Patient Awake While Scanned

Program to Reduce the Need for Anesthesia in Pediatric MRI

Camille Fraser, MS, CCLS; Sarah Beth Gray BS, CCLS; Jessika Boles, PhD, CCLS

Disclosures

Pediatr Nurs. 2019;45(6):283-288. 

In This Article

Abstract and Introduction

Abstract

The number of magnetic resonance imaging (MRI) scans used in pediatric health care is on the rise. Due to the developmental, coping, and physiological factors that make completing an MRI difficult for children, pediatric patients often require anesthesia to complete the scan successfully and produce clear images for diagnostic or evaluative purposes. Certified Child Life Specialists (CCLS) support patients throughout radiology procedures by providing developmentally appropriate preparation, procedural support, and an individualized coping plan. To ensure the availability of these supportive services for children undergoing MRI scans and minimize the use of anesthesia, the child life and radiology teams collaborated to create and implement the Patient Awake While Scanned (PAWS) program at Monroe Carell Jr. Children's Hospital at Vanderbilt. Through developmentally appropriate preparation and procedural support provided by a CCLS, 958 pediatric patients have participated in the PAWS program over the past 6 years, with a 96% rate of successful scan completion without sedation. As a result, this program has minimized health risks associated with anesthesia use in MRI and lowered the overall cost to families and the institution. Therefore, it is essential that health care providers consider the implementation of child life services through formalized programs such as PAWS to promote similar positive outcomes across pediatric settings.

Introduction

Rates of magnetic resonance imaging (MRI) use among pediatric populations are increasing; in fact, according to a recent study, the probability of a pediatric patient requiring an MRI as part of their treatment plan has increased by 84% over the course of 9 years (Tompane, Bush, Dansky, & Huang, 2013). A potential explanation for this increase is that an MRI is a safer option when compared to other imaging techniques, such as computed tomography (CT), X-ray, and fluoroscopy, because it does not use ionizing radiation (Cauldwell, 2011; Centers for Disease Control and Prevention, n.d.). Although an MRI may be considered a safer option in terms of radiation exposure, this type of scan is often challenging for pediatric patients to complete due to the longer duration of the scan, the need for the patient to remain motionless throughout the scan, the loud and sudden noises made by the machine, the tightly enclosed space in which the patient is positioned, and the potential need for an intravenous (IV) catheter for contrast use.

As a result of these many stressors, pediatric patients often require anesthesia to obtain clear images for diagnostic or evaluative purposes. Uffman and colleagues (2017) documented this positive correlation between the increase in pediatric MRIs and the use of anesthesia necessary during these scans, which is concerning given that anesthesia use is associated with adverse effects, including potential for oxygen desaturation and drug interactions (Barton, Nickerson, Higgins, & Williams, 2018). Evidence even suggests that anesthesia exposure could lead to long-term neurodevelopmental impacts (Barton et al., 2018). Further-more, when anesthesia is required for a child to complete an MRI, there are not only health concerns for the pediatric patient, but increased costs to the hospital and family, and longer appointment times (Cauldwell, 2011; Uffman et al., 2017; Vanderby, Babyn, Carter, Jewell, & McKeever, 2010). However, little has been done to explore cost-effective and developmentally appropriate programs to support children attempting to complete an MRI without sedation.

In pediatric health care, cost is an important driver in both health care administration and patient and family satisfaction with medical care (Institute for Healthcare Improvement, 2019). As the average cost of an outpatient MRI is steadily increasing, the inclusion of anesthesia raises prices even further. In 2011, the cost of an MRI with anesthesia was $902; three years later, the cost had risen to $1,116 (Uffman et al., 2017). A lengthened appointment time is also needed for an MRI with anesthesia. The mean appointment time for an MRI with anesthesia is 4 hours and 7 minutes compared to only 2 hours and 21 minutes for appointments without anesthesia. Anesthesia adds an average of 1 hour and 46 minutes to the length of the patient's appointment time (Vanderby et al., 2010). Shorter health care appointments lead to increased patient satisfaction (Holbrook et al., 2016); thus, the increase in time required to administer anesthesia could lead to decreased overall patient satisfaction.

