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Anesthesia services outside of the operating room.

Primary Children's Medical Center (PCMC) is a 232-bed facility that serves as a Trauma-1 center for the largest geographical area in the United States, including Utah, Idaho, Wyoming, Montana, and Nevada. The Primary Children's Association of The Church of Jesus Christ of Latter-Day Saints founded PCMC in 1922. In 1975, PCMC became part of Intermountain Healthcare. The Rapid Treatment Unit (RTU) Anesthesia area, established in September 2000, offers a unique service to the five-state-region for children undergoing procedures performed under general anesthesia outside of the operating room. Because of the increasing number of patients seen from surrounding states, this service was developed by PCMC's physicians and nurses to improve cost effectiveness by decreasing length of stay, improving time-management, and increasing family involvement and efficiency.

This service occurs within PCMC's Rapid Treatment Unit (RTU), a 24-hour, 25-bed occupancy, extended care unit. The RTU anesthesia team has been providing anesthesia services since September 2000 and continues to improve as adjustments are made to meet the demands of our patient population and evolving patient care goals. Early in 2001, parents (N = 110) were asked to compare their experiences through a five-question parent satisfaction survey designed for the RTU anesthesia area, to other forms of sedation, operating room experiences, and personal expectations with sedation. Parents were asked to complete the survey prior to discharge. Sixty-six parents (a 60% response rate) of the RTU anesthesia patients completed the survey. Overall satisfaction with the experience was high, with 89% of respondents reporting superior or above average satisfaction (see Figure 1). Currently, parents continue to verbalize their satisfaction with cost effective, efficient care, parental participation, friendly atmosphere, and means to a pain free procedure for their child (see Figure 2).

[FIGURE 2 OMITTED]

RTU Anesthesia Development

At PCMC, several factors led to the development of the RTU anesthesia multidisciplinary team that provides peri-anesthesia care (PAC) in the RTU. First, the operating room (OR) schedule often was unable to accommodate unexpected procedures, which resulted in frustrated parents and patients who at times waited hours. Second, hospital clinics and the ED were providing sedation for procedures, such as lumbar punctures, bone marrow aspirates, joint injections, and Phenol and Botox injections, without adequate monitoring. Of patients seen currently in the OR, 65% are outpatient and 35% are inpatient. It was reasonable to believe that some procedures could be done in a more cost-efficient manner than in the OR. A child friendly area and service was needed for these procedures, where parents could be more involved during the process. Parents are now involved in the RTU by accompanying their child during the onset of anesthesia. The RTU offers a child-friendly environment, flexible availability, and decreased cost compared to the OR. On an anonymous survey, the value of this service was illustrated by the following comment made by a parent:

RTU is a very valuable resource for us. [My son] has had his lumbar puncture both ways in RTU and the clinic. Clinic, although easier for the oncology staff and cheaper for us personally, is extremely hard emotionally [to have lumbar punctures]. Having him not be fully sedated and have a single tear come down his face just kills me! I know he can feel it even though he can't respond! RTU also has its risks, but it is worth it to have a smooth procedure with a child who looks forward to going [and] to have him fully sedated. The staff is always excellent and very competent. Cancer is hard enough emotionally on a family. Any little thing that can make the treatment easier becomes a need!

RTU Anesthesia Team

In 2000, when the need for RTU anesthesia was identified, emergency department (ED) physicians, ED and RTU nurse managers, and anesthesiology developed a team to safely provide for the needs of children. The multidisciplinary team consists of PCMC pediatric specialists, including anesthesiologists, registered nurses, respiratory therapists, a patient care assistant, and a child life specialist.

Anesthesiologists. Multiple PCMC anesthesiologists provide care in the RTU. Each has his/her own preferred methods of delivering anesthesia. The staff must be knowledgeable about each anesthesiologist's preferences (i.e., IV placement, timing of monitor placement, and parental presence during onset of anesthesia) to prepare the patients and families appropriately for induction of general anesthesia.

Registered nurses. One registered nurse (RN) works Monday-Friday as the anesthesia coordinator to facilitate patient flow and consistency of care. The coordinator, along with seven other RN's, is required to complete ongoing education to ensure safe care for children. Requirements include Basic Life Support (BLS), Pediatric Advanced Life Support (PALS) certification, Emergency Nursing Pediatric Course (ENPC) and four quarterly in-services. Orientation includes three 12-hour orientation days with an experienced RTU anesthesia nurse observing inductions, assisting the anesthesiologists in the operating room, and completing a PCMC anesthesia module and skills checklist that reviews pre-operative, intra-operative, and post-operative policies and procedures.

