Careful instructions reduce risks at discharge

Because most children go home after conscious sedation, it's essential to provide parents with understandable discharge instructions. "Very few kids are admitted after the procedure, so parents need to be given very clear discharge instructions," advises Steven Weber, RN, CEN, CFRN, MICN, manager of the children's ED at WakeMed in Raleigh, NC.

Here are some things to consider when discharging children after conscious sedation:

Use specific criteria. At Boston Children's Hospital, a form was developed to give children numerical scores after the procedure is completed. Points from 0 to 3 are given for various criteria, including motor activity, respiration, blood pressure, consciousness, and room air oxygen saturation, and the child isn't discharged unless he or she scores a total of at least 9. "If it takes too long to achieve that score, we keep them overnight for observation," says Francis Damian, MS, RN, the ED's director of nursing and patient services.

Get input from parents. Parents are a valuable resource for assessing whether a child is ready to leave the ED. "It's really important to get an understanding of the child's usual behavior at that time of day, their sleep schedule, and what their developmental level is, because all of that plays an important role in discharging the patient," says Damian.

Give written instructions. Verbal discharge instructions aren't enough. "The parent may not be listening or completely understand what has been told to them," Weber explains. "Written instructions give them something to go back to once they are home and questions arise, or they help to explain what they were told. It is also good to have a number to call in case questions arise after discharge."

Consider time of day. A three-year old who presents with a forehead laceration at 9 a.m. will respond differently than a child who arrives at midnight, notes Damian. "In the middle of the night, the child will sedate much easier, and isn't going to be active when they go home, so discharge instructions will be different," she says. "How soundly they sleep when they go home will depend on the time of day they get their medication."

Provide support to parents. If parents appear worried, be sure to address their concerns when giving discharge instructions. "Parents can be so anxious that they will keep arousing the child to make sure they wake up, which isn't necessary," says Damian.

Mention possible side effects. Children's Hospital Medical Center in Cincinnati, OH, gives parents one-page handouts with information about the drugs used in conscious sedation, including fentanyl and midazolam. "We explain why the medicine is used, how it is given, and possible side effects to watch out for," says Lynn Daum, RN, an emergency nurse at Children's Hospital Medical Center in Cincinnati, OH.

Address the child's activity level. "If it's an active child, we restrict them from activities that require coordination for up to 12 hours," Damian says. "If it's time for the child to go to sleep, we instruct parents to wake the child one or two hours after they fall asleep. Then, if they respond normally, they can let them sleep through the night."