Kamat et al. presents a well-written manuscript describing the state of pediatric procedural sedation programs belonging to the Society for Pediatric Sedation (SPS), with data derived from a survey administered to sedation program directors belonging to the SPS in 2014. Results described the growing diversity of providers practicing pediatric procedural sedation (PPS). The majority of respondents (78.1%) reported having pediatric critical care physicians in their sedation program. Programs also employed providers specializing in pediatric anesthesia (26.8%), pediatric emergency medicine (23.4%) and pediatric hospital medicine (19.5%). 36 percent of respondents stated that all sedation providers in their program received specialized sedation training, most commonly an “elective” in sedation (58.3%). The majority of institutions (80.5%) required special credentialing to practice PPS, most often obtained through a primary specialty (78.7%).
This article provides insight into the provision of PPS and the components of privileges at 41 institutions. It also offers a foundation on which we can base many follow up questions to improve our understanding of the current state of PPS providers and the components of credentialing and privileging for this practice.
I agree with the authors’ suggestions that the increasing demands for PPS, variability of provider training and experience and concerns about sedation safety should motivate us to improve our understanding of PPS practice. The intent of this type of study is to understand the nuances of (1) the process and components of deep sedation privileges, and (2) physician background and training, in order to demonstrate the variability in the landscape of training, skills and experience current PPS providers bring. As the authors suggest, this knowledge can help in the development of benchmarks and standards for the field of PPS, to ensure that all providers, regardless of training background, have a shared mental model of best practices in sedation. To move forward in this arena, we must ask more specific questions to determine how providers from various backgrounds can acquire suggested competencies for delivering sedation, particularly deep sedation1. As my mentor, Greg Hollman, counseled me during my sedation training, “the devil is in the details”.
For example, a recent manuscript by Couloures et al., showed no statistical difference in major complication rates based on the specialty board certification of the sedation provider2. While reassuring, board certification does not provide a complete picture of the duration, context and currency of sedation training an individual provider has experienced. Additionally, the authors discussed that the study did not evaluate depth of sedation or range of medications used, and thus did not fully assess the safety of propofol sedation stratified by provider board certification, which is likely the biggest question that comes up at the institutional level when determining who can be credentialed for propofol sedation.
If we better understand the complexity of competency as it relates to training and background, we can begin to discuss topics that will further advance the field. We know that PPS can be conducted safely, but can it be safer? Should there be a minimum number of sedations needed to be privileged and to maintain privileges? More complex questions entail balancing sedation risk and safety when resources are insufficient or indications for a procedure/sedation are dubious. Finally, what additional tools are required to assess quality? Recent work takes quality and our ability to competently achieve high quality sedation to the next level, by measuring sedation states, patient pain and anxiety3, but how do we ensure providers are meeting these standards?
The questions I pose are shaped by my own experience and background in pediatric hospital medicine (PHM). PHM was recently approved by the American Board of Pediatrics as a subspecialty in the field of pediatrics. Consequently the time is ripe to develop a shared model of the necessary components for training sedation providers, and to determine the role this training may have in PHM fellowships. As the need for PPS providers continues to increase, we should consider how to purposefully train PHM physicians to provide this service.
While we come from different backgrounds, all sedation providers have the same patient centered goals: to safely complete the procedure, while minimizing patient anxiety and pain. However, we each bring different perspectives and experiences from our respective training programs. By better understanding this diversity and embracing numerous perspectives, we can work together to move sedation forward to an even safer, standardized, and evidence-based field. The article by Kamat advances us in that direction by helping to answer who we are, and by providing a starting point for future work.
- Core Competencies for Pediatric Providers Who Deliver Deep Sedation. http://www.pedsedation.org/resources/quality-safety/core-competencies/.
- Couloures KG, Beach M, Cravero JP, Monroe KK, Hertzog JH. Impact of provider specialty on pediatric procedural sedation complication rates. Pediatrics. 2011;127(5):e1154-1160.
- Cravero JP, Askins N, Sriswasdi P, Tsze DS, Zurakowski D, Sinnott S. Validation of the Pediatric Sedation State Scale. Pediatrics. 2017;139(5).