Background and Objective: Children often need procedural sedation for painful procedures. There are few data on type of provider, site of sedation, and agents used for procedural sedation in hospitals across the nation. The objective was to determine procedural sedation practices for hospitalized children outside the PICU and emergency department.
Methods: Surveys were sent to 89 pediatric hospitalist (PH) leaders in hospitals belonging to the Child Health Corporation of America or the National Association of Children’s Hospitals and Related Institutions.
Results: We received responses from 56 PHs (63%), of whom 49 (55%) completed the survey. PHs provided sedation in 18 hospitals. Provider, setting, and agents used for procedural sedation varied. The primary providers of procedural sedation for abscess incision and drainage, renal biopsy, joint aspiration, computed tomography, and MRI were anesthesiologists. A significantly greater percentage of hospitals where PHs did not provide procedural sedation used the operating room for abscess incision and drainage compared with hospitals where PHs provided procedural sedation (63% vs 28%, respectively). Postoperative/abscess dressing change, vesicocystourethrogram, and ≥1 painful procedure were performed without sedation in significantly greater percentage of hospitals where PHs did not provide procedural sedation compared with hospitals where PHs provided procedural sedation.
Conclusions: There is variability in sedation practices in hospitals across the nation, which affects patient care and use of resources such as the operating room. In hospitals where PHs provide procedural sedation, there is less operating room use and fewer painful procedures for which no sedation is provided.
Hospitalized children often undergo painful procedures that necessitate provision of procedural sedation and analgesia to ameliorate pain and anxiety. There are few data on procedural sedation practices such as type of provider, site of sedation, and agents used for procedural sedation in hospitals across the nation. With growing focus on efficient resource use to control costs yet maintain optimal clinical care, it is important to determine hospital procedural sedation practices so that barriers to provision of appropriate procedural sedation are identified and strategies are implemented to overcome them.
Anesthesiologists used to be the primary sedation providers for children. However, nonanesthesiologists such as pediatric intensivists, emergency department (ED) physicians, and pediatric hospitalists (PHs) are increasingly providing procedural sedation for painful and radiologic procedures.1–5 Of the various nonanesthesiologist sedation providers, PHs also provide care to children in inpatient units (outside the PICU) in their role as inpatient ward attending to hospitalized children, so they may be more aware of the sedation needs of hospitalized children under their care.
The primary goal of this study was to determine the procedural sedation practices such as type of provider, site of sedation, and agents used for procedural sedation of children outside the PICU and ED in hospitals across the nation. The secondary goal of the study was to determine whether there is variability in procedural sedation practices in hospitals where PHs provide procedural sedation compared with hospitals where PHs do not provide procedural sedation.
A survey was developed to collect data on the procedural sedation practices used in hospitals across the nation for commonly performed painful procedures and radiologic imaging outside the ED and PICU. The survey was sent to 42 hospitals belonging to the Child Health Corporation of America and to 46 hospitals belonging to the National Association of Children’s Hospitals and Related Institutions in states that did not have a hospital belonging to Child Health Corporation of America. One state had no major freestanding children’s hospital, and we sent the survey to a hospital with a pediatric unit. The survey was sent to division directors of PH medicine or chiefs of inpatient pediatrics. Because of the wide variability in sedation providers for different procedures in each hospital, it was difficult to identify the primary sedation service in each hospital in our initial query to obtain contact information for the survey. Traditionally, anesthesiologists have been the primary sedation providers in many hospitals. However, increasingly many hospitals also have other sedation providers (ED physicians, PHs, critical care physicians). In addition, anesthesiologists may be aware of the sedation practices only for children whom they provide sedation. They may not be aware of children who need sedation for a procedure but are not being provided sedation or are being provided sedation by other sedation providers. We thought that because PHs take care of hospitalized children in their role as inpatient attending physicians, they might be aware of the sedation needs and practices for the children under their care. This was the rationale for surveying the PH division directors. Each hospital received a single survey except for 1 hospital that received 2 surveys at their request, but only a single response was obtained from that hospital. In total, the survey was sent to 89 hospitals (across 49 states) via e-mail with a web link to Survey Monkey in February 2013. Three reminder e-mails were sent to hospitals that did not respond, with the final reminder sent in May 2013. The study was approved by the institutional review board at Washington University. A link to the survey can be found at https://www.surveymonkey.com/s/finalrevisedsedationsurvey. The survey had 17 questions and took about 15 minutes to complete. We specified in the survey that we were querying about procedural sedation practices for healthy children who were American Society of Anesthesiology category 1 or 2. The survey queried about sedation agents used, provider types, and sites of sedation for multiple procedures. Fischer’s exact test was used to determine significant differences in the rates of operating room (OR) use and the provision of procedural sedation between hospitals where PHs provided procedural sedation compared with hospitals where PHs did not provide procedural sedation.
