Meeting Summary 1st Meeting of the Pediatric Sedation
Research Consortium – Hotel Sofitel – Chicago Il
May 17th, 2003

Int...
Assistant Professor
Pediatric Intensivist (Pediatrics background) and Medical Director of our Pediatric
Procedural Sedatio...
P.O. Box 269
Wilmington, DE 19899
(302) 651-4530
fax (302) 651-4736
 mrhoads@nemours.org

Rosemary Orr MD
Associate Profes...
lederm@pediatrics.ohio-state.edu

Jill A. Fitch MD
Critical Care Medicine
Columbus Children's Hospital
700 Children's Driv...
Avera McKennan Hospital
911 E. 20th St
Suite 102
Sioux Falls, SD 57105
Arvind.Kasaragod@mckennan.org
Phone: 605.322.3440

...
– should be confidential to the rest of the group. It was also agreed that no one person in
the consortium should know the...
is no specific sedation service provided by the hospital but there is common credentialing
and guidelines for sedation in ...
12-1500 cases done per year in the hospital as a whole. Patients are screened by an
intensivist. Extremely complex problem...
out of the PICU. About 1500 sedations per year are provided. A common data flow sheet
is used. He noted that sedation is s...
easy. Essentially when done, only the bold categories would be seen initially – clicking on them would
bring up a pull dow...
•    Ex Premature infant (< 30 weeks and delivery and < 52 weeks post conceptual age at the time of the
         procedure...
• Botox injection
    Nerve/Brain/ear
   • Brainstem Auditory Response Test
   • EMG
   • EEG
  Surgical or Invasive Proce...
• Succinylcholine
    Inhaled Anesthetics
    • N2O
    • Sevoflurane
    • Halothane
    Sedative/Analgesic Reversal Agen...
Q: Choose route of medication delivery for Chloral hydrate.
    • PO
    • Rectal
    • Total dose

Q: Inspired % of N2O

...
•    Other
    •    None

Q: Specify other type of monitoring used during the procedure.

 (text field provided)

Q: Selec...
•    Emergency Medicine Physician
    •    Pediatric Emergency Medicine Physician
    •    Anesthesiologist
    •    Pedia...
•    Blood Pressure < 50% baseline
    •    Heartrate < 50% baseline
    •    Dysrhythmia

    Neuro
    • Seizure
    • D...
•   Peds floor
    •   ED
    •   Critical Care
    •   Peds/specialty clinic
    •   OR
    •   Radiology
    •   Cath la...
Once again it was emphasized that full disclosure of grants made in the name of the
consortium should be made and a full a...
the leadership of the group be shared between individual of different specialties and that
no one person dominate the grou...
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Meeting Summary 1st Meeting of the Pediatric Sedation ...

  1. 1. Meeting Summary 1st Meeting of the Pediatric Sedation Research Consortium – Hotel Sofitel – Chicago Il May 17th, 2003 Introduction: Dr. Cravero began the meeting by welcoming the participants and informing them of the history of the formation of the Pediatric Sedation Research Consortium. Essentially the origin of the group began with a multispecialty conference on pediatric sedation held in Sept 2000 at Dartmouth Hitchcock Medical Center under a grant from AHRQ ( See Dartmouth Pediatric Sedation Summit on http://an.hitchcock.org/pedisedation/). The formation of this group is an outgrowth from that conference where it was felt that more information sharing would be essential to any improvement in the provision of pediatric sedation in the United States. More importantly we felt that the only way to bring the practice of pediatric sedation forward at this point was to form a group that would allow sharing of national/international data on the subject of pediatric sedation. Subsequent to this introduction members of the consortium who were present introduced themselves. They included: Joseph Cravero MD Associate Professor of Anesthesia and Pediatrics Children’s Hospital at Dartmouth Hitchcock Medical Center One Medical Center Drive Lebanon, NH 03756 603-650-2908 Joseph.Cravero@Hitchcock.org George Blike MD George.Blike@Hitchcock.org (all other info same as above) Kristine Cieslak, MD Senior attending physician Cook County Children's Hospital Department of Pediatric Emergency Medicine Cook County Children's Hospital Chicago,IL 60612 (312)633-5355 ED (312) 760-0608 page (312) 572-3717 fax klcieslak@aol.com John Berkenbosch, MD
