- Email: [email protected]
Using a Learning Needs Assessment to Identify Knowledge Deficits Regarding Procedural Sedation for Pediatric Patients
Using a Learning Needs Assessment to Identify Knowledge Deficits Regarding Procedural Sedation for Pediatric Patients 1.7 ANNE D. JEST, MS, RN, CPN, CSRN; ANDREA TONGE, BSN, RN, CPN, CSRN
www.aorn.org/CE
ABSTRACT Procedural sedation is a cost-effective method of providing sedation and analgesia for patients undergoing diagnostic and therapeutic procedures. Sedation ranges on a continuum from minimal sedation to deep sedation, so procedural sedation can pose many risks for patients (eg, compromised airway, depressed respirations, hypotension). The unique variables inherent in the pediatric population and the associated risks of procedural sedation make it imperative that RNs be knowledgeable and competent in monitoring and managing these patients. Through the use of a learning needs assessment, perioperative resource nurses at a pediatric hospital in a large, southeast metropolitan area identified practice concerns associated with staff RNs’ management of pediatric patients undergoing procedural sedation. As a result of these findings, the perioperative resource nurses are in the process of implementing annual sedation competency skills testing in a special procedures laboratory for all nurses who participate in sedation procedures. AORN J 94 (December 2011) 567-574. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2011.05.020 Key words: pediatric procedural sedation, learning needs assessment, continuing education, competence.
C
ontinuing education is crucial for professional RNs to remain current with developments in the nursing field. Highquality nursing care is dependent on a nursing
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire December 31, 2014.
workforce that maintains competence through continuing professional development.1 According to Phippen et al,2 competence is defined as the knowledge, skills, and abilities needed to function successfully. Continuing education to verify competence is a mandate for nursing relicensure in 32 states3; therefore, educators and health care organizations should make continuing education easily available to RNs. An effective strategy for identifying gaps in knowledge and appropriately focusing continuing education is evaluation via a learning needs
doi: 10.1016/j.aorn.2011.05.020
© AORN, Inc, 2011
December 2011
Vol 94
No 6 ●
AORN Journal
567
December 2011
Vol 94
JEST—TONGE
No 6
assessment (LNA). Use of an LNA is an important part of education to incorporate changes in practice and policy.4 According to Grant,5 Malcolm Knowles, PhD, a prominent adult educator, believed that it is important for learners to identify their own educational needs as part of self-directed learning. The practice of procedural sedation is governed by standards and guidelines from various health care regulatory agencies, and nursing educators are challenged to provide ongoing educational programs and resources to keep staff RNs up to date on changes in practice and regulations related to these procedures. The perioperative resource nurses at a pediatric hospital in a large, southeast metropolitan area developed an LNA tool to evaluate the knowledge of RNs who care for patients receiving procedural sedation in the special procedures laboratory (SPL), radiology department, and satellite center. The perioperative
resource nurses chose to use an LNA tool because this is an effective strategy for directing continuing education programs.
BACKGROUND AND DEFINITIONS Procedural sedation is a cost-effective means of providing pain relief and decreasing anxiety for patients undergoing diagnostic and therapeutic procedures. In 1985, the American Academy of Pediatrics6 and the National Institutes of Health issued guidelines addressing procedural sedation and analgesia in response to several deaths related to sedation. These guidelines defined three levels of sedation: conscious sedation, deep sedation, and general anesthesia.6 Procedural sedation has evolved rapidly since that time, expanding the scope of medications, practitioners, and monitoring guidelines.7 The American College of Emergency Physicians defines procedural sedation as a “technique of administering sedatives or dissociative agents with or without analgesia to induce a state that allows the patients to tolerate an unAORN Resources pleasant procedure while maintaining cardiorespiratory AORN, Inc. Perioperative nursing care of the patient receiving function.”8 Use of procemoderate sedation analgesia (2010). Ciné-Med. http://cine-med dural sedation has moved .com/index.php?nav⫽nursing&subnav⫽aorn&id⫽1946. outside of the controlled en Austin B. Preparing children for surgery (1991). Ciné-Med. vironment of the OR into http://cine-med.com/index.php?nav⫽nursing&subnav⫽ many other clinical and outaorn&id⫽1699. patient areas. Patients receiv Individual Periop 101 Learning Modules. Patient care modules: ing procedural sedation may anesthesia. AORN, Inc. http://www.aorn.org/Education/ be undergoing Periop101/LearningModules. Managing the patient receiving moderate sedation/analgesia. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:327-336. Moderate sedation: confidence-based learning module. AORN, Inc. http://www.aorn.org/Education/ConfidenceBasedLearning/ ModerateSedation. Safe Medication Administration Tool Kit. AORN, Inc. http:// www.aorn.org/Community/OrganizationalLeadershipDevelopment.
Web site access verified September 19, 2011.
The American Society of Anesthesiologists defines
568
AORN Journal
endoscopic examinations, burn and wound debridement, fracture reduction, lumbar puncture, central venous line placements, or diagnostic procedures.
LEARNING NEEDS ASSESSMENT FOR PROCEDURAL SEDATION sedation levels as minimal, moderate (procedural), deep, and general anesthesia: Minimal Sedation (Anxiolysis) is a druginduced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.9
ROLES OF NURSES AND PHYSICIANS Usually, one physician and at least one RN are needed during a procedure in which procedural sedation will be used. The physician is responsible for medication administration, while the RN
www.aornjournal.org
continuously monitors the patient. It is important for the RN to understand that sedation is a continuum. A moderately sedated patient could respond to a medication in an unusual way and progress to deep sedation; therefore, sedated patients require careful monitoring at all times. The RN should monitor the patient’s
vital signs, oxygen saturation level, cardiac rate and rhythm, respiratory rate and adequacy of ventilation, and level of consciousness.
