Paediatric Surgery

1
Paediatric Surgery

• Guidance and Standards

2
Remit

• Review relevant national guidance
• DH and professional
• Identify givens
• We may reject but, if so, conscious decision
• Identify required co-location
• Identify quality or service standards
• All for discussion on 13th 15th October

3
Background
2000 Childrens Surgery A First Class Service
2002 Review of Surgery for Children in the West Midlands
2003 Self-assessment of compliance with West Midlands surgery standards (PiP)
2005 Paediatric Anaesthesia added to Standards for the Care of Critically Ill and Critically Injured Children in the West Midlands (CIC Stds) Version 2
2005/6 Peer review of paediatric anaesthesia services
2007 PiP repeat self assessment of compliance with surgery standards (comparison with paediatric anaesthesia reviews available)
2009 Draft CIC Standards Version 3 circulated for consultation

4
Major references
1

• Surgery for Children Childrens Surgical Forum
  (CSF), 2007
• Good Surgical Practice, 2008
• Training Curricula - specialty specific
• NHS Workforce Review Team - Workforce summaries
• Specialty-specific guidance including
• ENT.uk 2008
• Childrens Orthopaedics and Fracture Care, 2006
• Ophthalmic Services for Children (2005)
• Guidance on provision of Anaesthetic Services
• Guidance on paediatric services and services for
  children in Emergency Departments
• Already in CIC Standards but re-checked
• Including Tanner Report

5
Structure

• What surgery can be done in general hospital/ who
  should be referred?
• Conditions, procedures, age of child
• Who can do the surgery?
• Minimum numbers for maintaining competence
• Service organisation
• Co-locations
• Additional standards required
• Other issues
• Future trends
• Specific queries / still checking

6
Not covered in detail

• Cardiothoracic surgery
• Neurosurgery
• Neonatal
• as defined in West Midlands service specification
• Cleft lip and palate
• Major burns
• Dental

7
Included

• General surgery
• Oral-maxillo facial
• Otorhinolaryngology, head and neck (ENT)
• Trauma and orthopaedics
• Urology
• Plastic surgery
• Ophthalmology
• Gynaecology
• Also
• Anaesthesia and pain management
• Imaging (partially)

8
Quality requirements / service standards
2

• Built on Critically Ill Children standards
• Recently reviewed and consulted widely
• Addressed EDs / PAUs without on-site in-patient
  paediatrics
• Include children in general intensive care units
• Now consistent with draft national PICS standards
  
• Include specialist surgical wards
• Include paediatric anaesthesia
• Considerable overlap of relevant literature
• Used across West Midlands already
• Additional standards

14
9
Not done (yet)

• Pathway diagrams
• Pathways are implicit not explicit
• ? Link with Map of Medicine
• Prevention
• Out of hospital care (pre- or post-surgery)
• Outcome measures
• Detail of imaging or pathology
• Procedures done by medical specialties
• Cross-reference to specialised services
  definitions

10
The nub of the problem ......

• There is unanimous agreement that surgical care
  for children, if safe and appropriate, should be
  delivered locally. (CSF,2007)
• The centralisation of some complex surgery is
  appropriate. However it is vital that children
  and their families are able to access more
  routine surgery locally. (CSF,2007)
• Surgeons must treat children only if they have
  the appropriate training and ongoing experience
  in the clinical care of children in their
  specialty, except in the case of emergency.......
  In an emergency, unfamiliar operative procedures
  should be performed only if there is no clinical
  alternative, if there is no colleague who is more
  experienced available or if transfer to a
  specialist unit is considered a greater risk.
  (GSP,2008)

11
Principles (CSF,2007)

• The decision to operate should include the
  provision of information, informed consent and
  confidentiality.
• The appropriate experience and training of
  surgeons, anaesthetists and the availability of
  nursing staff with appropriate knowledge and
  skills should be a prime consideration.
• Pre-operative preparation for children and
  parents should use a range of media and
  pre-admission programmes, with contributions from
  all members of the multidisciplinary team.

