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  • American College of Surgeons Childrens Surgery Verification and

    Quality Improvement Program

    Jayant K. Deshpande, MD MPH SVP/Chief Medical Officer, Arkansas Childrens Hospital Harvey and Bernice Jones Endowed Chair in Pediatrics

    Jonathan Bates, MD Endowed Chair for Improving Childrens Health Director, Jonathan Bates, MD Center for Improving Childrens

    Health Professor of Pediatrics and Anesthesiology, UAMS

    SPA Representative,

    ACS Childrens Surgery Center Verification Committee

    1

  • Objectives

    2

    Discuss current status of the verification program

  • No conflicts of interest

    3

  • Anesthesiology representatives to ACS task force and committee Jayant K. Deshpande, MD, MPH, FAAP Constance S. Houck, MD, FAAP Randall P. Flick, MD, MPH, FAAP Lynn Martin, MD, FAAP

  • Quality improvement focus and Collaboration Four other ACS quality improvement programs

    Bariatric Surgery Breast Disease Cancer Surgery Trauma

    Optimal Resources in Childrens Surgery Task Force from the beginning, has included American Academy of Pediatrics (AAP), Section on Anesthesiology

    and Pain Medicine Society for Pediatric Anesthesia (SPA) Committee on Pediatric Anesthesia (COPA) of the American

    Society of Anesthesiologists (ASA) Endorsed by Childrens Hospital Association (CHA) and AAP.

    5

  • The purpose The ACS Childrens Surgery Verification Committee was established with the goal of improving the care of children with surgical needs. This process includes defining optimal resource standards and matching them prospectively to an individual childs needs. Achievement of this goal requires an appropriately designed system of care and includes verification that these standards are met in individual childrens surgical centers. We intend to continuously review and improve this document as new information and more data are developed that can be applied to its content. Our intent is to use evidence-based scientific methods to support recommendations. We have used existing data, where possible, combined with expert opinion to establish consensus and formulate these current standards. Multiple research efforts are under way to strengthen the evidence base as well. 6

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  • A pediatric anesthesiologist individual certified or eligible for certification in

    pediatric anesthesiology by the American Board of Anesthesiology (ABA) or equivalent body,

    Or, similarly qualified by demonstrable experience, training via Pediatric Anesthesia Alternative Pathway (see below)

    An anesthesiologist with pediatric expertise (see below) Alternative Pathway for Pediatric Anesthesiologists (see

    below)

    8

  • A pediatric anesthesiologist An anesthesiologist with pediatric expertise

    either eligible to certify or with a current certificate from the ABA or equivalent

    must demonstrate continuous experience with children < 24 months of age (25 patients per anesthesiologist per year)

    will demonstrate ongoing pediatric clinical engagement with patients 18 years of age

    Will complete 10 or more relevant Category 1 CME credit hours annually.

    Alternative Pathway for Pediatric Anesthesiologists (see below)

    9

  • A pediatric anesthesiologist An anesthesiologist with pediatric expertise Alternative Pathway for Pediatric Anesthesiologists

    Successfully completed residency in anesthesiology, certified by a letter from program director detailing pediatric component

    > 30% practice devoted to pediatric cases; including neonates and children < 2 years, and procedures considered high risk

    Current provider or instructor, Pediatric Advanced Life Support (PALS) 48 hours of children's anesthesia-related CME in last 3 years Documentation of membership or attendance at children's anesthesia meetings List of patients < 2 years of age and related procedures during the reporting year Licensed to practice medicine; documentation of privileges to care for children <

    2 years by hospitals credentials committee Anesthesiologists care will be evaluated by on-site reviewer, with oversight by

    other anesthesiologists who are members of CSV Committee

    10

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  • The ACS Childrens Surgery Verification Program

    1. Pre-review questionnaire (PRQ) 2. On-site review (2 days) by multidisciplinary peer review

    team composed of individuals experienced in the field of childrens surgical and anesthetic care. Assesses commitment, readiness, resources, policies, patient care, performance improvement, and other relevant features

    3. Process results in report outlining findings and, if successful,

    4. Certificate valid for 3 years

  • Why do all of this?

