Pediatric Sedation Newsletter
Newsmaker Interview:
David Fagan, MD; and Jana Stockwell, MD
We continue our series of interviews with sedation providers who are actively involved in providing high quality sedation services. For this newsletter we have interviewed two providers from Children’s Healthcare of Atlanta – David Fagin MD from the Scottish Rite Campus and Jana Stockwell MD from the Egleston Campus.
Newsletter
Could you describe the nature of the institution in which you work?
Fagin
Children’s Healthcare of Atlanta consists of 3 Children’s Hospitals, Scottish Rite Children’s Hospital, Egleston Children’s Hospital and Hughes Spalding Children’s Hospital. All 3 are freestanding children’s hospitals. Our group (Pediatric Emergency Medicine Associates – or PEMA) covers the sedation service at Scottish Rite as well as the ER at Scottish Rite and 2 community hospitals. Scottish Rite is a large community children’s hospital with over 200 inpatient beds and approximately 70 ICU beds. The only services we do not provide are cardiac and transplant services. Our ER sees about 80,000 visits/year.
Stockwell
Egleston is a 250 bed quarternary care teaching hospital associated with the Emory University School of Medicine. The hospital has very busy solid organ (heart, liver, renal) transplant and bone marrow transplant services, as well as ECMO and CVVH, and is soon to be Level 1 trauma center. There are separate PICU, CICU and NICUs.
Newsletter
Please explain who works in your sedation system? How was the sedation service initiated in your hospital? Who runs the service? How was that decided? What kind of quality assurance process do you run for the service and who oversees this process?
Fagin
Our group [PEMA] runs the physician end of the sedation service. The hospital supplies dedicated sedation nursing coverage in radiology, hematology and in the special procedures lab. We started the service over 5 years ago primarily with Radiology. The radiologist felt that they were not the best group to be overseeing the sedation of their patients. The anesthesia and ICU groups did not have the staffing to take this on so it fell into our laps. We've done several things to insure quality care. We have a medical director who receives a stipend and oversee the service. Our initial medical director [Shani Freilich] developed protocols and order sets to help with consistency in our care. We've limited our service to PEM boarded physicians in our group and we encourage additional time (training in with anesthesiologists) and taking the Airway Course. We have a regular bimonthly meeting to discuss issues/concerns. We have developed a quality assurance form on every patient detailing any adverse event or intervention needed. There is also a nursing director and a nurse who oversees the collection of our quality assurance data and the data we send to the consortium.
Stockwell
At Egleston, Children’s Sedation Services (CSS) is a wholly owned subsidiary of CHOA. It is comprised of 9 EM board-certified physicians and 9 board-certified/board eligible critical care physicians. The service is co-directed by Dr. Jeff Linzer (EM) & Jana Stockwell (CCM). Shifts with the sedation service are considered PRN or moonlighting shifts. The service originated, as noted by David above, when the radiologists said, “no way”. Quality data is reviewed each month by chart review by a sedation service RN and reported/reviewed by me. I also do quarterly chart audits to verify compliance with documentation. We currently are working with Mike Mallory (Scottish Rite service) to utilize a new database he designed with more standardized definitions for events, so that our quality data will be similarly based and reviewed on each campus.
Newsletter
Which other care providers use the sedation service? Has any group of providers refused to use the sedation service? Why?
Fagin
We provide sedation for various services in the hospital. Our largest volume is with radiology but we also provide sedation for hematology/oncology, orthopedics, rehab and many other services. No group has refused our services that we're aware of. For a short time we were performing sedation for a limited number of endoscopies, colonoscopies and bronchoscopies and for a number of reasons we decided we would no longer sedate for those procedures.
Stockwell
We sedate children in 4 different locations within the hospital: radiology (facilities on 2 floors), oncology, and transplant clinic (for biopsies). We, also, briefly delved into endoscopies but have now gone away from that, primarily because we were having issues with inconsistent scheduling, and not because of issues with the sedations or the patients. No clinical service has refused to utilize our services.
Newsletter
Where are you located within your institution? Do you have a dedicated room or area? Do you go offsite to provide service? If a child is having something like an MRI - do they come to your location first or do they go to the MRI and you take care of them there?
Fagin
We have a 16 room sedation suite in the radiology department. Patients (for the most part) come to the suite to be evaluated by a sedation nurse and physician and then are sedated. (We also do ABR's in the radiology area.) At least 2 days a week a sedation physician will go to outpatient hematology to do LP's and bone marrow aspirates and biopsies. We also will perform scheduled sedations in our special procedures area (fracture reductions, PICC lines, botox injections, LP's etc).
Stockwell
In radiology, we have MRI, and PET-CT on the ground floor, for which there are 9 sedation bays. Our 1st floor Radiology has 7 sedation bays (CT and nuclear med). Sedation for PICC lines, LPs, and ABR‚s (out-patient) and wound care, etc are done in our MRI radiology sedation bays. Sedation for biopsies and oncology are done in their clinics on specified days & include nurses familiar with the sedation process, criteria and concerns.
Newsletter
What kind of medications and techniques do you use to provide sedation? If you use potent meds like propofol - was it a fight to get that approved or was there any "approval" process at all? Do you use any inhaled sedation agents?
