Quality Story – Arkansas Children’s Hospital

This Quality Story was contributed by Abdallah Dalabih, MD, MBA; Paula Grigorian, MD; Dana Thomas, RN; Lauren Edwards, MD

Dr. Dalabih and his team sought to relieve the overloaded OR by taking on a “never done outside the OR” procedure to impact timeliness and efficiency.

Goals

1. Timeliness: Utilize sedation services to perform Congenital Lacrimal Duct Obstruction (CLDO) stenting to decrease the use of operating room and anesthesia services from 100% anesthesia to 40% within one year increasing patient access and decreasing waiting times.
2. Efficiency: Decrease cost of procedure for patients

Metrics

1. Sedations for CLDO stenting performed by sedation team to those performed by anesthesia
2. Cost savings between the teams.

Project Description

The Ophthalmology department approached the sedation team in December 2017 to assist in providing sedation for CLDO stenting procedures due to the high demand on operating rooms and the lack of reserved spots for short procedures.  CLDOs are usually unilateral and require inserting a probe through the lacrimal duct, then leaving a stent to maintain patency for a few weeks before it is removed.  Due to the need of entering the nasal cavity, the resulting blood and nasal secretions may be associated with increased risk of aspiration or laryngospasm. For this reason, historically these procedures had been primarily handled by our anesthesia team.

Interventions

We started with a pilot run to evaluate the possibility of performing CLDOs with the sedation team. The procedures were found to be associated with nasal secretions and mild bleeding, but were manageable by simple suctioning. After the pilot we implemented a process of referral.  All CLDO cases were referred to the sedation team first and the team would screen them for appropriateness for sedation by our team.

After performing sedation for this group of patients some providers voiced their concern with the amount of secretions and the possibility of higher rates of complication. We then adjusted the process by changing the style of the stent inserted to one that is less invasive.  Additionally, we adjusted the schedule of the sedation team to avoid placing some providers on days when those procedures are done.

Outcomes

In the first 12 months of implementation, the sedation team performed sedation for 24/28 (86%) of those procedures; higher than the goal set at the beginning of the project (60%).

We achieved an average savings of $2500 /unilateral case, and $4500/ bilateral cases. The only difference in charges was the operating room charges.

Challenges

1. Sedation provider discomfort with new procedure. Although as a team we elected to perform these procedures, we made a significant effort to work with those providers in finding coverage for those cases when they were sedating for that day. Our sedation team is large but accommodating two providers, and not scheduling them on those procedures’ days proved to be challenging.
2. Procedural equipment adjustments. The initial stent used by ophthalmology was invasive enough to produce large amounts of secretions and mild bleeding. After discussions with ophthalmology, they agreed to adjust their practice and start using a less invasive stent that requires less airway manipulation.

Lessons Learned

1. Sedation services are utilized in many areas of the hospital. This may bring unique challenges depending on the type of the procedure and the risk of sedation. But to be able to provide a service that is timely and efficient, continuous evaluation of the process should be the standard approach.
2. Decreasing health care costs could be achieved by changing our routine practices to be more adaptive and utilize capabilities that we already have.
3. Notice and respect the different comfort levels that providers have with sedation, and try to accommodate those individual variabilities as much as possible