If hospitals can reduce the need for anesthesia support for pediatric MRI, then health risks, patient appointment time lengths, and costs to the patient and institution will decrease. Inversely, patient and family satisfaction will increase. The support of a Certified Child Life Specialist (CCLS) lowers the need for anesthesia in pediatric MRI by providing developmentally appropriate preparation and the creation of a coping plan (Durand, Young, Nagy, Tekes, & Huisman, 2015). Similar results have been found in CT as well (Khan et al., 2007). CCLSs are professionals who provide support to patients during stressful health care experiences (Association of Child Life Professionals [ACLP], 2018). Through the lens of development and play, a CCLS teaches patients how to cope in a positive way with their medical journey. The American Academy of Pediatrics (AAP) (2014) attests to the important role child life specialists play in health care for pediatric patients and their families through developmentally appropriate, play-based interventions.

CCLSs working with radiology patients use a variety of techniques to promote positive coping and reduce stress and anxiety. A CCLS will often meet with a patient and family prior to the radiology procedure to provide developmentally appropriate preparation (Shenoy-Bhangle & Gee, 2016; Thacker, Collins, & Hill, 2016). Some child life programs incorporate a pre-appointment phone call to begin supporting the patient and family prior to the radiology appointment (Durand et al., 2015).

Psychological preparation is a technique that CCLSs use to reduce distress in children prior to a hospitalization, procedure, surgery, or other stressful event. Goals of preparation are to increase predictability by providing sensory and procedural information, allow for expression of feelings and identification of stressors, and facilitate opportunities to identify and rehearse coping strategies. Preparation helps patients become familiar with medical equipment and experiences, and decreases overall anxiety (Brewer, Gleditsch, Syblik, Tietjens, & Vacik, 2006). When preparatory information is shared with patients, their developmental level must be considered because it should influence both the language used and the time frame in which the preparation is provided (Jaaniste, Hayes, & Von Baeyer, 2007). Patients need the opportunity to learn about upcoming stressful procedures. According to a study in pediatric surgery, school-age and teenage patients said they wanted to know information about their upcoming procedure, especially relating to pain (Fortier et al., 2009). In addition to the reduction of anxiety and stress, preparation from a CCLS can also lead to increased parental satisfaction scores (Gursky, Kestler, & Lewis, 2010).

Each procedural preparation is unique to the needs of the patient and family. The CCLS considers the patient's cognitive level, previous medical experiences, and family variables when deciding what type of preparation experience will best suit the patient's needs (McGee, 2003). CCLSs receive extensive training in child development and understand how medical experiences impact children of all ages. The language used during preparation and procedural support is adapted to meet the developmental needs and potential concerns of each individual child based on their cognitive level. Preparation with a CCLS prior to an MRI may include rehearsing the procedure, showing pictures of the scanner, and playing scanner noises (Cejda et al., 2012). CCLSs sometimes use an approach called medical play to help familiarize patients with medical equipment used in their care (Moore, Bennett, Dietrich, & Wells, 2015). The CCLS uses both medical toys and real medical equipment to allow for exploration. Children may want to rehearse their upcoming procedure, process previous medical experiences, or simply ask questions about the role of specific pieces of equipment (Burns-Nader & Hernandez-Reif, 2016). Some institutions may also have patients practice the MRI scan prior to the actual appointment. Mock MRI scanners can be used to further support patients in gaining exposure to the medical equipment prior to a patient's radiology appointment (de Bie et al., 2010; Hallowell, Stewart, de Amorim e Silvia, & Ditchfield, 2008).

In addition to developmentally appropriate preparation, the CCLS may work with the family to create a coping plan for the procedure. This plan may involve the use of an alternate focus to divert the patient's attention from the procedure and minimize stress. Examples of this form of support are guided imagery, movie goggles, listening to audio-books, color projectors, and pinwheels. (Durand et al., 2015). CCLSs also help support the patient's care-givers throughout the radiology experience. A CCLS can provide the child's caregiver with language to use when answering their child's questions about the procedure and make suggestions of ways to help support the child throughout the procedure. CCLSs empower caregivers to participate in procedures by providing them with supporting roles, including comfort positioning, calming touch, and encouraging language. These skills learned by caregivers can be used during future medical procedures the child experiences (McGee, 2003). When a family works with a CCLS, parents and caregivers are more satisfied and report a decrease in their child's distress. Children report an improved experience and decrease in fear associated with the procedure. Benefits of child life involvement are extended to medical team members as well. Radiology staff also cite positive outcomes when a CCLS works with a family (Tyson, Bohl, & Blickman, 2014).

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