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Regionalization of pediatric anesthesia care: has the time come?

The most appropriate setting for the care of children has been and remains a subject of intense debate and discussion among pediatric providers including anesthesiologists and surgeons. Age-based subspecialty care delivered in a children’s hospital setting is seen as the ideal by most pediatric anesthesiologists and surgeons, whereas the generalists tend to believe that they are more than capable of providing care to all but the most complex and critically ill children. The data informing the debate are meager leaving the issue largely unresolved. In this issue of Pediatric Anesthesia, Mudumbai and colleagues provide an important addition to that body of knowledge (1). In a study of the more than 250 000 children under age 6 years, Mudumbai examined geographic variation in surgical care among 402 California hospitals with varying pediatric caseloads and capability. The intent of the study was to evaluate the feasibility of regionalizing anesthetic and surgical care. Hospitals were categorized as to size (low, intermediate, high), pediatric capability (California Children’s Service or not), and location (rural, urban) as well as distance from a high-volume center. Of the 402 hospitals, 90% of those hospitals were found to perform less than 100 pediatric anesthetics per year and also tend to be in close proximity to a larger more extensively equipped center. They estimate that excess of 40 000 children requiring inpatient anesthesia could have been transferred during the observation period to a higher-volume center (>100 cases per annum), of which half were infants. Based on their findings, the authors suggest that policy makers revise existing guidelines to further define the scope of care for hospitalized children. The debate for and against regionalization of care is by no means new nor is it confined to anesthesia (2–4). In the United States, regionalization has been limited to two primary areas: trauma and neonatal care. A recently published and, in the United States, controversial proposal from the American College of Surgeons seeks to extend the concept of regionalization to all pediatric surgical care (5). The American College of Surgeons Task Force for Children’s Surgical Care was created to serve as a platform for the development of guidelines for regionalization of pediatric surgical care. The task force was initially composed of primarily pediatric surgeons but has since gathered input from a variety of pediatric specialists including pediatric anesthesiologists. The guideline calls for hospitals to be stratified on three different tiers (basic, advanced, and comprehensive) contingent upon the scope of pediatric resources available. Each tier is progressively more capable of caring for increasingly complex pediatric surgical cases. Anesthesiologists would be designated either as those with pediatric expertise (generalist anesthesiologist) or as pediatric anesthesiologists (subspecialty board certified or eligible). In order to be designated as ‘comprehensive’, the facility is required to have a full complement of pediatric subspecialists, equipment, and facilities including pediatric anesthesiologists available 24/7/365. If implemented, the ACS guidelines will require ongoing accreditation and site inspection similar to that for trauma center designation. Other parts of the world have taken steps toward regionalization or are considering them. European countries are geographically relatively small when compared with the United States and are heterogeneous with regard to training, practice, and resource allocation ranging from an almost complete regionalization in the UK to its near complete absence in other European countries. The UK has been at the forefront of regionalization likely due to resource constraints imposed by the National Health Service (NHS) as well as due to the results of the National Confidential Enquiries into Perioperative Deaths (NCEPOD) (6). In the NHS model, health services for children are a national priority detailed in the Specialized Services Definition and are increasingly centralized (7,8). In addition and similar to the ACS, the Royal College of Surgeons recently updated and extended their original guidelines in the Standards for Children’s Surgery (9). These guidelines may have served as a model for those of the ACS. In Australia, healthcare governance is largely state based. Nationally over the last 6 years, pediatric health services have followed the development of a hub and spoke model where specialized tertiary pediatric services are provided within the metropolitan children’s hospital or hub. Peripheral/rural services form the spokes. Pediatric services provided peripherally or within rural environments are guided by a reasonably explicit State Clinical Services Capability Framework, defining the minimal requirements for services, including staffing and support services, based on patient and procedural complexity. This framework, as in Queensland, also guides care provided within both public and private institutions (10).