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Enhancing Pediatric Perioperative Patient Safety
CONTINUING EDUCATION
Enhancing Pediatric Perioperative Patient Safety 1.4
www.aornjournal.org/content/cme
QUINN JOHNSON, MD, MBA; JANETTE McVEY, MD Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www .aornjournal.org/content/cme. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #17538 Session: #0001 Fee: Free for AORN members. For non-member pricing, please visit http://www.aornjournal.org/content/cme. The contact hours for this article expire November 30, 2020. Non-member pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to enhancing pediatric perioperative patient safety.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Quinn Johnson, MD, MBA, and Janette McVey, MD, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss how pediatric surgical care has evolved. 2. Identify the perioperative needs of pediatric patients. 3. Describe how nonpediatric facilities can provide safe care for pediatric patients.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
https://doi.org/10.1016/j.aorn.2017.09.007 ª AORN, Inc, 2017
434 j AORN Journal
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PATIENT SAFETY FIRST
Enhancing Pediatric Perioperative Patient Safety 1.4
www.aornjournal.org/content/cme
QUINN JOHNSON, MD, MBA; JANETTE McVEY, MD
T
he frequency of surgery for patients younger than 18 years of age is increasing, and pediatric procedures are being performed in all types of facil1 ities. Approximately 450,000 pediatric patients are admitted for inpatient surgery on an annual basis in the United States, with 115,000 of those procedures occurring in patients who are three years old or younger.2 It is estimated that 40% of pediatric inpatient surgical procedures are performed in nonpediatric hospitals in the United States.1 In 2006, an estimated 2.3 million ambulatory anesthesia episodes of care were provided to patients younger than 15 years of age in the United States.3 This number reflects an increase of almost 50% compared with the previous decade, and the number of pediatric surgical procedures is expected to rise.3 Shifting care from pediatric to nonpediatric facilities raises questions about how surgical teams can best provide consistently safe and
appropriate care for pediatric patients of varying age and health across surgical settings.
PERIOPERATIVE PEDIATRIC PATIENT CARE Regardless of the location in which a procedure takes place, perioperative pediatric care requires facility administrators and staff members to recognize their limitations (eg, appropriately trained personnel, access to pediatric equipment). Careful development of care protocols and guidelines specifically designed for pediatric patients and regular assessment and consistent development of pediatric skills are required. Nurses play a critical role in the delivery of care for the pediatric patient during pediatric emergencies. Participating in pediatric crisis simulations can help personnel identify areas for
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improvement and ensure all members of the team understand their individual roles and responsibilities. In addition, all facilities should have a robust method for reporting errors or safety concerns, followed by identification and analysis of the problem and correction of the root cause to improve the delivery of care. The Society for Pediatric Anesthesia, American Society of Anesthesiologists, and the American Academy of Pediatrics have produced guidelines to ensure pediatric perioperative safety and help delineate how perioperative nurses can assist with optimizing the care and safety of the pediatric patient. In this article, we discuss current published guidelines and recommendations specific to basic pediatric perioperative safety, standards of care, and crisis management.
UNDERSTANDING AND ASSESSING RISK Each member of the surgical team plays a vital role in the safe care of the pediatric patient. Most health care providers understand that pediatric patients cannot be treated as small adults and that unique challenges and risks accompany the treatment of the pediatric surgical patient. Risk stratification varies widely among the pediatric population because of a combination of factors including age and coexisting medical conditions. In 2013, the Task Force for Children’s Surgical Care4 created consensus recommendations using patient comorbidities and facility resources to aid with decision making and risk stratification. Members of the key disciplines of surgery, pediatrics, anesthesiology, and nursing have endorsed these guidelines, which delineate the basic requirements and minimum-resource standards of care. The Task Force for Children’s Surgical Care advocates that patients who are less than 50 weeks postconception age or less than one year old should have a pediatric anesthesia professional administer anesthesia because of a higher risk of postoperative apnea. Other studies have supported this finding and have shown that pediatric surgical patients less than one year old and those with complex comorbidities are at an increased risk of morbidity and mortality.1,2,5,6 Finally, studies also have shown that pediatric patients undergoing complex surgery in high-volume, comprehensive-care pediatric centers have improved outcomes.6 These studies help to illustrate the importance of a multifactorial approach to providing optimal outcomes for pediatric surgical patients.
Variables Used to Determine Risk The increasing demand on facilities to accommodate both inpatient and outpatient pediatric surgeries requires personnel to identify appropriate patients, procedures, and 436 j AORN Journal
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facility resources. After determining whether a patient requires surgery in a pediatric or nonpediatric facility, we recommend that care providers carefully consider three major factors: patient age and medical condition, complexity of the procedure and staff members’ skill level, and facility’s resources (eg, equipment, support, staff members, other resources).
Patient age and medical condition To determine risk, the surgical team should comprehensively evaluate the patient’s medical condition. The American Society of Anesthesiologists (ASA) Physical Status Classification System is the most commonly used system to help categorize patients, including children.7 Healthy patients and those with mild systemic disease (eg, obesity, mild lung disease, well-controlled diabetes) are classified as ASA I and ASA II, respectively. Patients classified as ASA III have moderate to severe comorbidities, and patients classified as ASA IV have severe conditions that are a constant threat to life.7 An anesthesia professional should evaluate each pediatric patient and assign the appropriate ASA classification before surgery. The ASA classification of each patient is one of the most crucial factors in determining the appropriate location for surgery because this rating affects the complexity of the surgical procedure and the required skill level of the perioperative team.
