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Zucker EJ, Wintch S, Chang Y, Commerford L, Diaz RB, Redfern TH, Wang TN, Lam L, Frush DP, Larson DB. Increasing the Utilization of Moderate Sedation Services for Pediatric Imaging. Radiographics 2021; 41:2127-2135. [PMID: 34723694 DOI: 10.1148/rg.2021210061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Performing motion-free imaging is frequently challenging in children. To bridge the gap between examinations performed in children who are awake and in those under general anesthesia, a moderate sedation program was implemented at our institution but was seldom used despite substantial eligibility. In conjunction with a 5-month quality improvement (QI) course, a multidisciplinary team was assembled and, by using an A3 approach, sought to address the most important key drivers of low utilization, namely the need for clear moderate sedation eligibility criteria, reliable protocol routing order, consistent moderate sedation screening performed by registered nurses (RNs), and enhanced visibility of moderate sedation services to ordering providers. Initial steps focused on developing better-defined criteria and protocoling standard work for technologists and RNs, with coaching and audits. Modality-specific forecasting was then implemented to reroute profiles of patients who were awaiting scheduling or already scheduled for an examination with general anesthesia to the moderate sedation queue to identify more eligible patients. These manual efforts were coupled with higher reliability but more protracted electronic health record changes, facilitating automated protocol routing on the basis of moderate sedation eligibility and order entry constraints. As a result, scheduled imaging examinations requiring moderate sedation increased from a mean of 1.2 examinations per week to a sustained 6.1 examinations per week (range, 4-8) over the 5-month period, exceeding the team SMART (specific, measurable, achievable, relevant, and time bound) goal to achieve an average of five examinations per week by the QI course end. By targeting the most high-impact yet modifiable process deficiencies through a multifaceted team approach and initially investing in manual efforts to gain cultural buy-in while awaiting higher-reliability interventions, the project achieved success and may serve as a more general model for workflow change when there is organizational resistance. ©RSNA, 2021.
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Affiliation(s)
- Evan J Zucker
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Stephanie Wintch
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Young Chang
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Lindsey Commerford
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Rizza-Belen Diaz
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Trista H Redfern
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Tammy N Wang
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Linda Lam
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - Donald P Frush
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
| | - David B Larson
- From the Department of Radiology, Stanford University School of Medicine, 725 Welch Rd, Palo Alto, CA 94304 (E.J.Z., Y.C., L.C., R.B.D., T.H.R., D.P.F., D.B.L.); and Sedation Program (S.W.), Department of Anesthesia (T.N.W.), and Department of Performance Improvement (L.L.), Stanford Children's Health, Stanford, Calif
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Le May S, Genest C, Hung N, Francoeur M, Guingo E, Paquette J, Fortin O, Guay S. The Effect of Virtual Reality Game Preparation for Children scheduled for MRI (IMAGINE): a Randomized Controlled Trial Protocol (Preprint). JMIR Res Protoc 2021; 11:e30616. [PMID: 35700000 PMCID: PMC9237773 DOI: 10.2196/30616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 03/06/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background It is known that magnetic resonance imaging (MRI) procedures generate fear and anxiety. Children may become restless during scanning, which results in movement artifacts requiring the MRI procedure to be repeated with sedation. Few studies seem to have looked at the effect of immersive virtual reality (IVR) on anxiety in children scheduled for MRI scans and how to identify which children are more responsive. Objective The aims of this study are 3-fold: develop an algorithm of predictability based on biofeedback, address feasibility and acceptability of preprocedural IVR game preparation for anxiety management during MRI procedures, and examine the efficacy of IVR game preparation compared with usual care for the management of procedural anxiety during MRI scans. Methods This study will have 2 phases. We will first conduct a field test with 10 participants aged 7 to 17 years to develop a predictive algorithm for biofeedback solution and to address the feasibility and acceptability of the research. After the field test, a randomized controlled trial will be completed using a parallel design with 2 groups: an experimental group (preprocedural IVR game preparation) and a usual care group (standard care as per the radiology department’s protocol) in an equal ratio of 49 participants per group for 98 participants. Recruitment will be carried out at a hospital in Quebec, Canada. The experimental group will receive a preprocedural IVR game preparation (IMAGINE) that offers an immersive simulation of the MRI scan. Participants will complete a questionnaire to assess the acceptability, feasibility, and incidence of side effects related to the intervention and the biofeedback device. Data collected will include sociodemographic and clinical characteristics as well as measures of procedure-related anxiety with the French-Canadian version of the State-Trait Anxiety Inventory for Children (score 1-3) and the Children’s Fear Scale (score 0-4). Physiological signs will be noted and include heart rate, skin conductance, hand temperature, and muscle tension. Measures of the level of satisfaction of health care professionals, parents, and participants will also be collected. Analyses will be carried out according to the intention-to-treat principle, with a Cronbach α significance level of .05. Results As of May 10, 2022, no participant was enrolled in the clinical trial. The data collection time frame is projected to be between April 1, 2022, and March 31, 2023. Findings will be disseminated through peer-reviewed publications. Conclusions Our study provides an alternative method for anxiety management to better prepare patients for an awake MRI procedure. The biofeedback will help predict which children are more responsive to this type of intervention. This study will guide future medical practice by providing evidence-based knowledge on a nonpharmacological therapeutic modality for anxiety management in children scheduled for an MRI scan. Trial Registration ClinicalTrials.gov NCT04988516; https://clinicaltrials.gov/ct2/show/NCT04988516 International Registered Report Identifier (IRRID) PRR1-10.2196/30616
