1. ICU Sedation Models Home in the PICU James Hertzog, MD Nemours Children’s Clinic Alfred I. duPont Hospital for Children

2. 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

3. 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

4. Getting Started involve the Department of Anesthesiology and the Department of Pediatrics be consistent with published guidelines: AAP, ASA, JCAHO

5. Personnel Pediatric Intensivist Pediatric CCM Fellow Pediatric CCM APN/PA PICU RN PICU RRT

6. 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

7. 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

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

9. Pre-Procedure informed consent for anesthesia/sedation and procedure intravenous access-peripheral canula inserted or CVL accessed

10. Procedure cardiorespiratory monitoring: continuous ECG, respiratory, SpO 2, 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

11. 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

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

13. Post-Procedure monitoring continues after the procedure until patient awake and able to ingest clear liquids

14. 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

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

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

17. 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

18. 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

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

20. 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

21. Challenges pre and post procedure evaluation QAI credentialing reimbursement