Conference Reviews: Wednesday, May 21
Evolution of Pediatric Sedation and the Dawn of the Sedation Specialist
Reviewed by Kevin Couloures, DO
Joseph Cravero, MD presented historical background about how different pediatric sedation programs were established and how these programs vary widely in the type of providers, medications and monitors being used. He also pointed out how the understaffing of sedation services led to 30% of respondents in one study reporting that no sedation was given for 50% of bone marrow biopsies while 0% of European respondents reported no sedation.
Dr. Cravero then reviewed the DOCS study done at Dartmouth where they demonstrated that expert providers always achieved adequate sedation and non-expert providers failed 8% of the time. Also, these non-expert providers did not promptly recognize and correct desaturations that were prolonged for more than five minutes. The solution appears to be, train a few providers to do a really good job and not try to credential all providers.
The last point was that well-run pediatric sedation services will have very low complication rates as seen in several studies published using the Pediatric Sedation Research Consortium (PSRC) database. These low rates are the result of skilled providers with established competencies in airway management. The resulting challenge is then how to maintain and teach these skills to established and new providers. The key component in this maintenance of airway skills is demonstrated practice that meets an established standard and is not simply something that is signed off on by a proctor. Ultimately, these high standards will improve the care of children and help promote this new specialty.
Panel Discussion: Sedation Specialist as a Career
Reviewed by Kevin Couloures, DO
Lia Lowrie, MD described how her unintentional path to sedation opened when her institution had difficulty providing adequate sedation service. Along the way she created a service and published the process, which lead to academic and institutional recognition. She then highlighted how a sedation service relates to pain and palliative care services and the ongoing balance between acute “add-on” requests and scheduled outpatients.
Judson Barber, MD outlined how he had been asked to chair a sedation committee, which led to the initiation of a Radiology Sedation Service. Dr. Barber then began to provide sedation for MRI studies and became involved in the SPS. He continues to work as an ED physician but spends a quarter of his time collaborating and overseeing sedation services.
Deborah LaViolette, RN elaborated on how she transitioned from being a PICU nurse to sedation and subsequently developed the sedation nurse role in three institutions. She was able to utilize this model with physicians from three different specialties overseeing the care. Ms. LaViolette is the chair of the SPS Nursing Committee which has been working hard to standardize competencies and standards of care.
Jason Reynolds, MD explained how an interest in anesthesia resulted in a year of critical care fellowship, another year as a transport fellow and then jobs in the ED and as a 'Sedationist' at Texas Children’s Hospital. He then proposed a model for a sedation fellowship and is creating a program to be offered at Children’s Hospital of San Antonio.
David Banks, MD concluded the panel discussion with how he started in sedation as a result of the ED group at Children’s Hospital of Atlanta filling a void that existed after the radiologists at Scottish Rite Campus of Children’s Healthcare of Atlanta stopped doing sedation. He and five partners created a business plan and were able to negotiate third party payer contracts and expand their professional liability coverage. The service has subsequently grown and Dr. Banks took over the role of Medical Director of the group, which is currently performing 600 sedations per month. A group of 30 physicians provide eight clinical FTE’s. At the end, Dr. Banks stressed the ongoing need for research and to identify those quality metrics that best reflect quality and safety.
Forging the Culture of Safety and Quality: Pediatric Sedation Credentialing and Privileging
Reviewed by Gregory Hollman, MD
Pediatric procedural sedation is a high-risk clinical activity that is ubiquitous in any hospital that cares for children. As the demand for pediatric sedation services has increased, the role non-anesthesiology practitioners have assumed in providing this service has grown substantially. Yet non-anesthesiologist practitioners comprise a diverse group with varying levels of training, education and experience in sedation.
In order to promote safe sedation practice, hospitals must have a systematic process for assigning sedation privileges to only those individuals who are qualified. Standards for pediatric sedation practice are often developed from the guidelines established by the American Society of Anesthesiologists (ASA), the American College of Emergency Physicians (ACEP), the American Academy of Pediatrics (AAP), the Joint Commission and the Center for Medicare and Medicaid Services (CMS).
