Optimal Resources for Children s Surgical Care. Keith T. Oldham, MD. ACS Quality and Safety Conference New York, New York July 22, 2017

Transcription

1 Optimal Resources for Children s Surgical Care The American College of Surgeons Children s Surgery Verification Quality Improvement Program Keith T. Oldham, MD ACS Quality and Safety Conference New York, New York July 22, 2017

2 Disclosure Keith T. Oldham, MD I do not have any relevant financial relationships with any commercial interest that pertains to the content of my presentation.

3 Objectives 1) Understand the rationale for the CSV program (Why?) 2) Identify the 4 foundational principles for the CSV program. (What?) 3) Review the timeline and key events in CSV program development (How?) 3

4 Vision Every child in need of surgical care in North America today will receive this care in an environment with resources optimal for his/her individual need. 4

5 WHY?

6 I. A large proportion of children s surgical care is provided in nonspecialized environments in the U.S. today. This includes relatively simple procedures but also high risk patients and complex procedures. Somme S. Pediatrics 2013 Dec;132(6):e

7 Why are children often treated in adult facilities? Care of healthy (insured) children is economically favorable for health care institutions Newborn intensive care units can provide a strong source of revenue Medical referral patterns are highly dependent upon personal relationships Americans expect and demand care that is convenient and close to home. Major complications are relatively infrequent in children so anecdotal experience can be misleading

8 II. A specialized environment is associated with better outcomes for some patients. This is most readily demonstrable for complex procedures in high risk patients. 8

9 CHILDHOOD TRAUMA ATC = Adult Trauma Center MTC = Mixed Trauma Center PTC = Pediatric Trauma Center 9

10 Kastenberg, et al. JAMA Pediatrics Jan 2015; Vol 169 (1). 10

11 III. A specialized children s environment is likely important for (relatively) simple pediatric surgical problems. 11

12 IV. Specialized pediatric anesthesia is critical for safe, contemporary children s surgery. 12

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14 Mortality, is fortunately rare; perioperative morbidity is more common and is demonstrably higher in the absence of pediatric anesthesiologists. 14

15 Relationship between Complications of Pediatric Anesthesia and Volume of Pediatric Anesthetics A significant inverse correlation was shown between volume and complication rate in pediatric anesthesia. Annual number of anesthetics Number of complications per 1000 anesthetics >200 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. Auroy Y, Ecoffey C, Messiah A, et al. Anesth Analg, 84: ,

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17 Anesthesiologists providing the anesthesia care of patients in the categories designated by the facility s anesthesiology department as having elevated anesthesia risk should be graduates of an ACGME pediatric anesthesiology fellowship training program or its equivalent. 17

18 V. A comprehensive (Level III or IV) NICU is essential for optimal surgical care of neonates. 18

19 Presented at AAP National Conference and Exhibition- October 24,

20 V. A multidisciplinary PICU is necessary for comprehensive contemporary care of critically ill children. 1. PICU mortality in Trent (North Central England) compared to Victoria (Southeast Australia). At the time of this report, Trent had care organized similar to U.S. at present, while Victoria had formal triage/regionalization of PICU patients. Interpretation If Trent is representative of the whole country, there are 453 ( ) excess deaths a year in the UK that are probably due to suboptimal results from pediatric intensive care. The Lancet, Vol 349: , April 1997 The U.S. population is ~ 5x that of the U.K. 20

21 2. evidence supporting regionalized care for critically ill children was sufficiently strong to recommend its implementation. Consensus report for regionalization of services for critically ill or injured children. Council of the Society of Critical Care Medicine. Crit Care Med 2000, 28: American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Critical Care Medicine, Society of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Pediatrics 2000, 105: Unfortunately, a growing body of evidence suggests that many hospitalized critically ill children with fatal outcomes in the United States never received the highest level of care available. Curr Opin Crit Care 2002, 8:

22 What is the CSV Program? 22

23 Models to define and verify optimal resources do exist and their use demonstrably improves patient outcomes eg. Trauma /Others 23

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25 STANDARDS & INFRASTRUCTURE

26 Overriding Principle: Tiered Care LEVEL I LEVEL II LEVEL III Age Any Any > 6 months ASA Co-morbidities All complex Typically single specialty management None healthy kids Operations All complex diseases, multi-specialty care Common anomalies, single specialty care Common low-risk procedures by single specialty Ambulatory ASA 1-3, guidelines for post anesthesia monitoring ASA 1-3, guidelines for post anesthesia monitoring Age > 6 months Healthy 26

27 Creating a National Framework for SYSTEMS of Children s Surgical Care 27

28 Resources by CSV Program Level Resource Level 1 Level 2 Level 3 NICU Level 4 Level 3 N/A PICU Required Critical care services required; not separate unit N/A Minimum of number of children s surgery cases annually 1000 N/A N/A Data collection NSQIP-Pediatrics Safety events NSQIP-Pediatrics Safety Events Safety Events 28

29 Physician Resources by CSV Program Level Physicians Level 1 Level 2 Level 3 Pediatric Surgery 2 Pediatric surgeons 24/7 coverage, age 5 1 Pediatric surgeons 24/7 coverage, age 5 General surgeons with pediatric expertise, age 5 Anesthesia 2 Pediatric anesthesiologists 24/7 coverage, age 2 1 Pediatric anesthesiologists 24/7 coverage, age 2 Anesthesiologist with pediatric expertise age 2 Radiology 2 Pediatric radiologists 24/7 coverage 1 Pediatric radiologist 24/7 coverage; can use radiologist with pediatric expertise Radiologist with pediatric expertise 24/7 coverage Emergency Medicine Pediatric EM 24/7 on-site EM with pediatric expertise 24/7 on-site N/A Medical specialists Comprehensive 24/7 coverage Limited N/A 29

30 Dr. Barnhart Data Collection and Performance Improvement Level I and Level II centers, MUST participate in ACS NSQIP-Pediatric Level I, II and III centers MUST collect surgery safety data (Appendix 2) Level I, II and III centers MUST have a multidisciplinary center-wide performance improvement process for children s surgery. Institutional performance MUST be examined relative to external norms, with demonstrable loop closure. 30

31 Dr. Oldham Performance Improvement Framework required for continuous performance improvement for all children s surgical programs. Outreach and educational programs Peer review, corrective action, loop closure Research and scholarship Ethical standards 31

32 Verification of Centers to Perform Children s Surgery in the United States National standard with 3 levels of verification Institutions will voluntarily apply for verification American College of Surgeons will serve as the verifying body

33 HOW? 33

34 Development Timeline Task Force for Children s Surgical Care Key Endorsements 2013 American College of Surgeons 2015 American Academy of Pediatrics 2013 American Pediatric Surgical Association 2013 Society of Pediatric Anesthesiology others 2014 Preliminary Standards (J Am Coll Surg 2014;218(3): ) 2015 ACS CSV Program established 2015 Final Standards , 2016 Pilot Program 6 site visits at volunteer centers 34

35 Lessons Learned 5/6 pilot sites verified Level I in 2016 (3 freestanding children s hospitals; 2 hospitals within hospitals) No site met all standards initially Alternative pathways created for pediatric anesthesiology, pediatric emergency medicine, pediatric radiology PIPS process required most change (institution-wide, multidisciplinary structure for all of children s surgery) Focused attention and new resources for children s surgery programs > 125 institutions self identified for participation at present January 2017 ACS CSV program opens 35

36 There is public interest in this program and the issues it addresses. This CSV program is focused on patients and the public is paying attention. 36