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Psrc meeting may 22, 2004
PSRC Meeting May 22, 2004
Introduction and Overview:
Members present (in no particular order and without titles):
Joseph Cravero, George Blike, Desmond Henry, David Polaner, Jeffrey Galinkin, Susan
Kost, Steven Freilich, Esther McClure, Peter Foley, Charlene Cowley, Rosemary Orr,
Michelle Rhoads, Kim Barber, Arvind Kasaragod, Marc leder, Patricia Cantwell, Jill
Fitch, Sally Webb, John Garrison, Ron Litman, Charlie Coté, Lynne Maxwell, Lia
Lowerie, Mary Hegenbarth, Rob Seal, Carloyne Montgomery, John Berkenbosch,
Charlotte Bell, Heleh Sadat, James Hertzog
Introduction and Overview:
Dr. Cravero opened the meeting with a review of the goals of the Pediatric Sedation
Research Consortium (PSRC) – that is to promote better practice in pediatric sedation
throughout the various disciplines that are involved in this work. He pointed out the we
believe we can do this by collecting data and understanding outcomes from the various
ways individuals accomplish the task of sedating children for procedures.
We currently have 29 institutions signed up to share data through the consortium. Of
these institutions about a dozen have been actively communicating with Dr. Cravero and
have completed the IRB process etc. There appears to be extensive interest in many
institutions coming on board with the consortium – we will discuss a system for
admitting new institutions to this group.
It was pointed out that we have been through several phases of development of the PSRC.
These included the initial formation of the group, the development of the data collection
tool, and the Beta testing of the data tool at 8 separate institutions. We are now at the
point of making final changes to the tool and we need to begin the period of official data
collection – within the next month.
Funding for the initial data collection and development of the consortium has been made
possible through a two year grant from the National Patient Safety Foundation (NPSF).
Because of this (and the initial donations from institutions) the data collection tool
development and data maintenance for the first two years of this project is completely
Dr. Cravero summarized the organization of the PSRC – a consortium of interested
institutions committed to sharing information on the safety and effectiveness of pediatric
sedation practice. The consortium is not a political organization. It does not advocate for
a specific type practice, it does not “approve” of any particular practice.
Dr. Cravero reiterated his goal that the data collection tool should remain simple and
should be filled out on an average patient (by someone who has used the tool before) in
about 2 minutes. The hope would be that (like the aviation industry) we could evolve a
“mind-set” among pediatric sedation providers that would include a recording of the
summary data from each sedation encounter - with the idea that this information is
critical to improving over all practice.
It was pointed out the work of the PSRC at each institution should be included in quality
improvement and quality assurance activities. Data will be sent to the main data servers
at Dartmouth Medical School. Secure storage and maintenance of the data will be
assured. Regular reports will be generated on the performance of pediatric sedation at
each member institution. In addition, each institution will be able to access its own
information on pediatric sedation performance at any time. Finally there will be
comparison data available that will contrast the performance at each institution in to that
from the aggregate consortium. The exact form of these reports will need to be
determined by the members of the consortium itself.
Finally there is the obvious opportunity to report the sedation experience within the
research consortium and evaluate the effect of different providers and techniques vis a vis
the safety and efficacy of sedation work. This academic work forms the basis of the
funded mission for the group.
Discussion of the data collection tool began with pointing out that the current tool is
available in two forms – one that uses a Java Script programming platform
(t uses HTML formatting.
The HTML has been trialed on pocket PC’s and seems to work well. It should also work
on Palm based systems, but that has not been specifically tested. It was noted that use on
a handheld at this moment requires a lot of screen navigation. If desired by the group,
programming could be employed to “fit” the data screens on to a hand-held better in the
Dr. Cravero cautioned all present that there was a desire to keep the data collected on the
current version of the tool to “meaningful” outcomes – avoid unneeded detail that would
lengthen the time needed to fill out the data for each sedation.
