2015 Conference Review
Growth and Development of Pediatric Procedural Sedation in the ED
Reviewed by Daniel Tsze, MD
We had the pleasure of having Robert “Bo” Kennedy, MD speak to us about the history, turning points, and challenges of providing procedural sedation and analgesia (PSA) in the emergency department (ED) setting. His talk was not only an opportunity to reflect on how far we have come, but a chance to dream about how things could continue to become better.
We have certainly come a long way. Dr. Kennedy reminded us how options were limited in the early 1980’s, with physical restraints or the classic cocktail of intramuscular Demerol/Phenergan/Thorazine being as commonplace in the sedation of children as having to wait 45 minutes to onset of sedation and up to 5 hours to time of discharge.
With the introduction of the first pediatric emergency medicine (PEM) fellows in 1983 and the recognition of PEM as a subspecialty in 1992, began greater attention and focus on the inadequacies of pain prevention and treatment, as well as PSA, in children in the ED. Progress continued in the form of new technologies (e.g. pulse oximetry in the late 1980’s), collaboration with other specialties (e.g. anesthesiology), and the proliferation of new studies, particularly with pediatric-friendly agents such as ketamine and nitrous oxide. More recently has been the development of standardized definitions for ED PSA-related adverse events, increased use and study of propofol, intranasal analgesics and sedatives, and developments such as rapid-infusion protocols for ketamine.
However, challenges remain. One, in particular, remains the issue of identifying rare adverse events related to ED PSA. Does brief PSA cause neurotoxicity, compared to what is being described in prolonged general anesthesia? What exactly is the relationship between fasting and aspiration events? The need for larger ED-specific databases to identify these risks was highlighted, and reminiscent of the call to action that initially brought about the PSRC.
Despite all the progress and developments we have made with pharmacologic interventions for PSA, Dr. Kennedy concluded his talk by calling to attention that perhaps future directions should turn towards actually reducing the need for ED PSA. Perhaps it is by emphasizing the use of comfort measures (e.g. parental presence, positions of comfort); painless anesthesia (e.g. LET, Child Life); and teaching children to use their own coping mechanisms more and more, that we can one day achieve the ideal model of what it is like to provide safe and effective PSA in the ED for children.
Hospital Medicine Based Sedation
Reviewed by Michelle Rhoads, APRN-BC
Michael Turmelle, MD who is the Medical Director of St. Louis Children’s Hospital Children’s Direct, provided an engaging and informative presentation on sedation teams in the hospital setting. He discussed the growing trend of general pediatricians providing procedural sedation.
Dr. Turmelle shared his organizations’ background and experience in developing a sedation program that incorporates “tiered” sedation providers working together to provide various levels of sedation. He expounded upon the range of patients, procedures and tests that pediatric hospitalists sedate for as well as the various settings and situations in which they sedate patients.
He discussed data supported outcomes related to wait times, completion rates, and adverse outcomes. Dr. Turmelle emphasized that starting a sedation service requires a lot of work, and at the same time much needed. Along those lines, it is important that children not be in pain and scared because we cannot provide them with sedation. He concluded with the fact that safe systems, appropriate patient selection, and provider rescue skills are key factors to providing safe, effective, high quality pediatric procedural sedation.
SPS Proposed Standards for Excellence in Sedation Programs
Reviewed by Trish Scherrer, MD
Cheri Landers, chair of the SPS Quality and Safety Committee, reviewed one of the major ongoing projects of the committee: developing standards of practice for high quality pediatric sedation services.
Currently there is a definite need for developing metrics for measurement of quality and excellence in sedation care. We do have robust data on sedation safety from the PSRC database. However, benchmarks for other dimensions of quality care – efficacy, efficiency, patient/family centered care, timeliness, and equitability – remain largely undefined. Therefore, the committee is proceeding with development of the concept of “The Pediatric Sedation Service Center of Excellence,” using benchmarks where and as they become available, but also focusing on describing approaches to achieving high quality care when such metrics are not available. The description is meant to be primarily a consensus statement describing the “ideal” pediatric procedural sedation service and a guide and template for programs wishing to start or build upon an existing service with high quality care as the goal.
As defined by the committee, a Pediatric Sedation Center of Excellence is “a team of pediatric healthcare providers committed to safe and effective pediatric procedural sedation utilizing current best practices in a patient and family centered environment with continual self-review, evaluation, and changes aimed at achieving the highest quality of care with efficient use of limited healthcare resources.”
The Center of Excellence document addresses a number of areas, including general service qualities as well as:
Safety – including a robust patient pre-screening process, standard approach to setup and start of case, outcomes tracking, a case review process, defined emergency response system, and standard monitoring and discharge criteria. The incorporated safety benchmark is that the goals for mortality, cardiac arrest, and unanticipated increase in level of care should be zero.
Efficiency – including minimal waste of resources through appropriate scheduling of patients and staff and tracking of resource utilization and scheduling inefficiencies.
Timeliness – including service availability to avoid significant process delays.
Effectiveness – including monitoring of adequacy of sedation conditions with validated scoring and surveying proceduralists and families. The incorporated effectiveness benchmark is that zero cases are cancelled due to inability to produce effective sedation.
Patient and family centered – including child life specialists, separate pediatric care areas, maximal family presence, standardized methods for communicating with families and including in the scheduling process, specialized policies and procedures for unique. populations such as children with developmental differences, and follow up surveys for feedback from families.
Equitability – including universal pain assessment and management and access to the same types and quality of sedation care throughout the institution.
Credentialing/personnel – including pediatric trained providers and nurses with expertise and significant ongoing experience in pediatric procedural sedation, formal privileging processes, and ongoing practice reporting and critical incident training.
System requirements – including a robust emergency response system, leadership from a designated medical director and sedation nurse manager, and a collaborative and cooperative relationship with anesthesiology and the institutional quality and safety department.
Although it may seem daunting for every institution to reach all of these goals, these do represent the characteristics we feel are inherent to a true “Pediatric Sedation Center of Excellence.”
Child Life: Help with Sedation Process and/or Avoid it Altogether
Reviewed by Lorie Reilly, CRNP
Megan Finney, CCLS described the important roles of child life specialists to promote coping mechanisms and decreased anxiety. She reviewed the key questions used to screen children and their families. The answers to these questions are so important to providing the appropriate support.
Educating children about what to expect is critical, since often their imagination is scarier than the truth. Even a simple explanation of a nasal cannula smelling like a beach ball can help in this preparation. Describe what things will sound and smell like in advance so there are no “surprises.”
The appropriate distraction should be fun, and may simply involve singing verses of “Wheels on the Bus.” Silence is also an important tool as is “one voice” in the room to avoid over stimulation. It is important to remember that teens can be very stoic but they often fear “not waking up.” Quite often, they need the reassurance that someone will be monitoring their breathing.
Ms. Finney highlighted the fact that it is necessary to consider whether a procedure or scan can be done without sedation. The opportunity to avoid the NPO status may be all the impetus that is needed by the teen. She cautioned us to not mention sedation without explaining the procedure, educating and providing teens with options to help them cope. Lastly, even if the support of child life specialists is not immediately available, we can all pitch in to prepare children and families for what to expect. A distraction basket containing simple things such as an “I Spy book” and a bottle of bubbles are helpful tools. Start by tuning up your singing voice……