Identifying Best Practice for Healthcare Providers Caring for Autistic Children Perioperatively

Monday, 30 October 2017

Margaret A. Gettis, DNP
Nursing Research and EBP Department, Children's Healthcare of Atlanta, Atlanta, GA, USA

Purpose: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by abnormal social interaction, communication difficulties and stereotypical behavioral patterns (Arnold et al, 2015). Frequently autistic children have difficulty tolerating change and encounters with unfamiliar people and environments may be particularly threatening (Lindberg et al, 2012). In addition, children with ASD can have co-morbidities including intellectual and motor difficulties, mental health problems, epilepsy and sleep disturbances (Taghizadeh et al, 2015).The purpose of this evidence based practice project is to identify the most effective strategies for healthcare providers managing pediatric surgical patients with ASD and to incorporate them into easily accessible electronic care plans for all providers to give individualized treatment.

Method: The nurse researcher was consulted by clinical staff for help searching best practice recommendations for healthcare workers who care for autistic children undergoing outpatient surgical procedures at a large urban pediatric healthcare organization. A literature search was conducted via PubMed and CINAHL and included psychological, nursing and anesthesia journals. The majority of relevant articles were published during the past five years (2011-2016). The key terms used were: Coping perioperative surgery, coping strategies for preoperative/perioperative anxiety in developmentally delayed children, stress coping strategies for pediatric surgical patients, preparing developmentally delayed children for surgery, preparing autistic children for surgery. In addition, MeSh terms were used: perioperative or postoperative anxiety/prevention limited to children, perioperative stress, psychological/prevention limited to children, perioperative or postoperative adaption, psychological limited to children. The nurse researcher in collaboration with the interdisciplinary team then created an evidence summary table.

 Results: The recommendations for best practice based on the literature review are used as the basis for the development of an individualized electronic care plan for each autistic patient. Effective strategies for healthcare providers fall broadly into three categories: medication interventions, distraction/play therapy interventions and management interventions. Medications including Dexmedetomidine with or without midazolam are recommended as an effective sedative in this population with few side effects as well as Clonidine and Ketamine (Taghizadeh et al, 2015). Evidence also strongly supports play therapy and distraction techniques as effective interventions in patients with autism including play activities with Child Life therapists, animal assisted therapy, personal comfort items and visual aids or story boards. (Vagnoli et al, 2015; Goddard et al, 2015; Sahiner et al, 2015; Lee et al, 2013). Lastly, evidence supports strategies that control the external environment and stimuli as well as individualized safety precautions and communication techniques shown to be effective with the autistic child. These strategies include parental presence in the PACU, and preregistration prior to surgery to avoid the noisy waiting area (Johnson et al, 2013; Drake et al, 2012). These plans are coupled with individual patient information given by parents.

 Conclusions/Implications for Practice: The information provided by families to help the perioperative team align with patient and parent preferences, is obtained prior to surgery via questionnaire or phone call and is incorporated into the perioperative care plan housed in the electronic medical record. This “coping plan” is easily accessed by the multiple disciplines involved in the care of these vulnerable patients and is used to meet the patient’s specific needs before and after surgery. This collaborative effort results in the use of strategies based on current evidence leading to better communication, individualized care and a more positive patient experience by autistic patients and parents during the surgical experience.