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Emergency Department Based Sedation Services
Emergency Department Based Sedation Services Jay Pershad, MD, ⁎ Susanne Kost, MDy Increased demand for procedural sedation in areas of the hospital outside the traditional emergency department and operating room settings has led to a growing trend of these services being rendered by pediatric emergency physicians. We will review the pros and cons of establishing an emergency department-based sedation service, discuss the scope of the service, review practical considerations in successfully implementing and administering this service, and highlight challenges and opportunities for reimbursement. Clin Ped Emerg Med 8:253-261 C 2007 Elsevier Inc. All rights reserved. KEYWORDS sedation service, procedural sedation, emergency services
P
rovision of procedural sedation and analgesia is an essential skill in the practice of pediatric emergency medicine (PEM). Over the last decade, PEM specialists have made significant contributions to the science and practice of procedural sedation [1-12]. With an increase in sedation encounters outside the traditional operating room setting, hospital administrators have called upon PEM physicians to meet these service demands. Emergency physicians have traditionally been approved for moderate and deep sedation based on their training, core privileges, experience in the use of a broad range of sedatives, and demonstration of research in the field. Emerging data suggest that PEM physicians are providing sedation services as sole providers or in collaboration with pediatric intensivists and anesthesiologists [7,13-15]. In a recent survey of 116 children's hospitals in North America, only 26% used anesthesiologists as the sole provider of these services. Fifty-nine percent used mobile MD/RN teams, 11% had dedicated sedation units, and 33% used mixed models for delivery of these services. Sixtythree percent of respondents cited use of propofol regularly by non-anesthesiologists [16]. ⁎Division of Emergency Services, Le Bonheur Children's Medical Center, Memphis, TN. †Division of Emergency Services, A.I.Dupont Hospital for Children, Wilmington, DE. Reprint requests and correspondence: Jay Pershad, MD, Division of Emergency Services, Le Bonheur Children's Medical Center, 50 N Dunlap St., Memphis, TN 38103. (E-mail: [email protected]) 1522-8401/$ - see front matter C 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2007.08.005
We will review the pros and cons of establishing an emergency department (ED)–based sedation service (EDSS), discuss the scope of the service, review practical considerations in implementing and administering an EDSS, and highlight challenges and opportunities for reimbursement.
Pros and Cons An EDSS offers several advantages. By fulfilling a service need for the institution, it provides an opportunity for the department to build alliances and create leverage with hospital administration. A jointly staffed sedation service may create opportunities for collaboration with colleagues from other disciplines such as critical care, anesthesiology, and hospital-based medicine. For the individual practitioner, it may enhance professional satisfaction by instilling variety to one's practice and offer an opportunity for more “day shifts.” In some markets, the EDSS may bring financial rewards and higher relative value unit (RVU) productivity [7]. As with any new patient care–related service, it is timeand-resource intensive. Depending on the volume and scope of service, success usually requires a dedicated team of 1 or more PEM physicians. The practice of procedural sedation is high risk and increases malpractice exposure. Although critical adverse events are rare, the occurrence of serious adverse events ranging from apnea, desaturation, laryngospasm, and emesis has been reported in 0.2% to 253
254
Table 1
Scope of service and selection of agent.
Primary Service Radiology
Common Procedures MRI CT
Typical Length of Procedure 30-60 min; spines and vascular studies longer 5 min
Pain
Suggested Medication Regimen
Special Considerations
No
PI; PB ± midazolam or fentanyl
Noisy, confining, magnetic field
No
Propofol bolus; etomidate; ketamine; dexmedetomidine PI or PB Midazolam; N2O
Contrast, positioning
Nuclear medicine Fluoroscopy
45-120 min Enteral tubes: varies; VCUG: 5-10 min
No
Interventional
Varies widely
Yes
Lumbar puncture
5-10 min
Yes
Midazolam; propofol; ketamine; N2O
10-15 min
Yes
Cardiology
Bone marrow aspirate and/ or biopsy ECHO
15-20 min
No
Fentanyl/midazolam; propofol or ketamine Midazolam, chloral hydrate in infants
Gastroenterology
Endoscopy; colonoscopy
10-15 min
No
Ketamine/midazolam; propofol/fentanyl
Airway, gagging, laryngospasm
Orthopedics
Fracture reduction
5-10 min
Yes
Postreduction imaging, second attempts
Appliance removal
5-10 min
Yes
Botox injection Abscess drainage Minor skin procedures Burn debridement Complex laceration repair
5-10 min 5-10 min 10-15 min 15-30 min 30 -60 min
Yes Yes Yes Yes Yes
Foreign body removal Sedated examination; IOP ABR/BAER
5-10 min 5 min 45-60 min
No No No
Neurology
EEG/EMG/SSEP Lumbar puncture
30-60 min 5-10 min
Minor Yes
Ketamine; N2O with regional block; propofol/fentanyl Ketamine; propofol/fentanyl; N2O with regional block Midazolam ± ketamine Ketamine; propofol Midazolam ± ketamine; propofol Ketamine ± midazolam; propofol + fentanyl LET gel + midazolam or N2O; LET gel + ketamine; LAT gel + propofol Midazolam; ketamine; propofol Midazolam or propofol Chloral Hydrate (infants); PB or PI; Dexmedetomidine Chloral hydrate (infants); dexmedetomidine Midazolam; propofol
Dental Nephrology
Examinations; dental surgery Renal biopsy
Varies 10-15 min
Yes
N2O Ketamine or propofol/fentanyl; fentanyl/midazolam for adolescents
Rheumatology Vascular
Arthrocentesis Difficult vascular access
5-10 min 15 min
Yes Yes
Midazolam ± ketamine; propofol; N2O Topical anesthetic + N2O or midazolam
Hematology/ oncology
General surgery
ENT Ophthalmology Audiology
Isotope injection timing, expense Discomfort, gagging with tubes, ? psychological implications of VCUG Varied depth of sedation during procedure Combined procedures, underlying risks Biopsy quite painful
Underlying neurologic issues Supplement with local anesthetic Supplement with local anesthetic On finger, supplemental digital block is recommended Potential airway issues Avoid ketamine
PI indicates propofol infusion; PB, pentobarbital; CT, computed tomography; N2O, nitrous oxide; EEG, electroencephalogram; EMG, electromyogram; LET, lidocaine, epinephrine, tetracaine; MRI, magnetic resonance imaging; IOP, intraocular pressure, ABR, auditory brainstem response; ECHO, echocardiography; BAER, brainstem auditory evoked response; SSEP, somatosensory evoked potential; VCUG, voiding cystourethrogram.
J. Pershad, S. Kost
Effect of sedative on EEG Airway in infants, raised intracranial pressure Secretions, airway issues Underlying hypertension, renal pathology, usually prone position, renal insufficiency
Emergency department based sedation services 1.6% of encounters [13]. It is crucial that adequately trained and credentialed providers are available to manage potential complications.
