www.hse.ie/anaesthesia

MODEL OF CARE FOR PAEDIATRIC ANAESTHESIA

NATIONAL CLINICAL PROGRAMME FOR ANAESTHESIA 1

Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

Endorsed by:

Endorsed by: Irish Paediatric Anaesthesia Network Endorsed by:

Irish Paediatric Anaesthesia Network Irish Paediatric Endorsed Anaesthesia by: Network Irish Paediatric Anaesthesia Network

Published April 2015 PublishedPublished A April pril 2015 2015

Published April 2015

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TABLE OF CONTENTS

1 FOREWORD 6

2 eXECUTIVE SUMMARY 7

3 INTRODUCTION 9

4 PAEDIATRIC ANAESTHESIA LITERATURE REVIEW 11

5 PAEDIATRIC ANAESTHESIA AND PATIENT DEMOGRAPHIC DATA FOR IRELAND 20

6 PROFESSIONAL AND CLINICAL STANDARDS FOR SAFE PAEDIATRIC ANAESTHESIA 29

7 PERFORMANCE MEASURES AND QUALITY IMPROVEMENT METHODS FOR 36

PAEDIATRIC ANAESTHESIA AND INTENSIVE CARE MEDICINE IN IRELAND

8 PAEDIATRIC CRITICAL CARE 43

9 strUCTURE AND GOVERNANCE OF PAEDIATRIC ANAESTHESIA SERVICES: 49

LOCAL, REGIONAL/ HOSPITAL GROUPS AND NATIONAL

10 ABBREVIATIONS 60

11 MODEL OF CARE FOR PAEDIATRIC ANAESTHESIA STEERING/WORKING GROUP MEMBERSHIP 62

12 ACKNOWLEDGEMENTS 63

13 referenCES 65

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1. FOREWORD 2. EXECUTIVE SUMMARY

FOREWORD TO PAEDIATRIC ANAESTHESIA No single service can work in isolation within the 2.1. Introduction analysed data regarding paediatric anaesthesia in ______MODEL OF CARE ______healthcare system. Particular focus has been given Ireland; nevertheless, the paediatric anaesthesia to clinical governance for paediatric anaesthesia The aim of the Model of Care for Paediatric and patient demographic data for Ireland section When the National Clinical Programme in at a local hospital level, across hospital groups Anaesthesia is to describe what is required in order of this document describes and discusses the sources Anaesthesia, NCPA, was set-up just over three years and nationally within the context of the clinical to establish a network to safely deliver anaesthesia to that are available – specifically, national surveys ago, we decided to focus on projects that delivered governance structures for the New Children’s Hospital children in the Republic of Ireland. and databases. We review activity data, manpower on our top three goals: Group. In order to maximise peri-operative service numbers, surgical speciality breakdown, cut-off age delivery and patient experience, the paediatric The Model of Care for Paediatric Anaesthesia limits for paediatric anaesthesia and waiting lists for • Better patient safety anaesthesia team need to work in collaboration proposes the redesign of paediatric anaesthesia day case and in-patient procedures. We conclude • Better patient care with their multi-disciplinary colleagues within clinical services, in order to provide better, safer and with a discussion on the relevance of the data. • Better collegiate support governance structures to effectively achieve better more sustainable care to children in Ireland who patient safety, better patient care and better need anaesthesia. It complements the National 2.4. Professional and Clinical Standards for When the Irish Paediatric Anaesthesia Network (IPAN) collegiate support. Model of Care for Paediatrics, which will guide the Safe Paediatric Anaesthesia ______joined forces with the National Clinical Programme reorganisation of hospitals that deliver paediatric for Anaesthesia (NCPA) to collaborate on the Our thanks to all our colleagues who contributed to services; such services include paediatric surgery, The Professional and Clinical Standards for Safe development of a model of care for the delivery of this project. We were proud to work alongside such anaesthesia and peri-operative nursing care. The Paediatric Anaesthesia section opens with an Paediatric Anaesthesia throughout the country, the dedicated team players and are happy our work will National Model of Care for Paediatrics is likely to overview of the professional status of paediatric result was a model that embraced these key priorities. make such a positive contribution to the Irish Health propose a hub-and-spoke model of care, with the anaesthesia. This leads to a discussion on the current Services. new Children’s Hospital linked into three/four regional state of manpower, and recommends what will It was gratifying to lead and be part of a group centres, all of which will provide 24-hour paediatric be required for future service delivery. There is a of professionals who all gave of their time for free surgical, anaesthesia and peri-operative care. These considerable gap between current staffing levels, and contributed so much effort to this project. All three/four regional centres will in turn be linked to what is required in order to deliver current service concerned were highly motivated, dedicated ______other hospitals in their Hospital Group areas; they requirements, and what will be required to deliver professionals who brought decades of experience Dr Bairbre Golden will provide paediatric surgery, anaesthesia, routine future service needs. to the project. Whilst much discussion and debate Director operations and peri-operative care to healthy took place during the development of the model, National Clinical Programme for Anaesthesia children of an age group that would be appropriate The section of the document also includes sub- consensus was ultimately achieved and all parties HSE for treatment in those hospitals. sections covering facilities, equipment and have taken ownership and signed off on the final medication in paediatric anaesthesia, as well as product. The high standard of this model is a fitting 2.2. Paediatric anaesthesia literature review standards for peri-anaesthesia care and monitoring. ______testament to their professionalism and enthusiasm. ______It concludes with a description of the leadership Dr. William Casey The paediatric anaesthesia literature review section role of the anaesthetist in pre-admission units and a This Model of Care is intended to be a guide to the Chair of the document contains an extensive review of paediatric pain management service. standards and services required in order to deliver Irish Paediatric Anaesthesia Network guidelines and papers which were prepared with acceptable levels of care in paediatric anaesthesia both a national and international setting in mind. 2.5. P erformance measures and quality throughout Ireland, irrespective of whether the child Many papers relating to the provision of paediatric improvement methods for paediatric is being cared for in a large, paediatric-only hospital anaesthesia services have been published; we have anaesthesia and intensive care medicine catering for the very sick high-risk patient or in a selected the most important and the most relevant in Ireland ______smaller Model 2 Hospital looking after the needs of materials, and, where practical, we have applied healthy low-risk paediatric patients. them to an Irish setting. We have examined guidelines The aim of Model of Care for Paediatric Anaesthesia and protocols devised in the United Kingdom, is to provide the HSE with national guidelines, and Australia and New Zealand – countries with similar establish quality improvement networks in line with the health infrastructure to Ireland. acute hospitals reform agenda and implementation of the Hospital Groups, in order to improve the 2.3. P aediatric anaesthesia and patient outcome and quality of services provided to children demographic data for Ireland in Ireland who are undergoing anaesthesia. Currently, ______there are no national guidelines on performance It is difficult to access timely, relevant and appropriately measurement or quality improvement initiatives for

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2.7. Conclusion paediatric anaesthesia and intensive care medicine ______in Ireland. 3. INTRODUCTION There is a strong consensus among the leaders of 1.25 million (23%) of Ireland’s 4.6 million population is to design services that will improve outcomes in We have developed a suite of performance a wide range of stakeholders involved in the safe are children aged under 16 years. Ireland, which paediatric anaesthesia. The Hospital Groups’ role, measures specific to paediatric anaesthesia. They delivery of paediatric anaesthesia in Ireland of the has the highest birth rate in the European Union (16.3 on the other hand, is to reconfigure services in their can be broken down into three areas. As follows: need for a national steering group with oversight per 1,000), currently registers approximately 70,000 network and implement this Model of Care; such • To evaluate the implementation of the Model of all paediatric services throughout Ireland. This births each year. In 2013, according to Hospital In- services will include paediatric surgery, anaesthesia of Care for Paediatric Anaesthesia national steering group would comprise leaders Patient Enquiry (HIPE) scheme data, 43,207 children and peri-operative nursing care. A hub-and-spoke • Activity measures appropriate for an from anaesthesia, critical care, paediatric surgery, had general anaesthesia administered for surgical or model of care is proposed, with the New Children’s established, stable paediatric anaesthesia paediatrics, neonatology, transport medicine, as medical procedures carried out in public hospitals in Hospital linked into three/four regional centres, all service well as nursing representatives and management the Republic of Ireland. A total of 21,127 anaesthetics of which will provide 24-hour paediatric surgery, • Outcome measures to demonstrate the quality representatives. were administered in the three children’s hospitals anaesthesia and peri-operative care. These three of paediatric anaesthesia. in Dublin, and a further 22,080 anaesthetics were regional centres will in turn be linked to other hospitals A considerable amount of work needs to be done administered to children in adult hospitals across the in their Hospital Group, or in the Children’s Hospital 2.6. Structure and governance of in order to clearly identify which units will provide country. Group, which will provide paediatric anaesthesia, paediatric anaesthesia services: local, paediatric care, and what type of facilities and surgery, routine operations and peri-operative care regional/Hospital Group and national appropriate staffing will be required. This work 3.1. Aim of this Model of Care for Paediatric for healthy children of an age and ASA classification ______must also align with the National Model of Care for Anaesthesia group that would be appropriate for such hospitals. ______Strong management of an individual hospital’s Paediatrics. paediatric anaesthesia service is vital at both The aim of this Model of Care for Paediatric Paediatric anaesthesia and peri-operative nursing clinical and managerial level. Effective governance The work must be carried out on a partnership basis; Anaesthesia is to highlight what is required in order to services in Ireland should be delivered by competent, arrangements recognise the inter-dependencies it must be evidence based, use best reliable activity set up a network to safely deliver anaesthesia to Irish trained staff in a safe working environment, with between corporate, financial and clinical data, and take into account of international best children. adequate and appropriate facilities, medication governance across the service. practice in the delivery of paediatric care. and equipment in place to safely anesthetise and 3.2. Why we need a Model of Care for manage elective and acute paediatric surgery that We propose a model for the management of The findings should feed into the National Model of Paediatric Anaesthesia is appropriate for each institution. ______paediatric anaesthesia services at a local hospital Care for Paediatrics. It should outline the delivery level. We outline what is required at every institution of care for children, and it should be signed off by Modernisation of our health services demands 3.4 Breadth of paediatric anaesthesia services ______where it is proposed to deliver paediatric anaesthesia, the Department of Health (DoH), Health Service changes in practice. The fundamental issue to be surgery, and peri-operative nursing care. Executive (HSE), and all key stakeholders. addressed in the care of children in Ireland (be Anaesthetists who are trained and experienced in they sick or healthy) is where these children should paediatric peri-operative care are involved in not The management of a paediatric anaesthesia service The policy position adopted by the Government in be treated. Given anaesthesia’s essential role in only delivery of anaesthesia but also other aspects of is outlined, with suggestions on how this should be June 2014 (when it approved the Project Brief for investigative procedures, surgery, pain management, children’s care such as: integrated into a regional/Hospital Group paediatric the New Children’s Hospital) is that the new hospital intensive care medicine, as well as transport and • Pre-operative assessments and preparation of peri-operative clinical governance structure, when it should act as the central player in an integrated retrieval, it is intrinsic to the successful delivery and children for anaesthesia and surgery is in place. clinical network for paediatrics on the island of implementation of any model of care addressing the • Diagnostic procedures that will require general Ireland. The Hospital Groups service delivery model needs of this patient population. anaesthesia, not normally required in adults, This section provides a broad overview of current will implement the service design modelled in the e.g., MRI, CT scan, cardiac catheterisation, and future requirements for paediatric intensive National Model of Care for Paediatrics. This Model of Healthy children undergoing routine operations bronchoscopies and endoscopies care services, including a dedicated section on the Care for Paediatric Anaesthesia will form part of the should be treated as close to home as possible, while • Insertion of long-term intravenous access transport of critically ill children. National Model of Care for Paediatrics. simultaneously recognising that the institution needs for long-term antibiotic/chemotherapy to provide a safe and child-friendly environment, as administration Government policy adopted in June 2014 states that The Children’s Hospital Group, in collaboration with well as meet the anaesthesia and nursing standards • Active member of resuscitation team the New Children’s Hospital will be the central player the other six geographically based Hospital Groups, recommended by professional bodies. • Provision of acute and chronic pain in an integrated clinical network for paediatrics will plan and design a network for paediatric service management services on the island of Ireland. It is expected that the delivery. This will form the structure through which the 3.3. Our proposal for the future • Involvement in delivery of paediatric intensive ______New Children’s Hospital will take on this leadership National Model of Care for Paediatrics and other care service in children’s hospitals – although position, coordinating the input and contributions national clinical programmes, including paediatric The Model of Care for Paediatric Anaesthesia there is now an evolving separation between from the relevant paediatric clinical programmes anaesthesia, paediatric critical care, paediatric proposes the reorganisation of all hospitals that paediatric anaesthesia and paediatric and facilitating the implementation of their models surgery and medicine, will be implemented. are currently delivering paediatric services, and to intensive care unit (PICU) care of care, including the Model of Care for Paediatric instead introduce a networked approach. Our aim • Involvement in paediatric transport service. Anaesthesia.

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This Model of Care provides detailed information 4. PAEDIATIC ANAESTHESIA on the care of infants and children undergoing anaesthesia or receiving critical care in a paediatric LITERATURE REVIEW critical care unit (PCCU); it does not, however, In designing a Model of Care for Paediatric local anaesthetists, who would still be expected to provide information relating to infants cared for in Anaesthesia for Ireland, we felt it was important to get involved in the resuscitation of critically ill and neonatal units within maternity hospitals. Those infants carry out an extensive literature review of guidelines critically injured children. During this time, a pattern are cared for by specially trained neonatologists. and papers that were prepared with both a national began to emerge whereby non-specialist paediatric and international context in mind, and to then anaesthetists were reluctant to become involved apply those guidelines/papers to an Irish setting. in the resuscitation of critically ill children. In 2002, Fortunately, many papers relating to the provision the Royal College of Anaesthetists of Ireland felt it of paediatric anaesthesia services have been necessary to circulate correspondence notifying published over the years; what we have done is departments of anaesthesia in all hospitals that on- select the most important and relevant materials, call anaesthesia/critical care teams may be asked and, where practical, apply them to an Irish setting. to get involved in the resuscitation and stabilisation We have examined guidelines and protocols devised of critically ill children. In this correspondence the in the United Kingdom, Australia and New Zealand – College went on to point out that such assistance countries whose health infrastructure is similar to the should always be provided. Irish health infrastructure. From a paediatric general surgery point of view, 4.1. Historical perspective in 2006, a joint statement was issued on behalf of ______the Association of Paediatric Anaesthetists, the Much of the literature relating to the anaesthesia Association of Surgeons of Great Britain and Ireland, model of care for children dates back to 1989 – to the Royal College of Paediatrics and Child Health the Report of the National Confidential Enquiry into and the Senate of Surgery for Great Britain and Perioperative Deaths (NCEPOD) (Campling, Devlin Ireland. They recommended that a lead paediatric & Lunn, 1989). This extensive report examined peri- anaesthetist should be nominated in each hospital operative deaths in children under 10 years of that is performing paediatric anaesthesia. That age. It is important to note that the vast majority of the lead paediatric anaesthetist should process these deaths were children with severe medical co- one paediatric list or equivalent each week; that morbidities. NCEPOD advised against occasional they would be responsible for coordinating and paediatric anaesthesia practice, and recommended overseeing anaesthesia services for children, and that consultant anaesthetists should maintain would also be responsible for establishing regional competencies in the management of children. networks. The joint statement went on to recommend which elective and emergency surgical procedures Following on from the NCEPOD report, Lunn (1992) should be performed in district general hospitals, and recommended the nomination of a lead paediatric which should not. anaesthetist in each institution that is involved in carrying out anaesthetic procedures on children; In 2008, the Australian and New Zealand College he also recommended a minimum case load on a of Anaesthetists updated its statement on weekly, monthly and annual basis. Specifically, from a anaesthesia care of children in healthcare facilities paediatric general surgery perspective, Arul & Spicer without dedicated paediatric facilities. These (1998), perhaps controversially, advocated that recommendations will be referred to later in this both specialist and non-specialist paediatric general document. surgery should be centralised, and that such surgery should not be carried out in district general hospitals. In 2013, the Children’s Surgical Forum – involving The implications of this latter recommendation would contributions from all the stakeholders involved in have been the transfer of all children’s surgical providing anaesthesia, surgery and nursing care specialities to centralised facilities, thus causing to children – released a document in which they specialist centres to become overwhelmed, as well highlighted the success that clinical networks have as leading to loss of confidence and deskilling of achieved in the National Health Service (NHS) in

