Would Changes to the 4 Hour Target Benefit Paediatric Procedural Sedation? A Service Review

Aims: As Paediatric Emergency Departments (PED) become busier the number of children requiring painful procedures continues to increase. We aimed to evaluate a locally developed paediatric procedural sedations (PPS) service using ketamine for safety, efficiency and efficacy in the context of the national 4 hour operational target which is due to be revised this year in the UK.

Methods: We enrolled consecutive patients over 12 months suitable for PPS ketamine and collected data for demographics, time to patient identification, time to ketamine administration, procedural duration and time to recovery. We also documented procedure outcome, adverse events, consent, ketamine dosage and baseline physiological observations.

Results: From May 2017 to May 2018 ketamine PPS was performed on 36 patients with a mean age of 7 years (range 1.8 to 14.6 years). The most common procedure performed was manipulation of forearm fractures (n=21, 58%), followed by facial laceration repair (n=10, 28%). Total intravenous Ketamine dosages were; 1mg/kg (n=23, 64%) 1.5mg/kg (n=10, 28%) and 2mg/kg (n=3, 8%). Average time to referral to surgical speciality was 33 minutes which improved from 40 minutes (pre Sept) to 27 minutes (post Sept). Average time to ketamine administration was 168 minutes, improved from 185 minutes (pre Sept) to 155 minutes (post Sept). The average time taken to complete procedures, all under 20 minutes, also decreased from 19 minutes (pre Sept) to 10 minutes (post Sept) averaging 15 minutes overall. The recovery time was similar throughout the study period. The overall average length of stay (LOS) was 284 minutes, improved from 297 minutes (pre Sept) to 274 minutes (post Sept) figure 3. 20 (55%) of the 36 patients breached the 4 hour target. 10 (28%) patients were admitted, 9 for further neurovascular observations and only 1 where the outcome of a procedure was unsatisfactory. There were no seminal untoward incidents in our study. Vomiting occurred in 4, there was 1 drug error and one patient required brief airway manoeuvres for decreased oxygen saturations.

Conclusion: We have confirmed PPS ketamine service to be safe and further demonstrated good outcomes in procedures carried out. Despite improved efficiency in the study period the average LOS still falls outside the 4 hour target and a revision would be welcomed to reduce anxiety related to breaches in this group and encourage more uptake of PPS ketamine nationally.

Keywords: paediatric emergency med, quality improvement, emergency care systems, efficiency.