Sedation Service Considerations Scope of the Sedation Service A major consideration with provision of procedural sedation beyond the walls of the ED is the proposed scope of service. The radiology department is the most obvious example of a department with a significant demand for sedation services. However, any pediatric medical or surgical service performing procedures that invoke pain and/or distress, outside the operating room setting, would benefit from this service. Table 1 illustrates examples of the wide scope of sedation services in a fullservice pediatric hospital. There are several factors that could influence the practice of procedural sedation. Within the radiology department, issues include environmental factors (magnetic fields, radiation) and timing of sedation relative to the procedure. For example, in the magnetic resonance imaging (MRI) suite, the airway equipment needed for resuscitation may not be permitted within the gaussian range of the scanner. Although available, MRI-compatible laryngoscopes are relatively expensive. In the computed tomography and nuclear medicine suites, timing of sedation relative to administration of contrast is important. In the event of an unsuccessful sedation, recurrent dosing of contrast material may be potentially harmful. Furthermore, some of the nuclear isotopes cost several thousand dollars per dose and require injection up to 24 hours before the scan. These issues highlight the importance of careful risk assessment and skillful sedation. In the inpatient setting, most patients have comorbidities that may influence sedation practices. Although emergency physicians are skilled in caring for acutely ill patients, the risks must be weighed against the benefits of sedation to facilitate a particular procedure. Unlike
Table 2 American Society of Anesthesiology risk classification [18]. ASA Class I ASA Class II ASA Class III
ASA Class IV
ASA Class V
A normal, healthy patient. A normal patient with mild systemic disease (no functional limitation) A patient with moderate or severe systemic disease that limits activity but is not incapacitating. A patient with an incapacitating systemic disease that is a constant threat to life. A moribund patient not expected to survive 24 hours with or without the procedure.
255 Table 3 Documentation of a presedation focused history and physical examination. Parameter 1. Age and weight 2. Allergies 3. Medications
4. Current medical status
5. Review of systems
6. Medical history
7. Family history 8. Vital signs 9. Physical examination
Comments Egg and/or soy allergy may preclude propofol use. Medications metabolized by the cytochrome P-450 enzyme pathway, such as some anticonvulsants and psychotropic medications, may interfere with pharmacokinetics of some sedatives. Especially conditions predisposing to airway obstruction or pulmonary compromise; pregnancy status Cardiovascular, hepatic, renal, neurologic, or hematologic conditions that may influence use of sedatives or radiographic contrast materials; presence of contact lenses, dental appliances or loose dentition; vomiting or risk factors for aspiration Relevant hospitalizations particularly prior sedation or anesthesia-related adverse events Anesthetic complications such as malignant hyperthermia Including baseline pulse oximetry Including focused airway evaluation (Mallampati classification, limitation of cervical spine mobility) [19]
the ED setting, not all procedures need to be accomplished emergently. In some cases, it may be prudent to reschedule or refer the case for completion under general anesthesia. When confronted with the task of initiating a hospitalbased sedation service, it may be advisable to begin with a limited set of services before broadening the scope of the practice. Factors that may affect this decision include availability and experience of the sedation providers, and physical attributes of the facility.
Centralized vs Mobile Sedation Services Sedation services beyond the scope of the ED are generally based on 1 of 2 models: a “centralized” model, where patients come from throughout the hospital to a dedicated area, or a “mobile” model, where members of the sedation team travel to various patient care areas to provide the service. Each of these models has its pros and cons. A
J. Pershad, S. Kost
256 Table 4
Overview of sedation and analgesia medications [1].
Agent
Pediatric Dosing
Sedative-hypnotics Choral hydrate Oral: 25-100 mg/kg, after 30 min can repeat 25-50 mg/kg; maximum total dose: 2 g or 100 mg/kg (whichever is less); single use only in neonates Diazepam IV: initial 0.05-0.1 mg/kg, then titrate slowly to maximum 0.25 mg/kg Etomidate IV: 0.1 mg/kg; repeat if inadequate response Midazolam
Methohexital
Pentobarbital
Propofol
Thiopental Analgesics Fentanyl
Morphine
IV (0.5-5 y): initial 0.05-0.1 mg/kg, then titrated to maximum 0.6 mg/kg; IV (6-12 y): initial 0.025-0.05 mg/kg, then titrated to maximum 0.4 mg/kg IM: 0.1-0.15 mg/kg PO: 0.5-0.75 mg/kg IN: 0.2-0.5 mg/kg PR: 0.25-0.5 mg/kg PR: 25 mg/kg IV: 0.5-1 mg/kg IV: 1-6 mg/kg, titrated in 1- to 2-mg/kg increments every 3-5 min to desired effect IM: 2-6 mg/kg, maximum 100 mg PO/PR (>4 y): 3-6 mg/kg, maximum 100 mg; PO/PR (>4 y): 1.5-3 mg/kg; maximum 100 mg IV: 1 mg/kg, followed by 0.5 mg/kg; repeat doses as needed
Onset (min)
Duration (min)
Comments
PO: 15-30
PO: 60-120
Effects unreliable if age >1 yr and/or >10kg
IV: 4-5
IV: 60-120
IV: >1
IV: 5-15
IV: 2-3
IV: 45-60
Reduce dose when used in combination with opioids Adverse effects include respiratory depression, myoclonus, nausea, emesis Reduce dose when used in combination with opioids; may produce paradoxical excitement
IM: 10-20 PO: 15-30 IN: 10-15 PR: 10-30 PR: 10-15
IM: 60-120 PO: 60-90 IN: 60 PR: 60-90 PR: 60
IV: 3-5
IV: 15-45
Dosing limited to 5 mg (1 mL) Avoid if there is temporal lobe epilepsy or porphyria May produce paradoxical excitement; avoid in patients with porphyria
IM: 10-15 IM: 60-120 PO/PR: 15-60 PO/PR: 60-240
IV: >1
IV: 5-15
PR: 25 mg/kg
PR: 10-15
PR: 60-120
IV: initial 1 μg/kg up to 50 μg per dose, may repeat every 3 min, titrate to effect
IV: 3-5
IV: 30-60
IV: initial 0.05-0.15 mg/kg up to 3 mg per dose, may repeat every 5 min, titrate to effect
IV: 5-10
IV: 120-180
IV: 1
Dissociation: 15; Multiple recovery: 60 contraindications; unpleasant dreams or hallucinations rare in kids Often given with Dissociation: 15-30; recovery: concurrent atropine 90-150 or glycopyrrolate to counter hypersalivation
Dissociative drug Ketamine IV: 1-1.5 mg/kg slowly over 1 min, may repeat every 10 min as needed
IM: 4-5 mg/kg, may repeat (2-4 mg/kg) after 10 min
IM: 3-5
Inhalational drug b5 Nitrous oxide Preset mixture with minimum 30% oxygen self-administered by demand valve mask (requires cooperative child); continuous flow nasal mask in uncooperative child with close monitoring
>5 after discontinuation
Frequent hypotension and respiratory depression; avoid with egg or soy allergies Avoid in patients with porphyria Reduce dosing when combined with benzodiazepines Reduce dosing when combined with benzodiazepines
Requires specialized apparatus and gas scavenger capability; several contraindications
Emergency department based sedation services
Table 4
257
(continued).