Usually, the RN monitors the patient’s vital signs continuously and documents them every five minutes. The RN monitoring the patient should not have any other duties or responsibilities, such as circulating for the procedure. Suction and an emergency code cart with narcotic reversal agents should be immediately available. The RN assesses and documents the patient’s status by using the Aldrete scoring system before a medication is administered and after the procedure. The Aldrete scoring system is used to assess the patient’s oxygenation, respiration, circulation, consciousness, and motor activity.10 Patients are discharged from the recovery area and the hospital to a responsible, designated adult by a qualified, licensed, independent health care provider.11 GOALS AND RISKS OF SEDATION The goal of procedural sedation in the pediatric population is to select the lowest dose of medication with the highest therapeutic effect.6 With any sedation, there are serious risks that necessitate excellent assessment skills and pharmacologic knowledge. Levels of sedation occur on a continuum, and a sedated child can go in and out of an intended level of sedation quite rapidly.9 One potential complication with procedural sedation is that a pediatric patient often requires a deeper level of sedation for a procedure than an adult would need for a similar procedure.12 Safe and AORN Journal
569
December 2011
Vol 94
No 6
JEST—TONGE
effective procedural sedation and analgesia desupported that procedural sedation as practiced is pends on appropriate assessment, monitoring, at least as safe as general anesthesia.14 The low incidence of adverse events does not mean that and use of rescue skills by knowledgeable and procedural sedation is without risk. Skilled percompetent health care providers. Serious comsonnel, close monitoring, and precautionary airplications associated with sedation of pediatric way measures reduce the possibility of adverse patients include hypotension, compromised air6 events during the procedure. way, depressed respirations, and cardiac arrest. Adverse responses related to procedural sedation may be minimized but not completely elimiCURRENT GUIDELINES nated by a careful pre-procedure assessment and The Joint Commission,11 American Academy of Pediatrics,6 and American Society of Anesthesiolreview of the patient’s medical history. This inogists9 have established guidelines for administercludes identifying how the patient’s underlying ing procedural sedation. Hospitals, committees, medical conditions might be affected by the seda6 states, and regulatory agencies have their own tion process. A study performed by a group of emergency departsets of guidelines ment physicians reand regulations reported on 1,244 segarding procedural Risks associated with procedural sedation in dation procedures sedation. Pediatric the pediatric population necessitate excellent with a complication sedation monitoring assessment skills and pharmacologic knowledge. rate of 17.8%; the guidelines from the most common comAmerican Academy plication was hypof Pediatrics focus oxia, which was on the concept of easily treated with supplemental oxygen.13 The preparedness to rescue a patient from an uninPediatric Sedation Research Consortium (PRSC) tended depth of sedation while also highlighting collects prospective sedation data and, in 2006, patient discharge criteria and home care.6 14 published data on 30,000 procedures. Data colRecommendation IX of AORN’s “Recomlected from these procedures showed minor admended practices for managing the patient receivverse events, such as stridor, laryngospasms, airing moderate sedation/analgesia” states that “the way obstruction, wheezing, and apnea. Between perioperative RN should be clinically competent, 2004 and 2008, the PRSC reported 122 major possessing the skills necessary to manage the complications in 131,751 procedures.14 The PSRC nursing care of the patient receiving moderate defined major complications as aspiration, unsedation/analgesia.”15(p332) Competencies verify planned hospital admission, emergency anesthesia that personnel have an understanding of moderate consultation, and cardiac arrest.14 In these sedation; the risks of unplanned, deeper sedation; 131,751 procedures, there was one case of cardiac and safe use of monitoring equipment. Competenarrest requiring cardiopulmonary resuscitation, no cies related to procedural sedation should include, aspirations, and no deaths. but not be limited to, However infrequent these risks may be in the patient selection and assessment criteria; pediatric population, it is vital that all periopera knowledge of anatomy and physiology; tive personnel be adequately trained to handle any selection, function of, and proficiency in the emergency situation by using rescue resources 6 use of physiological monitoring equipment; that are immediately available. In 2008, the pharmacology of the sedation medications; PSRC data from 90,000 sedation procedures 570
AORN Journal
LEARNING NEEDS ASSESSMENT FOR PROCEDURAL SEDATION
recognition of complications associated with sedation and analgesia; management of airways; use of continuous positive airway pressure; basic dysrhythmia recognition and management; emergency response and management; and advanced cardiac life support and pediatric advanced life support according to the patient population served.15
LEARNING NEEDS ASSESSMENT According to DeSilets,16 an LNA is important for identifying objectives and content for educational activities, and its scope should be based on its purpose. Performing self-assessments is an effective strategy for learners to identify their own strengths and weakness as well as for helping educators make decisions regarding staff development. There are a variety of types of needs assessments, such as questionnaires, surveys, interviews, and observation. The facility resource nurses selected a questionnaire method because it is one of the most commonly reported methods of needs assessment, and it is relatively easy to create. To develop the LNA questionnaire, the perioperative resource nurses reviewed the literature to examine current practice standards as defined by various regulatory agencies, including AORN,15 The American Society of Anesthesiologists,9 The Joint Commission,11 and the American College of Emergency Physicians.8 They identified 11 topics regarding the role of the staff RN in managing a sedated patient. From these topics, they developed a questionnaire with a four-response option, Likerttype scale to assess and rate staff RNs’ knowledge of the 11 topics (Figure 1). The RNs were asked to rate their knowledge of current analgesia/sedation policy, airway management, sedation medications, equipment usage, electrocardiograph rhythms, patient selection criteria, recognition and management of associated risks of sedation, NPO guidelines, oxygen delivery
www.aornjournal.org
devices, signs and symptoms of respiratory distress, and discharge criteria by indicating their response as no knowledge, little knowledge, some knowledge, or significant knowledge.
The questionnaire also included space for written comments from the participants regarding any other educational concerns and issues about sedation that could enrich the data collected on the questionnaire. Demographic data were requested regarding the RNs’ credentials, highest degree attained, and length of time used on the unit. To gain different perspectives from clinical experts, the resource nurses presented the first draft of the questionnaire for review to two clinical educators in the perioperative setting and the nurse manager of sedation services in the radiology department. After incorporating the suggestions of the clinical experts, they presented the second draft to the medical director of sedation services at the hospital for review. Based on input from the medical director, the resource nurses made appropriate revisions to the questionnaire. QUESTIONNAIRE RESULTS Managers from the different clinical settings identified a sample of 55 RNs. The resource nurses distributed questionnaires by hand to the RNs in the SPL and radiology departments, and distributed them online to RNs at the satellite center. The RNs were instructed to complete the anonymous questionnaire within two weeks. Managers and educators helped retrieve the data. A total of 33 completed questionnaires were received, all from the SPL and the radiology department, for a response rate of 60%. Of the 33 RNs who responded, 16 had a bachelor of science degree in nursing (BSN), 14 had an associate of science degree in nursing (ASN), and three had diplomas in nursing. None of the RNs listed any certifications or other credentials. The number of years in the practice setting ranged from six to 24 years. AORN Journal
571
December 2011
Vol 94
JEST—TONGE
No 6
Please complete this survey describing your knowledge of sedation. Your responses will help determine what topics need to be included in the design of continuing education programs addressing sedation. For each question, determine your level of knowledge from 0 to 3. Please answer all of the questions. At the end, there is a comment section; please feel free to add additional topics you feel need to be addressed. We appreciate your participation and support of optimal clinical practice. Thank you. Unit/Campus: ______________________________________
Title: ___________________________________________
Highest degree obtained: _____________________________
Length of time employed in this unit: __________________ No knowledge 0
I. II.
III.