12

• Procedures should minimise anxiety.
• The anaesthetic room should be child-friendly and
  parents given appropriate support to reassure and
  comfort their child during induction.
• There should be a separate recovery area for
  children and parents should be able to be with
  their child when they wake up.
• There should be appropriate post-operative pain
  assessment and management policies, supported by
  a pain team.
• There should be appropriate preparation for
  timely discharge, liaison between acute and
  community services, and community childrens
  nurses available to provide support when
  required.

13
Specialist Paediatric Surgery

• Training in paediatric setting from ST1
• All training posts in specialist centres
• Includes sub-specialties
• Neonatal
• Urology
• Hepatobiliary
• Gastrointestinal
• Oncological Surgery

12
14
All surgery for children key issues

• Links with paediatrics and anaesthesia essential
• Managed networks
• More general surgeons with interest in children
• Specialist surgeons outreach
• day surgery, out-patient clinics, lists and
  clinics with general surgeons and trainees
• supports local delivery, CPD for local surgeons,
  trainee development
• Trainees have more exposure to paediatric surgery
  in DGHs and through placements in specialist
  services.
• Retrieval and transfer services essential.

3
15
General Surgery
4

• Appropriate conditions and procedures defined
• Age of child depends on experience of surgeon
  and anaesthetist
• Assessment and life-threatening emergencies
• All surgeons (for ages 5)
• Small hospital
• Out-patients, day cases, life-threatening
  emergencies
• May need general paediatric surgeons outreach
  from intermediate centre
• Intermediate centre
• All ages all procedures
• At least 2 general paediatric surgeons plus
  specialist outreach
• Issues Trainees not required to gain
  child-related competences so little interest in
  general paediatric surgery (ST5) consultant
  posts

16
Oral and Maxillo-facial Surgery
5

• Managed locally except for cleft lip and palate
  and complex surgery.
• Most surgeons operate regularly on children
• Emergencies
• Assessment and transfer to site with emergency
  service
• Mostly day cases some longer stays
• Co-location
• Anaesthesia
• Emergency service with in-patient paediatrics

17
Otolaryngology (ENT)
6

• Managed routine surgery managed locally, most as
  day cases
• Most surgeons operate regularly on children
• Increasing paediatric sub-specialisation
• Some services already work over more than one
  site
• May increase with increasing sub-specialisation
• Co-location
• Anaesthesia
• Emergency service with in-patient paediatrics
• Audiology co-location needed for out-patient
  clinics

18
Trauma and Orthopaedics
7

• Role of DGH and DGH orthopaedic surgeons clear.
• Role of Intermediate Centre (referral
  population 500K 1m)
• Unclear in guidance
• Unclear because of West Midlands specialist
  orthopaedic hospitals
• Potential role for Intermediate Centre ???
• Clarification needed
• Activity estimates
• Co-locations, especially PICU / HDU
• Role and staffing of Intermediate Centre
• Links with Trauma Centre standards and plans
• Hand surgery

19
Urology
8

• Conditions to be treated locally clearly defined.
• Emergency surgery (torsion) All urologists
• Routine surgery
• Mainly day cases
• Limit to one or two urologists so they maintain
  expertise
• Sub-regional emergency rotas for childrens
  surgery
• general surgeons and urologists with paediatric
  interest
• Possible development of outreach from specialist
  centres
• Clinics and day surgery
• Significant changes in organisation of adult
  services
• Issues around long-term follow up and transition
  identified

20
Plastic surgery
9

• Conditions to be treated locally / referred
  defined
• Emergencies
• Assessment and transfer to site with emergency
  service
• Mostly day cases some longer stays
• Co-location
• Anaesthesia
• Emergency service with in-patient paediatrics
• TO if providing combined hand surgery service

21
Ophthalmology
10

• Conditions for local treatment / referral defined
• Mostly day cases
• Routine surgery may be undertaken by
  ophthalmologist with continuing experience
• Numbers to maintain competence not defined
• Most units have a consultant with sub-specialist
  interest in paediatric ophthalmology and
  strabismus.
• Guidance implies co-location of emergency and
  in-patient surgery with in-patient paediatrics in
  all but the largest centres.
• Links with local visual disability teams very
  important

