Context Our Emergency Department (ED) is a busy District General Hospital caring for 20,000 acute paediatric cases per year. Many children sustain minor injuries that need basic emergency treatment, often requiring a level of sedation to ensure it is undertaken safely, and without distress to the patient.
Problem Many children with minor lacerations and foreign bodies are currently referred onto inpatient specialties for these procedures. Sedation in the ED reduces the number of admissions for this and reduces the child and parent’s distress.
Assessment of problem and analysis of its causes We audited 61 children aged 0–16 who attended the Emergency Department and were referred to our Maxillofacial Surgeons during September and October 2014. Of those 61, 9 were required to undergo a general anaesthetic (GA) for repair of their facial wounds.
A lack of set guidelines, which allow for a consistent and safe approach to ketamine sedation, was cited for the lack of service.
Intervention Based on the College of Emergency Medicine Guideline on ketamine sedation in the ED, we developed our own ketamine sedation guideline. It is a comprehensive guide that, accompanied with adequate training of individuals performing sedation should produce consistent methods of ketamine sedation, which adheres to college guidelines.
We also developed a standard operating procedure (SOP) checklist to be completed during sedation. Trainees must undergo a period of experiential training and observation of practice prior to independent practice. Finally, a patient satisfaction questionnaire was developed.
Strategy for change Following the audit, we met with the consultant body and ED management, who approved our plans to introduce the ketamine sedation service.
Once the guideline was written, we liaised again with consultants and paediatric ED nurses to discuss the practicalities of the service being implemented. Here, we also developed the strategy for training of medical staff undertaking ketamine sedation.
The final pack of written guideline, SOP, competency assessment and patient questionnaire was submitted to ED consultants and management. Since approval we have commenced the sedation service within our ED
Measurement of improvement Since implementation of the guideline, we have sedated 4 children in the ED. Using the patient satisfaction questionnaire, feedback, has so far been positive. We will look to audit all children sedated in the ED in February 2015, assessing levels of adherence to the guideline, patient outcomes and patient satisfaction. Cost-Benefit analysis is also being undertaken at present.
Effects of changes Since our service commenced, we have avoided 4 patients needing to be put under GA, consequently increasing the efficiency of patient care, without affecting quality, and freeing up vital space on both the paediatric ward and operating theatre time.
Having adequate staffing levels to conduct sedations, along with space in the department, especially when the department is busy has proved difficult. Sedations are only conducted between 0800 and 2000, and in some cases, it will be necessary to bring children back the following morning to address this issue.
Lessons learnt Due to the small numbers of sedations being conducted, and the shift nature of Emergency Medicine work, our training has been limited to ad hoc experiential training and competency assessment of senior trainees. A comprehensive training programme, consisting of theoretical, simulation and experiential learning for all trainees at the commencement of the service may alleviate some anxieties amongst trainees and increase competency levels.
Message for others Drawing knowledge from trainee’s previous experiences in other ED’s where successful ketamine sedation service already exists, we were able to understand the pragmatic implications of introducing such a service. Discussion of ideas and methods of practice in different departments should be encouraged within the multidisciplinary team to promote improvement and development of services.
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