How would you rate your knowledge of our current analgesia/sedation policy? How would you rate your knowledge in maintaining airway stability? A. Reposition jaw B. Suction C. Oral airway D. Nasal trumpet How knowledgeable are you about the use of the following medications? A. Fentanyl B. Ketamine C.
Midazolam
D.
Naloxone
E. Propofol IV. How would you rate your knowledge of the NPO guidelines for the different age groups in the pediatric population? V. How would you rate your knowledge in treating the most commonly associated risks of sedation? A. Upper airway obstruction B. Partial laryngospasm C. Complete laryngospasm D. Hypotension E. Oxygen desaturation F. Apnea VI. How would you rate your knowledge level about the following equipment A. Bag valve mask B. Cardiac monitor C. Suction equipment D. Pulse oximeter E. Capnography end-tidal carbon dioxide monitor VII. How would you rate your knowledge of the following oxygen delivery devices? A. Face mask B. Nasal cannula C. Venturi mask D. Non-rebreather mask VIII. How would you rate your knowledge of electrocardiogram rhythms? IX.
How would you rate your knowledge regarding the recognition of signs and symptoms of respiratory distress? X. How would you rate your knowledge of the ASA physical health status classification? XI. How would you rate your knowledge regarding use of the modified Aldrete system to assess recovery? Comments or suggestions:
Figure 1. Sedation Learning Needs Assessment.
572
AORN Journal
Little knowledge 1
Some knowledge 2
Significant knowledge 3
LEARNING NEEDS ASSESSMENT FOR PROCEDURAL SEDATION Regarding sedation therapy, four BSN-prepared nurses documented the highest rating of significant knowledge compared with 12 ASN-prepared nurses and two diploma-prepared nurses. On the topic of electrocardiograph rhythms, six BSNprepared nurses, 12 ASN-prepared nurses, and two diploma-prepared nurses indicated significant knowledge. All of the ASN nurses worked in the radiology department. Overall, the RNs in the SPL and the radiology department rated their knowledge levels differently. The majority of the radiology RNs rated themselves as having significant knowledge in all areas except medications and oxygen delivery devices. The majority of the RNs in SPL rated themselves as having some knowledge in most areas. Differences in learning needs between the two units may be a result of inconsistent sedation education within the institution. Nurses in the SPL only complete institution sedation modules, whereas radiology RNs have annual sedation competency and attend sedation conferences in addition to completing the institution sedation module.
DISCUSSION Results of the questionnaire identified and isolated differences in learning needs among two units in the facility in which sedation services are provided. Further data collection using interviews and observations could be useful to help educators collaborate and provide standardized instruction on procedural sedation throughout the institution. Ratings using the Likert-type scale will help educators prioritize learning needs and plan various levels of educational offerings, such as update courses, competency courses, or advanced education courses. An LNA survey has been shown to be vital to the identification of learning needs and, according to DeSilets,16 promotes participation of learners in the their own professional development. Feedback from educators about the LNA tool has been positive.
www.aornjournal.org
Educational Implications As a result of the LNA, the perioperative resource nurses and educators are discussing implementation of educational opportunities for nurses who participate in sedation procedures, how they should validate whether the selfrated scores equated with actual knowledge, and whether different programs should be developed depending on the RNs’ self-rated scores.
Currently, the educators are in the process of implementing annual sedation competency skills testing, including case scenarios and mock codes in the SPL for all nurses who participate in sedation procedures. They plan to perform a follow-up LNA after implementing the educational programs to evaluate the success of these programs.
CONCLUSION Continuing education and learning is critical for health care professionals to be competent in performing their jobs. Ongoing education offers personnel an opportunity to enhance their skills and learn about changes in practice, regulations, and standards. Nurses must recognize that continuing education should be an integral part of professional life to ensure patients’ safety. Development of an LNA questionnaire addressing procedural sedation provided a valuable means for an educator to identify knowledge deficits among RNs, differentiate needs among RNs in different units, and allow for feedback and input from members of the interdisciplinary team. As the practice of procedural sedation and analgesia continues to evolve and expand through research and technology, RNs who provide procedural sedation will need continuing education to enhance their training and ensure safe and quality care for their patients. An LNA has been shown to be an effective method for the development of continuing education offerings, and is a valuable tool for the nurse educator. AORN Journal
573
December 2011
Vol 94
JEST—TONGE
No 6
Acknowledgement: The authors acknowledge the contributions of Michelle Byrne, PhD, RN, CNE, CNOR, program coordinator for the Masters of Science Nursing Education Program, North Georgia College and State University, Dahlonega, GA, in directing the authors to a wide range of resources and answering many questions during the preparation of this manuscript.
10.
References
13.
1.
2.
3.
4.
5. 6.
7. 8.
9.
574
While A, Ullman R, Forbes A. Development and validation of a learning need assessment scale: a continuing professional education for multiple sclerosis specialists nurses. J Clin Nurs. 2007;16(6):1099-1108. Phippen M, Ulmer B, Wells M. Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, CO: Competency and Credentialing Institute; 2009. Nationwide state legislative agenda reports 2011-2012. American Nurses Association. http://nursingworld.org/ MainMenuCategories/ANAPoliticalPower/State/State LegislativeAgenda.aspx. Accessed September 8, 2011. Akhtar-Danesh N, Valaitis RK, Schofield R, et al. A questionnaire for assessing community health nurses’ learning needs. West J Nurs Res. 2010;32(8):10551072. Grant J. Learning needs assessment: assessing the need. BMJ. 2002;324(7330):156-159. American Academy of Pediatrics; American Academy of Pediatric Dentistry; Coté CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118(6):2587-2602. Kraus B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367(9512):766-780. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005;45(2):177-196. http://www.annemergmed.com/article/S0196-0644(04) 01616-6/fulltext. Accessed September 8, 2011. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. American Society of Anesthesiologists (ASA). http://www.asahq .org/Search.aspx?q⫽Continuum⫹of⫹depth⫹of⫹ sedation%3a⫹Definition⫹of⫹general⫹anesthesia⫹ and⫹levels⫹of⫹sedation%2fanalgesia&site⫽All. Accessed August 2, 2011.
