QI Spotlight: Scheduling Anesthesia vs. Nurse Sedation

In our open-access endoscopy unit, we have limited anesthesia staff/slots available for GI procedures. There is not clear, research-driven guidance for which patients should be scheduled with anesthesia (propofol) vs. nurse sedation.  

Before this project, we frequently needed to change patients’ anesthesia plan after meeting them, leading to procedure delays and decreased patient and staff satisfaction.  

The mission of our quality improvement project was to create criteria to help decide whether a patient should be scheduled with anesthesia vs. nurse sedation for endoscopy procedures. The goal was to decrease the number of day-of anesthesia add-ons to improve efficiency of unit flow, while providing adequate, safe and appropriate sedation for our patients. 

Changes in anesthesia plan were identified by chart review. During the baseline period of May-November 2019, 59 patients were converted from nurse to anesthesia sedation.

We did not set a target number of converted procedures. 

We collected process data from team meetings. Procedure nurses report add-ons or cases that are aborted related to need for anesthesia sedation. We discuss these at quarterly meetings to monitor and evaluate need for changes. We also conducted discussions with physicians to record their perspectives. 

We took a PDSA approach to this project. 

The sedation plan decision seems to vary by GI physician. Some physicians were noted to be more proactive about documenting recommendations for future sedation after a procedure, and this was identified as important in directing appropriate scheduling.  

From reviewing the cases with changes in sedation plan, from team meetings, and from physician discussions, we developed a list of common reasons that procedures had a change in anesthesia plan. 

A multidisciplinary team created a list of criteria for our consult nurses to use when scheduling anesthesia for our endoscopy procedures. We formulated our criteria based on overarching themes identified from the chart review/research, add-on reporting and physician experience. 

We have quarterly group meetings to seek continued process improvement. 

Unfortunately, it would be difficult to compare repeat measures of performance with our pre-intervention experience, as our intervention happened during the COVID pandemic. This resulted in decreased procedure numbers and increased acuity of procedures. The issue of anesthesia add-ons causing delays does seem to have decreased using the new scheduling criteria. 

The primary goal of this project was achieved, in that we now have criteria to guide our consult nurses when scheduling anesthesia for endoscopy procedures. 

We identified the importance of charting future recommendations within procedure reports. 

This process change is financially beneficial as it decreases the risk of having to repeat procedures. 

We believe that the change will improve patient satisfaction as well, as there will be fewer delays in procedures. However, we are not measuring this. 

The findings and plan have been relayed to all parties involved throughout this project in the form of meeting minutes, updates and requests for feedback. 

The improvements are sustainable and can continue to be built upon, altered and shared as needed.