Decreasing Discomfort for Breast Sentinel Node Patients

Team Leads: Miranda Roark DNP RN NPD-C, Carlos Vieira MD, FACS, Susan Streit BSN RN, Ralph Wischmeyer MD

Team Members: Sheryl Robertson BSN RN CAPA, Kim Johnson BSN RN CPAN, Post Anesthesia Care Unit Staff, Outpatient Surgery Staff

Columbus Regional Health, Columbus Indiana

Background Information: Dr. Vieira, a fellowship trained breast surgeon had post-surgical patients reporting to him in follow up visits that they received great care and had a great experience with the exception of the Sentinel Node injection prior to the procedure. Patients were reporting significant pain with the injections and described the pain as “horrible” and the “worst part of the whole experience”. Dr. Vieira had trialed Lidocaine patches to the areola, patient applied the day of procedure and even as early as twenty four hours prior to the procedure. Often patients were unable to get these from their pharmacy and for some they were cost prohibitive. Patients reported little to no improvement in the injection site discomfort. Dr. Vieira initiated a collaboration with entire team-post anesthesia staff, anesthesia, and outpatient surgery staff, to come up with a process for addressing this major discomfort.

Objectives of Project: To find a way to decrease discomfort for patients receiving sentinel node injections prior to breast surgery.

Process of Implementation: Out of the team collaboration came the sedation trial for the sentinel node injection. Dr. Vieira decided he could do all of the injections without imaging and this allowed for them to take place in the post Anesthesia Care Unit (PACU). The Sentinel Node was scheduled 90 minutes prior to the surgical time to allow for optimal uptake of the radioactive isotope. The patient arrives to the Outpatient Surgery (OPS) area one hour prior to injection time. Most patients are seen in Pre-Admission Testing (PAT) and have labs and necessary testing already completed. Dr. Vieira communicates with the patient/family/significant others in the OPS room before being transported to the PACU for the injection. The OPS nurse gives a bedside handoff to the PACU nurse and the patient is monitored for the sentinel node procedure. Before the sedation, the OR nurse lead is at the bedside to confirm correct patient and procedure. The Nuclear Medicine staff member and the anesthesiologist are in attendance for the injection. The patient is appropriately monitored until surgery. Bedside handoff is given to the Operating Room nurse.

Statement of Successful Practice: Patients involved in the trial had no recollection of the sentinel node injection. Patients all reported in follow up visits that they had no pain or discomfort for the injection. This trial was adopted by the team as the new standard of practice.

Implications for Advancing the Practice of Perianesthesia Nursing: Results of this trial were shared with other general surgeons at Columbus Regional Health and this has become the standard of care for them as well. These results have possible implications for implementation on a larger scale. A substantial part of perianesthesia nursing practice is decreasing discomfort for patients postoperatively. This process change also helped a select population decrease their discomfort from a necessary pre-surgical procedure that was previously causing significant discomfort for patients.