Agent Reversal drugs Naloxone
Flumazenil
Pediatric Dosing IV/IM: 0.1 mg/kg per dose up to maximum of 2 mg per dose, may repeat every 2 min as needed IV: 0.02 mg/kg per dose, may repeat every 1 min up to 1 mg
Onset (min)
Duration (min)
IV: 2
IV: 20-40 IM: 60-90
IV: 1-2
IV: 30-60
Comments If shorter-acting than the reversed drug, serial doses may be required If shorter-acting than the reversed drug, serial doses may be required
Alterations in dosing may be indicated depending on the clinical situation and the practitioner’s experience with these drugs. Individual dosages may vary when used in combination with other drugs, especially when benzodiazepines are combined with opiates. Ketamine is absolutely contraindicated in patients younger than 3 months (airway risk) or when there is known psychosis (may exacerbate). Relative contraindications include age younger than 12 months; procedures involving stimulation of posterior pharynx; history of tracheal surgery or stenosis; active pulmonary infection or disease (including upper respiratory tract infection); known or suspected cardiovascular disease; suspected raised intracranial or intraocular pressure; globe injury; porphyria or thyroid dysfunction. IV indicates intravenous; IM, intramuscular; PO, per os; IN, intranasal; PR, per rectum.
combined model offers the greatest flexibility in meeting patient care–related demands. A centralized unit permits a more efficient use of personnel and equipment. For example, an EDSS team member could work up a new patient while monitoring a patient during recovery. Moreover, in the event of a sedation-related adverse event, assistance from other personnel on the team is more readily available in a centralized model. The full complement of necessary equipment and backup is more readily available in a centralized unit. Furthermore, by having a locked cabinet in a central area, dispensing and monitoring of controlled substances is greatly facilitated. The primary disadvantage of a centralized unit is that very few pediatric facilities have sufficient space in one location. Sedated patients may require transport over distances ranging from a few feet to a city block, depending on the physical layout of the hospital. Also, an “open” unit may not be ideal for all phases of the sedation encounter. Despite best efforts to minimize distractions, the induction of one patient may be interrupted by emergence agitation of another. A mobile EDSS allows for greater flexibility, thus minimizing the need for patient transport. It is ideal in a community hospital setting where pediatric resources may not be available in all patient care areas. Because a mobile EDSS usually consists of fewer members than a large centralized sedation unit, the team members tend to develop a rapport, making the practice more consistent and efficient. The drawbacks of a mobile EDSS are those inherent with travel. The lack of ready availability of a certain piece of equipment or medication can lead to delays. Traveling teams also need to become familiar with the location of resuscitation equipment and monitors in other areas of the hospital. In a busy mobile EDSS, the temptation to move on to the next procedure before the
previous patient is fully recovered may create challenges to patient safety.
Staffing The staffing needs of an EDSS depend on several factors, such as patient volume, types and duration of procedures, pharmacokinetics of sedatives used, and physical plant space considerations. Another consideration is that institutional policies and best practices dictate that all patients have an observer dedicated exclusively to monitoring the patient for the entire duration of the sedation process. With this, a single provider should not be left alone, in a remote environment, with a sedated patient. In institutions such as ours, where the MRI scanner is physically remote from the centralized sedation unit, 3 nurses are responsible for staffing: one to monitor the patient while in the scanner, one to begin the evaluation of the next patient, and one to aid in patient transport and to provide additional assistance as needed, particularly in a sedation-related adverse event. In addition to the traditional “doctor-nurse” model, a sedation service could employ nurse anesthetists, physician's assistants, advanced practice nurses, or respiratory therapists in various capacities, according to institutional, local, and state policies.
Credentialing of Sedation Providers Establishing a process for credentialing is important to ensure that the providers are trained and possess the requisite skill set to practice procedural sedation safely. Sedation encounters are monitored during joint commission surveys of hospitals [17]. Each institution can establish its own criteria for granting sedation privileges. Our institution requires viewing a video, obtaining a passing score on a written test, a current pediatric advanced life support course certificate, and lastly, being precepted on 10 sedation encounters in the ED.
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258
Patient Scheduling Scheduling sedation encounters requires careful planning, to ensure optimal use of the service and institutional resources. The hospital appointment desk is usually responsible for scheduling outpatient visits. The nurse administrators on the team usually handle requests for inpatient sedations. Because requests from the inpatient service are unpredictable, it is inevitable that decisions that involve prioritization of patients become a challenge. Proper screening of patients, ongoing communication with referring services, and being sensitive to patients who are nil per os (NPO) for extended duration is crucial. More specifically, scheduling sedation for radiologic procedures requires close coordination between the scheduler and the sedation team, to minimize MRI scanner down time. Reserving “pods” for inpatients on select days of the week may be helpful. Scheduling younger children and high-risk patients early in the day minimizes prolonged NPO times for infants and permits appropriate management of adverse events when ancillary services are well staffed.
Quality Assurance Documentation of a sedation encounter must reflect appropriate history and physical examination results, risk assessment using standard American Society of Anesthesiologists (ASA) class definition, screening for a difficult airway, selection of agent, anticipated level of sedation, and a proper monitoring record of vital signs including depth of sedation during induction, recovery, and actual procedure. Establishing protocols that are specific to the institution are important to ensure delivery of safe and cost-effective sedation services. Quality assurance benchmarks for PEM staffed sedation services may include the following:
⋅ Number of failed sedations ⋅ Percentage of cases referred for general anesthesia ⋅ Frequency and type of adverse events ⋅ Scores on patient satisfaction surveys ⋅ Referring physician surveys Communication With Referring Physicians Effective communication with referring pediatricians and subspecialists is important to ensure patient and caregiver satisfaction with procedural sedation. It may be helpful to develop and distribute a written policy or service description that includes the following information:
⋅ Hours of service ⋅ Contact phone or
pager number of the sedation practitioner on call ⋅ Characteristics of patients who typically require sedation in support of procedures. This includes patients with developmental delay, hyperactivity, and the very young.
