Newsmaker Interview
Dr. Mick Connors
Children’s Hospital of Eastern Tennessee

Harvard Sedation Service Conference San Francisco

Gravenstein D, Berkenstadt H, Ziv A, Shavit I, Keidan I, Sidi A. Supplemental oxygen compromises the use of pulse oximetry for detection of apnea and hypoventilation during sedation in simulated pediatric patients.
Pediatrics. 2008 Aug;122(2):293-8

Sedation Newsletter Newsmakers Interview 

For this issue of the newsletter we have imposed on Dr. Mick Connors of the Children’s Hospital of Eastern Tennessee for his views on some of the sedation projects he has been working on.

Newsletter questions in italics.

Mick - you initiated the listserv for pediatric sedation. How did the idea of running a listserv come about? Could you explain the process of how it is run at this point?

I initiated the listserv as a way to develop a forum for discussion related to pediatric sedation. Being a relatively new field, this type of discussion and dialogue is critical. Selfishly, as we were starting out, I was hoping to gleen information for our own practice, allow folks to highlight how they approach sedation, and be able to compare and contrast all the different practice patterns that are out there. The running of the listserv per se, is through a contract I have with a company that specializes in listservs.  They provide a format for us to establish members, provide feedback, establish rules for posting, and help moderate and filter the postings.  This service allows us to limit spam, limit vacation messages, review messages, and gives us a simple format to post messages and to subscribe.

Could you tell us  the most interesting aspects of the questions and answers that you are seeing on this listserv? Is there a specific purpose you expected this service to provide? Is it meeting your expectations?

The sole purpose in establishing the listserv was to provide a format for folks to explore and discuss this newly developing field of pediatric sedation.  The greatest part of the listserv is the wide perspective and diverse opinions that are shared from the members of the list.  Members represent nursing, respiratory therapy, advanced practice nurses, nurse practitioners, dentistry and physicians (from hospitalists, EM, anesthesia, and critical care) have all posted to the list.  Overall, the listserv is exceeding expectations as we now have over 400 members registered.  Topics have included individual cases discussions, “how do you do this….”, protocols, and much discussion about who and how we should be providing access to safe sedation.

What are the biggest difficulties you have encountered in running this
ongoing conversation about pediatric sedation?

Clearly the biggest challenge is getting folks to feel comfortable sharing their perspective.  Whether shy, uncertain, or concerned about whom is going to see their post, I wish we could get more participation from all of the members.

Where do you see a service like this serving its greatest purpose?

The purpose will continue to be providing a format where experiences anecdotes, research and policy can all be shared. To address the concerns I mentioned earlier, I think it is important to make this a list where folks feel comfortable in posting their thoughts, ideas and experiences. One thought that may enhance dialogue would be to see this listserv become part of the Society of Pediatric Sedation and only allow registered society members access to the list. This may allow more open dialogue and discussion.  Ultimately it might allow us all to improve our sedation practice through this communication.
 
We understand that you are a full time sedation provider. Can you explain how that position evolved over the years for you?

We began our service five years ago with the concept that it would be part-time service providing sedation for a few procedures each day.  We identified a need as several practitioners were ‘scheduling’ procedures in the emergency department in order to obtain some sedation for procedures outside of the operating room.  We also approached our Radiology Department which was in need of improved efficiency for MRI sedation.  We discussed our plans with our anesthesiologists and they were extremely supportive.  Our anesthesia group felt it would be much better to have a small group of providers focused on sedation, as opposed to the many physicians with different training providing sedation for a variety of procedures outside of the operating room. The anesthesiologists graciously helped us gain credentialing, provided information on other sedation services and supported our reimbursement via insurance companies.  Therefore, after some research and visiting our pioneering emergency medicine colleagues at Scottish Rite in Atlanta, we started in January 2004.  We began as a radiology based sedation service with MRI as our primary responsibility.  From there, we began to add other procedures, and within 6 months we were providing sedation Monday through Friday 8 a.m. – 4 p.m. We started with several physicians working part-time sedation and part time in the emergency department. As we grew and the service became busier (and we had one physician leave for an anesthesiology residency), we quickly needed to increase our shifts to cover all the procedures.  It was at this point that I moved to providing sedation full-time.  This move allowed us to expand our practice, our hours, and also enabled us to define a small group of dedicated physicians and nurses whose sole purpose was to provide sedation. We currently staff the service with one physician FTE Monday through Friday and have a second physician on Wednesday and Thursday.

As I began full-time, I really felt I would miss the ED and had plans to return within a short time.  Well, that was 3 years ago and I continue to practice full time pediatric sedation.  This experience has been wonderful and the challenges/rewards of providing sedation have clearly been a blessing to me professionally and personally.
 