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the UK. This document also contained a number of out in non-specialist centres (Royal College of surgery (Royal College of Surgeons of Surgeons of and for children of all sizes and ages. recommendations on information and standards for Anaesthetists, 2014). Children with significant acute England (2010); National Confidential Enquiry into children’s surgical service provision. The overarching or chronic medical problems; those undergoing Patient Outcome and Death (NCEPOD) (2011); Efforts should be made to progress the adoption principle of the document is that children are complex procedures, as well as neonates and small Scottish Government (2008); Welsh Government of a clinical information management system in all treated safely, and as close to home as possible, in infants, are usually referred to specialist children’s (2009); Department of Health, Social Services and theatres. This system should include the facility to an environment that is suitable for their needs; that units (NHS (2013); Scottish Executive (2009); NHS, Public Safety, Northern Ireland (2010). move towards electronic prescribing. As advocated the children’s parents are involved in decisions, and Wales (2008); Department of Health, Social Services by safety agencies worldwide, all paediatric infusions that optimal quality of care is delivered. In addition, and Public Safety Northern Ireland (2010)). Paediatric resuscitation equipment must be available should ideally be run as standardised concentrations, all those involved in children’s surgical services should wherever and whenever children are treated facilitated by the use of smart-pumps. be suitably trained and supported. Non-specialist centres should have arrangements (Resuscitation Council, UK (2013), and anaesthetists in place for managing and treating simple surgical must maintain their skills in a team approach for Resuscitation medications and equipment, including Finally, in 2014, the Royal College of Anaesthetists emergencies in children; in addition, they should be resuscitation and stabilisation of the sick child an appropriate defibrillator, should be readily issued comprehensive guidelines on the provision of able to resuscitate and stabilise seriously ill infants and (Paediatric Intensive Care Society, 2010. available wherever children are anaesthetised paediatric anaesthesia services. These guidelines are children of all ages prior to transfer for surgery and/ (Royal College of Anaesthetists, 2014). Paediatric referred to extensively in the rest of this section. or intensive care (Royal College of Anaesthetists, Successful networks ensure that children are safely high dependency and intensive care facilities should (2014)). treated as close to home as possible; that they have be available and delivered within a network of care 4.2. Summary of literature review access to the appropriate level of care, and that that supports major/complex surgery and critically ______Anaesthesia for children should be either carried out high-quality care is delivered by the correct staff ill or injured infants or children (Royal College of Wherever and whenever children and young or supervised by consultants who have undertaken with appropriate skills. Networks underpin the local Anaesthetists, 2014). people undergo anaesthesia and surgery, their appropriate training. Unless there is no requirement to delivery of safe services; they provide opportunities particular needs must be recognised. In addition, anaesthetise children, it is expected that confidence for training, CPD and refresher training; in addition, While it is acknowledged that critical care facilities these children/young people must be managed in and competence to anaesthetise children will they provide support to clinicians if unexpected for children are not available in all hospitals that appropriate facilities, and must be looked after by be sustained through direct care, continuous circumstances require that they act beyond their anaesthetise children, facilities for initiating intensive staff with relevant experience and ongoing training. professional development and/or refresher courses, practised competencies (Royal College of Surgeons care prior to transfer/retrieval to a designated (Getting the right start. National service framework for and should be considered as part of annual appraisal of England, 2013). regional PICU/HDU facility should be available. This children: standard for hospital services. DH, London and revalidation procedures (Royal College of may involve the short-term use of adult/general ICU 2003) Anaesthetists, 2014). 4.3. Staffing facilities and equipment facilities (Paediatric Intensive Care Society, 2010). support levels ______http://webarchive.nationalarchives.gov.uk/+/ All centres where children are admitted for surgery Multi-modal analgesia for children should be www.dh.gov.uk/en/Consultations/ should have a nominated consultant who is When a child undergoes anaesthesia, the anaesthetist available in all settings, with paracetamol and NSAIDS Closedconsultations/DH_4085150 responsible for policies and procedures related to should be supported by staff who have undergone providing the mainstay of simple painkillers for both emergency and elective anaesthesia for children. paediatric training and experience, and who have hospital and home use after minor surgery. Opioids Delivering a healthy future. An action framework This consultant should also be involved in the delivery maintained these skills. These skills should also extend may be required for more severe pain and for rescue for children and young people’s health in Scotland. of such service (Royal College of Anaesthetists, 2014). into the post-operative/recovery phase, when analgesia, particularly if paracetamol and NSAIDS Scottish Executive, 2007 Locally agreed guidelines should be in place; these children should be managed by designated staff with are contra-indicated; opioids may also be required (www.scotland.gov.uk/Resource/ guidelines should specify which cases could generally up-to-date paediatric competencies, particularly for more severe pain (Royal College of Anaesthetists, Doc/165782/0045104.pdf). be managed on site, and which would require that resuscitation (Royal College of Anaesthetists, 2014). 2014). the child be transferred to a more specialised unit. National service framework for children, young Emergency, life-threatening situations would dictate If children undergo surgery and anaesthesia in a All opioids should be used with caution in children people and maternity services. Welsh Assembly when it may be necessary to consider providing initial facility that does not have in-patient paediatric with obstructive sleep apnoea (Medicines and Government, 2004 management locally. These arrangements should be medical beds, they should have ready access at all Healthcare Products Regulatory Agency, 2013), and www.wales.nhs.uk/sites3/Documents/441/ part of defined clinical pathways, organised and times to a named paediatric consultant with acute for other patients who have problems with central EnglishNSF_amended_final.pdf commissioned within a surgical and anaesthesia care responsibilities (Royal College of Surgeons of control of respiration (Royal College of Anaesthetists, network for children (Royal College of Anaesthetists, England, 2013). 2014). Surgery for children: delivering a first class service. 2014). R Col Surg Eng, London 2007 (www.rcseng.ac.uk/ A full range of monitoring devices and paediatric A fully resourced acute pain management service publications/docs/CSF.html Non-specialist and specialist centres catering for anaesthesia equipment should be readily available that covers the needs of children should be in place children should participate in multidisciplinary in theatres and other areas where children are to (Royal College of Anaesthetists, 2014). Much of the surgery carried out on children is both networks for surgery and anaesthesia. Networks be anaesthetised and recovered (Association of elective and very straightforward. It is usually carried would agree standards of care and formulate care Anaesthetists of Great Britain and Ireland, 2007). All facilities should have ready access to current out on fit infants and children, and it can be carried pathways for common elective and emergency Equipment must be capable of being used for infants paediatric dosing information. Where a local

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paediatric formulary is not available, alternative discussed on an individual basis (Royal College of and New Zealand College of Anaesthetists, 2008). A liaison service should be established with a specialist sources such as the BNFC (British National Formulary Anaesthetists, 2014). paediatric facility, so that authoritative advice is for Children) should be made available; guidelines At least one member of the team should have available at all times (ANZCA – Australia and New for the management of pain, nausea and vomiting Parents and children should be provided with current advanced paediatric life support training. All Zealand College of Anaesthetists, 2008). and post-operative fluids should also be readily good quality pre-operative information, including team members should have up-to-date basic skills for available in theatres and ward areas (Royal College fasting guidelines and advice on what to do if the paediatric resuscitation (ANZCA – Australia and New A clear clinical pathway should exist, in order to of Anaesthetists, 2014). child becomes unwell before the operation date. Zealand College of Anaesthetists, 2008). obtain medical paediatric advice should the need Post-operative analgesia requirements should be arise. In addition, there should be clear policies in Analgesia guidance that is appropriate for children anticipated, and should be discussed at the pre- 4.6. Factors to be considered when place for the transfer of children to neighbouring should be readily available, and pain scoring, using assessment visit Royal College of Anaesthetists, 2014). developing policy paediatric facilities, should the need arise (ANZCA – ______tools that are appropriate to the developmental Australia and New Zealand College of Anaesthetists, age of the child, should be carried out routinely with There should be clear discharge criteria for the 4.6.1. Age 2008). any child who has undergone a surgical procedure period following day case surgery. Discharge criteria There should be a specified age at which any (Association of Paediatric Anaesthetists of Great should be detailed and carefully worded, in order restrictions on management and referral policies 4.6.3. Equipment and facilities Britain and Ireland, 2012). to facilitate ongoing care by parents. A local policy come into effect. Children aged under 12 months Anaesthesia equipment must comply with the on analgesia for home use should be in place, with are classified as infants; children aged under 28 days Recommendations on Minimum Facilities for Safe Children should be separated from (and not either the provision of medications or the provision corrected gestational age are classified as neonates. Anaesthesia Practice in Operating Suites and Other managed directly alongside) adults, whether in an of advice to parents/carers to purchase suitable Risks associated with anaesthesia are greater in small Anaesthetising Locations (ANZCA) Australian and operating department, in-patient ward, day ward or simple analgesics before the child is admitted to children, and therefore policies are more likely to New Zealand College of Anaesthetists. Specific critical care unit – except as a temporary measure, if hospital. In both instances, there should be clear apply to infants and neonates (ANZCA – Australia requirements include: required, before transfer to a PICU (Royal College of instructions to parents about the regular use of such and New Zealand College of Anaesthetists, 2008). • Appropriate equipment for the needs of infants Anaesthetists, 2014). Theatre design and appearance medications, the correct dose and duration. Parents and children should reflect the emotional and physical needs should be given written instructions on administration Any policy should formulate inclusion and exclusion • Climate control and equipment designed to of children (Royal College of Anaesthetists, 2014). of analgesia and know who to contact if problems criteria, so as to ensure that all children are managed meet the special needs of small children so that Recovery areas should be separate or screened from arise (Royal College of Anaesthetists, 2014). in an appropriate setting. Assessment of any body temperature is maintained throughout those used by adults (Royal College of Anaesthetists, borderline cases for suitability for surgery should occur the peri-operative period. 2014). Processes should be in place to transfer the child pre-operatively, following a multidisciplinary pre- • Monitoring equipment which complies with within a network, should complications arise (Royal operative process involving surgeons, anaesthetists monitoring during anaesthesia protocols and is 4.4. Day case surgery and anaesthesia College of Surgeons of England, 2013). and paediatricians. suitable for use in infants and children ______• A separate ward area in the facility, staffed by Day case surgery is particularly appropriate for 4.5. A naesthesia care of children in 4.6.2. Staff training and experience appropriately trained personnel and able to children, provided the operation is not complex healthcare facilities that do not have Paediatric anaesthetists are expected to have cater for children and their families; this area or prolonged and that the child is well, with either dedicated paediatric facilities training in the care of infants and children. However, will be separate from adult patient areas. ______no morbidity, or with only mild, well-controlled co- individual anaesthetists may have varying recent There will also be an area where the parents morbidity. Even children with relatively complex A hospital that is not dedicated to paediatric care, but experience managing anaesthesia for children. and the child can be seen privately in the peri- needs – for example, cerebral palsy, cystic fibrosis – which proposes to manage children for anaesthesia They should not be required to provide anaesthesia operative phase, to discuss any intraoperative, can be managed as day cases, provided they are and surgery, should develop a policy which details care without having had regular clinical exposure surgical or anaesthesia-related issues stable and have minimal cardio-respiratory problems, criteria for management of anaesthesia, surgery to an extent necessary in order to maintain and and provided the surgery is minor (British Association and nursing care. This policy should be developed be comfortable with their competence (ANZCA – 4.7. Criteria for transfer to a specialist of Day Surgery, 2007). and documented jointly by representatives of Australia and New Zealand College of Anaesthetists, children’s hospital or facility ______anaesthesia, pharmacy, surgical and nursing staff, 2008). Children should have their day surgery delivered and it should be reviewed at intervals of not more The distance to the nearest appropriate national to the same standards as in-patient care, but with than five years (ANZCA – Australia and New Zealand Anaesthesia assistants and nursing staff providing or regional centre will be an important factor in additional consideration of measures to promote College of Anaesthetists, 2008). care in the peri-operative period must be trained in determining transfer of a child. The following groups early discharge (Royal College of Anaesthetists, the care of children. Regular experience and tuition of patients should be considered for transfer to a 2014). The lower age limit for day surgery will depend It must be recognised that the initial treatment is essential if care of the appropriate standard is to specialist children’s hospital or facility: on the facilities and experience of staff, and the of paediatric emergencies may be necessary in be provided. Sufficient numbers of staff must be • Neonates: infants born at less than 28 days medical condition of the infant. Ex-preterm infants facilities and under circumstances where paediatric available whenever children are managed in the corrected gestational age, and with a post- should generally not be considered for day surgery care is not normally provided. In this situation, the facility (ANZCA – Australia and New Zealand College conceptual age of less than 52 weeks unless they are medically fit and have reached 55 child should be transferred to a specialist paediatric of Anaesthetists, 2008). • Medical or surgical problems classified as ASA to 60 weeks post-conceptual age. Risks should be centre at the earliest opportunity (ANZCA – Australia 3 or greater.

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4.8. Care and transfer of the critically ill 4.9. Transfer and transport ______an appropriate senior anaesthetist will need to In all centres that admit children, one consultant infant and child ______accompany the child during the emergency transfer should be appointed as lead consultant for Currently, in Ireland, a dedicated 24/7 neonatal of the patient (Society of British Neurological Surgeons paediatric anaesthesia. Typically, this consultant Arrangements for the immediate care of critically transfer team is in place. A paediatric retrieval service and Royal College of Anaesthetists, 2010). would undertake at least one paediatric list every ill children should be in place in any hospital that has begun operations, and is offering a Monday to week and would be responsible for coordinating and manages children. This need can arise suddenly Friday daytime service for patients weighing more Patients being transferred should normally overseeing anaesthetic services for children, with and unpredictably in an emergency department, than 5 kg and/or of six weeks corrected gestational be accompanied by a doctor with relevant particular reference to teaching and training, audit, operating theatre or in-patient ward. In-house age. Initially, the service will be run on a limited basis, competencies in the care of a critically ill child and equipment, guidelines, pain management, sedation arrangements are therefore required for providing pending a further increase in staffing and resources. the transfer of intubated patients, including airway and resuscitation (Royal College of Anaesthetists, emergency treatment, for stabilising critically ill The service will be limited to patients who have been management skills. They should be accompanied by a 2014) infants and children, and for initiating intensive care admitted to a PICU, and who have been referred suitably trained nurse (Royal College of Anaesthetists, prior to the transfer of the critically ill infant/child to through the 1890-213-213/PICU.ie system. 2014). Members of the team should be competent All anaesthetists who work with children should a paediatric or neonatal intensive care unit (Royal in the operation of all key transport equipment (i.e., maintain appropriate clinical skills. In paediatric College of Anaesthetists, 2014). Set out below is a summary of a review of the literature infusion devices, monitor, ventilator and transport anaesthesia, as in all areas of practice, anaesthetists relating to the transfer of the critically ill child, as well trolley), medical gas supply, ambulance electrical must recognise and work within the limits of their In all emergency departments receiving infants as principles relating to retrieval. power sources and communications. professional competence. Some anaesthetists and children, neonatal and paediatric resuscitation working in non-specialist centres will not have regular equipment, medications (including anaesthetic Children may require short-term admission to a Each hospital that is providing paediatric services children’s lists, but may have daytime and out-of- drugs), fluids and access to current paediatric general critical care facility while awaiting the should have in place a nominated clinician who, in hours responsibility to provide care for children who dosing information should be available to prepare arrival of the PICU retrieval team. Other situations conjunction with other disciplines – including nursing, require emergency surgery. the infant or child for PICU transfer (Royal College include where a child requires a very short period of pharmacists and bioengineering – is responsible for of Paediatrics and Child Health, 2012). Equipment intensive care that does not necessitate transfer to a the organisation of paediatric transport. Arrangements should be in place for undertaking should include a suitable ventilator, infusion devices PICU. This is acceptable, provided there is a suitable regular supernumerary attachments to lists or and full monitoring, including capnography (Royal treatment facility within the hospital; there are staff Responsibilities should include: secondments to specialist centres. Paediatric College of Anaesthetists, 2014). with appropriate competencies, and the episode (i) familiarisation with protocols for the mobilisation simulator work may also be useful in helping to only lasts a few hours. The general critical care units of ground and/or air ambulances maintain paediatric knowledge and skills. There Infants and children may require admission to critical should have a nominated lead consultant and nurse (ii) Protocols for assembling, checking, securing, should be evidence of appropriate and relevant care facilities as a planned part of their care, for who are responsible for the policies and procedures battery charging and operating transport paediatric CPD in a five-year revalidation cycle example after surgery, or due to trauma or an acute for infants and children when they are admitted to a equipment (Royal College of Anaesthetists, 2013). illness, or due to extreme prematurity or illness at birth. critical care unit (Paediatric Intensive Care Society, (iii) Checklists and protocols for the provision, Paediatric and neonatal intensive care is provided 2010). carriage and administration of medications, In centres that do not have an on-site PICU, in designated units staffed by doctors and nurses medical gases and consumables required for anaesthesia involvement will also be required in the with specialised training. Infants and children who Hospitals admitting children should be part of a transport management of critically ill children who frequently are likely to need intensive care after an operation fully funded critical care network. Specialist centres (iv) f amiliarisation with CEN Standards (CEN 1789: require intubation, resuscitation and initiation of should undergo their surgery in a hospital/unit with with PICU facilities within the network have the European Union Standards for Ambulances intensive care, before the arrival of the retrieval team a designated PICU or neonatal intensive care unit responsibility to provide ongoing education. They and Medical Transport Vehicles) and National or direct transfer to a PICU. All anaesthetists should (NICU) (Department of Health, UK, 2009). also have a clear responsibility to provide clinical Transport Medicine Programme (NTMP) maintain paediatric resuscitation skills, unless they advice and help in locating a suitable PICU bed recommendations for transport equipment, work in a unit that does not have open access for Hospital protocols for the management of once a referral has been made (Royal College of communication and clinical records. It is also children (Royal College of Anaesthetists, 2014). critically ill children should be in place. The clinical Anaesthetists, 2014). recommended that the readiness for transport management of these children in both specialist and should be checked and tested on a regular The establishment of regional networks for paediatric non-specialist units will require close cooperation Transfer of critically ill children to specialist centres basis. anaesthesia should facilitate joint CPD and refresher and multidisciplinary teamwork between nurses, is generally undertaken by paediatric emergency training in paediatric anaesthesia and resuscitation paediatricians, surgeons, anaesthetists, intensivists, retrieval teams. In certain circumstances it may 4.10. Training and education (Royal College of Anaesthetists, 2014). pharmacists and other relevant clinicians. Clear, be necessary for the referring hospital to provide ______local guidelines on the roles and responsibilities of emergency transfer of a sick child, who is intubated Anaesthetists who care for children should have All staff need to be cognisant of the fact that the multidisciplinary team, including anaesthetic and ventilated. This may occur in the case of a child received appropriate training, and should ensure that the first step in delivering a safe, quality service services, should be in place (Paediatric Intensive who presents at a non-specialist centre with an their competency in anaesthesia and resuscitation is is the recognition and acknowledgement of risk Care Society, 2010). It is important that further acute neurosurgical emergency (for example, an adequate for the management of the children they management. stabilisation and management are not the sole remit expanding intracranial haematoma or a blocked serve (Royal College of Anaesthetists, 2014). of the anaesthetist (Department of Health, UK, 2005). ventriculo peritoneal shunt). In such circumstances,