  2. 2. Assistant Professor Pediatric Intensivist (Pediatrics background) and Medical Director of our Pediatric Procedural Sedation Service Child Health, Pediatric Critical Care University of Missouri-Columbia One Hospital Dr. Columbia, MO 65212 Phone: 573-882-6544 Fax: 573-882-2742 berkenboschj@health.missouri.edu Kevin M. Creamer M.D. LTC, MC Medical Director of PICU and Pediatric sedation Unit Walter Reed Army Medical Center 6900 Georgia Ave N.W. Washington DC 20307 202-782-2826 Office 202-782-4326 Fax Kevin.Creamer@NA.AMEDD.ARMY.MIL Barry Gelman, M.D. Associate Professor of Clinical Pediatrics University of Miami School of Medicine PO Box 016960 (R131) Miami, FL 33101-6960 305-585-6051 Fax 305-325-0293 BGelman@med.miami.edu James Hertzog, MD Pediatric Intensivist Department of Anesthesiology and Critical Care Medicine Alfred I. duPont Hospital for Children 1600 Rockland Road P.O. Box 269 Wilmington, DE 19899 (302) 651-5390 fax (302) 651-5365 jhertzog@nemours.org Michelle Rhoads, MSN, CRNP Sedation Advanced Practice Nurse Day Medicine Unit Alfred I. duPont Hospital for Children 1600 Rockland Road
  3. 3. P.O. Box 269 Wilmington, DE 19899 (302) 651-4530 fax (302) 651-4736 mrhoads@nemours.org Rosemary Orr MD Associate Professor of Anesthesiology and Pediatrics, University of Washington Attending Anesthesiologist and head of Sedation Services Children's Hospital Regional Medical Center Seattle, WA 98105 Tel 206 987 2123/987 2047 rosemary.orr@seattlechildrens David M. Polaner, MD, FAAP Attending Pediatric Anesthesiologist The Children's Hospital 1056 East 19th Avenue, B090 Denver, CO 80218 Associate Professor of Anesthesiology University of Colorado School of Medicine voice: 303-861-6226 fax: 303-837-2899 polaner.david@tchden.org david.polaner@uchsc.edu Lynne G. Maxwell, MD Department of Anesthesiology/Critical Care Medicine Children's Hospital of Philadelphia #9331 Main 34th St. and Civic Center Blvd. Philadelphia, PA 19104 ph: 215.590.3842 fax: 215.590.1415 email: maxwell@email.chop.edu Maxwell@email.chop.edu Marc S. Leder,MD Assistant Professor of Clinical Pediatrics Attending Physician, Pediatric Emergency Medicine Children's Hospital 700 Children's Drive Columbus, Ohio 43205 Phone: (614) 722-4386 Fax: (614) 722-4380
  4. 4. lederm@pediatrics.ohio-state.edu Jill A. Fitch MD Critical Care Medicine Columbus Children's Hospital 700 Children's Drive Columbus Ohio 43205 Office 614-722-3441 Fax 614-722-3443 Fitchj@pediatrics.ohio-state.edu Esther McClure, RN, MSN Nurse Coordinator for Pediatric Sedation Team University of Virginia esther@nexet.net Lia Lowrie, MD Medical Director, Pediatric Intensive Care Unit Rainbow Babies and Children's Hospital Associate Professor of Pediatrics Case Western Reserve University School of Medicine Department of Pediatrics Rainbow Babies and Children's Hospital 11100 Euclid Ave. Cleveland, Ohio 44106-6010 Phone: 216-844-3310 Fax: 216-844-3310 lhl3@po.cwru.edu Desmond Henry MD Chairman, Department of Anesthesia Director, Department of Surgical Services The Children’s Hospital henry.desmond@tchden.org John C. Brancato, MD Assistant Professor of Pediatrics and Emergency Medicine University of Connecticut School of Medicine Division of Emergency Medicine Connecticut Children's Medical Center Hartford, CT (860) 545-9108 (860) 545-9202 fax Dr. Arvind Kasaragod Pediatric Critical Care Services
  5. 5. Avera McKennan Hospital 911 E. 20th St Suite 102 Sioux Falls, SD 57105 Arvind.Kasaragod@mckennan.org Phone: 605.322.3440 Discussion of Mission Statement and Organizing principles (please see the mission statement and organizing principles on the website for the consortium) After informal introductions a focused conversation ensued concerning the organizing principles of the group (available on the website as well). All present agreed to the principles which emphasize the collaborative nature of the group and the “equal” nature of all the partners. Dr Polaner pointed out the need to use the language “what is feasible resources” rather that “economically practical” when referring to the idealized structures for sedation care. Dr. Blike pointed out the fact that all businesses and organizations need to deal with the fact that safety/protection must live in tension with “production” in order to have a viable entity. The absolute best safety may require resources that make adequate production for economic viability impossible. We proceed understanding that pediatric sedation operates in this type of environment. Dr. Cravero emphasized the need to cooperate in terms of publications and grant funding. Since all participants are dependent on the entire group, all papers must include all members as part of the authorship. In addition, all members of the group should be made fully aware of grant request and an accounting of what is done with grant monies must be made to the group each year. In terms of quality improvement, Dr. Birchenbosch emphasized the need for adding “anonymity” to paragraph concerning institutional involvement. Further discussion involved the concept of “benchmarking” internally