In order to stay out of trouble, all institutions who are going to participate in the project
and send data to the servers at Dartmouth should have IRB approval for the process. The
IRB approval should include a waiver of consent for the project owing to the fact that no
changes in care take place because of participation, and no patient-identifiable data is
being transmitted in this project. Examples of the IRB protocols are available on the Pediatric Sedation Project We or from Based on input from consortium members there is now capability to enter data and move on to another record without “submitting” data to the Dartmouth server. There is a possibility of reviewing the data and submitting the data after review. It was also noted that data collection could be initiated on a paper form and transferred to the data tool, or could be entered directly on to the data tool at the time that the sedation is completed. The most important point was that each “site” within an institution should commit to collecting 100% of sedation encounters performed at that site – be it the MRI scanner, CT scanner, hem-onc clinic etc. Dr. Cravero then reviewed the experience of the preliminary use of the web-based data tool. At this point we have collected over 1000 records. The biggest contributor to the database was Rainbow Babies and Children’s Hospital in Cleveland Ohio. Most of the individuals involved in this process have reported an entry time of 2-3 minutes for each record. It was emphasized that the format of the tool should be as user-friendly as possible, but that there is no need to go too far in this respect as the users of this tool should be well practiced at the data entry and will know where to find options etc over the time that they use the tool. We discussed the idea that institutions with data in other data bases might want to download data on to the servers at Dartmouth to add to the database. This might be possible, but the responsibility for programming this type of data exchange will lay with the individual institution and can not be done by the consortium using grant funds – there are simply not enough resources to support this activity. An extensive review of the data tool (as it exists) followed - for several hours. I will try to summarize the points that were made (doubtless a few comments will be left out). Dr. Cravero accessed the data tool on the internet and the group as a whole began to review its content: 1. As the session started it was requested that all questions have an option of “data not available”. After some discussion, it was agreed that there should be some questions which MUST be answered and others that should be optional. After this point, this issue was brought up with most of the questions as they were discussed. 2. It was pointed out that ASA status should be a separate question on a separate 3. The group asked for a change in the basic organization of the questions concerning coexisting conditions. There was a request to have a screen which requested “Primary Medical Problem” to describe the entity which brought the child in for the procedure which is being performed. This would be separated from the “Co-existing Medical Problems”. Identical choices will be available in each section – the only exception is that “none” will only be available for coexisting conditions. 4. The text of the questions will be altered in order to highlight the critical aspects of each question. This will involve capitalizing the letters of key words – it may be possible to change font as well. 5. The “metabolic” choice under coexisting diseases will be changed to 6. Under coexisting diseases, there will be a “renal” section and an “infection” 7. Under “Trauma” – there will subcategories that will allow stratification and specification of the extent and importance of this area of injury. 8. Under “Cardiovascular” in the coexisting disease section there will be “hypertension” and “hypotension”. 9. Under “Upper Airway Problems” – Sleep Apnea will be added. 10. Considering the Procedures section - it was noted noted that some procedures should be listed in more than one area. As an example, LP will be found under both the Hem/Onc section and the Neuro section. 11. MEG will be added as a Neuro diagnostic procedure. 12. Epidural blood patch will be added under Neuro procedures. 13. A “Surgical Procedure” section will be added that includes foreign body removal, 14. Under the “location of sedation/distraction section” Dental Suite will be added. 15. Under Medication categories there will now be a sublist under “Distraction Techniques” that will allow options such as DVD, music, Child Life etc. 16. Remifentanil will be moved to analgesics section. 17. For drugs under which there is an option for “infusion” – a question on total infusion time will be added – not mandatory. 18. “Other” will be added to all drug categories for route of administration. 19. Several routes will be added to various medications based on input from the group. For instance rectal midazolam will be added, intranasal and rectal ketamine will be added. 20. Nalbuphine will be added to the drug list. 21. TAC/LET will be added to the local anesthetic choices. 22. Compazine and phenergan will be added to the antiemetic list. 23. Under “Monitors Used” – temperature monitor and inspired oxygen monitor will 24. An extensive discussion occurred surrounding the list of “providers” for sedation. The list will be reorganized allowing subcategorization of “pediatricians” into different subspecialists, anesthesiologists into “pediatric” or “general”, “surgeons” into the various categories possible… and so on. These lists will be available for all divisions of providers (supervising vs. delivering meds vs. monitoring). An option to have a button that says “same as previous” will be attempted. 25. A new question will be added to define the “expected airway management” for a given procedure. This question will be distinct from the question “emergency airway management required” which will have identical choices. This is to allow differentiation between intubation which was planned vs. that done for emergency support. 26. A question concerning planned depth of sedation will be added. 27. The complication list was discussed and altered slightly. Questions concerning oxygen desaturation was addressed and will be clarified with a time frame of 30 seconds. Questions concerning reversal agents will be clarified. 28. As part of the discussion of all of these issues, it was decided that an extensive explanation document should be drawn up that would further describe what is meant by each choice in the web-tool. This would serve as a reference document for those who use the tool and should clarify questions about what is meant by each choice in the questionnaire. 29. The question concerning conditions during the procedure will be ordered from 30. The order of the questions within the data tool will be examined to make sure that the questions appear in an order that is somewhat intuitive and reflective of the general process of sedation. 31. When possible the options for answering any one question will be made in alphabetical order in order to make searching for an answer as easy as possible.
