Implementation of Safe, Effective Processes for Paediatric Mild to Moderate Sedation at Thunder Bay Regional Health Sciences Centre
Summary
My current role at Thunder Bay Regional Health Sciences Center (TBRHSC) is working as a Registered Nurse in a Paediatric Outpatient Department. TBRHSC is the leading teaching hospital serving Northwestern Ontario. As an RN working at TBRHSC it was determined there was a need for improved and enhanced paediatric procedural sedation guidelines for diagnostic tests, painful procedures, and minor surgical interventions that are commonly performed on paediatric patients in our facility. Due to limited options for paediatric procedural sedation which resulted in multiple failed attempts to sedate, unnecessary discomfort, and stress on the paediatric patient were noted. These negative effects were causing unnecessary trauma to the child and family. The pharmacology being used for paediatric sedation at TBRHSC was not meeting the current standards for clinical best practice when compared to other hospitals specializing in paediatric care. This contributed to delays in diagnosis, causing both acute and long-term negative consequences on the patients and families. This fellowship was needed to improve health outcomes and experiences for children and their families in our facility as well as within Northwestern Ontario.
The overall learning goal of this Leadership Fellowship was to enhance my nursing knowledge, experience, and clinical skills to help develop a safe, effective mild to moderate paediatric procedural sedation policy outside the operating room at TBRHSC. The project involved a variety of self-learning activities. I became well-educated on how to conduct a literature search, expand my awareness on paediatric sedation pharmacology, learn best practice standards for paediatric procedural sedation to help implement a current policy and procedure for our hospital.
Knowledge and skills gained throughout this fellowship were supported by attending workshops and courses on paediatric sedation through Toronto Sick Kids Hospital (TSK), acquiring my Paediatric Advanced Life Support certification, doing a focused literature search, attending a Mentorship Program at London Health Sciences Centre (LHSC), visiting Barrie Victoria Hospital, conducting a review of policies and procedures from other hospitals throughout Ontario, and consultation with Certified Child Life Specialists (CCLS) at LHSC and at TBRHSC. Through this, I became more experienced in best practice guidelines and the appropriate monitoring of paediatric patients before, during and after sedations. Deep sedation protocols for long extensive procedures, diagnostic imaging was also required. The benefits of incorporating a CCLS in the preparation of the child and family helped create a better experience for the patient and family and decreased the need for procedural sedation. With collaboration of all team members, the new knowledge gained was incorporated to assist in promoting policy and protocol changes. Our goal is a new pediatric procedural sedation program. This all occurred with guidance from a dedicated mentorship team at both our facility and LHSC. Collaborative discussions and review of activities were held to help implement the new policies and protocols; and are ongoing. I had never been a part of the development of a new policy and protocol before and I have learned the steps it takes to create and move policy change forward. I have learned that inter-professional collaboration is the key to a successful development and implementation of new policy and protocols. The knowledge and experiences I gained were significant and extensive throughout this entire fellowship.
Outcomes
The work associated with this fellowship will potentially impact all paediatric patients from Northwestern Ontario being treated at TBRHSC. Paediatric patients will be able to undergo mild to moderate sedation outside the operating room safely and effectively. Our goal is to ensure patient safety and welfare by decreasing trauma in minimizing physical discomfort and pain during therapeutic procedures and diagnostic tests. This reduces stress and anxiety of the child associated with the treatment. Procedural sedation will also help control patient movement/motor behaviors to facilitate better procedural success rates. Patients and families are already having better experiences during their hospital visits, decreasing acute and long-term negative consequences.
Unexpected outcomes from this fellowship was identifying the need to reduce sedation, as well reviewing our deep sedation procedures with anesthesia. To help decrease the need for sedation at LHSC, a CCLS assessed each child’s developmental consideration and perceived ability to cope when having any procedure or test completed. It was an important part of their protocol. We have now established a program where the CCLS will see all patients who may be undergoing any tests or procedures. We are hopeful that by introducing this new program in preparing the child appropriately, it will decrease the rate for our sedations required. When a child is properly prepared ahead of time there is a higher success rate for completion of the test or procedure. The CCLS assessment is only one part of our revised policy, another part is the inclusion of anesthesiology for deep sedation. This will include children between the ages of 6 months and 3 years of age undergoing long diagnostic tests (ie MRI’s) and children undergoing long painful procedures. Children need to be able to stay completely still for long periods of time for some tests/procedures to be completed successfully. Proper sedation can ensure a completed test or procedure with minimal complications. Best practices acquired and the adoption of an evidence-based sedation policy are being incorporated into our practice with goals of making sedation safer with fewer complications when required for these tests and procedures.
Through strong partnerships, and a collaboration process between LHSC, TBRHSC and also with TSK, where I completed their hospital base sedation course, implementation of an evidence informed paediatric sedation program are being established. We are in the process of improving health outcomes for the paediatric population of Northwestern Ontario. Collaboration, in establishing roles and responsibilities of paediatric sedation team members was required to device this new program. This process was completed in correlation with Management, Pediatricians, Anesthesiologists, Nurses, Registered Respiratory Therapists (RRT), and Pharmacists. Change is often difficult and there can be reluctance at times for change, however, the new information gained from this fellowship is based on best practice evidence and from procedures and protocols currently being used in other paediatric care facilities. From this, there has been an educational component implemented for our health care providers involved in paediatric procedural sedation. Courses, annual renewals, and competency tests are in development that will allow the health care providers in our facility to be better prepared in caring for patients undergoing pediatric procedural sedation. Implementation of evidence based best practices in new policies, procedures and a learning package for paediatric procedural sedation are being incorporated into our practice at TBRHSC. They are presently under review and being revised. I am confident that these new policies will be in place within the next 3-6 months. With the development of these new policies and procedures, I am hopeful this will later allow for expansion of other performed procedures to be completed at our facility, such as G-tube insertions and PICC line insertions, as well as the development of a dedicated procedural room. With the new paediatric sedation program being established, it will not only be beneficial to the improvement of quality of care for our patients, we are hopeful that it will also help limit unnecessary transfers or referrals to out of town facilities.
Overall experience
I am grateful to the RNAO for funding this opportunity and to my fellowship and leadership teams at TBRHSC and LHSC for their guidance, support, and mentorship. The need for collaborative practice was essential to the success of this fellowship. This fellowship allowed me to see how change can be facilitated in our hospital to better improve quality of care to our patients. I was able to broaden my knowledge and skills in paediatric procedural sedation in providing improved care to our patients. There were many moments to reflect on throughout this fellowship. The important benefit was a closely built relationship developed with LHSC. Working with their team enabled me to see how another facility devised its own paediatric sedation program. I had never been a part of the development of a new policy and protocol before. This fellowship not only gave me the opportunity to research best practice standards, but it also showed me how to take the next step of incorporating practice into policy and procedure.
I am hopeful, as we implement and evaluate these new processes on sedations, it will help expand the ability of our front-line nurses in delivering mild to moderate sedation safely to patients on our units. I am hopeful with continued development it will help open doors to expand opportunity for other procedures to be completed in our facility, as well as the development of a designated procedural sedation room for patients in our facility. TBRHSC is committed to the principles of Patient and Family Centered Care as an academic health science centre and is committed to the dissemination of knowledge and evidence based clinical best practice. In completing this fellowship, I will disseminate this acquired knowledge by continuing to assist with the update of the policies and procedures and by being a clinical lead and resource for paediatric nurses and colleagues at TBRHSC. Overall, I found this fellowship very rewarding and valuable to my personal and professional growth. In completing this fellowship, I am hopeful it will open new doors to enhance my career in the future.
