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Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship*

Hooper, Michael C., MD1; Kamat, Pradip P., MD, MBA, FCCM2,3; Couloures, Kevin G., DO, MPH1

Pediatric Critical Care Medicine: March 2019 - Volume 20 - Issue 3 - p 259–261
doi: 10.1097/PCC.0000000000001809
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Objectives: Pediatric procedural sedation has been increasingly performed by pediatric intensivists over the past decade. Pediatric Critical Care Medicine fellowship guidelines do not specify how fellows obtain proficiency in pediatric procedural sedation. We sought to survey the state of pediatric procedural sedation training during fellowship and whether fellows thought it was sufficient.

Design: A 21-question survey gathered data on pediatric procedural sedation training provided to Pediatric Critical Care Medicine fellows. Surveys were sent to fellowship directors with instructions to distribute to second- and third-year fellows or recent graduates. Over 2 months, up to three e-mail reminders were sent to fellowship directors whose program had not completed at least one survey.

Subjects: Senior fellows and graduates of 65 active Accreditation Council for Graduate Medical Education Pediatric Critical Care Medicine fellowship programs.

Interventions: None.

Measurements and Main Results: Sixty-five percent of fellowship programs (42/65) returned at least one response. Ninety senior fellows and 27 recent graduates responded. Of respondents, 38% received pediatric procedural sedation training during the fellowship, and 32% reported mandatory training. Nine percent of programs used simulation. Although 61% who received training felt adequately prepared to perform pediatric procedural sedation, 25% needed additional preceptorship to sedate independently. Nearly one third (31%) reported that completion of a predetermined number of cases was required to sedate independently. Forty-eight percent reported a minimum number of cases was required for hospital credentialing. Nearly 45% were allowed to perform pediatric procedural sedation off the unit after receiving credentials. When asked if inadequate pediatric procedural sedation training would be a deterrent to applying for a position that included pediatric procedural sedation, 8.6% replied yes, 52.6% replied no, and 38.8% replied they were unsure.

Conclusions: Pediatric procedural sedation lacks a clearly defined training pathway. Most fellows find pediatric procedural sedation a valuable skill set. We propose that all Pediatric Critical Care Medicine fellows receive training that includes pediatric procedural sedation critical incident simulation and cases performed outside the PICU to establish proficiency.

1Pediatric Critical Care Medicine, Yale School of Medicine, New Haven, CT.

2Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.

3Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA.

*See also p. 296.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

The authors have disclosed that they do not have any potential conflicts of interest.

This work was a collaboration between the Yale School of Medicine and Emory University School of Medicine.

Address requests for reprints to: Kevin G. Couloures, DO, MPH, Pediatric Critical Care Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520-8064. E-mail: kevin.couloures@yale.edu

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.

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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.

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RESULTS

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.

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DISCUSSION

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.

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CONCLUSIONS

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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REFERENCES

1. Cote CJ, Wilson S; American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. Pediatrics 2016; 138:e20161212
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4. Barbi E, Badina L, Marchetti F, et al. Attitudes of children with leukemia toward repeated deep sedations with propofol. J Pediatr Hematol Oncol 2005; 27:639–643
5. Accreditation Council for Graduate Medical Education: ACGME Program Requirements for Graduate Medical Education in the Subspecialties of Pediatrics. 2016. Available at: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/323_pediatric_critical_care_medicine_2017-07-01.pdf?ver=2017-06-30-083428-177. Accessed July 6, 2018
6. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists: Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96:1004–1017
7. Centers for Medicare and Medicaid Services (CMS): State Operations Provider Manual, Appendix A, Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, Certification. Revised Appendix A, Interpretive Guidelines for Hospitals 482.52 Condition of Participation: Anesthesia Services. Issued December 2, 2011; Revised December 29, 2017
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11. American Society of Anesthesiologists: Advisory for Granting Privileges for Deep Sedation to Non-Anesthesiologist Physicians. 2017. Available at: http://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/advisory-on-granting-privileges-for-deep-sedation-to-non-anesthesiologist.pdf. Accessed June 26, 2018
12. Biber JL, Allareddy V, Allareddy V, et al. Prevalence and predictors of adverse events during procedural sedation anesthesia-outside the operating room for esophagogastroduodenoscopy and colonoscopy in children: Age is an independent predictor of outcomes. Pediatr Crit Care Med 2015; 16:e251–e259
13. Grunwell JR, Marupudi NK, Gupta RV, et al. Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies. Paediatr Anaesth 2016; 26:628–636
14. Shiley SG, Lalwani K, Milczuk HA. Intravenous sedation vs general anesthesia for pediatric otolaryngology procedures. Arch Otolaryngol Head Neck Surg 2003; 129:637–641
15. Cravero JP, Beach ML, Blike GT, et al; Pediatric Sedation Research Consortium: The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: A report from the Pediatric Sedation Research Consortium. Anesth Analg 2009; 108:795–804
Keywords:

anesthesia; child; credentialing; critical care; pediatrics

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