AORN Journal
11.
12.
14.
15.
16.
Panagiotis K, Maria P, Argiri P, Panagiotis S. Is postanesthesia care unit length of stay increased in hypothermic patients? AORN J. 2005;81(2):379492. Provision of care, treatment, and services. In: Comprehensive Accreditation Manual E-dition. Oakbrook Terrace, IL: The Joint Commission; 2011:PC.03.01.07. https://e-dition.jcrinc.com/Frame.aspx. Accessed September 8, 2011. Updated guidelines focus on monitoring pediatrics: recommendations address before, after sedation. Same Day Surg. 2007;31(2):19-21. Baxter AL. Pediatric procedural sedation. Medscape Education. https://remote.aorn.org/viewarticle/, DanaInfo⫽www.medscape.org⫹568824_2?new EmailAddress⫽[email protected]&confirmNewEmail Address⫽[email protected]&submitemailupdate⫽ Update⫹Email⫹Address. Accessed September 12, 2011. Cravero JP, Blike GT, Beach M, et al; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006;118(3):1087-1096. Recommended practice for managing the patient receiving moderate sedation/analgesia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:327-336. DeSilets LD. Needs assessments: an array of possibilities. J Contin Educ Nurs. 2007;38(3):107-114.
Anne D. Jest, MS, RN, CPN, CSRN, is a resource nurse at Children’s Healthcare of Atlanta, GA. Ms Jest has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Andrea Tonge, BSN, RN, CPN, CSRN, is a resource nurse at Children’s Healthcare of Atlanta, GA. Ms Tonge has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
EXAMINATION CONTINUING EDUCATION PROGRAM
1.7
Using a Learning Needs Assessment to Identify Knowledge Deficits Regarding Procedural Sedation for Pediatric Patients
www.aorn.org/CE
PURPOSE/GOAL To educate perioperative nurses about the importance of assessing learning needs to ensure competency in procedural sedation for pediatric patients.
OBJECTIVES 1. 2. 3. 4. 5.
Discuss procedural sedation. Explain the role of the procedural sedation nurse during the procedure. Identify potential complications of procedural sedation. Describe learning needs assessments. Discuss how the results of a learning needs assessment were applied.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS 1. According to the American Academy of Pediatrics and the National Institutes of Health, levels of sedation include 1. conscious sedation. 2. deep sedation. 3. general anesthesia. 4. local anesthesia. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 2. The American College of Emergency Physicians definition says procedural sedation 1. induces a state that allows the patient to tolerate an unpleasant procedure. © AORN, Inc, 2011
2. involves administration of sedatives or dissociative agents. 3. allows the patient to maintain cardiorespiratory function. 4. may or may not involve the use of analgesia. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 3. Types of procedures for which procedural sedation may be applicable include 1. burn and wound debridement. 2. central venous line placements. 3. colostomy closure. 4. fracture reduction. 5. lumbar puncture. December 2011
Vol 94
No 6 ●
AORN Journal
575
December 2011
Vol 94
CE EXAMINATION
No 6
a. 4 and 5 c. 1, 2, 4, and 5
b. 1, 2, and 3 d. 1, 2, 3, 4, and 5
4. The nurse providing procedural sedation is responsible for medication administration. a. true b. false 5. The procedural sedation nurse should 1. monitor the patient’s oxygen saturation level. 2. circulate for the procedure. 3. monitor the patient’s cardiac rate and rhythm. 4. evaluate the patient’s level of consciousness. 5. monitor the patient’s respiratory rate and adequacy of ventilation. 6. measure and document the patient’s vital signs. a. 1, 3, and 5 b. 2, 4, and 6 c. 1, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 6. A potential complication of procedural sedation is that a pediatric patient often requires a deeper level of sedation than an adult would need for a similar procedure. a. true b. false 7. In a study of complications in procedural sedation cases performed by a group of emergency department physicians, the most common complication was a. hypoxia. b. cardiac arrest. c. death. d. hemorrhage. 8. A learning needs assessment 1. is important for identifying objectives and content for educational activities.
2. is an effective strategy for learners to identify their own strengths and weaknesses. 3. helps educators make decisions regarding staff development. 4. is the process of determining the value of a course or a program. a. 1 and 2 b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 9. Types of needs assessments include 1. interviews. 2. observation. 3. questionnaires. 4. surveys. a. 1 and 2 b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 10. As a result of performing a learning needs assessment, the perioperative resource nurses and educators at this facility are 1. determining how to validate whether the RNs’ self-rated scores equated with actual knowledge. 2. discussing educational opportunities for nurses who participate in sedation procedures. 3. identifying different programs that could be developed depending on the RNs’ self-rated scores. 4. implementing annual sedation competency skills testing for nurses who participate in sedation procedures. 5. perform a follow-up learning needs assessment to evaluate the success of implemented educational programs. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5
The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
576
AORN Journal
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
1.7
Using a Learning Needs Assessment to Identify Knowledge Deficits Regarding Procedural Sedation for Pediatric Patients
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss procedural sedation. Low 1. 2. 3. 4. 5. High 2. Explain the role of the procedural sedation nurse during the procedure. Low 1. 2. 3. 4. 5. High 3. Identify potential complications of procedural sedation. Low 1. 2. 3. 4. 5. High 4. Describe learning needs assessments. Low 1. 2. 3. 4. 5. High 5. Discuss how the results of the learning needs assessment described in this article were applied. Low 1. 2. 3. 4. 5. High CONTENT 6. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
www.aorn.org/CE
9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.) 9A. 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: 9B. 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: 10. Our accrediting body requires that we verify the time you needed to complete the 1.7 continuing education contact hour (102-minute) program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. 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.