Complexity of the procedure and staff members’ skill level The complexity of the proposed surgical procedure and the ability and experience of the surgeon and staff members to perform and support that procedure affect the risk to patients. Although studies have shown that it is often difficult to measure and assess complexity of the procedure and level of skill of the surgeon accurately in every situation, performing a thorough history and physical examination can correlate with pediatric patient outcomes in specific types of pediatric surgery, from pediatric general surgery to more advanced cardiac and neurosurgical procedures.6 Anesthesia professionals and nursing educators should routinely assess staff members for competency in caring for pediatric patients. Nurses and other surgical team members are crucial in determining the types of procedures they can perform safely. Accurate anticipation of the level of nursing care required in the pre- and postoperative periods is an equally important skill for perioperative nurses to possess because the ability to provide adequate perioperative nursing care is vital to protect the pediatric patient’s safety. Derieg8 provides an excellent
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Patient Safety First
summary of perioperative pediatric nursing care and covers key topics such as fluid management, airway evaluation, and pain management. Regardless of the location in which nursing and technical personnel administer pediatric patient care, they should have training indand be experienced indroutine and emergency pediatric perioperative care.5 Personnel should regularly evaluate and re-evaluate pediatric patient outcomes at their facility to determine what types of pediatric procedures they can perform safely.
care for a high-risk pediatric patient, the ASA recommends pediatric-specific arterial and venous monitoring equipment and portable monitoring equipment to aid in patient transport to and from the postanesthesia care unit or intensive care unit.9 Anesthesia, nursing, and surgical personnel at all facilities caring for pediatric patients should take an inventory of the resources available and plan for regular reviews of the ASA recommendations to ensure that their facilities are in compliance.
Facility resources
Determining Acceptable Limits and Risks
The final variable affecting risk is the level of care that the facility can provide as a whole. This variable is determined at the facility by the presence or absence of pediatric subspecialties, support services, and equipment. The ASA Statement on Practice Recommendations for Pediatric Anesthesia9 covers both ambulatory and inpatient pediatric surgeries, and their recommendations are broad enough to apply to any facility caring for pediatric patients. Health care facilities are categorized as basic, advanced, or comprehensive based on their available resources and their staff members’ ability to care for the pediatric patient.4 Basic facilities have no multidisciplinary management resources for pediatric comorbidities; advanced centers typically offer single surgical specialties such as neurosurgery and craniofacial surgery, neonatology, and pediatric anesthesia; and comprehensive centers offer pediatric anesthesia along with the resources and equipment for multiple medical and surgical specialties pertaining to all pediatric conditions.4 A facility’s employees may overlook, underappreciate, or even diminish the true limitations of their facility; however, the lack of support services to manage a pediatric crisis successfully becomes all too apparent in an emergency. Therefore, facility staff members should make every effort to assess the facility’s available resources accurately. To provide quality pediatric care, a facility should possess the following:
pediatric-specific resuscitation equipment, pediatric advanced life supportetrained personnel, medications specific for use in pediatric patients, standardized medication dosages, and dedicated physical space designed for the pre- and postoperative emotional comfort of the pediatric patient.4
To meet the standards of care for monitoring a pediatric patient who is under anesthesia, the ASA recommends providing pediatric-specific airway devices and ventilation systems, fluid administration practices, warming devices, and equipment.9 For example, if a facility is expected to provide
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Assuming that each facility follows the ASA guidelines regarding anesthesia equipment and personnel, surgical centers can use the following stratifications to assign pediatric procedures to the correct location. The Task Force for Children’s Surgical Care has deemed basic children’s surgical centers acceptable for routine, low-risk procedures for patients aged one year or older and classified as ASA I or II. For patients classified as ASA I, II, or III and who are full- or preterm infants, and for common anomalies treated by pediatric surgeons, advanced centers are needed. Finally, comprehensive centers can care for all pediatric patients regardless of age, comorbidity, or the planned surgery.4 It is important for care providers to identify those patients whose medical needs exceed the capacity of the proposed facility and may need to be referred to a location that possesses pediatric capabilities that are more specialized. Basic and advanced centers must have a formal mutual agreement among hospitals to facilitate timely, appropriate, and safe transfer to a comprehensive children’s center so that the more specialized facility may provide progressive medical treatment, if necessary.4
Patient Hand Overs A common theme throughout perioperative patient safety literature is communication.10-13 Clear and concise communication of key information to the next care provider minimizes risk and optimizes patient care. The most crucial time to ensure clear perioperative communication occurs is during staff member turnover (eg, changes of shift, breaks). Minimizing the number of hand overs during each surgery and developing facility-specific hand-over tools and checklists are two areas in which perioperative personnel can make improvements to prevent the breakdown of communication and adverse outcomes.10 Patient hand overs should occur at every phase of perioperative care and continue through patient discharge from the facility. Hand overs should occur among nurses, anesthesia professionals, and surgeons, as well as AORN Journal j 437
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Figure 1. The Society for Pediatric Anesthesia’s cardiac arrest checklist. PEA ¼ pulseless electrical activity; ETT ¼ endotracheal tube; CPR ¼ cardiopulmonary resuscitation; EtCO2 ¼ end tidal carbon dioxide; ROSC ¼ return of spontaneous circulation; O2 ¼ oxygen; VF ¼ ventricular fibrillation; VT ¼ ventricular tachycardia; ECMO ¼ extracorporeal membrane oxygenation. Reprinted with permission from the Society for Pediatric Anesthesia, Richmond, VA. among all levels of care providers. During hand overs, care providers should convey all of the important patient information pertinent to the surgical care plan. Some key items that are regularly included in hand-over reports are
allergies, administered medications and doses, the planned or completed surgical procedure, and any perioperative issues the patient experienced.
