SPS Plenary Session | May 20, 2019, 12:15 pm
Moderator – Deb Faulk, MD | Presenters – Troy Sands, MD; Carmen Sulton, MD
The holy grail of any service line is providing the same level of care and customer service 24/7/365, and this is particularly true when caring for children. A panel of sedation experts provided insight into how various institutions have tried to confront this challenge. Dr. Mike Turmelle from Washington University/St. Louis Children’s Hospital described a full coverage model that uses multiple practitioner types to sedate varying ASA level patients in different clinical venues. This is accomplished by having specific training requirements for practitioners that provide deep sedation and provide care for ASA level 3 or higher. Practitioner coverage is shared by anesthesiology, hospital medicine, and emergency medicine depending on procedural urgency and patient acuity. In addition to patient outcome metrics, utilization rate and procedural success are tracked. Dr. Turmelle acknowledged increasing challenges as the PHM service provides coverage across more than one campus. The details of this institution’s comprehensive training program were published in the Journal of Hospital Medicine in 2012.
Dr. Sands from CHMCA outlined an approach to meeting procedural sedation for multiple clinical venues while ensuring consistent care between daytime and after hours. Transitioning to block scheduling maximizes effective scheduling of elective cases while leaving open slots for unscheduled cases from overnight admissions or overflow from the ED. Additionally, using similar block calls for practitioners ensures accurate matching of patients and physicians.
But perhaps the most effective change was to define the requirements for an after-hours sedation – the test result must change management. Imaging studies were protocolized to ensure fastest test times, emergent vs. urgent was defined so as to ensure correct choice of anesthesia vs sedation, and finally, non-pharmacologic strategies were taught to ensure that these alternatives could be maximized particularly in cases of shortened NPO times.
Dr. Sulton from CHOA emphasized performing a needs assessment to identify institution-wide service demands and how they can be matched with available practitioners. Mapping that construct to include patient candidacy and ensuring minimal impact on patient workflow in the ED can facilitate more accurate determination of the need for anesthesiology or critical care resources.
All programs underscored the need for balancing the indication for after-hours procedural sedation with practitioner availability, recognizing that under-utilization of this service would fail to demonstrate value. However, failure to provide this service could negatively impact patient care.