Event: #11526; Session: #0001 Fee: Members $8.50, Nonmembers $17 The deadline for this program is December 31, 2014. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
© AORN, Inc, 2011
December 2011
Vol 94
No 6 ●
AORN Journal
577
www.aorn.org/CE
ABSTRACT Procedural sedation is a cost-effective method of providing sedation and analgesia for patients undergoing diagnostic and therapeutic procedures. Sedation ranges on a continuum from minimal sedation to deep sedation, so procedural sedation can pose many risks for patients (eg, compromised airway, depressed respirations, hypotension). The unique variables inherent in the pediatric population and the associated risks of procedural sedation make it imperative that RNs be knowledgeable and competent in monitoring and managing these patients. Through the use of a learning needs assessment, perioperative resource nurses at a pediatric hospital in a large, southeast metropolitan area identified practice concerns associated with staff RNs’ management of pediatric patients undergoing procedural sedation. As a result of these findings, the perioperative resource nurses are in the process of implementing annual sedation competency skills testing in a special procedures laboratory for all nurses who participate in sedation procedures. AORN J 94 (December 2011) 567-574. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2011.05.020 Key words: pediatric procedural sedation, learning needs assessment, continuing education, competence.
C
ontinuing education is crucial for professional RNs to remain current with developments in the nursing field. Highquality nursing care is dependent on a nursing
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire December 31, 2014.
workforce that maintains competence through continuing professional development.1 According to Phippen et al,2 competence is defined as the knowledge, skills, and abilities needed to function successfully. Continuing education to verify competence is a mandate for nursing relicensure in 32 states3; therefore, educators and health care organizations should make continuing education easily available to RNs. An effective strategy for identifying gaps in knowledge and appropriately focusing continuing education is evaluation via a learning needs
doi: 10.1016/j.aorn.2011.05.020
© AORN, Inc, 2011
December 2011
Vol 94
No 6 ●
AORN Journal
567
December 2011
Vol 94
JEST—TONGE
No 6
assessment (LNA). Use of an LNA is an important part of education to incorporate changes in practice and policy.4 According to Grant,5 Malcolm Knowles, PhD, a prominent adult educator, believed that it is important for learners to identify their own educational needs as part of self-directed learning. The practice of procedural sedation is governed by standards and guidelines from various health care regulatory agencies, and nursing educators are challenged to provide ongoing educational programs and resources to keep staff RNs up to date on changes in practice and regulations related to these procedures. The perioperative resource nurses at a pediatric hospital in a large, southeast metropolitan area developed an LNA tool to evaluate the knowledge of RNs who care for patients receiving procedural sedation in the special procedures laboratory (SPL), radiology department, and satellite center. The perioperative
resource nurses chose to use an LNA tool because this is an effective strategy for directing continuing education programs.
BACKGROUND AND DEFINITIONS Procedural sedation is a cost-effective means of providing pain relief and decreasing anxiety for patients undergoing diagnostic and therapeutic procedures. In 1985, the American Academy of Pediatrics6 and the National Institutes of Health issued guidelines addressing procedural sedation and analgesia in response to several deaths related to sedation. These guidelines defined three levels of sedation: conscious sedation, deep sedation, and general anesthesia.6 Procedural sedation has evolved rapidly since that time, expanding the scope of medications, practitioners, and monitoring guidelines.7 The American College of Emergency Physicians defines procedural sedation as a “technique of administering sedatives or dissociative agents with or without analgesia to induce a state that allows the patients to tolerate an unAORN Resources pleasant procedure while maintaining cardiorespiratory AORN, Inc. Perioperative nursing care of the patient receiving function.”8 Use of procemoderate sedation analgesia (2010). Ciné-Med. http://cine-med dural sedation has moved .com/index.php?nav⫽nursing&subnav⫽aorn&id⫽1946. outside of the controlled en Austin B. Preparing children for surgery (1991). Ciné-Med. vironment of the OR into http://cine-med.com/index.php?nav⫽nursing&subnav⫽ many other clinical and outaorn&id⫽1699. patient areas. Patients receiv Individual Periop 101 Learning Modules. Patient care modules: ing procedural sedation may anesthesia. AORN, Inc. http://www.aorn.org/Education/ be undergoing Periop101/LearningModules. Managing the patient receiving moderate sedation/analgesia. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:327-336. Moderate sedation: confidence-based learning module. AORN, Inc. http://www.aorn.org/Education/ConfidenceBasedLearning/ ModerateSedation. Safe Medication Administration Tool Kit. AORN, Inc. http:// www.aorn.org/Community/OrganizationalLeadershipDevelopment.
Web site access verified September 19, 2011.
The American Society of Anesthesiologists defines
568
AORN Journal
endoscopic examinations, burn and wound debridement, fracture reduction, lumbar puncture, central venous line placements, or diagnostic procedures.
LEARNING NEEDS ASSESSMENT FOR PROCEDURAL SEDATION sedation levels as minimal, moderate (procedural), deep, and general anesthesia: Minimal Sedation (Anxiolysis) is a druginduced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.9
ROLES OF NURSES AND PHYSICIANS Usually, one physician and at least one RN are needed during a procedure in which procedural sedation will be used. The physician is responsible for medication administration, while the RN
www.aornjournal.org
continuously monitors the patient. It is important for the RN to understand that sedation is a continuum. A moderately sedated patient could respond to a medication in an unusual way and progress to deep sedation; therefore, sedated patients require careful monitoring at all times. The RN should monitor the patient’s
vital signs, oxygen saturation level, cardiac rate and rhythm, respiratory rate and adequacy of ventilation, and level of consciousness.
