Transcript ICU Sedation Models - Dartmouth–Hitchcock Medical Center

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
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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
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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
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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
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pre and post procedure evaluation
QAI
credentialing
reimbursement