Professionally, my skills, understanding, and appreciation for pediatric sedation have improved dramatically. I have also enjoyed my exposure to the variety of procedures we help with and the physicians we interact with around the hospital.  This practice gives you great appreciation for the wonderful work that goes on in the hospital.  Much of this I was not exposed to in the ED. The perspective and continual challenge of investigating a variety of co-existing conditions and developing sedation plans has kept me very engaged clinically. Overall, though, I would say my greatest reward has been developing relationships with patients and their families.  There are many patients, especially the oncology patients, who we sedate on a regular basis.  Having the opportunity to get to know these patients and their families and improving their experience for procedures has been a great gift.
 
On the personal side, I have enjoyed the fact that this job primarily involves scheduled patients, scheduled work times and more time with my four children and wife.  Moving from the erratic scheduling and shifts of an ED doc to full-time day time work has been wonderful. I have found much more balance and time for family, and the kids’ extracurricular activities.

How is your sedation service configured? For what procedures do you provide sedation? Who is on the team? What kind of providers and provider-extenders do you use?  

Our service continues to be based within radiology and we utilize the radiology nurses and radiology MRI scheduler to schedule/screen all or our procedures.  For non-radiology procedures, we currently have a treatment room in radiology, or we travel to other departments with a traveling cart.  Soon we will open a new four-bed sedation suite adjacent to radiology which will greatly assist with our efficiency.

Currently we have three physicians who practice sedation and we have 1-2 physicians here each day during the week.  Our physicians are board certified in pediatric emergency medicine and have credentialing in deep sedation at our hospital. Our nurse staffing is made up of 5-6 nurses per day, depending on the number of physicians and procedures scheduled.  Three to four nurses work with the sedation service and 1-2 of these nurses work in radiology.  We are also recruiting a tech to assist with procedures, IV’s etc. We provide deep sedation with a physician and a nurse for every procedure and perform only one procedure at a time. We currently do not utilize midlevel providers in our service. We provide deep sedation for radiology (MRI, CT, Nuc Med, Interventional), Cardiology (TEE’s and Echos), Neurology (LP’s/EMG’s), Nephrology (renal bx’s), Oncology (LP’s and bone marrows) Surgery (I and D’s, G-tubes, Brovia removal), Gastroenterology (EGD, Colon) and ENT (BAER’s). We also provide moderated sedation for EEG’s, BAER’s and ERG’s and anxiolysis for VCUG’s.
 
What are the greatest challenges that your service faces at this point?

The greatest challenges for our service are similar to any practice which is new and experiencing significant growth.  We are challenged to continually improve our practice, to become more efficient, to offer our service to more areas and to make more patients and physicians aware of our practice. We are excited about our expanding space and the continued excellent support we are receiving from our hospital administration.  We hope to be able to continue this relationship as we work to meet the increasing demand for sedation services.

What changes do you anticipate in the care that you deliver over the
next 5 years?

I am hopeful that the greatest change in care will be the recognition of the practice of pediatric sedation as a subspecialty in pediatrics. Working full time in pediatric sedation for three years has helped me recognize the impact a sedation focus can have on patient safety and efficiency.  Enhanced pediatric sedation research will show these effects and the need to expand sedation practices around the country.  I believe we will see less discussion about what and how as it relates to deep sedation/monitored anesthesia care. I believe through collaboration of non-anesthesiologists (sedationists) and anesthesiologists, we will see continually improving access to safer sedation.

Can you give us an idea of the financial aspects of running your
service? How does the hospital value what you do for the institution?

We are unique, since East Tennessee Children’s Hospital is one of the few non-academic freestanding children’s hospitals in the country.  Therefore, the physicians are part of a private practice in pediatric sedation and we provide our own billing, contracting etc. We bill anesthesia codes for deep sedation/monitored anesthesia care and consult codes for minimal or moderate sedations in which we are not present. From a physician salary/reimbursement standpoint, our salaries are similar to emergency medicine or critical care physicians. Although we would welcome an anesthesiologist in our practice, I don’t think we could provide the type of salary they could obtain elsewhere.  We are limited by our practice model, our traveling service, and a significant Tenncare population in our practice.  I think these issues are important for folks to know, especially as we see debate about billing practice or who should provide this service.  For us, billing anesthesia codes is critical to our service.  Other codes would not allow us to be able to offer the access to physician-driven sedation practice that we offer.  We are committed to providing our service in the safest manner possible and do not deny any child care based on their ability to pay.  Our billings allow us to put patient care ahead of reimbursement, but also recognize that adequate reimbursement is a key issue for us to continue to offer this care.

The remainder of the service is supported by the hospital and they provide monitoring, medications, nursing, etc., and bill the facility codes to obtain reimbursement for these services.  Our hospital has been very supportive and, I believe, recognizes how this service benefits patient safety, patient/family satisfaction and improved efficiency for all procedures and diagnostic testing.
 
Thanks, Mick!

Editors:
Joseph Cravero MD
George Blike MD

Departments of Anesthesiology
and Pediatrics,
Children’s Hospital
at Dartmouth,
Dartmouth Hitchcock
Medical Center,
Lebanon, NH

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