Usually, the RN monitors the patient’s vital signs continuously and documents them every five minutes. The RN monitoring the patient should not have any other duties or responsibilities, such as circulating for the procedure. Suction and an emergency code cart with narcotic reversal agents should be immediately available. The RN assesses and documents the patient’s status by using the Aldrete scoring system before a medication is administered and after the procedure. The Aldrete scoring system is used to assess the patient’s oxygenation, respiration, circulation, consciousness, and motor activity.10 Patients are discharged from the recovery area and the hospital to a responsible, designated adult by a qualified, licensed, independent health care provider.11 GOALS AND RISKS OF SEDATION The goal of procedural sedation in the pediatric population is to select the lowest dose of medication with the highest therapeutic effect.6 With any sedation, there are serious risks that necessitate excellent assessment skills and pharmacologic knowledge. Levels of sedation occur on a continuum, and a sedated child can go in and out of an intended level of sedation quite rapidly.9 One potential complication with procedural sedation is that a pediatric patient often requires a deeper level of sedation for a procedure than an adult would need for a similar procedure.12 Safe and AORN Journal
569
December 2011
Vol 94
No 6
JEST—TONGE
effective procedural sedation and analgesia desupported that procedural sedation as practiced is pends on appropriate assessment, monitoring, at least as safe as general anesthesia.14 The low incidence of adverse events does not mean that and use of rescue skills by knowledgeable and procedural sedation is without risk. Skilled percompetent health care providers. Serious comsonnel, close monitoring, and precautionary airplications associated with sedation of pediatric way measures reduce the possibility of adverse patients include hypotension, compromised air6 events during the procedure. way, depressed respirations, and cardiac arrest. Adverse responses related to procedural sedation may be minimized but not completely elimiCURRENT GUIDELINES nated by a careful pre-procedure assessment and The Joint Commission,11 American Academy of Pediatrics,6 and American Society of Anesthesiolreview of the patient’s medical history. This inogists9 have established guidelines for administercludes identifying how the patient’s underlying ing procedural sedation. Hospitals, committees, medical conditions might be affected by the seda6 states, and regulatory agencies have their own tion process. A study performed by a group of emergency departsets of guidelines ment physicians reand regulations reported on 1,244 segarding procedural Risks associated with procedural sedation in dation procedures sedation. Pediatric the pediatric population necessitate excellent with a complication sedation monitoring assessment skills and pharmacologic knowledge. rate of 17.8%; the guidelines from the most common comAmerican Academy plication was hypof Pediatrics focus oxia, which was on the concept of easily treated with supplemental oxygen.13 The preparedness to rescue a patient from an uninPediatric Sedation Research Consortium (PRSC) tended depth of sedation while also highlighting collects prospective sedation data and, in 2006, patient discharge criteria and home care.6 14 published data on 30,000 procedures. Data colRecommendation IX of AORN’s “Recomlected from these procedures showed minor admended practices for managing the patient receivverse events, such as stridor, laryngospasms, airing moderate sedation/analgesia” states that “the way obstruction, wheezing, and apnea. Between perioperative RN should be clinically competent, 2004 and 2008, the PRSC reported 122 major possessing the skills necessary to manage the complications in 131,751 procedures.14 The PSRC nursing care of the patient receiving moderate defined major complications as aspiration, unsedation/analgesia.”15(p332) Competencies verify planned hospital admission, emergency anesthesia that personnel have an understanding of moderate consultation, and cardiac arrest.14 In these sedation; the risks of unplanned, deeper sedation; 131,751 procedures, there was one case of cardiac and safe use of monitoring equipment. Competenarrest requiring cardiopulmonary resuscitation, no cies related to procedural sedation should include, aspirations, and no deaths. but not be limited to, However infrequent these risks may be in the patient selection and assessment criteria; pediatric population, it is vital that all periopera knowledge of anatomy and physiology; tive personnel be adequately trained to handle any selection, function of, and proficiency in the emergency situation by using rescue resources 6 use of physiological monitoring equipment; that are immediately available. In 2008, the pharmacology of the sedation medications; PSRC data from 90,000 sedation procedures 570
AORN Journal
LEARNING NEEDS ASSESSMENT FOR PROCEDURAL SEDATION
recognition of complications associated with sedation and analgesia; management of airways; use of continuous positive airway pressure; basic dysrhythmia recognition and management; emergency response and management; and advanced cardiac life support and pediatric advanced life support according to the patient population served.15
LEARNING NEEDS ASSESSMENT According to DeSilets,16 an LNA is important for identifying objectives and content for educational activities, and its scope should be based on its purpose. Performing self-assessments is an effective strategy for learners to identify their own strengths and weakness as well as for helping educators make decisions regarding staff development. There are a variety of types of needs assessments, such as questionnaires, surveys, interviews, and observation. The facility resource nurses selected a questionnaire method because it is one of the most commonly reported methods of needs assessment, and it is relatively easy to create. To develop the LNA questionnaire, the perioperative resource nurses reviewed the literature to examine current practice standards as defined by various regulatory agencies, including AORN,15 The American Society of Anesthesiologists,9 The Joint Commission,11 and the American College of Emergency Physicians.8 They identified 11 topics regarding the role of the staff RN in managing a sedated patient. From these topics, they developed a questionnaire with a four-response option, Likerttype scale to assess and rate staff RNs’ knowledge of the 11 topics (Figure 1). The RNs were asked to rate their knowledge of current analgesia/sedation policy, airway management, sedation medications, equipment usage, electrocardiograph rhythms, patient selection criteria, recognition and management of associated risks of sedation, NPO guidelines, oxygen delivery
www.aornjournal.org
devices, signs and symptoms of respiratory distress, and discharge criteria by indicating their response as no knowledge, little knowledge, some knowledge, or significant knowledge.
The questionnaire also included space for written comments from the participants regarding any other educational concerns and issues about sedation that could enrich the data collected on the questionnaire. Demographic data were requested regarding the RNs’ credentials, highest degree attained, and length of time used on the unit. To gain different perspectives from clinical experts, the resource nurses presented the first draft of the questionnaire for review to two clinical educators in the perioperative setting and the nurse manager of sedation services in the radiology department. After incorporating the suggestions of the clinical experts, they presented the second draft to the medical director of sedation services at the hospital for review. Based on input from the medical director, the resource nurses made appropriate revisions to the questionnaire. QUESTIONNAIRE RESULTS Managers from the different clinical settings identified a sample of 55 RNs. The resource nurses distributed questionnaires by hand to the RNs in the SPL and radiology departments, and distributed them online to RNs at the satellite center. The RNs were instructed to complete the anonymous questionnaire within two weeks. Managers and educators helped retrieve the data. A total of 33 completed questionnaires were received, all from the SPL and the radiology department, for a response rate of 60%. Of the 33 RNs who responded, 16 had a bachelor of science degree in nursing (BSN), 14 had an associate of science degree in nursing (ASN), and three had diplomas in nursing. None of the RNs listed any certifications or other credentials. The number of years in the practice setting ranged from six to 24 years. AORN Journal
571
December 2011
Vol 94
JEST—TONGE
No 6
Please complete this survey describing your knowledge of sedation. Your responses will help determine what topics need to be included in the design of continuing education programs addressing sedation. For each question, determine your level of knowledge from 0 to 3. Please answer all of the questions. At the end, there is a comment section; please feel free to add additional topics you feel need to be addressed. We appreciate your participation and support of optimal clinical practice. Thank you. Unit/Campus: ______________________________________
Title: ___________________________________________
Highest degree obtained: _____________________________
Length of time employed in this unit: __________________ No knowledge 0
I. II.
III.
