Using Quality Improvement Methodology to Inform Safe Implementation of Propofol Procedural Sedation in a Pediatric Emergency Department

Objectives: This study used quality improvement (QI) methodology to safely introduce propofol for use in pediatric procedural sedation across a multisite emergency department (ED) system and to evaluate its impact on length of sedation, length of stay (LOS), and serious adverse events (SAEs). Methods: We conducted a QI initiative across 4 pediatric EDs within a quaternary children’s hospital network. A multidisciplinary team used the Define-Measure-Analyze-Improve-Control (DMAIC) framework to develop and implement a standardized propofol sedation protocol for short procedures in low-risk patients. Interventions included protocol development, multidisciplinary education, simulation training, electronic medical record (EMR) order set modifications, and phased site rollout. The primary outcome measure was median length of sedation. Secondary outcomes included ED LOS and proportion of sedations using propofol. The balancing measure was airway-related SAEs. All outcomes were analyzed using statistical process control charts and nonparametric testing. Results: During the study period, 2368 children underwent procedural sedation with ketamine (2251) or propofol (117). Median length of sedation for all sedations showed no special cause variation. However, propofol sedation duration was significantly shorter than ketamine across sites (18 to 24 vs. 33 to 52 min; P < 0.001). At the primary site, propofol sedation was shorter than ketamine sedations performed within propofol scope (23 vs. 32.5 min; P < 0.001). ED LOS was shorter for propofol sedations at the primary and secondary sites. SAE rates remained low and stable, with propofol‑associated SAEs occurring in 2.6% of cases. Propofol accounted for 4.9% of all sedations and 20% of sedations among eligible patients. Conclusions: Using QI methodology, propofol was feasibly and safely implemented across a multi‑site pediatric ED system. While the overall length of sedation did not change, propofol use within a defined clinical scope was associated with shorter length of sedation and LOS for selected patients, providing a reproducible framework for implementation.