Additional items should be added to the report based on the patient’s care needs. If checklists are used, they must be 438 j AORN Journal
reliable, easy to use, and evolve over time. Each staff member participating in the information exchange should be unafraid to speak up if an error is identified.11
SOCIETY FOR PEDIATRIC ANESTHESIA CRITICAL EVENTS CHECKLISTS After personnel meet the basic facility, staffing, protocol, and equipment needs for safe pediatric care, they should focus on their ability to manage perioperative emergencies and define surgical team roles during these crises. The World Health Organization released its Surgical Safety Checklist in 2009,
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Patient Safety First
Figure 2. The Society for Pediatric Anesthesia’s trauma checklist. C-spine ¼ cervical spine; PIP ¼ peak inspiratory pressure; H2O ¼ water; LR ¼ Lactated Ringer’s; NS ¼ normal saline; RBC ¼ red blood cell. Reprinted with permission from the Society for Pediatric Anesthesia, Richmond, VA. constructing a team approach for the nurse, anesthesia professional, and surgeon to ensure essential perioperative care basics for patient safety.12 Checklists such as these have proved to be beneficial in day-to-day practice to help prevent critical events and mistakes.13 Knowing how to use surgical safety checklists when a perioperative pediatric emergency occurs is crucial. The Society for Pediatric Anesthesia has developed the Critical Events Checklists to guide anesthesia professionals and surgical team members during pediatric perioperative crises.14 These checklists help provide crisis guidelines and protocols when surgical team member roles may be difficult to define, the risk of error is high, and order is needed. Even the most seasoned surgical teams experience difficulties recalling critical steps and medication dosages and making decisions quickly in times of crisis and need an accurate and timely resource to guide them.15
information to all surgical team members.14 Topics covered by this resource include information and guidance for responding to many emergency situations (eg, bronchospasm, cardiac arrest, difficult airway, airway fires, local anesthetic toxicity, trauma).16 This tool is available for download online (http:// www.pedsanesthesia.org/critical-events-checklists/) and via interactive mobile device application (https://itunes.apple.com/us/ app/pediatric-critical-events/id709721914). Personnel at the University of Missouri, Columbia, use a printed version of the checklist attached to each pediatric anesthesia machine or cart, with copies also available in the holding area and postanesthesia care unit. Figure 1 provides an example of the cardiac arrest checklist and Figure 2 provides an example of the initial treatment of trauma checklist.16
The Quality and Safety Committee of the Society for Pediatric Anesthesia designed these evidence-based checklists to provide
Simulation is playing an increasing role in all forms of medical and nursing training. To provide quality pediatric care,
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Critical Event Simulation
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personnel at all facilities should participate in simulation exercises that allow each team member to practice his or her role, refine his or her communication skills, and identify weaknesses and errors during simulated critical events. The use of checklists as a cognitive aid in combination with simulation training is essential to providing pediatric patient safety. Simulation exercises help users identify team roles, familiarize themselves with the checklists, and ensure their checklists are complete; simulations also expose teams to crisis scenarios and provide the opportunity for personnel to review their responses and participate in performance evaluations through debriefings.14 The goal of a simulation is for personnel to recognize their own deficiencies and those of their facility, and ultimately improve outcomes.15 Personnel can tailor cognitive aids (ie, simulation and surgical crisis checklists) to be facility specific and include personnel practicing in areas of the hospital outside the OR, such as the pharmacy, laboratory, intensive care unit, and administrative department.17
IMPROVING CARE BEYOND THE OR When caring for pediatric surgical patients, the goal is to provide safe, effective, and patient-centered care.18 The Society for Pediatric Anesthesia developed the Wake Up Safe initiative to fill gaps in knowledge and find ways to reduce or eliminate near misses and adverse events.19 Wake Up Safe is a voluntary, multi-institutional, error-reporting system to identify strategies for improvement and root cause analysis when patterns or issues emerge that are specific to pediatric anesthesia.20 The most commonly identified events are respiratory or cardiac; other events that require escalation of care, such as cardiac dysrhythmia and medication errors, are also included.18 Through this reporting process, the Society for Pediatric Anesthesia has developed advisories on hyperkalemia, cardiac arrest, wrong-site or wrong-side procedures, and IV medication errors.19 Similarly, each facility may have its own means of reporting patient safety concerns. For example, at the University of Missouri, Columbia, an electronic patient safety network is available for all levels of personnel to report patient safety concerns. By approaching unanticipated events in a transparent manner, personnel at the facility are attempting to understand how issues occurred rather than trying to assign blame; as a result, personnel are more likely to improve processes and patient outcomes.
CONCLUSION As the number of pediatric surgeries increases at specialized and general hospitals, the need for thorough, realistic evaluations of available resources is vital to ensuring safe pediatric patient care. Pediatric patient safety requires a team approach; 440 j AORN Journal
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all health care providers caring for pediatric patients should advocate for frequent assessments of staff member skills and equipment and reviews of surgical procedures to determine what is appropriate for each facility. Nurses often are role models for conveying the importance of using checklists to optimize patient care during routine care and times of crisis and should lead by example. By focusing on the critical areas discussed in this article, health care providers can improve the quality and safety of perioperative care at all facilities responsible for the care of pediatric patients.
