Objectives:
Evaluate a QI project to improve preparation and the use of premedication in pediatric patients before anesthesia.

Background: 
The Anesthetic Department undertook a QI project during 2017 to address the management of preoperative anxiety and sedative premedication among children.  The collected data revealed only 10% received sedative premedication and 30% showed moderate to severe anxiety during induction. The findings indicated room for improvement.

Methods:
From April to September 2017, awareness regarding the use of sedative premedication was raised through in-service lectures to staff in the Anesthetic Department and perioperative Nursing. A Sedative Pre-Medication Guideline was drafted and disseminated. Plan, Do, Study & Act (PDSA) technique was used to identify and overcome obstacles. 

Results:
Data were collected from 137 patients coming through Day Surgery Unit (DSU). The patients were divided into groups by age (Group I = 6 months to 6 years; Group II = 7 to 14 years).  
There were 79 patients in Group I and 58 patients in Group II. 40% of patients (n=55) received sedative premedication of which 69% were in Group I (n=38) and 31% in Group II (n=17).
53% (n=57) received EMLA cream in acceptable time before intravenous cannula insertion.
Moderate to severe anxiety was exhibited at induction of anesthesia by 33% of patients (n=45) as per VAS scale and 45% (n=62) as per the ICC assessment tool. In this subgroup 27% (n=17) received sedative premedication. On closer subgroup analysis we found that all 17 patients either received too low a dose in relation to weight or inadequate timing of premedication in relation to induction of anesthesia.

Conclusion:
We work in a multi-cultural hospital where only 40% of health care staff speak Arabic with a patient population that is almost exclusively Arabic speaking. This implies that sedative premedication is an important tool to deliver safe, efficient and high-quality care.  A small investment in multiprofessional awareness was noted to have improved anxiety management by increasing sedative premedication to pediatric patients. 
In the next step, we will focus on implementing non-pharmacological methods such as  pre-operative information package to both children and relatives before anesthesia. In addition, we are trying to change the operating room sign-in process to facilitate a more silent and calm atmosphere for children unlike the current situation.


10 / Perioperative Quality Improvement (QI) Project for Pediatric patients aged 6 months to 14 years, with Emphasis on Anxiety and Premedication in a Tertiary level Hospital.