The survey was sent to 89 hospitals across the nation. We obtained responses from 56 hospitals (63% response rate). Of those, 7 were incomplete surveys, which were excluded from analyses. Most hospitals were identified as academic children’s hospitals (83%) with >100 beds (73%). Response rates varied for each procedure queried (55%–67% for agents used, 73%–87% for site of sedation, and 82%–86% for procedural sedation provider). PHs provided procedural sedation in 18 of 56 hospitals (32%).
The primary providers of procedural sedation for abscess incision and drainage (I&D), renal biopsy, joint aspiration or injection, computed tomography (CT), and MRI were anesthesiologists (Table 1). For postoperative/abscess dressing changes and vesicocystourethrograms (VCUGs) PHs were the primary sedation providers, whereas pediatric emergency medicine physicians or intensivists were the primary providers of sedation for peripherally inserted central catheter (PICC) placements and burn dressing changes.
Abscess I&D and renal biopsy were performed predominantly in the OR (Table 2). Procedural sedation for imaging procedures was performed predominantly in radiology. For all of the nonimaging procedures, a significant fraction of hospitals (range, 22%–51%, depending on the procedure; Table 2) used the resources of a procedural sedation unit or procedure room to provide sedation. Postoperative dressing changes were performed at the bedside in a significant fraction of hospitals.
Propofol was the most frequently used sedation agent for radiologic imaging and for painful procedures such as abscess I&D, renal biopsy, PICC placement, and joint aspiration (Table 3). Ketamine was used less. Five hospitals reported that PHs were unable to obtain credentialing for the use of ketamine. Nitrous oxide was infrequently used for procedural sedation: in 1 hospital for postoperative dressing changes, in 2 hospitals for VCUGs, and in 1 hospital for joint aspirations or joint injections. VCUG stood out as a procedure where procedural sedation agents were used much less frequently than with other procedures. As Table 2 shows, 43% of respondents reported that no procedural sedation was provided for VCUGs in their hospital. In 2 hospitals oral or intravenous (IV) midazolam, which provides no analgesia, was used for burn and postoperative/abscess dressing changes.
The survey reported significant variability in procedural sedation practices between hospitals where PHs provided procedural sedation compared with those where PHs did not provide procedural sedation. Postoperative/abscess dressing changes, VCUGs, and ≥1 painful procedures were performed without sedation in significantly greater percentage of hospitals where PHs did not provide sedation compared with hospitals where PHs provided procedural sedation (Fig 1). In all hospitals, regardless of the procedural sedation provider type, VCUGs and postoperative dressing changes were the 2 procedures for which procedural sedation was not provided most frequently.
For all procedures combined, the survey reported that 44% of hospitals where PHs provided procedural sedation used the OR for ≥1 procedure (Fig 1). In contrast, 74% of hospitals where PHs did not provide procedural sedation reported use of the OR for ≥1 procedure. Abscess I&D, renal biopsy, and joint aspiration were the procedures with the highest OR use in both groups of hospitals. A significantly greater percentage of hospitals where PHs did not provide procedural sedation used the OR for abscess incision and drainage compared with hospitals where PHs provided procedural sedation (63% and 28%, respectively).