16 17 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

It is the role and responsibility of all staff to: theatre infection control policies. (See AAGBI safety anaesthesia care unit (Royal College of Anaesthetists, by placing them at the beginning of the mixed list of • be familiar with the HSE Safety Incident guideline – http://www.aagbi.org/sites/default/files/ 2012). elective or emergency cases, thus minimising fasting Management Policy 2014 infection_control_08.pdf and also see times (Royal College of Anaesthetists, 2014). (See http://www.hse.ie/eng/about/Who/ http://www.hse.ie/eng/about/Who/ 4.12. Organisation and management ______qualityandpatientsafety/incidentrisk/ qualityandpatientsafety/safepatientcare/HCAI_ All patients should be assessed before their operations Riskmanagement) Programme/HCAILinks/hcailinks.html) This literature review reflects commissioning structures by the anaesthetist. Parents and carers, as well as • comply with this policy from the UK. Regional networks for surgery and the child, should be given the opportunity to ask • ensure that safety incidents are reported, 4.11. Audit, quality improvement and research anaesthesia should be in place, and should be questions (Royal College of Anaesthetists, 2014). ______managed and investigated in a timely manner maintained by commissioning groups. Networks • participate in and cooperate with investigations Audit plays an important role in the quality assurance should agree standards of care, and should develop 4.13. Patient information and consent ______conducted in accordance with this policy process and also in measuring performance. Simple policies and agreed care pathways based on the • participate in the introduction of changes quality indicators such as unplanned in-patient complexity of the procedure, the child’s age and co- Before the admission of a child for elective surgery, identified as a consequence of an investigation. admission following day case surgery, or admission morbidity, as well as the clinical urgency of the case. parents should receive full written information, to intensive care following surgery, can easily be Policies should relate to local service provision and together with a contact telephone number, should All staff need to recognise and acknowledge the need measured and the reasons for such admission geography, and should be developed in consultation they have any further questions (Royal College of and benefits of open disclosure when an adverse documented. This information should be collated with representative groups within the network (Royal Anaesthetists, 2008). event occurs. Disclosure is not about blame – either and analysed and can be compared usefully within College of Anaesthetists, 2014). apportioning blame or accepting blame. It is about regional networks (Royal College of Anaesthetists, Children should also receive information before integrity and being truly professional. Accepting 2013). Surgical and anaesthetic networks should work with admission; this information should be appropriate to responsibility and embracing accountability are part networks that have been established for the care of their age and level of understanding (Royal College of that professionalism. (See HSE Open Disclosure Regional networks should provide agreed quality the critically ill child; moreover, such networks should of Anaesthetists, 2010). National Guidelines – Communicating with Service standards for surgical care of infants and children, provide links between the departments of paediatrics, Users and their Families Following Adverse Events in and units should be encouraged to participate in surgery, anaesthesia and critical care in non-specialist Although separate written consent is not mandatory, Healthcare http://www.hse.ie/opendisclosure) regular collation of data relating to these standards. centres and the corresponding specialist paediatric discussions should take place with the child and/ Participation in national audits should also be centres. This should facilitate provision of advice or parents about the method of induction and the National Clinical Guidelines have been developed encouraged (General Medical Council, 2013). (when required) and the production of evidence- provision of post-operative pain relief, including the to provide guidance and standards for improving the based protocols and guidelines. Arrangements should use of suppositories (Royal College of Anaesthetists, quality, safety and cost effectiveness of healthcare Multidisciplinary audit and morbidity meetings, be in place with the regional specialist paediatric 2014). in Ireland. These guidelines are available at http:// relating to paediatric surgery and anaesthesia, units for the transfer of sick infants and children (Royal health.gov.ie/patient-safety/ncec/national-clinical- should be held regularly. Audit activity should College of Anaesthetists, 2014). Where special techniques such as epidural guidelines-2 include regular analysis and multidisciplinary review blockade, invasive monitoring and blood transfusions of untoward incidents (Royal College of Surgeons of Hospitals should define the extent of elective and are anticipated, there should normally be written The Paediatric Early Warning Score (PEWS) Steering England, 2013). emergency surgical provision for children and evidence that this has been discussed with the child Group has developed new national age-specific the thresholds for transfer to other centres. An (where appropriate) and with the parents/carers paediatric observation charts that incorporate the Anaesthetic research in children should be facilitated appropriately constituted committee comprising a (Royal College of Anaesthetists, 2014). PEWS system, and also comprise an accompanying when possible, and should follow strict ethical paediatrician, anaesthetist, surgeon, senior children’s Arrangements must be in place to ensure that training package. Since January 2015, these are standards (Royal College of Paediatrics and Child nurse and other relevant health professionals and appropriate and understandable information is being piloted in four paediatric units. Health, 2000). managers should formulate and review these provided to parents, including after they have left (See http://www.hse.ie/eng/ policies. The committee should be responsible for the hospital; arrangements must also be in place about/Who/clinical/natclinprog/ Anaesthetists who care for children and young the overall management and quality improvement to ensure that subsequent sources of support are paediatricsandneonatologyprogramme/ people should be familiar with relevant patient of anaesthetic and surgical services for children, and provided (Royal College of Surgeons of England, earlywarningscore) safety issues (Safety in Anaesthesia Royal College of should report directly to the Hospital Group board. (2013). Anaesthetists). A representative of this committee should liaise with The prevention of healthcare associated infections the regional network lead for surgery, and should 4.14. Conclusion ______(HCAIs) must be a priority for all staff. Precautions In particular, it is important that a World Health provide input into regional audit, standards and care against the transmission of infection between Organization (WHO) checklist is carried out before pathways (Royal College of Anaesthetists, 2014). This literature review helps to provide an international patient and staff, or between patients, should be a and during surgical and radiological procedures perspective for the Model of Care for Paediatric routine part of anaesthesia practice. In particular, for children, and that it is appropriate for use. Such Children undergoing surgery should generally be Anaesthesia. It is not meant to be prescriptive but, on anaesthetists must ensure that hand hygiene a checklist should include issues that are particularly placed on designated children’s operating lists, the other hand, it gives us indicators of standards we becomes an indispensable part of their clinical relevant for the paediatric age group, e.g., flushing of ideally in a separate children’s theatre area. Where can aspire to when designing an Irish version of the culture and training. All staff must comply with local IV cannulae prior to discharge to the recovery/post- this is not possible, children should be given priority model of care for paediatric anaesthesia.

18 19 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

5.2.2. National Children’s Hospital as part of The (9%) had paediatric anaesthesia fellowships and 5. PAEDIATRIC ANAESTHESIA AND PATIENT Adelaide and Meath Hospital, Tallaght six consultants (2%) had paediatric intensive care fellowships. The number of consultant anaesthetists DEMOGRAPHICDATA FOR IRELAND The National Children’s Hospital (which is part of varied between two and 27 per hospital. A valid the Adelaide and Meath Hospital, Tallaght) differs APLS/PALS or equivalent certification was held by It is difficult to access timely, relevant and centres in Dublin; this finding is in line with the 2013 HIPE from OLCHC and CUHTS in that the 17 consultant 62 consultants (24%). Only five consultants had appropriately analysed data regarding paediatric data (see below). The survey found that anaesthesia anaesthetists have a mix of children and adults in completed a work placement as a consultant in a anaesthesia in Ireland. was administered to children in 29 general public their practice. The majority of these consultants do paediatric hospital to “refresh/revalidate” in the hospitals throughout Ireland; this figure represents a not have paediatric anaesthesia and/or paediatric previous five years. In the hospitals that provided The available sources, i.e., national surveys and significant decrease on the number of general public intensive care fellowships. No elective procedures anaesthesia for elective and emergency procedures databases, are described and discussed below: hospitals reported in the 1995 survey, i.e., 37 hospitals. are performed on neonates. All children are on children, one in 10 consultant anaesthetists (22, 9%) The number of anaesthetic procedures carried out anaesthetised for emergency procedures, whereas did so for emergency procedures only. This reflects the 5.1. National surveys of anaesthesia practice in general hospitals on children aged less than 12 ______ASA 1– 3* patients are anaesthetised for elective practice whereby some anaesthetists only provide months also decreased. It was 1,235 (3.9%) in 1995 procedures. on-call cover for paediatric emergencies and do not 5.1.1. The National Survey of Paediatric Anaesthetic versus an estimated 600 (2.3%) in 2012. anaesthetise children for elective procedures during Practice in General Hospitals in the Republic of Finally, there is no dedicated intensive care facility their regular working day. Ireland, 1995 5.1.3. Paediatric Anaesthesia and Intensive Care available on site for paediatric patients. The National Survey of Paediatric Anaesthetic Survey 2014 The total estimated number of paediatric Practice in General Hospitals in the Republic of A further survey (i.e., the Paediatric Anaesthesia and * ASA Physical Status Classification System anaesthesia cases performed in the 21 hospitals that Ireland, 1995 sought to characterise the practice Intensive Care Survey 2014) was conducted in acute ASA Physical Status 1 – provided figures for 2013 was 16,990, and varied of paediatric anaesthesia outside the three main public hospitals in Ireland via the National Clinical A normal healthy patient greatly between hospitals, i.e., between 30 and children’s hospitals in Dublin, i.e., Our Lady’s Children’s Programme in Anaesthesia (NCPA) programme ASA Physical Status 2 – 5,000 paediatric cases per year per hospital and Hospital, Crumlin; the Children’s University Hospital, leads (or their representatives). The main focus was to a patient with mild systemic disease between eight and 360 paediatric cases per year Temple Street (standalone hospitals providing care gather additional data, mainly around staffing and ASA Physical Status 3 – per consultant. only for children and adolescents); The National current practice in paediatric anaesthesia. Thirty- A patient with severe systemic disease Children’s Hospital, which is part of The Adelaide eight (95%) of the 40 leads contacted completed the ASA Physical Status 4 – 5.4.2. Paediatric anaesthesia nurses and Meath Hospital, Tallaght. Data were gathered survey. Hospitals with no response were contacted A patient with severe systemic disease that is In 2013, the availability of anaesthetic nurses and prospectively. The survey revealed that anaesthesia directly to confirm that no paediatric anaesthesia a constant threat to life their role as peri-operative nurses varied widely in was administered to children in 37 general public care was provided in those hospitals. The survey ASA Physical Status 5 – the other 28 mixed adult and paediatric hospitals hospitals throughout Ireland. A total of 31,316 found that paediatric anaesthesia is provided in the A moribund patient who is not expected to throughout Ireland. In 25 hospitals, the majority of anaesthetics were administered during that year three Dublin paediatric hospitals (as above) and 28 survive without the operation anaesthetic nurses rotated between paediatric and (1995). Of these anaesthetics, 4% were administered additional public hospitals across Ireland. The main ASA Physical Status 6 – adult anaesthesia theatre lists on a daily basis (eight to children aged under 12 months. findings were as follows: A declared brain-dead patient whose organs out of 25, 33%) or monthly basis (one out of 25, 4%). are being removed for donor purposes Of necessity, and in order to maintain competencies, 5.1.2. Survey of anaesthetic surgical activity in 5.2. Paediatric anaesthesia consultants ______nurses were rotated through other peri-operative Ireland, 2012 5.3. Paediatric anaesthesia nurses roles (i.e., recovery, theatre etc.). In adult/paediatric A detailed survey of anaesthesia activity in Ireland 5.2.1. Our Lady’s Children’s Hospital, Crumlin and ______mixed hospitals, this proved more challenging, due to was conducted over a one-week period in 2012 as the Children’s University Hospital, Temple Street Peri-operative nurses undertake additional roles/ different patient demographics and smaller absolute part of the fifth National Audit Project. Information 16.2 whole-time equivalent consultant anaesthetists tasks in these centres, such as vene-puncture, IV numbers of paediatric patients. Such role rotations was collected on all cases in Ireland where work in Our Lady’s Children’s Hospital Crumlin cannulation, basic airway manoeuvres, administration can happen on either a daily (nine out of 25, 36%) anaesthesia care (i.e., general, regional or local (OLCHC) and the Children’s University Hospital, of IV analgesia, and removal of LMAs (laryngeal mask or weekly (two out of 25, 8%) basis. In one hospital, anaesthesia, sedation or monitored anaesthesia Temple Street (CUHTS). All of these paediatric airways) and ETTs (endotracheal tubes) in recovery. arrangements were in place for the nursing staff care) was provided. The survey estimated that anaesthetists have paediatric anaesthesia and/or from a dedicated paediatric centre to assist with 58,600 children in Ireland received anaesthesia intensive care fellowships and a valid APLS/PALS or 5.4. Paediatric anaesthesia services in 28 paediatric cases. care during 2012. This was the first ever survey of equivalent certification. additional public hospitals throughout anaesthesia carried out in public and independent Ireland There was considerable variability in the role of peri- hospitals in Ireland. Interestingly, 79% of anaesthesia An estimated 20,300 patients in OLCHC and CUHTS ______operative nurses in the 28 hospitals, particularly in procedures were provided in public hospitals, and received anaesthesia for procedures in 2013; this 5.4.1. Paediatric anaesthesia consultants relation to the following activities: pre-operative; 21% of such procedures were provided in 15 of the figure is in line with the HIPE figures detailed later in In 2013, there were a total of 256 consultant recording of ECG; basic airway manoeuvres, e.g., 21 independent hospitals. It is also worth emphasising this section. anaesthetists working in an additional 28 public bag-mask ventilation, removal of laryngeal mask that 57% of all public hospital paediatric anaesthesia hospitals throughout Ireland. Of these, 22 consultants (LMA) in recovery room, extubation of endotracheal cases occurred outside the three main paediatric

20 21 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

tube in recovery room, and administering IV analgesia (79%, or 22 of the 28) provided anaesthesia care to Table 5.1: The cut-off age limits for elective paediatric in recovery room. children for elective and emergency procedures, procedures in different hospitals while the remaining 21% (i.e., six of the 28), provided Number of 5.5. Paediatric surgical speciality breakdown paediatric anaesthesia care for elective procedures ______hospitals (%) only. All 28 hospitals provided a combination of All children aged >5 years 3 (11%) Figure 5.1 illustrates the percentage of non-specialist both paediatric and adult anaesthesia care in their All children aged >3 years 3 (11%) paediatric hospitals providing different surgical hospital units. specialties on site. The majority of these hospitals All children aged >2 years 10 (36%) All children aged >1 year 4 (14%) Figure 5.1 – Paediatric Anaesthesia and Intensive Care Survey Results All children aged >9 months 1 (3.6) All children aged >1 month 1 (3.6%) No age limit is set by the department. Individual anaesthetists determine this themselves. 2 (7%) No age limit is set by department. Children of all ages are anaesthetised. 4 (14%)

and is administered by the Economic and Social 5.7. Paediatric intensive care and high Research Institute (ESRI). HIPE provides the only dependency care alternative source of information on activity – other ______than engaging in time-consuming, labour-intensive Fourteen (50%) of the 28 mixed adult and paediatric direct activity surveys. A crude estimate of 25,498 hospitals provided high dependency or intensive procedures that may have required anaesthesia care to children; of these, only three hospitals was obtained from the ESRI Activity in Acute Public provided such care for elective admissions. The Hospitals in Ireland, 2010 Annual Report. The 25,948 majority (11, 79%) of the hospitals that can admit procedures estimate does not include a category children to an ICU accept emergency admissions of procedures “not elsewhere classified”, which only. This category comprises unplanned post- amounts to an additional 13,564 procedures. The operative admissions (5, 36%); and/or emergency paucity of reliable data relating to anaesthesia admissions of short anticipated stay (9, 64%); and/or workload and practice in this age group is evident. prior to transfer to a paediatric centre (10, 71%). In 2013, a total of 113 children were admitted to ICUs Table 5.2 presents details on the number of patients in the 22 hospitals that provided figures for this survey that required general anaesthesia nationally in (mean 6, range 0–35 per hospital). 2013; these figures were obtained from HIPE during the preparation of this document. No HIPE results for 5.8. National databases paediatric cases were available for Kerry General ______Hospital, Mayo General Hospital and Merlin Park 5.8.1. Hospital In-Patient Enquiry (HIPE) system University Hospital for 2013; such data are therefore A further source of information is the HIPE system, excluded from the tables below. which captures activity in public hospitals in Ireland

Table 5.2: Number of general anaesthetics and sedation in 2013, given to children aged under 17 years in the Republic of Ireland

5.6. Cut-off age limits for paediatric Not all of the respondents provided annual estimates/ Age/ASA grade 1 2 3 4 5 Unspecified Grand total anaesthesia ______figures so averages are calculated for the hospitals in which we had data for both the number of 0–28 days 49 119 192 38 1 267 666 Table 5.1 shows the number of hospitals with cut-off consultants and the number of procedures 29 days–1 year 667 568 391 24 2 819 2,471 age limits for the provision of paediatric anaesthesia 1–5 years 9,112 3,133 1,282 25 4 420 17,786 in elective surgery. All 28 hospitals provided NOTE: n ot all of the respondents provided annual estimates/ 6–16 years 11,671 4,361 1,117 26 2 5,107 22,284 anaesthesia to ASA 1 and ASA 2 patients, but only figures so averages are calculated for the hospitals in Grand total 21,499 8,181 2,982 113 9 10,423 43,207 ten hospitals (36%) will care for ASA 3 patients and which we had data for both the number of consultants and the number of procedures. only two hospitals (7%) will care for ASA 4 patients.

