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Investigating factors affecting children's surgical care quality, including organisation, facilities, and teamwork, to enhance outcomes and patient experience. Recommendations for clinical networks, transfer policies, team working, governance, and audit practices.
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Method Hannah Shotton
Background • Many changes in the last 20 years • NCEPOD reports 1989/1999 • Kennedy Report • NSF for children • Clinical and organisational change to healthcare provision for children • Specialisation and centralisation of children’s services
Background Less surgery in DGH Concern regarding deskilling Networks Timing of study Expert group
Aims To explore remediable factors in processes of care of children 17 years and younger, including neonates, who died prior to discharge and within 30 days of emergency or elective surgery • Organisational structure of services • Quality of care received by individuals
Objectives: Organisational Facilities Networks Transfer Management of the “older child” Skills and competencies of staff Policies & procedures Team working Theatre scheduling Audit
Objectives: Case Review • Pre-operative care and admission • Intra-hospital transfer • The seniority of clinicians • Multidisciplinary team working (involvement of paediatric medicine) • Delays in surgery • Anaesthetic and surgical techniques • Acute pain management • Critical care • Comorbidities • Consent
Method • Hospital participation • Organisational questionnaire • Case ascertainment • Population • Exclusions • Data collection for 2 years
Method Surgical/Anaesthetic questionnaire Case notes Peer review
Data returns - organisational • 77% return rate
Organisational Data David Mason
Networks • ‘Clinical network for children’s surgery’ • Informal / formal • 49% (96/194) of NHS hospitals included in a network
Structure and Function 51/107 were in informal networks without specific accountability or clinical governance arrangements 50/107 clinical leads and 46/107 undertook educational meetings 64/107 agreed policies for clinical care few of these included specific surgical conditions 28/107 hospitals held network based multidisciplinary team meetings 21/107 hospitals held network based audit morbidity and mortality meetings
Recommendations Clinical networks for children’s surgery There is a need for a national Department of Health review of children’s surgical services in the UK to ensure that there is comprehensive and integrated delivery of care which is effective, safe and provides a high quality patient experience. National NHS commissioning organisations including the devolved administrations need to adopt existing recommendations for the creation of formal clinical networks for children’s surgical services. These need to provide a high quality child focused experience which is safe and effective and meets the needs of the child.
Transfer of children 93.3% (266/285) of hospitals had a policy No policy in 10 DGHs, 4 UTHs and 1 STPC Elements included in policy (259) 130 staffing arrangements 127 family support 188 communication procedures 74 equipment provision 95 transport arrangements
Recommendation Transfer of children All hospitals that admit children should have a comprehensive transfer policy that is compliant with Department of Health and Paediatric Intensive Care Society guidance and should include; elective and emergency transfers, staffing levels for the transfer, communication procedures, family support, equipment provision and transport arrangements.
Recommendation Team working All hospitals that provide surgery for children should have clear operational policies regarding who can operate on and anaesthetise children for elective and emergency surgery, taking into account on-going clinical experience, the age of the child, the complexity of surgery and any co-morbidities. These policies may differ between surgical specialities.
Clinical governance • 53% of hospitals held audit and M&M meetings for children • 4/26 hospitals with a >4000 operations/year did not undertake meetings
Pre-admission assessment 80% (228/284) of hospitals had pre-admission clinics Written information 90% (240/267) for surgery 56% (149/267) for anaesthesia
Recommendations Clinical governance and audit All hospitals that undertake surgery in children must hold regular multidisciplinary audit and morbidity and mortality meetings that include children and should collect information on clinical outcomes related to the surgical care of children. Pre-operative assessment of elective paediatric surgical patients Hospitals in which surgery in children is undertaken should provide written information for children and parents about anaesthesia. Good examples are available from the Royal College of Anaesthetists website.
Children’s operating theatres • 9 hospitals of all categories that reported >4000 operations/year did not have dedicated children’s operating theatres
Non-elective operating • “Out of Hours” • 14/27 of STPCs children only emergency lists. • Of note five of the remaining STPCs undertook between 4,000 and 10,000 cases per annum
Recovery • 35% (99/277) children recovered not separately from adults
Recommendations Theatre scheduling for children Hospitals that have a large case load for children’s surgery should consider using dedicated children’s operating theatres. Hospitals in which a substantial number of emergency children’s surgical cases are undertaken should consider creating a dedicated daytime emergency operating list for children or ensure they take priority on mixed aged emergency operating list.
Hospital facilities • No separate provision in 1/3 of DGHs, 1/2 STPCs & UTHs
Specialised staffing 13% (37/278) hospitals surgery undertaken on a site remote from the inpatient paediatric beds 6 hospitals (2 small DGH, 1 UTH, 2 PH, 1 SSH) no provision for paediatric medical support 10.3% (23/223) hospitals trainees from an adult only surgical specialty provided medical cover for inpatient children 8.4% (23/275) hospitals did not have at least one children’s registered nurse per shift on non critical care wards
Specialised staffing Anaesthetic assistance
Specialised staffing Recovery staff
Recommendations Specialised staff for the care of children Children admitted for surgery whether as an inpatient or an outpatient must have immediate access to paediatric medical support and be cared for on a ward staffed by appropriate numbers of children trained nurses. There is a need for those professional organisations representing peri-operative nursing and operating department practitioners to create specific standards and competencies for staff that care for children while in the operating theatre department.
Management of the seriously ill child 18.5% (51/276) no policy for the identification of the sick child 56.4% (155/275) hospitals used track and trigger (paediatric early warning scoring)
Resuscitation 15/277 hospitals no resuscitation policy that included children 3 DGH, 4 UTH, 5 PH, and 3 SSH 6 hospitals no onsite resuscitation team for any age of patient 3 DGH, 3 PH 16 hospitals no member of resuscitation team had advanced training in paediatric resuscitation 4 small DGH, 3 large DGH, 1 UTH, 2 PH 6 SSH
Recommendations Management of the sick child All hospitals that admit children as an inpatient must have a policy for the identification and management of the seriously ill child. This should include Track & Trigger and a process for escalating care to senior clinicians. The National Institute for Health and Clinical Excellence needs to develop guidance for the recognition of and response to the seriously ill child in hospital. All hospitals that admit children must have a resuscitation policy that includes children. This should include the presence of onsite paediatric resuscitation teams that includes health care professionals who have advanced training in paediatric resuscitation.
Acute pain management 69% (137/198) of NHS hospitals had an Acute Pain Service
Acute pain management 1/4 hospitals had APN for children 95% (264/ 277) hospitals routinely assessed pain and sedation 48% (131/273) hospitals provided regular education programmes 14% (38/272) hospitals did not have protocols for the management of postoperative pain
Recommendation Paediatric acute pain management Existing guidelines on the provision of acute pain management for children should be followed by all hospitals that undertake surgery in children.
Peri-operative care Kathy Wilkinson
