7 years of analgesia & sedation in pre-hospital care: how safe are we? A clinical audit summary.
Background:
Analgesia and sedation are key elements of the care delivered by HEMS teams across the country. Adequate analgesia is important on humanitarian grounds, facilitates fracture reduction and may reduce blood loss. In circumstances such as entrapment, the use of analgesia and sedation may facilitate extrication and reduce time to definitive care.1
Aim
Primary Objective: Compliance of monitoring during procedural sedation with current guidelines (ECG, NIBP, SO2, ETCO2)
Secondary Objective: Note any complications of sedation (Hypotension, Hypoxia, Bradycardia, CPR/ALS, Airway compromise, unplanned intubation)
Methods
Retrospective database review using HEMSBASE of all procedural sedation using Ketamine and/or Midazolam from 01/01/2016 till 31/12/2016.
Patients receiving these drugs as part of an RSI drug regimen, maintenance of anaesthesia or seizures were excluded.
Results
Total patients which met inclusion criteria: 141. The most common indications for sedation were fracture reduction (33%) and agitation (17%). 90% of patients had full observations recorded and this is a marked improvement from previous audit cycle (2009-2013: 27.8%, 2013-2015 56%). 51 patients (36%) had one or more complications following sedation, most commonly hypotension and hypoxia.
Conclusion
There has been a marked improvement in monitoring patients undergoing procedural sedation from previous audit cycles. The interventions which have led to this improvement include sedation sticker, KPI stickers/sedation checklist and the addition of ‘Sedation treatment modality’ onto HEMSBASE. To improve this further, a flagging system could be incorporated into HEMSBASE to alert clinicians to incomplete or abnormal observations.
Finally, a number of clinicians felt it would be valuable to conduct a patient survey assessing the quality & depth of sedation being administered to patients. This avenue is currently being explored however, it poses challenges- namely around confidentiality & use of patient data.
Limitations
Majority of Patients are critically ill and it is often difficult to ascertain whether complications were due to sedation or whether they are due to the clinical course of the patient. Recording times for sedations would be very useful in differentiating these.
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