In the PRIS survey, most hospitalists who provide sedation reported that they received on-the-job training. The intensity of this training varies widely, from being involved in a few sedations prior to performing them independently, to very structured programs. It is important that hospitalists have defined training prior to performing sedations and are never placed in a position of performing sedations simply because no one else is willing to [3].

Exposure to and training for safe sedation practice is highly variable during pediatric residencies. Many pediatric residents have significant exposure, and many pediatric residents perform sedations under direct supervision of pediatric-trained attendings. However, since the training is so highly variable, it should not be assumed that most pediatricians have adequate training in residency to perform sedations independently without further training and experience.

This is really part of on-the-job training but implies a more detailed and comprehensive program of gaining experience in safe sedation practice. This training can be done with anesthesiology staff or pediatricians with significant experience and proficiency in sedation. The number of directly supervised sedations and number performed with each drug used should be determined by the local institution.

This can be an important adjunct to other types of training. In the operating room (OR) there will likely be opportunities for airway management that are difficult to obtain elsewhere. This is particularly important with the concept of rescue. Most patients in the operating room need advanced airway management. Skills that can be practiced in the OR include maintaining airways with positioning, positive pressure ventilation with a bag, laryngeal mask airway (LMA) placement, and intubation. OR time allows improvement of airway management skills in a controlled environment. This type of training is not essential for everyone that is providing sedation but is something that should be strongly considered.

There are an increasing number of simulation labs available for use in sedation training, particularly in academic medical centers. Training in a simulation lab can be very helpful in training for sedation. Mannequins are becoming more and more sophisticated and are more closely simulating real-life experiences. Simulation labs can be particularly helpful with management of difficult situations that are hopefully avoided in safe sedation practice on actual patients. Simulation can also be useful in training for rare events such as laryngospasm.

Pediatric advanced life support (PALS) training is an important adjunct to the provision of safe sedation. However, it should not be used as a proxy for adequate training for those that are providing sedation. PALS should be a part of a training program for safe sedation, but should never be used alone as adequate indication of sufficient training to provide moderate and deep sedation.

Once a hospitalist has been trained and credentialed in the provision of safe sedation, it is important to maintain the skill and have a method for measuring those competencies. There are no set standards for the number of sedations to be completed on an annual basis in order to maintain competencies. Each institution should establish a minimum number and type of sedations performed on an annual basis or develop a program that includes other methods of maintaining skills, such as OR time or simulation lab time. Some drugs, such as propofol, should have very defined minimum numbers of annual sedations provided by each provider in order to maintain credentialing. At St. Louis Children’s Hospital, non-anesthesiologist providers who are credentialed to use propofol are required to document 25 propofol sedations on an annual basis. This number is not meant to be a guide for others but an example of one institution’s decision [4, 5].

The number of hospitalists needed to provide sedation services will vary depending on the need that they are meeting. While some pediatric hospitalists provide sedation services full time, most involved in sedation services do it as one of several clinical responsibilities. The number of hospitalists needed to provide a sedation service needs to account for this, as well as the need to maintain a minimum number of sedations performed on an annual basis for competency. In general, pediatric hospitalists should perform a minimum of 25–50 sedations per year to maintain skills. With less than 25 sedations per year there should be a rigorous plan for further operating room time, simulation time, and supervised time. Further operating room time and simulation time is also an important part of maintaining skills for pediatric hospitalists who are performing more than 25 sedations per year.

Providing a pediatric hospitalist for sedations 5 days per week, 10 h per day requires about 1.5 full-time equivalents (FTE) to staff the service. Therefore, if each pediatric hospitalist provides 4–5 days per month on a sedation service, four pediatric hospitalists would be needed to staff the service. Four to five days per month of providing sedation generally establishes a good balance between maintaining sedations skills and the other skills important to the clinical responsibilities of a pediatric hospitalist.

Sufficient time needs to be planned for training prior to starting a sedation service. It is important to plan for operating room time, supervised sedation time, and any other activities involved in training. If you underestimate the amount of time that it will take to establish a program, the start date will be delayed and promised expectations may not be met. It is also important to plan for turnover of staff. It is a good idea to get commitment of pediatric hospitalists for a prolonged period after the training while recognizing that some turnover is inevitable. Training of new personnel takes time and other resources that need to be accounted for in the planning stages [3].

