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


Pediatr Nurs. 2019;45(6):283-288. 

In This Article

The Patient Awake While Scanned (PAWS) Program

At Monroe Carell Jr. Children's Hospital at Vanderbilt, a program to help patients complete their MRIs without the need for anesthesia is flourishing under the leadership of the radiology CCLS. In 2012, the radiology CCLS and the radiology manager noticed the high rate of anesthesia among their MRI patients and decided to create the Patient Awake While Scanned (PAWS) program to minimize the need for anesthesia.

The first step in the creation process included extensive benchmarking by the radiology CCLS to identify methods that would best support patients and families cared for at the Children's Hospital at Vanderbilt. Benchmarking targeted children's hospitals that were currently facilitating a non-sedate MRI program. Various members of the interprofessional care team were involved in the creation of the PAWS program to ensure the program met the needs of the hospital patient population and benefitted staff working with MRI patients. A taskforce, led by the radiology CCLS and composed of radiology and MRI management, MRI technologists, radiologists, radiology schedulers, radiology nurses, and anesthesia personnel met over the course of 3 months to design the program protocol. The protocol outlined procedures, such as recruitment, appointment scheduling, pre-appointment events, appointment day sequence of events, and staffing. Before official implementation, the program was trialed two Sundays a month over the course of 8 months. Twenty patients participated in the trial with a 100% success rate. These results were presented to medical center administrators by radiology and child life managers to advocate for implementation of the program. Upon approval to implement, the program was officially named. The acronym PAWS was chosen because it is a direct link to the Children's Hospital at Vanderbilt's mascot, a hound dog named Champ. To prepare for implementation, the radiology CCLS and MRI manager provided education regarding program goals, potential coping techniques, and referral procedures to Vanderbilt specialty clinic staff to enhance program referrals. Program education was also provided to staff working with MRI patients.

Any patient age 3 years or older is eligible to be referred to the PAWS program. This includes patients who have been diagnosed with autism, developmental delays, attention deficit hyperactivity disorder (ADHD), and anxiety, further challenging their ability to complete their MRI awake. Although program referrals typically come from the ordering Vanderbilt specialty clinic staff, referrals can be made from anyone, including family members, CCLSs, nurses, and MRI technologists. Although most referrals are received through the electronic medical record (EMR), verbal referrals are also accepted. Within the EMR, a provider can indicate a referral to the PAWS program by clicking a check box in the MRI requisition. When the referral is completed through the EMR, the PAWS CCLS on staff receives information, including the patient's name and age, along with the name of the referring provider and type of MRI scan requested.

Following a referral, a PAWS program CCLS conducts a phone assessment with the patient's caregiver. The call is conversational, involving information sharing between the caregiver and CCLS. The goals of the call include introducing the PAWS program, providing information regarding the upcoming medical event, learning patient and family needs, and developing a coping plan (see Figure 1).

Figure 1.

PAWS Program Process Illustration

To gain an accurate assessment, the CCLS addresses variables known to impact a child's coping in the medical environment. Some known variables include the child's developmental level, previous medical experiences, coping style, and temperament (Child Life Council, 2011; Turner & Fralic, 2009). Assessment information is documented within a program assessment form, an Outlook calendar appointment, and the patient's EMR. The CCLS also communicates information learned with appropriate medical staff that will be involved with the patient's care.

If the CCLS and the patient's caregiver decide not to continue with the PAWS program, the physician is contacted, and options are discussed. These options include anesthesia, an awake scan without the PAWS program, or a cancellation. If the patient continues in the PAWS program, the MRI is scheduled during the assessment phone call. Designated MRI appointment times are held for the PAWS program, and the PAWS CCLS maintains program appointment availability. This practice allows for a continued focus on patient and family-centered care by including the family in selecting the appointment date and time that best fits their schedule. If the designated PAWS appointments are not options for the family due to urgency of scan or family schedule, additional choices are discussed. These include the patient completing the MRI with anesthesia or awake but without the PAWS program. On average, the PAWS program offers 22 appointments each month. Following the assessment phone call and approximately 2 weeks before the MRI, PAWS CCLS staff send the caregiver an email with appointment reminders, pictures of the MRI camera, and tips for preparing their child for the MRI.

On the day of the MRI, the patient and family arrive 30 minutes prior to their scheduled appointment. Upon arrival, a PAWS program CCLS meets with the patient and family to provide individualized preparation and support dependent on the patient's developmental level, previous medical experiences, and potential concerns discussed in the assessment phone call. The PAWS program CCLS engages the patient and family in preparation, which is focused on the procedural sequence of events and the patient's sensory needs. Preparation could include seeing pictures of the MRI machine, exploring the medical equipment (head phones and movie goggles) and supplies (e.g., IV catheter, tourniquet, and cleaning sponge) that will be used in their care, and hearing the MRI scanner noises. A coping plan is discussed and created with input from the patient, family, and involved staff. Coping plans could include a caregiver in the MRI room, movie goggles, listening to music, holding a stress ball, and using the patient's comfort item.

When it is time for the patient's MRI, the PAWS CCLS and MRI technologist walk the patient into the imaging suite and help the patient transition onto the bed. If needed, the patient receives coaching, explanation, and support from the CCLS, MRI technologist, and caregiver during the MRI to promote coping and completion of the scan. Following a completed MRI, the patient receives program participation items that include a Ben and Jerry's ice cream gift card and a program graduation diploma. If the child is unable to complete the full scan but diagnostic images are obtained, the images are sent to the referring provider for review. In the rare instance that no diagnostic images are obtained, the attempt is not charged to the family and the family is encouraged to follow up with the referring provider to discuss next steps. Next steps could include an MRI with anesthesia or cancellation. The PAWS program process illustration can be seen in Figure 1.

To date, 958 patients have participated in the PAWS program, with a completion rate of 96%. This program has become integrated into the radiology department at Monroe Carell Jr. Children's Hospital at Vanderbilt. The PAWS program has reduced medical risks associated with anesthesia and lowered cost to both families and the institution. Perhaps one of the greatest cost savings has been the decrease in essential medical personnel required during a PAWS MRI. For an MRI with anesthesia at the Children's Hospital at Vanderbilt, an anesthesiologist, certified registered nurse anesthetist, registered nurse, anesthesia technologist, and MRI technologist are necessary members of the patient's treatment team. When compared to the minimal personnel needed for a PAWS MRI, a CCLS and an MRI technologist, there is a cost savings of $241.82 an hour in salaries alone. Table 1 outlines the cost of essential medical personnel required to support an MRI with anesthesia and an MRI without anesthesia through the PAWS program.