VOLUME 27, ISSUE 1

The American College of Surgeons (ACS) has recently published the first iteration of new consensus guidelines defining the resources that surgical facilities need to perform operations “effectively and safely” in infants and children¹. Representatives of the Regents of the American College of Surgeons, the Board of Governors and members of the American Pediatric Surgical Association and the board of the Society of Pediatric Anesthesia (initially 1 member, then 3 members at the second meeting) developed these consensus recommendations over the past three years with the vision that “every infant and child undergoing surgery in the United States today should receive care in an environment with prospectively defined optimal resources matched to his/her needs.”² The group reviewed published data regarding outcomes in children undergoing surgery in specialized versus non-specialized environments. The benefit of the specialized environment was most apparent in higher risk patients: neonates, infants, and inpatients having more complicated procedures such as cardiac surgery. The Task Force wanted to create standards for an “optimal environment” for an infant or child with a specific level of surgical need. Their proposal is a survey and verification process to stratify facilities that provide pediatric surgical care modeled after the ACS trauma centers.

Their initial proposed classification system for children’s surgical centers stratified centers into 3 Levels based on the level of resources available including availability of staffing by pediatric specialists: surgeons, subspecialty surgeons, pediatric anesthesiologists, pediatric interventional radiologists and pediatric emergency physicians; age of child; and level of NICU. Level 3 (basic children’s surgical centers) were restricted to children older than 1 year who were otherwise healthy and also allowed general surgeons and anesthesiologists with pediatric expertise instead of requiring certified pediatric surgeons and pediatric anesthesiologists.

In a letter to the editor, Drs. Jane Fitch and Mark Singleton on behalf of the American Society of Anesthesiologists (ASA) expressed their concern that these recommendations had the potential to shift a large portion of pediatric surgical care from non-specialty hospitals, which provide the “vast majority” of pediatric care with resultant reduced access to care in areas where specialized pediatric facilities and expertise do not exist³. They further stated that anesthesia care for otherwise healthy children less than 1 year old undergoing common outpatient surgery can be provided safely by physician anesthesiologists who have completed anesthesiology residency and are licensed and credentialed, although not subspecialty fellowship trained since pediatric care is a core competency.

In response, the chair of the Task Force as well as the three pediatric anesthesiologists on the Task Force expressed appreciation of the ASA’s comments and replied that these proposals are in the development stage. Also, these are only recommendations, not requirements, and that the proposed process does not mandate transfer of patients nor prohibit any specific practitioner activity³. Simply, the Task Force is trying to prospectively define resource standards while balancing patient access.

The Task Force subsequently met in May 2014 with the addition of Dr. Randy Flick, MD, MPH, a pediatric anesthesiologist, on behalf of the ASA, and developed new language in the most recent draft specifically addressing many of the ASA’s concerns. The age threshold below which a patient needs the resources of a Level 1 or Level II children’s surgical center was changed to 6 months. The definition of an anesthesiologist with pediatric expertise was changed to include demonstration of continuous experience with children less than 24 months of age with a minimum of 25 patients in the preceding twelve months in this age group, and ongoing pediatric clinical work with patients less than 18 years of age, and 10 relevant category I CME