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Sedation Procedures in MR Imaging: Safety, Effectiveness, and Nursing Effect on Examinations¹

¹ From the Department of Radiology, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287. Received July 8, 1999; revision requested August 25; final revision received January 7, 2000; accepted January 12. Address correspondence to D.A.B.

View larger version (30K): [in a new window]   Figure 1. List of MR sedation database variables. BUN = blood urea nitrogen, GI = gastrointestinal, GU = genitourinary, Hct = hematocrit, HgB = glycosylated hemoglobin, PT = prothrombin time, PTT = partial thromboplastin time.

View larger version (53K): [in a new window]   Figure 2a. Bar graphs of the number of MR sedation procedures according to the month. (a) Scheduled examinations. (b) Incomplete conscious sedation procedures from March 1, 1991, through November 1, 1998. Reasons for an incomplete examination included patients who did not meet the hospital requirements for conscious sedation (eg, recent respiratory illness), patient appointment cancellation, lack of need for sedation after evaluation by the conscious sedation staff, and failure of the sedation medication. Beginning in May 1995, additional nursing personnel were added to the sedation service, and sedation slots were reserved with the MR scheduling system as demand for the service increased. In a and b, exams = examinations.

View larger version (24K): [in a new window]   Figure 2b. Bar graphs of the number of MR sedation procedures according to the month. (a) Scheduled examinations. (b) Incomplete conscious sedation procedures from March 1, 1991, through November 1, 1998. Reasons for an incomplete examination included patients who did not meet the hospital requirements for conscious sedation (eg, recent respiratory illness), patient appointment cancellation, lack of need for sedation after evaluation by the conscious sedation staff, and failure of the sedation medication. Beginning in May 1995, additional nursing personnel were added to the sedation service, and sedation slots were reserved with the MR scheduling system as demand for the service increased. In a and b, exams = examinations.

View larger version (38K): [in a new window]   Figure 3a. Quality control charts for the time from the administration of sedation medication to the onset of sedation. This is plotted on a monthly basis. (a) Xbar chart shows mean times, with only a single month with times beyond the upper control limit (upper dashed horizontal line). The mean time was 24.9 minutes. The upper control limit is 34 minutes; the lower control limit (lower dashed horizontal line) is 15.8 minutes. (b) Sbar chart demonstrates the mean SD (Std. Dev.) of 17.5 minutes. Months in which this SD was exceeded by 3 are shown when the upper control limit (upper dashed horizontal line) and the lower control limit (lower dashed horizontal line) are exceeded. Large variation from the mean SD indicates the sedation times become unpredictable. This is shown near the end of 1998, when the chief sedation nurse retired and new nurses were trained. The upper control limit is 24, and the lower control limit is 10. Control limits are at the 3 level. In a and b, exam = examination.

View larger version (42K): [in a new window]   Figure 3b. Quality control charts for the time from the administration of sedation medication to the onset of sedation. This is plotted on a monthly basis. (a) Xbar chart shows mean times, with only a single month with times beyond the upper control limit (upper dashed horizontal line). The mean time was 24.9 minutes. The upper control limit is 34 minutes; the lower control limit (lower dashed horizontal line) is 15.8 minutes. (b) Sbar chart demonstrates the mean SD (Std. Dev.) of 17.5 minutes. Months in which this SD was exceeded by 3 are shown when the upper control limit (upper dashed horizontal line) and the lower control limit (lower dashed horizontal line) are exceeded. Large variation from the mean SD indicates the sedation times become unpredictable. This is shown near the end of 1998, when the chief sedation nurse retired and new nurses were trained. The upper control limit is 24, and the lower control limit is 10. Control limits are at the 3 level. In a and b, exam = examination.

View larger version (17K): [in a new window]   Figure 4a. Total procedure time for sedation MR imaging. (a) Quality control chart shows the mean total procedure time (xbar plot) for the three nursing groups. The mean time is 88.6 minutes (solid horizontal line). (b) Quality control chart shows the variability of the SD (Std. Dev.) (sbar plot) for the three nursing groups. Lower procedure times, as well as less variability, are present in nursing group A. In a and b, group A: Four sedation nurses perform the majority (76%) of procedures. Group B: Sixteen other sedation nurses with less dedicated time perform the MR sedation (23% of procedures). Floor: sedation procedures performed by nurses accompanying patients from the wards (1% of procedures). Control limits (dashed horizontal lines) indicated at 3.

View larger version (18K): [in a new window]   Figure 4b. Total procedure time for sedation MR imaging. (a) Quality control chart shows the mean total procedure time (xbar plot) for the three nursing groups. The mean time is 88.6 minutes (solid horizontal line). (b) Quality control chart shows the variability of the SD (Std. Dev.) (sbar plot) for the three nursing groups. Lower procedure times, as well as less variability, are present in nursing group A. In a and b, group A: Four sedation nurses perform the majority (76%) of procedures. Group B: Sixteen other sedation nurses with less dedicated time perform the MR sedation (23% of procedures). Floor: sedation procedures performed by nurses accompanying patients from the wards (1% of procedures). Control limits (dashed horizontal lines) indicated at 3.

View larger version (18K): [in a new window]   Figure 5a. Time from the administration of the first sedation medication until the patient was adequately sedated for MR imaging. (a) Quality control chart shows the mean total procedure time (xbar plot) for the three nursing groups. All paired differences are statistically significant (P < .001). The mean time is 24.9 minutes (solid horizontal line). (b) Quality control chart shows the variability of the SD (Std. Dev.) (sbar plot) for the three nursing groups. Lower procedure times, as well as less variability, are present in nursing group A. In a and b, group A: Four sedation nurses perform the majority (76%) of procedures. Group B: Sixteen other sedation nurses with less dedicated time perform the MR sedation (23% of procedures). Floor: Sedation procedures performed by nurses accompanying patients from the wards (1% of procedures). Control limits (dashed horizontal lines) indicated at 3.

View larger version (18K): [in a new window]   Figure 5b. Time from the administration of the first sedation medication until the patient was adequately sedated for MR imaging. (a) Quality control chart shows the mean total procedure time (xbar plot) for the three nursing groups. All paired differences are statistically significant (P < .001). The mean time is 24.9 minutes (solid horizontal line). (b) Quality control chart shows the variability of the SD (Std. Dev.) (sbar plot) for the three nursing groups. Lower procedure times, as well as less variability, are present in nursing group A. In a and b, group A: Four sedation nurses perform the majority (76%) of procedures. Group B: Sixteen other sedation nurses with less dedicated time perform the MR sedation (23% of procedures). Floor: Sedation procedures performed by nurses accompanying patients from the wards (1% of procedures). Control limits (dashed horizontal lines) indicated at 3.

View larger version (36K): [in a new window]   Figure 6. Assessment of medication dose. Quality control chart for the use of chloral hydrate (xbar chart) shows the mean medication dose over time. The upper and lower control limits are shown as dashed horizontal bars set to the 3 level. The upper control limit (upper dashed horizontal line) is 97 mg/kg; the lower control limit (lower dashed horizontal line) is 77 mg/kg. The mean dose (solid horizontal line) is 87 mg/kg.

View larger version (24K): [in a new window]   Figure 7. Graph of the cost of MR sedation versus reimbursement. The heavy solid line indicates the reimbursement level. Group A nurses (•, , ) were nurses assigned specifically to MR sedation. Group B nurses (, , ) were nurses with general radiology nursing assignments. For each group, costs are indicated at MR room time costs of $5/min (• and ), $10/min ( and ), and $15/min ( and ). The intersection of these lines with the reimbursement line (heavy dark line) is the break-even point.