References 1. Sømme S, Bronsert M, Morrato E, Ziegler M. Frequency and variety of inpatient pediatric surgical procedures in the United States. Pediatrics. 2013;132(6):e1466-e1472. 2. Tzong KYS, Han S, Roh A, Ing C. Epidemiology of pediatric surgical admissions in US children: data from the HCUP Kids Inpatient Database. J Neurosurg Anesthesiol. 2012;24(4):391-395. 3. Rabbitts JA, Groenewald CB, Moriarty JP, Flick R. Epidemiology of ambulatory anesthesia for children in the United States: 2006 and 1996. Anesth Analg. 2010;111(4):1011-1015. 4. Task Force for Children’s Surgical Care. Optimal resources for children’s surgical care in the United States. J Am Coll Surg. 2014;218(3):479-487, 487.e1-487.e4. 5. Polaner DM, Houck CS; Section on Anesthesiology and Pain Medicine Executive Committee. Critical elements for the pediatric perioperative anesthesia environment. Pediatrics. 2015;136(6): 1200-1205. 6. McAteer JP, LaRiviere CA, Drugas GT, Abdullah F, Oldham KT, Goldin AB. Influence of surgeon experience, hospital volume, and specialty designation on outcomes in pediatric surgery: a systematic review. JAMA Pediatr. 2013;167(5):468-475. 7. ASA Physical Status Classification System. American Society of Anesthesiologists. https://www.asahq.org/resources/clinical -information/asa-physical-status-classification-system. Accessed June 27, 2017. 8. Derieg S. An overview of perioperative care for pediatric patients. AORN J. 2016;104(1):4-10. 9. American Society of Anesthesiologists. Statement on Practice Recommendations for Pediatric Anesthesia. Washington, DC: American Society of Anesthesiologists; 2016. http://www.asahq.org/ w/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/ statement-on-practice-recommendations-for-pediatric-anesthesia .pdf. Accessed July 28, 2017. 10. Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaesth. 2013;23(7):647-654. 11. Low DK, Reed MA, Geiduschek JM, Martin LD. Striving for a zeroerror patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. Paediatr Anaesth. 2013;23(7):571-578. 12. WHO Surgical Safety Checklist. World Health Organization. http:// www.who.int/patientsafety/safesurgery/checklist/en/. Accessed June 22, 2017.
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13. Pugel AE, Simianu VV, Flum DR, Dellinger EP. Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health. 2015;8(3):219-225. 14. Clebone A, Burian BK, Watkins SC, Galvez JA, Lockman JL, Heitmiller ES; the Society for Pediatric Anesthesia Quality and Safety Committee. The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists. Anesth Analg. 2017;124(3):900-907. 15. Marshall S. The use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg. 2013;117(5): 1162-1171. 16. Critical events checklists. Society for Pediatric Anesthesia. http:// www.pedsanesthesia.org/critical-events-checklists/. Accessed June 22, 2017. 17. Oak SN, Dave NM, Garasia MB, Parelkar SV. Surgical checklist application and its impact on patient safety in pediatric surgery. J Postgrad Med. 2015;61(2):92-94. 18. Buck D, Kurth CD, Varughese A. Perspectives on quality and safety in pediatric anesthesia. Anesthesiol Clin. 2014;32(1):281-294. 19. Wake Up Safe: The Pediatric Anesthesia Quality Improvement initiative. The Society for Pediatric Anesthesia. http://www.wakeup safe.org/. Accessed June 22, 2017. 20. Kurth CD, Tyler D, Heitmiller E, Tosone SR, Martin L, Deshpande JK. National pediatric anesthesia safety quality improvement program in the United States. Anesth Analg. 2014; 119(1):112-121.
Quinn Johnson, MD, MBA, is the chairman of the Department of Anesthesiology and Perioperative Medicine and an associate professor of Anesthesiology at the University of Missouri Health, Columbia. Dr Johnson has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Janette McVey, MD, is an assistant professor of Anesthesiology at the University of Missouri Health, Columbia. Dr McVey has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN JOURNAL RECEIVES ITS FIRST IMPACT FACTOR The AORN Journal has been included in Clarivate Analytics’ 2017 Journal Citation Reports® and has received its first-ever Impact Factor. The Impact Factor designation is based on impact and influence metrics, along with citation data from the Web of Science, and measures a journal’s influence in the scientific community. The Journal would like to thank the myriad authors, peer reviewers, editors, and publishing partners for their contributions that have raised the Journal’s standing in scholarly literature and helped the Journal achieve this prestigious recognition.
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LEARNER EVALUATION
Continuing Education: Enhancing Pediatric Perioperative Patient Safety 1.4
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T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
PURPOSE/GOAL To provide the learner with knowledge of best practices related to enhancing pediatric perioperative patient safety.
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1.
Discuss how pediatric surgical care has evolved. Low 1. 2. 3. 4. 5. High
2.
Identify the perioperative needs of pediatric patients. Low 1. 2. 3. 4. 5. High
3.