vs. externally. Comments were then made by several individuals concerning the fact that this group may evolve into one that advocates for better pediatric sedation care – including better reimbursement. Caution was given that the group’s mission would be undermined if it became overly concerned with improving reimbursement. Difficulties involved in obtaining data on all patients in any one institution were discussed. It was pointed out by Dr. Cravero that rather that push for 100% collection from every site in a hospital (although ideal), we should push for 100% collection of data from any sites that participate within a given hospital – (i.e. MRI, CT scan etc.) It is hoped that this would avoid the problem of “selective” data reporting. At this close of this discussion it was agreed that there should be a Chair of the consortium and that there should be committees that served key functions such as overseeing data requests and research proposals. It was agreed that each institution should have ready access to their own information and that of the group as a whole. It was thought to be important that the identity of which institution is sending specific data
  6. 6. – should be confidential to the rest of the group. It was also agreed that no one person in the consortium should know the identity of the institutions submitting each data set. This “key” that would link the data to an institution should rather reside with the data manager at the Bioinformatics Group at Dartmouth. Requests for information and possible identification of sites that have extremely favorable or unfavorable data would have to go through a steering committee and obtain approval prior to being released. The steering committee would have the charge of assuring protection of institutional identification, assuring that requests were reasonable, and that there was no way to achieve the desired improvement of practice without some release of data. Dr. Cravero then presented a brief discussion of the HIPPA implications of the data collection for the PSRC (please see HIPPA presentation on the website for the consortium). He emphasized that the data as described thus far met the description of a “limited data set” under the HIPPA regulations. As such there should be no specific requirement to encrypt the information placed on the database for patient purposes. In addition it may be possible to be exempt from consent requirements although an IRB approval for the project should be sought at each institution. Dr. Cravero also mentioned that in the near future it may be possible to have one institution (Dartmouth) approve the protocol for data gathering and have that approval apply to all the institutions involved in a project such as this. David Polaner pointed out the difficulty that investigators at his institution had in obtaining consent for a data gathering proposal and indicated that Denver may be a difficult institution to get a consent exemption. Discussion of Sites and Sedation Issues The second session of the day began with a general discussion of the different institutions represented at the meeting and the nature of the pediatric sedation practice at those institutions. Dr. Cravero described an anesthesia-run sedation system at Dartmouth that performed approximately 2000 procedural sedations per year. There are sedations performed by pediatric cardiology and the emergency department that are not included in this number but it was thought that this data could possibly collected on the web-based tool. Dr. Maxwell then described the sedation situation at the Children’s Hospital of Philadelphia. She believed that was at least 3000 sedations performed in a wide variety of locations in the hospital with approximately 1000 sedations provided by the anesthesia service which is called for specific patients and specific procedures. There is standard documentation on a scanned data collection tool. QI tracks “unanticipated occurrences”. Anesthesia records are automated and therefore are very different from the data collection obtained by other providers. Barriers to participation include the size of the institution and the huge number of providers involved in the very different areas that deliver sedation. Dr. Henry the described the situation at Denver Children’s Hospital. He heads a multidisciplinary sedation committee that oversees 20 different sedation locations. There