22 23 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

Table 5.3: Number of general anaesthetics and sedation in 2013, given to children aged under 17 Table 5.7: Number of general anaesthetics and sedation in 2013, given to children under 17 years, years, in the new Children’s Hospital Group, i.e., Our Lady’s Children’s Hospital, Crumlin; in general hospitals in South/South West (excluding Kerry General Hospital figures) Children’s University Hospital, Temple Street; The National Children’s Hospital as part of The Adelaide and Meath Hospital, Tallaght Age/ASA grade 1 2 3 4 5 Unspecified Grand total 0–28 days 2 1 0 0 0 92 95 Age/ASA grade 1 2 3 4 5 Unspecified Grand total 29 days–1 year 71 16 4 0 0 80 171 0–28 days 44 117 192 38 1 131 523 1–5 years 1,819 286 28 0 0 642 2,775 29 days–1 year 556 551 384 24 2 601 2,118 6–16 years 2,848 637 55 4 0 1,107 4,651 1–5 years 4,218 2,355 1,060 25 4 1,938 9,600 Grand total 4,740 940 87 4 0 1,921 7,692 6–16 years 3,942 2,691 940 18 2 1,293 8,886 Grand total 8,760 5,714 2,576 105 9 3,963 21,127 Table 5.8: Number of general anaesthetics and sedation in 2013, given to children aged under 17 years, in general hospitals in the Soalta group Table 5.4: Number of general anaesthetics and sedation in 2013, given (excluding Merlin Park University Hospital and Mayo General Hospital) to children aged under 17 years, in Dublin North East Group Age/ASA grade 1 2 3 4 5 Unspecified Grand total Age/ASA grade 1 2 3 4 5 Unspecified Grand total 0–28 days 0 0 0 0 0 6 6 0–28 days 0 0 0 0 0 4 4 29 days–1 year 22 1 0 0 0 40 63 29 days–1 year 2 0 0 0 0 8 10 1–5 years 879 137 2 0 0 639 1,657 1–5 years 586 90 7 0 0 248 931 6–16 years 1,328 260 10 1 0 954 2,553 6–16 years 952 227 43 3 0 400 1,625 Grand total 2,229 398 12 1 0 1,639 4,279 Grand total 1,540 317 50 3 0 600 2,570

Table 5.9: Number of general anaesthetics and sedation in 2013, given to children Table 5.5: Number of general anaesthetics and sedation in 2013, given to children under 17 years, in general hospitals in the Midwest Group aged under 17 years, in general hospitals in the Dublin Midlands Group Age/ASA grade 1 2 3 4 5 Unspecified Grand total Age/ASA grade 1 2 3 4 5 Unspecified Grand total 0–28 days 3 1 0 0 0 37 37 0–28 days 5 3 0 0 0 5 13 29 days–1 year 38 1 0 0 0 97 136 29 days–1 year 46 21 1 0 0 38 106 1–5 years 1,741 257 5 0 0 1,063 3,066 1–5 years 1,106 249 8 0 0 466 1,829 6–16 years 2,539 475 21 1 0 1,549 4,585 6–16 years 1,699 447 16 0 0 841 3,003 Grand total 4,321 734 26 1 0 2,743 7,825 Grand total 2,856 720 25 0 0 1,350 4,951

5.8.2. Waiting list and waiting time databases Waiting time data over specific timeframes for The future provision of quality anaesthesia care for each hospital (with analysis by in-patient, day case, Table 5.6: Number of general anaesthetics and sedation in 2013, given to children children will be influenced by the number of children endoscopy as well as hospital trends for child and aged under 17 years, in general hospitals in the Dublin East Group requiring anaesthesia care. The current waiting list for adult patients) are available. Although the current Age/ASA grade 1 2 3 4 5 Unspecified Grand total paediatric anaesthesia and diagnostic investigations minimum dataset that hospitals are required to indicates a deficit of service provision at this time. complete – for submission to the NTPF regarding their 0–28 days 0 0 0 0 0 11 11 in-patient and day case waiting list – does not include 29 days–1 year 1 1 0 0 0 3 5 The National Treatment Purchase Fund (NTPF) has a field to indicate whether a general anaesthetic 1–5 years 434 86 1 0 0 142 663 been responsible for the collection, collation and (GA) is required or not, it can be deduced (by the 6–16 years 844 210 20 0 0 362 1,436 publication of in-patient and day case waiting nature of the procedures) that an anaesthetic will be Grand total 1,279 297 21 0 0 518 2,115 lists since 2005. It does this through the PTR (Patient required for the majority of procedures. Treatment Register). Information on the in-patient and day case waiting lists for 42 public hospitals in The current target for children is that no child should Ireland is presented in three different report formats, wait more than 20 weeks for their procedure; the and is based on extract file submissions from each comparable target for adults is eight months for an hospital. in-patient or day case procedure, and 13 weeks for

24 25 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

a scope. The most recent data available are for 31 date for their procedure, were on waiting lists. Table Table 5.12: NTPF waiting list for in-patient procedures as of 31 October 2014 October 2014, and are as follows: 5.10 illustrates the numbers by Hospital Group, with Waiting list category the National Children’s Hospital (part of The Adelaide 0–3 3–6 6–9 9–12 >12 Total 5.8.3. Number of children on waiting lists and Meath Hospital, Tallaght) being included in the months months months months months A total of 5,305 children, who had not been given a new Children’s Hospital Group. New Children’s 548 390 209 153 156 1,456 Hospital Group Table 5.10: The number of paediatric patients on waiting lists for in-patient, day case and Ireland East 50 31 15 9 1 106 gastro-intestinal endoscopy procedures as of 31 October 2014 Dublin Midlands 85 123 75 44 0 327 Dublin North-East In-patient and Gastro-intestinal Grand Proportion of 72 72 63 5 7 219 day case endoscopy total annual (RCSI Hospital Group) procedures procedures activity ** University of Limerick 41 29 32 23 2 127 New Children’s Hospital Group 2,545 70 2,615 12% Hospital Group South/South West 94 84 64 6 0 248 Ireland East 236 6 242 11% Saolta Group 96 82 42 13 5 238 Dublin Midlands 545 6 551 11% Grand total 986 811 500 253 171 2,721 Dublin North-East 543 6 549 21% Changes in the number of patients on waiting lists are published by NTPF, and Table 5.13 illustrates the trend in figures for October 2013, (RCSI Hospital Group) compared to October 2014, for the two main paediatric referral hospitals. University of Limerick 291 7 298 4% Table 5.13: NTPF waiting list trend changes between October 2013 and October 2014, Hospital Group for day case and in-patient paediatric procedures South/South West 538 4 542 7% >3 >6 >9 >12 All waiting Saolta Group 507 1 508 12% months months months months lists Grand total 5,205 100 5,305 12% Oct - 13 182 53 14 5 452 New Children’s Oct - 14 146 43 14 5 436 ** Number of patients on waiting lists as proportion of number of procedures performed in 2013, as confirmed by HIPE Hospital Group Change -36 (-20%) -10 (-19%) 0 (0%) 0 (0%) -16 (3.5%) Tables 5.11 and 5.12 provide a breakdown of the patients are on a waiting list for more than six months; Oct - 13 750 347 149 33 1,448 waiting categories for day case and in-patient of these, 719 paediatric patients (49%) are on lists in Our Lady’s Children’s Oct - 14 1,213 669 366 179 1,958 waiting lists, respectively (excluding endoscopy the new Children’s Hospital Group. Hospital, Crumlin Change +463 (+62%) 322 (+93%) 217 (+145%) 146 (+442%) 510 (+35%) figures). Almost one-third (1,464, 28%) of paediatric 5.8.5. Type of procedures on NTPF waiting lists illustrates the 10 surgical/interventional procedures, Table 5.11: NTPF waiting list for day case procedures as of 31 October 2014 The number of patients awaiting specific surgical with the largest number of patients on the waiting lists procedures is provided by the NTPF. Table 5.14 nationally. Waiting list category 0–3 3–6 6–9 9–12 >12 Total Table 5.14: The 10 surgical/interventional procedures, with highest number of months months months months months paediatric patients on waiting lists, as of 31 October 2014 New Children’s 576 312 130 43 28 1,089 Type of procedure Total (proportion of waiting list) Hospital Group Tonsillectomy with adenoidectomy 1144 (22%) Ireland East 78 31 15 6 0 130 Other 450 (8.5%) Dublin Midlands 49 82 65 22 0 218 Myringotomy 397 (7.5%) Dublin North-East 137 92 28 66 1 324 Non-invasive diagnostic tests, measures or investigations, not elsewhere classi- (RCSI Hospital Group) 319 (6%) fied University of Limerick 99 37 28 0 0 164 Hospital Group Male circumcision 212 (4%) South/South West 149 69 32 22 18 290 Strabismus procedure involving one or two muscles, one eye 210 (4%) Saolta Group 140 93 23 10 3 269 Excision of lesion of skin and subcutaneous tissue of other site 198 (4%) Grand total 1,228 716 321 169 50 2,484 Diagnostic intervention cardiac catheterisation 172 (3%) Posterior spinal fusion, one or two levels 141 (3%) Comprehensive oral examination 122 (2%) Total 3365 (63%)

26 27 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

5.9. Why is this relevant? ______coupled with the very wide range of exposure to paediatric cases (8–360 cases per year per 6. PROFESSIONAL AND CLINICAL STANDARDS This overview of published and newly obtained data consultant) may result in a decrease in competency relating to paediatric anaesthesia practice illustrates for individual consultant anaesthetists if special FOR SAFE PAEDIATRIC ANAESTHESIA the paucity of information previously available for arrangements, e.g., refresher weeks in paediatric 6.1. Professional status to the recovery room/post-anaesthesia care unit service planning. Even with the latest available data, centres are not made available. ______(PACU), and should ensure the handover of that care it is clear that there are still deficiencies, especially Anaesthesia services are a vital component of basic to appropriately trained personnel. An anaesthesia relating to independent hospital activity. Currently, there are 48 consultant anaesthetists with healthcare, and they require appropriate resources. professional should retain overall responsibility for a fellowship in paediatric anaesthesia in Ireland; Medically trained anaesthesia specialists who are the patient during the recovery period, and should Practice varies between individual anaesthetic of these, the majority (26) work in the three Dublin accredited, and therefore should have clinical and be readily available for consultation until the patient departments and anaesthetic consultants, as paediatric centres. The majority of anaesthetic nurses administrative autonomy. has made an adequate recovery. If responsibility for illustrated by the variation in age limits for elective working in non-paediatric centres are not registered care is transferred from one anaesthesia professional procedures, as well as admission criteria for intensive paediatric nurses, or have no higher training in 6.2 Training, certification and accreditation to another, a handover protocol should be followed; care units. paediatric peri-operative nursing. Many rotate ______during this handover, all relevant information about through other peri-operative roles on a frequent basis. Adequate time, facilities and financial support should the patient’s medical history, medical condition, These limits are determined mainly by local need, be available for professional training, both initial and anaesthesia status and care plan should be capacity and staff expertise – often arbitrarily and This results in nursing staff with varied paediatric continuing, in order to ensure that an adequate communicated. with no physiological basis. The age limits for elective experience working with anaesthetists. Recruitment standard of knowledge, expertise and practice is procedures are not currently determined by or and retention of skilled staff with paediatric attained and maintained. If or when aspects of direct care are delegated, the aligned to classification of hospital as defined by “The anaesthesia expertise in general hospitals will have anaesthesia professional should ensure that before, Establishment of Hospital Groups as a transition to to continue while alignment of service need and 6.3 Peer review and incident reporting during, or after an anaesthetic the person to whom Independent Hospital Trusts” (DOH, 2013). The majority availability is resolved at Hospital Group and national ______responsibility is delegated is both suitably qualified of anaesthetists who provide care to children in adult level. Institutional, regional and/or national mechanisms to and conversant with relevant information regarding Model 2 and Model 3 hospitals do so in conjunction provide continuing review of anaesthetic practice the anaesthetic and the patient. with an adult anaesthesia practice. Almost all The ‘target’ currently is that no child should wait should be instituted. Regular, confidential discussion consultant anaesthetists would have completed six more than 20 weeks for a hospital procedure. The of appropriate topics and cases with multidisciplinary The Working Group has had robust discussions around months’ paediatric anaesthesia training during their NTPF waiting list figures highlight that many children professional colleagues should take place. a number of issues relating to the delivery of care for Specialist Anaesthesia Training SAT 3-6 programme, are still waiting for periods of longer than 20 weeks. Protocols should be developed, so as to ensure that children undergoing anaesthesia. and some would have completed a longer period Of great concern is the 35% increase in waiting list deficiencies in individual and collective practice are of specialist paediatric anaesthesia training within numbers for OLCHC (Crumlin hospital) from October identified and rectified. Incident reporting systems, Should all children only be anaesthetised in hospitals or outside the Specialist Anaesthesia Training SAT 2013 to October 2014. The other national referral with case analysis and resulting suggested remedies, with on-site paediatricians? The APA and Royal 3-6 programme. Some consultants may have centres for neurosurgery, ENT and ophthalmologic are recommended. College of Anaesthetists (RCoA) in their documents APLS certification and/or paediatric anaesthesia surgery appear to be facing similar challenges. The recommend this requirement. However, they have fellowships. impact on quality of life and other outcomes in 6.4 Workload taken their recommendations from the Royal College children when there is a delay in certain surgeries ______of Paediatricians document, which referred only to The variation (30–5,000 paediatric cases per year per (e.g., scoliosis correction surgery) is well known. A sufficient number of trained anaesthesia acute medical units. In contrast, Australian and the hospital) in anaesthesia activity between hospitals Appropriate allocation of resources and alignment professionals should be available, so that individuals American documents do not specify this requirement. other than the three paediatric centres in Dublin, of service needs is required. can practise to a high standard without suffering undue fatigue or physical demands. In the analysis of the literature review, no evidence was found to support improved outcomes for healthy Time should be allocated for education, professional children undergoing routine surgery due to the development, administration, research and teaching. availability of paediatricians.

6.5 Anaesthesia professionals ______As a result of the reconfiguration of paediatric services (following the construction of the new An anaesthesia professional (consultants and National Children’s Hospital), there should be more doctors in anaesthesia training) should be dedicated centralisation of paediatric services, including to each patient, and should be present throughout paediatric surgery and anaesthesia. each anaesthetic procedure (general, regional or monitored sedation); this anaesthesia professional An anaesthetist or other physicians trained and should be responsible for the transport of the patient experienced in paediatric peri-operative care

