Quality and safety in sedation is often reflected by how we, as providers, deliver safe, effective sedation for an imaging study or procedure. Managing a child on the autism spectrum can be a wild ride, particularly if that child has the added barriers of being non-verbal or exhibits aggressive behaviors when confronted with an interruption in their routine. Parents experience a significant amount of stress when trying to navigate a foreign environment with a child who is less than tolerant of new or unfamiliar places. These parents face a constant fear that the only way to manage their children in a health care setting is with brute force. The following experience started me on a path to validate that we are capable of delivering high quality experiences for these families without sacrificing safety.
A mother presented to our sedation unit requesting to speak with “someone in charge” regarding her son’s appointment for a lab draw with sedation. I escorted her to a consultation room where she promptly broke down in tears. She proceeded to tell me about her 19-year-old son. She described him as a verbal, but cognitively delayed 6′ 2″, 225 lb. young man who is absolutely terrified of needles. As in, he will “tear the place apart” if he sees a needle. Clearly, at 6’2” and 225 lbs., tearing the place apart was well within his wheelhouse of skills. This mother was beside herself that he was going to hurt us. This was why she was crying. Not that he might get hurt, but that we would be in harm’s way. That was my pivotal moment.
How can we, as a team of healthcare providers, create an environment that can help to ease the burden and stress that these dedicated, exhausted parents feel when they have to bring their children into our care?
Well, it starts with an empathetic conversation. I held her hand and told her that together, we would come up with a plan to ensure everyone’s safety. I told her I was touched by her concern for our well-being and that I would carry that same level of concern for her son while he was in our care. I began by trying to gain an understanding of what his autism looks like. How developed are his verbal skills? Can he follow simple commands? Hold a conversation? We discussed triggers that could result in aggressive behaviors as well as what helps him to remain calm.
Below is a table of these responses:
|Promotes calming behaviors||Triggers that can escalate to aggression|
|Loves bunny rabbits, real or toys||Waiting in a unfamiliar environment|
|Favorite movie: Cars||NEEDLES|
|Therapy Dogs||People in uniforms (i.e., police or security)|
|Car rides||Large crowds of people, too much noise|
Armed with this information I began to formulate a plan. During these questions, I asked the mother what keeps him happy when he comes to the hospital. Her immediate response was “staying in the car!” There it is – that one nugget of information that will drive the whole process. Keep him in the car, until you can’t.
We developed a plan to have our sedation provider call the mother to complete the history and obtain consent by phone. I identified a side entrance, adjacent to our department, that could be used in order to avoid the crowded, stimulating main entrance and long walk to our unit. I instructed the mother to arrive 30 minutes prior to their sedation time as the history and consent would already be done. I instructed her to call our team when she arrived on campus in case we were running late (as often happens), but these special needs patients do not tolerate delays. I explained that security would be in the immediate area but would do their best to remain out of sight. Lastly, I told her I would reach out to our Child Life Specialist (CLS) for support during the patient encounter.
We discussed potential sedation options and I explained the sedation provider would go over the options in more detail when he called. The mother left, armed with her feeding instructions and a clear understanding of how we would manage her son’s care. I notified security and Child Life of the plan. The sedation provider informed me that she and the mother agreed that a Ketamine dart was the best option to manage this patient.
Game day! The mother called when she arrived at our campus and was instructed to drive around campus for a few minutes as we were running a little behind. Security and Child Life were notified of the family’s arrival. The sedation provider placed the Ketamine order (the mother provided a weight obtained that morning at home) and the sedation nurse prepared the meds and gathered all necessary equipment.
Upon arrival, the patient was very cooperative and walked directly to the exam room. Imagine his delight when he saw a collection of stuffed rabbits on the bedside table, the movie Cars was playing AND one of our therapy dogs was there to greet him! The sedation nurse asked him if he could lie on the bed so he could watch the movie and pet the dog, which he willingly did. Keeping the number of people in the room to a minimum, the sedation provider was able to complete a quick physical exam.
The therapy dog and handler then exited the room. The sedation nurse was able to distract the patient with the stuffed rabbits and gained his cooperation with obtaining a blood pressure. While the cuff was inflating, the nurse very quickly (and discretely) administered the Ketamine dart. The patient turned to the nurse and asked, “what was that?” to which the nurse clapped his hands and announced, “a mosquito! But I got him!” The patient accepted this explanation and was sedated in about five minutes. The lab supplies were then brought into the room, samples were drawn, and all evidence of needles and blood collection equipment were removed before he woke up. He did experience the expected side effects associated of Ketamine: confusion, dizziness and nystagmus. However, he tolerated this fairly well. He also immediately drank more than 16 oz. of water, and not surprisingly, vomited. He was discharged less than 30 minutes later.
Our team has now developed a triage assessment tool to screen patients for aggressive behaviors and assist us with personalizing our Autism Safety Plan (ASP). This must be a collaborative process, between staff and family, to ensure safe, effective care in a family centered environment. The ASP is denoted in the appointment notes with a notifier going out to security, registration associates, APN’s and the sedation/anesthesia physicians. The APN or physician will obtain the history and consent prior to the appointment. Lesson learned from this initial process roll-out: the more effort made on the front end of these difficult encounters, the better the outcome.
This work has led me to take a more critical look at what the health care industry defines as violence in the workplace. Violence can be intentional or unintentional. Patients with a history of aggression due to behavioral barriers engage in intentional violence, whereas patients who are cognitively delayed will often lash out with aggressive behaviors out of fear, resulting in unintended violence. Either scenario requires the healthcare team to prepare for these patients to enter their environment and make thoughtful preparations to mitigate the potential for harm to either the patient or staff.