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What is the Impact of the Implementation of an Evidence Based Procedural Sedation Protocol in the Emergency Department?

Nisreen Maghraby, Eleena Pearson, Xiaoqing Xue, Antoinette Colacone and Marc Afilalo

Background: Procedural sedation and analgesia (PSA) enables emergency physicians to provide pain and anxiety relief for many procedures. However, PSA introduces an independent risk factor and requires continuous monitoring. Recently, we applied the principles of knowledge translation (KT) to develop and implement a PSA protocol in our ED.

Objectives: To evaluate the impact of a PSA protocol developed and implemented using KT principles on changes in ED physician practices with respect to length of monitoring time in resuscitation area, complication rate, medication types and doses.

Methods:

Design: Pre- Post retrospective chart review.

Setting: Adult tertiary-care academic centre.

Participants: Patients who underwent PSA in the ED as per physician billing code from September 2008 to August 2010. The Pre protocol implementation was from Sept 2008 to Aug 2009 and the Post was from Sept 2009 to Aug 2010. One of the authors (NM) reviewed all charts and recorded patient information such as sociodemographics, past medical history, allergies, monitoring time, complications, medication and doses. Pre and post periods information was compared using two-sample T-test and Chi-square test as appropriate.

Results: There were 318 billing codes for PSA from September 2008 to August 2010 of which the 150 occurred during the Pre protocol period and 134 during the Post protocol implementation period. Excluded were 34 patients due to lack of documentation. There were no statistical differences in Pre vs. Post for baseline characteristics (mean age+standard deviation (52+20 vs. 53+22 years), male gender (54% vs. 53%), with a past medical history (36% vs. 47%) and allergies (16% vs. 15.7%)). As well no differences in outcomes with respect to complication rate (7.4% vs. 9.9%) and medication types (70% vs. 65% Ketafol, 23% vs. 23% propofol) and doses used. However, monitoring time in minutes recorded from time of first medication given until patient was moved out of resuscitation area was significantly reduced during the Post period (Pre period: mean 49 (95% CI: 42-56) versus Post period: mean 19 (95% CI: 17-21).

Conclusion: The implementation of the PSA protocol using KT principles resulted in a significant and important decrease in monitoring time required for PSA thus liberating important resources in busy EDs.