A Path Toward Standardized Pediatric Procedural Sedation Education Across Subspecialties

The practice of pediatric procedural sedation (PPS) outside of the operating room (OR) has grown dramatically over the years, with an increasing number of pediatric subspecialists other than anesthesiologists performing PPS. Pediatric critical care medicine (PCCM) and pediatric emergency medicine (PEM) physicians perform the largest number of PPS cases outside of the OR, and the most rapid growth in recent years has occurred among pediatric hospital medicine (PHM) physicians who now account for 10% of all cases.^1,2 PPS training poses unique challenges, requiring mastery of both knowledge and skills that occur in a diversity of settings. Professional society guidelines including those published by the American Academy of Pediatrics³ under-score the high level of expertise required, including adequate knowledge of patient risk stratification and pharmacology of sedative medications. Additionally, the Centers for Medicare and Medicaid Services require practitioners to possess the capability to rescue patients from a deeper level of sedation than intended.^4,5 Despite the need for rigorous training to care safely for the sedated pediatric patient and recognition that PPS is an essential component of PCCM, PEM, and PHM fellowship programs by the Accreditation Council for Graduate Medical Education (ACGME), standardized training and assessment methods are lacking. Currently, the ACGME only requires dedicated procedural sedation time for PHM fellows,⁶ but there is no PPS or anesthesia rotation requirement for PCCM or PEM outside of their respective clinical units.^7,8 The American Board of Pediatrics created entrustable professional activities (EPAs) to describe the essential tasks specific to each subspecialty that are required to be performed safely and effectively before graduation.^9,10 Whereas EPAs for PEM and PHM specifically mention PPS,^11,12 the PCCM EPAs focus instead on sedation administration and monitoring within the care of a critically ill patient.¹³ Table 1 provides a comparison of specific language for PPS in the ACGME guidelines and EPAs for each subspecialty. EPAs encompass the essential practices of each specialty, which may not account for practice variations within each specialty and across institutions. With the existence of PPS-specific service lines within some institutions, the educational context or environment that a physician trained within may not directly translate to their clinical practice upon graduation. Regardless of practice variances, providers must possess core PPS skills and knowledge, and training programs are responsible for educating fellows to the highest level of the practice.