1. Everything that we do as pediatric anesthesiologists, from preoperative evaluation through postoperative care, happens within larger systems that encompass many layers and great complexity. Understanding how patients interact with and flow through these systems is necessary to optimize perioperative care.
2. Most of these systems arose independently, so multidisciplinary communication, planning, and organization is required to achieve the best result.
3. Information technology, if effectively and thoughtfully utilized, may provide data to assist in these tasks, but only if valid metrics and methodologies and well designed interfaces are chosen. Computing in high acuity intensive environments like the operating suite has the potential to be both an aid and a hazard to our patients.
4. Systems based approaches should be integrated into education and training.
HISTORY AND THE SYSTEMS-BASED APPROACH
The specialty of pediatric anesthesiology can be viewed in the same light as the developing human. In fact, it might be best compared to the patient who has recently completed intrauterine growth and development and now enters the world fully formed yet requiring further maturation on its own. Pediatric anesthesia began with men and women who struggled to raise the bar for safety and quality by recognizing the special care requirements and equipment needs of infants and children (1,2). Their efforts, and those of the many who followed, have resulted in the remarkable record of safe, effective anesthesia and analgesia care that exists today. This level of professionalism has been recognized in the recent establishment of a board certification in pediatric anesthesiology. The anointing of the new specialty is not the conclusion of a process, but rather a new opportunity for further development of care systems. Pediatric anesthesia needs to learn to communicate and network through a “childhood” and “adolescence” that will see it take on new challenges, responsibilities, and self-awareness. Only through this process will the specialty fully realize systems of practice that will optimize outcomes for children undergoing surgery, tests, and procedures.
Pediatric anesthesia is not practiced in a vacuum but interacts with multiple systems of information, resources, and service management that support and facilitate clinical care. Anesthesiology requires collaboration with a variety of consultants and has assumed a greatly expanded role and visibility in the comprehensive arena of perioperative care. Moreover, because of the increasing footprint of pediatric anesthesiologists in a large number of “off-site” locations that may be less familiar to the general anesthesiologist, a systems approach to organizing care is a necessity. Indeed, the American Academy of Pediatrics (AAP) Section on Anesthesia and Pain Management recognized this more than a decade ago, when it published its first Guidelines for the Pediatric Perioperative Environment (3). This document from the AAP, an updated but conceptually unchanged version of which is currently awaiting publication, points out that critical factors in pediatric perioperative care, whether in a dedicated children’s hospital or in a general hospital, are not dependent merely on the expertise of the anesthesiologist and surgeon, but rather on the interdependence of many systems in the institution. To achieve the highest level of care, it is necessary for the pediatric anesthesiologist to become involved in coordinating and organizing the prehospital and hospital systems that affect anesthesia care for children (Table 11.1).
In support of this expanding role for the anesthesiologist, the American Society of Anesthesiologists (ASA) has vigorously promoted the concept of the perioperative surgical home which highlights the creation of innovative, patient-centered, and coordinated models of care for patients undergoing procedures and operations. This model targets a patient-centered improvement in care and decreased cost through several pathways, including early patient engagement, reduced preoperative testing, increased intraoperative efficiency, analysis of outcomes, postprocedural care initiatives, reduced postprocedural complications, and improved care coordination and transition planning (4). The Pediatric Perioperative Surgical Home would be a natural extension of this effort; however, any such effort needs to take into account specific issues involved in caring for children and their families, including the large number of children with special health-care needs and chronic, congenital illnesses. The pediatric surgical home therefore should involve perioperative care integration across the entire span of the operative care interaction, including communication with primary care practices and interrelated medical, social, developmental, behavioral, educational, and financial resources. Integration of care services should extend from the preoperative planning visit to the 30-day postoperative evaluation. Pediatric anesthesiologists are ideally suited to provide leadership in this kind of care improvement especially as financial pressures on health care increase.
TABLE 11.1 Systems-based practice in pediatric anesthesiology
General and regional anesthetics in children—systems to ensure availability and optimal performance of supplies, equipment, support, and professional personnel (OR nursing, PACU nursing)
Thorough knowledge and understanding of monitoring systems, anesthetic delivery systems (anesthesia machines, pumps, vascular infusion sets and devices), and diagnostic and interventional devices such as ultrasonography for vascular access or regional anesthesia
Thorough knowledge and understanding of computer systems and software, especially with regard to acquisition of patient records, results of diagnostic studies, and literature relevant to patient management
Thorough knowledge of organizational systems used to structure departmental component services such as the clinical anesthesia service, critical care unit, perioperative pain management, etc.
OR, operating room; PACU, postanesthesia care unit.
