Time to Get on the Bus: Children’s Surgery and Where We Need to Go

Who should do the operation? Where should the operation be done? After ensuring that their child needs a surgical procedure, these are among the most important questions anxious parents ask. Although factors such as travel distance and insurance requirements play a role in these decisions, the most important consideration is what will be safest and provide the best possible outcome. In this edition of Pediatrics, Somme and colleagues1 give us a view of the current landscape. This view is essential because it is hard to reach a destination if you do not know where you are.Somme et al describe inpatient pediatric surgical case volumes from the Kids Inpatient Database (KID) from 2009. This includes 216 081 procedures performed in children <18 years at either a general hospital or pediatric hospital. The first important observation is that 40% of these operations occurred in general, not pediatric, hospitals. Although it is unlikely that children’s hospitals could quickly absorb this entire volume of pediatric general surgery, even if desired, some continued shift toward children’s hospitals is likely to occur as work-hour restrictions in general surgery residency training programs have mandated less and less exposure to pediatric specialty training. Secondly, Somme et al show that 58% of the pediatric inpatient procedures in general hospitals are appendectomies. Central venous access, burn care, and cholecystectomy account for another 20% of the operations performed in general hospitals. If one is striving to provide safe, quality care close to home, one focus needs to be on ensuring that these common procedures are done well in general hospitals. Alternatively, it is the children who need less common procedures who could be considered for transfer to a pediatric specialty hospital. Given the relatively small number of these more complex children, the increased case volume could likely be absorbed by children’s hospitals, and the financial viability of the general hospitals would not be threatened.Two major limitations of the KIDS sample are lack of outpatient and provider-specific data. This is significant because a large proportion of pediatric operations are ambulatory, and some proportion of pediatric operations performed in general hospital settings are performed by pediatric specialists. It is important to recognize that some of the pediatric ambulatory procedures not included in the KIDS database, such as outpatient airway procedures, have a high risk of anesthetic complication.2 Lack of provider-specific data makes it impossible to determine whether a pediatric surgical or pediatric anesthesia specialist performed the operation. Data suggest that even common pediatric procedures have fewer complications if performed by a pediatric surgeon3–5 and the presence of an experienced pediatric anesthesiologist decreases the risk of cardiac arrest and other perianesthetic complications.2,6,7 Simultaneously, however, it is important to recognize that modern health care is a team sport. Even in children with straightforward problems, it is impossible to consider surgical quality without simultaneously considering anesthesia and perioperative nursing. For children with more complex problems, this team extends to include other pediatric subspecialists, the ICU, radiology suite, and emergency department. Rapid response teams, code teams, and transfer teams provide a critical safety net for children in the perioperative period providing safe, high-quality care in these most complex patients.Although many pediatric medical and surgical specialists can anecdotally support the observation that mismatches between the needs of individual children and available resources occur, there is limited research in this area. To date the definition of appropriate pediatric resources has been left to the individual practitioner and hospital. The report by Somme et al1 is an important first step in this direction. Beyond this rigorous description of our baseline, we should recognize that the need for increased levels of pediatric-specific resources are dependent on several patient factors including patient age, comorbidities, and the complexity of the condition and operative procedure. Obviously, premature babies and infants and complex pediatric anomalies or diseases will require a more resource-intense setting. In an attempt to match patient needs with optimal available resources, the Task Force for Children’s Surgical Care was convened in April 2012.8 This task force has been working through the American College of Surgeons (ACS) on a proposal for designation of “Pediatric Surgical Centers: Basic, Advanced, and Comprehensive.” This novel proposal is not unlike the established system for ACS-certified trauma care in which centers providing trauma care are formally designated as trauma centers level I, II, or III. Notably, both advanced and comprehensive pediatric surgical centers would be required to have pediatric anesthesiologists and pediatric surgeons. They would also have pediatric critical care capabilities and at least a level 3 NICU. It is proposed that basic centers that lack these resources not perform surgery in children <1 year of age or with an American Society of anesthesiology class greater than ASA II. All centers would be required to have an adequate safety net for pediatric resuscitation and transfer.The findings and proposal of this task force are summarized in “Optimal Resources for Children’s Surgical Care in the United States.”8 This document has been approved by the Regents of the American College of Surgeons, the American Pediatric Surgical Association, and the Society of Pediatric Anesthesia. A voluntary verification system, again analogous to the current verification system used for ACS accredited trauma centers, is envisaged. Although this will undoubtedly be a long road, with lots of rocks and potholes on the way, most agree that formal designation of Pediatric Surgery Centers could lead us to a place where surgical care for children is convenient and local when possible and guaranteed to be safe and competent when the child’s care is rare and complex. Somme and colleagues have given us insight to where we are; the report by the Task Force for Children’s Surgical Care has given us a glimpse of where we need to go. The question before us is, will we get on the bus?