Sedation and Analgesia for Diagnostic and Therapeutic Procedures – Part 10 pps

Quality Monitoring of Sedation Analgesia Once indicators are chosen for measurement, a methodology for data lection, analysis, and reporting must be defined.. Because sedation is a high-

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by the data itself or by benchmarking Once initial quality improvementdata collection has been completed, the data can be used to generate a thresh-old performance standard The mean or average occurrence can serve as athreshold It is important to calculate the weighted average because eachmeasurement is the average of the cases for that time period Since the vol-ume of activity varies, the effect of each measurement should be in accor-

dance with its proportionate volume (18).

An important concept in threshold development is variation—specifically,the variation around the mean If the goal is to consistently meet perfor-mance standards, the weighted mean average can also serve as the threshold

of acceptable performance if a defined level of standard deviation (SD) of

the mean is added (18) Fig 5 demonstrates the resultant threshold obtained

by adding one standard deviation to the calculated mean average for the rate

Fig 4 Example of a run chart.

Fig 5 Example of a control chart: bar graph with threshold.

QA and CQI in Sedation Analgesia 287

of oxygen desaturation over a 1-year period If this threshold number is tinually recalculated as more data points are collected over time, a rollingmean is obtained that continually drives for improved performance (Fig 6).This dynamic measurement approach is consistent with the philosophy of

con-continuous quality improvement (2).

The second approach, benchmarking, is a comparison of the published ornon-published experience or the results of other similar programs Thesecould be within the same institution, with other similar institutions, or to anational database Benchmark data, when compared to institutional data,can identify obvious initial areas for improvement and often allow for iden-tification of practices, which might be used to improve performance Overtime, if used alone, benchmark data tends to result in acceptance of thestatus quo once the performance matches that of the benchmark

One nationwide study, The Quality Indicator Project (QI Project) sored by The Association of Maryland Hospitals & Health Systems (MHA)

spon-began in 1985 as a voluntary pilot project of seven Maryland hospitals (18).

The goal of the QI Project is to serve as a tool to assist hospital leadership inoverseeing patient care quality and identifying opportunities for improve-ment The MHA QI Project now provides clinical performance measure-ment and national comparative databases for over 1,800 participatinghospitals Quality indicators relating to Sedation Analgesia were added tothe database in 1999 The results are available in the aggregate to non-mem-

ber hospitals and can serve as a beginning source of benchmarking (19) The

project reports an overall rate of severe oxygen desaturation during sedationanalgesia between 1.5% and 4.2% Before accepting this range as a bench-mark, it is important to note that hospitals of varying sizes participate in theproject and that the measurement is for all sedation locations within those

Fig 6 Example of a control chart: bar graph with rolling mean.

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institutions A measurement of interest for one particular location may notreflect the case mix of an entire institution The project also defines severedesaturation as a drop of 5% or more At this level of measurement (5%), theresult would be a larger number of severe desaturations than if 10% wereused as the quantifier for the indicator Thus, care must be taken in interpret-ing and using any benchmarking results

5.3 Quality Monitoring of Sedation Analgesia

Once indicators are chosen for measurement, a methodology for data lection, analysis, and reporting must be defined Depending on availableresources, the data is usually collected by either random sampling of seda-tion cases or by databasing all sedation cases Because sedation is a high-risk activity and occurrences of adverse events are relatively rare, it may beadvisable to collect data on all cases Databasing all sedation cases has cer-tain advantages Low levels of compliance and variation can be betterdetected Demographic and clinical information can be readily available tounderstand the results of the quality indicators Aspects of sedation practicethat are of interest to practitioner credentialing, such as number of casesperformed or levels of sedation attained, can be reported

col-In order to understand what is being measured, a flow chart of the dataprocess can be helpful Fig 7 depicts the methodology used for data collec-tion, analysis and reporting of all sedation cases Fig 8 is a replication of thescreening tool, the Clinical Quality Indicator Screen, (QI Screen) used at theauthor’s institution As shown in Fig 7, the QI Screen is critical to twooutputs: the Quarterly Report of activity and quality indicator events includ-ing the Case Review Process The shaded areas indicate possible points oflost information It can be seen that the denominator for quality indicators isthe number of cases for which the QI Screen was completed and databased.Given the particular culture of an organization, lost information could besignificant Thus, an important QA activity would be to occasionally evalu-ate the proportion of sedation cases for which a screening form is submitted

