Development and implementation of an education and credentialing programme to provide safe paediatric procedural sedation in emergency departments.

OBJECTIVE: In the conduct of paediatric procedural sedation (PPS) within the ED the combination of powerful drugs, variable competency levels and high staff turnover carry the potential for sedation-associated adverse events. Yet, currently, there is no set programme for education and accreditation of ED staff in PPS. We set out to develop such a programme. METHODS: We outline the development process of a comprehensive multidisciplinary PPS programme and present its key educational elements (sedation manual, lecture, treatment order form and checklist, parent information handout) and credentialing through multiple-choice questions and competency assessments. We describe issues associated with the implementation of the programme at a metropolitan mixed ED and the ED of a major tertiary paediatric centre. RESULTS: Since its inception a total of 294 emergency staff have either completed or have partially completed the programme. Staff feedback showed that the majority of staff scored the elements of the programme as very good to excellent, and felt that their sedation skills had improved and their practice was safer. The development and implementation of the PPS programme raised many issues and posed a number of challenges. We describe the strategies we used to overcome such challenges and barriers. CONCLUSION: We present the development and implementation of a comprehensive PPS programme for emergency staff. As a result of the multicentre development process involving a community and a tertiary paediatric ED the programme will likely have broad applicability in different types of ED caring for children.

Evaluation of the impact of a paediatric procedural sedation credentialing programme on quality of care.

OBJECTIVES: The aim of the present study is to describe changes in documentation, risk assessment and patient care resulting from implementation of a credentialing process for medical and nursing staff in paediatric procedural sedation (PPS) in two EDs - one an urban mixed ED and the other a specialist paediatric ED. METHODS: Chart review of 100 patients undergoing PPS prior to and 100 patients following introduction of the PPS programme. Information was extracted from medical records and sedation checklists. Demographics, drugs used, procedure performed and elements of the pre-procedural, intra-procedural and post-procedural care were compared pre- and post implementation of the PPS programme. RESULTS: Significant improvements in the post-implementation period compared with pre-implementation were seen in: frequency of documentation of informed consent (87 vs 15%, P < 0.0001); evidence of performance of a pre-procedural risk assessment (87 vs 1%, P < 0.0001); and appropriate recording of vital signs (58 vs 27%, P < 0.0001). Improvements were also noted in documentation of weight, allergies, fasting status and recording of drug orders. There were no adverse events recorded in the pre-programme period and 6 recorded in the post-programme period. CONCLUSION: The implementation of a PPS credentialing programme into these two EDs resulted in significant improvements in risk assessment, monitoring and documentation of important information related to safe PPS. These improvements should result in improved quality and safety of PPS.

Caring for adolescents with mental health problems: challenges in the emergency department.

AIM: To explore management issues in adolescents with mental health problems who presented to a children's hospital emergency department (ED). METHODS: Retrospective chart review of all mental health presentations of adolescents (12-18 years) to a tertiary children's hospital ED, over a 1-year period (2003-2004). Patients were identified based on a search of the electronic ED log. Medical and mental health records were manually abstracted. RESULTS: There were 203 presentations during the study period. Eighteen per cent of patients presented more than once. Mean age was 14.7 years, 73% were female and 67% presented after 6 pm. Fifty-seven per cent presented with non-accidental overdose, self-harm or suicide risk. There were 110 security incidents in 26% of presentations during the ED stay. A total of 47% were admitted, 27% to the medical inpatient service and 20% to a psychiatric inpatient facility. CONCLUSION: Adolescent mental health presentations to the ED require a high number of ED, mental health and inpatient service resources. Security incidents occur frequently. We propose changes to address identified problems. These include redesigning the physical structure of the ED, more mental health training and support for ED staff, better access to mental health records and crisis plans for adolescents at risk, and improved after-hours mental health services for children and adolescents.

Inhaled methoxyflurane as a prehospital analgesic in children.