  7. 7. is no specific sedation service provided by the hospital but there is common credentialing and guidelines for sedation in all the areas. Difficult cases can be referred to anesthesiology. Each of the different sedation locations reports quarterly on the number of sedations provided in that venue. He estimated 4000-5000 sedations per year provided at DCH. Current controversies involved that use of ketamine in the emergency department, propofol use by non-anesthesiologists, and CO2 monitoring for all sedations. Dr. Henry highlighted his questions as to how to benchmark sedation practice – local vs. national data to be used? Dr. Rosemary Orr reported on the experience at Children’s Hospital Seattle. A free- standing sedation unit is used for the sedation team. There is sedation committee which reviews forms on occurrences. Sedation forms are completed by non-anesthesia providers, while anesthesiologists complete an anesthesia record. There are 23 areas in which sedation is done. The huge number of individuals involved in the sedation workforce was seen as a barrier to completing the web-based form. Kevin Creamer reported on the current status of Walter Reed Army Med Center. He believed that 12-1300 cases were performed per year. The hospital has a sedation unit run by intensivists. Anesthesiology is involved in failed sedations. A standard form is completed by non-anesthesiologists and an OR record by anesthesia providers. He also described a very well developed sedation training course which includes an on-line power point presentation and PALS certification. The providers are rated by a “color” to reflect their level of sedation training and can only participate in sedation at a level which is approved for their color. Barriers to collecting data included the anesthesia providers who so not use standard forms etc. Columbus Children’s Hospital practice was described by Mark Leder and Jill Fitch. In this institution moderate sedation is generally tried first followed by referral to the ICU sedation service for failed cases. The emergency department takes care of a large number of sedations using ketamine sedation with a very high success rate. QI efforts include a checklist form that is completed on all sedations and a uniform audit form for pediatric sedation. It was estimated that 3000 cases are performed in the radiology department while 400 cases are performed by the ICU sedation team. Thousands of other cases occur throughout the institution – notably in the very busy emergency department. Cape Fear Hospital practice was described by Cindy Fletcher . It was estimated that 1500-2000 cases are performed per year. A nurse practitioner screens patients for sedation and refers to anesthesia in the OR or peds intensivist/ED/PICU for others. Most sedations are overseen by the nurse practitioner with one of these other providers as back- up. There is a common sedation tool for recording data and all individuals are credentialed for sedation by the same process. The same general process for sedation was described for Sioux Falls. University of Miami practice was described by Barry Gelman. Sedation there is practiced in an ICU sedation unit. 600-700 cases per year are done in the unit with a total of
  8. 8. 12-1500 cases done per year in the hospital as a whole. Patients are screened by an intensivist. Extremely complex problems or patients are referred to the OR with anesthesia but access to this system has historically bee a big problem. Jim Hertzog discussed Alfred I. duPont Hospital for Children’s sedation practice. The sedation practice there was reorganized in 1992. A PICU sedation service is available and staffed by intensivists but sedation is practiced in many areas of the hospital. They now perform approximately 2500 sedations per year. There is an online sedation training module. A common tool is used for sedation data from all areas except the PICU and anesthesia. The institution has a well-developed triage and screening process. Flowsheets for sedation are extensive and there are over 14,000 that have been collected over the last 10 years. Esther McClure reported on the current pediatric sedation practice at UVA. There are multiple possibilities for sedation including PO sedation by any one of a number of providers in the institution, sedation by an ICU sedation group, or sedation by anesthesiology. The sedation group performs approximately 800 cases per year while the hospital in total performs as many as 1200 sedations per year. Sedation is provided at the site where the procedure is usually done. Sedation reports are forwarded to the director of anesthesia. John Brancato was present to report on the situation at Connecticut Children’s Medical Center. He estimated 1,500-1,800 sedations are provided by the sedation group there. The sedation team is run out of the emergency department in an area adjacent to the emergency department. Other sedation is provided