2015 HSC Section 1 Book of Articles

Original Investigation Research

Sedation Wean After Laryngotracheal Reconstruction

On the basis of information gathered at the focus group, we formulated an IHI-based action plan and developed a “se- dation wean document” that contained essential informa- tion about the postoperative sedation wean, including dates, times, and dosages of keymedications, that was readily com- prehensible to all teammembers. The document was based on previously establishedMGHfC sedationweanmedication cal- culations and documents; original documents were authored by theMGHfC PICUWithdrawal Committee and adapted from published literature. 19 Becausewe previously determined that transfer from the PICU to the ward was the most likely time for communication breakdown, it was determined that the document should be placed in the EHR as a stand-alone docu- ment at the time of patient transfer. Because the intensivists and associated pediatric residents in the PICU are in charge of the sedationweanmedications, it was agreed that theywould be the authors of the document and communicate its infor- mation to other health care practitioners, including otolaryn- gology and nursing staff. Methods of Evaluation and Statistical Analysis We compared the primary outcome of sedation wean length in LTRs from baseline period of 2011 through 2012 (prewean group) and after implementation of the sedation wean docu- ment (LTR in 2013-2014; postwean group). Additional out- comes included presence of sedation wean document at time of transfer to the floor and discharge (process measure), loca- tion of discharge, hospital length of stay (LOS), and need for continuedwean at time of discharge (balancemeasures). A sta- tistical process control run chart of sedationwean lengthwith baseline data and 99% confidence intervals was constructed with an XmR chart and then reanalyzed following new pro- cess using Minitab version 17.1 (Minitab Inc). Descriptive sta- tistics were usedwith parametric data presented asmean and standard deviation. The t test (unpaired) and Fisher exact test were used for study armcomparisons. Statistical analyseswere performed by Stata version 12.1 (StataCorp). Results were con- sidered statistically significant at P < .05. The sedation wean document was revised several times by stakeholders, with the final form completed in February 2013 ( Figure 2 ). The document was converted into an EHR tem- plate titled “MGH/MEEI Sedation Wean Plan,” accessible by health care practitioners at both hospitals and all 3 locations. Physicians andnurses at all locations received in-service train- ing for its implementation as a new standard communication tool. Figure 3 provides a run chart of 29 consecutive LTR pa- tients over 3.5 years, with a baseline period (prewean, n = 16) and postprocess implementation (postwean, n = 13). The pro- cess measure of an electronic sedation wean plan was ad- opted in 12 of 13 eligible patients (92%). There are 2 notable pa- tient outliers in the prewean group, with length of wean longer than others in the study cohort. These patients had pro- Results Implementation of New Process

Figure 1. Institute of Healthcare (IHI) Improvement Algorithm Adapted to Improve Pediatric Sedation Wean in Postoperative LTR Patients

Problem: Lack of Communication Regarding LTR Sedation Wean

IHI Steps Forming a team

MGHfC/MEEI LTR-Tailored Experience Otolaryngologists, intensivists, hospitalists, residents, pharmacists, nurses, and social workers

• Prolonged hospitalizations • Unanticipated transfers • Confusion among health care practitioners

Identifying opportunities for improvement

Create a standardized wean document that will be implemented at time of patient transfer from the PICU

Developing clear aims

Designing and testing standard work for key changes

Document reviewed by MEEI and MGHfC committees

Implementation of document

Identifying problems and redesigning the process

Evaluation of length of stay, length of wean, need for wean at time of discharge

Displaying measures over time

Implementing and spreading the reliable design and processes

Continued revision of wean document and in-service training of health care practitioners

IHI Field Guide’s 7 steps used to improve outcomes related to sedation wean. LTR indicates laryngotracheal reconstruction; MEEI, Massachusetts Eye and Ear Infirmary; MGHfC, Massachusetts General Hospital for Children; and PICU, pediatric intensive care unit.

vened in August 2012 and included attending pediatric oto- laryngologists, pediatric intensivists, hospitalists, fellows, resi- dents, nurses, pharmacists and social workers. The multidisciplinary focus group reviewed our center’s experi- ence for all LTR patients in 2011 and 2012. Three issues stood out among LTR patients related to sedation wean: (1) pro- longed and disparatewean protocols, (2) unanticipated trans- fer from floor to ICU-level care because of oversedation, and (3) confusion among health care practitioners regarding seda- tion wean protocol. The focus group identified key communication break- downs typically occurredduring transfer of care fromthe PICU to the MGHfC ward or MEEI ward. The group identified that existing hospital documents, in the PICU and on patient trans- fer notes to theward, didnot routinely convey a plan forwean- ing sedation, arguably the main reasons for continued post- operative inpatient status. Sedation wean approaches, which typically consists ofmethadone and lorazepamtaperedat regu- lar intervals, were communicated from physicians to physi- cians or nurses to nurses, in inconsistent fashion. In addi- tion, sedationweans typically requiredmanagement onMGHfC wards instead of MEEI wards due to lack of existingwean pro- tocols at MEEI and training.

JAMA Otolaryngology–Head & Neck Surgery Published online October 30, 2014

jamaotolaryngology.com

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