The RN's responsibilities include calling patients before the procedure to obtain a health history, giving diet instructions, and instructing parents on what to expect for their child's procedure. Upon admission, the RN performs a physical assessment, coordinates care with other healthcare personnel, and completes pre-operative documentation. The RN assists the anesthesiologist with airway management, monitoring vital signs, placing IVs, and drawing labs. He/she also assists physicians/practitioners with the procedure by holding the patient in proper positions, obtaining supplies, and cleaning or washing the patient. The RN administers medication, and monitors the patient's respiratory status, circulation, level of consciousness, pain level, nausea, oxygen saturation, activity, and color during recovery (see Figure 3). Follow-up calls are made the day after the procedure to identify and discuss any health care problems or concerns with the patient's family and to provide follow up with a physician/licensed independent practitioner if needed.

[FIGURE 3 OMITTED]

Respiratory therapist. The registered respiratory therapist (RRT) assists throughout the procedure as necessary and is active in monitoring the patient's airway during the recovery process. The RRT education and experience includes (a) membership in the Quality Care Assessment Team (QCAT), (b) 6 months of experience in Pediatric Intensive Care Unit (PICU), (c) PALS certification, and (d) completion of the Neonatal Resuscitation Program (NRP). The RRT also is required to complete pediatric pharmacology and fluid balance/electrolyte modules, created from a nursing curriculum focusing on the RRT's scope of practice. During RTU orientation, the RRT spends three 8-hour days with the anesthesia team.

Patient Care Assistant. The Patient Care Assistant (PCA) is a certified nursing assistant who assists the RN in obtaining and recording baseline vital signs, NPO status, height, and weight; and placing identification bands on both patient and parent. The PCA helps to complete necessary admission paperwork and notifies the team when the paperwork is ready for the RN's review. Each PCA is educated in pediatric resuscitation and basic life support at PCMC.

Child Life Specialist. A Certified Child Life Specialist (CCLS) must hold a minimum of a bachelor degree in child life, child development, human development, or a closely related field, complete a 480-600-hour child life internship under the supervision of a certified child life specialist, and pass a national certification exam (Child Life Council, 2007). The specialist prepares the majority of patients for procedures through play therapy to help the children to cope with and familiarize themselves with the procedure and the RTU. If the child life specialist is unavailable, the RTU RN provides instruction. The child life specialist uses age-appropriate toys, books, games, projects, movies, or video games to normalize the environment and to teach and/or facilitate coping mechanisms. Children can view pictures of staff, play with equipment such as an oxygen mask, and go on a tour of the procedure and recovery room. When the RN or RRT initiates the pre-operative phone call on the day prior to the procedure, parents have the opportunity to alert staff if their child is anxious about having the procedure. At this time, a member of the team can describe ways to prepare the child at home, hopefully leading to decreased anxiety toward the procedure. Preparation helps alleviate anxiety and stress the child may feel about undergoing general anesthesia and painful procedures as seen by increased compliance and cooperation with healthcare procedures and staff (Cassell, 1965; Clatworthy, 1981; Knudsen, 1974; Melamed & Siegel, 1975; Vaughan, 1957; Wolfer, Gaynard, Goldberger, Laidley & Thompson, 1988).

Integration of Procedures

When the patient and family arrive and registration is complete, he/she is taken to one of the two pre-operative rooms for the pre-operative assessment. The anesthesiologist evaluates the child's surgery risk by using the American Society of Anesthesiologists (ASA) scoring system (Hazinski, 2002). ASA I, II, and occasionally III are acceptable for the RTU. ASA IV and V should be performed in the OR. However, it is the anesthesiologist's decision on the appropriateness of RTU anesthesia patients. The anesthesiologist and attending physician discuss their plan of care and answer parent/patient questions while the patient is prepared for the procedure. The anesthesiologist assesses the child's developmental level and decides if the parents will accompany their child in the procedure room until the child is unconscious. This decision is made solely by the anesthesiologist. Parental presence is what separates the RTU from the OR at PCMC. Due to the sterility of the setting, parents do not have the privilege to accompany their child into the OR. Factors that play an important role in parental presence are (a) the patient/parent anxiety level and cooperation, (b) coping mechanisms, and (c) the child's health history. Parents help reassure, comfort, and distract the child during induction.

When the anesthesiologist determines the child is adequately anesthetized and unaware, the parents are escorted out of the procedure room and asked to wait in the pre-operative room until completion of the procedure. As the child is waking up from anesthesia, the patient is stabilized in the RTU recovery room and the parents are reunited with their child to offer comfort as the child wakes up from anesthesia. Once the child's vital signs and level of consciousness return to baseline, they meet discharge criteria. Discharge criteria are defined by returning to pre-procedure baseline in eight categories: (a) respiratory, (b) circulatory, (c) color, (d) level of consciousness, (e) activity level, (f) pain control, (g) oxygen saturation, and (h) absence of nausea/vomiting.

Written instructions (available in English and Spanish) regarding anesthesia and the procedure are given to the parents by the RN or RRT under supervision of the RN. Verbal instructions also are explained to the patient and family based upon their previous experience and knowledge. For those needing an interpreter, PCMC has Spanish interpreters in the hospital and 24-hour access to phone interpreters of other languages. Prior to discharge, parents are expected to verbalize understanding of the instructions given and demonstrate tasks or techniques when applicable. Home care is arranged if needed.

