The Child Induction Behavioral Assessment Tool: A Tool to Facilitate the Electronic Documentation of Behavioral Responses to Anesthesia Inductions

ORIGINAL ARTICLE

The Child Induction Behavioral Assessment Tool: A Tool to Facilitate the Electronic Documentation of Behavioral Responses to Anesthesia Inductions Abby V. Winterberg, DNP, CNP, Christine L. Colella, DNP, CNP, Karyn A. Weber, MSN, CNP, Anna M. Varughese, MD, MPH Purpose: The purpose of this study was to develop and implement an electronic tool for documenting pediatric patients’ behavioral responses to anesthesia induction. Design: Quality improvement methodology was used in the tool development and implementation. Methods: The Child Induction Behavioral Assessment (CIBA) tool was developed based upon existing validated tools and through discussions with content experts and key stakeholders. Staff usage of the tool was monitored and the clinical utility of the tool was assessed. Findings: The CIBA tool facilitated frequent documentation of behavioral responses to inductions. The majority of clinicians reported that they found the prior CIBA ratings useful when developing induction plans for returning patients. Conclusions: Electronic documentation using the CIBA tool may provide useful information for optimizing induction plans for returning patients. Future research is needed to directly test the CIBA tool’s validity.

Keywords: anesthesia, child behavior, electronic health records, pediatrics. Ó 2016 by American Society of PeriAnesthesia Nurses

PEDIATRIC PATIENTS OFTEN EXPERIENCE anxiety during the induction of anesthesia. Common stressors faced during anesthesia inductions

include separation from family, fear of bodily harm, loss of control, placement of an intravenous (IV) line, and inhalation of anesthesia gas

Abby V. Winterberg, DNP, CNP, nurse practitioner, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, and College of Nursing, University of Cincinnati, Cincinnati, OH; Christine L. Colella, DNP, CNP, professor, Clinical Nursing, College of Nursing, University of Cincinnati, Cincinnati, OH; Karyn A. Weber, MSN, CNP, nurse practitioner, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; and Anna M. Varughese, MD, MPH, chief, Division of Clinical Anesthesia, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, and professor of Anesthesiology, College of Medicine, University of Cincinnati, Cincinnati, OH. Funding: This research was carried out without funding.

Conflicts of interest: None to report. Ethical considerations: The study was reviewed by the hospital’s institutional review board. This study was considered ‘‘not human subject research,’’ as there was no direct interaction or intervention with patients and no identifiable protected health information was collected. Address correspondence to Abby V. Winterberg, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229; e-mail address: [email protected]. Ó 2016 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2016.10.004

Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2016: pp 1-8

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from a mask. Research has consistently demonstrated that high preoperative anxiety in children is associated with negative postoperative outcomes such as emergence delirium, separation anxiety, tantrums, and sleep disturbances.1-4 In one research study, maladaptive postoperative behaviors persisted for 6 months in 20% of patients and up to a year in 7% of the patients.2 With the potential to have long-lasting effects on patient behavior, it is important to attempt to minimize patient anxiety during anesthesia inductions. Minimizing patient anxiety is also important because when patients are highly anxious they are more likely to experience combative behaviors during inductions such as kicking, flailing, and pushing staff or equipment.5 Patient safety is the most important consideration when formulating an induction plan, but there are a number of interventions that can potentially be used to decrease patient anxiety during inductions. These interventions may include parental presence at induction, anxiolytic premedication, behavioral interventions, and modifying the induction method. When patients return for subsequent anesthetics, it is important to assess how they responded to prior induction interventions. This assessment is generally obtained by asking for patient or family input about the previous experience. Although family input provides valuable information, there are many circumstances when this information is not available. These circumstances may include when the child is unable to describe the induction, the accompanying family member was not present for the prior induction, or the family cannot remember the details of the last induction experience. Family and patient input are always important to assess (when available), but having an experienced clinician’s assessment of the prior induction experience may provide a more objective assessment. Clinician documentation could also promote earlier identification of patient responses to prior induction plans, facilitating more efficient planning of subsequent interventions. Currently, some induction interventions are commonly documented in clinical practice (eg, method of induction, premedication, and use of induction room), but behavioral responses to inductions are not routinely documented. One reason

