SEDATION SERVICES FOR THE ANESTHESIOLOGIST

In addition to the growth of anesthesia practice to encompass the perioperative period, anesthesia has expanded to include services to a wider array of inpatient care areas. Providing anesthetic services to patients outside the operating room is not a particularly new concept. Critical care and pain management services have become well integrated into the practice patterns of most hospitals. The formalization of perioperative anesthesia services, such as intensive care, pain management, or sedation for procedures in remote locations, can result in optimization of patient management in these situations, eliminate waste, and in some cases, actually foster the growth of patient referrals. The focus of this article is on the evolution of anesthetic services in nonoperating room locations. More specifically, it will focus on the development of an anesthesia care team to manage the increasingly complex task of providing sedation for patients in these nontraditional settings. What exactly is a sedation service? How does one define it as a clinical enterprise? The answer may be a matter of perspective. Most active anesthesia practices probably already provide many aspects of such a service in one form or another. For the purpose of this article, we will define sedation service as a hospital-based anesthesia service whose practice is focused primarily outside the operating room. All necessary equipment to provide a safe anesthetic is mobile and brought on-site to facilitate diagnostic and therapeutic procedures. In addition, this type of service must be flexible and available on an as-needed basis. This means that such a service is subject to the same usage swings incurred by any operating room. The primary mission of a sedation service is safe, efficient facilitation of diagnostic and therapeutic procedures. The widespread use of anesthesia services outside of the operating room has come about for several reasons. First, it facilitates the use of technologies, which, owing to physical limitations, cannot be brought into the operating room, such as interventional radiology and magnetic resonance imaging (MRI). 11 In addition, there is an increasing demand in the health care industry for increased speed, convenience, and patient comfort. Finally, not only must patient care be safe and efficient, but owing to the pressures of managed care, there is more demand than ever to provide these services with as little additional cost as possible. Insofar as anesthesia providers are able to consolidate services with attention to these forces, the benefits of their presence outweighs the liabilities. The availability of sedation services may find usefulness in a variety of clinical arenas. Interventional procedures are one of the fastest growing fields of radiology (see article by Mason and Koka), with formal services emerging from the domain of academic institutions to the suites of many surrounding community hospitals. The growing volume and complexity of these procedures has stimulated an increased demand for anesthetic services in this area. A variety of gastroenterologic procedures require profound sedation, many times to the point of general anesthesia without the benefit of airway protection. Examples of such complex and stimulating procedures include endoscopic retrograde cholangiopancreatography or percutaneous endoscopic gastrotomy. Procedures on pediatric patients are a major component of the demographics of most mobile anesthetic services. Procedures such as lumbar puncture, MRI, radiation therapy, bone marrow biopsy, and peripheral and central catheter insertions and removals all may be performed in the setting of an appropriately equipped area, under the supervision of a sedation service. Most dental procedures are comfortably performed under conscious sedation; however, certain pediatric patients, developmentally delayed adults, as well as those with profound anxiety disorders may require deep sedation beyond the scope of standard dental practice. In certain situations, where clinical offices or clinics are in adjacent buildings on the hospital campus, a hospital-based sedation service may be extended to include sedation management for office-based procedures, such as minor plastic surgery, laser treatments, in-vitro fertilization, and minor general surgery. Critically ill patients in the intensive care unit often require invasive procedures, but their dire condition prohibits care in the appropriate clinical area because of the high risk of physiologic deterioration. In those situations where the procedure can be brought to the patient, sedation services may provide appropriate levels of amnesia, analgesia, and monitoring to ensure hemodynamic stability and airway patency for both the procedure and postprocedure recovery. The evolution of formal sedation services is different for each institution. Its growth, for the most part, is guided by the clinical strengths in the individual hospitals. As might be expected, the demographics of patient populations among facilities offering such services are quite heterogeneous. However, the majority of successful services note that what makes them active is the consistent flow of pediatric patients through their practice. In addition, most patients—whether adult or pediatric—tend to be outpatients. Since these patients arrive for a procedure and leave on the same day, this requires a service to not only maintain effectiveness and safety as a priority, but also to keep prompt recovery as a component of care. It is the assurance of optimal safety and efficiency that may make a sedation service of unique value to clinical departments throughout a hospital. Practices with successful formalization of sedation services outside of the operating room have used it as a way of advocating and introducing a full range of anesthetic options to a broad range of patients. The service is usually organized as a group of anesthesia providers who are led by an appointed anesthesiologist manager. This clinician acts as a liaison with various other hospital services, which enhances consistency in preprocedural assessments and practice patterns. The advantages of sedation services are readily seen by those practitioners who are unfamiliar with sedative agents. When a sedation service is utilized, these clinicians are assured of safe, efficient, and consistent approaches to patient management. Another benefit provided by a sedation service is that of being the hospital agent that assures compliance with the guidelines set forth by regulatory agencies such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Recently, the JCAHO has addressed the issue of sedation outside of the operating room. The 1996 standards continue to define anesthesia as the administration of any agent that likely results in loss of protective reflexes. Currently, it also states that because sedation is a continuum, and it is not always possible to predict a patient's response, an institution needs to develop protocols for the care of patients receiving any sedation that carries the risk of loss of protective reflexes. 5 While JCAHO does not set any specific standards for the practice of hospital-wide conscious sedation, they do outline that provisions must be made for preanesthetic evaluation, adequate personnel, equipment, physiologic monitoring, and postanesthesia recovery. They expect hospitals to develop their own practice guidelines, applicable to all practitioners throughout the institution, as well as show evidence of monitoring for compliance. A sedation service holds a similar priority, which is the assurance that the standard of care for patients getting sedation are as consistent for those outside the operating room as those treated in the surgical suites. The sedation service anesthesiologist should be aware of the practice patterns at their particular institution because their expertise is a valuable asset in the establishment of hospital policies regarding conscious and deep sedation. Quality of care may be further enhanced through identification of patients and situations requiring the more advanced levels of care provided by the anesthesia specialist. An analysis of adverse events reported through the hospital quality assurance mechanisms at any given institution may provide a starting point to identify clinical departments that may benefit from this type of service.