⋅ Patients with an ASA classification of greater than 3 may be best managed by a referral to an anesthesiologist for general anesthesia (see Table 2). ⋅ The process of scheduling patients and requesting a “sedation evaluation” for those that may need sedation. An emphasis on having patients present at least 30 minutes before their scheduled appointment would ensure that sufficient time is available to evaluate the patient, perform a risk assessment, and develop a sedation plan. ⋅ Informing the physician staff that because of the nature and length of certain radiologic procedures, that there are limited numbers of openings available each day for patients requiring sedation. ⋅ The institution's NPO policy ⋅ Patient preparations, including the need to have a working intravenous line, because certain cases typically require parenteral sedatives. Here, any guidelines for use of topical anesthetics may be included. ⋅ An overview of commonly used medications
Administrative and Reimbursement Issues The sedation encounter begins with a focused history and physical examination to identify patients who may
Table 5 Appropriate intake of solids and liquids before elective sedation [20]. Ingested Material Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee Breast milk Infant formula Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period Light meal: a light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time; both the amount and type of foods ingested must be considered when determining an appropriate fasting period
Minimum Fasting Period 2 hrs
4 hrs 6 hrs 6 hrs
6 hrs
Emergency department based sedation services be at high risk for sedation-related adverse events. Table 3 summarizes key elements of this process. The selection of a sedative agent depends on several factors that include type and duration of the procedure, degree of patient immobility desired, the need for analgesia, and comfort level of the sedation practitioner. Table 1 outlines suggestions for selection of agents for various types of procedures that may be performed by an EDSS. Table 4 provides an overview of the different classes of medications, dose range, duration of action, adverse event profile, and contraindications to their use. A presedation checklist includes verification of the child's NPO status and a review of necessary equipment for rescue and resuscitation (see Tables 5 and 6).
Documentation Appropriate documentation of a sedation encounter involves 3 stages: before, during, and after the procedure. The use of standardized sedation forms or computerized documentation tools increases efficiency. Before sedation, an appropriately licensed practitioner must document a focused history and physical examination with particular attention to high-risk patients (Table 7). In addition to the history and physical examination, the Joint Commission on Accreditation of Healthcare Organizations requires documentation of the patient's ASA risk class and a plan for sedation and recovery, before performing the procedure. Informed consent must be obtained according to institutional guidelines. Immediately before the initiation of the procedure, a “time out” should be called and documented,
Table 6
Preparation and setup for sedation procedures [20].
Part of the safety net for sedation is to use a systematic approach so as not to overlook having an important drug, piece of equipment, or monitor immediately available at the time of a developing emergency. To avoid this problem, it is helpful to use an acronym that allows the same setup and checklist for every procedure. A commonly used acronym that is useful in planning and preparation for a procedure is SOAPME: Suction: size-appropriate suction catheters and a functioning suction apparatus (eg, Yankauer-type suction) Oxygen: adequate oxygen supply and functioning flow meters/other devices to allow its delivery Airway: size-appropriate airway equipment (nasopharyngeal and oropharyngeal airways, laryngoscope blades [checked and functioning], endotracheal tubes, stylets, facemask, bagvalve-mask or equivalent device [checked and functioning]) Pharmacy: all the basic drugs needed to support life during an emergency, including antagonists as indicated Monitors: functioning pulse oximeter with size-appropriate oximeter probes and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, end-tidal carbon dioxide, electrocardiogram, stethoscope) Equipment: special equipment or drugs for a particular case (eg, defibrillator)
259 Table 7
High-risk patients.
Snoring, stridor, sleep apnea Craniofacial abnormalities, history of airway difficulty Vomiting, bowel obstruction, gastroesophageal reflux Asthma exacerbation, pneumonia Cardiac disease, hypovolemia, sepsis Altered mental status, neurologic/neuromuscular disorder History of sedation failure Age b1 y Moderate or severe systemic disease that limits activity (ASA 3)
confirming the appropriate patient, procedure, and correct site of the procedure. During the procedure, the following elements should be documented on a time-based record: name, dose, route, site, and time of administered sedative; and the patient's response. Response to sedation may be recorded using any of several depth-of-sedation scores according to institutional preference [21-23]. The onset and duration of inhaled agents and infusions should be recorded, along with the use of supplemental oxygen when applicable. Vital signs, including pulse oximetry and capnography, should be documented at regular intervals throughout the procedure. Adverse or unexpected events and the response to those events should be recorded. With transfer to the recovery area, timing and any personnel change should be documented. Vital signs should continue to be monitored and recorded, along with depth of sedation, until the patient returns to baseline status or a predetermined level on a recovery scale. When the patient is discharged, the person responsible for the child should be provided with instructions and information regarding the medication given and any expected after effects, in addition to a 24-hour telephone number to call in the event of questions or problems.
Coding and Reimbursement In 2006, new Current Procedural Terminology (CPT) codes were introduced for moderate sedation. The RVUs Table 8
Moderate-sedation CPT codes.
CPT code
Age of patient
Duration of Procedure (intraservice time)
Sedation practitioner performing the procedure (Y/N)
99143 99144 +99145 99148 99149 +99150
b5 y N5 y Any age b5 y N5 y Any age
First 30 min First 30 min Each + 15 min First 30 min First 30 min Each + 15 min
Y Y Y N N N
260 are carrier priced, that is, left to the discretion of individual carriers because the Centers for Medicare and Medicaid Services has not presently assigned any RVUs to these codes [24]. These codes incorporate the time needed to perform presedation assessment, administration of the sedative, and monitoring (Table 8). The Joint Commission on Accreditation of Healthcare Organizations terminology of deep sedation is analogous to monitored anesthesia care (MAC) used in anesthesiology parlance [17]. This service is described by the CPT codes 00100 to 01999. The latter are billed in units of time (10- to 15-min increments). Each code has a fixed number of base units assigned that incorporates pre-procedure risk assessment and evaluation. For example, CPT code 00192 includes MAC in support of diagnostic imaging. If a typical cranial MRI requires 30 minutes of deep sedation, the cumulative reimbursable units would be 7 “base” units plus 2 additional units of 15-minute increments. There has been a general reluctance by payers to pay for sedation services, especially by non-anesthesiologists. This is largely a result of a lack of understanding of the complexity and risk involved in performing MAC in support of diagnostic or therapeutic services outside the operating room setting. In our anecdotal experience, this is changing. Payers in several states are now recognizing that EDSS is a medically necessary, cost-effective service that is being provided by PEM providers and others outside the ED, in support of diagnostic or therapeutic procedures.
Summary and Future Directions Dedicated EDSS are playing a crucial role in ameliorating distress and pain associated with a variety of hospital-based procedures in pediatric patients. The continuing challenge is meeting the ever-increasing demand for these services. Long-term sustainability will require creative methods of staffing and higher levels of reimbursement. Many centers are using dedicated, trained advanced practice nurses with physician oversight. Educating payers, soliciting support from the institution, and persistence with billing and coding for MAC services are some of the strategies to enhance reimbursement for an EDSS. We believe that it should be a priority for the PEM community to conduct research that refines sedation practice and protocols, with an emphasis on increasing efficiency, safety, customer satisfaction, and cost-effectiveness.