for this is because most of the validated tools for describing induction behaviors and preoperative anxiety (eg, the modified Yale Preoperative Anxiety Scale,6 the Perioperative Adult Child Behavioral Interaction Scale,7 and the Induction Compliance Checklist [ICC]8) were not created for routine use in busy clinical practice settings. The aforementioned tools require that the clinician review anywhere between 10 and 22 behavioral descriptions and determine which behaviors are exhibited. These tools provide a thorough assessment of the induction behaviors for research purposes, but time constraints in busy clinical practice settings can make them impractical to use on a routine basis. An ideal method for documenting induction behaviors should be thorough, but also succinct because there are more critical details that clinicians must attend to after a patient undergoes anesthesia induction including airway management, IV line placement, and administration of medications. In a recently published article, Beringer et al9 described a more concise tool for assessing pediatric induction behaviors. This tool, named the Pediatric Anesthesia Behavior (PAB) score, has only three behavioral categories. The PAB score demonstrates both reliability and validity and provides a more concise assessment of the induction behaviors than the previously mentioned tools. The PAB score, however, was only developed for children undergoing IV inductions. In many outpatient surgery locations, younger patients may undergo inhalation rather than IV inductions. Having a clinical practice tool for describing behavioral responses to both IV and inhalation inductions would be useful in these settings. Local Problems There were two problems to be addressed through this quality improvement (QI) initiative. The first was that the hospital did not have a standardized method for documenting patients’ behavioral responses to inductions. This was problematic because when patients returned for subsequent anesthetics there was no way to evaluate the effectiveness of previous induction interventions if the family or patient was unable to provide input. Our hospital cares for many patients who have chronic medical conditions, and more than 40% of the patients return for a subsequent anesthetic. Research

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has demonstrated that having a previous anesthetic increases the likelihood of experiencing a difficult induction.5 Having an induction behavioral assessment documented on the anesthesia record could provide useful information for optimizing induction plans for returning patients. The second problem was that the hospital did not have an efficient method for collecting induction quality data on patient populations. The importance of induction quality in pediatric anesthesia has been demonstrated in multiple research studies that have associated induction experiences with patient’s postoperative outcomes, including emergence delirium and behavioral disturbances once the patient returns home.1,3,4 In addition, the quality of the patient’s recovery has been shown to influence parental satisfaction with the perioperative experience.10 Recognizing the impact that induction quality has on postoperative outcomes and family satisfaction, our hospital previously collected induction quality data by having trained research coordinators score patient’s behavioral responses to inductions using a tool named the ICC8,11 (further description of prior methods for collecting induction quality data can be found in Appendix 1). Induction quality data were collected from 2003 to 2012 by research coordinators and targeted interventions resulted in a decrease in the percentage of poor inductions observed at the hospital.11 Data collection was discontinued in 2012 because of the significant amount of resources required to have research coordinators continually collect induction quality data.

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for documenting behavioral responses to anesthesia inductions in the EHR. The aims for this project included the following: 1. Increase the percentage of patients who have an induction behavioral assessment documented from 0% to greater than 90% within 1 year. 2. Compare the percentage of difficult inductions reported by clinicians with the CIBA tool to the historical ICC data by using a statistical process control chart. 3. Assess the clinical utility of the CIBA rating by administering a clinician survey.

Methods Setting The setting for this project was a free-standing, urban, academic pediatric hospital. The hospital has 629 registered beds, and anesthetics are performed across 38 operating rooms (ORs) and in non-OR anesthetizing locations throughout the hospital. More than 30,000 anesthetics were administered during the fiscal year of 2015. The clinical anesthesia team for the perioperative area consisted of 103 full-time equivalent anesthesia providers (including attending anesthesiologists, anesthesia fellows, and nurse anesthetists) and 16 anesthesia nurse practitioners (NPs).

The implementation of a new electronic health record (EHR; Epic, Verona, WI) in the anesthesia department during April of 2013 provided an opportunity to design a novel approach for documenting behavioral responses to inductions and for monitoring induction quality data electronically. Epic provided the capability to easily modify the user interface of the EHR and to collect information documented through automated reports. To address the aforementioned problems by optimally using the new technology, a QI team was established.