Describe how nonpediatric facilities can provide safe care for pediatric patients. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
5.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
442 j AORN Journal
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Enhancing Pediatric Perioperative Patient Safety 1.4
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QUINN JOHNSON, MD, MBA; JANETTE McVEY, MD Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www .aornjournal.org/content/cme. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #17538 Session: #0001 Fee: Free for AORN members. For non-member pricing, please visit http://www.aornjournal.org/content/cme. The contact hours for this article expire November 30, 2020. Non-member pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to enhancing pediatric perioperative patient safety.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Quinn Johnson, MD, MBA, and Janette McVey, MD, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Objectives 1. Discuss how pediatric surgical care has evolved. 2. Identify the perioperative needs of pediatric patients. 3. Describe how nonpediatric facilities can provide safe care for pediatric patients.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
https://doi.org/10.1016/j.aorn.2017.09.007 ª AORN, Inc, 2017
434 j AORN Journal
www.aornjournal.org
PATIENT SAFETY FIRST
Enhancing Pediatric Perioperative Patient Safety 1.4
www.aornjournal.org/content/cme
QUINN JOHNSON, MD, MBA; JANETTE McVEY, MD
T
he frequency of surgery for patients younger than 18 years of age is increasing, and pediatric procedures are being performed in all types of facil1 ities. Approximately 450,000 pediatric patients are admitted for inpatient surgery on an annual basis in the United States, with 115,000 of those procedures occurring in patients who are three years old or younger.2 It is estimated that 40% of pediatric inpatient surgical procedures are performed in nonpediatric hospitals in the United States.1 In 2006, an estimated 2.3 million ambulatory anesthesia episodes of care were provided to patients younger than 15 years of age in the United States.3 This number reflects an increase of almost 50% compared with the previous decade, and the number of pediatric surgical procedures is expected to rise.3 Shifting care from pediatric to nonpediatric facilities raises questions about how surgical teams can best provide consistently safe and
appropriate care for pediatric patients of varying age and health across surgical settings.
PERIOPERATIVE PEDIATRIC PATIENT CARE Regardless of the location in which a procedure takes place, perioperative pediatric care requires facility administrators and staff members to recognize their limitations (eg, appropriately trained personnel, access to pediatric equipment). Careful development of care protocols and guidelines specifically designed for pediatric patients and regular assessment and consistent development of pediatric skills are required. Nurses play a critical role in the delivery of care for the pediatric patient during pediatric emergencies. Participating in pediatric crisis simulations can help personnel identify areas for
https://doi.org/10.1016/j.aorn.2017.09.007 ª AORN, Inc, 2017
www.aornjournal.org
AORN Journal j 435
JohnsondMcVey
improvement and ensure all members of the team understand their individual roles and responsibilities. In addition, all facilities should have a robust method for reporting errors or safety concerns, followed by identification and analysis of the problem and correction of the root cause to improve the delivery of care. The Society for Pediatric Anesthesia, American Society of Anesthesiologists, and the American Academy of Pediatrics have produced guidelines to ensure pediatric perioperative safety and help delineate how perioperative nurses can assist with optimizing the care and safety of the pediatric patient. In this article, we discuss current published guidelines and recommendations specific to basic pediatric perioperative safety, standards of care, and crisis management.
UNDERSTANDING AND ASSESSING RISK Each member of the surgical team plays a vital role in the safe care of the pediatric patient. Most health care providers understand that pediatric patients cannot be treated as small adults and that unique challenges and risks accompany the treatment of the pediatric surgical patient. Risk stratification varies widely among the pediatric population because of a combination of factors including age and coexisting medical conditions. In 2013, the Task Force for Children’s Surgical Care4 created consensus recommendations using patient comorbidities and facility resources to aid with decision making and risk stratification. Members of the key disciplines of surgery, pediatrics, anesthesiology, and nursing have endorsed these guidelines, which delineate the basic requirements and minimum-resource standards of care. The Task Force for Children’s Surgical Care advocates that patients who are less than 50 weeks postconception age or less than one year old should have a pediatric anesthesia professional administer anesthesia because of a higher risk of postoperative apnea. Other studies have supported this finding and have shown that pediatric surgical patients less than one year old and those with complex comorbidities are at an increased risk of morbidity and mortality.1,2,5,6 Finally, studies also have shown that pediatric patients undergoing complex surgery in high-volume, comprehensive-care pediatric centers have improved outcomes.6 These studies help to illustrate the importance of a multifactorial approach to providing optimal outcomes for pediatric surgical patients.
Variables Used to Determine Risk The increasing demand on facilities to accommodate both inpatient and outpatient pediatric surgeries requires personnel to identify appropriate patients, procedures, and 436 j AORN Journal
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facility resources. After determining whether a patient requires surgery in a pediatric or nonpediatric facility, we recommend that care providers carefully consider three major factors: patient age and medical condition, complexity of the procedure and staff members’ skill level, and facility’s resources (eg, equipment, support, staff members, other resources).
Patient age and medical condition To determine risk, the surgical team should comprehensively evaluate the patient’s medical condition. The American Society of Anesthesiologists (ASA) Physical Status Classification System is the most commonly used system to help categorize patients, including children.7 Healthy patients and those with mild systemic disease (eg, obesity, mild lung disease, well-controlled diabetes) are classified as ASA I and ASA II, respectively. Patients classified as ASA III have moderate to severe comorbidities, and patients classified as ASA IV have severe conditions that are a constant threat to life.7 An anesthesia professional should evaluate each pediatric patient and assign the appropriate ASA classification before surgery. The ASA classification of each patient is one of the most crucial factors in determining the appropriate location for surgery because this rating affects the complexity of the surgical procedure and the required skill level of the perioperative team.
