not Dictated by CPG Facility specific Scavenging system to be used WAGD vs suction Credentialing criteria Medical staff structure Which nurses to train Focused group vs every nurse Cost recovery No CPT code CCMC Credentialing Criteria Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has. Margaret Mead QUESTIONS?? 15

16 References Babl, F. E., Oakley, E., Seaman, C. (2008). High concentration nitrous oxide for procedural sedation in children: Adverse events and depth of sedation. Pediatrics, e528 e532. Bar Meir, E., Zaslansky, R., Regev, E. (2006). Nitrous oxide administration by the plastic surgeon for repair of facial lacerations in children in the emergency room. Plastic Reconstructive Surgery, 117, Burnweit, C., Diana Zerpa, J. A., Nahmad, M. H. (2004). Nitrous oxide analgesia for minor pediatric surgical procedures: An effective alternative to conscious sedation. Journal of Pediatric Surgery, 39, Clark, M. S., & Brunick, A. L. (2008, 3 rd ed.). Handbook of nitrous oxide and oxygen sedation. St. Louis, MI: Mosby Elsevier. Farrell, M. K., Drake, F. J., Rucker, D. (2008). Creation of a registered nurse administered nitrous oxide sedation program for radiology and beyond. Pediatric Nursing, 34, Fishman, G., Botzer, E., Marouani, N., & DeRowe, A.(2005). Nitrous oxide oxygen inhalation for outpatient otologic examination and minor procedures performed on the uncooperative child. Journal of Pediatric Otorhinolaryngology, 69, Frampton, A., Browne, G. J., Lam, L. T., & Lane, L. G. (2007). Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department. Emergency Medical Journal, Kanagasundaram, S. A., Lane, L. J., Cavalletto, B. P. (2001). Efficacy and safety of nitrous oxide in alleviating pain and anxiety during painful procedures. Archive of Disease in Childhood, 84, Luhmann, J. D., Kennedy, R. M., Jaffe, D. M., & McAllister, J. D. (1999). Continuous flow delivery of nitrous oxide and oxygen: a safe and cost effective technique for inhalation analgesia and sedation of pediatric patients. Pediatric Emergency Care, 15, Luhmann, J. D., Kennedy, R. M., Porter, F. L., & al, e. (2001). A randomized clinical trial of continuous flow nitrous oxide and midazolam for sedation of young children during laceration repair. Annals of Emergency Medicine, 37, Reinoso Barbero, F., Pascual, S. I., de Lucas, R. (2011). Equimolar Nitrous oxide/oxygen versus placebo for procedural pain in children: A randomized trial. Pediatrics, e1464 e1470. Ransom, E.R., Joshi, M.S., Nash, D.B & Ransom, S.B. (2008). Health Care Quality Book: Vision, Strategy, and Tools (2 nd ed.). Chicago, Il: Heath Care Administration Press. Washington D.C.: AUPHA Press. Sandy, N. S., Nguyen, H. T., Ziniel, S. I., & al, e. (2011). Assessment of parental satisfaction in children undergoing voiding cystourethrography without sedation. Journal of Urology, Zier, J. L., Kvam, K. A., Kurachek, S. C., & Finkelstein, M. (2007). Sedation with nitrous oxide compared with no sedation during catheterization for urologic imaging in children. Pediatric Radiology, 37,