28 29 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

(including the management of post-operative hospitals. There is, therefore, a current deficit of 20 will have to provide pre-operative assessment clinics in the New Children’s Hospital for between two and complications and the provision of paediatric WTE paediatric anaesthetists. as well as a chronic pain management service. three whole-time paediatric anaesthetists to staff cardiopulmonary resuscitation) should be All elective ASA 3 patients should be seen in pre- weekly pre-operative assessment clinics. immediately available to evaluate and treat any Currently, there are six paediatric intensivists operative clinics. child in distress. Advanced paediatric life support employed in PICUs. The Joint Faculty of Intensive In 2014, the National Clinical Programme in (APLS) or PALS is recommended. Care Medicine of Ireland, National Standards for OLCHC has seen an increase in ASA 3 patients Anaesthesia published the Model of Care for Pre- Adult Critical Care Services Report 2011 on paediatric presenting for anaesthesia; this figure has risen from Admission Units in Ireland. The minimum guidelines on A paediatrician should generally be available for critical care recommended that there should be 16% in 2010 to 21% in 2014. There will be a requirement staffing levels recommended: consultation on the management of children with between 12 and 18 full-time paediatric intensivists in co-morbidities who are undergoing anaesthesia. place by 2012. There is, therefore, a PICU deficit of Table 6.1: Minimum guidelines on staffing levels 6–12 paediatric intensivists. Nurse WTE All professionals working with children should Consultant anaesthetist WTE have some training in child protection, so that the As outlined in Section 5, in non-children’s hospitals In-patient sur- 15 hrs/week per 1,000 adult in-patients/year 0.9 WTE per 1,000 adult in-patients/year re- appropriate mechanisms can be activated, and also the situation is less clear. We do not know how many gery requiring the services of an anaesthetist* quiring the services of an anaesthetist so that there is good inter-disciplinary cooperation. anaesthetists are comfortable with the practice of 5 hrs/week per 1,000 adult day cases/year 0.6 WTE per 1,000 adult in-patients/year Day case surgery All anaesthetists should be aware of the need to anaesthetising children across the various age groups. requiring the services of an anaesthetist ** requiring the services of an anaesthetist ***

refer suspected cases of child abuse. A named We do know that only 22 anaesthetists have paediatric * Includes time for non-clinical duties (service development etc.) as per RCoA recommendations, but does not include backfill for leave. paediatrician, trained in paediatric child protection, anaesthesia fellowships, and only six anaesthetists ** Does not include time for non-clinical duties, as day case pre-assessment clinics are usually affiliated with should be available for advice and consultation. have paediatric intensive care fellowships. We also in-patient pre assessment units. However, institutions with only day case pre-assessment clinics should know that 22 consultants only anaesthetise children be allowed one hour/week extra for non-clinical duties. *** Institutions that do not have facilities/clinical services to support in-patient admissions should factor a 6.6 Paediatric anaesthesia workforce in emergency situations, i.e., they have no ongoing ______local attrition rate into their calculations, so as to account for those patients who are initially pre-assessed paediatric anaesthesia experience. It is heartening as day cases, but are deemed unsuitable for day case surgery at that institution. 6.6.1 Current situation to see that 24% of consultants employed in hospitals Currently, there are three children’s paediatric other than children’s hospitals have valid APLS/PALS Particular emphasis was given to the role of secretarial/ In addition, many of the hospitals currently providing hospitals providing anaesthesia cover for 12 operating certification, which indicates their commitment to clerical support. This was seen as being “crucial to paediatric anaesthesia may continue to do so, albeit theatres. In addition, there are three MRI scanners; paediatric care. the efficient and cost-effective administration of a with a lesser level of complexity than is required for one cardiac interventional theatre; two interventional Pre-Admission Unit”. patients who are anaesthetised in peripheral centres. radiology theatres, and a radiotherapy unit (St Luke’s 6.7 Model of Care recommendation ______The question that arises is: What level of training will be Hospital). The three hospitals employ 19.2 whole- Currently, in Dublin, there are five fully functioning and required for paediatric anaesthetists in the paediatric time equivalent (WTE) anaesthetists between them. This Model of Care describes our ideal model for serviced pain management clinics for adults in the regional hubs? Given that the anaesthetists will be Of these, 1.5 of OLCHC’s WTEs is seconded to PICU provision of anaesthesia and paediatric intensive public hospital service, and four pain management anaesthetising children of all ages and with varying cover, giving a total anaesthesia cover of 17.7 WTEs. care for children in the future. Providing Quality, Safe clinics in private hospitals. There is no properly funded co-morbidities, 1.5 years of paediatric anaesthesia/ and Comprehensive Anaesthesia Services in Ireland and resourced pain management clinic service in paediatric intensive care training would not seem In 2014 the College of Anaesthetists of Ireland and the - A Review of Manpower Challenges document sets the three children’s hospitals. The Pain Faculty of the unreasonable. In addition, as with anaesthetists in National Clinical Programme in Anaesthesia issued a out the templates and standards expected for such College of Anaesthetists of Ireland (CAI) recommends the New Children’s Hospital, APLS/PALS certification joint document on Anaesthetic Manpower in Ireland. provision, and allows us to estimate future numbers of one chronic pain consultant per 100,000 population. should be recommended. In addition to providing templates for estimating paediatric anaesthetists. The situation with respect to Given that children probably have less chronic pain anaesthesia workforce needs, this document paediatric intensive care is clearly delineated by the conditions than adults, it may be safe to halve that The level of training required for regional centres clarified the standards expected for provision of Det Norske Veritas (DNV) report, i.e. 12–18 intensivists number; nonetheless, that would still indicate a should be achievable within the current CAI anaesthesia in Ireland. Principal among these was to cover paediatric (not neonatal) intensive care. For requirement for six chronic pain WTEs to service the anaesthesia training scheme. that there should be one consultant anaesthetist per anaesthesia, the requirements may be divided into national paediatric population. site where anaesthesia is being delivered. The AAGBI those required for the New Children’s Hospital and All trainees spend six months in a paediatric hospital document Workload for Consultant Anaesthetists in those required for paediatric anaesthesia in locations In the hub-and-spoke Model for Paediatric during their training, and it is now possible for trainees Ireland allows us to estimate that it takes 1.8 WTEs to other than the New Children’s Hospital. Anaesthesia Services in Ireland, it is estimated there to spend the sixth and final year training in their choice provide cover for one anaesthesia site for one year. will be three/four paediatric regional anaesthetic of specialty. Currently, both OLCHC and CUHTS offer The New Children’s Hospital proposes 22 anaesthetic centres, each intending to provide 24/7 cover for special interest years in paediatric anaesthesia for This allows for a 75% anaesthesia workload sites, and this will require 39.6 WTE paediatric paediatric surgical and anaesthetic care. Each trainees in their final year. For those who do not attain commitment; it also factors in annual leave, study anaesthetists to provide anaesthesia to the national centre will require a minimum of six paediatric the required training within the training scheme, leave, on call etc. On this basis, 36 WTEs should be standards. anaesthetists to fill the 24/7 duties and on-call rosters. there is also the possibility of post-CCST training in employed to cover the sites where anaesthesia There will, therefore, be a requirement for at least 24 paediatric anaesthesia at OLCHC. is being provided currently in the three children’s In addition to anaesthesia, the New Children’s Hospital paediatric anaesthetists in peripheral hospitals.

30 31 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

6.8 Summary 6.10 In-service training and verification 6.14 Pre-anaesthesia checks 6.17 Circulation ______

Currently, in the three children’s hospitals, there are In service training and verification of an individual’s An appropriate “pre-list check” should be established Continuous monitoring and display of heart rate 17.7 WTEs in paediatric anaesthesia and six (+1.5) ability to use a specific piece of equipment correctly in the healthcare institution providing paediatric with ECG is essential. Display of cardiac rhythm and PICU WTEs. and safely is required. anaesthesia services. peripheral pulse rate with pulse oximetry are highly This should include checks of the anaesthesia system, recommended. In contrast, currently, there should be 38 WTEs in 6.11 World Health Organization 2009 Safe facilities, equipment and supplies; it should form part anaesthesia and 12–18 WTEs in PICU. Surgery Checklist of the preparations for each operating list, and it 6.18. Blood pressure ______should be adapted to the physical location where The New Children’s Hospital will require 67 WTE The World Health Organization 2009 Safe Surgical the anaesthesia is to be carried out. Arterial blood pressure should be measured paediatric anaesthetists and intensivists, to include 40 Checklist comprises evidence-based vital checks The relevant components of the World Health continually at appropriate intervals, usually non- general paediatric anaesthetists, three anaesthetists in three phases: before starting anaesthesia, before Organization Safe Surgery Checklist should be invasively every five minutes, and more frequently if specialising in pre-operative assessment, six starting surgery, and at the end of surgery. The performed. indicated by clinical circumstances. anaesthetists specialising in providing a chronic pain use of the Checklist (locally modified for children if service and 18 paediatric intensivists. In addition, the appropriate) in anaesthesia care is national policy in 6.15 Monitoring during anaesthesia 6.19 Tissue perfusion ______regional centres will require at least 24 paediatric Ireland. anaesthetists. During all anaesthetics, the patient’s oxygenation, The adequacy of tissue perfusion should be monitored 6.12 Peri-anaesthesia care and monitoring ventilation, circulation and temperature must be continuously by clinical examination, e.g., inspection, The total number of paediatric anaesthetists and standards continually evaluated.. palpation of a pulse, auscultation of heart sounds. ______intensivists required for 2019 will be 91 WTEs. Currently, In addition, continuous monitoring of peripheral there are 25.2 employed. The deficit of 65.8 WTE Monitoring of the anaesthetised child under the care Essential monitoring devices include pulse perfusion with pulse plethysmography or oximetry is anaesthetists represents a considerable challenge of an anaesthetist for local, regional, monitored or oximeter, non-invasive blood pressure monitor, highly recommended, as is continuous capnography to overcome if we are to have paediatric services general anaesthesia must be in compliance with electrocardiograph for induction and maintenance monitoring during general anaesthesia. working correctly for children in Ireland. It will the current Recommendations for Monitoring during of general anaesthesia, in addition to airway gas require acknowledgement of the problem and a Anaesthesia and Recovery as defined by the AAGBI. analysis – oxygen, carbon dioxide and vapour, and 6.20 Temperature ______commitment to gradually increase numbers from The first and most important component of peri- airway pressure monitor. the commissioning authorities – currently the HSE. In anaesthetic care, including monitoring of the A suitable means of measuring the child’s temperature addition, while the training structures are in place, anaesthesia delivery system and the patient, is 6.16 vENTILATION and oxygenation should be available, and should be used at frequent ______it will require proactive measures on the part of the the continuous presence of a vigilant anaesthesia intervals when clinically indicated, e.g., prolonged or CAI and the current children’s hospitals to direct professional during anaesthesia. In addition to the use Adequacy of ventilation and oxygenation is clinically complex cases for young children. trainees into paediatric posts. At the moment, the of monitoring technology, careful continuous clinical assessed by continual inspection of the patient, task of encouraging paediatric practice is hampered observations are required, because equipment may evaluation of chest excursion, observation of the 6.21 Neuromuscular function ______by what is perceived by trainees as an onerous not detect clinical deterioration as rapidly as would reservoir bag during spontaneous ventilation, and workload and long hours. This can be overcome if be detected by the skilled professional. auscultation of breath sounds. When neuromuscular blocking medications a clear career pathway is developed, thus allowing are administered, monitoring the degree of trainees to step out of their training scheme and into 6.13 Pre-anaesthetic care Continuous monitoring of the child’s oxygenation neuromuscular blockade with a peripheral nerve ______paediatric posts. with pulse oximetry is essential, with the addition stimulator is recommended. Children must be evaluated by an anaesthesia of continuous capnography during assisted or 6.9 Facilities, equipment and medications professional prior to administration of anaesthesia, controlled ventilation. The use of an oxygen analyser 6.22 Depth of anaesthesia ______ and an appropriate anaesthetic plan must be with an audible alarm monitoring the inspiratory gas Appropriate equipment and facilities, which are formulated. Prior to initiating anaesthetic care, mixture is essential during general anaesthesia. A Level of consciousness and depth of anaesthesia adequate both in quality and quantity, should be the anaesthesia professional must ensure that all disconnect alarm must be installed and activated should be regularly assessed by clinical observation. in place during anaesthesia for children, and also necessary equipment is present and is functioning within the breathing circuit. During general anaesthesia with vapours, the during recovery, in every location, including outside correctly. The anaesthesia professional should continuous measurement of inspired and expired the traditional hospital operating room environment ensure that assistance is available as needed, and The National Audit Project (NAP) 4 states that all concentrations of anaesthetic gases and volatile – such as, for example, in procedure or imaging that the assistant is competent. The development of patients with artificial airways should have continuous agents is essential, and may provide an indication rooms. Appropriate anaesthetic, resuscitative, and protocols and checklists to facilitate such verification monitoring of end tidal carbon dioxide. This applies of the depth of anaesthesia. While it is controversial, adjuvant medications must be age specific and must is recommended. to patients in the post-anaesthesia care unit (PACU), and is not universally recommended, the application be available in every institution that intends to carry intensive care unit (ICU) and the emergency of an electronic device to measure brain electrical out paediatric anaesthesia. department (ED); it also applies to the transport of activity as an adaptation of level of consciousness critically ill patients. should be considered during general anaesthesia in scenarios where there is a high risk of awareness.

32 33 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

6.23u A dible signals and alarms 6.28 Paediatric pain service ______Pre-operative anaesthetic assessment should ______of the pain, the environment, the psychological minimise risk for all children, as well as identify children status of the child and the family support available. Available audible signals (such as the variable pitch at particularly high risk. The pre-operative assessment Paediatric pain services were first established in large In order to evaluate the effectiveness of the pulse tone of the pulse oximeter), and audible clinic should cooperate with primary care to achieve paediatric centres over two decades ago. At the multimodal analgesia, the use of a pain assessment alarms with appropriately set limit values, should be these aims. time, children’s acute pain was poorly managed, due tool (appropriate to the age of the child) must be an activated at all times, and should be loud enough to to misconceptions, safety concerns and variability in ongoing process. Following regular pain assessment, be heard by the anaesthesia professional and care In the process of preparing patients for anaesthesia, practice. While many large paediatric centres now analgesia can be titrated according to the response. team in the operating room. skilled clinical nurse specialists are both safe and have acute pain services, there remains a need for A pain relief service will involve many members of the cost effective, and they should work closely with better pain management to be provided in smaller multidisciplinary team, including anaesthesia, pain 6.24 Post-anaesthesia care facilities or geographical locations that have fewer ______anaesthetists with a special interest in pre-operative nurse specialists, pharmacists, health and social care assessment and preparation. resources. professionals, and others. All children who have been given an anaesthetic that affects their central nervous system function and/ Most anaesthesia departments should plan for one Major obstacles hindering the implementation of such It is important to determine whether the proposed or a loss of protective reflexes should remain in the WTE consultant to run and manage daily high-risk services include institutional acknowledgement, lack services intends to treat acute, chronic, procedural location where they were anaesthetised until they clinics with appropriate secretarial support. The of a desire to change, lack of appropriate staffing, and/or cancer and palliative pain, as each have recovered, or are ready be transported safely Department of Anaesthesia must establish clear and lack of funding. When establishing a pain service, requires different skills and resources. An ideal and with care monitoring, as indicated, to a specifically pathways of care for unplanned admissions in the principal objectives are better recognition and comprehensive paediatric pain service should be designated recovery location for post-anaesthetic conjunction with surgeons, emergency department assessment, as well as safer and more effective equipped to diagnose and treat pain, persistent monitoring. consultants, intensivists and theatre personnel. treatment of pain. (chronic), procedural, and cancer/palliative pain. It Special consideration must be given to children and is neither feasible nor necessary for every hospital to 6.25 Monitoring A holistic approach to pain management is ______young people undergoing anaesthesia and surgery. manage all. Establishing the scope of practice based Operating sessions and the individual anaesthetist’s recommended in order to cater for each individual on case mix and caseload in any given hospital or All children should be observed and monitored in a work load must be arranged so as to allow time for child’s needs, taking into account the age of the region will determine which resources are required. manner that is appropriate to the state of their nervous the anaesthetist responsible for an individual patient’s child, the affective nature of pain, the physical effect system function, vital signs and medical condition, care to visit and review the patient at an appropriate with emphasis on the adequacy of oxygenation, time before surgery. ventilation, circulation, and temperature. In all but exceptional circumstances this patient 6.26 Pain relief ______review should take place in a designated reception area, dedicated clinic room or in a ward, in order to All children are entitled to appropriate efforts ensure privacy and respect the patient’s dignity. Pre- to prevent and alleviate post-operative pain operative anaesthesia clinical reviews should only be employing appropriate available medications and conducted in the anaesthetic room in exceptional modalities; the use of such efforts is therefore highly circumstances. recommended. Usually, the anaesthesia professional involved in the child’s case assumes initial responsibility Clinical directors for anaesthesia and theatres for this. should work with appropriate managers to establish comprehensive and integrated pre-operative 6.27 Pre-operative assessment of in-patients – assessment facilities, and ensure that there is a lead the role of the anaesthetist ______anaesthetist available to carry out pre-operative assessments. The anaesthetist should assume the central role in the organisation of pre-operative services – a role The National Clinical Programme in Anaesthesia that encompasses much more than preparing the published a Pre-Admission Unit (PAU) Model of delivery of anaesthesia. Care in December 2014. This document contains considerable detail about the establishment, delivery The anaesthetist has the skills necessary to assess, and ongoing improvement of anaesthesia-led, nurse- optimise and estimate risk, and support patients in delivered pre-admission units. the process of deciding whether or not to proceed with surgery and anaesthesia.

