For this year’s Fall newsletter focus on quality, we are fortunate to include an interview with Dr. Nicole Johnson and the sedation COE program at Rainbow Babies’ and Children’s Pediatric Sedation Unit (PSU). Rainbow has one of the oldest and most robust pediatric sedation units in the country, established and staffed by the division of pediatric critical care medicine. The service provides sedation for approximately 200 patient encounters per month, utilizing eight physician FTEs, eight nursing FTEs, and a full time child life specialist, all based out of the beautiful centralized PSU. For more information, check out the sedation program’s dedicated web page at www.uhhospitals.org/rainbow/services/pediatric-critical-care/pediatric-sedation-unit.
Are there particular facets of your program that especially demonstrate high quality care?
We consistently perform at or above national benchmark for all safety events and consistently above for serious safety events. We love that we have our own dedicated child life specialist and even a housekeeper. Everyone takes pride in making our unit a safe, family-centered, and efficient place for patients.
What are you and your team most proud of with regard to the quality of sedation care you provide?
We are all especially proud of the privilege we have to care for and get to know some of the most vulnerable patients. We are proud of relationships we build with chronically ill patients and procedure services. It is especially gratifying to hear procedure services throughout the hospital tell us they enjoy working with our staff and love that we can safely and effectively sedate their patients for procedures outside of the OR sparing them the need for anesthesia.
What challenges have you and the service faced with regard to new and/or improved quality care initiatives?
The biggest challenge for our service for new initiatives is getting by-in from staff. For example, when implementing the use of our pre-sedation equipment checklist, the intent was to have the physicians lead and fill out the checklist since the nurses were responsible for gathering all of the equipment. There was no verbal opposition, but when roll-out began, the attending physicians didn’t really want to add an additional step to the process. The nurses found it easier to appease the docs by filling it out and having the physician sign.
Please share an example of quality initiatives from the Center of Excellence application process.
At the end of 2014, our institution was facing a six month scheduling backlog for sedated dental procedures. Patients were not being scheduled for sedation on the same day as their dental appointment, and there was no consistent process for communicating about these patients between our services. Also, the screening process and indications for referral to sedation versus general anesthesia practice were inconsistent among the various dental providers. We set out to develop a process for screening and scheduling the sedated procedure appointment on the day of the dental visit and to decrease the total time from scheduling to procedure from six months to three months. Our interventions included:
- Identifying barriers to timely scheduling, which included limited education on referral on screening to dental residents and dental scheduling personnel, variable communication mechanisms with the PSU staff, and insurance pre-approval process delays
- Educating senior dental residents regarding patient characteristics that determine eligibility for procedural sedation versus general anesthesia
- Creating a direct line of communication from the dental clinic to the PSU
- Developing a method to screen and schedule patients on the day of the dental visit, which now means the patient and family are escorted in person from their dental visit to the PSU to be screened and scheduled in person by a sedation RN or by the PSU coordinator
- Improving the efficiency of the treatment day, with designated equipment and space within the PSU as well as block scheduling for dental patients
Education of dental residents began in 2015, and the new scheduling process was implemented in October, 2016. After overcoming challenges related to multiple personnel changes in the dental scheduling group, the interventions proved to be quite successful, with a 50% decrease in the total number of patients waiting to be scheduled, a decrease in wait times to six to eight weeks, and an increase in sedated dental procedure volumes by 13% annually.
Please share a story about a particularly “stand out” sedation encounter that illustrates the high quality care provided by your team.
This is the most difficult portion of the interview because there are so many moments where I think we do great work. I think the most challenging cases are the ones when the parents are on the ceiling with anxiety over a new diagnosis of a major medical illness and their child comes to us for their first sedation ever. Our child life specialist, nursing staff, and physicians interact with the family and walk them through the sedation process, and the parents breathe a sigh of relief. If the child comes to us multiple times, we create a PSU chart for them recording names of the family, including pets and lovies, if they like their needle removed before or after they wake up, etc. We really get to know them well and personalize their experience. By the time the child is completing their last sedation with us, we have become a part of their family and they ours. We keep their photos and hang one on our Christmas tree annually. We recently had a child come back for surveillance studies all the way from the Middle East. The mom was nearly in tears seeing the child’s photo posted in our unit.
What value does achieving and being recognized with the Center of Excellence designation bring to your program?
We think we do a great job and take pride in our unit, but to get national recognition for excellence is a large boost for our staff ego and morale. This award also gives us greater visibility in our own local community. Because our unit’s location is a little hidden from the rest of the pediatric hospital, many in the health system community do not know where to find us. We often joke that sedation services are like the step-parents of the larger health system because no one calls or visits unless they need something. Ha ha. So, it felt really great to be congratulated by the department chair and the president of the hospital. Finally, the recognition is inspiration to continue to provide excellent care and motivation to continue making improvements.
What future projects are planned or in the works regarding quality care in the sedation service?
We are in the early process of redesigning our entire unit space to improve not only efficiency of our daily clinical operations but also to accommodate other procedures that are currently being done in the operating room. This is a tremendous opportunity for us to grow our service and to make even more improvements in our efficiency for both the staff and the patients. We will also be participating in the patient satisfaction survey study led by Corrie Chumpitazi, MD. Another goal for this year is to roll out our service satisfaction survey so that we can improve our collaboration with referring services. It has already been designed and is set to be distributed in phases.