Despite these guidelines, provider qualifications used by hospitals for delineating sedation privileges vary considerably among institutions. As a result, one of the greatest challenges hospitals face is establishing a consistent privileging process that defines the training, education and experience that ensures practitioners are competent to perform moderate and/or deep sedation.
Privileging is the process used to grant practitioners permission to provide specific clinical services and/or procedures. A hospital examines the individual’s formal training, education, and experience before determining competency and awarding privileges. Core privileging is the process used by many institutions in which a core set of privileges is granted to a practitioner who is deemed qualified based upon successful completion of a residency or fellowship in a particular area. A hospital may also define special privileges for performing specific clinical activities that are not included in their core privileges. Specific privileges are often considered more specialized and higher risk and require extra training and/or experience. Based on a practitioner’s formal education and training, moderate and deep sedation privileges may or may not be considered part of their core privileges. If not, additional training will be required.
Competency in pediatric sedation requires that the practitioner, within the context of their practice, integrate their cognitive, psychomotor and affective skills to achieve the desired outcome. The process of delineating sedation privileges is all about competency; establishing what competencies are required, deciding how to achieve these competencies, determining how to assess the competencies and clarifying how the competencies are to be maintained. The reports by Coté et al, describing systems-related sedation complications and data from the Pediatric Sedation Research Consortium (PSRC) provide information regarding the types of skills/competencies needed to safely and effectively perform sedation.
These reports plus the published sedation guidelines from the AAP, ACEP, ASA, and The Joint Commission describe the general competencies:
Performance of a pre-sedation risk assessment
Administration of sedative drugs and their antagonists
Evaluation and monitoring of the sedated patient
Recognition and management of sedation-related complications
Recovery and discharge of patients following sedation
Achieving sedation competency requires training, education and experience in pediatric sedation. Thresholds for the amount and type of training and experience will vary among hospitals. The requirements for sedation privileges may sometimes be included as part of the core privileges, based on successful completion of a subspecialty in which formal sedation training is part of the educational curriculum. When moderate or deep sedation is not part of an individual’s formal training most institutions will require additional training and experience to receive sedation privileges. Below is a list of the different types of training, education and experience that institutions will consider to determine whether a practitioner has the qualifications to be granted sedation privileges:
Formal Training and Education (Residency-Fellowship)
Additional Training, Education, and Experience
Didactic written materials and lectures
Interactive small group sessions
Clinical experience and mentoring
Assessment is an important component of medical education and essential to determining if an individual is competent. Miller’s competency pyramid describes assessment of clinical performance at four levels. “Knows” is the lowest level of assessment and deals with testing factual knowledge (e.g. written examinations), followed by “knows how”, the ability to apply knowledge in solving problems.
Assessment at higher levels of performance, “shows how” includes testing of cognitive, psychomotor and behavioral skills in a controlled setting, (e.g. full human simulation). While knowledge and the ability to apply and demonstrate intellect in an artificial setting are important components of training and assessment, they do not guarantee competent performance in real life.
The highest level of the pyramid, “does”, assesses actual clinical performance by a qualified instructor in the setting in which the practitioner works, and is the framework in which competency is determined. Common methods of assessing knowledge, skills and competency in sedation include:
Direct Assessments of Clinical Practice: Proctoring and Multisource Evaluation
The focused professional practice evaluation (FPPE) is a process established by The Joint Commission that requires institutions to ensure that a new provider is competently performing the clinical activity he/she had been privileged to do. Re-privileging occurs every two years and like initial privileges, requirements will vary among hospitals. Some form of quality measure is often used and may include documentation of a minimum number of sedations, and outcome data including the incidence of critical adverse events.
In summary, procedural sedation is a complex, high-risk clinical activity. Institutions must have a formal, evidence-based privileging process that ensures only individuals who are qualified to administer sedation are allowed to do so.