Are District General Hospital Paediatric Day Case Services Still Safe?

2. Are District General Hospital Paediatric Day Case Services Still Safe? By Mr Dan Cocker (SpR) Matron Heather Hanlon (Paeds Recovery) Mr Raj Bhutiani (Cons)

3. Are we providing a safe paediatric day surgery service at North West London Hospitals?

4. Discussion of national recommendations made regarding services Our service compared Audit of follow-up questionnaires Discussion of cancellations Discussion of safety Method

5. Recommendations • “Improving Services for Children in Hospital” (2007) recommended 100 cases/year for a surgeon to maintain skills • Children’s Surgical Forum – “Surgery for Children” (2007) recommended about • Dedicated lists • Paediatric day surgery units • Qualified children’s nurses

6. Further Recommendations • Childrens Surgical Forum also recommended that: • Experienced Paeds-trained Anaesthetist be available • Patients and carers receive instruction for post-op problems • Pain management policy • Audit and review of services • Prior arrangement for critical care cover at a nearby hospital • List every week/fortnight

7. Does NWLH meet these? • Paediatrics-dedicated lists • Paediatrics-dedicated pre-op • Paediatrics-dedicated staff • 1000-1200 patients per year • ENT, OMFS, Ophthalmology, Urology and General Surgery • 4 sessions per week

8. Does NWLH meet these? • Operations only on children over 2 years of age • Fully Paeds-trained (& EPLS) Anaesthetist and Sister • Mr Bhutiani – two lists/month • Five cases per list • Over 100 cases per year • Written instructions given to parents • Telephone call at 24hrs po (Jonas)

9. All patients pre-operatively assessed by specialist staff Those deemed high-risk or weight >98th centile referred Procedures Herniae (umbilical/inguinal) Orchidopexy Circumcision Excision of lumps/biopsies Which patients?

10. Study of patients between March 2008 and March 2010 Information from operating lists Analysis of telephone questionnaires asked at day one post-op Information gathered about cancellations Surgical Audit

11. Total of 221 procedures on 209 patients over 24 months 183/209 patients had operations carried out (26 cancelled) 121/183 (67%) had follow-up call questionnaires completed Surgical Audit

12. 26 patients were cancelled 7 unwell 7 surgery not needed 4 cancelled by parent 3 required further investigation 5 other reasons Cancellations

13. Telephone questionnaires collected retrospectively for 67% of patients (n=121) One patient taken to A&E within 24hrs (so removed) Average age 6yr 11mth 100% well on discharge 93% well overnight (112/120) Surgical Audit

14. 4% (5/120) vomited Only one could not tolerate diet 21% (25/120) reported pain… but… Only 5% felt that the analgesia advised was not adequate Suitability for Day-Case

15. 92% (111/120) reported that the wound was dry and clean Only two (2%) had a temp 3% (4/120) had pain on micturition 93% (112/120) of parents - no concerns Only one advised to seek medical help Surgical Audit

16. 4/120 had a further follow-up call organised Three of these well on 2nd call One did not answer Over the period studied, one patient taken to A&E prior to telephone call, one advised to go after telephone call (2/120) Favourable to Awad et al 2004 Surgical Audit

17. Day-case paediatric general surgery offered within the trust meets the official recommendations The safety of cases done in our trust demonstrated by our audit Any more complex/younger cases referred to regional units Discussion

18. Children’s Surgical Forum – Surgery for Children (2007), Healthcare Commission Improving Services for Children in Hospital (2007), Healthcare Commission Unplanned hospital admission in children undergoing day-case surgery. Awad IT et al. Eur J Anaesthesiol. 2004 May;21(5):379-83 Parent's management of their child's pain in the home following day surgery. Jonas DA. J Child Health Care. 2003 Sep;7(3):150-62 References

19. Any Questions…?