Our study demonstrates a wide variability in type of sedation provider, site of sedation, and agents used for sedation for various procedures in children’s hospitals. This variation in practice affects patient care and resource use.
Abscess I&D is a procedure performed routinely in the ED by pediatric emergency medicine physicians, who often provide sedation for the procedure.6–8 It also has been performed in procedural sedation units in the hospital setting, with sedation provided by PHs.1,9 However, in our survey anesthesiologists provide procedural sedation for abscess I&D in 50% of hospitals. In addition, abscess I&D is performed in the OR in 50% of the hospitals. This is probably because anesthesiologists use the OR for the procedure, whereas nonanesthesiologists use a sedation unit or procedure room. Of the various locations where procedural sedation can be provided, the OR probably uses more resources and may be more expensive than a sedation unit or a procedure room. A study by Lalwani et al10 demonstrated that an office-based dental service using a pediatric procedural sedation service model for children with special needs was efficient and resulted in a savings of $4849 in hospital charges per patient compared with the use of the OR for the same procedure.
Resources used for procedural sedation can vary depending on the agents used. For example, use of nitrous oxide does not require placement of an IV line. IV placement requires IV supplies, nursing time to place an IV, and associated trauma to the child during IV placement. However, nitrous oxide is used in only 4 hospitals that we surveyed. Thus, there is underuse of an agent that is effective, has rapid recovery time, has a low rate of complications, and uses fewer resources.1,7,11 Ketamine provides effective procedural sedation for painful procedures and has an excellent safety profile with a low risk of respiratory depression.1,12–14 It is underused in the hospital setting for painful procedures, as reported in this survey.
Postoperative/abscess dressing change can be painful if there is packing in the surgical site that must be removed or if wound debridement is performed during the dressing change.15 Similarly, bladder catheterization for VCUG can be painful and traumatic, especially in toddlers and older children, without at least some analgesia or procedural sedation.16 No procedural sedation was provided for postoperative dressing changes or VCUGs in 45% and 62%, respectively, of hospitals where PHs do not provide procedural sedation, compared with 12% for both procedures in hospitals where PHs do provide procedural sedation.
Studies have shown that use of PHs for inpatient care reduces length of stay, inpatient hospital costs, and resource use (tests and radiologic procedures ordered per patient).17 Our study demonstrates that OR use for abscess I&D is significantly less in hospitals where PHs provide procedural sedation. It is likely that OR use rates are also lower in hospitals where pediatric intensivists or pediatric emergency physicians provide sedation because nonanesthesiologist sedation providers do not provide sedation in the OR. Nationally, there has been an increase in resource use for admissions of children hospitalized with skin and soft tissue infections, including a 72% increase in mean charges per hospitalization and a twofold increase in the rates of I&D procedures for these children.18 Decreased use of ORs for abscess I&D by PHs and other nonanesthesiologist sedation providers may help decrease the charges for this procedure.
There are several limitations to this study. The information reported in the survey may be different from the actual practices in the hospital. The PH division directors may not be aware of all procedural sedation practices for children in the hospital, especially in hospitals where PHs do not provide procedural sedation. In addition, the findings may not reflect the sedation practices of hospitals that did not respond to the survey or of the hospitals including community children’s hospitals that do not belong to the Child Health Corporation of America or the National Association of Children’s Hospitals and Related Institutions and were not surveyed in this study.
There is variability in procedural sedation practices in hospitals across the nation that affects patient care and use of resources such as ORs. In hospitals where PHs provide sedation, there is less OR use and fewer painful procedures for which no sedation is provided.
Assistance with statistical analysis was provided by the Washington University Institute of Clinical and Translational Sciences.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding was provided for this research.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- computed tomography
- emergency department
- incision and drainage
- operating room
- pediatric hospitalist
- peripherally inserted central catheter
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