Survey of Sedation in HospItal (SuSHI)

Introduction

• The number of UK hospital patients receiving procedural sedation is unknown.

• Central to contemporary medicine and in hospital practice. • New drugs, increasing complexity of procedures performed

and sicker patients • Few reports describe adverse events following sedation,

those that do focus on a single procedure such as gastrointestinal endoscopy1,2, or on adverse events relating to a single drug.3

Aims

• Prospective sprint survey for a 48 hour midweek period

• Characterise local practice: clinical areas, patient groups, procedures, personnel and sedation techniques

• Identify hotspots where application of current and improved standards could reduce patient risk

• Establish methodology and provide pilot data to aid the future development of a formal national audit

Method

• Pharmacy, clinicians and nursing staff consulted to identify clinical areas

• 16 SWARM anaesthetic trainees assisted by 54 PMS students

• Allocated a small number of clinical areas to monitor throughout the day

• No clinical outcomes measured

Results

• 360 patients received procedural sedation

• Large number of data collectors ensured an excellent capture rate

• Survey well received and sedationists freely participated

• Out of hours staff reported no sedation given overnight

Breakdown of numbers in the region

0

50

100

25

91

62 65 51

66

Total number episodes of sedation = 360

First the RCH data….

Time No. Urgency No. Personnel No.

0800-1300 33 Planned 58 Consultant 64

1300-1800 29 Urgent 8 Staff Grade 2

1800-2300 4 Emergency 0

2300-0800 0

RCH drugs

• 63 Midazolam (median dose 2mg)

• 30 of these co-administered with Fentanyl (median dose 50mg)

• 5 Propofol TCI (all anaesthetists)

• 4 Pethidine (all with Midazolam)

• 4 Ketamine (all anaesthetists)

• 1 Diazepam (cardiology)

RCH sedation location

• 2 cath lab

• 18 theatre

• 4 radiology

• 40 endoscopy

• 2 respiratory out-patients

Now the results of the whole region…..

Patient demographics

0

10

20

30

40

50

60

70

80

90

100

Nu

mb

er

of

pat

ien

ts

Age (years)

Age of patients receiving sedation

0

5

10

15

20

25

30

35

40

45

50

Nu

mb

er

of

pat

ien

ts

Weight of patients

Weight of patients receiving sedation

Who is giving sedation?

Specialty n

Anaesthetist 107

Cardiologist 28

Medical endoscopists

(including radiology) 97

Surgical endoscopists 106

Emergency medicine 4

Gynaecology/fertility 7

ICU/cardiac ICU 4

Interventional radiologist 2

other 5

Grade n

Consultant 298

Staff doctor 28

Nurse specialist 20

ST3-7 14

CT1-2 0

Fy1-2 0

Where is sedation being given?

Distribution and percentage of patients

0

10

20

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80

90

100

Site 1 Site 2 Site 3 Site 4 Site 5 Site 6

% o

f p

atie

nts

wh

o r

ece

ive

d t

he

dru

g

Propofol

Midazolam

Fentanyl

Diazepam

Ketamine

Pethidine

Morphine

Alfentanil

Remifentanil

Results

• 19 received IV Diazepam 5(2.5-10) mg, median(range), all given by cardiologists

• Propofol used 82 times by anaesthetists and 6 times by

others (3 ICU consultants, 1 cardiology consultant, 1 other consultant, 1 ED trainee (who gave 350 mg) )

• Midazolam was the commonest sedative used at all sites • Fentanyl most prevalent analgesic apart from one site

where endoscopists favoured a combination of Pethidine and Midazolam

Discussion • Extrapolation that 9270 patients across the NHS

undergo procedural sedation per day

• Current practice seems to be relatively consistent and mainly performed in hours, with senior clinicians.

• Successful deployment of networked anaesthetic registrars and medical students

• Demonstrates that sedation practice can be audited in acute trusts

Conclusion

• Developed and tested methodology that could be used to estimate sedation across the NHS and provide the denominator for future studies

• National Audit Project to collect indexed serious adverse events due to sedation?

• Repeat study examining adherence to national guidance?

References

1. Sedation for upper gastrointestinal endoscopy: results of a national survey. Gut Jan 2001

2. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing and sedation methods. GuT March 1995

3. Reducing the risk of midazolam injection in adults, NPSA/2008/RRR011).

Thank you.

Questions?