Published in the June 2009 issue of Today’s Hospitalist
WHILE PEDIATRIC ANESTHESIOLOGISTS have always been in short supply, a recent standard from the Joint Commission has made that problem worse. The Joint Commission now expects providers administering sedation to remain in “close vicinity” to patients and to be present for the first dose of any new medication. That standard and the fact that more procedures and studies are now being done outside the OR have helped open up opportunities for pediatric hospitalists interested in launching sedation services of their own.
A good example can be found at Chicago’s Children’s Memorial Hospital, where all 10 members of the PICU hospitalist team work the sedation service. Laura Badwan, MD, site leader of the PICU hospitalist program, says that providing sedation not only fills an important need, but is a welcome change from her day-to-day work in the ICU.
“A lot of our sedations are for outpatients,” explains Dr. Badwan, whose group has been doing sedations for the past five years. “When clinical care becomes overbearing or you get emotionally involved, it’s nice to step into something more low key and actually see a walking, talking patient.”
Perhaps more importantly, she adds, hospitalist- staffed sedation “as opposed to a service staffed exclusively by anesthesiologists “saves hospitals money and ensures faster service for patients. “You can take care of the patient flow more quickly,” says Dr. Badwan, “and patients get appointments faster because we have more time slots available.”
Dr. Badwan spoke to Today’s Hospitalist about the challenges hospitalists can expect in launching ” and sustaining “a pediatric sedation service.
Can pediatric hospitalists who want to launch a sedation service expect resistance from anesthesiologists?
It depends on how the current services are being run and how much money those services generate. Plus, anesthesia teams aren’t your only potential competition. Some services are run by intensivists, radiologists, emergency physicians or even advanced nurse practitioners.
At our hospital, the anesthesiologists were extremely supportive of the hospitalist sedation service and frequently serve as our advocates. Our hospitalist group sedates patients up to and including ASA class 3, which covers patients with severe systemic disease but not life-threatening conditions. We refer patients in a higher ASA class and those with illnesses that tend to have complications to our anesthesia team, which works the sedation service at least two days a week.
Those patients likely will need a secure airway from the start. We feel comfortable doing sedations when children already have an airway in place, like a trach, but we’re hesitant to sedate children who have any kind of facial anomaly or known airway problem.
One decision you need to make is what level of sedation the hospitalists will provide. At Children’s, we provide minimal to deep sedation. The historical struggles that hospitalists seem to have with anesthesiologists are over what medications the hospitalists are allowed to use.
In the past, for instance, ketamine was a drug that only anesthesiologists could use, but now it’s used by pediatricians across the board. The current debate involves the medication propofol.
Does you group use propofol?
We do not, but that’s not standard across the country, and I’ve heard of other hospitalist groups using it. At this point, we have a stable group with very low turnover. The anesthesiologists have said that it would be OK for our group to use it if we first undergo a training program.
Among the medications we now use are pentobarbital, chloral hydrate, ketamine, versed and fentanyl.
What are other challenges getting a service up and running?
You need to have qualified personnel, and you need to have enough of them. You need physicians who are comfortable administering these medications and resuscitating patients.
Initially, the number of physicians available to staff the service can be an obstacle because you may not have many patients at first. But if you provide the service, it will grow, so you “and the administration “need to be patient.
Part of staffing is making sure that physicians are available for the pre-sedation assessment, which is close to a full history and physical and an exam, paying particular attention to the airway and any past sedation experiences. On average, we spend between 15 and 30 minutes per patient. You also obviously need the other staff associated with the service: nurses comfortable with sedation and medical imaging technicians who are familiar with kids.
Billing is another issue. Some states allow you to bill anesthesia codes for sedation, while others let you bill only moderate sedation codes. Depending on which state you’re in, you may be billing a bit less than anesthesiologists, even though you’re technically providing the same service. Find out what billing your state allows for sedation and anesthesia.
What issues do groups with established services grapple with?
Balancing staffing is always an issue: figuring out how many cases you have and how many physicians you need. Then there’s keeping up with new medications. Some groups now use nitrous oxide, while others are starting to use dexmedetomidate and propofol, to name two.
You also have to know your limits, especially sedating sicker children. At Children’s, our sedation hospitalists also work in the ICU, so we’re all comfortable establishing or maintaining airways. But in the sedation lab, you have to respect those boundaries and say, “I’m going to refer this to somebody else.”
You need to know about the patients you’re sedating and their sedation history, which can sometimes be a challenge. People can become too cavalier or they become too afraid to sedate anybody except a normal, healthy patient.
You also need to be able to address children with special needs “autism or those who are hearing impaired “who certainly come to tertiary academic centers. In those situations, you have to work closely with the family or child life specialists.
What are the training requirements for physicians?
At this point, those depend on the institution. The Society for Pediatric Sedation is currently working to establish guidelines for training requirements.
At Children’s, we do training twice a year and a lecture series, and we’re fortunate to have a simulation lab. When you’re first starting out, you have to shadow a physician for a couple of days and perform at least five supervised sedations before you’re on your own. We also require new hospitalists to shadow an anesthesiologist either in or outside of the OR, paying special attention to airway management.
How has doing sedation affected your clinical work?
I’ve been pleasantly surprised at how much I’ve enjoyed sedation, but it’s made me think twice or three times before I order scans.
When I was a resident, I used to order scans all the time and never once thought about what happens after I wrote the order. But now I know that it’s a big deal for a family and a whole day for children who have to go without food or fluids. Before I order a scan now, I think, “Does this child really need it? Does the risk of sedation outweigh the benefit of performing the scan?”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
A snapshot of one pediatric sedation service
FOR THE PAST FIVE YEARS, the PICU hospitalist group at Children’s Memorial Hospital in Chicago has been staffing a sedation service. Here’s a look at what kind of sedation service and coverage the group provides:
Number of physicians: All 10 full-time members of the group are trained to work the service, as are several moonlighting pediatricians. The group provides the service not only at Children’s Memorial, but at several nearby outreach clinics and a suburban hospital campus.
Who they sedate: The pediatric hospitalist group sedates up to and including ASA class 3 outpatients and inpatients, which includes patients with severe systemic disease. The pediatric hospitalists provide minimal to deep sedation and refer patients in a higher ASA class or those with special airway needs to their anesthesiology team.
Service coverage: Physicians are assigned in-house to the service from 7:30 a.m. to 10 p.m., then take call for the service from home. Sedation services on Sundays are on-call only.
Service volume: During the week, the service typically performs between eight and 15 sedations per day, with fewer cases scheduled on Saturdays.
Medications used: Pentobarbital, chloral hydrate, ketamine, versed and fentanyl.