34 35 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

essential for success. Involving clinicians in the design The Model for Quality Improvement highlights five and running of the project via their professional key points. 7. PERFORMANCE MEASURES AND QUALITY bodies and clinical networks helps to provide further • Knowing why or what you need to improve IMPROVEMENT METHODS FOR PAEDIATRIC quality assurance of the audit process. Finally, if the (audit will have provided this information). measurements are not correct, the wrong areas • Having a feedback mechanism to identify if ANAESTHESIA AND INTENSIVE CARE MEDICINE may be tackled in an effort to seek improvement. improvement has occurred (closing the audit Accurate and valid data are necessary in order to loop). IN IRELAND guide continual improvements. • Developing a change that will lead to Performance measurement is the process of only way clinicians can be certain about the quality improvement. collecting, analysing and/or reporting information of care they provide is by measuring what actually The clinical audit cycle is a well-established way for • Testing a change before implementation; this regarding the performance of an individual, group, happens, and comparing this to established best clinicians to progress quality improvement work. Using may lead to multiple cycles of further change. organisation, system or component. practice. Only then can clinicians know what action this model, clinicians measure their own practice • Knowing when you have an effective change to take in order to improve the care they provide. against established national standards. Once they that will lead to an improvement. Quality improvement is the combined and unceasing have data about their own performance, they can efforts of everyone – healthcare professionals, Clinicians and non-clinical personnel working in take action to improve it. The Model for Quality Improvement (Langley GJ et al. patients and their families, researchers, payers, paediatric anaesthesia require easily measureable, The Improvement Guide (2nd Edition). Jossey-Bass, planners and educators – to make the changes that consistent and definable clinical and non-clinical 7.4 What is quality improvement? San Francisco 2009) requires clinicians to look at data ______will lead to better patient outcomes (health), better outcomes for paediatric anaesthesia that are over time, in order to help understand variation – both system performance (care) and better professional applicable nationally. By examining and interpreting Quality improvement is a formal approach to the wanted and unwanted – for the purpose of quality development (learning). This definition arises from these outcomes, we can ensure ongoing quality analysis of performance, followed by systematic improvement (Model for Improvement reproduced our conviction that healthcare will not realise its full improvement measures. efforts to improve it. Improvement comes from from the Improvement Guide) (NHS, 2013; National potential unless change-making becomes an intrinsic the application of knowledge and a thorough Steering Group for Specialist Children’s Services, part of everyone’s job, every day, in all parts of the We improve what we can measure. Data will flag understanding of the system you are trying to improve. Scottish Executive, 2009). system. Defined in this way, improvement involves a the need for improvement; will confirm that we are substantial shift in our idea of the work of healthcare, improving, and will help us to understand the degree a challenging task that can benefit from the use of a of improvement that would be possible following a wide variety of tools and methods (Royal College of given change in practice. Meaningful reporting of Anaesthetists, 2014). outcomes allows the consumers and providers of paediatric anaesthesia and paediatric intensive AIM 7.1. Why measure outcome? care services to make informed decisions. Consistent ______reporting of outcomes informs clinicians and There is an increasing emphasis on improving managers in their efforts to drive quality improvement TEST healthcare quality nationally and internationally. Irish initiatives. examples include the recent publication by HIQA of the National Healthcare Standards, the issuance 7.2 Why measure? ______MEASURE of guidance by the HSE Quality and Patient Safety Division which assists hospitals to comply with these • It is a critical part of testing and implementing and other guidelines. change. • It allows us to determine further impact of the Currently, there are no national guidelines on change. performance measurement or quality improvement • Performance and quality improvement initiatives for paediatric anaesthesia and intensive measurements provides evidence of the care medicine in Ireland. The aim of this Model of improvements made and the weaknesses Care is to provide national guidelines and establish identified. quality improvement networks, in order to improve the outcome and quality of services provided to 7.3 H ow do we measure, and how does this children in Ireland who are undergoing anaesthesia. lead to quality improvement? ______

All clinicians want to provide patients with the best Clinicians need evidence to persuade them that possible standard of care. Many believe that they their practice needs to change. Ensuring that can do this by focusing on the individual patient. The clinical audits are high quality and well-designed is

36 37 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

7.5 Which outcomes should we measure? ______a compendium of audit recipes, 3rd Edition 2012: entrusted to healthcare professionals (Lunn, 1992). It operative management, staff experience, as well Suggested audit projects is essential that this responsibility is discharged safely as the day care facilities, geographical factors and Outcome measures are the cornerstone of clinical and effectively. case mix (Campling, Devlin & Lunn, 1989). governance, strengthened by acceptance of the • Pre-operative parent and child information value of systematic critical and objective examination Parents and their children demonstrate a high • Peri-operative fluid audit in children • Care pathways for dental extractions under of practice by clinicians and management alike. The incidence of anxiety prior to surgery (Royal College There have been a number of concerns and case general anaesthesia in children quality of delivery of healthcare can be divided into of Surgeons of England, 2013). reports of morbidity associated with hyponatraemia Each year in Ireland many children undergo general three domains: due to water intoxication in the peri-operative period anaesthesia for dental extractions. Although the Adequate pre-operative information and preparation (Campling, Devlin & Lunn, 1989; Lunn 1992). The facilities and organisation of paediatric dental Structure: e.g., how many emergency operating will help allay these concerns and reduce anxiety NPSA (National Patient Safety Agency) produced a services vary widely, these children should receive theatres are available 24 hours a day? (ANZCA – Australia and New Zealand College of safety alert to reduce the risk of hyponatraemia in the same standard of care as children undergoing Anaesthetists, 2008). children and the APAGBI (Association of Paediatric general anaesthesia for any other procedure. Process: e.g., is there a local guideline for paediatric Anaesthetists of Great Britain and Ireland) produced sedation? • Pre-operative fasting in elective a consensus guideline on peri-operative fluid • Post-operative nausea/vomiting in children paediatric surgery management in children (Arul & Spicer, 1998; RCoA, Post-operative nausea/vomiting (PONV) is Outcome: e.g., what is your hospital’s rate of Adequate pre-operative fasting reduces the risk 2002). The purpose of this audit is to observe the use approximately twice as frequent in children as it is in unplanned admissions for day case surgery? of regurgitation of stomach contents at the time of of intravenous fluids given to children during the peri- adults, with an incidence of 13–42% in all paediatric induction of anaesthesia. This must be balanced operative period, and therefore to check that current patients (Campling, Devlin & Lunn, 1989; Lunn There is an infinite list of outcome measures that can against the risks of prolonged fasting leading to guidance is being followed. 1992). PONV is one of the major causes of parental be looked at both locally and nationally. It is vital hypoglycaemia, dehydration and distress. However, dissatisfaction after surgery, and is the major cause of that a national quality improvement programme for maintaining such a balance can be logistically • Paediatric sedation unanticipated hospital admission after day surgery, paediatric anaesthesia is initiated, in order to make difficult. When sedation is administered to a child by a with resulting increased healthcare costs (Arul & the necessary changes that will lead to better patient person who is not an anaesthetist, this can result in Spicer, 1998; RCOA, 2002). outcomes (health), better system performance (care) • Pre-medication in pre-school age children unintended loss of consciousness. In contrast, some and better professional development (learning). Induction of anaesthesia may be a stressful sedation techniques may not be effective enough • Performance measures specific to paediatric experience for pre- school-aged children and their and can lead to patient distress and failure to anaesthesia 7.6 S ample outcome measurements parents. If the child resists intervention, unnecessary complete the procedure. Practitioners need to know In the design of this Model of Care for Paediatric from the UK ______distress may occur. As well as being undesirable, this how to deliver effective sedation and be able to Anaesthesia, a multidisciplinary workshop was held may also influence the child’s attitude to medical manage the complications of airway obstruction, to establish a consensus on performance measures, Clinical audit is a component of quality improvement. care in the future. and cardio-respiratory depression. activity measures and outcome measures applicable The Royal College of Anaesthetists (RCoA) publication: to paediatric anaesthesia that could be used to guide Raising the Standard: a compendium of audit recipes, • Parent satisfaction with arrangements for being • Children experiencing pain at home after the development, delivery and growth of services 3rd Edition 2012 is a most comprehensive book present with their child at induction undergoing day surgery locally, within Hospital Groups and at a national level. that guides the user through the process of quality A child-centred approach to anaesthesia and It is well established that the expansion of day surgery improvement using the Model for Improvement surgery should be employed with, as far as possible, has not been mirrored by a corresponding increase in It was agreed that the Model for Quality Improvement system. provision for parents to accompany children to the provision of analgesia at home following surgery would be adopted to improve outcome and the both the anaesthetic room and the recovery area’ (Campling, Devlin & Lunn, 1989). quality of service provided to children in Ireland The section on paediatric surgery provides a list of (Campling, Devlin & Lunn, 1989; Lunn 1992). who are under the care of anaesthetists. The group sample audit projects that could be utilised in Ireland, With an increasing amount of surgery joining the list of included a combination of personnel both from both locally and nationally, to evaluate current • Peri-operative temperature control in children ‘suitable for day case’ procedures, it is incumbent on dedicated paediatric-only hospitals and from adult clinical standards of care in paediatric anaesthesia Thermoregulation is known to be disrupted in the anaesthetists charged with the administration of peri- Model 3 and Model 4 hospitals throughout the and to begin the quality improvement process for peri-operative period, with the paediatric population operative pain control to look further than the day country. The latter group covered a broad range of Irish children in the peri-operative setting. particularly at risk. This audit will establish whether surgery discharge lounge when assessing the success paediatric anaesthesia practice sizes. warming techniques are being used effectively in of their post-operative analgesia regime. The following is a list of suggested audit projects children and whether appropriate intra-operative Table 7.1 lists the top 14 performance and quality outlined in detail in the RCoA’s Raising the Standard: monitoring is being used. • Unplanned hospital admission following improvement measures ranked in order of importance a compendium of audit recipes – covering the ‘why, paediatric day case surgery by the group as implementation priorities. who, when and where’ of how to proceed in setting • Post-operative pain management Unplanned overnight admission to hospital is stressful, up and conducting clinical audits in paediatric peri- Pain is experienced by paediatric patients of all ages, and is a major inconvenience for children and their These measures will be useful when setting up a operative care. especially in the post-operative period (Campling, families. High unplanned admission rates may be due paediatric anaesthesia governance and clinical Devlin & Lunn, 1989). Pain relief is a basic humanitarian to inadequacies in one or more aspects of the care service, either de novo or as a result of building Royal College of Anaesthetists Raising the Standard: requirement, which in the hospital environment is pathway; patient selection, pre-assessment, peri- on existing structures. Not all measures may be 38 39 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

appropriate in all situations, but we have included all not listed in order of priority. • Theatre take-back • Defined targets metrics generated by our group. The measures are • Unplanned transfer to another hospital • National governance structure • Pre-admission unit • Peri-operative committee • Trolley waits • M&M resources Table 7.1 Performance and quality improvement measures for evaluation of implementation • Patient information (pre- and post-op) • Overall staff satisfaction with quality of clinical of the Model of Care for Paediatric Anaesthesia • Pre-op fasting service • PEWS • Model for continuous quality improvement National, regional and local governance • Pre-med • Cost savings Identification of local age profile • Paediatric sedation • Audit of metrics Identification of local volume of cases • Emergency transfer to another hospital • Audit of guidelines Implementation champion • National information-sharing (policies, • Local/Hospital Group/national integration guidelines, patient information, questionnaire) • Ongoing investment in service, structure, Critically ill child – identify, stabilise, transfer • Patient and guardian satisfaction equipment Continuous audit cycle • Child friendly • Manpower planning Communication • Temperature control • Staff training Update of continuous professional development (CPD) week in paediatric hospital • Teenager satisfied • M&M feedback • Day case rates • Uptake of paediatric anaesthesia refresher Safe site surgery checklist • Consultant anesthetist satisfaction week in children’s hospital National information sharing of PPG • Pain at home • Quality of paediatric emergency transfers Appropriate paediatric physical infrastructure • Post-op nausea vomiting Definition of paediatric hospital models • Same-day cancellation Below are the top 19 unranked outcomes measures Clinical incident reporting • DOSA for the evaluation of the quality of clinical paediatric • Peri-operative paediatric governance anaesthesia service delivery. Ongoing review of policies and guidelines • Reporting to management team • Meetings • Percentage day case surgery Table 7.2 lists the top three performance measures, service according to our model of care. These are • Communication • DOSA (day of surgery admittance) ranked in order of importance, for the establishment critical to the quality of a paediatric anaesthesia • CPD • Unplanned admission and implementation of a paediatric anaesthesia service. • Review policies and guidelines • Cancellation rate Table 7.2 – Top three performance measures for establishment of a • Percentage day case • Fasting times paediatric anaesthesia service • Percentage DOSA • Percentage admission of patients through pre- • Fasting admission unit by ASA grade 1 Definition of paediatric hospital models • Emergency/elective • Pain management service • Reporting and audit of implementation • Out-of-hours emergency service 2 National, regional and local governance • Peri-operative risk meeting • PONV 3 Critically ill child – identify, stabilise, transfer • M&M meetings • Post-op pain • Critical incident reporting • Peri-op fluids Table 7.3 lists the top two activity performance paediatric anaesthesia that is seeking to evaluate • Adherence to guidelines • Temperature control measures identified as most important and relevant its current practice, with a view to streamlining its • Patient and staff surveys • Satisfaction surveys to paediatric anaesthesia in Ireland today. These processes and improving its clinical services. • Monitoring of staffing levels • Patient information are appropriate for an established, stable service in • Equipment maintenance and replacement • Unplanned theatre take-back schedule • PEWS Table 7.3 – Activity performance measures – appropriate for an established, • Day case surgery versus percentage in-patient • Pre-medication stable service in paediatric anaesthesia • Unplanned admission • Paediatric sedation • Cancellation rate • Unplanned transfer to another hospital 1 Volume of cases by age by Hospital Group • Pre-admission unit ratio 2 Wait list data – by age, region, procedure • Fasting times Table 7.4 lists the top four outcome measures for the • Pain management service evaluation of the quality of paediatric service For paediatric anaesthesia services that are regarded suitable, appropriate and relevant for this purpose. • Emergencies Delivery, ranked in order of importance, with as being in an established and stable phase of • Out of hours unplanned admissions regarded as the most development and service delivery, a multitude of • ISBAR (identify - situation - background - • Resuscitation and transfer of critically ill child important, and with both the presence of an out-of- performance measures are available to assess the assessment - recommendation) • Hub-and-spoke reporting hours emergency service and the use of satisfaction • Safe site surgery quality of anaesthesia service being delivered. Below • Delayed admission transfer surveys ranked as equally important (i.e., in second • Unplanned admission is a list of measures identified in our workshop as • Local and national audits place). 40 41 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

Table 7.4 – Top four outcome measures for quality of paediatric anaesthesia 8. PAEDIATRIC CRITICAL CARE 1 Unplanned admission 8.1 Definition ______an acute ward, require the input of the critical care 2 Out-of-hours emergency service team. 3 Use of satisfaction surveys A paediatric critical care unit (PCCU) is a specialised 4 Unplanned transfer to another hospital facility within a children’s hospital charged with the Level 2 care of infants and children. It is staffed by a specialist Critical care requiring a nurse to patient ratio of 1:1 team and is designated to provide an increased level 7.8 Next steps • Key areas to be identified for quality The child requiring continuous nursing supervision ______of detailed clinical observation, invasive monitoring, improvement. This may be at a local, regional who is receiving advanced respiratory support focused interventions and technical support, in order • Agreement should be reached on at least one or national level. (complex NIV or invasive ventilation). Level 2 also to facilitate the care of critically ill paediatric patients national outcome measure, and this measure • Quality improvement initiatives can be pertains to the unstable, non-intubated child, e.g., over an indefinite period of time. should be included in the national data designed at both a local and national level the haemodynamically unstable patient requiring collection mechanisms within the HSE. using the model for improvement. invasive cardiovascular monitoring, frequent fluid A PCCU will care for patients who, typically, are • A robust method of collecting data should • A steering group should be convened to challenges and vasoactive drug infusions. aged 0–16 years; are diagnosed with life-threatening, be in place, in order to collect data relating govern the process. potentially recoverable conditions; are post- to structure, process and outcome at a local, • Key stakeholders would include senior Level 3 operative patients who may benefit from close nursing Hospital Group and national level. These managers, clinical directors, senior clinicians Critical care requiring a nurse to patient ratio of 1:1 or technical support; have chronic complex medical data are required in order to establish quality and senior nurses, so as to ensure the The critically ill child with two organ failures or greater, co-morbidities which exceed the capabilities of other improvement networks. appropriate allocation of resources and requiring intensive supervision, who needs additional clinical care areas within the hospital. • All data collections should include a plan for support for the process. complex therapeutic procedures, e.g., respiratory analysis and dissemination of relevant and support with multiple organ failure requiring usable information to all stakeholders in a Between the ages of 16 and 18, new patients may vasoactive and inotropic medications. timely fashion. be admitted to a paediatric service where there is a clinical indication that they should be treated in Level 3S: a paediatric setting. It is also widely recognised that Critical care requiring a nurse to patient ratio of 2:1 end-of-life care, including potential organ donation The critically ill child requiring the most intensive and family bereavement counselling, are skills that therapeutic interventions, e.g., ECMO and/or renal are integral to the care of a critically ill child, and are replacement therapy. facilitated within the PCCU. These criteria may change in line with advances in The PCCU team comprises paediatric intensivists, technology. nurses, pharmacists and allied professionals (such as clinical engineers, physiotherapists, dieticians, speech 8.3 Current status ______and language therapists, occupational therapists, social workers and psychologists) who are certified Ireland currently has two paediatric critical care units. in, and/or have received recognised specialised These are located in Our Lady’s Children’s Hospital training (particular to their profession) in the care Crumlin and the Children’s University Hospital, Temple of critically ill infants and children. These individuals Street. The total number of beds (divided between should deliver care within a PCCU that conforms to the two sites) is 32, and the total number of admissions the agreed guidelines and standards of the relevant per year is more than 1,600. Both units are capable professional regulatory bodies. of delivering Level 3 and Level 3S care. The PCCUs can be contacted on the National Paediatric Critical 8.2 Levels of critical care ______Care Network telephone number 1890-213-213 and via www.picu.ie. The parent/guardian of any Level 1 neonate, infant or child who is critically unwell, or who High dependency care requiring a nurse to patient has the potential to become critically unwell, can ratio of 0.5:1 access the PCCUs via the 1890-213-213 number. The Close monitoring and observation is required, but professionals staffing this telephone service locate acute mechanical ventilation is not. Patients who an appropriate PCCU bed, and provide advice on require basic respiratory/circulatory/neurological or resuscitation, stabilisation and transfer of the critically renal support, and whose needs cannot be met on ill child to the appropriate facility. Access to this