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  • 2009 US (KID) Data

    87,110/189,977 childrens general and thoracic inpatient procedures done in general hospitals45.9%

    Ziegler et al, Pediatrics 2013; 132(6):1466-1472

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  • Where are surgical neonates definitively treated in U.S.? (KIDS 2009 Data) Free Standing

    Childrens Hospital Childrens Unit

    within a Hospital General Hospital

    n (%) 20.57% 34.33% 45.10%

    20.57%

    34.33%

    45.1%

    Free Standing Children's Hospital Children's Unit within a Hospital

    General Hospital

    Preliminary data/unpublished

    19

  • Table 2. Complex neonatal procedures by hospital type for 2009

    Procedures

    All Hospital Types*

    Childrens Hospital & Childrens unit

    General Hospital

    Fold Change

    Weighted Frequency

    Weighted Frequency

    Per 10,000 (95% CI)

    Weighted Frequency

    Per 10,000 (95% CI)

    Operation for malrotation 1,176 760 9 (7.3-10.8) 278 1.3 (1.1-1.6) 6.8

    Repair esophageal atresia 1,077 816 9.7 (7.6-11.8) 156 0.7 (0.5-1.0) 13.1

    Lung biopsy 899 612 7.3 (5.6-8.9) 141 0.7 (0.4-0.9) 10.8

    Pull through for Hirschsprung 675 503 6 (4.7-7.3) 77 0.4 (0.2-0.5) 16.4

    Repair diaphragmatic hernia 475 340 4 (3.1-4.9) 66 0.3 (0.2-0.4) 12.8 *Includes general hospital, childrens hospital, childrens unit in a general hospital, and childrens specialty hospital.

    Rao Scott 2 test for difference in surgical volume rates between hospital types were all p

  • McAteer JP. Lariviere CA. Oldham KT. Goldin AB. Shifts towards pediatric specialists in the treatment of appendicitis and pyloric stenosis: Trends and outcomes. Journal of Pediatric Surgery 2014 Jan. 49(1):123-8.

    21

  • Study Conclusion 2015- Substantial volumes of childrens surgery, including

    relatively simple procedures, but also neonates and other high risk patients with complex procedures, are performed in nonspecialized environments.

    22

  • Chang RK, Klitzner TS. Can Regionalization Decrease the Number of Deaths for Children Who Undergo Cardiac Surgery? A Theoretical Analysis. Pediatrics. 2002; 109 (2):173-181

    23

  • 0

    1

    2

    Obs

    erve

    d to

    exp

    ecte

    d m

    orta

    lity

    rat

    io

    Annual number of pediatric discharges

    O/E Mortality for Surgical Neonates with Intrinsic Risk of Mortality >5%

    KID 2009

    General hospitals Childrens units in general

    hospitals

    Childrens general

    hospitals

    Low High

    O/E ratio for hospital category

    Preliminary data/unpublished 24

  • Study Conclusion Specialized environment is associated with better

    outcomes for some procedures. This is most readily demonstrable for complex procedures in high risk patients.

    25

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  • Keenan RL, Boyan CP. Cardiac Arrest due to Anesthesia: A Study of Incidence and Causes. JAMA 1985; 253 (16): 2373-2377

    27

  • Pediatric Anesthesia 2015 Neonatesrisk of cardiac arrest ~ 10x adults

    Infants . risk of cardiac arrest ~ 5x adults

    Risk of death 25-30% if perioperative cardiac arrest

    Morray JP, Anesthesiology 2000:93:6-14

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  • Anaesthesia services for children require specially trained clinical staff together with equipment, facilities and environment.

    The service should be led at all times by

    consultants who regularly anaesthetise children.

    Surgeons and anesthesiologists should not undertake occasional paediatric practice

    The 1989 Report of the National Confidential Enquiry into Perioperative Deaths (NHS)

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  • Relationship between Complications of Pediatric Anesthesia and Volume of Pediatric Anesthetics

    Annual number of anesthetics Number of complications per 1000 anesthetics

    1-100 100-200

    >200

    Auroy Y, Ecoffey C, Messiah A, et al. Anesth Analg, 84: 228-36, 1997

    A significant inverse correlation was shown between volume and complication rate in pediatric anesthesia.

    31

  • Relationship between Complications of Pediatric Anesthesia and Volume of Pediatric Anesthetics

    we recommend that a minimum case load of 200 pediatric anesthetics per year is necessary to reduce the incidence of complications and improve the level of safety in pediatric practice.

    32 Auroy Y, Ecoffey C, Messiah A, et al. Anesth Analg, 84: 228-36, 1997

  • JAMA 2010;304[9]:992-1000

    Survival for Very Low Birth Weight Infants

    33 Laswell et al. JAMA. 2010;304(9):992-1000

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  • Should paediatric intensive care

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