How would you rate your knowledge of our current analgesia/sedation policy? How would you rate your knowledge in maintaining airway stability? A. Reposition jaw B. Suction C. Oral airway D. Nasal trumpet How knowledgeable are you about the use of the following medications? A. Fentanyl B. Ketamine C.
Midazolam
D.
Naloxone
E. Propofol IV. How would you rate your knowledge of the NPO guidelines for the different age groups in the pediatric population? V. How would you rate your knowledge in treating the most commonly associated risks of sedation? A. Upper airway obstruction B. Partial laryngospasm C. Complete laryngospasm D. Hypotension E. Oxygen desaturation F. Apnea VI. How would you rate your knowledge level about the following equipment A. Bag valve mask B. Cardiac monitor C. Suction equipment D. Pulse oximeter E. Capnography end-tidal carbon dioxide monitor VII. How would you rate your knowledge of the following oxygen delivery devices? A. Face mask B. Nasal cannula C. Venturi mask D. Non-rebreather mask VIII. How would you rate your knowledge of electrocardiogram rhythms? IX.
How would you rate your knowledge regarding the recognition of signs and symptoms of respiratory distress? X. How would you rate your knowledge of the ASA physical health status classification? XI. How would you rate your knowledge regarding use of the modified Aldrete system to assess recovery? Comments or suggestions:
Figure 1. Sedation Learning Needs Assessment.
572
AORN Journal
Little knowledge 1
Some knowledge 2
Significant knowledge 3
LEARNING NEEDS ASSESSMENT FOR PROCEDURAL SEDATION Regarding sedation therapy, four BSN-prepared nurses documented the highest rating of significant knowledge compared with 12 ASN-prepared nurses and two diploma-prepared nurses. On the topic of electrocardiograph rhythms, six BSNprepared nurses, 12 ASN-prepared nurses, and two diploma-prepared nurses indicated significant knowledge. All of the ASN nurses worked in the radiology department. Overall, the RNs in the SPL and the radiology department rated their knowledge levels differently. The majority of the radiology RNs rated themselves as having significant knowledge in all areas except medications and oxygen delivery devices. The majority of the RNs in SPL rated themselves as having some knowledge in most areas. Differences in learning needs between the two units may be a result of inconsistent sedation education within the institution. Nurses in the SPL only complete institution sedation modules, whereas radiology RNs have annual sedation competency and attend sedation conferences in addition to completing the institution sedation module.
DISCUSSION Results of the questionnaire identified and isolated differences in learning needs among two units in the facility in which sedation services are provided. Further data collection using interviews and observations could be useful to help educators collaborate and provide standardized instruction on procedural sedation throughout the institution. Ratings using the Likert-type scale will help educators prioritize learning needs and plan various levels of educational offerings, such as update courses, competency courses, or advanced education courses. An LNA survey has been shown to be vital to the identification of learning needs and, according to DeSilets,16 promotes participation of learners in the their own professional development. Feedback from educators about the LNA tool has been positive.
www.aornjournal.org
Educational Implications As a result of the LNA, the perioperative resource nurses and educators are discussing implementation of educational opportunities for nurses who participate in sedation procedures, how they should validate whether the selfrated scores equated with actual knowledge, and whether different programs should be developed depending on the RNs’ self-rated scores.
Currently, the educators are in the process of implementing annual sedation competency skills testing, including case scenarios and mock codes in the SPL for all nurses who participate in sedation procedures. They plan to perform a follow-up LNA after implementing the educational programs to evaluate the success of these programs.
CONCLUSION Continuing education and learning is critical for health care professionals to be competent in performing their jobs. Ongoing education offers personnel an opportunity to enhance their skills and learn about changes in practice, regulations, and standards. Nurses must recognize that continuing education should be an integral part of professional life to ensure patients’ safety. Development of an LNA questionnaire addressing procedural sedation provided a valuable means for an educator to identify knowledge deficits among RNs, differentiate needs among RNs in different units, and allow for feedback and input from members of the interdisciplinary team. As the practice of procedural sedation and analgesia continues to evolve and expand through research and technology, RNs who provide procedural sedation will need continuing education to enhance their training and ensure safe and quality care for their patients. An LNA has been shown to be an effective method for the development of continuing education offerings, and is a valuable tool for the nurse educator. AORN Journal
573
December 2011
Vol 94
JEST—TONGE
No 6
Acknowledgement: The authors acknowledge the contributions of Michelle Byrne, PhD, RN, CNE, CNOR, program coordinator for the Masters of Science Nursing Education Program, North Georgia College and State University, Dahlonega, GA, in directing the authors to a wide range of resources and answering many questions during the preparation of this manuscript.
10.
References
13.
1.
2.
3.
4.
5. 6.
7. 8.
9.
574
While A, Ullman R, Forbes A. Development and validation of a learning need assessment scale: a continuing professional education for multiple sclerosis specialists nurses. J Clin Nurs. 2007;16(6):1099-1108. Phippen M, Ulmer B, Wells M. Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, CO: Competency and Credentialing Institute; 2009. Nationwide state legislative agenda reports 2011-2012. American Nurses Association. http://nursingworld.org/ MainMenuCategories/ANAPoliticalPower/State/State LegislativeAgenda.aspx. Accessed September 8, 2011. Akhtar-Danesh N, Valaitis RK, Schofield R, et al. A questionnaire for assessing community health nurses’ learning needs. West J Nurs Res. 2010;32(8):10551072. Grant J. Learning needs assessment: assessing the need. BMJ. 2002;324(7330):156-159. American Academy of Pediatrics; American Academy of Pediatric Dentistry; Coté CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006;118(6):2587-2602. Kraus B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367(9512):766-780. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005;45(2):177-196. http://www.annemergmed.com/article/S0196-0644(04) 01616-6/fulltext. Accessed September 8, 2011. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. American Society of Anesthesiologists (ASA). http://www.asahq .org/Search.aspx?q⫽Continuum⫹of⫹depth⫹of⫹ sedation%3a⫹Definition⫹of⫹general⫹anesthesia⫹ and⫹levels⫹of⫹sedation%2fanalgesia&site⫽All. Accessed August 2, 2011.
