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.
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.
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
Do you have a similar program or other innovative ideas? Please reply below to continue this important discussion.