Dr. Cravero pointed out that with the total amount of data being collected with this tool
there is literally thousands of options for the manner in which reports on performance
could be delivered. For instance, one could report age vs. procedure vs.
success/complication rates – or one could list types of providers vs. techniques used vs.
success/complication rates. The consortium group was charged with the job of giving
input to Dr. Cravero concerning which of these outcome/provider/patient/procedure data
are most important in a reporting system.
The reports could be customized for a given institution, but there should be some
agreement on the critical data that should go into a standard report that would be
generated for all of the participating institutions after data collection starts. As data
collection is slated to begin this summer it is critical that individuals input their opinions
on the most important data within the next month so work on the creation of reports can
It was noted that Jim Hertzog MD is the current charge of the research review committee.
Dr. Cravero emphasized that all proposals for research and data analysis should go
through a committee review process to assure that spurious activity does not exist within
the consortium. The committee will also ensure that only members who are actively
contributing data to the consortium can use the data for the purpose of publication and
research. The research committee will also screen requests which may violate the
confidentiality of the institutions that are submitting data to the database.
The group discussed several models for similar research groups such as the Vermont-Oxford group and the Northern New England Cardiovascular Study Group. Several models exist. Some large groups allow sub-groups to investigate specific areas that are interesting to them – in this case radiology vs. hem/onc etc. Other large groups take up one theme and the entire organization can focus on data collection and process improvement in this area. No conclusions were drawn at this point, but it was generally agreed that subgroups would form that would look into specific areas of investigations. Future areas for investigation included: z Effect of pre-sedation preparation. z Long-term outcomes of sedation. z Neonatal data. z Regional anesthesia and sedation. z NPO status and outcomes. z Effect of various providers on outcome. z Effect of different training/credentialing regimens
Along the lines of research organization, Dr. Cravero emphasized that any member of the
consortium are encouraged to apply for funding to further the groups goals. The current
NPSF grant does not obviate other funding for consortium projects both on the local
institutional level and on the national level.
Dr. Cravero described the current grant which is an award of $100K for two years. The
grant has been used to fund the programming of the data tool, the purchase of some of the
hardware used in the project, and to allow for 0.1FTE (Dr. Cravero) to organize and run
the consortium for the first two years. Under the grant, data collection should begin in
6/04 and continue for one year. At the end of this time, data analysis will be undertaken
to define institutions with the best data for success and safety. An analysis of practice at
these institutions will then take place. Dissemination of some of these techniques and
processes will be followed by a subsequent period of data collection and analysis of
whether or not significant improvement in practice has taken place.
Dr. Cravero described the creation of a new website – exact name to be determined – that
will house all information related to the PSRC. Advantages will include:
z Improved communication. z All documents available. z All current projects available. z List of participants and contact information. z Links to other sites and information related pediatric sedation.
Membership on current committees related to the consortium includes:
z Data Management: Lia Lowrie, Lynne Maxwell, John Berckenbosch, Mark z Annual Meeting Committee: David Polaner,Jill Fitch, Kevin Creamer z Research Oversight: Jim Hertzog
The Data Management committee is charged with assuring appropriate management and
protection of the data in the consortium. In addition to the research committee, this
committee will review all requests for data related to research and will help decide where
information concerning individual institutional performance can be released.
Dr. Cravero continues to serve as the president of the consortium. He noted that he would
like to see another member of the consortium take over this role a year from now.
A discussion took place at the end of the meeting concerning where the next meeting
should take place. There were a number of comments. The majority of members present
felt as though a priority should be placed on finding a location that is easy to get in and
out of, and that would be relatively attractive for a weekend visit. Further input was
requested so that a decision could be made in the coming months concerning where and
when the next meeting should take place.
Temporal Existentials and the Amount Perfect This paper examines new data concerning the Perfect aspect and its modification by since clauses. Past analyses of such adverbials have argued that the complement of since can be a clause expressing an event, but that the event must be unique (Iatridou 2003); and that the complement can be a Universal Perfect, but not an Existential Perfect (von Fin