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Do children with high 
body mass indices have a higher incidence of emesis when undergoing ketamine sedation?

Etomidate for short pediatric procedures in the emergency department

Intranasal fentanyl and
high-concentration inhaled nitrous oxide for procedural sedation: A prospective observational pilot study of adverse events and depth of sedation


SPS and Vanderbilt University School of Medicine launch partnership to develop online CME for physicians

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Looking forward to the 2013 Society for Pediatric Sedation Conference

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Quality Corner

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Current Topics for the Pediatric Sedation Nurse

Child Life Corner

Quality Corner

Welcome to the Quality Corner!

Cheri LandersBy Cheri Landers, MD, FAAP, FCCM
Section Editor

Welcome to the first installment of the Quality Corner of the SPS Newsletter.  This column will be devoted to the various domains of quality as they apply to Pediatric Procedural Sedation. 

Initially the focus will be on broad definitions of quality and the terminology used.  Then we will address how they could be applied to procedural sedation, and shift to measures of quality, benchmarks and targets for procedural sedation and how systems have approached moving their programs forward with regard to quality.  Your feedback is welcome and suggestions for specific topics for future newsletters are encouraged! 

In addition, if you would like to provide a case study from your center illustrating how you moved an aspect of pediatric sedation quality forward, please let me know.

Why are we and our hospital administrators, the insurance carriers, some of our patients and our state and federal governments so focused on quality health care right now?

We have all heard, perhaps over and over again, about the Institute of Medicine’s report on the appalling state of health care quality published in 1999 called “To Err is Human: Building a Safer Health System”.1 Shocking statistics were reported as headline news items across the globe regarding deaths caused by medical errors and the costs associated with preventable adverse events.  The biggest achievement of this publication, perhaps, was in bringing the discussion of patient safety out into the open, despite the malignant state it was in, so that it could be examined, diagnosed and a treatment plan initiated. 

Quickly following this report was the IOM’s “Crossing the Quality Chasm” document which set to provide a pathway for improvement for health care in the United States via redesign of the system at all levels.2 Pediatrician Dan Berwick’s “User’s Manual for the IOM Report” boiled the IOM’s dense document down to something providers and health care agencies/institutions could begin to conceptualize and fix.3 

An over-reaching premise of these reports is that errors and poor quality in health care are due to design properties of the system and that focusing on individuals and blame or providers “trying harder” rather than changing the system in which care is delivered will not change the dismal outcomes.  The systems involved in health care were more specifically defined (Table 1).  Each larger system has within it the smaller system(s): the most important one affected by all the others being the patient experience.

Table 1

As providers of pediatric procedural sedation, we work daily with other physicians, nurses, child life professionals, etc. in a microsystem that provides procedural sedation to our patients.  We also work within a larger health care organization; whether that is a university or community hospital or a large dental group or multi-site health care system.  And, whether we embrace it or not, regulatory bodies, financial factors, national medication shortages, etc. impact our health care organization’s decisions, the ability and type of care we provide and what our patients experience (Level D).  What is clear is that the individual provider cannot impact lasting quality of care solely by themselves without making changes in the microsystem or larger levels to sustain the improvement. Ideally the system will provide the framework by which quality improvement can be sustained by all practitioners within. 

But what is quality?  How do we know that one hospital or clinic provides better quality care than another?  Most of us have an idea of what it is like to have a quality experience; whether we are at the bank, the local hardware store, the physician’s office or an amusement park.  Think Disney World vs. the carnival in K-mart’s parking lot.  In healthcare, we often talk about all the “right” things: the right procedure on the right patient at the right time with the right dose of the right medication, etc.  Commonly the terms quality and safety are linked together and, while quality does encompass safety, quality healthcare is so much more than safety.