Our hospital uses an NP-assisted preoperative evaluation program where the NPs participate in most preoperative assessments for patients by obtaining health history, physical examination, and providing education regarding the anesthesia process. NPs can also order preoperative medications, laboratories, or laboratory tests when applicable. The attending anesthesiologist is consulted regarding acute illnesses, abnormal physical findings, or laboratory studies.12 The anesthesiologist delivering the anesthetic meets with the family before induction, reviews the evaluation, confirms the findings and anesthesia plan, and addresses any additional questions and concerns.

Purpose and Aims

Improvement Team

The purpose of this project was to develop and implement a standardized tool (named the Child Induction Behavioral Assessment or CIBA tool)

The improvement team consisted of two NPs from the anesthesia department, an attending anesthesiologist, and an EHR analyst. Key

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stakeholders, including anesthesiologists, nurse anesthetists, and NPs were consulted throughout the project. A specialist from the clinical and translational science center at a local university was consulted for designing the clinician survey and an EHR analyst from our hospital designed the electronic data reports. Planning the Intervention To determine an optimal method for documenting behavioral responses, the QI team reviewed prior methods of documentation used at the hospital. Previously, clinicians were not asked to routinely document behavioral responses to inductions. When behavioral responses were documented, a qualitative description of the induction was written in a comment box. In a chart review of 150 anesthesia records there were no comments documented about behavioral responses to inductions, indicating that this documentation happened infrequently. Qualitative comments did not provide an optimal method for documentation because these comments were not objective and could be time consuming to complete. TOOL DEVELOPMENT. To develop a tool that would be practical to implement and use in a busy clinical setting, the relevant literature was discussed with content experts from the anesthesia department. From these discussions, it was determined that currently existing validated tools did not meet the needs for our practice because they were either too time consuming to document or they did not include behaviors that described both IV and inhalation inductions. After discussing the possible options for documentation with the content experts, it was determined that creating a modified and more concise version of the ICC would be useful in our practice setting. The ICC is an observational induction behavior scale consisting of 10 negative behavioral descriptions. The ICC is scored as the sum of the behaviors exhibited during the induction (0 to 10), where an ICC score of greater than 6 is considered to be a ‘‘poor’’ induction. Behaviors from the ICC were used in creating the CIBA because the ICC has good inter-rater reliability5,8 and has been used in research studies and QI initiatives conducted at our hospital.5,8,11,13 In addition, the

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ICC has versions that describe both inhalation inductions (the original tool) and IV inductions (a modified ICC developed and tested internally by our hospital for QI purposes). The CIBA tool (Table 1) was developed by grouping the ICC behaviors into three categories, which were designated as ‘‘smooth,’’ ‘‘moderate,’’ and ‘‘difficult.’’ The three-category structure was designed using a format similar to a validated scale for grading behaviors during IV inductions named the PAB score.9 The PAB score was not used in our practice setting because this scale does not include behaviors describing inhalation inductions. EHR analysts from the anesthesia department were consulted when designing the user interface of the CIBA. As shown in Figure 1, the CIBA was added to the already existing anesthesia ‘‘induction assessment’’ section in the EHR to facilitate easy workflow. Once documented, the CIBA rating would be recorded on the patient’s anesthesia record. Before implementation, the CIBA’s design was discussed with and approved by the Anesthesia Working Group (AWG). The AWG is an interdisciplinary team, which includes anesthesiologists, nurse anesthetists, NPs, and EHR specialists. The AWG team meets monthly to discuss issues and improvements related to the EHR and represented both key stakeholders and end users of the CIBA. CLINICIAN TRAINING. The team leader presented an educational PowerPoint to the clinicians at a staff meeting. The presentation emphasized the importance of documenting induction behavioral responses and also provided seven video examples of patients undergoing anesthesia inductions. The clinicians watched the induction videos and graded the inductions as either smooth, moderate, or difficult using the CIBA tool. After the clinicians graded the videos, the QI team leader reviewed the behaviors exhibited by the patient and the corresponding CIBA category. The PowerPoint was emailed to clinicians who were unable to attend the meeting for review. METHODS OF EVALUATION. The outcome measures that were monitored included staff use of the CIBA tool and the percentage of difficult inductions reported. An EHR analyst was consulted to create electronic reports that would display the clinician usage of the tool and the number

