Ketamine is a well-studied and safe medication used for procedural sedation in the pediatric emergency department (ED). However, in our ED and urgent care (UC), we had higher rates of respiratory events receiving intervention (REs) than has been reported nationally.
A quality improvement (QI) project was initiated to address this problem with the following aim: during a 24-month period, we aimed to decrease REs during i.v. ketamine sedation from > 10% to < 6% in our network of EDs and UCs.
Inclusion criteria included patients in our EDs and UCs who received i.v. ketamine for procedural sedation. We organized a multidisciplinary team to identify key drivers for the primary outcome (i.e., REs) and establish interventions. We based process measures on key interventions and utilized 2 Plan-Do-Study-Act (PDSA) cycles, which we evaluated with Shewhart P (provost) charts. Balancing measures included length of sedation, success of sedation, and length of stay.
REs decreased from 11.4% to 4.9%; this rate was maintained for 12 months, starting 1 month after PDSA cycle 2 implementation. There was no difference in REs for length of stay, length of sedation, or success of sedation.
Using QI methodology, we reduced and maintained rates of RE to < 6%. Due to the nature of the project, it is difficult to link one intervention to the reduction in REs; however, a significant shift occurred just after PDSA cycle 2 interventions. This project can give a guideline for interventions to improve the safety of pediatric ketamine sedations.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Journal of Emergency Medicine
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- What works and what's safe in pediatric emergency procedural sedation: an overview of reviews.Acad Emerg Med. 2016; 23: 519-530
- Procedural sedation outside of the operating room using ketamine in 22,645 children: a report from the Pediatric Sedation Research Consortium.Pediatr Crit Care Med. 2016; 17: 1110-1116
- Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children.Ann Emerg Med. 2009; 54: 158-168
- Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update.Ann Emerg Med. 2011; 57: 449-461
- Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.Pediatrics. 2006; 118: 2587-2602
- 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: 1087-1096
- Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs.Acad Emerg Med. 2005; 12: 508-513
- Dosing ketamine for pediatric procedural sedation in the emergency department.Pediatr Emerg Care. 2008; 24: 529-533
- Intravenous ketamine dosing in children undergoing emergency department procedural sedation.J Emerg Med. 2019; 56: 1-6
- American Society of Anesthesiologists: practice guidelines for sedation and analgesia by non-anesthesiologists.Anesthesiology. 2002; 96: 1004-1017
- Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.Ann Emerg Med. 2009; 53: 426-435
- Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis.BMJ Open. 2016; 6: e011384
- Adverse events during a randomized trial of ketamine vs co-administration of ketamine and propofol for procedural sedation in a pediatric emergency department.J Emerg Med. 2017; 53: 1-9
- Central antinociception induced by ketamine is mediated by endogenous opioids and μ- and δ-opioid receptors.Brain Res. 2014; 1562: 69-75
- Is there a role for intravenous subdissociative-dose ketamine administered as an adjunct to opioids or as a single agent for acute pain management in the emergency department?.J Emerg Med. 2016; 51: 757
- Risk factors for adverse events in emergency department procedural sedation for children.JAMA Pediatr. 2017; 171: 957-964
- The impact of obesity on pediatric procedural sedation related outcomes: results from the Pediatric Sedation Research Consortium.Pediatr Anesth. 2015; 25: 689-697
- The Health Care Data Guide: Learning from Data for Improvement.1st ed. Jossey-Bass, San Francisco, CA2011
- Pharmacokinetics of nasal fentanyl.J Pharm Pract Res. 2003; 33: 59-63
Published online: April 10, 2020
Accepted: March 18, 2020
Received in revised form: March 5, 2020
Received: October 7, 2019
© 2020 Elsevier Inc. All rights reserved.