The use of pediatric procedural sedation (PPS) has grown over the past 3 decades (1). The growth in this practice is likely due to changing perceptions of pain and discomfort in children (2–4), and the logistical advantages of being able to perform procedures outside the operating room. One of the pediatric specialties involved in providing sedation has been Pediatric Critical Care Medicine (PCCM). PCCM fellows are required to be proficient in the sedation of pediatric patients; however, the Accreditation Council for Graduate Medical Education (ACGME) does not specify how this proficiency is to be obtained (5). Although the ACGME specifies the number of admissions, daily census, and caseload mix for PCCM fellowship program accreditation, there are no similar requirements for procedural sedation training (5).
The American Academy of Pediatrics, American Academy of Pediatric Dentistry, and ASA have provided guidelines (1 , 6) on the provision of PPS, but these guidelines also do not address how proficiency is to be obtained or assessed. And, although the Centers for Medicare and Medicaid Service has recognized the need for additional sedation providers, it does not specify how these providers should receive their training (7). Hence, each fellowship program can determine how their fellows become proficient in the sedation of conscious patients.
We sought to survey the current state of PPS training during PCCM fellowships, to understand how variable the training was, and whether fellows thought their training sufficiently prepared them for postfellowship positions.
MATERIALS AND METHODS
A 21 question RedCap survey (RedCap Consortium, Nashville, TN) (Supplemental Fig. 1, Supplemental Digital Content 1, http://links.lww.com/PCC/A850) evaluated the procedural sedation training provided to PCCM fellows and whether increased training would be considered valuable. The online survey also evaluated the use of simulation for critical incidents and resolving conflicts with patients and their families. An e-mail with a survey link was sent to the fellowship directors of all active ACGME PCCM programs that had been extant for at least 3 years in September 2017. The fellowship director was asked to forward the survey to their senior (second- and third-yr) fellows and graduates.
Responses were tracked via the RedCap software. Those fellowship programs that did not log any responses were sent personalized reminder e-mails in October and November 2017, followed by a final e-mail in January 2018. The survey closed 2 weeks after the last e-mail reminder when no further responses were logged. The survey results were then recorded and tallied.
A total of 65% of the fellowship programs responded (42/65), with 90 current fellows (41.9% second yr fellows, 35% third yr fellows) and 27 attending physicians (recent graduates—13.7% attending physicians < 5 yr and 9.4% attending physicians > 5 yr) responding (Supplemental Table 1, Supplemental Digital Content 2, http://links.lww.com/PCC/A851). Most of the 117 returned questionnaires were incomplete. Incomplete answers were excluded from analysis of the individual item (Supplemental Table 2, Supplemental Digital Content 2, http://links.lww.com/PCC/A851).
Most participants stated that their program did not offer a specific PPS rotation (62%; 72/117), and 7% (8/117) reported PPS training as an elective. In those programs offering a formal sedation curriculum, the length was usually at least 4 weeks. Use of simulation in the PPS curriculum was uncommon (9.4%; 11/117). Fifty-three percent of the respondents were not allowed to provide sedation outside the PICU setting (62/116; one incomplete response), but just under half were allowed to if they were credentialed (48%).
Despite these statistics, 61% of the fellows and recent graduates (71/117) thought that their procedural sedation training was sufficient. Still, 30% reported that they needed additional preceptorship to sedate independently or required additional training to receive sedation credentials or privileges. A comparison of second year fellows versus third year fellows found 35% versus 17% needed additional precepting. And a greater number of third year fellows reported feeling comfortable (75%) with PPS then second year fellows (39%). Both of these differences were statistically significant by chi-square test. Finally, only 31% of respondents felt prepared to seek a position with PPS duties in the absence of training during fellowship.
The majority of programs had one to five respondents to the survey, which represented a mean value of 2.4% of the total response rate. Two programs had more than five respondents, and the combined response of these two programs is 14.5% of the total. When sample responses of these two programs were compared with the group as a whole, there were no significant differences except for specialty overseeing sedation.
Our survey examines the current state of PPS training in PCCM fellowships and was intended to establish a benchmark, which could then inform future training requirements. A prior institutional survey (8) of 41 institutions determined that 58% of the PPS providers completed a sedation elective during fellowship, 39% spent time in the operating room with anesthesia, and 17% completed the Society for Pediatric Sedation’s Sedation Provider Course (9). These variations reflect the multitude of ways that practitioners attained proficiency as well as the individual institutions’ requirements. In the same survey, 49% of the institutions required documentation of a predetermined number of previously completed procedural sedation cases and/or proctoring of a set number of cases, and 58% required evidence of procedural sedation training during fellowship. Mastery of these skills by pediatric critical care fellows is important because the same survey revealed that 78% had training as PCCM physicians. We believe that as more attending positions are incorporating PPS, fellows who are trained in programs with established PPS programs will be better prepared to function in that role and that mastery of procedural sedation skills may provide a competitive advantage after fellowship (10).
The ASA states that the sedation practitioner will have satisfactorily completed formal training in the safe administration of deep sedation during an ACGME residency or fellowship program (11). However, the advisory does not specify how the sedation training should be incorporated into the fellowship curriculum. The ambiguity surrounding what is sufficient training is also reflected in our survey results, in which only 38% of the respondents reported that their fellowship program had a separate PPS rotation or elective. A formalized procedural sedation curriculum and case-mix requirements for PCCM training programs would ensure that all fellows have consistent training in procedural sedation. A mandated curriculum would also assure credentialing bodies that the training could be verified by documentation software that most fellowship programs are already using. The ability to standardize and document this training will become more important as hospitals incorporate high-reliability organization principles and want to assure their patients that each provider has adequate and verifiable skills. These advantages combined with the near unanimous interest in additional PPS training by both fellows and graduates suggest an unmet need in the current PPS training.
A mandated fellowship training curriculum will need to encompass the provision of sedation outside the operating room, critical incident simulation, and instruction on how to prescreen appropriate candidates for sedation (12 , 13). The ability to provide sedation outside the operating room can help reduce costs since these nonprofessional hospital charges are one fourth to one third of a similar case performed in the operating room (14). Use of critical incident simulation is essential because the more serious adverse events occur less than once every 1,000 sedation events and would not be routinely encountered even in a busy clinical setting (15). The incorporation of critical incident training will provide practice in managing these rare events and in working as a team with the nursing staff. Last, the ability to properly prescreen patients is an important skill that can avoid unduly burdening the anesthesia team with low-risk cases. Mastery of these components will ensure that fellows are comfortable providing sedation as attending physicians.
One limitation to our work was that we could not contact trainees directly and were dependent on fellowship program directors to forward the survey. Although we received responses from several trainees and graduates, the lack of a direct way to contact each fellow may have compromised our response rate. However, the tracking feature of the survey allowed us to send reminders to programs that did not respond. Hence, we were able to generate responses from 65% of the active U.S. PCCM programs. However, programs varied widely in how they responded. Some programs chose to enter just one response for the entire program and for other programs each fellow responded.
Another limitation is that we did not assess if responses from multiple programs were equivalent since the focus of the survey was the individual fellows and their perception of the PPS training. We took the individual responses and used them to assess where fellows across the country stood in relation to each. In the future, it may be interesting to see if programs that have a PPS curriculum are more likely to have fellows who felt prepared to provide PPS, then those programs that do not already have a PPS program.
Our survey findings suggest that PPS should become a mandated subject during PCCM fellowship training. Mandated training during fellowship would help ensure that programs give their fellows necessary clinical experience in this field with subsequent reduction in post fellowship on-the-job training.
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