In general, pediatric hospitalists who are trained and credentialed to provide sedation do so on patients with mild sedation risk. Sedations performed by most pediatric hospitalists do not include planned airway intervention. However, it is essential that pediatric hospitalist have the ability to rescue patients from a deeper-than-intended level of sedation. Most often this includes skills of effective positive pressure ventilation and direct airway management through the LMA placement or endotracheal tube (ETT) placement. Patients must be properly triaged so that those with increased risk from sedation have the proper personnel attending the sedation. At St. Louis Children’s Hospital, the conditions listed in Table 13.5 are referred to anesthesiologists for consultation.

At Santa Clara Valley Medical Center (SCVMC), with a hospitalist- and intensivist-based sedation service, the comorbidities in Table 13.5 are taken in context of the procedure to be performed.

This list is not meant to be comprehensive or complete. All patients should be carefully evaluated for the risk of needed air intervention and the ability to intervene. If there are any concerns about higher-than-usual risks, consultation with an anesthesiologist is recommended. Pediatric hospitalists providing sedation should be comfortable and have experience with rescue from complications of sedation, but should refer patients that are high risk for complications.

Pediatric hospitalists provide sedations independently, and may also be asked to supervise sedations performed by others, including nurses. The responsibility for evaluation of patients undergoing sedation belongs with the supervising hospitalist when one is performing the procedure personally and when supervising someone else. Rules and regulations vary by hospital, but in most cases the sedating or supervising physician needs to perform a pre-sedation evaluation. This is not meant to replace a requirement for a pre-sedation physical exam performed by the ordering physician. This exam is meant to be focused on the risks of performing a scheduled sedation. This exam needs to be scheduled with ample time prior to the scheduled sedation. It is important to have the space and equipment to properly perform this exam. This exam is essential to the final decision-making of how and whether to proceed with a sedation. This exam is also essential in determining whether the sedation should proceed under the guidance of a pediatric hospitalist or whether it is best done by an anesthesiologist. Complication rates can increase when there is not ample time to evaluate patients immediately prior to sedation.

For elective sedations that allow performance of a test or procedure that is needed but not urgent, safety standards (including nil per os [NPO] times) should be carefully followed. If issues are found at the time of a pre-sedation exam, the sedation should be rescheduled unless rescheduling could increase risk to the patient. The risks of proceeding must be carefully measured against the risk in delaying diagnosis or treatment. At St. Louis Children’s Hospital, the following are minimum recommendations for rescheduling elective sedations:

NPO Guidelines for SCVMC and St. Louis Children’s Hospital’s Pediatric Sedation Units:

These are meant as general guidelines and not as absolute rules. This is one hospital’s guidelines and does not mean that other guidelines are not valid. If the urgency of sedation requires that the test or procedure be performed in the presence of one of the aforementioned conditions or without inadequate NPO time, consultation with an anesthesiologist is generally recommended.

Pediatric hospitalist sedation programs are generally funded from two sources: (1) physician professional fees and (2) financial support from hospitals. Depending upon the number of sedations done, the ability to bill anesthesia codes, and reimbursement percentage, the level of funding of pediatric hospital sedation programs varies from institution to institution. In the United States, the Centers for Medicare and Medicaid (CMS) determines most rules in regard to physician billing [7]. CMS rules require that sedation services are overseen by a hospital’s anesthesiology division/department. This generally requires a close working relationship between a hospital’s anesthesiology group and others providing moderate and deep sedation. Most sedations performed reach the level of “deep sedation” as defined by the American Society of Anesthesiologists (ASA) and the American Academy of Pediatrics [8, 9]. In most cases, anesthesia codes can be used. Anesthesia codes are used appropriately by non-anesthesiologists when the level of care provided meets the standard of those codes. Ability to use anesthesia codes varies across the United States, sometimes on a state-by-state or local basis. Anesthesia codes are most often successfully billed when there is agreement within an institution about the appropriate use of these codes by non-anesthesiologists. If there is disagreement among departments of a hospital, it is often difficult to get reimbursed for these codes. Separate codes for moderate sedation were developed in 2006. These do not have RVUs attached. Each institution is responsible for determining the charges for these codes. Success in reimbursement for moderate sedation codes varies from region to region.