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Emergency department based sedation services 21. Malviya S, Voepel-Lewis T, Tait R, et al. Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). Br J Anaesth 2002;88:241-5. 22. De Jonghe B, Cook D, Appere-de-Vecchi C, et al. Using and understanding sedation scoring systems: a systematic review. Intensive Care Med 2000;26:275-85.
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23. Malviya S, Voepel-Lewis T, Ludomirsky A, et al. Can we improve the assessment of discharge readiness? A comparative study of observational and objective measures of depth of sedation in children. Anesthesiology 2004;100:218-24. 24. National Correct Coding Policy Manual. Anesthesia Services. Vol. I.I. Chapter, Version 10.3.; 2005. p. 10. Available at: www.cms.hhs.gov/ physicians/cciedits.
P
rovision of procedural sedation and analgesia is an essential skill in the practice of pediatric emergency medicine (PEM). Over the last decade, PEM specialists have made significant contributions to the science and practice of procedural sedation [1-12]. With an increase in sedation encounters outside the traditional operating room setting, hospital administrators have called upon PEM physicians to meet these service demands. Emergency physicians have traditionally been approved for moderate and deep sedation based on their training, core privileges, experience in the use of a broad range of sedatives, and demonstration of research in the field. Emerging data suggest that PEM physicians are providing sedation services as sole providers or in collaboration with pediatric intensivists and anesthesiologists [7,13-15]. In a recent survey of 116 children's hospitals in North America, only 26% used anesthesiologists as the sole provider of these services. Fifty-nine percent used mobile MD/RN teams, 11% had dedicated sedation units, and 33% used mixed models for delivery of these services. Sixtythree percent of respondents cited use of propofol regularly by non-anesthesiologists [16]. ⁎Division of Emergency Services, Le Bonheur Children's Medical Center, Memphis, TN. †Division of Emergency Services, A.I.Dupont Hospital for Children, Wilmington, DE. Reprint requests and correspondence: Jay Pershad, MD, Division of Emergency Services, Le Bonheur Children's Medical Center, 50 N Dunlap St., Memphis, TN 38103. (E-mail: [email protected]) 1522-8401/$ - see front matter C 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2007.08.005
We will review the pros and cons of establishing an emergency department (ED)–based sedation service (EDSS), discuss the scope of the service, review practical considerations in implementing and administering an EDSS, and highlight challenges and opportunities for reimbursement.
Pros and Cons An EDSS offers several advantages. By fulfilling a service need for the institution, it provides an opportunity for the department to build alliances and create leverage with hospital administration. A jointly staffed sedation service may create opportunities for collaboration with colleagues from other disciplines such as critical care, anesthesiology, and hospital-based medicine. For the individual practitioner, it may enhance professional satisfaction by instilling variety to one's practice and offer an opportunity for more “day shifts.” In some markets, the EDSS may bring financial rewards and higher relative value unit (RVU) productivity [7]. As with any new patient care–related service, it is timeand-resource intensive. Depending on the volume and scope of service, success usually requires a dedicated team of 1 or more PEM physicians. The practice of procedural sedation is high risk and increases malpractice exposure. Although critical adverse events are rare, the occurrence of serious adverse events ranging from apnea, desaturation, laryngospasm, and emesis has been reported in 0.2% to 253
254
Table 1
Scope of service and selection of agent.
Primary Service Radiology
Common Procedures MRI CT
Typical Length of Procedure 30-60 min; spines and vascular studies longer 5 min
Pain
Suggested Medication Regimen
Special Considerations
No
PI; PB ± midazolam or fentanyl
Noisy, confining, magnetic field
No
Propofol bolus; etomidate; ketamine; dexmedetomidine PI or PB Midazolam; N2O
Contrast, positioning
Nuclear medicine Fluoroscopy
45-120 min Enteral tubes: varies; VCUG: 5-10 min
No
Interventional
Varies widely
Yes
Lumbar puncture
5-10 min
Yes
Midazolam; propofol; ketamine; N2O
10-15 min
Yes
Cardiology
Bone marrow aspirate and/ or biopsy ECHO
15-20 min
No
Fentanyl/midazolam; propofol or ketamine Midazolam, chloral hydrate in infants
Gastroenterology
Endoscopy; colonoscopy
10-15 min
No
Ketamine/midazolam; propofol/fentanyl
Airway, gagging, laryngospasm
Orthopedics
Fracture reduction
5-10 min
Yes
Postreduction imaging, second attempts
Appliance removal
5-10 min
Yes
Botox injection Abscess drainage Minor skin procedures Burn debridement Complex laceration repair
5-10 min 5-10 min 10-15 min 15-30 min 30 -60 min
Yes Yes Yes Yes Yes
Foreign body removal Sedated examination; IOP ABR/BAER
5-10 min 5 min 45-60 min
No No No
Neurology
EEG/EMG/SSEP Lumbar puncture
30-60 min 5-10 min
Minor Yes
Ketamine; N2O with regional block; propofol/fentanyl Ketamine; propofol/fentanyl; N2O with regional block Midazolam ± ketamine Ketamine; propofol Midazolam ± ketamine; propofol Ketamine ± midazolam; propofol + fentanyl LET gel + midazolam or N2O; LET gel + ketamine; LAT gel + propofol Midazolam; ketamine; propofol Midazolam or propofol Chloral Hydrate (infants); PB or PI; Dexmedetomidine Chloral hydrate (infants); dexmedetomidine Midazolam; propofol
Dental Nephrology
Examinations; dental surgery Renal biopsy
Varies 10-15 min
Yes
N2O Ketamine or propofol/fentanyl; fentanyl/midazolam for adolescents
Rheumatology Vascular
Arthrocentesis Difficult vascular access
5-10 min 15 min
Yes Yes
Midazolam ± ketamine; propofol; N2O Topical anesthetic + N2O or midazolam
Hematology/ oncology
General surgery
ENT Ophthalmology Audiology
Isotope injection timing, expense Discomfort, gagging with tubes, ? psychological implications of VCUG Varied depth of sedation during procedure Combined procedures, underlying risks Biopsy quite painful
Underlying neurologic issues Supplement with local anesthetic Supplement with local anesthetic On finger, supplemental digital block is recommended Potential airway issues Avoid ketamine
PI indicates propofol infusion; PB, pentobarbital; CT, computed tomography; N2O, nitrous oxide; EEG, electroencephalogram; EMG, electromyogram; LET, lidocaine, epinephrine, tetracaine; MRI, magnetic resonance imaging; IOP, intraocular pressure, ABR, auditory brainstem response; ECHO, echocardiography; BAER, brainstem auditory evoked response; SSEP, somatosensory evoked potential; VCUG, voiding cystourethrogram.
J. Pershad, S. Kost
Effect of sedative on EEG Airway in infants, raised intracranial pressure Secretions, airway issues Underlying hypertension, renal pathology, usually prone position, renal insufficiency
Emergency department based sedation services 1.6% of encounters [13]. It is crucial that adequately trained and credentialed providers are available to manage potential complications.