42 43 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

8.7 PICU training programme telephone service and advice is available 24/7. Group is in the process of writing a PCCU Model of ______2012). Care document; this is expected to be published Equipment should include a suitable ventilator, 8.4 Model of Care recommendation for in mid-2015. Templates and standards for the PCCU The PCCU Model of Care document that is currently infusion devices and full monitoring, including paediatric critical care Model of Care document will be drawn from being prepared by the PCCU cross-city working group capnography, (Royal College of Anaesthetists, ______international publications, e.g., DNV 2008 and PICS will take account of the creation of a paediatric 2014). This section covers two time periods: Standards 2010, and the National Standards for Irish critical care sub-speciality within the Medical • Infants and children may require admission 1. Up to the opening of the New Children’s Paediatric Critical Care Services 2013. It will allow Council specialty registration (as per the Adult ICU to critical care facilities as a planned part Hospital (NCH) for the estimation of future numbers of paediatric programme). The vision for PCCU is that it will sit of their care – for example, after surgery; intensivists. In addition, it will take account of planning under the umbrella of the Joint Faculty of Intensive due to trauma or an acute illness, or due to 2. Following the opening of the NCH and beyond for staffing at NCHD and consultant level in PCCUs, Care as a specialty in its own right, with a fellowship extreme prematurity or illness at birth. Infants as well as the establishment of a formal training exam. A PCCU training programme will subsequently and children who are likely to need critical This Model of Care describes the ideal model for programme in PCCU. follow. Trainees will be drawn from all specialties, e.g., care after an operation should undergo their provision of a paediatric critical care unit for children, anaesthesia, paediatrics, neonatology etc. surgery in a hospital/unit with a designated both now and in the future following the opening The situation with regard to paediatric critical care PCCU (Department of Health, UK, 2009). 8.8 Intensivists of the NCH. Currently, there is no PCCU manpower has been delineated by the DNV report 2008 – an ______• Each hospital should have a nominated document which clearly sets out the templates and interim report that made 13 recommendations. clinician dedicated to the organisation of standards expected for the provision of safe PCCU Currently, PCCUs are at 40% of the recommended The vision for paediatric critical care is that there will resuscitation and stabilisation protocols for the care in the Republic of Ireland. The PCCU Working NCHD and consultant staffing levels. be a core group of full-time paediatric intensivists, critically ill child. Protocols for the management with a two-year post fellowship training programme in of critically ill children should be in place. Table 8.1 Current and recommended bed status and staffing levels in OLCHC/CUHTS PCCU PCCU/CCCU drawn from many sub-specialties. It will Clinical management of critically ill children OLCHC OLCHC + CUHTS PICS Standards 2010 also allow for dual accreditation across anaesthesia in both specialist and non-specialist units will CUHTS Jan 2015 combined Jan 2015 and DNV 2008 and paediatrics, as well as providing a wealth of require close cooperation and multidisciplinary 23 training and experience and a world-class service. teamwork between nurses, paediatricians, PCCU beds open 9 34 34 capacity 25 surgeons, anaesthetists, intensivists and other WTE PCCU consultants 12 8.9 Recommendation relevant clinicians. Local guidelines should be 4 2 6 ______Jan 2015 add retrieval >16 clear on the roles and responsibilities of the WTE Reg/SpR in PCCU • Arrangements for the immediate care of multidisciplinary team, including anaesthetic 6.5 2 8.5 25 EWTC critically ill children must be in place in any services (Paediatric Intensive Care Society, Approx. number of hospital that manages children. This need 2010). It is important that further stabilisation >1,100 >450 >1,500 admissions per year can arise suddenly and unpredictably – in the and management are not the sole remit of the emergency department, operating theatre, or anaesthetist (Department of Health, UK, 2009). 8.5 Pre-NCH 8.6 NCH PICU staffing ______in-patient wards. In-house arrangements are • Children may require short-term admission to a therefore required for providing emergency general critical care facility while awaiting the Up to the time when the NCH is expected to open, Based on our current validated PICAnet data (from treatment, for stabilising critically ill infants and arrival of the PCCU retrieval team, if available. there will continue to be two PCCUs in Dublin, 2009), and allowing for population expansion and children, and for initiating intensive care prior There may also be occasions when a child between them providing a total of 34 beds; of these, the treatment of Belfast-based cardiac patients in to the child’s transfer to a paediatric critical requires a very short period of critical care that 32 beds are currently staffed. Because the two PCCUs the Republic of Ireland, we have created a capacity care unit (Royal College of Anaesthetists, does not necessitate transfer to a PCCU. This is are located across two sites (OLCHC and CUHTS), modelling diagram which has allowed us to predict 2014). It is recommended that during the initial acceptable, provided that there is a suitable this has implications for the staffing model and the PCCU/CCCU bed numbers for the NCH. stabilisation period, early communication is facility within the hospital; provided that there numbers of staff required to run two units across two established with the Paediatric Critical Care are staff with appropriate competencies in sites. (See table above) Network. This communication facilitates the place; and provided that the episode lasts only early provision of a paediatric critical care bed a few hours. Children who require Level 2, Level Table 8.2 NCH PICU bed numbers and staffing recommendations PICS Standards 2010/DNV 2008 and the provision of specialist advice from the 3, and Level 3S critical care support for >12 hours outset. should be transferred to a PCCU. There should NCH PCCU beds 20 NCH CCCU 22 Total = 42 • All emergency departments receiving infants be a nominated lead consultant and nurse WTE intensivists 8 8 16 and children, neonatal and paediatric in the critical care unit who is responsible for WTE NCHDs 16 16 32 resuscitation equipment, medications overseeing admission policies and procedures 24/7 retrieval as part (including anaesthetic and resuscitation for infants and children (Paediatric Intensive +8 0 40 of the PICU rota NCHDs medications) and fluids should be available to Care Society, 2010). Retrieval intensivists 20 = 42 PICU beds prepare the infant or child for PCCU transfer • Hospitals that admit children should be part of +4 0 as part of PICU rota and 24/7 retrieval (Royal College of Paediatrics and Child Health, a critical care network. Specialist centres with

44 45 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

PCCU facilities within the network have the than 3 kg, IPATS will consider transporting the patient. acute care to infants, children and adolescents. This by a call from the accepting intensivist, or responsibility to provide ongoing education. The team will be dispatched from the Children’s includes: will be contacted at the earliest opportunity. They also have a clear responsibility to provide University Hospital Temple Street or from Our Lady’s • All infants of over four weeks corrected Ideally, the retrieval process will be initiated by clinical advice and help in locating a suitable Children’s Hospital Crumlin. gestational age and who weigh more than 5 a consultant-to-consultant conversation. PICU bed once a referral has been made kg; children and adolescents up to their 16th • Ideally, the receiving PICU will have identified (Royal College of Anaesthetists, 2014. 8.10.2 Post-pilot phase of IPATS birthday who are, triaged, identified and a bed before the team is dispatched. In the It is planned to have a full-time, consultant led- accepted to be in need of paediatric critical event that a PICU bed is not identified, the 8.10 Transport of critically ill children service in place towards the end of 2015. This service care in an appropriate paediatric facility. Paediatric Retrieval team will be dispatched, ______will have the following aims: • The repatriation of these children from a critical with the expectation that a PICU bed will 8.10.1 Current status • Provide a single point of telephone contact for care unit to an appropriate facility not located be designated within the hours delineated The Paediatric Critical Care Retrieval Service referring clinicians. in a paediatric hospital, in order to continue for operation of the Paediatric Critical Care commenced (on a six/eight-month pilot basis) on 13 • Facilitate access to immediate specialist their care if it is in the patient’s best interest Retrieval Service. However the team will not October 2014. It became known as the Irish Paediatric clinical advice. (and once the Paediatric Retrieval Service has transport a patient until a PICU bed has been Acute Transport Service (IPATS), part of the National • Facilitate access to online clinical support been fully resourced and is fully operational). designated – even if the team has arrived on Transport Medicine Programme (NTMP). The service is tools. • In exceptional circumstances, and at the site at the referring hospital. not due to be formally launched until the end of pilot • Work with accepting PICUs to identify a PICU discretion of the receiving institution, children phase, at which time a full review will take place to bed, so that the most appropriate care is aged over 16 years who, due to their specialist 8.10.5 Types of transfer undertaken establish the feasibility, safety and sustainability of the provided in the most appropriate location needs, require care in a PICU. Paediatric transfers to PCCUs of patients over six programme. A neonatal transport service is now in for any infant, child or adolescent requiring • In certain circumstances, referral of infants weeks corrected gestational age, and/or greater place 24/7/365. specialist care in Ireland. or children to the care of a regional hospice, than 5 kg, deemed to require paediatric critical care. • Triage to an appropriate level of transport following discussions with the referring PICU. The following types of patients will be considered: The retrieval team initially began operating three or provision, and dispatch transport teams within • Transfer of critically ill child to a facility outside four days a week, with an expectation of having five a clinically appropriate time window. the State for ongoing medical care that is not • Two organ failures including/or respiratory days a week cover in the coming months. The hours • Work with referring hospital teams to stabilise available in Ireland. failure of service are from 10.00am until 8pm. The team patients before transferring them to an • Facilitate the repatriation of critically ill Irish • Receiving invasive mechanical ventilation via must return to base by 8pm. Currently, cover is not accepting PICU. children from institutions outside the State for a tracheal tube, and currently in the first 24 provided on national holidays and at weekends. • Provide logistical support for the high-risk continuing medical care in the State. hours after its withdrawal All requests for service must be made by 4pm (for transfer of critically ill infants, children and • The service will only be operational on the day • Non-invasive mechanical ventilation for any calls in the Dublin region, e.g., Tallaght). Calls from adolescents for continuing medical care that there is a named transport consultant available part of the day the south, west and northwest have to be received is not available in Ireland. to support or provide the service. • Life-sustaining extra-corporeal therapies (such earlier than 4pm, in order to ensure that the team are • Repatriate or facilitate the repatriation of • It is hoped that the service will expand to a as extracorporeal membrane oxygenation back at base by 8pm. The decision to travel is made patients from paediatric intensive care units to 24/7/365 service when additional funding and (ECMO)) by the IPATS consultant, and is dictated by the place, continue their care in an institution nearer their appropriate staffing is in place. • Infusion of an inotrope, pulmonary vasodilator time and nature of the referral. home, or transfer them to a facility that best or prostaglandin The service will support the transfer of critically ill infants suits the patients’ ongoing needs (once service 8.10.4 Acceptance criteria for transfer into PICU • Infusion of a bronchodilator and children from the referring hospital to the PICU is fully resourced). • To activate a transfer, the referring consultant • Infusion of a central nervous system (CNS) in the Children’s University Hospital, Temple Street or will be required to make an initial telephone depressant, or of a drug concentration or to Our Lady’s Children’s Hospital Crumlin. Referrals to In order to achieve this, the Paediatric Retrieval referral to PICU.ie. Telephone: 1890-213-213. dosage likely to cause CNS depression the general wards will not be facilitated. The patient Service will: • This will be a consultant-to-consultant referral. • Infusion of cardiac anti-arrhythmic medications must be accepted by a paediatric intensivist in either • Maintain appropriate communication Referrals from trainees will not be accepted • Infusion of anti-hypertensive medications hospital, in addition to any specialist service (e.g., between all parties, so as to ensure efficient unless it is confirmed that the referring consultant • Infusion of medications, which may cause cardiology). and effective continuity of patient care. is not in a position to make the phone call and wide fluctuations in cardiac output, respiratory A request for the referral and retrieval team must be • Ensure that every transfer is carried out in a way has delegated this task to a suitably qualified minute ventilation and level of consciousness directed to the PICU referral phone line 1890-213-213. that maximises patient safety, comfort and trainee. • Any very unstable child (in the opinion of the Requests channelled through other routes will not be dignity, and minimises patient pain, discomfort, • The referring hospital will follow the existing nurse in charge) who generally requires 1:1 considered. or distress, and also minimises the discomfort/ guidelines for such referral requests. Referral • Any child expected to have large flux in IPATS retrieves patients aged from four weeks distress of parents/guardians. processes that do not follow this protocol will circulating blood volume, or with the potential corrected gestational age to patients who are on not be accepted by the Paediatric Retrieval to require larger infusion of blood, colloid or the eve of their 16th birthday. The neonatal team 8.10.3 Scope of service team. crystalloid solutions retrieves all infants aged under four weeks corrected The Paediatric Retrieval Service serves approximately • The patient must be accepted by the receiving • A child recovering from a complex surgery to gestational age or weighing < 5 kg. When the neonatal 1.1 million children in the Republic of Ireland by intensivist before the team is activated. the airway, or who has an unstable airway team is unavailable, and if the infant weighs more providing support to hospital sites that provide • The Paediatric Retrieval team will be activated • A child who has suffered a major trauma with

46 47 Model of Care for Paediatric Anaesthesia Model of Care for Paediatric Anaesthesia

an injury severity (or similar) score higher than 8 • Out-of-hours, low-dependency transfers: in • Transfer of acute patients requiring specialist exceptional circumstances such a transfer 9. STRUCTURE AND GOVERNANCE OF PAEDIATRIC out-of-region services, e.g., burns, cardiac may be undertaken at the discretion of the ANAESTHESIA SERVICES: LOCAL, REGIONAL/HOSPITAL care, and in some circumstances, in discussion consultant on call for CHICA. with ECMO centres, transfer of these patients • Patients who have been exposed to hazardous GROUPS AND NATIONAL for ECMO/extracorporeal life support (ECLS) materials, or who have a highly infectious 9.1 Management of local hospital services • Neonatal patients will ordinarily be transferred disease which poses a risk to hospital staff, ______place, appropriate line reports with relevant clinical by the neonatal transport team (NNTT). despite the application of normal barrier leads and specialities should be unambiguous. Exceptions to this will be considered in precautions. Strong management of an individual hospital’s paediatric anaesthesia service is vital at both clinical 9.3 Standalone paediatric hospitals consultation with the consultant neonatologist • Certain time-critical requiring emergency ______on duty. surgery or intervention: Patients with ‘time- and managerial level, in order to ensure successful critical lesions’ (which are deemed so by the implementation of operational policy and day-to- For standalone paediatric hospitals, peri-operative 8.10.6 Exclusions appropriate specialist) should not wait for the day management of the unit. This will require input governance will be similar to peri-operative The Paediatric Retrieval team will not be responsible transport team; this is because there could and support from all relevant stakeholders within the governance structures in any Adult Model 3 or Adult for the transfer of the following patient groups: be a risk of adverse clinical outcome if there hospital/Hospital Group and community services. Model 4 hospital. This could be similar to the first half • Adult patients (patients who have passed were to be a delay in transferring the patient to of the governance structure outlined in the table 9.2 Overall quality and safety structure their 16th birthday). In exceptional circumstances, the specialist service. Such patients should be ______below, but could be detailed in a way that reflects young adults aged over 16 years who have specialist transferred to the accepting unit at the earliest the complexity and diversity of clinical practice needs; who are in transitional arrangements, and and safest opportunity. Examples include Effective governance arrangements recognise the undertaken in these hospitals. who require care in a tertiary paediatric setting will patients with rapidly expanding intracranial inter-dependencies between corporate, financial be transferred. lesions or transposition of the great vessels with and clinical governance across the service. Obviously, with the development of the New • Primary pre-hospital transfers intact interventricular septum. Children’s Hospital, and planned development of • Patient transport service for patients to meet in- To support quality and safety of an individual the hub-and-spoke model for paediatric services patient or out-patient planned appointments department’s paediatric anaesthesia service within in Ireland, there is scope for a functioning cross- • Inter-hospital transfers of paediatric patients a hospital/Hospital Group, governance should be hospital or inter-hospital peri-operative group which that do not require critical care clearly set out in the context of the overall peri- would reflect the governance structures into which operative group (see below for sample peri-operative individual hospitals and departments will eventually governance structure) and its interface with the merge. Hospital Executive. If clinical directorates are in

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Table 9.1 A model for governance as a network for paediatric anaesthesia Table 9.2 A proposed model for governance of the NEW Children’s Hospital Group services in Hospital Groups

Executive accountability for resources, ownership, place). The quality and safety structures, processes, leadership, peri-operative, management and and appropriate referral mechanisms will need to be monitoring of paediatric anaesthesia services communicated both internally (within the hospital) should be set out in the terms of reference for the and externally to key partners, such as primary care paediatric peri-operative quality and safety group. teams or other major referring agents. Each Hospital The paediatric peri-operative quality and safety Group will liaise with the clinical lead in paediatric group itself should be integrated into the clinical anaesthesia on the standardisation of core processes, and managerial infrastructure with the rest of the education, training, audit and peer support. hospital (e.g., directorates, where these are in