Complexity of the procedure and staff members’ skill level The complexity of the proposed surgical procedure and the ability and experience of the surgeon and staff members to perform and support that procedure affect the risk to patients. Although studies have shown that it is often difficult to measure and assess complexity of the procedure and level of skill of the surgeon accurately in every situation, performing a thorough history and physical examination can correlate with pediatric patient outcomes in specific types of pediatric surgery, from pediatric general surgery to more advanced cardiac and neurosurgical procedures.6 Anesthesia professionals and nursing educators should routinely assess staff members for competency in caring for pediatric patients. Nurses and other surgical team members are crucial in determining the types of procedures they can perform safely. Accurate anticipation of the level of nursing care required in the pre- and postoperative periods is an equally important skill for perioperative nurses to possess because the ability to provide adequate perioperative nursing care is vital to protect the pediatric patient’s safety. Derieg8 provides an excellent
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summary of perioperative pediatric nursing care and covers key topics such as fluid management, airway evaluation, and pain management. Regardless of the location in which nursing and technical personnel administer pediatric patient care, they should have training indand be experienced indroutine and emergency pediatric perioperative care.5 Personnel should regularly evaluate and re-evaluate pediatric patient outcomes at their facility to determine what types of pediatric procedures they can perform safely.
care for a high-risk pediatric patient, the ASA recommends pediatric-specific arterial and venous monitoring equipment and portable monitoring equipment to aid in patient transport to and from the postanesthesia care unit or intensive care unit.9 Anesthesia, nursing, and surgical personnel at all facilities caring for pediatric patients should take an inventory of the resources available and plan for regular reviews of the ASA recommendations to ensure that their facilities are in compliance.
Facility resources
Determining Acceptable Limits and Risks
The final variable affecting risk is the level of care that the facility can provide as a whole. This variable is determined at the facility by the presence or absence of pediatric subspecialties, support services, and equipment. The ASA Statement on Practice Recommendations for Pediatric Anesthesia9 covers both ambulatory and inpatient pediatric surgeries, and their recommendations are broad enough to apply to any facility caring for pediatric patients. Health care facilities are categorized as basic, advanced, or comprehensive based on their available resources and their staff members’ ability to care for the pediatric patient.4 Basic facilities have no multidisciplinary management resources for pediatric comorbidities; advanced centers typically offer single surgical specialties such as neurosurgery and craniofacial surgery, neonatology, and pediatric anesthesia; and comprehensive centers offer pediatric anesthesia along with the resources and equipment for multiple medical and surgical specialties pertaining to all pediatric conditions.4 A facility’s employees may overlook, underappreciate, or even diminish the true limitations of their facility; however, the lack of support services to manage a pediatric crisis successfully becomes all too apparent in an emergency. Therefore, facility staff members should make every effort to assess the facility’s available resources accurately. To provide quality pediatric care, a facility should possess the following:
pediatric-specific resuscitation equipment, pediatric advanced life supportetrained personnel, medications specific for use in pediatric patients, standardized medication dosages, and dedicated physical space designed for the pre- and postoperative emotional comfort of the pediatric patient.4
To meet the standards of care for monitoring a pediatric patient who is under anesthesia, the ASA recommends providing pediatric-specific airway devices and ventilation systems, fluid administration practices, warming devices, and equipment.9 For example, if a facility is expected to provide
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Assuming that each facility follows the ASA guidelines regarding anesthesia equipment and personnel, surgical centers can use the following stratifications to assign pediatric procedures to the correct location. The Task Force for Children’s Surgical Care has deemed basic children’s surgical centers acceptable for routine, low-risk procedures for patients aged one year or older and classified as ASA I or II. For patients classified as ASA I, II, or III and who are full- or preterm infants, and for common anomalies treated by pediatric surgeons, advanced centers are needed. Finally, comprehensive centers can care for all pediatric patients regardless of age, comorbidity, or the planned surgery.4 It is important for care providers to identify those patients whose medical needs exceed the capacity of the proposed facility and may need to be referred to a location that possesses pediatric capabilities that are more specialized. Basic and advanced centers must have a formal mutual agreement among hospitals to facilitate timely, appropriate, and safe transfer to a comprehensive children’s center so that the more specialized facility may provide progressive medical treatment, if necessary.4
Patient Hand Overs A common theme throughout perioperative patient safety literature is communication.10-13 Clear and concise communication of key information to the next care provider minimizes risk and optimizes patient care. The most crucial time to ensure clear perioperative communication occurs is during staff member turnover (eg, changes of shift, breaks). Minimizing the number of hand overs during each surgery and developing facility-specific hand-over tools and checklists are two areas in which perioperative personnel can make improvements to prevent the breakdown of communication and adverse outcomes.10 Patient hand overs should occur at every phase of perioperative care and continue through patient discharge from the facility. Hand overs should occur among nurses, anesthesia professionals, and surgeons, as well as AORN Journal j 437
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Figure 1. The Society for Pediatric Anesthesia’s cardiac arrest checklist. PEA ¼ pulseless electrical activity; ETT ¼ endotracheal tube; CPR ¼ cardiopulmonary resuscitation; EtCO2 ¼ end tidal carbon dioxide; ROSC ¼ return of spontaneous circulation; O2 ¼ oxygen; VF ¼ ventricular fibrillation; VT ¼ ventricular tachycardia; ECMO ¼ extracorporeal membrane oxygenation. Reprinted with permission from the Society for Pediatric Anesthesia, Richmond, VA. among all levels of care providers. During hand overs, care providers should convey all of the important patient information pertinent to the surgical care plan. Some key items that are regularly included in hand-over reports are
allergies, administered medications and doses, the planned or completed surgical procedure, and any perioperative issues the patient experienced.