by a multitude of providers. There is standard data collection on a paper record. ASA class III or worse are referred to anesthesia. Lia Lowry appraised the gathering on the sedation practice at Rainbow Babies and Childrens Hospital in Cleveland. The physical plant includes a free standing 200 bed children’s hospital attached to a University Hospital. Credentialling for deep sedation is very rigorous with providers taking a written course and completing 10 viewed cases on patients where bag-mask ventilation and other airway management is required. An advanced ICU-based sedation unit is in place. She reported that approximately 4000 sedations are accomplished per year and all are captured in a common database. Scottish Rite Hospital (Atlanta) sedation practice was reported by David Fagin and Steven Freilich. The sedation service is largely run by emergency medicine physicians with 4-6000 cases done per year. Most sedations are started by EM physicians and monitored by RN’s. Anesthesia is consulted on extremely difficult situations. There is a common data collection tool used by sedation providers but not by anesthesiology. Collection of anesthesia data was seen as a problem in going forward with web-based data collection. John Berkenbosch discussed University of Missouri’s pediatric sedation situation. They exist as a children’s hospital within a hospital. The sedation service is run by intensivists
  9. 9. out of the PICU. About 1500 sedations per year are provided. A common data flow sheet is used. He noted that sedation is sometimes provided by residents on surgical or other services. Capture of this sedation data will present a major logistical problem. Kristine Cieslak reviewed the sedation situation at Cook County Memorial Hospital. She stated that there was no sedation team per se at her institution. Most sedations were performed by either emergency medicine attendings or anesthesiology. There is apparently a standard flowsheet for sedation, but the practice is very decentralized and she thought that collecting data on a large percentage of sedations performed in the institution would be quite difficult given the variety of individuals involved. At the end of this session George Blike reviewed the sedation numbers put forth by the various institutions involved (at this meeting) and estimated 40,000 sedations were taking place and could possibly be captured. Although this may be optimistic for the participating institutions, it was thought that when all the institutions that were not present were considered, this number was not at all unlikely for a year of data collection. Web Tool Development The next session involved the development of the web-based data collection tool. The discussions involved in this 4 hour long process are too detailed to completely review here. I will present the tool that resulted from the discussion with notes in italics that indicate key points that were made. Almost everyone present reported that they had used the preliminary form of the tool and that it had worked will on their system. We then proceeded with a question by question discussion of what should and should not be included for outcome data. There was a lot of discussion on almost every question. It was generally agreed that the tool should not take more than a few minutes to complete for any one patient. In the end it was thought that we would come up with a comprehensive tool and trial it extensively before deployment. Questions that were not considered critical would be eliminated as needed to edit the data to that which was possible to enter in the acceptable amount of time. Q: Age (select appropriate age range, then enter number of months or years in text box). Age in months (0 - 35) Age in years (3 - 18) Q: Enter patient weight in kilograms. (field for entry of number provided) Q: What is the patient's gender? Male Female Q: Select any coexisting medical problems. (A very detailed discussion on the various entities to be included took place. As the list grew, it was decided that we would break the list down into categories so that scrolling through would be quick and
  10. 10. easy. Essentially when done, only the bold categories would be seen initially – clicking on them would bring up a pull down list of the entities below.) None Metabolic • Failure to thrive • Dehydration • Renal failure • Inborn error of metabolism • Metabolic disorder • Diabetes • Obesity Gastrointestinal • GI bleed • GERD • Vomiting • Cardiovascular • Congenital heart disease cyanotic • Congenital heart disease non-cyanotic • arrhythmias • Cardiac disease (other) Heme/Onc • Leukemia • Mediastinal mass • SS disease • Brain Tumor • Mediastinal Mass • Hem/Onc (other) Neurological • CP • Seizure disorder • ADHD • Neuromuscular disease - hypotonia • Developmental delay • Autism Respiratory - Upper Airway • Snoring • Croup • Cough • Tracheostomy • URI • Stridor Respiratory - Lower Airway • Cystic fibrosis • Pulmonary (other) • Asthma history • Wheezing • Pleural disease Prematurity Related • Apnea • BPD • Cardiorespiratory monitoring at home