Preoperative and perioperative systems, including the waiting area in the preoperative unit, must effectively anticipate and provide for the specific needs of infants and children and their families. Perioperative systems should employ specialists specifically trained to address the emotional and psychological stress of hospitalized children (such as Child Life Specialists). These individuals can also help design environments that address the special needs of this population. Such family-centered care has been shown not only to improve satisfaction, but also to positively influence outcomes, including postanesthetic delirium, analgesia, and discharge times (5). Separate facilities (or at least a separate area) for children and their families awaiting surgery should be provided and appropriately furnished, as should a separate area of the postanesthetic care unit (PACU) where pediatric equipment can be readily found and child-oriented care can be administered. In institutions that care for both adults and children, these measures obviously benefit the adults as well. The circulating nurse in the operating room (OR) must be familiar with the sequence and expected events during inhalation induction, and should be skilled in the placement of pediatric intravenous cannulae should the airway be difficult and the anesthesiologist need assistance. These same nurses should be familiar with pediatric advanced life support algorithms so that they can actively assist in emergency events. In institutions where parental presence during induction is offered, personnel must be available to escort parents out of the OR after their child loses consciousness. Anesthesia technicians should be familiar with the equipment needs for pediatric cases and have the requisite supplies available in age- and weight-appropriate sizes. The ORs should be able to have temperatures readily regulated for infant cases, and warming devices such as radiant heaters and appropriate forced air heaters must be available. The anesthesiologist, no matter how skilled, cannot safely anesthetize a child if the PACU nurses have inadequate experience with or knowledge of pediatric postoperative care. In this setting, pediatric airway skills (especially if deep extubation is practiced) must be modeled and tested on a regular basis. The early reunion of child and parent should be facilitated as soon as clinical conditions permit (6). Critical care facilities with pediatric expertise, or a cooperative program that delineates clearly and explicitly defined protocols for transfer to such a unit, must be available in the event of a complication.
The provision of pre- and postoperative care for “off-site” cases in locations such as radiology, oncology, and procedural suites must be even more highly organized. These programs may require either the duplication of services offered in the OR when logistic and architectural considerations make sharing of those facilities impractical or unsafe, such as when the procedural or diagnostic suite is many floors away from the OR. Alternatively, carefully organized and orchestrated transport systems, including oxygen, monitoring, communications, and personnel, to ensure patient safety for transport to and from OR facilities should be implemented. The department of anesthesiology, not the procedural department, must be in charge of pre- and postanesthetic policies. Recovery nursing care should be delivered and administered by individuals with the same training, expertise, and commitment to pediatric care excellence as those in the OR PACU. The quality of care provided should be consistent regardless of the clinical venue.
Performance-based credentialing has become a standard in most institutions. Expertise increases with training and experience in any field that involves significant risk and demands cognitive and manual skills, which in turn can translate into improved outcomes. In pediatric anesthesia, limited data suggest that outcomes are improved when pediatric specialists (rather than generalists with limited pediatric experience and training) care for children younger than 1 year as judged by the frequency of anesthetic-related cardiac arrest (7,8). A study of the demographics of inpatient pediatric anesthesia care in northern California noted that more than half of the 205 hospitals in the region performed fewer than 20 cases per year in children younger than 2 years, but three quarters of those institutions were within 50 mi of an institution that anesthetized >100 cases per year (9). This is likely to be the situation in other localities, and implies that (i) adequate target numbers for maintenance of competency for an individual anesthesiologist may be difficult to achieve at some institutions and (ii) regionalization of care may be both practical and desirable in some locales.
Nonsubspecialty anesthesiologists anesthetize the vast majority of children in the United States and can be expected to continue to do so into the foreseeable future. It is, however, important for any institution to identify an anesthesiologist who, by virtue of training or experience, will be responsible for organizing pediatric anesthesia services. This responsibility should also include oversight of the institution’s pediatric sedation policy and emergency airway management policy and postoperative pediatric pain management program or guidelines. The criteria for delineation of privileges for pediatric cases of increased complexity (neonates, children younger than 2 years, ASA 3, 4, and 5 patients, complex intrathoracic or intra-abdominal cases, placement and use of invasive monitoring, etc.) should be defined.
Integration with the pediatric health-care network. Entry to the hospital system for most elective pediatric anesthesia cases is ultimately through the pediatrician or family practitioner. Thirty percent of pediatricians examine children as part of their preoperative “clearance” for surgery, and an additional 30% believe that they should be doing so, yet the only study to date on this issue found that fewer than 8% had any exposure to anesthesiology or preoperative medicine in their residency training (10
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