By Lorie Reilly MSN, CRNP, CPNP-AC, FAARIN
Sedation/Radiology Nurse Practitioner
The Children’s Hospital of Philadelphia
In November 2011, a multidisciplinary group of sedation experts convened to define the core aspects of quality in pediatric sedation. They integrated the framework of the Institute of Medicine’s Six Quality Aims: safety, effectiveness, patient and family centered care, timeliness, efficiency and equitability.
We must consider these 6 aims beginning in the prescreening process for sedation. At times it is challenging to identify the high risk patients and anticipating problems unless our process is thorough and we are prepared prior to the patient’s arrival to the sedation environment.
Where, how and when do we prescreen? For outpatients, is it before they even get scheduled for the scan or procedure. In some cases, we are like detectives trying to solve a crime as we dig through the electronic medical record. Care Everywhere has allowed to access medical records from encounters at other institutions. Additionally, there is a phone call to obtain the medical history. Among the challenges are leaving messages and waiting for a return phone call, using the interpreter line for a non-English speaking family and arranging for a face to face pre-sedation evaluation if needed. If the child resides in a long term care facility, often the staff members will provide us with much of the prescreening information. We may email a family if we are unable to contact them by phone. Parents may upload pictures or videos to the medical record if we are concerned about their child’s weight, their history of snoring or even to ascertain if a facial hemangioma is present. It may take time to clear a child for sedation as we wait for clearance (ENT, Cardiology, sleep studies, Endocrine).
Being thorough with our prescreening is critical so as to avoid scheduling a child incorrectly (i.e. a sedation slot if he/she needs general anesthesia). Perhaps we think that the child will NOT require deep sedation for a procedure or scan. We consult with our Child Life Specialists and schedule them in a non-sedated slot if deemed appropriate. In this case the child does not need to be NPO and the typical 48-72 hour COVID screening is waived. A behavioral plan is completed for child with special behavioral health needs. This starts with a list of questions regarding triggers and planning for a smooth transition to the sedation environment. Often we are asked to sedate for multiple scans and procedures during the same sedation appointment. Can we draw labs when the IV is placed? Can we combine an MRI and a lumbar puncture? Can the ophthalmologist do a quick eye exam or the dentist do an oral exam while the child is sedated? There are time restrictions, the need to coordinate services and in some cases it is not possible to transport the sedated patient to another area of your institution.
The past medical history includes:
- Prior history of sedation or anesthesia
- Family history of sedation or anesthesia issues
- History of prematurity
- Recent acute illness (or prior COVID infection/exposure)
Review of systems includes:
- Respiratory (including snore history)
Despite asking all of the questions in your prescreening, there is the occasion in which we miss details and discover them when the patient arrives on the sedation unit. The child may present with new congestion that started the morning of the scan or procedure. So, the prescreening process is always ongoing.
Please share your experiences with prescreening- how you get the information, challenges that you have faced, and any other information that may be helpful.
- Connors, JM et al. (2015). Great Expectations- Defining Quality in Pediatric Sedation: Outcomes of a Multidisciplinary Consensus Conference. Journal of Healthcare Quality 37 (2), 139-154.