Literature Review

Reviewed by Daniel Tsze, MD and Joseph Cravero, MD

Current State of Institutional Privileging Profiles for Pediatric Procedural Sedation Providers

Kamat PP, Hollman GA, Simon HK, Fortenberry JD, McCracken CE, Stockwell JA. Hosp Pediatr 2015;5:487-94.

Pediatric procedural sedation (PPS) outside of the operating room is a service in great demand, and has been provided by an increasingly diverse range of pediatric subspecialists.  These providers all come from a variety of backgrounds with different training experiences, yet all practice in similar contexts requiring a specialized set of skills and competencies.  It is not clear at this time how these clinicians who provide PPS are credentialed or trained.  This study aimed at describing the credentialing process for sedation physicians who provide PPS from a number of different institutions.

The authors conducted a descriptive analysis of survey responses collected from directors of sedation programs in the Society of Pediatric Sedation (SPS).  The survey consisted of 20 questions broken down into three sections addressing credentialing, composition of sedation teams, and quality metrics.  For the purposes of this brief review, we will be focusing on the questions related to credentialing.

Fifty-six program directors were surveyed. The overall response rate of complete responses was 73%.  The majority of programs were freestanding children’s hospitals or medical centers (51%), or children’s hospitals within a larger medical center (44%).  All programs sedated ASA class I and II patients, and 76% sedated ASA class III patients.  Propofol was the most common sedative used for radiologic procedures (78%).

About 80% of physicians from the programs surveyed required special credentialing to provide sedation service.  Of these physicians, the majority was credentialed through a primary specialty (78.7%).  Initial credentialing requirements for sedation providers were variable, with the most common requirement being current PALS certification (73.2%).  Approximately only half of providers had completed one or more of the following: documentation having performed a certain number of pediatric procedural sedates or documented proctoring of a certain number of deep sedation cases; evidence of procedural sedation/analgesia training during fellowship; and successful completion of pediatric procedural sedation orientation packet.

The majority of providers were re-credentialed through a primary subspecialty (82.9%).  The two most common requirements for re-credentialing were maintenance of proficiency in safe administration of procedural sedation by performing a minimum number of sedations per year (63.4%), and maintaining current certification in PALS (65.9%).

Comment
The provision of PPS outside of the OR requires a specialized set of skills and competencies, and the clinicians who deliver these services come from a diverse range of backgrounds and experience.  Although professional organizations have provided guidelines for administration of sedatives services, specific requirements for credentialing are not well defined, and often left up to individual institutions and departments to determine. (1-5) Absent from this discussion is the establishment of “core competencies” for sedation that could be taught to providers and tested prior to granting credentials to provide sedation.

Although the variable requirements for credentialing were derived from a group of institutions with a demonstrated low incidence of serious adverse events (i.e. the SPS) this does not mean that a more structured and codified credentialing process is not necessary. (6)  The institutions that comprise the SPS are a self-selected group of providers working in high-performance systems, and have many other checks and balances in place, aside from the described credentialing practices.  What is evident is that providers of PPS outside of the OR may engage in higher-risk procedures involving more medically complex patients (i.e. ASA III) and more potent sedatives (i.e. propofol).  Therefore, it is important that benchmarks for competency are established to ensure providers from any institution will have the skills necessary to safely provide PPS in this manner.

The exact nature of benchmarks and requirements for credentialing of sedation providers is not clear at this time.  There will have to be consideration of the variability in resources and personnel, patient populations, and practice patterns amongst different institutions, while prioritizing patient safety and well-being, when developing such guidelines.  There is now a valuable opportunity to propose standards for credentialing and the establishment of a group of standard competencies for this practice, in conjunction with establishing and measuring quality standards, so as to move towards a model of best-practice and continued improvement in the provision of PPS by pediatric specialists.

References

  1. Coté CJ et al. American Academy of Pediatrics; American Academy of Pediatric Dentistry; Work group on sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Paediatr Anaesth. 2008;18:9-10.

  2. Coté CJ. American Academy of Pediatrics sedation guidelines: are we there yet? Arch Pediatr Adolesc Med. 2012; 166:1067-1069.

  3. Mace SE et al. Clinical policy: critical issues in the sedation of pediatric patients in the emergency department. J Emerg Nurs. 2008;34:e33-e107.

  4. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists.  Practice guidelines for sedation and analgesia by non-anesthesiologists.  Anesthesiology. 2002;96:1004-1017.

  5. The Joint Commission.  Provision of Care, Treatment, and Services Standards, Record of Care, and Improving Organizational Performance. Oakbrook Terrace, IL: The Joint Commission; 2014.

  6. Cravero JP  et al. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operation room: Report from the Pediatric Sedation Research Consortium. Pediatrics. 2006;118: 1087-1096.

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