  11. 11. • Ex Premature infant (< 30 weeks and delivery and < 52 weeks post conceptual age at the time of the procedure) • Ex Premature infant (< 36 weeks at delivery and < 52 weeks post conceptual age at the time of the procedure) Craniofacial abnormalities • Unusual facies • Pierre Robin sequence • Microagnathia • s/p craniofacial surgery S/P Trauma – in the last 24 hours or reason for current hospitalization Liver disease ASA status III-IV s/p transplant Immune compromise Burn injury Q: Specify other coexisting medical problems. (text field provided) Q: Select the procedure to be performed. (Once again this will consist of the bold fields and the subcategories will only come up when the bold field is clicked) Radiology • Venogram/arteriogam • PICC line placement • MRI/MRA/MRV/MRS • CT (diagnostic and interventional) • Bone scan • VCUG • Ultrasound body • Transthoracic echo • Nuclear scan - Bone or Renal • PET scan Cardiology • Cardiac cath (diagnostic) • EP • Interventional cardiac cath • TEE • Pericardiocentesis • Cardioversion Gastroenterology • Colonoscopy • Upper endoscopy • Wound/burn care • Bronchoscopy • Liver biopsy • Manometry Hematology/Oncology • Bone Marrow Aspiration/Biopsy • Lumbar Puncture/intrathecal meds • Radiation therapy Bone and Joint/Skeletal • Fracture Reduction • Joint injections/aspiration • Joint reduction
  12. 12. • Botox injection Nerve/Brain/ear • Brainstem Auditory Response Test • EMG • EEG Surgical or Invasive Procedures • Central line placement • Central line removal • Arterial line – peripheral • Laceration Repair • Burn dressing changes • I & D of abscess • Peritoneal dialysis catheter placement • Renal biopsy • Chest tube/thoracentesis Ophthalmology exam Dental examination/treatment Foreign body removal (ear or nose) Sexual abuse exam Other Q: Specify other procedure to be performed. (text field provided) Q: Select medication used. Sedatives • Propofol • Midazolam • Ketamine • Pentobarbital • Chloral hydrate • Remifentanil • Valium • Etomidate • thiopental • Ativan • Methohexital • Dexmedetomidine • DPT combination Analgesics • Fentanyl • Morphine • Meperidine • Alfentanil Local Anesthetics • Lidocaine • Bupivacaine • EMLA cream • Ionterphersis on lidocaine Muscle Relaxants • Nondepolarizing Muscle relaxants
  13. 13. • Succinylcholine Inhaled Anesthetics • N2O • Sevoflurane • Halothane Sedative/Analgesic Reversal Agents • Naloxone • Flumazenil Antiemetics • Ondansetron • Hydroxyzine • Reglan Anticholinergics • Glycopyrrolate • Atropine Inhaled Meds • Albuteral • Racemic Epinephrine Distraction Techniques • Other (these questions will only appear if you have clicked on the appropriate medication from the list above. Total dose was the only number thought to be clinically relevant given all of the other confounders in this data collection. Investigators who had tried to track this before reported that dose data added little to sedation evaluation) ) Q: Propofol total dose • Bolus • Infusion Q: Choose route of medication delivery for Fentanyl. • PO • IV • IM • Intranasal • Total dose Q: Choose route of medication delivery for Midazolam. • PO • IV • IM • Intranasal • Total dose Q: Choose route of medication delivery for Ketamine. • PO • IV • IM • Total dose Q: Pentobarbital total dose
  14. 14. Q: Choose route of medication delivery for Chloral hydrate. • PO • Rectal • Total dose Q: Inspired % of N2O Q: Total dose for Remifentanyl. Bolus Infusion Q: Choose route of medication delivery for Morphine. • IV • IM • Total dose Q: Total dose of Etomidate. Q: Total dose of Pentathal Q: Choose route of medication delivery for Ativan. • PO • IV • IM Total dose of Ativan Q: Choose route of medication delivery for Glycopyrulate. • IM • IV • Total dose Q: Choose route of medication delivery for Lidocaine. Sub Q IV Topical Q: Rocuronium dose. Q: Succinylcholine dose. Q: Specify other medication used, and its route of administration. (text field provided) Q: Indicate type of monitoring used during the procedure. • SPO2 • ECG • BP • ETCO2 • BIS • Pleth • Precordial steth
