The Pediatric Sedation Home

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In a recent article, Thomson et al1 highlighted a significant reduction in the length of stay for adolescent patients with idiopathic scoliosis following the implementation of a perioperative surgical home platform. These findings are echoed in the pediatric community and has led to the term Pediatric Perioperative Surgical Home.2 This group described some of the important differences in the value components and clinical outcomes metrics when used to assess these adult and pediatric surgical homes.1 Not mentioned were the many pediatric patients and those with chronic life-long disease processes who present to the hospital for nonoperating room anesthesia (NORA) procedures. Therefore, we would like to describe our unique variation of the Pediatric Perioperative Surgical Home: the Pediatric Sedation Home.
At the University of Vermont Children’s Hospital, the Comfort Zone (CZ) serves as the outpatient Pediatric Sedation Home. The friendly environment and the child- and family-centered care provided by a consistent team of nursing, anesthesia, and child life services help to reduce patient and family anxiety. Using a preanesthesia telephone call, which includes education and instructions for the parents and specific protocols, we plan care for patients who are scheduled for monitored anesthesia care or general anesthesia (GA) in NORA environments and for procedures requiring an intravenous access (eg, contrast for computed tomography, magnetic resonance imaging, infusions, and lab draws). Our CZ nurses establish intravenous access in the majority of our patients before their transport to NORA sites. This improves safety by limiting the number of mask inductions (negligible complications of laryngospasm and respiratory arrest since CZ inception 2007), makes the process more efficient (ie, hub-and-spoke delivery model) by allowing our anesthesia providers to work independently as appropriate, and enables our department to induce anesthesia in procedural areas not routinely equipped with anesthesia machines or gas scavenging.
This unique approach to a periprocedural experience requires collaboration among multiple medical specialties. We encourage our providers and parents to complete multiple procedures during a single encounter where it is emotionally and medical appropriate. There is a dedicated scheduler located within the CZ, and this allows the Department of Anesthesiology to operate the NORA block allocations as distinct and independent from the main operating rooms. By utilizing patient-centered, shared decision-making processes with our ordering pediatric providers, radiologists, and proceduralists, we ensure that the medically appropriate diagnostic or therapeutic procedure (including any constraints imposed by the procedure itself) is provided to our pediatric patient with the optimal anesthetic. In doing so, we have improved overall safety; reduced day of procedure cancellations (nearly negligible, 0.4% in 2016); decreased the use of anesthesia services for some minor procedures (using age-appropriate education and coping skills for patients and their families, goggles for children >4 years, and feed and swaddle protocols for infants); and increased satisfaction for all of those involved with the child’s care (99% from providers and families in satisfaction surveys conducted by CZ [2009–2015]).
At the keynote address of the 2016 American Society of Anesthesiologists’ annual meeting, Porter3 shared his framework to transform health care. We believe that the CZ, our Pediatric Sedation Home, incorporates many facets of this framework. Our Pediatric Sedation Home integrates pediatric hospital services and departments, coordinates care across delivery systems, provides a consistent and safe environment, and increases patient access to valuable and limited hospital resources by decreasing last minute cancellations. We know that these resources are costly and expansive.4 For anesthesiologists at the helm of a Pediatric Sedation Home, our framework focuses on the preprocedural aspects because our NORA sites are predominantly staffed by an anesthesiologist.
From an operational perspective, we know that anesthesiologist-led services can provide further value.
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