Parents are instructed to monitor their child for problems in respiratory effort, level of consciousness, pain, toleration of fluid/food, activity level, and the operation/procedure site. They are instructed to call 911 if the child has increased work of breathing or apnea, or if they have difficulty waking the child. Parents are told to notify a physician, or to go to the nearest emergency room for problems, questions, or concerns related to their child's diagnosis and procedure.

Scheduling and Procedures

The RTU Anesthesia service is scheduled through the hospital surgical scheduling office and finalized the evening before each procedure. Same day scheduling is provided upon avail ability of RTU rooms and the child's physician designated to perform the procedure. The minimum length for a procedure is 30 minutes and longer cases generally are no more than 1 1/2 to 2 hours. The RTU anesthesia service is available Monday through Friday, 9 am to 3 pm, excluding holidays. One anesthesia RN is available daily from 7 am to 5 pm. Numerous disciplines use the RTU services (see Table 1 and Figure 4). The number of patients served each year has increased as more disciplines choose to use the service (see Figure 5). The RTU anesthesia service can accommodate children of all ages depending on the severity of illness and ASA score. Of patients who have used the RTU Anesthesia service more than once, at least 50% are from the Hematology/Oncology service.

The RTU anesthesia service has achieved success as evidenced by a dramatic increase in use over the past 4 years and continued satisfaction of both parent and patient. Physicians express their satisfaction of the RTU Anesthesia area because of its accessibility and convenience. The RTU anesthesia unit and team provide a safe, family friendly environment that is efficient, cost effective, and flexible for both clinicians and families.

References

Cassell, S. (1965). Effects of brief puppet therapy on the emotional responses of children undergoing cardiac catheterization. Journal of Consulting Psychology, 29, 1-8.

Child Life Council and Committee on Hospital Care. (2006). American Academy of Pediatrics policy statement: Child life services. Pediatrics, 118(4), 1757-1763.

Clatworthy, S. (1981). Therapeutic Play: Effects on hospitalized children. Children's Health Care, 9(4), 108-113.

Hazinski, Mary F. (Ed.). (2002). PALS Provider Manual. American Heart Association, 380-382.

Knudsen, K. (1974). Play therapy: Preparing the young child for surgery. Nursing Clinics of North America, 10, 679-686.

Melamed, B., & Siegel, L. (1975). Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling. Journal of Consulting Psychology, 43, 511-521.

Vaughan, G.F. (1957). Children in hospital. Lancet, 272(6979), 1117-1120.

Wolfer, J., Gaynard, L., Goldberger, J., Laidley, L., & Thompson, R. (1988). An experimental evaluation of a model child life program. Children's Health Care, 16(4) 244-254.

Kendall Adams, BSN, RN, is Anesthesia Coordinator, Primary Children's Medical Center, Salt Lake City, UT.

Natalie Pennock, BSN, RN, is Staff Nurse, Primary Children's Medical Center, Salt Lake City, UT.

Becky Phelps, RN, is Staff Nurse, Primary Children's Medical Center, Salt Lake City, UT.

Wendy Rose, BSN, RN, is Staff Nurse, Primary Children's Medical Center, Salt Lake City, UT.

Matthew Peters, MS, RN, is Content Engineer, Remedy MD, Sandy, UT.
Table 1. Procedures Performed in
the Rapid Treatment Unit

Lumbar Puncture
Bone Marrow Aspiration
Bone Marrow Biopsy
Esophageal-Gastro-Duodenoscopy
Colonoscopy
Gastric Tube Placement
Bronchoscopy
Liver and Renal Biopsy
PICC Placement
Hearing Screens
Phenol and Botox Injections
Cardioversion
Echocardiogram
Steroid Joint Injections
Abscess Drainage
Central Line removal
Dental Extractions and Exams
Lesion Removal
Extraventricular Drain Placement
EMG

Figure 1. Parent Satisfaction Survey

Average          9%
Above Average   48%
Superior        41%
Fair             2%

Note: Table made from pie chart.

Figure 4. Disciplines Using the RTU, by Percent

Miscellaneous              5%
Neurology                  5%
Surgery                    3%
Rheumatology               4%
Rehabilitation             8%
IV Therapy                 4%
Gastroenterology          11%
Hematology,
  Oncology, Bone Marrow   49%

Note. The miscellaneous section includes dental, audiology,
cardiology, safe and healthy families, and orthopedic
services.

Note: Table made from pie chart.

Figure 5. Monthly Average of Patients Served by the RTU, by Year

Year     # Patients

2000        33
2001        49
2002        87
2003       109
2004       125
2005       124

Note: Table made from bar graph.
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Author:Adams, Kendall; Pennock, Natalie; Phelps, Becky; Rose, Wendy; Peters, Matthew
Publication:Pediatric Nursing
Geographic Code:1USA
Date:May 1, 2007
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