Interview with a Sedation Center of Excellence
University of Chicago Comer Children’s Hospital

By Trish Scherrer, MD

The Pediatric Sedation Team at Comer Children’s, along with Remoc (Comer spelled backwards), a friendly green monster that greets patients, families, and visitors in the hospital lobby.

As part of our fall newsletter focus on quality, we present the inaugural edition of, “Interview with a Sedation Center of Excellence.”  Dr. Mark Abe and the sedation COE program at the University of Chicago Medicine Comer Children’s Hospital have graciously agreed to be our first interviewees.

The sedation program at Comer Children’s was established in 2006 through the section of pediatric critical care medicine and now includes a pediatric hospital medicine physician.  The sedation service provides sedation for approximately 1800 patient encounters per year, utilizing 4 physician FTEs (Two physicians spend 100% of their clinical time in sedation), 13 nurse FTEs (all nurses spend 100% of their clinical time in sedation), and one child life specialist FTE.  Approximately 60% of sedated procedures are performed in a centralized unit specifically designed for pediatric sedation which includes two procedure rooms with integrated surgical booms and lighting.

Quality highlights for the Comer Children’s sedation program include:

• Safety
  • Robust pre-screening system
  • Checklists for equipment, emergency management algorithms
  • Formal tracking and review of sedation-related adverse events
• Effectiveness
  • Tracking and review of inadequate or failed sedations
  • Surveys of patients and families regarding sedation effectiveness
• Efficiency/timeliness
  • Tracking and review of service and staff utilization, average appointment wait times, same day cancellations, and no show rates
  • Tracking and review of urgent add on availability, on time starts, and average length of stay
• Patient and family centered care
  • Dedicated web page for the Sedation and Procedure Service
  • Downloadable program brochure
  • FAQ regarding sedation options and common procedures requiring sedation
  • Parent/guardian presence for 100% of inductions and when requested, certain sedated procedures

Are there particular facets of your program that especially demonstrate high quality care?

1. Sedation nurses need to have a minimum of two years of pediatric critical care and/or pediatric emergency medicine experience.  Most of our nurses have more than 10 years of experience including pediatric sedation experience and have Pediatric Nursing board certification (RN-BC).
2. Physician sedation providers received pediatric sedation training during fellowship and are board certified and/or eligible in pediatric critical care medicine (PCCM) and/or participated in the SPS Sedation Provider Course.
3. Full-time sedation hospitalist partnered with PCCM physicians utilizing standardized sedation guidelines to provide continuity and consistency of care as well as a staffing model that allows for backup and support.
4. Integrated vascular access team staffed with Vascular Access Board Certified (VA-BC) nurses who participate in the Association for Vascular Access.
5. Outstanding multidisciplinary collaboration including with our Pediatric Anesthesiology colleagues.

What are you and your team most proud of with regard to the quality of sedation care you provide?

Everyone member of our team is dedicated to putting the care of our patients and families first.  They work very hard to coordinate care and minimize the exposure to sedation whenever possible.  Achieving this requires really understanding the patient’s issues and needs. Having experienced sedation nurses who do the initial screening and scheduling really facilitates this process.  We often have to reach out to multiple healthcare providers and/or medical services throughout a much larger medical center to coordinate our patient’s care.  Sometimes last minute changes and/or unanticipated events occur despite careful planning.  Having a team of experienced, highly skilled providers who believe in the importance of putting the care of our patients first makes adapting to daily challenges in providing quality sedation services seamless.

What challenges have you and the service faced with regard to new and/or improved quality care initiatives?

1. In an effort to streamline how providers request sedation services and to facilitate coordination of care, we embarked on a process improvement project.  Projects that involve multiple stakeholders from different areas within as well as outside Pediatrics can be a particular challenge.  Fortunately, UChicago Medicine has an Office of Operational Excellence to promote a culture of continuous improvement across our medical center.  Operational Excellence was able to organize and facilitate a successful Kaizen event that included representatives from the key areas to streamline how requests for pediatric sedation services are made.
2. Being part of a large medical center with a greater volume of adult patients and services can present challenges when initiating new and/or improved quality care initiatives for children.  Navigating the process to develop a new program that involves several stakeholders within the larger medical center can be a challenge.  For example, we are very interested in adding nitrous oxide as a sedation option for our patients.  The process for us is on hold while the Department of Anesthesia implements a patient-administered nitrous oxide program for pain management in other areas of the medical center.

