Changes in technology, training, medication, and resource availability will continually alter the dynamic of procedural sedation. Impacts may be greatest for children, who are more likely to require sedation for any given procedure and have unique anatomic and developmental issues that require specialized expertise. Health care systems and pediatric patients and their families benefit when imaging studies and procedures are performed in a patient-centered manner, without unnecessary delays and with the appropriate amount of sedation for optimizing clinical outcomes as well as ensuring patient safety, comfort, and satisfaction. Although anesthesiologists and nurse anesthetists provide anesthesia inside the operating room (OR), considerable variability exists in providers who offer sedation outside of the OR.
In this issue of Pediatrics, Kamat et al1 examine trends from 2007 to 2018 in procedural sedation outside of the OR using the Pediatric Sedation Research Consortium (PSRC) database. The PSRC is a self-selected, voluntary collaborative of clinicians in the United States who provide sedation and collect prospective observational data on sedation encounters outside of the OR. The authors reviewed 432 842 sedation encounters and found an increasing trend in the use of dexmedetomidine, decreased use of chloral hydrate and pentobarbital, a slight decrease in the proportion of children <3 months old undergoing sedation, and an increase in the proportion of pediatric hospitalists (PHs) providing sedation from 0.6% to 9.5% (P < .001). Serious adverse event (SAE) rates were low and did not change significantly during the study period.
The increased percentage of PH sedations in the database is a striking finding that deserves investigation. The PSRC database most likely reflects nationwide trends but has limitations. Institutions self-select to be part of the consortium, and even within the same institution, some provider groups offering sedation report to the database, whereas others may not. PHs may have preferentially joined the database given their emphasis on data-driven outcomes and added value.2 Also, although it is reassuring that SAE rates remained stable as the proportion of PH providers increased, further breakdown of SAEs by provider specialty would further support the safety of this trend.
PHs have an opportunity to provide a service that is within their scope of care with the potential to save costs and provide value for patients and the health care system. With respect to cost and resource use, it is best practice to use providers to the extent of their licensure and training. An appropriately trained PH is a cost-effective option for most procedural sedations, allowing anesthesiologists and intensivists to care for patients who demand their expertise. Another advantage of PH sedation providers is in general hospitals with limited pediatric resources. The inpatient census may be low, allowing the PH time to provide sedation services, and other pediatric subspecialists who provide sedation may not be available at these institutions. At least 70% of pediatric inpatients are cared for in such hospitals.3
The last group of pediatric residents who were eligible for pediatric hospital medicine (PHM) board certification through the practice pathway graduated in 2019, and all current and future pediatric residents will have to undergo fellowship training if they desire PHM certification. It is unclear whether fellowship training will increase PH competency in sedation. Kamat et al1 cite the 2015 survey revealing that most fellowship- and nonfellowship-trained PHs did not feel competent in delivering sedation4 and state, “It is imperative that pediatric hospital medicine program directors inculcate robust sedation training in their curriculum.” An informal poll of PHM fellowship directors revealed that most require at least 2 weeks of sedation training in addition to offering more exposure in electives. Turmelle et al5 describe the training requirements in their PHM sedation program. PHs were sequentially credentialed in 3 tiers of sedation proficiency. Although the training in each tier could be accomplished in 1 to 2 weeks, each PH spent 1 year providing sedation in each tier before graduating to the next. The final tier required 25 supervised propofol sedations (and maintenance of certification required >75 propofol sedations every 2 years).5 If this model were to be adopted in fellowship, sedation training would need to occur early on (when training in research and quality improvement may be prioritized to complete a scholarly project in the 2-year time frame of most PHM fellowships), and the propofol monitoring would need to occur after fellowship.
Other factors besides training and PH competence need to be considered. Sedation services are usually well compensated, and the teams are often not responsible for nights and weekends, making this an attractive service that, depending on culture and other hospital dynamics, may lead to turf wars among different providers. Despite these issues and the previously discussed limitations of the PSRC database, this study reveals a change in the landscape of pediatric sedation delivery that is likely to continue as the number of fellowship-trained PHs increases.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-3559.
pediatric hospital medicine
Pediatric Sedation Research Consortium
serious adverse event
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.