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ICU Sedation Models Home in the PICU

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

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ICU Sedation Models Home in the PICU

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  1. ICU Sedation ModelsHome 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, 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

  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

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