Authors (including presenting author) :
Lui CW(1), Leung KL(1), Sit NM(1), Cheng LS(2), Law CY(2), Yim KS(2), Chow YF(3), Ip SL(3), So J(3), Chan WY(1)
Affiliation :
(1) Accident and Emergency Department, United Christian Hospital (UCH), (2) Accident and Emergency Department, Princess Margaret Hospital (PMH), (3) Accident and Emergency Department, Tseung Kwan O Hospital (TKOH)
Introduction :
Procedural sedation and analgesia (PSA) is frequently performed in the Accident and Emergency Departments (AEDs) to reduce pain and anxiety in patients undergoing short painful procedures. Orthopaedic manipulation of dislocated joints and displaced fractures is the most common indication for PSA in AEDs.
Patient safety is an important consideration as significant adverse events, such as airway compromise and respiratory depression, can occasionally occur during PSA. At present, there are variations of practice in PSA among different AEDs, some of which are below the standard of care recommended in the current guidelines. A cross-clusters CQI program was hence conducted in three (UCH, PMH & TKOH) AEDs.
Objectives :
Our aim was to enhance the safety and quality of care for adults undergoing PSA for closed reduction in AED.
Methodology :
A CQI program was designed and implemented using the ‘Focus-Analyze-Develop-Execute’ (FADE) model.
A staff survey and case review were conducted to identify areas of PSA practice which were below the standard of existing guidelines. A comprehensive root-cause analysis was then performed and specific interventions were developed and implemented to address the areas of concerns.
The effectiveness of the interventions was evaluated by the ‘Structural-Process-Outcome’ approach using pre-post comparison of staff survey on training coverage, knowledge and perceived self-efficacy level. Case review were also conducted in the evaluation phase.
Result & Outcome :
Four areas of concerns in PSA practice in AED were identified. These included inadequate equipment preparation, insufficient patient monitoring, poor documentation and lack of written discharge advice.
Five specific interventions were implemented. A dedicated procedural sedation trolley was set up, a poster and a cue card on recommended PSA practice were produced, a standardized procedural sedation proforma was introduced, a written discharge advice was developed, and nursing staff training sessions were organised.
As a result of the interventions, staff training coverage was increased by 69.5%, 71% & 80% in UCH, PMH & TKOH AED respectively. Pre-post training comparison showed significant improvement in the knowledge level and perceived self-efficacy on PSA among nursing staff in the three AEDs. Case review of 58 cases of PSA in the evaluation period showed more frequent and regular patient monitoring; more comprehensive and detailed documentations were also observed.
Conclusion
The cross-cluster CQI program was successfully adopted in UCH, PMH & TKOH AEDs resulting in improved safety and quality of care in PSA for closed reduction in AED.
