ICU Sedation Models Home in the PICU

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ICU Sedation ModelsHome in the PICU

• James Hertzog, MD
• Nemours Childrens Clinic
• Alfred I. duPont Hospital for Children

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Why a PICU Sedation Service?

• increasing number of subspecialty procedures
• increasing recognition of advantages of deep
  sedation patient comfort, ideal operating
  conditions, efficiency
• desire to optimize patient safety

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Why a PICU Sedation Service?

• limitations in Anesthesia personnel availability
• desire to avoid the OR/parent satisfaction?/practi
  tioner satisfaction?
• AAP/ASA guidelines
• increasing JCAHO attention

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Getting Started

• involve the Department of Anesthesiology and the
  Department of Pediatrics
• be consistent with published guidelines AAP,
  ASA, JCAHO

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Personnel

• Pediatric Intensivist
• Pediatric CCM Fellow
• Pediatric CCM APN/PA
• PICU RN
• PICU RRT

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Scheduling

• elective procedures for ambulatory, ward, and
  PICU patients
• defined time slots during the day M-F that can be
  booked
• urgent/emergent procedures for ward and PICU
  patients at discretion of team

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Screening

• current and past medical history
• ASA physical status
• experience with anesthetics/sedatives
• intercurrent illness
• occurrence of allergic reactions to medications
  or soy and egg proteins
• fasting status

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Screening

• PE of airway, cardiorespiratory, neurologic
• significant labs
• screening done at time of procedure
• fasting guidelines, time of procedure provided by
  subspecialist beforehand

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Pre-Procedure

• informed consent for anesthesia/sedation and
  procedure
• intravenous access-peripheral canula inserted or
  CVL accessed

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Procedure

• cardiorespiratory monitoring continuous ECG,
  respiratory, SpO2, intermittent (q1-3 min) NIBP
• pediatric intensivist
• monitors CR, neurologic status continuously
• administers propofol/other agent to maintain
  desired level of sedation/anesthesia
• provides supportive measures as needed

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Procedure

• PICU RN
• monitors vital signs
• provides written documentation of course of
  sedation/anesthesia on a standardized form
• assists with supportive measures as needed
• neither involved directly with procedure

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Procedure

• equipment at bedside
• BVM
• tonsillar suction catheter
• equipment for maintaining airway patency and
  tracheal intubation
• supplemental oxygen via blow-by

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Post-Procedure

• monitoring continues after the procedure until
  patient awake and able to ingest clear liquids

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Post-Procedure

• discharge when meet predefined criteria defined
  by AAP
• stable and satisfactory airway patency and
  hemodynamics
• intact protective airway reflexes
• able to talk and sit unaided if age appropriate
• adequate state of hydration

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Billing

• Anesthesia CPT codes
• 01999 (unlisted procedure)
• 00520 (bronchoscopy)
• 00532 (central venous access)
• 00740 (upper GI endoscopy)
• 00810 (lower GI endoscopy)

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Billing

• Anesthesia CPT codes
• 00702 (percutaneous liver biopsy)
• 01112 (bone marrow aspiration/biopsy)
• 00635 (diagnostic or therapeutic lumbar puncture)

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Billing

• other CPT codes
• 99141 sedation (moderate) analgesia-IV, IM,
  inhalational
• 99241 office consultation new or established
  patient
• 99251 inpatient consultation new or established
  patient
• key components problem focused hx and PE,
  straightforward decision making, 15-20 min

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Billing

• other CPT codes
• 90780 IV infusion for therapy/diagnosis,
  administered by MD or under direct supervision of
  MD, up to 1 hour
• 90781 IV infusion for therapy/diagnosis,
  administered by MD or under direct supervision of
  MD, each additional hour, up to 8 hours

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Advantages

• geographically localized-all done in one place
• resource utilization-all of the components are
  already available
• flexibility-PICU open 24/7
• comfort level

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Challenges

• geographically localized-cant provide service
  for procedures that cant be brought to the PICU
• resource utilization-what if all the beds are
  full or the RNs have assignments?
• managing the scheduling

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Challenges

• pre and post procedure evaluation
• QAI
• credentialing
• reimbursement