Sedation Service Considerations Scope of the Sedation Service A major consideration with provision of procedural sedation beyond the walls of the ED is the proposed scope of service. The radiology department is the most obvious example of a department with a significant demand for sedation services. However, any pediatric medical or surgical service performing procedures that invoke pain and/or distress, outside the operating room setting, would benefit from this service. Table 1 illustrates examples of the wide scope of sedation services in a fullservice pediatric hospital. There are several factors that could influence the practice of procedural sedation. Within the radiology department, issues include environmental factors (magnetic fields, radiation) and timing of sedation relative to the procedure. For example, in the magnetic resonance imaging (MRI) suite, the airway equipment needed for resuscitation may not be permitted within the gaussian range of the scanner. Although available, MRI-compatible laryngoscopes are relatively expensive. In the computed tomography and nuclear medicine suites, timing of sedation relative to administration of contrast is important. In the event of an unsuccessful sedation, recurrent dosing of contrast material may be potentially harmful. Furthermore, some of the nuclear isotopes cost several thousand dollars per dose and require injection up to 24 hours before the scan. These issues highlight the importance of careful risk assessment and skillful sedation. In the inpatient setting, most patients have comorbidities that may influence sedation practices. Although emergency physicians are skilled in caring for acutely ill patients, the risks must be weighed against the benefits of sedation to facilitate a particular procedure. Unlike
Table 2 American Society of Anesthesiology risk classification [18]. ASA Class I ASA Class II ASA Class III
ASA Class IV
ASA Class V
A normal, healthy patient. A normal patient with mild systemic disease (no functional limitation) A patient with moderate or severe systemic disease that limits activity but is not incapacitating. A patient with an incapacitating systemic disease that is a constant threat to life. A moribund patient not expected to survive 24 hours with or without the procedure.
255 Table 3 Documentation of a presedation focused history and physical examination. Parameter 1. Age and weight 2. Allergies 3. Medications
4. Current medical status
5. Review of systems
6. Medical history
7. Family history 8. Vital signs 9. Physical examination
Comments Egg and/or soy allergy may preclude propofol use. Medications metabolized by the cytochrome P-450 enzyme pathway, such as some anticonvulsants and psychotropic medications, may interfere with pharmacokinetics of some sedatives. Especially conditions predisposing to airway obstruction or pulmonary compromise; pregnancy status Cardiovascular, hepatic, renal, neurologic, or hematologic conditions that may influence use of sedatives or radiographic contrast materials; presence of contact lenses, dental appliances or loose dentition; vomiting or risk factors for aspiration Relevant hospitalizations particularly prior sedation or anesthesia-related adverse events Anesthetic complications such as malignant hyperthermia Including baseline pulse oximetry Including focused airway evaluation (Mallampati classification, limitation of cervical spine mobility) [19]
the ED setting, not all procedures need to be accomplished emergently. In some cases, it may be prudent to reschedule or refer the case for completion under general anesthesia. When confronted with the task of initiating a hospitalbased sedation service, it may be advisable to begin with a limited set of services before broadening the scope of the practice. Factors that may affect this decision include availability and experience of the sedation providers, and physical attributes of the facility.
Centralized vs Mobile Sedation Services Sedation services beyond the scope of the ED are generally based on 1 of 2 models: a “centralized” model, where patients come from throughout the hospital to a dedicated area, or a “mobile” model, where members of the sedation team travel to various patient care areas to provide the service. Each of these models has its pros and cons. A
J. Pershad, S. Kost
256 Table 4
Overview of sedation and analgesia medications [1].
Agent
Pediatric Dosing
Sedative-hypnotics Choral hydrate Oral: 25-100 mg/kg, after 30 min can repeat 25-50 mg/kg; maximum total dose: 2 g or 100 mg/kg (whichever is less); single use only in neonates Diazepam IV: initial 0.05-0.1 mg/kg, then titrate slowly to maximum 0.25 mg/kg Etomidate IV: 0.1 mg/kg; repeat if inadequate response Midazolam
Methohexital
Pentobarbital
Propofol
Thiopental Analgesics Fentanyl
Morphine
IV (0.5-5 y): initial 0.05-0.1 mg/kg, then titrated to maximum 0.6 mg/kg; IV (6-12 y): initial 0.025-0.05 mg/kg, then titrated to maximum 0.4 mg/kg IM: 0.1-0.15 mg/kg PO: 0.5-0.75 mg/kg IN: 0.2-0.5 mg/kg PR: 0.25-0.5 mg/kg PR: 25 mg/kg IV: 0.5-1 mg/kg IV: 1-6 mg/kg, titrated in 1- to 2-mg/kg increments every 3-5 min to desired effect IM: 2-6 mg/kg, maximum 100 mg PO/PR (>4 y): 3-6 mg/kg, maximum 100 mg; PO/PR (>4 y): 1.5-3 mg/kg; maximum 100 mg IV: 1 mg/kg, followed by 0.5 mg/kg; repeat doses as needed
Onset (min)
Duration (min)
Comments
PO: 15-30
PO: 60-120
Effects unreliable if age >1 yr and/or >10kg
IV: 4-5
IV: 60-120
IV: >1
IV: 5-15
IV: 2-3
IV: 45-60
Reduce dose when used in combination with opioids Adverse effects include respiratory depression, myoclonus, nausea, emesis Reduce dose when used in combination with opioids; may produce paradoxical excitement
IM: 10-20 PO: 15-30 IN: 10-15 PR: 10-30 PR: 10-15
IM: 60-120 PO: 60-90 IN: 60 PR: 60-90 PR: 60
IV: 3-5
IV: 15-45
Dosing limited to 5 mg (1 mL) Avoid if there is temporal lobe epilepsy or porphyria May produce paradoxical excitement; avoid in patients with porphyria
IM: 10-15 IM: 60-120 PO/PR: 15-60 PO/PR: 60-240
IV: >1
IV: 5-15
PR: 25 mg/kg
PR: 10-15
PR: 60-120
IV: initial 1 μg/kg up to 50 μg per dose, may repeat every 3 min, titrate to effect
IV: 3-5
IV: 30-60
IV: initial 0.05-0.15 mg/kg up to 3 mg per dose, may repeat every 5 min, titrate to effect
IV: 5-10
IV: 120-180
IV: 1
Dissociation: 15; Multiple recovery: 60 contraindications; unpleasant dreams or hallucinations rare in kids Often given with Dissociation: 15-30; recovery: concurrent atropine 90-150 or glycopyrrolate to counter hypersalivation
Dissociative drug Ketamine IV: 1-1.5 mg/kg slowly over 1 min, may repeat every 10 min as needed
IM: 4-5 mg/kg, may repeat (2-4 mg/kg) after 10 min
IM: 3-5
Inhalational drug b5 Nitrous oxide Preset mixture with minimum 30% oxygen self-administered by demand valve mask (requires cooperative child); continuous flow nasal mask in uncooperative child with close monitoring
>5 after discontinuation
Frequent hypotension and respiratory depression; avoid with egg or soy allergies Avoid in patients with porphyria Reduce dosing when combined with benzodiazepines Reduce dosing when combined with benzodiazepines
Requires specialized apparatus and gas scavenger capability; several contraindications
Emergency department based sedation services
Table 4
257
(continued).
