2000 OPEN FORUM Abstracts
SEDATED PROCEDURES (SP): EXPANDED ROLE FOR A RESPIRATORY CARE PRACTITIONER (RCP)
Jeffrey W. Wright BS, RRT, Primary Children's Medical Center (PCMC), Howard Kadish, MD, Associate Professor of Pediatrics University of Utah School Medicine, Medical Director of the Rapid Treatment Unit, PCMC, Salt Lake City, Utah
Background: PCMC has adopted the philosophy of an "Ouchless Environment". We recognized that there were many in/out patient procedures that are considered to cause anxiety and discomfort. PCMC acknowledged that in the course of treatment some patients would have painful procedures repeated numerous times as in the case of bone marrow aspirates, bone biopsies, and lumbar punctures. Many of these historically painful procedures were performed in the OR, so certain medications could be used to reduce the pain and anxiety for the patient. Our Emergency Department (ED) Physicians (MD's) decided to use those medications (Propofol and Ketamine) in the ED to sedate their patients for particularly painful procedures (i.e. the setting of a fractured bone) in the spirit of the "Ouchless Environment". The ED then proposed a plan to do SP outside the OR in a 26 bed, 23-hour Rapid Treatment Unit that is adjacent to the ED. ED sited potential benefits as: cost savings to the patient, a patient/family friendly environment (reduced anxiety for the patient, Mom and Dad could hold the child until they fell asleep), the patient's pain/discomfort would be minimized (as seen in the OR), and there would be a reduction of the time required to perform the procedure and in recovery of the patient. Current Model of Care: The SPs are performed by a team: ED MD, a RN, a RCP, and a Child Life Specialist (CLS). The ED MD's, RN's, and CLS's rotate their staff. The RCP is the only constant member of the team in our care model. Roles: The ED MD is in charge of the patient's care. S/he completes tasks such as a history and physical exam, explaining risks, obtaining consent, and the administration of the Propofol and other medications. The RN and RCP, through cross training, are both responsible for obtaining, preparing, verifying doses, administering medication given during the procedure (usually through a central line), documenting medications given, and giving IV fluid if indicated. The RN and RCP are responsible for cardio-respiratory monitoring, oximetry, automatic blood pressure monitoring, and the documentation of vital signs as often as every two minutes. The CLS role is to give psycho/social support to patient and family before, during, and after the procedure. They do this by using diversionary activities for the child, explaining the procedure in a way the patient and family will understand, and answering any questions the patient and family may have. The RCP and RN may be required to perform the same tasks as the CLS. The primary function of the RCP on this team is managing the airway. Airway management includes: O2 administration, removal of secretions as needed, monitoring respiration (rate, depth, WOB, and SaO2), mask-bag ventilation (if apnea occurs), and patient positioning to maximize air exchange. Summary: Current care model has achieved the stated goals. A typical patient having a lumbar puncture has had charges decreased from approximately $3000 (when done in O.R.), down to approximately $300. The time requirements for the patient have been reduced to < 90 minutes when compared with the O.R. (3 to 4 hours). As for the friendly environment the findings are subjective, but the families of the patients have overwhelmingly gave positive feed back, including those familes who have experienced both the old and new care models. No significant adverse effects have been reported during SPs using Propofol, Fentanyl, and Ketamine outside the OR.