SPS Plenary Session | May 20, 2019, 8:45 am | Dr. Vanessa Olbrecht and Dr. Michael Turmelle
Dr. Michael Turmelle, hospitalist, and Dr. Vanessa Olbrecht, anesthesiologist, presented the privileging processes from their respective institutions (Washington University, St. Louis Children’s Hospital and Cincinnati Children’s Hospital) along with the challenges associated with their environments, and they proposed an ideal state for us to aspire to for privileging providers to provide pediatric procedural sedation.
Cincinnati Children’s Hospital has no dedicated sedation service; therefore, procedural sedation is provided by a multitude of sub-specialties outside of the ICUs. These specialties are limited to provide sedation to patients classified as ASA I or II and the providers must be attendings.
There is a process that was develop for APRNs that is only for patients with previously secured airways, but as yet no APRN has gone thru the privileging process. Privileging includes having residency training in a specific field, doing 10 sedation cases in a year with supporting documentation, and completing an education module which is focused on hospital policy as well as an exam on this module with an 80% correct score. For re-privileging, providers need to show evidence of 20 sedation cases over 2 years with appropriate documentation.
The challenges that Cincinnati has encountered are: the range of supervision the initial 10 cases receive is variable; the number of the initial cases is not based on any evidence but was chosen purely for logistical reasons; their patients are increasingly complex; management of complications in the first 10 cases are rare; and, there is no real education provided on patient care since the education module is policy based. In addition, there is no real assessment of competence.
St. Louis Children’s has a hospitalist sedation team with two physical sedation units. They also provide an on call after hours service and provide sedation in the ED setting. Anesthesia, critical care and emergency medicine providers all provide sedation in their units. To be privileged, providers must have completed a residency and must either complete training in sedation involving pre-sedation assessment, medications, etc. in residency or complete an approved training sequence with didactic and practical components, do 20 cases in 12 months supervised in the ED setting, and have quality outcomes that meet anesthesia chief guidelines as a hospitalist.
Completing these things gets the provider sedation privileges but not a position on the sedation service. To get on the sedation service they must be on the ED team for one year, as well as having 4 days of orientation in each unit and five days of training in the OR (BVM/intubation in high turnover rooms).
The presenters moved from privileging to monitoring quality in the systems. Quality standards are set by the Joint Commission and/or Center for Medicare and Medicaid Services, but these are broad guidelines and much is left for interpretation and for the individual hospital to organize. This process is typically done thru an anesthesia-led sedation and pain committee with members from multiple disciplines. Both organizations currently use Epic as their EMR.
Prior to Epic, quality monitoring was done by entering events on paper QI sheets that were entered onto spreadsheets and brought to the Sedation committee for discussion. In Epic, sedation documentation includes event checkboxes that can be queried, and the data is again brought to the sedation oversight committee.
The Ideal State
Dr. Olbrecht went on to describe an ideal state of privileging for pediatric procedural sedation that Cincinnati is working towards. This would include three pillars of privileging: education, simulation, and experience. To do this requires comprehensive documentation from which information can be extracted for assessment of safety/adverse events and quality improvement.
First, education is broken into two components; didactic and simulation.
Didactic: focus on policy and practice and include case-based learning
Simulation: standardized scenarios which should address the most common events that occur but that are not so common that they will occur in the 10-20 cases typically required in current privileging procedures. Allows assessment of basic competencies.
***Another shameless plug*** The SPS Sedation Provider course provides didactic and simulation training exactly as described and Cincinnati is anticipating using that course to provide training some way to its providers.
The documentation of sedation should be a stand-alone sedation module, much like the anesthesia record, which includes hard stops for pre-sedation screening that identifies patient risk factors warranting referral to other providers and with the ability to identify events (get reports).
The challenge of this ideal state is its feasibility for healthcare systems with limited resources (i.e. all healthcare systems). Providing didactic and simulation training to all providers (over 100 in Cincinnati) is an immense undertaking. Currently there is no stand-alone sedation documentation module and there have been challenges to get adverse event data pulled from EMRs.