Agent Reversal drugs Naloxone
Flumazenil
Pediatric Dosing IV/IM: 0.1 mg/kg per dose up to maximum of 2 mg per dose, may repeat every 2 min as needed IV: 0.02 mg/kg per dose, may repeat every 1 min up to 1 mg
Onset (min)
Duration (min)
IV: 2
IV: 20-40 IM: 60-90
IV: 1-2
IV: 30-60
Comments If shorter-acting than the reversed drug, serial doses may be required If shorter-acting than the reversed drug, serial doses may be required
Alterations in dosing may be indicated depending on the clinical situation and the practitioner’s experience with these drugs. Individual dosages may vary when used in combination with other drugs, especially when benzodiazepines are combined with opiates. Ketamine is absolutely contraindicated in patients younger than 3 months (airway risk) or when there is known psychosis (may exacerbate). Relative contraindications include age younger than 12 months; procedures involving stimulation of posterior pharynx; history of tracheal surgery or stenosis; active pulmonary infection or disease (including upper respiratory tract infection); known or suspected cardiovascular disease; suspected raised intracranial or intraocular pressure; globe injury; porphyria or thyroid dysfunction. IV indicates intravenous; IM, intramuscular; PO, per os; IN, intranasal; PR, per rectum.
combined model offers the greatest flexibility in meeting patient care–related demands. A centralized unit permits a more efficient use of personnel and equipment. For example, an EDSS team member could work up a new patient while monitoring a patient during recovery. Moreover, in the event of a sedation-related adverse event, assistance from other personnel on the team is more readily available in a centralized model. The full complement of necessary equipment and backup is more readily available in a centralized unit. Furthermore, by having a locked cabinet in a central area, dispensing and monitoring of controlled substances is greatly facilitated. The primary disadvantage of a centralized unit is that very few pediatric facilities have sufficient space in one location. Sedated patients may require transport over distances ranging from a few feet to a city block, depending on the physical layout of the hospital. Also, an “open” unit may not be ideal for all phases of the sedation encounter. Despite best efforts to minimize distractions, the induction of one patient may be interrupted by emergence agitation of another. A mobile EDSS allows for greater flexibility, thus minimizing the need for patient transport. It is ideal in a community hospital setting where pediatric resources may not be available in all patient care areas. Because a mobile EDSS usually consists of fewer members than a large centralized sedation unit, the team members tend to develop a rapport, making the practice more consistent and efficient. The drawbacks of a mobile EDSS are those inherent with travel. The lack of ready availability of a certain piece of equipment or medication can lead to delays. Traveling teams also need to become familiar with the location of resuscitation equipment and monitors in other areas of the hospital. In a busy mobile EDSS, the temptation to move on to the next procedure before the
previous patient is fully recovered may create challenges to patient safety.
Staffing The staffing needs of an EDSS depend on several factors, such as patient volume, types and duration of procedures, pharmacokinetics of sedatives used, and physical plant space considerations. Another consideration is that institutional policies and best practices dictate that all patients have an observer dedicated exclusively to monitoring the patient for the entire duration of the sedation process. With this, a single provider should not be left alone, in a remote environment, with a sedated patient. In institutions such as ours, where the MRI scanner is physically remote from the centralized sedation unit, 3 nurses are responsible for staffing: one to monitor the patient while in the scanner, one to begin the evaluation of the next patient, and one to aid in patient transport and to provide additional assistance as needed, particularly in a sedation-related adverse event. In addition to the traditional “doctor-nurse” model, a sedation service could employ nurse anesthetists, physician's assistants, advanced practice nurses, or respiratory therapists in various capacities, according to institutional, local, and state policies.
Credentialing of Sedation Providers Establishing a process for credentialing is important to ensure that the providers are trained and possess the requisite skill set to practice procedural sedation safely. Sedation encounters are monitored during joint commission surveys of hospitals [17]. Each institution can establish its own criteria for granting sedation privileges. Our institution requires viewing a video, obtaining a passing score on a written test, a current pediatric advanced life support course certificate, and lastly, being precepted on 10 sedation encounters in the ED.
J. Pershad, S. Kost
258
Patient Scheduling Scheduling sedation encounters requires careful planning, to ensure optimal use of the service and institutional resources. The hospital appointment desk is usually responsible for scheduling outpatient visits. The nurse administrators on the team usually handle requests for inpatient sedations. Because requests from the inpatient service are unpredictable, it is inevitable that decisions that involve prioritization of patients become a challenge. Proper screening of patients, ongoing communication with referring services, and being sensitive to patients who are nil per os (NPO) for extended duration is crucial. More specifically, scheduling sedation for radiologic procedures requires close coordination between the scheduler and the sedation team, to minimize MRI scanner down time. Reserving “pods” for inpatients on select days of the week may be helpful. Scheduling younger children and high-risk patients early in the day minimizes prolonged NPO times for infants and permits appropriate management of adverse events when ancillary services are well staffed.
Quality Assurance Documentation of a sedation encounter must reflect appropriate history and physical examination results, risk assessment using standard American Society of Anesthesiologists (ASA) class definition, screening for a difficult airway, selection of agent, anticipated level of sedation, and a proper monitoring record of vital signs including depth of sedation during induction, recovery, and actual procedure. Establishing protocols that are specific to the institution are important to ensure delivery of safe and cost-effective sedation services. Quality assurance benchmarks for PEM staffed sedation services may include the following:
⋅ Number of failed sedations ⋅ Percentage of cases referred for general anesthesia ⋅ Frequency and type of adverse events ⋅ Scores on patient satisfaction surveys ⋅ Referring physician surveys Communication With Referring Physicians Effective communication with referring pediatricians and subspecialists is important to ensure patient and caregiver satisfaction with procedural sedation. It may be helpful to develop and distribute a written policy or service description that includes the following information:
⋅ Hours of service ⋅ Contact phone or
pager number of the sedation practitioner on call ⋅ Characteristics of patients who typically require sedation in support of procedures. This includes patients with developmental delay, hyperactivity, and the very young.