If pediatric hospitalist sedation programs have scheduled sedations each day, it is likely that the cost of providing this service will be met through the billing and collection of physician professional fees. If a sedation program is responsible to meet urgent demand and thus not able to schedule a full day, there is likely to be a shortfall in meeting the cost of the program. The ability to provide timely, safe sedation is important to many hospital services. Radiology, surgery, inpatient services, and outpatient services all benefit. Hospital administration and some services independently will likely be willing to provide financial support of sedation services outside of professional billing. It is important to understand who benefits from efficient sedations and to use that in negotiating support for those services.

As training for hospitalists is standardized, sedation training will likely become part of that standard. However, there are currently no national standards for training and credentialing pediatric hospitalists.

Most pediatric hospitalists gain competence for providing sedation after residency. Fifty percent of hospitalists report depending on continuing medical education (CME) as part of gaining and maintaining sedation skills. There are national conferences dedicated to pediatric sedation outside the operating room with full-day sedation workshops utilizing simulation. Core Competencies in Pediatric Hospital Medicine have been developed and providing safe sedation is part of those recommended competencies [1].

It is likely that national courses in sedation will be developed, but it is unlikely that a standardized training and certification process will emerge within the next few years. Credentialing for sedation will likely remain a local process. It is important that pediatric hospitalists providing sedation receive additional training, maintain skills, appropriately select patients, have the ability to rescue from deeper-than-intended levels of sedation, and work within systems where backup is available.

All children undergoing sedation should be carefully screened for the potential of adverse events during sedation and recovery. A focused pre-sedation history and physical should be performed by the sedation provider. This evaluation should focus on characteristics that would indicate increased risk of sedation for the patient or the potential for difficult airway management. The history should include previous problems with sedation or anesthesia, stridor, snoring and sleep apnea, and recent respiratory illness. Significant physical exam findings include significant obesity, short neck, small mandible, dysmorphic facial features, small mouth opening, and large tonsils.

If a patient has significant history and physical exam findings indicating increased risk of providing sedation, the risks of providing the sedation need to be weighed against the absolute need for the procedure or diagnostic study. A hospitalist performing sedation should always feel comfortable providing rescue from a stage of sedation deeper than that intended to perform the procedure. If airway problems are anticipated, or are not anticipated but would be difficult to manage because of a patient’s anatomy, consultation of an anesthesiologist is recommended.

The patient physical exam status endorsed by the ASA can be useful in assessing sedation risk. ASA class I and II children are at low risk for adverse events during sedation when carefully monitored. ASA III patients are by definition at increased risk. In general, for urgent hospital-based sedations most hospitalists should provide sedation only to ASA class I and II patients. Before providing sedation to ASA class III patients, consultation with anesthesiology is advised. Hospitalists working on a sedation service or providing sedation regularly can provide sedation to ASA class III patients safely as long as those patients are carefully evaluated and a backup system of care has been planned and is in place.

There is no proven relationship between fasting time prior to sedation and the risk of aspiration in humans. The general opinion is that fasting will likely reduce the risk of aspiration. For elective procedures, individual hospital guidelines for fasting should be followed just as they would be for general anesthesia. For urgent procedures, patients should be fasted as soon as the possible need for sedation is identified. The risk of clinically significant aspiration is small for most patients, but needs to be weighed carefully against the need to perform a diagnostic or therapeutic procedure quickly. In addition, even with proper NPO guidelines, there is still a risk of vomiting and aspiration, so the sedation provider needs to be able to monitor and respond quickly.

For moderate sedation, a provider with adequate sedation training and experience needs to be responsible for the sedation and analgesia. This person may also perform the procedure, if patient safety and the unit policy allows. A second person with knowledge in basic pediatric life support is also required. This person is responsible for monitoring the patient’s cardiopulmonary status. This person is also generally responsible for recording the data in a sedation record and may assist in brief, interruptible tasks once the level of sedation is stabilized.

For deep sedation, a provider trained in advanced pediatric life support must be in the room. The provider of the deep sedation should provide direct monitoring of the patient and must not be primarily responsible for the procedure. Problems with ventilation and oxygenation during deep sedation are generally easily managed when rapidly recognized. Deeper-than-intended sedation may occur in any patient; it is generally recommended that the sedation provider be prepared to manage deep sedation even when moderate sedation is expected and general anesthesia when deep sedation is intended.

For moderate sedation, a minimum of pulse oximetry is strongly recommended. In addition, continuous monitoring of heart rate, respiratory rate, and intermittent noninvasive blood pressure (NIBP) measurements are recommended. If intravenous access is not otherwise established, it is not required, but should be carefully considered.