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Table 1. The Child Induction Behavioral Assessment (CIBA) Tool SMOOTH: Patient did not exhibit negative behaviors, fear, or anxiety MODERATE: Patient cried, pulled away from mask/IV line, or verbalized fear/refusal/worry DIFFICULT: Patient pushed away staff or equipment, covered face/limb, cried/screamed hysterically, kicked/flailed body, required restraint, or made body rigid or limp

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planned to administer the clinician survey at 4 months postimplementation of the CIBA tool. The 4-month timeframe would allow time for some of the patients to return for an anesthetic while also obtaining feedback from clinicians early on in the process.

Results Documentation Frequency and Difficult Inductions Reported

IV, intravenous.

of smooth, moderate, and difficult inductions documented. The EHR analyst used Epic’s data warehouse to access the raw data that were documented in the EHR. Crystal Reports (SAP, Walldorf, Germany) were used to aggregate the data. The reports were scheduled to run monthly in SAP Business Objects. Data trends for the percentage of difficult inductions reported would be compared with the historical data by creating a statistical process control chart. To obtain clinician feedback on the CIBA tool, a survey (Appendix 2) was developed in collaboration with a clinical and translational science center at a local university. Face validity of the survey was assessed by having a nurse anesthetist, anesthesiologist, and NP from the anesthesia department, provide feedback and modifications to the survey questions before administration. The team leader

The CIBA tool was implemented in the EHR on May 15, 2014. After the first year, the CIBA was documented by clinicians 98% of the time in more than 30,000 anesthesia cases. The percentage of difficult inductions reported using the CIBA tool was compared with historical data by using a control chart. The control chart is a graph used to evaluate the performance of a process over time to improve processes and reduce variability. Control charts have a central line for the mean and upper and lower lines for the control limits. By comparing data points to the control limits, one can draw conclusions about whether the process is stable and in control (common cause variation) or unstable (special cause variation).14 As shown in the control chart (Figure 2), both the historical data (2008 to 2010) and CIBA data (2014 to 2015) have no data points that fall outside the control limits. In addition, there are no patterns

Figure 1. User interface for the anesthesia induction assessment in the electronic health record. CT, computed tomography; ECHO, echocardiography lab; IV, intravenous; MRI, magnetic resonance imaging; OR, operating room.Ó 2016 Epic Systems Corporation. Used with permission.

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indicating special cause variation. This indicates that the percentage of difficult inductions reported remained stable, although a different process was used to collect the data starting in 2014. The control limits are narrower for the CIBA data because the sample sizes were much larger. The historical data from 2008 to 2010 was chosen for comparison because the conditions were most similar to the current data (inhalation inductions, main campus ORs, and baseline data).

perts and key stakeholders early on provided an opportunity for feedback and improvements to the CIBA tool before implementation. Consideration of clinician workflow facilitated the design of a tool that was practical for clinicians to document routinely. Finally, the interactive staff education emphasized how documenting using the tool could contribute to improved patient outcomes, making the documentation clinically relevant.

Clinician Survey

Comparison of the CIBA Method to the Historical Method of Induction Quality Data Collection

The clinical utility of the tool was assessed by administering a staff survey 4 months after implementation of the CIBA tool. The survey was completed on paper at a staff meeting by 68 anesthesia staff members, representing 76% of the clinicians attending the staff meeting and 57% of the perioperative anesthesia clinicians. When compared with the anesthesia providers, a higher percentage of the NPs reported the CIBA rating as being useful in formulating induction plans for returning patients (Table 2). All clinicians surveyed were asked open-endedly what could make the CIBA tool more useful and if they had any additional comments about the CIBA. Suggestions for improvement included possible modifications to the wording of the tool, improving documentation of induction interventions, and making the CIBA rating easier to locate on the EHR of returning patients. Clinicians also suggested that patients who are intubated or aged less than 1 year be excluded from documentation, as the scale is not applicable.