Please share one of your example quality initiatives from the Center of Excellence application process.

Quality improvement projects over the 12 years have shaped how we now provide sedation services.  We also partner with colleagues on projects to improve healthcare delivery even when the project is not designed to directly improve our delivery of sedation.  Annual influenza vaccination is the most effective method for preventing influenza infection, but the rate of immunization is often low.  The influenza immunization rate was shockingly low in the pediatric subspecialty clinics where only a single vaccine was provided during the 2014-2015 season. Increasing this rate became a quality improvement goal set by our infectious disease colleagues who developed an influenza vaccine Best Practice Alert (BPA) for the 2015-2016 influenza season.  We partnered with them to integrate a clinical decision screening tool and vaccine orders into our sedation order set. The tool required physicians to ask parents and/or patients if they would like the influenza vaccine while sedated and streamlined the ordering process. As a result, 150 outpatients (55% of eligible outpatients) in sedation were vaccinated during the 2015-2016 season.  The influenza vaccination rates continued to increase during the 2016-2017 and 2017-2018 seasons. The initiative was generally well received by parents, patients, nurses, and physicians.  After overcoming initial challenges related to changes in workflow and insuring that adequate quantities of vaccine were available on the unit, the initiative proved to be a successful and an excellent way to utilize the pediatric sedation service to increase influenza vaccinations in our patient population.  Parents and patients liked the option of receiving the vaccine while sedated which likely contributed to our ability to vaccinate more eligible patients than other pediatric subspecialty clinics.

Could you share a story about a particularly “stand out” sedation encounter that illustrates the high quality care provided by your team?

Like the other members of the Society for Pediatric Sedation, our service strives to provide safe, high quality sedation services to all patients at Comer Children’s.  We also try to provide the best patient and family centered care possible even if it means not providing sedation.  Two of our nurses were recently successfully nominated by a family for the DAISY Award for Extraordinary Nurses. After 9 years of helping the family and their son, who was born with cancer, through serial MRIs requiring sedation, they helped them reach a milestone – their first MRI without sedation.  Excerpts from the family’s nomination included: “Her patience has been never ending…always prepared…always on top of things…made our experience here top notch….She is incredible with kids and we cannot begin to repay her for her incredible kindness and the amazing nurse she has been to our son.”  About 30% of our patients seen for radiology encounters just need someone to help them through the exam so they are not afraid. In addition to our dedicated certified child life specialist, our nurses have been trained to provide medical play and education to help a child through an MRI or CT without sedation.

What value does achieving and being recognized with the Center of Excellence designation bring to your program?

Achieving and being recognized with the Center of Excellence (COE) designation provided recognition across the larger UChicago Medicine for our program’s dedication to providing high quality sedation services to pediatric patients.  While providers who utilize our services and the medical center Sedation Committee were already aware of the high quality of care we provide, receiving the COE designation provided broader recognition and aligned perfectly with the focus of UChicago Medicine to provide the best care to our patients and their families.  The designation was an opportunity to formally acknowledge the hard work and group effort by our team to implement high standards of care and it reinforced our ongoing effort for continual service improvement.  It also validated our participation in the SPS as an institutional member and increased opportunities for collaboration with other SPS members.

What future projects are planned or in the works regarding quality care in the sedation service?

1. Partnering with our Child Life Program and our section of Developmental and Behavioral Pediatrics to create an autism toolkit.  Our goal is to provide families with a patient intake form/assessment tool that will help us as caregivers know the needs, triggers, comfort, and de-escalation methods that are best for their children with sensory processing disorders.  We want to be able to match these needs with the appropriate interventions without impeding patient flow on the sedation unit.  We hope to evaluate the toolkit via healthcare providers in the form of a survey (pre- and post-) that examines perception of the interactions pre- and post-intervention, and families/caregivers via a post-survey.
2. Our program has been very interested in initiating a nitrous oxide program to enhance the care we can provide to our patients.  We have been encouraged by all the valuable information on nitrous oxide provided by the SPS and its members.  As part of a larger medical center, we hope to be able to achieve this goal after a patient-administered nitrous oxide program for pain management is rolled out in other areas by the Department of Anesthesia.
3. We are partnering with other stakeholders to make pain control methods equitable for all children in Comer Children’s.  This ongoing project is part of the hospital’s goal to achieve ChildKind certification.