OBJECTIVE: Despite widespread use of methoxyflurane as an inhaled analgesic by ambulance services in Australia there are no published data as to its use pattern, efficacy and safety in the prehospital setting. We set out to characterize methoxyflurane use in children in the prehospital setting. METHODS: An observational case series was conducted over an 8 month period. Children who received methoxyflurane while being transported to a tertiary children's hospital by ambulance were enrolled. We analysed indications for use, verbal numerical pain scores, adverse events and depth of sedation based on paramedic, patient, parent and ED staff surveys and review of ambulance care records. RESULTS: During the study period 105 patients were enrolled with an age range of 15 months to 17 years (median age 11 years). Methoxyflurane was mainly used for extremity injuries (82%). Paramedic pain scores dropped from a mean of 7.9 (95% confidence interval [CI] 7.5-8.3) prior to methoxyflurane use to 4.5 (95% CI 3.9-5.0) at 2-5 min and to 3.2 (95% CI 2.8-3.7) at 10 min. There were no serious adverse events (one-sided 97.5% CI 0-3%). Mild adverse events occurred in 38 patients (36.2%; 95% CI 27.0-46.1%). Five of 15 (33.3%) patients under 5 years of age were deeply sedated. CONCLUSION: In the present paediatric case series methoxyflurane appears to be an efficacious analgesic with a low adverse events profile. In young children in particular it can briefly lead to deep sedation.

Non-urgent presentations to a paediatric emergency department: parental behaviours, expectations and outcomes.

OBJECTIVES: To identify factors that influence the attendance of children with non-urgent medical problems to a tertiary paediatric ED and to define parental expectations of the hospital visit. METHODS: A questionnaire administered to a convenience sample of 200 parents/carers who attended the paediatric ED and whose children were categorized as having non-urgent problems that had been present for at least 4 weeks. Subsequent outpatient attendances were then analysed retrospectively. RESULTS: Most patients had visited a general practitioner but remained unhappy with the outcome of the consultation. The hospital was expected to provide immediate diagnosis and initiate appropriate treatment by the vast majority of parent. Only four patients required admission. CONCLUSIONS: The expectations of parents who attend the paediatric ED with children who have non-urgent chronic complaints are high. Rapid access to outpatient clinics might provide an acceptable alternative for these patients, and free valuable ED resources.

Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and analgesia.

STUDY OBJECTIVE: Established fasting guidelines for analgesia and sedation are difficult to follow in the emergency department (ED), and the association between preprocedural fasting and adverse events has been questioned. We characterize the fasting status of patients receiving procedural sedation and analgesia with nitrous oxide (N2O) in a pediatric ED and assess the relationship between fasting status and adverse events. METHODS: A prospective case series was conducted in a children's hospital ED over an 8-month period. Patients receiving N2O for procedural sedation and analgesia were enrolled and followed up by telephone call. Preprocedural fasting state and adverse events, as well as N2O concentration, adjunctive drugs, and deepest level of sedation, were recorded. Adverse events were analyzed in relation to fasting status. RESULTS: Two hundred twenty children who underwent procedural sedation and analgesia with N2O were enrolled. Fasting status was obtained in 218 patients (99.1%). Of these, 155 (71.1%; 95% confidence interval [CI], 64.5%-77.0%) did not meet fasting guidelines for solids There were no serious adverse events and no episodes of aspiration (1-sided 97.5% CI, 0%-1.7%). While in the ED, 46 minor adverse events occurred in 37 patients (16.8%; 95% CI, 12.1%-22.4%). Emesis occurred in 15 patients (7%), including 4 (6.3%; 95% CI, 1.8%-15.5%) of 63 patients who met and in 11 (7.1%; 95% CI, 3.6%-12.3%) of 155 patients who did not meet fasting guidelines for solids. There was no significant difference in median fasting duration between patients with and without emesis. CONCLUSION: Seventy-one percent of patients undergoing ED procedural sedation and analgesia with N2O did not meet established fasting guidelines. In this series, there was no association between preprocedural fasting and emesis. There were no serious adverse events.