  15. 15. • Other • None Q: Specify other type of monitoring used during the procedure. (text field provided) Q: Select type of provider responsible for the sedation. • CRNA • APRN/PNP • Anesthesiologist/intensivist • Intensivist- Pediatrician • Pediatrician - subspecialist • Emergency Medicine Physician • Pediatric Emergency Medicine Physician • Anesthesiologist • Pediatric Anesthesiologist • Radiologist • Pediatric Radiologist • Dentist • Pediatric Dentist • Oral Surgeon • House staff • PA/Anesthesia Assistant Q: Select type of provider actually delivering the medication: • Medical Technologist – or equivalent training • RN • CRNA • APRN/PNP • Anesthesiologist/intensivist • Intensivist- Pediatrician • Pediatrician - subspecialist • Emergency Medicine Physician • Pediatric Emergency Medicine Physician • Anesthesiologist • Pediatric Anesthesiologist • Radiologist • Pediatric Radiologist • Dentist • Pediatric Dentist • Oral Surgeon • House staff • PA/Anesthesia Assistant Q: Select type of providers monitoring the patient (present for monitoring during the case. • Medical Technologist – or equivalent training • RN • CRNA • APRN/PNP • Anesthesiologist/intensivist • Intensivist- Pediatrician • Pediatrician - subspecialist
  16. 16. • Emergency Medicine Physician • Pediatric Emergency Medicine Physician • Anesthesiologist • Pediatric Anesthesiologist • Radiologist • Pediatric Radiologist • Dentist • Pediatric Dentist • Oral Surgeon • House staff • PA/Anesthesia Assistant Q: Was the sedation supervisor also performing the procedure? Q: How would you describe the conditions produced with regard to procedure completion? • Unsuccessful - could not perform procedure • Procedure performed - conditions not ideal • Ideal conditions - patient calm and still during procedure Q: Sedation start time (giving the drug) (field for entry of number provided) Q: Procedure end time – (field for entry of number provided) Q: Discharge time (return to previous care location) – (field entry for number provided. Q: Indicate any side effect or complication that occurred. None Respiratory • Apnea > 15 seconds • Unplanned intubation or • positive pressure ventilation • Desaturation: O2 Sat (below baseline) for greater than 60 seconds • Vomiting • Aspiration Need for reversal • Use of reversal agent for opiates • Use of reversal agent for benzodiazepines Airway • Emergency airway consultation required • laryngospasm • Delirium/agitation Cardiac Related • Cardiac Arrest
  17. 17. • Blood Pressure < 50% baseline • Heartrate < 50% baseline • Dysrhythmia Neuro • Seizure • Death related to sedation • Prolonged recovery time Unintended deeper level of sedation Unplanned admission to hospital or increase in level of care due to sedation Other Q: (if desat is clicked) What was the lowest level of O2 saturation. • < 90% • < 80% • < 70% Q: Specify other side effect or complication that occurred. Q: When did complication occur? Preprocedure/intraprocedure/transport/recovery/remote to procedure Q: Was the procedure aborted because of problems with sedation? Yes/No Q: What was the NPO status (in hours) at the time of sedation with respect to clear liquids? • <2 • 2 • 4 • 6 • >= 8 Q: What was the NPO status (in hours) at the time of sedation with respect to solids and non-clear liquids? • <2 • 2 • 4 • 6 • >= 8 Q: Airway management required during the case? • O2 mask or nasal cannula only • Repositioning • Oral airway • NP airway • Jaw thrust • LMA • ET tube Q: Location of sedation: • Sedation Unit
  18. 18. • Peds floor • ED • Critical Care • Peds/specialty clinic • OR • Radiology • Cath lab • Other Transport during sedation? Yes/no Finances: Dr. Cravero reviewed the current status of the financial underpinnings of the consortium. To date the group has been supported by the Department of Anesthesiology at Dartmouth Hitchcock Medical Center. Money has been spent to create the sample web-based data collection tool ($2500) and the incidental expenses for this meeting ($1500). Ongoing expenses for the group will include further development and deployment of the data collection tool. In addition there will be costs associated with maintenance of the data and generation of reports. The estimated cost to fully fund the consortium for the first year would be about $10,000. It is possible that work could continue on development of the web-based data collection tool for less money, but deployment and data maintenance with full functionality would be somewhere in this neighborhood. Dr. Cravero emphasized the point that grant funding for the project should be forthcoming and that future function of the consortium should be made possible with some type of funding mechanism. It was emphasized that grant funding would not be available until Jan 2004 at the earliest and other forms of seed money should be sought to “keep the ball rolling” until some other income can be found. Dr. Cravero