A quality experience also involves trust in the person(s) providing the service, that they have the requisite knowledge for the job, that the outcome desired will be the outcome obtained, that they value our input and opinions, that we are not wasting our time or theirs and that all customers receive the same treatment no matter what their background.  Then, even if we know two hospitals provide equal quality (once we know how to compare them), are they providing the service that should be expected, i.e. some appropriate minimal standard of care? 

In order to evaluate quality performance there should be some objective measure to track over time.  Some areas more easily lend themselves to objective measurements than others.  For example, tracking central line associated blood stream infections (CLABSIs) is relatively straightforward and results in a measureable number of infections per line day.  This number can then be tracked across time within an institution to monitor improvement and can be used to compare to other institutions.  Measuring compliance with standard of care for asthma treatment (the Asthma Core Measure) is more challenging. It encompasses not just a single incidence of a complication but covers whether appropriate treatment was given and whether discharge instructions included the necessary components. 

Each measure has pros and cons and is really meant as a surrogate marker for overall quality of a health care system (Level C).  By itself, CLABSI rates at a hospital will not tell you about the surgical care you will receive at that hospital and the Asthma Core Measure score will not say whether ulcerative colitis is managed appropriately.  However, the assumption is that if an institution is committed to developing a system that promotes quality in one area of care, then that culture of quality will spill over into areas that are not directly measured.  Obviously, there are flaws in this logic. 

The measures that are reported publically (like CLABSI, Asthma Core Measures, Acute myocardial infarction treatment, surgical complications, etc.) or that result in “no pay” situations (air embolism, blood incompatibility, etc.) from insurers will be heavily focused on, perhaps to the detriment of other areas.   However, that shouldn’t stop those working in a microsystem from determining what measures of quality make sense for their patients and developing measures and targets for themselves to move their care forward.

Most health care quality sources cite the IOM-proposed six “Aims for Improvement” as a jumping off point to drill down on more specific areas of quality.  The six aims and their definitions as paraphrased from Dr. Berwick are:

    1. Safety-patients ought to be as safe in health care facilities as they are in their own homes.
    2. Effectiveness-the health care system should match care to science, avoiding both overuse of ineffective care and underuse of effective care.
    3. Patient-centeredness-health care should honor the individual patient, respecting the patient’s choices, culture, social context, and specific needs.
    4. Timeliness-care should continually reduce waiting times and delays for both patients and those who give care.
    5. Efficiency-the reduction of waste and, thereby, the reduction of the  total cost of care should be never-ending, including, for example, waste of supplies, equipment, space, capital, ideas, and human spirit.
    6. Equity-the system should seek to close racial and ethnic gaps in health status.

Each one of these areas is called a quality domain.  Within each domain, specific measures (metrics) fit under that domain.  For example, CLABSIs are a metric for Safety; Asthma Core Measures are a metric for Effectiveness.  But this doesn’t get us very close to answering what is quality in pediatric procedural sedation and how we measure it. 

The Society for Pediatric Sedation received grants from the Agency for Healthcare Research and Quality (AHRQ) and the Mayday Fund to bring together pediatric sedation practitioners from multiple disciplines in order to discuss this very issue.  The “Society for Pediatric Sedation Consensus Meeting: Defining Quality in Pediatric Sedation” was held in November 2011 for 48 hours of in-depth exploration of how the six aims for improvement as defined by the IOM could be applied to pediatric procedural sedation.  The result was less a recipe for what and how to measure and more of a jumping off point for ideas in each domain.  The large amount of constructive discussion and input from the many participants is being worked into a document to share with the Society and the broader sedation community. 

As we move forward in future editions of this section of the newsletter, we will delve into each domain in more detail with examples of potential measures, proposed benchmarks for the measures and ideas from case studies of how to improve upon the care we provide to our patients.


  1. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer health system (Washington: National Academy Press, 1999).
  2. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001).
  3. Berwick, D.M. A User’s Manual for the IOM’s ‘Quality Chasm’ Report. Health Affairs. 2002 May/June: 80-90.

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