Fagin
We've been very fortunate that we've been able to use a wide variety of medications and primarily use propofol for patients requiring sedation only. For patients undergoing painful procedures we often use a combination of ketamine or fentanyl and propofol. Although we are not overseen by the Anesthesia Department they have been helpful in supplying suggestions and guidance over the last 5 years. We presently do not use any inhalation agents but we're in the process of becoming credentialed to use Nitrous Oxide.
Stockwell
At Egleston, we primarily use propofol; and to a much lesser extent Brevital, ketamine, chloral hydrate. We add fentanyl for bone marrow biopsies & aspirates, and for renal biopsies. Versed (PO, IN) or Ativan (PO) is not infrequently given for anxiolysis to agitated kids before procedural sedation. Ketamine & propofol were already used by the CCM group prior to the development of the service, so there has been little, if any, controversy regarding its use by CSS. We use inhaled isofluorane in the PICU, but are not allowed yet to use N2O. (No comment.) Thank goodness we do not have to use Nembutal anymore!
Newsletter
Are there any patients that you will not sedate - any that require referral to anesthesiology? If so - how is this done and how was this group determined? If not - what do you do with very ill or difficult
airway patients? Do you have some special protocols for that subgroup?
Fagin
There are many patients that we will not sedate and we believe that knowing the limitations and possible complications of deep sedation is imperative to providing a safe service. We do not sedate infants under 6 weeks of age because of our concern for apnea – post sedation. Any patient we feel may have a significant airway issue under sedation is referred to anesthesia. [we do not place LMA's or ET tubes for sedation cases]. In addition, there are many instances where we've worked closely with anesthesia to determine the best route to get a test performed.
Stockwell
Like our Scottish Rite colleagues, we do not routinely place oral airways or ETTs. If we think a patient will need GA, then our anesthesia colleagues are more than willing to provide that service at a later scheduled time. We do cardiac, even cyanotic kids (we have an active cardiac MRI team), liver transplants, etc. Most often the kids we will refer for GA are Pierre Robin Sequence kids, those with ascites that impedes diaphragm movement, patients awaiting tracheal reconstruction, huge tonsils, or history of significant obstructive sleep apnea. We will sedate kids <1 month, but have criteria for 12 hour observation for them. Children with complicated histories are discussed with the surgeons, the interventional radiologists, and the anesthesiologists when appropriate, though the CSS team is credentialed to sedate ASA 1-4 without mandatory consult. There are occasionally kids who the radiologists would prefer to do under procedural sedation rather than GA. Abscess drainage in the lung, for example, when the positive pressure generated during GA (with positive pressure ventilation) could make a pneumothorax more likely. Our scheduling tends to be more flexible, so sometimes the decision is made that the best interest of the child is served by doing a CT-guided abscess drainage followed by antibiotics with the option to go to the OR in a few days for a definitive open procedure if this doesn't work.
Newsletter
What were the barriers that were placed in front of you prior to beginning your sedation program?
Fagin
Our biggest barrier was ensuring that we would be compensated for our services as we are a private group and depend totally on our collections to support the service.
Stockwell
Manpower. We have struggled with fluctuations in manpower over the years, and the service keeps growing. Our service is staffed as moonlighting time, but we have never had an uncovered shift (3 docs per day average). We too, totally depend on collected revenue to pay our physicians. The institution provides no financial support.
Newsletter
What are the future plans for your service? Areas of expansion or new techniques planned?
Fagin
We continue to get busier. We have a dedicated physician in the evening who will take late hospital cases and also covers the ER. We're also hoping to consolidate nursing under a sedation department as opposed to working for radiology/hematology etc.
Stockwell
If you build it, they will come. Growth is projected for inpatient procedures and oncology.
Newsletter
Any sedation research going on?
Fagin
We're excited about our research. Amy Baxter and Michael Mallory have been directing this area and we've already had several papers published with other projects ongoing. Actually, we have one paper published and one in revision too, along with one paper being written and one enrolling.
Stockwell
Our group has published one paper and has one in revision. Given that there are no dedicated sedation docs, there has been only sporadic interest in sedation research (vs the doc’s primary employment
division). Amy Baxter, as mentioned by David, is really being very proactive in the sedation research arena.
Newsletter
Could you comment on the finances of your operation? Is the service self supporting (positive margin) or is it a negative? Does the hospital support the service?
Fagin
As I mentioned we are self supporting. So far we're in the black although our CFO Dr. Werner says our margins are shrinking.
Stockwell
Georgia is still a good state to be a procedural sedation provider. Our margin is positive, but the impact of Georgia “managed” Medicaid has not been helpful. We exist in a state of constant angst regarding reimbursement since the service has no institutional support.
Newsletter
Any other comments on your service that would be helpful to other individuals that are thinking of starting a service of their own?
Fagin
There are so may good reasons to start a sedation service. Most importantly your patients will have access to a safer more humane treatment modality that probably wasn't easily available before.
Stockwell
As an ICU doc, I was not thrilled when we first got involved in sedation because I thought it would be boring. But in short order I found that it really is very rewarding-- to play with an oncology patient before their BM biopsy, sedate them, get the biopsy done, and then see them wake up oblivious to the test they endure every 2 months - that makes it worthwhile.
Newsletter
Thanks so much for your time and insights.
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