There has been a fair bit of discussion regarding the need for a pediatric sedation rotation. Currently sedation is not mentioned anywhere by the American Board of Pediatrics or in the specific training requirement issued by the ACGME & RRC. As such, many programs that have identified a need for this training must attempt to incorporate it into a pediatric anesthesia rotation or offer it as a separate elective.
For many programs though residents get the bulk (if any) of their sedation experiences as part of an ER or ICU rotation. Since the need for sedation in these locations is somewhat unpredictable, it may leave many pediatric residents finishing their residency with neither the skills to safely provide sedation nor a proper understanding of the issues surrounding outpatient procedural sedation. In our institution most graduating residents report 0-5 sedation encounters. This is just not sufficient to develop any sort of competency in this important area of pediatric practice.
The Challenge
This presents a challenge for many of our pediatric colleagues who enter general practice. The sedation process begins with the ordering physician. For those of us non-anesthesiologists who provide procedural sedation outside the operating room, we know the most important aspect of our practice is proper patient selection. This process begins in the general pediatricians office, when the decision is made about what test to order and the need for sedation, general anesthesia, or perhaps a skilled non-pharmacological approach.
This also represents a challenge for the pediatric hospitalist. Given the shortage of pediatric anesthesiologists, intensivists, and ER docs, the responsibility of providing pediatric sedation is increasingly falling upon the shoulders of the pediatric hospitalist. This is especially true in smaller community centers where these subspeciality resources are particularly scarce.
When I attended the Sedation Provider Course offered by SPS in May of 2009, the overwhleming majority in attendance were pediatric hospitalists. Given that many pediatric hospitalists have no additional training following their general pediatric residency, it begs the question… Where will they get the experience and training needed to provide this important pediatric service?
All of this to say, I think all pediatric residents would benefit from formal training in sedation. This seems to be the consensus on the Listserve as well. What exactly does this mean? I think this question is a difficult one to answer. In general, I think this means that we as Sedation Providers and Members of the Society for Pediatric Sedation need to pursue options to have sedation training move from non-existent (or sporadic at best) to a formal RRC requirement.
The Solution
I think Joe Cravero and Jennifer O’ Flaherty with the PainFree Program at Dartmouth have taken the first steps toward an effective solution. They have a formal sedation rotation that all pediatric interns take. It comes complete with objectives, exams, didactics, and practical skills. The Primer of Pediatric Sedation is the foundation of the curriculum. It seems to me that this is a model we could all attempt to weave into the resident curriculum at our own institutions. Ultimately though, it really needs to be a formal part of pediatric residency training. Exactly where to place it in that already complicated list of requirements remains to be seen.
ChaD Pain Free Rotation for Pediatric Interns
Suggestions
Do you have a similar program or other innovative ideas? Please reply below to continue this important discussion.
Thank you for posting all of these rich resources. With the medical environment becoming increasingly more fraught with litigation and with the new CMS guidelines it is more and more important to have proof of competency for sedation providers. We are currently in the process of revamping our competencies specifically for mid level providers who participate in pediatric procedural sedation and found this most helpful.
The fact that the ordering care provider is the first touchpoint for the successful completion of the procedure, whether it be by means of procedural sedation, anesthesia, or non pharmacologic techniques makes training in the area of presedation assessment as well as the sedation process a necessity for physicians and mid level providers in training. I applaud CHaD’s ability to incorporate it into their program. I also applaud the SPS’s provider course. This course appears to equip all levels of providers for the process of providing pediatric procedural sedation.
Thank you again for a very intriguing and helpful post.
Jennifer Schoonover CPNP-PC, AC
Kosair Children’s Hospital
Louisville, KY
Before we decide to add MANDATORY sedation training to the RRC’s list of required “electives” for pediatric residents, we need to decide if a rotation will truly serve the purpose of educating potential sedation providers. Will a one-month rotation in sedation truly prepare a general pediatrician/hospitalist to provide safe and effective sedation/analgesia/anesthesia to a wide variety of patient ages, sizes, and medical conditions? I mention anesthesia because for a large percentage of pediatric patients undergoing painful procedures or procedures requiring immobility (especially for prolonged periods), moderate sedation may not be adequate, and deep sedation/general anesthesia is often required.
Also, since many peds residents will *not* be practicing as hospitalists or in other capacities where they would be called upon to provide their own sedation, requiring a sedation “elective” may not be in their best interests. So, while I agree that a sedation elective should be offered, I would not support making it mandatory.
Michael,
Thanks for your comments on this subject. I wholly agree that a pediatric sedation rotation does not make a sedation provider. At least no more than a PICU rotation makes an intensivist. However, an understanding of what goes on in the PICU is important, even for the general pediatrician. I would argue the same is true for ALL pediatricians when it comes to sedation. In fact I would argue it is more important given that the decision to order sedation generally is initiated by the office pediatrician for many procedures that we do. When evaluating the risk:benefit of a particular exam (like an MRI for a first time simple febrile seizure) I think it is important for the ordering physician to understand the issues surrounding procedural sedation.
Jason,
As a sedation provider, I agree that exposure to sedation services is important for those who will continue in areas of medicine where they may be called upon to perform sedation. However, in the face of ever-decreasing resident hours, making sedation (or any other procedure-specific or specialty-specific rotation) a requirement is hard to justify. I believe that it is in our best interests as sedation providers (and in the best interests of patients) to have a sedation rotation available, but don’t believe that it should be required.