Context The information for this project was collected from the children’s wards at UHCW. Patients attending for elective scans requiring sedation were included. Sedation was administered as per the trust protocol. This protocol is based on current NICE and BNFc guidance.
Weight <15 kg - Chloral hydrate sedation
Weight >15 kg - Midazolam sedation
Problem We found that sedation of children for elective MRI/CT scans was insufficient more often than not. This led to failed scans which in turn led to delays in diagnosis, stress for patients and families. In addition this incurred significant financial cost to the Trust due to failed scans and referrals to BCH for scans under GA.
Assessment of problem and analysis of its causes 60 scans were reviewed over a 6 month period in 2013. 38 children underwent midazolam sedation and 22 were given chloral hydrate.
Chloral hydrate sedation was successful in 90% of cases, whereas midazolam was only successful in 18% of cases.
After discussion with the finance department we calculated that failed scans combined with referrals to BCH was costing the trust c. £70,000 per year.
Intervention We have discontinued the use of midazolam sedation for MRI/CT scans
The trust is in the process of developing a paediatric GA scan service at UHCW
Strategy for change The initial results of the study were presented to the paediatric department at the monthly clinical audit meeting. After discussion, the decision to stop using midazolam for scan sedation was disseminated amongst community and hospital based paediatricians.
A multi-disciplinary team comprising paediatricians, radiographers, radiologists and anaesthetists was formed. This team is in the process of designing and trialling a GA scan service at UHCW. This will enable us to provide scans to children who would beforehand have probably had 1–2 failed scans and then been referred to BCH. In addition this service may also provide the trust with increased revenue and savings.
Measurement of improvement We now only have children weighing <15 kgs (i.e. eligible for chloral sedation) attending our unit for elective CT/MRI scans. Children weighing >15 kgs that require sedation are being referred directly to BCH for GA scans while we develop our own service. This ensures that they will not need to undergo a probably unsuccessful scan under sedation with us before being referred.
Effects of changes Discontinuing the use of midazolam sedation has prevented children undergoing a stressful procedure that was unsuccesful in 82% of cases. This has improved patient care in the form of reducing delays in diagnosis and lowering parental anxiety. It has also saved the trust c. £70,000 per year in failed scans and referrals to BCH.
Lessons learnt This project has shown me that using a structured approach when considering a problem makes it easier to change systems/processes. Our department knew that midazolam wasn’t particularly successful but when you present that as a 82% failure rate it makes things a lot clearer. Forming an MDT to try to find a solution was also of huge benefit as it very quickly became clear that the radiology department shared our frustrations regarding failure of sedation. This in turn has enabled us to move forward with development of our own GA scan service quite quickly.
Message for others If you feel there is a problem/issue in your department analyse it in a structured way and try to form a solution to the issue rather just presenting a problem
If an MDT needs to be involved ensuring that there are clear goals identified is very important so as to avoid being sidetracked.
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