Discussion Clinician Usage of the CIBA Tool The implementation of the CIBA tool provided the hospital with a standardized method for documenting behavioral responses to anesthesia inductions in children. The goal of having clinicians document the CIBA rating in more than 90% of the anesthesia cases was exceeded every month during the first year after implementation. There are multiple elements in the development process that likely contributed to the early acceptance from clinicians in documenting this information and the sustained high frequency of documentation. Discussions with content ex-

The CIBA method (clinician reported difficult inductions collected through electronic data reports) provides a more efficient process than the hospital’s historical method of collecting induction quality data (manual data collection of ICC scores by research coordinators). An advantage of using the CIBA method is the ability to capture data on more than 90% of patients receiving anesthesia versus less than 5% using the historical method. There are also fewer costs associated with the CIBA method, as no additional staff members are required to be present during induction and data are collected automatically through EHR reports. A further advantage of using the electronic data reports from the CIBA tool to collect induction quality data is that the reports were created using an EHR that is widely used in the United States (Epic). Epic is used in more than 350 healthcare facilities, which could facilitate easy transferability of the CIBA tool and benchmarking between institutions, after validity of the tool is confirmed. There are some potential limitations to using the CIBA method for collecting induction quality data. Having clinicians report difficult inductions could potentially result in under-reporting, as induction quality may be viewed as a reflection on the clinician’s ability. In addition, the three-category structure of the CIBA could be challenging for clinicians to reliably assign patients to a single category. Although there are possible limitations to using the CIBA method, the similarity in the percentage of difficult inductions reported in the historical data is encouraging for the tool’s validity. Future research will be needed to test the reliability and validity of the CIBA tool and to confirm

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Figure 2. Control chart showing the percentage of difficult inductions reported historically at the hospital by research coordinators using the Induction Compliance Checklist (2008 to 2010) and by clinicians using the CIBA tool (2014 to 2015). The percentage of difficult inductions reported remained stable, although a different process was used to collect the data starting in 2014. CIBA, Child Induction Behavioral Assessment.

the validity of using the CIBA method for collecting induction quality data. Clinician Survey The survey assessed whether clinicians found the CIBA rating useful when formulating induction plans for returning patients. As previously mentioned, a higher percentage of the NPs reported the CIBA rating as being useful when patients returned than did the anesthesia providers. One reason for this difference may have been because the anesthesia providers did not have enough patients return during the 4 months to adequately assess the usefulness of

the CIBA rating. The NPs assist in conducting most preoperative history and physical examinations at our hospital and are oftentimes the first clinician to discuss the prior induction experience with the family. This likely provided the NPs with more opportunities to consider the utility of the CIBA rating for returning patients during the 4-month time period. As shown in the survey (Table 2), 11% of the anesthesia providers indicated that they had not used the CIBA for a returning patient. Multiple anesthesia providers also stated in the open-ended questions that they did not know where to find the CIBA rating on the anesthesia record. Education was provided at a staff meeting to ensure that

Table 2. Clinician Survey Question When Making a Plan for Anesthesia Induction, How Useful is it to Know the Child Induction Behavioral Assessment Rating That was Documented on the Patient’s Previous Anesthesia Record? Very useful Moderately useful Not very useful Have not used the tool for this purpose

Nurse Practitioners (n 5 15)

Anesthesia Providers (n 5 53)

93.3% 6.7% 0% 0%

20.8% 43.4% 24.5% 11.3%

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providers know where to locate the CIBA rating. Feedback from the open-ended questions was considered in making modifications to the CIBA tool. Modifications were made in the EHR so that the CIBA tool does not appear if the patient is aged less than 1 year and clinicians may choose ‘‘not applicable’’ if the patient is intubated. Additional feedback will be obtained regarding the tool’s wording and intervention documentation to determine what modifications could make the tool more valuable. Although most clinicians surveyed reported the CIBA rating as being useful, it is important to mention that there are additional factors that should be considered when formulating an induction plan. These factors may include the patient or parent’s perception of the previous induction (if available), the patient’s age and developmental level, whether a premedication was previously administered, the length of time from the last anesthetic, and an assessment of the patient’s anxiety

level on the day of the procedure. Most importantly, patient safety must be considered when developing an induction plan. Consideration of the CIBA rating along with other relevant factors may help to facilitate an optimal induction experience for returning patients.

