Implementation of a Policy to Improve the Safety of Procedural Sedation: A Barrier and Facilitator Assessment

Authors: L Sanderson K, Spithoff K, Collerman A, and Schwalm JD

Presenters: Karen Spithoff and Kate Sanderson

Institution: McMaster University 


Many diagnostic and therapeutic procedures require the administration of sedation to induce decreased level of consciousness and minimize patients’ pain and anxiety. Procedural sedation is associated with risk of serious complications, including allergic reactions, over-sedation, and cardiorespiratory complications. A local hospital network developed a policy outlining best practices for caring for adult patients undergoing procedural sedation to optimize patient safety, including standards related to equipment and supplies; clinician competencies, roles, and accountabilities; patient screening criteria; documentation standards; and patient discharge criteria. An assessment was conducted to identify barriers and facilitators to policy implementation and determine current practices related to procedural sedation. 



Clinical units to which the policy applied were requested to complete a clinical environment risk assessment (CERA) form to determine baseline compliance with components of the procedural sedation policy and to identify mitigation strategies where there were gaps between current practice and policy requirements. Semi-structured focus groups were conducted with clinical leaders and frontline staff from selected representative clinical units to discuss the CERA form results and identify barriers and facilitators to policy implementation. Focus group questions were based on policy content and selected constructs of the Consolidated Framework for Implementation Research (CFIR). Focus groups were audio-recorded and results were summarized by the focus group facilitator and reviewed by clinical unit leadership. 



Completion of the CERA forms identified areas for improvement in patient screening, clarification of clinician roles during procedural sedation, and communication between the procedural physician and non-physician monitors before, during, and after the procedure. Focus groups were held with the following units: endoscopy, interventional radiology, medical diagnostic unit, surgical centre, intensive care, and cardiac intensive care. Although common barriers and facilitators to policy implementation were identified across units, other barriers and facilitators were unique to particular units due to type of procedures provided, staffing, unit culture, or physical environment. Common barriers included design, quality and packaging of the intervention; and available resources. Leadership engagement was a barrier in several units and a facilitator in others. Common facilitators included readiness for implementation; beliefs that implementing the policy would reduce patient risk; and relative priority of implementing the policy.



Results of the current practice assessment (i.e., CERA forms) and the barrier and facilitator assessment are being used by the implementation leadership team to tailor implementation strategies to each clinical unit (e.g., simulation-based training initiatives) and to improve tools and resources for policy implementation. Results will also be used as a baseline with which to compare post-implementation practices.


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