What is Quality Pediatric Sedation?

Society Obtains Grant Funding for Consensus Meeting with Sedation Experts

In 2006 alone, according to AHRQ’s Healthcare Cost Utilization Project, over 3 million procedures were performed on hospitalized children. These numbers are staggering but also do not include the additional millions of children who underwent procedures in an outpatient or office setting.

So how are all these procedures being completed? Are children being physically restrained, distracted, sedated or anesthetized? We in the sedation community, I would imagine from our experiences, recognize that most children will not simply lie still for painful or non-painful diagnostic tests or procedures. The majority of children require one of these four options in order to complete a procedure or test. So what care are all these children receiving? What factors impact this decision and ultimate delivery of care? When we are consulted to sedate a child for a procedure, do we deliver care of the highest quality?

I think we all feel we are delivering quality sedation care? However, do we really know what quality sedation is? Do we know the factors that make up quality? Do we really address all of these factors in the care we deliver? Also, how do we define, measure and compare quality related to pediatric sedation?

These questions led to the SPS applying for and receiving grants from AHRQ and The Mayday Fund help answer these questions. With this grant funding, The Society for Pediatric Sedation® Consensus Meeting: Defining Quality in Pediatric Sedation was held in Baltimore from November 13-15, 2011. The conference goals included:

1. Defining the Institute of Medicine’s (IOM) six aims of quality as related to pediatric sedation;
2. Identifying initial quality metrics and outcome goals within the field of pediatric sedation;
3. Developing concepts related to outcomes, processes and structure which are in place or need to be established to identify quality sedation care.

We explored each of these 6 aims of quality with a multi-professional group of clinical experts which included representation from pediatric anesthesia, child life, pediatric critical care, dentistry, emergency medicine, oncology, oral/maxillofacial surgery, hospital medicine, pediatrics, psychology, quality and safety, radiology and sedation providers. This group of forty four was made up of nurses, mid-level practitioners, physicians, dentists, and a clinical psychologist.

1. Safe: How do you define safety in sedation? Is it zero mortality and serious morbidity? Is it limiting the number of serious rescue events? Or is intubation required for every procedure because that is “safer”? Is intubation really safer in all cases?
2. Effective: How do you define effective sedation? Is “effective” sedation simply the ability to complete a procedure? What if you complete the procedure, but the patient was writhing about or crying during the procedure? Is that effective?
3. Patient and Family Centered Care: What is patient and family centered care and what are the basic principles? Do we involve the family and/or the patient in how we approach to the planning and delivery of health care that they receive related to procedures? Do we know how we are doing? How can we measure and improve patient and family centered care?
4. Timely: Timeliness refers to offering the right care without delay? How do we manage scheduling, add-on’s, prioritizing etc. as we try to offer care in the appropriate timeframe? Of course, what is the “appropriate” time? What are some of the factors that impact timeliness? How do we schedule efficiently, yet leave time available for emergency procedures? How do we accommodate emergency procedures after hours and on weekends? Is there a way to optimize readiness of all services to get procedures started on time?
5. Efficient: An efficient service would maximize throughput without compromising safety or effectiveness. From a procedural perspective the goal of efficiency is to match what the patient needs with the care provided, not more and not less. How do we provide the right level of care with the right personnel and right equipment/medications to maximize our efficiency? What factors impact efficiency?
6. Equitable: Is the care we are delivering equitable? That is, are there no disparities in the care delivered based on race, age, gender, ethnicity, income, geographic location, or socioeconomic status? If disparities exist, what factors are involved in these differences – provider education, staffing resources, reimbursement for the provision of this care? How do we address these differences?

We spent 48 hours exploring each of these areas in depth. The discussion was collaborative, patient centered and broad. We learned about quality, quality metrics and followed with great debate of how quality applies to sedation. Over the coming months, we will document and disseminate the findings from this consensus meeting. We will highlight some key questions raised in future newsletter as well. In the meantime, I would challenge you to consider your views related to each of these areas, and challenge your own practice. Are you delivering quality sedation? How do you define quality? Are you collaborating with your medical peers and families to improve this quality?

Mick Connors, MD

Past President – Society for Pediatric Sedation®