Conclusions In conclusion, the CIBA is a succinct tool that facilitates electronic documentation of behavioral responses to anesthesia inductions in clinical practice. Reviewing a patient’s CIBA rating on a prior anesthesia record may provide useful information for optimizing induction plans for returning patients. EHR reports from the CIBA tool could potentially be used to monitor induction quality data to identify target populations for QI initiatives and to facilitate measurement of baseline and outcome data. Before recommending implementation of this tool in other settings, future research will be needed to test the validity of the CIBA tool.

References 1. Beringer RM, Segar P, Pearson A, Greamspet M, Kilpatrick N. Observational study of perioperative behavior changes in children having teeth extracted under general anesthesia. Paediatr Anaesth. 2014;24:499-504. 2. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children: Predictors and outcomes. Arch Pediatr Adolesc Med. 1996;150:1238-1245. 3. Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg. 2004;99:1648-1654. 4. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006;118:651-658. 5. Varughese AM, Nick TG, Gunter J, Wang Y, Kurth CD. Factors predictive of poor behavioral compliance during inhaled induction in children. Anesth Analg. 2008;107:413-421. 6. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: How does it compare with a ‘‘gold standard’’? Anesth Analg. 1997;85:783-788. 7. Sadhasivam S, Cohen LL, Hosu L, et al. Real-time assessment of perioperative behaviors in children and parents: Development and validation of the perioperative adult child behavioral interaction scale. Anesth Analg. 2010;110:1109-1115.

8. Kain ZN, Mayes LC, Wang S, Caramico LA, Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication: Which intervention is more effective? Anesthesiology. 1998;89:1147-1156. 9. Beringer RM, Greenwood R, Kilpatrick N. Development and validation of the pediatric anesthesia behavior score—An objective measure of behavior during induction of anesthesia. Pediatr Anesth. 2014;24:196-200. 10. Gidman W, Elliott R, Payne K, Meakin GH, Moore J. A comparison of parents and pediatric anesthesiologists’ preferences for attributes of child daycase surgery: A discrete choice experiment. Pediatr Anesth. 2007;17:1043-1052. 11. Varughese AM, Hagerman NS, Kurth C. Quality in pediatric anesthesia. Pediatr Anesth. 2010;20:684-696. 12. Varughese AM, Byczkowski TL, Wittkugel EP, Kotagal U, Dean Kurth C. Impact of a nurse practitioner-assisted preoperative assessment program on quality. Pediatr Anesth. 2006;16: 723-733. 13. Sadhasivam S, Cohen LL, Szabova A, et al. Real-time assessment of perioperative behaviors and prediction of perioperative outcomes. Anesth Analg. 2009;108:822-826. 14. Varughese AM, Rampersad SE, Whitney GM, Flick RP, Anton B, Heitmiller ES. Quality and safety in pediatric anesthesia. Anesth Analg. 2013;117:1408-1418.

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Appendix 1 Description of the Historical Method of Induction Quality Data Collection The historical induction quality data from our hospital was collected using the Induction Compliance Checklist (ICC), an observational scale consisting of 10 negative behavioral descriptions, which has demonstrated good reliability (r 5 0.978).8 The ICC is scored as the sum of the

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behaviors exhibited during the induction (0 to 10), where a higher ICC score is considered to be a poorer induction. For quality improvement purposes at our hospital, an ICC score of greater than 6 indicated a poor induction. Research assistants observed anesthesia inductions and recorded induction quality data on less than 5% of patients annually from 2003 to 2012. Only a small percentage of patients could be observed because of the significant resources required to have research coordinators continually collect the data.

Appendix 2 Clinician Survey Please indicate your role in the department: , Nurse Anesthetist , Attending Anesthesiologist

, Anesthesia Fellow , Nurse Practitioner

When making a plan for anesthesia induction, how useful is it to know the Child Induction Behavioral Assessment rating (smooth/moderate/difficult) that was documented on the patient’s previous anesthesia record? , Very useful , Moderately useful , Not very useful , I do not use the tool for this purpose How could the Child Induction Behavioral Assessment tool be more valuable or useful? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Do you have any additional comments or suggestions relating to the Child Induction Behavioral Assessment tool? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________