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ICU Sedation Models Home in the PICU James Hertzog, MD Nemours Children’s Clinic Alfred I. duPont Hospital for Children 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 Why a PICU Sedation Service? • limitations in Anesthesia personnel availability • desire to avoid the OR/parent satisfaction?/practitioner satisfaction? • AAP/ASA guidelines • increasing JCAHO attention Getting Started • involve the Department of Anesthesiology and the Department of Pediatrics • be consistent with published guidelines: AAP, ASA, JCAHO Personnel • • • • • Pediatric Intensivist Pediatric CCM Fellow Pediatric CCM APN/PA PICU RN PICU RRT 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 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 Screening • PE of airway, cardiorespiratory, neurologic • significant labs • screening done at time of procedure • fasting guidelines, time of procedure provided by subspecialist beforehand Pre-Procedure • informed consent for anesthesia/sedation and procedure • intravenous access-peripheral canula inserted or CVL accessed 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 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 Procedure • equipment at bedside – BVM – tonsillar suction catheter – equipment for maintaining airway patency and tracheal intubation • supplemental oxygen via blow-by Post-Procedure • monitoring continues after the procedure until patient awake and able to ingest clear liquids 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 Billing • Anesthesia CPT codes – – – – – 01999 (unlisted procedure) 00520 (bronchoscopy) 00532 (central venous access) 00740 (upper GI endoscopy) 00810 (lower GI endoscopy) Billing • Anesthesia CPT codes – 00702 (percutaneous liver biopsy) – 01112 (bone marrow aspiration/biopsy) – 00635 (diagnostic or therapeutic lumbar puncture) 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 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 Advantages • geographically localized-all done in one place • resource utilization-all of the components are already available • flexibility-PICU open 24/7 • comfort level Challenges • geographically localized-can’t provide service for procedures that can’t be brought to the PICU • resource utilization-what if all the beds are full or the RNs have assignments? • managing the scheduling Challenges • • • • pre and post procedure evaluation QAI credentialing reimbursement