Additional items should be added to the report based on the patient’s care needs. If checklists are used, they must be 438 j AORN Journal
reliable, easy to use, and evolve over time. Each staff member participating in the information exchange should be unafraid to speak up if an error is identified.11
SOCIETY FOR PEDIATRIC ANESTHESIA CRITICAL EVENTS CHECKLISTS After personnel meet the basic facility, staffing, protocol, and equipment needs for safe pediatric care, they should focus on their ability to manage perioperative emergencies and define surgical team roles during these crises. The World Health Organization released its Surgical Safety Checklist in 2009,
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Figure 2. The Society for Pediatric Anesthesia’s trauma checklist. C-spine ¼ cervical spine; PIP ¼ peak inspiratory pressure; H2O ¼ water; LR ¼ Lactated Ringer’s; NS ¼ normal saline; RBC ¼ red blood cell. Reprinted with permission from the Society for Pediatric Anesthesia, Richmond, VA. constructing a team approach for the nurse, anesthesia professional, and surgeon to ensure essential perioperative care basics for patient safety.12 Checklists such as these have proved to be beneficial in day-to-day practice to help prevent critical events and mistakes.13 Knowing how to use surgical safety checklists when a perioperative pediatric emergency occurs is crucial. The Society for Pediatric Anesthesia has developed the Critical Events Checklists to guide anesthesia professionals and surgical team members during pediatric perioperative crises.14 These checklists help provide crisis guidelines and protocols when surgical team member roles may be difficult to define, the risk of error is high, and order is needed. Even the most seasoned surgical teams experience difficulties recalling critical steps and medication dosages and making decisions quickly in times of crisis and need an accurate and timely resource to guide them.15
information to all surgical team members.14 Topics covered by this resource include information and guidance for responding to many emergency situations (eg, bronchospasm, cardiac arrest, difficult airway, airway fires, local anesthetic toxicity, trauma).16 This tool is available for download online (http:// www.pedsanesthesia.org/critical-events-checklists/) and via interactive mobile device application (https://itunes.apple.com/us/ app/pediatric-critical-events/id709721914). Personnel at the University of Missouri, Columbia, use a printed version of the checklist attached to each pediatric anesthesia machine or cart, with copies also available in the holding area and postanesthesia care unit. Figure 1 provides an example of the cardiac arrest checklist and Figure 2 provides an example of the initial treatment of trauma checklist.16
The Quality and Safety Committee of the Society for Pediatric Anesthesia designed these evidence-based checklists to provide
Simulation is playing an increasing role in all forms of medical and nursing training. To provide quality pediatric care,
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Critical Event Simulation
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personnel at all facilities should participate in simulation exercises that allow each team member to practice his or her role, refine his or her communication skills, and identify weaknesses and errors during simulated critical events. The use of checklists as a cognitive aid in combination with simulation training is essential to providing pediatric patient safety. Simulation exercises help users identify team roles, familiarize themselves with the checklists, and ensure their checklists are complete; simulations also expose teams to crisis scenarios and provide the opportunity for personnel to review their responses and participate in performance evaluations through debriefings.14 The goal of a simulation is for personnel to recognize their own deficiencies and those of their facility, and ultimately improve outcomes.15 Personnel can tailor cognitive aids (ie, simulation and surgical crisis checklists) to be facility specific and include personnel practicing in areas of the hospital outside the OR, such as the pharmacy, laboratory, intensive care unit, and administrative department.17
IMPROVING CARE BEYOND THE OR When caring for pediatric surgical patients, the goal is to provide safe, effective, and patient-centered care.18 The Society for Pediatric Anesthesia developed the Wake Up Safe initiative to fill gaps in knowledge and find ways to reduce or eliminate near misses and adverse events.19 Wake Up Safe is a voluntary, multi-institutional, error-reporting system to identify strategies for improvement and root cause analysis when patterns or issues emerge that are specific to pediatric anesthesia.20 The most commonly identified events are respiratory or cardiac; other events that require escalation of care, such as cardiac dysrhythmia and medication errors, are also included.18 Through this reporting process, the Society for Pediatric Anesthesia has developed advisories on hyperkalemia, cardiac arrest, wrong-site or wrong-side procedures, and IV medication errors.19 Similarly, each facility may have its own means of reporting patient safety concerns. For example, at the University of Missouri, Columbia, an electronic patient safety network is available for all levels of personnel to report patient safety concerns. By approaching unanticipated events in a transparent manner, personnel at the facility are attempting to understand how issues occurred rather than trying to assign blame; as a result, personnel are more likely to improve processes and patient outcomes.
CONCLUSION As the number of pediatric surgeries increases at specialized and general hospitals, the need for thorough, realistic evaluations of available resources is vital to ensuring safe pediatric patient care. Pediatric patient safety requires a team approach; 440 j AORN Journal
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all health care providers caring for pediatric patients should advocate for frequent assessments of staff member skills and equipment and reviews of surgical procedures to determine what is appropriate for each facility. Nurses often are role models for conveying the importance of using checklists to optimize patient care during routine care and times of crisis and should lead by example. By focusing on the critical areas discussed in this article, health care providers can improve the quality and safety of perioperative care at all facilities responsible for the care of pediatric patients.