5.4 The Quality Improvement Process

Over the years, the management of quality has been intensely studied andconceptualized Quality assurance has evolved to incorporate sophisticatedmethodologies and measurements The development of quality indicatorsprovides a framework within which to objectively and systematically pur-sue opportunities to improve care and clinical performance By the early1990s, hospitals and health care associations across the country had embracedquality improvement, also known as “Continuous Quality Improvement”

QA and CQI in Sedation Analgesia 289

(CQI) or “Total Quality Management” (TQM), as an integrated, coordinated

approach to systematically review and evaluate clinical performance (2) The

broad inclusive concepts of continuous quality improvement today overshadowthe traditional department-based QA programs Indeed, one of the basic tenets

of the Quality Movement is that quality is not a department, a technique, or aphilosophy It is a fundamental way of managing organizations as well as the

systems, processes, and activities that define its outputs (20).

Fig 7 Sedation analgesia QI methodology flowchart.

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QA and CQI in Sedation Analgesia 291

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Many health systems use the Plan-Do-Check-Act (PDCA) cycle (Fig 9)

or a variation of it, as both a managerial and a quality tool (21,22) The

PDCA cycle is a checklist of the four stages which move from ing a process, evaluating a process, identification of a problem, correcting aproblem, and again evaluating the process This continuous feedback loop

understand-as depicted in Fig 9

The collection and analysis of QI data is within the check stage of thecycle This is traditional quality assurance or quality control Checking is acritical element in the sedation quality improvement process Since sedation

is a high-risk activity, the occurrences of indicators that are determined to

be critical or adverse events are reviewed The critical indicator case review

is an important source of information and identification of opportunities forimprovement A sample critical indicator case review process is described

as a flowchart in Fig 10 Quality improvement is practiced when there is asystematic movement from checking to acting, doing, and then re-checking.The assessment of quality indicators involves determining current levels

of performance, stability of the processes over time, comparison to external

Fig 9 The PDCA cycle Reprinted with permission from ref (22).

QA and CQI in Sedation Analgesia 293

Fig 10 Case review process flowchart.

6 CONCLUSION

Quality Management is now an integral component of health care agement Although QA remains an important part of high risk clinical prac-tice such as sedation analgesia, CQI, with its concepts of cross departmentalproblem solving and the understanding and redesigning key processes, is amodel for quality improvement in sedation practice Once sedation is takenout of the sheltered environment of the operating room, interaction withhospital systems and varied personnel can cause unwanted variability in thesedation analgesia process Only by working within a systematic framework,

man-in partnership with the clman-inical and support staff responsible for sedationperformed by the non-anesthesiologist, can variability be decreased andquality outcomes be attained more consistently

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Gastroint Endosc 48(4), 432–440.

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to Continuous Quality Improvement in Medical Imaging The American lege of Radiology Publications 1998.

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Analgesia American Society of Anesthesiologists http://www.asahq.org/

Standards/20.htm

7 Joint Commission Resources (2001) Anesthesia and Sedation, in Topics in Clinical Care Improvement Joint Commission on Accreditation of Healthcare

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QA and CQI in Sedation Analgesia 295

8 Schroeder, P (1991) Clinical indicators: development and use Journal of

Nurs-ing Quality 6(1), 1–87.

9 Deming, W E (1986) Out of the Crisis, MIT Press, Cambridge, MA.

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487

12 Donabedian, A (1980) The Definition of Quality and Approaches to its ment Ann Arbor, MI, Health Administration Press

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Quality Management Science in Health Care Organizations JAMA 262(20),

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manage-ment project Journal of Pediatric Oncology Nursing 12(3), 115–121.

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Healthcare Quality 23(4), 5–10.

19 The Association of Maryland Hospitals & Health Systems (MHA) (2000)

Quality Indicator Project http://www.qiproject.org/

20 Thomas, P., Kettrick, R., and Singsen, B (1992) Quality Assurance and tinuous Quality Improvement: History, Current Practice and Future Directions

Con-Delaware Medical Journal 64(8), 507–513.