⋅ Patients with an ASA classification of greater than 3 may be best managed by a referral to an anesthesiologist for general anesthesia (see Table 2). ⋅ The process of scheduling patients and requesting a “sedation evaluation” for those that may need sedation. An emphasis on having patients present at least 30 minutes before their scheduled appointment would ensure that sufficient time is available to evaluate the patient, perform a risk assessment, and develop a sedation plan. ⋅ Informing the physician staff that because of the nature and length of certain radiologic procedures, that there are limited numbers of openings available each day for patients requiring sedation. ⋅ The institution's NPO policy ⋅ Patient preparations, including the need to have a working intravenous line, because certain cases typically require parenteral sedatives. Here, any guidelines for use of topical anesthetics may be included. ⋅ An overview of commonly used medications
Administrative and Reimbursement Issues The sedation encounter begins with a focused history and physical examination to identify patients who may
Table 5 Appropriate intake of solids and liquids before elective sedation [20]. Ingested Material Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee Breast milk Infant formula Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period Light meal: a light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time; both the amount and type of foods ingested must be considered when determining an appropriate fasting period
Minimum Fasting Period 2 hrs
4 hrs 6 hrs 6 hrs
6 hrs
Emergency department based sedation services be at high risk for sedation-related adverse events. Table 3 summarizes key elements of this process. The selection of a sedative agent depends on several factors that include type and duration of the procedure, degree of patient immobility desired, the need for analgesia, and comfort level of the sedation practitioner. Table 1 outlines suggestions for selection of agents for various types of procedures that may be performed by an EDSS. Table 4 provides an overview of the different classes of medications, dose range, duration of action, adverse event profile, and contraindications to their use. A presedation checklist includes verification of the child's NPO status and a review of necessary equipment for rescue and resuscitation (see Tables 5 and 6).
Documentation Appropriate documentation of a sedation encounter involves 3 stages: before, during, and after the procedure. The use of standardized sedation forms or computerized documentation tools increases efficiency. Before sedation, an appropriately licensed practitioner must document a focused history and physical examination with particular attention to high-risk patients (Table 7). In addition to the history and physical examination, the Joint Commission on Accreditation of Healthcare Organizations requires documentation of the patient's ASA risk class and a plan for sedation and recovery, before performing the procedure. Informed consent must be obtained according to institutional guidelines. Immediately before the initiation of the procedure, a “time out” should be called and documented,
Table 6
Preparation and setup for sedation procedures [20].
Part of the safety net for sedation is to use a systematic approach so as not to overlook having an important drug, piece of equipment, or monitor immediately available at the time of a developing emergency. To avoid this problem, it is helpful to use an acronym that allows the same setup and checklist for every procedure. A commonly used acronym that is useful in planning and preparation for a procedure is SOAPME: Suction: size-appropriate suction catheters and a functioning suction apparatus (eg, Yankauer-type suction) Oxygen: adequate oxygen supply and functioning flow meters/other devices to allow its delivery Airway: size-appropriate airway equipment (nasopharyngeal and oropharyngeal airways, laryngoscope blades [checked and functioning], endotracheal tubes, stylets, facemask, bagvalve-mask or equivalent device [checked and functioning]) Pharmacy: all the basic drugs needed to support life during an emergency, including antagonists as indicated Monitors: functioning pulse oximeter with size-appropriate oximeter probes and other monitors as appropriate for the procedure (eg, noninvasive blood pressure, end-tidal carbon dioxide, electrocardiogram, stethoscope) Equipment: special equipment or drugs for a particular case (eg, defibrillator)
259 Table 7
High-risk patients.
Snoring, stridor, sleep apnea Craniofacial abnormalities, history of airway difficulty Vomiting, bowel obstruction, gastroesophageal reflux Asthma exacerbation, pneumonia Cardiac disease, hypovolemia, sepsis Altered mental status, neurologic/neuromuscular disorder History of sedation failure Age b1 y Moderate or severe systemic disease that limits activity (ASA 3)
confirming the appropriate patient, procedure, and correct site of the procedure. During the procedure, the following elements should be documented on a time-based record: name, dose, route, site, and time of administered sedative; and the patient's response. Response to sedation may be recorded using any of several depth-of-sedation scores according to institutional preference [21-23]. The onset and duration of inhaled agents and infusions should be recorded, along with the use of supplemental oxygen when applicable. Vital signs, including pulse oximetry and capnography, should be documented at regular intervals throughout the procedure. Adverse or unexpected events and the response to those events should be recorded. With transfer to the recovery area, timing and any personnel change should be documented. Vital signs should continue to be monitored and recorded, along with depth of sedation, until the patient returns to baseline status or a predetermined level on a recovery scale. When the patient is discharged, the person responsible for the child should be provided with instructions and information regarding the medication given and any expected after effects, in addition to a 24-hour telephone number to call in the event of questions or problems.
Coding and Reimbursement In 2006, new Current Procedural Terminology (CPT) codes were introduced for moderate sedation. The RVUs Table 8
Moderate-sedation CPT codes.
CPT code
Age of patient
Duration of Procedure (intraservice time)
Sedation practitioner performing the procedure (Y/N)
99143 99144 +99145 99148 99149 +99150
b5 y N5 y Any age b5 y N5 y Any age
First 30 min First 30 min Each + 15 min First 30 min First 30 min Each + 15 min
Y Y Y N N N
260 are carrier priced, that is, left to the discretion of individual carriers because the Centers for Medicare and Medicaid Services has not presently assigned any RVUs to these codes [24]. These codes incorporate the time needed to perform presedation assessment, administration of the sedative, and monitoring (Table 8). The Joint Commission on Accreditation of Healthcare Organizations terminology of deep sedation is analogous to monitored anesthesia care (MAC) used in anesthesiology parlance [17]. This service is described by the CPT codes 00100 to 01999. The latter are billed in units of time (10- to 15-min increments). Each code has a fixed number of base units assigned that incorporates pre-procedure risk assessment and evaluation. For example, CPT code 00192 includes MAC in support of diagnostic imaging. If a typical cranial MRI requires 30 minutes of deep sedation, the cumulative reimbursable units would be 7 “base” units plus 2 additional units of 15-minute increments. There has been a general reluctance by payers to pay for sedation services, especially by non-anesthesiologists. This is largely a result of a lack of understanding of the complexity and risk involved in performing MAC in support of diagnostic or therapeutic services outside the operating room setting. In our anecdotal experience, this is changing. Payers in several states are now recognizing that EDSS is a medically necessary, cost-effective service that is being provided by PEM providers and others outside the ED, in support of diagnostic or therapeutic procedures.
Summary and Future Directions Dedicated EDSS are playing a crucial role in ameliorating distress and pain associated with a variety of hospital-based procedures in pediatric patients. The continuing challenge is meeting the ever-increasing demand for these services. Long-term sustainability will require creative methods of staffing and higher levels of reimbursement. Many centers are using dedicated, trained advanced practice nurses with physician oversight. Educating payers, soliciting support from the institution, and persistence with billing and coding for MAC services are some of the strategies to enhance reimbursement for an EDSS. We believe that it should be a priority for the PEM community to conduct research that refines sedation practice and protocols, with an emphasis on increasing efficiency, safety, customer satisfaction, and cost-effectiveness.
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