AORN Journal
11.
12.
14.
15.
16.
Panagiotis K, Maria P, Argiri P, Panagiotis S. Is postanesthesia care unit length of stay increased in hypothermic patients? AORN J. 2005;81(2):379492. Provision of care, treatment, and services. In: Comprehensive Accreditation Manual E-dition. Oakbrook Terrace, IL: The Joint Commission; 2011:PC.03.01.07. https://e-dition.jcrinc.com/Frame.aspx. Accessed September 8, 2011. Updated guidelines focus on monitoring pediatrics: recommendations address before, after sedation. Same Day Surg. 2007;31(2):19-21. Baxter AL. Pediatric procedural sedation. Medscape Education. https://remote.aorn.org/viewarticle/, DanaInfo⫽www.medscape.org⫹568824_2?new EmailAddress⫽[email protected]&confirmNewEmail Address⫽[email protected]&submitemailupdate⫽ Update⫹Email⫹Address. Accessed September 12, 2011. Cravero JP, Blike GT, Beach M, et al; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006;118(3):1087-1096. Recommended practice for managing the patient receiving moderate sedation/analgesia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011:327-336. DeSilets LD. Needs assessments: an array of possibilities. J Contin Educ Nurs. 2007;38(3):107-114.
Anne D. Jest, MS, RN, CPN, CSRN, is a resource nurse at Children’s Healthcare of Atlanta, GA. Ms Jest has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Andrea Tonge, BSN, RN, CPN, CSRN, is a resource nurse at Children’s Healthcare of Atlanta, GA. Ms Tonge has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
EXAMINATION CONTINUING EDUCATION PROGRAM
1.7
Using a Learning Needs Assessment to Identify Knowledge Deficits Regarding Procedural Sedation for Pediatric Patients
www.aorn.org/CE
PURPOSE/GOAL To educate perioperative nurses about the importance of assessing learning needs to ensure competency in procedural sedation for pediatric patients.
OBJECTIVES 1. 2. 3. 4. 5.
Discuss procedural sedation. Explain the role of the procedural sedation nurse during the procedure. Identify potential complications of procedural sedation. Describe learning needs assessments. Discuss how the results of a learning needs assessment were applied.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS 1. According to the American Academy of Pediatrics and the National Institutes of Health, levels of sedation include 1. conscious sedation. 2. deep sedation. 3. general anesthesia. 4. local anesthesia. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 2. The American College of Emergency Physicians definition says procedural sedation 1. induces a state that allows the patient to tolerate an unpleasant procedure. © AORN, Inc, 2011
2. involves administration of sedatives or dissociative agents. 3. allows the patient to maintain cardiorespiratory function. 4. may or may not involve the use of analgesia. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 3. Types of procedures for which procedural sedation may be applicable include 1. burn and wound debridement. 2. central venous line placements. 3. colostomy closure. 4. fracture reduction. 5. lumbar puncture. December 2011
Vol 94
No 6 ●
AORN Journal
575
December 2011
Vol 94
CE EXAMINATION
No 6
a. 4 and 5 c. 1, 2, 4, and 5
b. 1, 2, and 3 d. 1, 2, 3, 4, and 5
4. The nurse providing procedural sedation is responsible for medication administration. a. true b. false 5. The procedural sedation nurse should 1. monitor the patient’s oxygen saturation level. 2. circulate for the procedure. 3. monitor the patient’s cardiac rate and rhythm. 4. evaluate the patient’s level of consciousness. 5. monitor the patient’s respiratory rate and adequacy of ventilation. 6. measure and document the patient’s vital signs. a. 1, 3, and 5 b. 2, 4, and 6 c. 1, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 6. A potential complication of procedural sedation is that a pediatric patient often requires a deeper level of sedation than an adult would need for a similar procedure. a. true b. false 7. In a study of complications in procedural sedation cases performed by a group of emergency department physicians, the most common complication was a. hypoxia. b. cardiac arrest. c. death. d. hemorrhage. 8. A learning needs assessment 1. is important for identifying objectives and content for educational activities.
2. is an effective strategy for learners to identify their own strengths and weaknesses. 3. helps educators make decisions regarding staff development. 4. is the process of determining the value of a course or a program. a. 1 and 2 b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 9. Types of needs assessments include 1. interviews. 2. observation. 3. questionnaires. 4. surveys. a. 1 and 2 b. 1, 2, and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 10. As a result of performing a learning needs assessment, the perioperative resource nurses and educators at this facility are 1. determining how to validate whether the RNs’ self-rated scores equated with actual knowledge. 2. discussing educational opportunities for nurses who participate in sedation procedures. 3. identifying different programs that could be developed depending on the RNs’ self-rated scores. 4. implementing annual sedation competency skills testing for nurses who participate in sedation procedures. 5. perform a follow-up learning needs assessment to evaluate the success of implemented educational programs. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5
The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
576
AORN Journal
LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
1.7
Using a Learning Needs Assessment to Identify Knowledge Deficits Regarding Procedural Sedation for Pediatric Patients
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss procedural sedation. Low 1. 2. 3. 4. 5. High 2. Explain the role of the procedural sedation nurse during the procedure. Low 1. 2. 3. 4. 5. High 3. Identify potential complications of procedural sedation. Low 1. 2. 3. 4. 5. High 4. Describe learning needs assessments. Low 1. 2. 3. 4. 5. High 5. Discuss how the results of the learning needs assessment described in this article were applied. Low 1. 2. 3. 4. 5. High CONTENT 6. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
www.aorn.org/CE
9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.) 9A. 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: 9B. 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: 10. Our accrediting body requires that we verify the time you needed to complete the 1.7 continuing education contact hour (102-minute) program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. 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.
Event: #11526; Session: #0001 Fee: Members $8.50, Nonmembers $17 The deadline for this program is December 31, 2014. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
© AORN, Inc, 2011
December 2011
Vol 94
No 6 ●
AORN Journal
577