21 Institute for Healthcare Improvement Quality Improvement Resources: A

Model for Accelerating Improvement National Academy Press 2001; http://

www.ihi.org/resources/qi/

22 HCi, PDCA Cycle: From Problem Faced to Problem Solved HCi Toolkits

2000; http://www.hci.com.au/hcisite2/toolkit/pdcacycl.htm

pharmacokinetics, 166Alpha-2-agonist-induced analge-sia and sedation, 19

Ambulatory centers, 119–120patient selection, 119American Academy of PediatricDentistry (AAPD)

vs AAP, 44sedation guidelines, 41–44American Academy

of Pediatrics (AAP)

vs AAPD, 44sedation guidelines, 37–40American College of EmergencyPhysicians (ACEP)

clinical policy, 44–45evidence-based, 45sedation guidelines, 44–46American Society for

GastrointestinalEndoscopy (ASGE)endoscopic sedation survey, 112American Society

of Anesthesiologists (ASA)Physical Class, 60t

practice guidelines, 38, 46–47,194–195

standards, 191–192Amnesic propertiessedating drugs, 5Analgesia, 55tf: figure

t: table

Baroreflex responsespropofol, 129Basic life support (BLS), 244Beer’s Law, 200

Benchmarking, 287Benzocaine, 205Benzodiazepine antagonistsendoscopic sedation, 112Benzodiazepines, 14, 144–146bronchoscopy, 110

colonoscopy, 111emergence phenomena, 135endoscopy

with opioids, 112metabolism, 144Bicuculline, 14Biliary colicmorphine, 163Bispectral Index (BIS), 7–8,69–70, 223, 235Bivona tubesMRI, 80Blood pressuremonitoring, 61–62, 206–208standards, 192

Bloomsbury Sedation Score,224t

BLS, 244Brainstem (BAEP, 0-20 ms), 8Brainstem cholinergic neuronsmodulate EEG spindlegeneration, 8–11Bronchoscopy, 109–110Butorphanol (Stadol), 161intranasal, 174

C

Cambridge Sedation Score, 224t

CT, 85dentistry, 93echocardiography, 90MRI, 82

time-course for sedation, 13–14Chloramphenicol

neonates, 155Choice reaction time (CRT), 220Cholinergic modulation

of arousal and breathing, 16Cholinergic neurotransmission,18f

modulates EEG arousal, 12fCirrhosis

opioidspharmacokinetics, 157Cirrhotics

midazolam, 114Clinical sedationdefinition, 2Clonidinebronchoscopy, 110Cochlear implantsMRI, 80, 109Codeine, 170–171bronchoscopy, 110Colonoscopy, 110, 111COMFORT score, 229, 230tCompetency-based educationnurses, 118, 244

Complicationsmanagement, 254–256Computerized tomography (CT)pediatric sedation, 84–85techniques, 85

Congenital heart disease (CHD),247

prevalence, 87Conscious sedation, 55t, 277AAP definition, 37

training, 91

Depth of sedation See also Level

of sedationassessment, 219–236clinical evaluative tools,220–232

sedation practice guidelines,47

Desflurane, 15Dezocine (Dalgan), 161Diazepam, 144

Digit symbol substitution test(DSST), 220

Dilaudid, 169–170Discharge, 64–65criteria, 65t, 268–269, 270teducation, 271, 272tDocumentation, 64, 256frequency, 60tDorsal pons, 10Drug-induced respiratorydepression, 15Drugs, 63

principles, 64tDSST, 220DTP (demerol, thorazine,phenergan) cocktail, 33, 88Dysrhythmias

ECG monitoring, 209

E

Ear oximeter, 202ECG

monitoring, 208–209pediatric sedation, 90–91Echocardiogram (ECG)monitoring, 208–209pediatric sedation, 90–91ECMO, 176

EDTA, 132Education, 248–249

Extra-corporeal membraneoxygenation (ECMO), 176

F

FACES scale, 267–268Failed sedation, 65–66Fentanyl

cardioversion, 137dosage, 168–169fracture reduction, 96intranasal, 174liver disease, 158with midazolam, 106pharmacokinetics, 166–168pruritus, 165

Fentanyl Actiq, 174Fentanyl lollipop, 169Ferromagnetic material, 109MRI, 81

Five-lead ECG system, 210fFLACC Behavioral Pain Tool,269t

Flexible sigmoidoscopy, 110Flowchart, 281–282, 289fFluid requirementscalculation, 267tFlumazenil

following midazolam, 113Fourier analysis, 233

Fracture reductionfentanyl, 96midazolam, 96

G

Gamma-aminobutyric acid A(GABA A) receptorsand arousal, 13–15propofol, 126