2015 HSC Section 1 Book of Articles

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.

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.

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

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

< .05.

Results

Implementation of New Process

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-

Figure 1. Institute of Healthcare (IHI) Improvement Algorithm Adapted

to Improve Pediatric Sedation Wean in Postoperative LTR Patients

IHI Steps

Forming a team

MGHfC/MEEI LTR-Tailored Experience

Otolaryngologists, intensivists,

hospitalists, residents, pharmacists,

nurses, and social workers

Identifying opportunities

for improvement

• Prolonged hospitalizations

• Unanticipated transfers

• Confusion among health care

practitioners

Developing clear aims

Create a standardized wean document

that will be implemented at time of

patient transfer from the PICU

Designing and testing

standard work for key

changes

Document reviewed by MEEI and

MGHfC committees

Identifying problems and

redesigning the process

Implementation of document

Displaying measures

over time

Evaluation of length of stay, length

of wean, need for wean at time of

discharge

Implementing and

spreading the reliable

design and processes

Continued revision of wean document

and in-service training of health care

practitioners

Problem: Lack of Communication Regarding LTR Sedation Wean

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.

Sedation Wean After Laryngotracheal Reconstruction

Original Investigation

Research

jamaotolaryngology.com

JAMA Otolaryngology–Head & Neck Surgery

Published online October 30, 2014