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Affiliation(s)
- Sylvie Le May
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Faculty of Nursing, Université de Montréal, Montreal, QC, Canada
| | - Christine Genest
- Faculty of Nursing, Université de Montréal, Montreal, QC, Canada
- Trauma Studies Centre, Institut Universitaire en Santé Mentale de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Est-de-l'Île de Montréal, Montreal, QC, Canada
| | - Nicole Hung
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Maxime Francoeur
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Estelle Guingo
- Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, QC, Canada
| | - Julie Paquette
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Olivier Fortin
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Stéphane Guay
- Trauma Studies Centre, Institut Universitaire en Santé Mentale de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Est-de-l'Île de Montréal, Montreal, QC, Canada
- School of Criminology, Université de Montréal, Montreal, QC, Canada
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Oztek MA, Brunnquell CL, Hoff MN, Boulter DJ, Mossa-Basha M, Beauchamp LH, Haynor DL, Nguyen XV. Practical Considerations for Radiologists in Implementing a Patient-friendly MRI Experience. Top Magn Reson Imaging 2021; 29:181-186. [PMID: 32511199 DOI: 10.1097/rmr.0000000000000247] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
For many patients, numerous unpleasant features of the magnetic resonance imaging (MRI) experience such as scan duration, auditory noise, spatial confinement, and motion restrictions can lead to premature termination or low diagnostic quality of imaging studies. This article discusses practical, patient-oriented considerations that are helpful for radiologists contemplating ways to improve the MRI experience for patients. Patient friendly scanner properties are discussed, with an emphasis on literature findings of effectiveness in mitigating patient claustrophobia, other anxiety, or motion and on reducing scan incompletion rates or need for sedation. As shorter scanning protocols designed to answer specific diagnostic questions may be more practical and tolerable to the patient than a full-length standard-of-care examination, a few select protocol adjustments potentially useful for specific clinical settings are discussed. In addition, adjunctive devices such as audiovisual or other sensory aides that can be useful distractive approaches to reduce patient discomfort are considered. These modifications to the MRI scanning process not only allow for a more pleasant experience for patients, but they may also increase patient compliance and decrease patient movement to allow more efficient acquisition of diagnostic-quality images.
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Affiliation(s)
- Murat Alp Oztek
- Department of Radiology, University of Washington School of Medicine, Seattle, WA.,Department of Radiology, Seattle Children's Hospital, Seattle, WA
| | | | - Michael N Hoff
- Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Daniel J Boulter
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Luke H Beauchamp
- Michigan State University College of Human Medicine, East Lansing, MI
| | - David L Haynor
- Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Xuan V Nguyen
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH
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Bermo MS, Patterson D, Sharar SR, Hoffman H, Lewis DH. Virtual Reality to Relieve Pain in Burn Patients Undergoing Imaging and Treatment. Top Magn Reson Imaging 2020; 29:203-208. [PMID: 32511197 DOI: 10.1097/rmr.0000000000000248] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Pain from burn injuries is among the most excruciating encountered in clinical practice. Pharmacological methods often fail to achieve acceptable level of analgesia in these patients, especially during burn wound dressing and debridement. Virtual reality (VR) distraction is a promising analgesic technique that progressed significantly in the last decade with development of commercially available, low-cost, high-resolution, wide field-of-view, standalone VR devices that can be used in many clinical scenarios. VR has demonstrated clinical benefit as an adjunctive analgesic during burn wound dressing and other painful medical procedures. The technique has proven useful also in preparing patients for magnetic resonance imaging scans, particularly in claustrophobic patients. Modulation of pain-related brain activity at cortical and subcortical levels by VR, and its correlation with subjective improvement in various laboratory and clinical pain experiences has been demonstrated using multiple functional brain imaging studies including functional magnetic resonance imaging and brain perfusion single photon emission computed tomography.
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Affiliation(s)
- Mohammed S Bermo
- Texas Tech University Health Science Center at El Paso, El Paso, TX
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Nguyen XV, Tahir S, Bresnahan BW, Andre JB, Lang EV, Mossa-Basha M, Mayr NA, Bourekas EC. Prevalence and Financial Impact of Claustrophobia, Anxiety, Patient Motion, and Other Patient Events in Magnetic Resonance Imaging. Top Magn Reson Imaging 2020; 29:125-130. [PMID: 32568974 DOI: 10.1097/rmr.0000000000000243] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Claustrophobia, other anxiety reactions, excessive motion, and other unanticipated patient events in magnetic resonance imaging (MRI) not only delay or preclude diagnostic-quality imaging but can also negatively affect the patient experience. In addition, by impeding MRI workflow, they may affect the finances of an imaging practice. This review article offers an overview of the various types of patient-related unanticipated events that occur in MRI, along with estimates of their frequency of occurrence as documented in the available literature. In addition, the financial implications of these events are discussed from a microeconomic perspective, primarily from the point of view of a radiology practice or hospital, although associated limitations and other economic viewpoints are also included. Efforts to minimize these unanticipated patient events can potentially improve not only patient satisfaction and comfort but also an imaging practice's operational efficiency and diagnostic capabilities.
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Affiliation(s)
- Xuan V Nguyen
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Brian W Bresnahan
- Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Jalal B Andre
- Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | | | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle, WA
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA
| | - Eric C Bourekas
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH
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