suggested that each institution participating in the consortium could be asked to donate $500-1000 for the first year. In the scope of most hospital budgets this would represent a modest contribution and in return each institution would receive the use of the web-based sedation tool and access to comparative information on sedation activity within the group. Several members of the group agreed that this should be possible from their institution – if the “pitch” was made correctly. NPSF Grant: As part of this discussion, Dr. Cravero and Blike presented a letter of intent that was written to the National Patient Safety Foundation (NPSF). The letter has been made available on the web. This letter asked for two years of funding for a total of $100,000 for data management expertise and for organizational time (Cravero). The goal as stated in the letter is to collect information on the practice of pediatric sedation across several specialties and in a wide geographic distribution with the goal of identifying best practice. Future years would be spent on modeling excellent practice and deploying changes in some of the member institutions while others retain their current practice.
  19. 19. Once again it was emphasized that full disclosure of grants made in the name of the consortium should be made and a full accounting of the grant money should be made to the group each year after a grant has been awarded. Affiliations: Dr. Cravero explained that he had discussed (with the AAP Section on Anesthesiology and Pain Management – specifically Dr. Polaner) the idea of working with their committee on quality assurance to obtain their endorsement for the PSRC. There were few comments from the group on this subject. It was generally agreed that this type of endorsement would be helpful but only so long as it came with no “strings” attached. Specifically it was felt that we do not want a particular group forcing us in any direction we do not want to go – or pushing a specific agenda. Conclusion: . Several members present brought up the possible difficulty of numbering the patients as they were entered into the data base. It was concluded that each site within a given institution would have a unique identifier and a system would have to be put in place to be sure that the next sequential number was used for each patient entered at each site. This was recognized as a significant problem that will likely take some time and effort by the PI at each institution to solve for themselves. It was agreed that information will need to be shared each step of the way as solutions to these logistical problems are pioneered. Future Meeting: Dr. Cravero suggested the idea that a multispecialty meeting on pediatric sedation by entertained as the site for the next PSRC meeting. Denver and Columbus Ohio were mentioned as possible meeting venues for the first annual meeting of the PSRC in combination with a pediatric sedation meeting. The ideal would be to have a one or two day meeting on sedation with speakers from various specialties on different aspects of pediatric sedation (credentialing etc.) The meeting would then provide a forum for a one day meeting of the PSRC for participating members. This suggestion was greeted with general approval as many thought such a meeting would be helpful and widely attended. Many suggestions were made as to how to publicize the meeting on various list-serves etc. Structure of PSRC At the end of this process there was a brief discussion of issues to be decided for the “structure” of the PSRC. Esther McClure then suggested that we should name individuals to the positions in the structure of the PSRC. At this Joe Cravero offered to serve as the chairman of the group for a two year term. George Blike will serve as Co- chair and assistant for the group during that time. Dr. Cravero reiterated his concern that
  20. 20. the leadership of the group be shared between individual of different specialties and that no one person dominate the group for any significant period of time. Committee appointment were made (fairly informally) and it was agreed that other members could easily be added and the make-up of the committees could change with time. The Data Management Steering Committee was appointed: Lia Lowrie Lynne Maxwell John Berckenbosch Mark Leader Esther McClure Annual Meeting Committee: David Polaner Jill Fitch Kevin Cream Jim Hertzog was asked to head up the research oversight committee. All in attendance agreed that it was too late to tackle any other issues at that point and the group adjourned for dinner at the Rosebud Restaurant in Chicago. JPC

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