References 1. Sømme S, Bronsert M, Morrato E, Ziegler M. Frequency and variety of inpatient pediatric surgical procedures in the United States. Pediatrics. 2013;132(6):e1466-e1472. 2. Tzong KYS, Han S, Roh A, Ing C. Epidemiology of pediatric surgical admissions in US children: data from the HCUP Kids Inpatient Database. J Neurosurg Anesthesiol. 2012;24(4):391-395. 3. Rabbitts JA, Groenewald CB, Moriarty JP, Flick R. Epidemiology of ambulatory anesthesia for children in the United States: 2006 and 1996. Anesth Analg. 2010;111(4):1011-1015. 4. Task Force for Children’s Surgical Care. Optimal resources for children’s surgical care in the United States. J Am Coll Surg. 2014;218(3):479-487, 487.e1-487.e4. 5. Polaner DM, Houck CS; Section on Anesthesiology and Pain Medicine Executive Committee. Critical elements for the pediatric perioperative anesthesia environment. Pediatrics. 2015;136(6): 1200-1205. 6. McAteer JP, LaRiviere CA, Drugas GT, Abdullah F, Oldham KT, Goldin AB. Influence of surgeon experience, hospital volume, and specialty designation on outcomes in pediatric surgery: a systematic review. JAMA Pediatr. 2013;167(5):468-475. 7. ASA Physical Status Classification System. American Society of Anesthesiologists. https://www.asahq.org/resources/clinical -information/asa-physical-status-classification-system. Accessed June 27, 2017. 8. Derieg S. An overview of perioperative care for pediatric patients. AORN J. 2016;104(1):4-10. 9. American Society of Anesthesiologists. Statement on Practice Recommendations for Pediatric Anesthesia. Washington, DC: American Society of Anesthesiologists; 2016. http://www.asahq.org/ w/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/ statement-on-practice-recommendations-for-pediatric-anesthesia .pdf. Accessed July 28, 2017. 10. Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaesth. 2013;23(7):647-654. 11. Low DK, Reed MA, Geiduschek JM, Martin LD. Striving for a zeroerror patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. Paediatr Anaesth. 2013;23(7):571-578. 12. WHO Surgical Safety Checklist. World Health Organization. http:// www.who.int/patientsafety/safesurgery/checklist/en/. Accessed June 22, 2017.
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13. Pugel AE, Simianu VV, Flum DR, Dellinger EP. Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health. 2015;8(3):219-225. 14. Clebone A, Burian BK, Watkins SC, Galvez JA, Lockman JL, Heitmiller ES; the Society for Pediatric Anesthesia Quality and Safety Committee. The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists. Anesth Analg. 2017;124(3):900-907. 15. Marshall S. The use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg. 2013;117(5): 1162-1171. 16. Critical events checklists. Society for Pediatric Anesthesia. http:// www.pedsanesthesia.org/critical-events-checklists/. Accessed June 22, 2017. 17. Oak SN, Dave NM, Garasia MB, Parelkar SV. Surgical checklist application and its impact on patient safety in pediatric surgery. J Postgrad Med. 2015;61(2):92-94. 18. Buck D, Kurth CD, Varughese A. Perspectives on quality and safety in pediatric anesthesia. Anesthesiol Clin. 2014;32(1):281-294. 19. Wake Up Safe: The Pediatric Anesthesia Quality Improvement initiative. The Society for Pediatric Anesthesia. http://www.wakeup safe.org/. Accessed June 22, 2017. 20. Kurth CD, Tyler D, Heitmiller E, Tosone SR, Martin L, Deshpande JK. National pediatric anesthesia safety quality improvement program in the United States. Anesth Analg. 2014; 119(1):112-121.
Quinn Johnson, MD, MBA, is the chairman of the Department of Anesthesiology and Perioperative Medicine and an associate professor of Anesthesiology at the University of Missouri Health, Columbia. Dr Johnson has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Janette McVey, MD, is an assistant professor of Anesthesiology at the University of Missouri Health, Columbia. Dr McVey has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
AORN JOURNAL RECEIVES ITS FIRST IMPACT FACTOR The AORN Journal has been included in Clarivate Analytics’ 2017 Journal Citation Reports® and has received its first-ever Impact Factor. The Impact Factor designation is based on impact and influence metrics, along with citation data from the Web of Science, and measures a journal’s influence in the scientific community. The Journal would like to thank the myriad authors, peer reviewers, editors, and publishing partners for their contributions that have raised the Journal’s standing in scholarly literature and helped the Journal achieve this prestigious recognition.
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LEARNER EVALUATION
Continuing Education: Enhancing Pediatric Perioperative Patient Safety 1.4
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T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aornjournal.org/content/cme. Rate the items as described below.
PURPOSE/GOAL To provide the learner with knowledge of best practices related to enhancing pediatric perioperative patient safety.
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1.
Discuss how pediatric surgical care has evolved. Low 1. 2. 3. 4. 5. High
2.
Identify the perioperative needs of pediatric patients. Low 1. 2. 3. 4. 5. High
3.
Describe how nonpediatric facilities can provide safe care for pediatric patients. Low 1. 2. 3. 4. 5. High
CONTENT 4.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High
5.
To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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