22
Gynaecology

• All hospitals should have a named consultant
  responsible for paediatric and adolescent
  gynaecology
• Vaginal discharge, labial adhesions, menstrual
  dysfunction
• Teenage pregnancy
• Specialist centre referral
• Complex congenital anomalies
• Specialist centre
• MDT with endocrinology, urology, psychology,
  specialist investigation and imaging
• Gynaecologist with advanced training in
  paediatric and adolescent gynaecology (Joint RCOG
  British Society of Paediatric and Adolescent
  Gynaecology programme)
• Transition

23
Anaesthetics
11

• All consultant anaesthetists should be competent
  to anaesthetise children aged 5
• So long as maintain skills
• All anaesthetists with emergency responsibility
  for children should ensure competence is
  maintained
• Regular supervised paediatric lists (??
  Simulators)
• Consultant anaesthetists with paediatric interest
• Regularly anaesthetise children (term )
• STs34 have key unit in paediatric anaesthesia
• Co-locations
• High dependency and intensive care appropriate
  for the type surgery being performed.

24
Pain Management

• Effective and safe management of acute pain in
  hospitals requires..... a dedicated service for
  paediatric acute pain management delivered by
  staff with appropriate training and
  competencies.
• Childrens pain management should be supervised
  by consultants and specialist nurses with
  competencies in acute and procedural paediatric
  pain management.
• Chronic pain management services should make
  special provision for vulnerable and potentially
  disadvantaged groups, including children.
• Requirement for a pain management service already
  in CIC Standards but not any detail.
• Detailed guidance from Association of Paediatric
  Anaesthetists

25
Longer-term high dependency care

• All in-patient paediatric services should be able
  to provide short-term high dependency care (up to
  48 hours)
• Done by flexing staffing
• Some services provide longer-term high dependency
  care
• ie staffed on ongoing basis
• Not clearly defined
• Children who require closer observation and
  intervention than is usually available on a
  childrens ward
• HRG definitions not generally accepted
• Proposal to undertake data collection to define
  need
• Draft standards available

14
26
Co-locations
13

• Structured as Commissioning Safe and Sustainable
  Specialised Paediatric Services
• Red Absolute dependency requiring
  co-location
• Amber Relationship under some
  circumstances
• Green Indirect of no relationship
• Read from left Required co-locations are across
  top
• Three versions
• Day surgery
• Emergency and in-patient
• Intermediate Centre

27
Paediatric Medical Specialty Co-locations

• Paediatric oncology shared care units (POSCU)
• Level 3 POSCUs giving ITC need paediatric
  anaesthesia rota
• All level POSCUs need in-patient paediatrics
• In practice, the level and training required for
  nurses in level 3 (and possibly 2) make
  co-location with longer-term high dependency care
  desirable.
• Local teams for children with haemoglobinopathies
• Co-location with level 2 or 3 POSCU longer-term
  high dependency care
• Children with Respiratory diseases
• Paediatricians with a special interest in
  respiratory medicine have competences in
  non-invasive ventilation.
• Co-location paed. anaesthesia rotas longer-term
  high dependency care.
• ? Others

28
Common Issues

• Anaesthetics
• Retrieval and transfer
• Surgical training
• How to inspire interest / experience in
  sub-specialising in surgery on children
• Specialist service outreach
• Transition
• Services for children with multiple disabilities

29
How much surgery locally if

• General surgery with paediatric interest
• Urology with paediatric interest
• ENT including paediatric interest
• TO including paediatric interest
• Paediatric HDU
• Anaesthesia with paediatric interest
• Imaging including paediatric interest
• Specialist centre outreach clinics day surgery

30
Implications for

• Quality of service provided
• Access
• Other local services
• Acute
• Community-based
• Services for children with multiple disabilities
• Transition to adult care
• Staffing