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9.4 quality and safety of paediatric without the operation administration and nursing; representatives from defibrillators that are designed for children anaesthesia ______ASA Physical Status 6 – hospital wards; patient representatives; laboratory should be in place. A declared brain-dead patient whose organs are representative; healthcare assistants; porters etc. • An acute pain service that is child appropriate Quality improvement and safety incorporates being removed for donor purposes should be available. accountability for clinical performance. The aim is to 9.5 Learning networks • A management policy on the care and ______create and support an environment where all staff This model of care provides a flexible framework for appropriate transfer for the critically ill child understand their role within the service, recognise paediatric peri-operative clinical governance, thus On a national basis, paediatric anaesthesia user should be in place. their accountability and are committed to the enabling different levels of hospitals to be responsive groups should try to develop learning networks, so as • A policy on the age and ASA classification of guiding principles for quality and safety. to individual local needs. to ensure the transfer of skills, expertise, information patients who are to be transferred should be in and evaluations. Units should share locally developed place. Each hospital should have a multidisciplinary Every paediatric peri-operative group should operate PPG algorithms; this would not only reduce duplication • A policy on what operative procedures are to paediatric peri-operative group that oversees the under the leadership of a consultant anaesthetist or of effort, but would also encourage peer review of be carried out should be in place. organisation and day-to-day running of paediatric surgeon. The lead clinician for the paediatric peri- such algorithms. • Hospital management will need to ensure that surgical services; agrees policies, protocols and operative group, within the context of the hospital appropriate policies are in place; that regular guidelines (PPGs) which are aligned with the PPGs of quality and safety structure, will oversee the quality 9.6 Su mmary of requirements for delivery audits are conducted, and that relevant staff the Children’s Hospital Group; timetables and plans and safety of the unit. Their remit will include the of care at each institution proposed to competencies are maintained. the service; manages resources; reviews operational development of local PPGs and clinical governance. deliver surgery, anaesthesia and peri- • Analysis of adverse events and regular audits problems, and organises audit strategies. Individual operative nursing care should take place at a local, regional and ______hospitals should formulate a staffing structure that The lead clinician will encourage innovations and national level. takes local needs into consideration. development in the range of issues encompassed • Compliance with minimum standards of • The multidisciplinary team should audit their within the broad remit of peri-operative paediatric monitoring (as recommended by AAGBI practice on key outcomes, including but not As hospitals become networked in groups, it may surgery and clinical governance, with particular guidelines) limited to, the following: complication rate; be more productive and appropriate to develop a emphasis on clinical risk management and clinical • Child and parent-friendly facilities, ideally with unexpected readmission rate; unexpected single paediatric peri-operative group to meet the audit. children managed in a separate environment referral to tertiary centres; post-operative needs of the local Hospital Group. This could be a from adults nausea and/or vomiting rates; regional single paediatric peri-operative leadership, quality The paediatric peri-operative group overseeing all • It is recommend that there should be an area anaesthesia success rates. These audits should improvement and management structure, with local aspects of paediatric surgery should be chaired by a near the operating theatres where parents and include anaesthetists and other healthcare on-site groups as required reflecting the needs of lead consultant in anaesthesia or surgery, and should medical staff can have a private conversation. professionals in local, regional and tertiary individual hospital clinical caseloads. include representatives from surgery; paediatrics; • Each hospital undertaking paediatric hospitals, in a network framework. Audits should senior nurse management; health and social care anaesthesia must have one designated be incorporated in a quality improvement Paediatric anaesthesia and surgical services and professions (such as physiotherapists, occupational lead anaesthetist who has sub-specialty framework at a local, Hospital Group and processes need to be adapted to suit individual therapists, dieticians and nutritionists); hospital interest in paediatric anaesthesia. The lead national level. hospital needs, as reflected by surgical case mix and administration; hospital management and finance. anaesthetist(s) should undertake a sufficient • A policy on child protection and safeguarding patient complexity (e.g., Adult Model 2 hospital with volume of procedures in order to maintain children in the operating theatre should be in paediatric day surgery for ASA Physical Status 1 and It is important that the paediatric surgery staff have competencies in the peri-operative care of place. ASA Physical Status 2 patients versus Adult Model 3 dedicated time allocated to the service, in order to children and adolescents. • The hospital should have: capacity/capacity and Adult Model 4 hospitals covering both paediatric ensure that it functions appropriately. The maximum • Each hospital undertaking paediatric planning; facility requirements for physical day surgery and day-of-surgery admission for high risk value from the paediatric peri-operative group will anaesthesia must have one designated lead infrastructure/specifications of specific units/ paediatric patients). be derived from the team working as a complete unit nurse. sites; bed stock (current/required); capacity to cover all aspects of care involved in paediatric • The WHO Safe Surgery Saves Lives checklist to manage the demands of surges and major ASA Physical Status Classification System surgery – from administration to nursing, medical should be in operation. surges. ASA Physical Status 1 – personnel and beyond. • Appropriately trained and competent staff for • The HR team should comprise members of the A normal healthy patient the age and ASA classification of the patients multidisciplinary team, as appropriate, in order ASA Physical Status 2 – Additionally, a paediatric anaesthesia user group, that the institution proposes to care for should to ensure that the competencies required A patient with mild systemic disease comprising representation from all specialties be in place. to deliver the model of care are available ASA Physical Status 3 – involved in paediatric anaesthesia, should be • Child-friendly pre-operative assessment clinics - business, administrative and support staff – A patient with severe systemic disease established, in order to allow discussion of wider should be in place. role, responsibilities and contributions of each ASA Physical Status 4 – issues relating to the operational function of the • Day ward, in-patient beds, operating theatres, member of the MDT A patient with severe systemic disease that is a individual service. Typical membership might include recovery areas that are appropriate for • There should be recognition of the constant threat to life the following: paediatric lead anaesthetist; nurse children should be in place. interdependencies with other national ASA Physical Status 5 – manager; representatives from theatre, recovery, • Equipment, medications and monitors, clinical programmes, e.g., acute medicine; A moribund patient who is not expected to survive

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emergency medicine; acute and elective other clinical staff as appropriate. “Trained assistance for the Anaesthetist must be operatively surgery; intensive care diagnostics; infection • The lead will link in with other lead clinicians for provided wherever anaesthesia is provided. The safe • Safe removal of an airway adjunct. prevention and control; palliative care; paediatric anaesthesia nationally, in order to administration of anaesthesia cannot be carried out transport medicine. Collaboration and cross establish a network of learning through the Irish singlehandedly; competent and exclusive assistance 9.8.2 Education programme initiatives is necessary. Paediatric Anaesthetic Network (IPAN). is necessary at all times. Staff assigned to the role of • All anaesthetists who provide anaesthetic anaesthetic assistant should not have any other duties 9.8.2.1 roles and responsibilities services for elective paediatric surgery must 9.7.2 Consultant surgeon and surgical team that would prevent them from providing dedicated a. the nurse must be responsible for completing have paediatric anaesthesia training and must Please refer to the Model of Care for Elective Surgery assistance to the Anaesthetist during anaesthesia” all local and national mandatory training maintain their skills in paediatric resuscitation to and the Model of Care for Acute Surgery. (The Association of Anaesthetists of Great Britain and relevant to their area of expertise. He/she must PALS/APLS level or equivalent Ireland (AAGBI), 2010). demonstrate the application of knowledge, 9.7.3 The peri-operative nurse based on scientific and nursing principles, while 9.7 Roles and responsibilities within paediatric Peri-operative nursing is the nursing care provided 9.8 Competence and education working within their scope of practice. Scope ______anaesthesia user groups to patients throughout their peri-operative journey. It of practice is defined as the range of roles, ______encompasses the care from the moment the patient 9.8.1 Competence functions, responsibilities and activities, which a 9.7.1 Lead clinician: consultant anaesthetist has a pre-operative assessment to the point of The skills required for peri-operative nursing care registered nurse is educated, competent, and The role of lead clinician for paediatric anaesthesia discharge from the operating department. of children is highly specialised and complex, and has authority to perform (An Bord Altranais, should be resourced appropriately, including ensuring involves caring for patients until they reach their 16th 2000). that designated time is allocated to the respective The Association of Perioperative Registered Nurses birthday. anaesthetic department. (AORN) recognizes the “peri-operative nurse” as one b. i t is recommended that all paediatric nurses who provides, manages, teaches, and/or studies Children undergoing anaesthesia must be cared caring for children should have access to and • The lead clinician for paediatric anaesthesia the care of patients experiencing the peri-operative for by nurses who are skilled in both paediatrics undertake advanced paediatric life support should be an anaesthetist who acts as the journey. and anaesthesia/recovery room nursing. Specific (APLS), paediatric advanced life support key point of contact with surgical, nursing and specialist knowledge, skills and training are required (PALS) or paediatric life support (PLS) training. anaesthetic departments. This nursing care must be of a high standard and is in order to deliver holistic quality care in accordance Depending on local service needs and the • The lead may act as Chairperson of the governed by policies, procedures and guidelines with best practice guidelines. Peri-operative nurses age range of children being cared for, nurses Paediatric Peri-Operative Group. (PPGs). Such PPGs must be in place, in order to define should be trained and experienced in providing both may also be required to undertake a neonatal • The lead will act as Chairperson of the the role and responsibilities of the peri-operative routine care and emergency care. resuscitation programme (NRP). Paediatric Anaesthesia User Group. nurse in caring for a child or young person who is • The lead oversees the implementation of the undergoing any form of anaesthesia or surgical Structured competencies using a competency c. the clinical nurse facilitator (CNF) in peri- operational PPGs for paediatric anaesthesia. procedure. framework, with mentorship and support, allows operative nursing/anaesthetics and recovery • The lead is responsible for establishing nurses to advance in the area of anaesthesia and plays an important role in the development evidence-based PPGs for paediatric The anaesthetic nurse works as part of the peri- recovery. and preservation of an anaesthetic nursing anaesthesia, data collection for clinical audit; operative team in collaboration with the anaesthetist service. The CNF facilitates the anaesthetic the establishment of a risk register/reporting in the preparation and safe delivery of general, The competency assessment document should and recovery nurses in maintaining their system for risk management, which is reported regional or local anaesthesia. The success of adhere to British Anaesthetic and Recovery Nurses competence, and ensuring that a high to the Peri-operative Quality Improvement and a coordinated team approach is dependent Association (BARNA), Nursing and Midwifery Board of standard of care is delivered. This role Safety Group and from there to the overall on respect and communication between the Ireland (NMBI), and AAGBI guidelines. The following includes competency assessments, education Quality and Safety Executive Committee for anaesthetist, anaesthetic nurse, scrub nurse and is not an exhaustive list of competencies; moreover it programmes, auditing practice, quality the hospital(s). surgeon. Paediatric nursing is very much a family- must be understood that this list should be completed initiatives, regular simulation sessions, as well as • The lead will arrange executive and clinical centred approach to care. Pre-operative education within a realistic and achievable timeframe. PPG development and maintenance. ratification and circulation of protocols. of parents/guardians is vital, in order to afford them • The lead will ensure that risk assessment, KPIs the knowledge required to prepare and support their Competencies which should be included are: All peri-operative nurses must have knowledge of the (key performance indicators) and audits of child. The nurse provides emotional and psychological • Pre-operative management, including pre- following policies: paediatric anaesthesia services and care are support to both the patient and their families. assessment • National Consent Policy, 2010 conducted as appropriate, and that outputs • Airway management • WHO guidelines for safe surgery, 2009 are monitored and reviewed. The group will While the patient is under general anaesthesia, the • Patient monitoring and the equipment used for • National Policy and Procedures for Safe Surgery adopt the Model for Quality Improvement. nurse assumes the role of advocate, as the patient is same 2013 • The lead will ensure that paediatric anaesthesia unable to serve his/her own needs, make decisions • Anaesthetic pharmacology is a consultant-led service and that hospital regarding his/her wellbeing, protect his/her dignity • Pain management and assessment 9.9 Programmes available ______management is informed of the requirements and maintain respect for his/her confidentiality • Infection control for adequate staffing by anaesthetists and (BARNA, 2012). • Immediate care of the paediatric patient post- Currently, there is one paediatric peri-operative nurse

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education programme with a module in paediatric to provide clinical leadership and management paediatric anaesthesia caseload, to rotate through a hospital issues to the peri-operative group, in anaesthesia in place in both OLCHC and CUHTS. in paediatric anaesthesia, as determined by local paediatric department in one of the three paediatric accordance with the governance structure From September 2015, this programme will become service needs/governance, and may be guided by hospitals: OLCHC and CUHTS or Tallaght Hospital. and reporting relationships. Typical issues a Post Graduate Diploma/MSc in Peri-operative factors including hospital model, patient complexity, to be reviewed by the PPOGG operational Children’s Nursing, with the opportunity to specialise individual hospital size and numbers to treat. 9.13 Health and social care professions group might include: Utilisation of theatre time, ______in anaesthetics/recovery room children’s nursing or waiting list management, bed capacity, case surgical children’s nursing. The programme will be run 9.10.2 Surgical access coordinator There is substantial evidence that health and social mix, staffing levels and expenditure. Auditing by OLCHC in conjunction with the Royal College of For a standalone day unit that may consider care professions (HSCPs) play a significant role within of cancellations, DNA rates, unplanned Surgeons in Ireland (RCSI). paediatric lists, the role of surgical access coordinator the multidisciplinary team involved in pre-operative admissions/re-admissions and quality of service can prove to be an integral part of the overall service, assessment of patients prior to surgery. The impact of as reviewed by the patient. Tallaght Hospital delivers a Post Graduate Diploma in as coordination of lists, surgeons and support staff is provision of HSCP services from an early stage can Peri-operative Nursing, with a paediatric component, required if staff are visiting from other hospitals within also effect a speedier discharge post-operatively 9.16.2 Regional/Hospital Group paediatric peri- incorporating anaesthesia, recovery and the surgical the group. through establishment of, for example, mobility operative groups scrub side of care. status, equipment needs, dietary/nutritional support As the Hospital Groups develop into collaborative The skill set and role of a surgical access coordinator and the resolution of social needs that may have integrated networks, it is hoped that the paediatric The national clinical programme in anaesthesia is at is different from the role of waiting list manager, and been identified. peri-operative groups from individual hospital sites will an advanced stage in the development of a national it is important that their roles and responsibilities are come together into a single Hospital Group PPOGG, standardised foundation programme in anaesthesia/ not confused. 9.14 Healthcare assistant/support staff in order to service needs across all hospital sites within ______recovery room nursing for nurses and midwives. This the Hospital Group. This would enable delivery of programme comprises core theoretical lectures and 9.11 Paediatric anaesthesia nursing policy The role of healthcare assistants/support staff in the considerable economies of scale and full utilisation core competencies, with a component in paediatric recommendation ______peri-operative setting is well established. The service of scarce resources, while simultaneously balancing anaesthesia. provided by these staff enables rapid turnover of the needs of patients to receive as much of their For hospitals providing anaesthesia for children, PPGs cases and greater efficiency and effectiveness in care locally as is both possible and appropriate. 9.10 Nurse management that clearly define the roles and responsibilities of the ______service delivery within the theatre environment. peri-operative nurse in caring for a child undergoing 9.17 National leadership of paediatric services ______The paediatric nursing staff should be supported by any form of anaesthesia should be in place. 9.15 H ospital administration/clerical officer/ a nursing framework of governance for quality and The hospital policies must be evidence based. secretarial staff Government policy adopted in June 2014 states that ______safety, as delineated by local service decision-makers. Such policies may be guided by the Association of the New Children’s Hospital will be the central player in The agreed nurse management structure should Anaesthetists of Great Britain and Ireland (AAGBI) Dedicated administration staff are key team an integrated clinical network for paediatrics services support the development of a clinical directorate and by the British Anaesthetic and Recovery Nurses members, as they ensure: on the island of Ireland. It is to be expected that the structure through PPGs, strategic planning of the unit, Association (BARNA). • Effective and efficient running of pre-admission New Children’s Hospital will take on this leadership and implementation of the recommendations of the units position, coordinating input and contributions from paediatric unit leadership team. 9.12 Peri-operative nursing – future trends ______• Effective and efficient running of the theatre the relevant paediatric clinical programmes, and complex – the productive operating theatre facilitating the implementation of their models of It is likely that the nurse manager will take on a • Cannulation and vene-puncture (in hospitals • Effective and efficient running of day surgery care, including this Model of Care for Paediatric leadership role within the paediatric unit user group. with a sufficient patient throughput) units Anaesthesia. • Nurse prescribing (valuable for providing pain • Ensure that most patients are management by Role relief during recovery period) day of surgery admission – DOSA While this document is focused on the narrow area of 1 Promote and maintain the highest standards • Nurse-led extubation (increases efficiency in paediatric anaesthesia, the reality is that any clinical and quality care based on individual patient the theatre department) 9.16 M anagement of a paediatric anaesthesia service design and delivery involves considerable needs. • Pre-operative admission units service overlap, crossover and interdependency within other ______2 lead, direct and support the nursing team in • Advanced nurse practitioner in paediatric clinical specialities. Alterations of clinical services in the delivery of safe quality patient care. anaesthesia 9.16.1 Meetings one area generally impacts on service providers 3 encourage and ensure that staff are supported • Weekly meetings to plan service delivery, elsewhere within the local hospital, or further afield in achieving the required education and Although the above roles/skills are not practised workload etc. within the Hospital Group and nationally. competencies. at a national level currently, our aim is that all • Monthly meetings to review quality and 4 develop PPGs in line with safe quality evidence- nurses involved in paediatric anaesthesia would efficiency of the paediatric surgery pathway Given the specific nature of specialist services in based practice. have the opportunity to achieve these standards. • Regular, scheduled meetings of the Paediatric paediatrics, this situation becomes polarised very As recommended for consultant anaesthetists, Peri-operative Group (PPOGG) allow for rapidly. For example, should a local hospital at 9.10.1 Clinical nurse specialist (CNS) opportunities should be afforded to nurses from mixed ongoing paediatric peri-operative services some distance from Dublin decide to no longer A clinical nurse specialist (CNS) may be appointed adult/paediatric hospitals, with limited exposure to a assessment. This group should refer wider anaesthetise children aged under five years, these

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patients would need to find care elsewhere – either National Model of Care for Paediatrics. This Model of be provided in each hospital location must be clearly within their Hospital Group or further afield. Care for Paediatric Anaesthesia will form part of the defined; there is also a need to define what age group National Model of Care for Paediatrics. and ASA classification each hospital will cover. Each Another relevant example is the dependency The Children’s Hospital Group, in collaboration with specialty needs to define the number of procedures of paediatric surgery on paediatric anaesthesia, the other six geographically based Hospital Groups, that will need to be carried out on paediatric patients paediatric pain services, general paediatric will plan and design a network for paediatric service in order to maintain competencies. medicine, paediatric transport medicine and delivery. paediatric intensive care medicine. Alterations to The findings should feed into the National Paediatrics services within any one of these specialities will have This network will form the structure through which the Model of Care, outlining delivery of care for children. consequences, planned or unintended, on related National Model of Care for Paediatrics and other Such findings should be signed off by the Department paediatric specialities. Changes to service delivery national clinical programmes, including Paediatric of Health, the HSE and all key stakeholders. The need to be managed in a planned and controlled Anaesthesia, Paediatric Critical Care, Paediatric Paediatric Anaesthesia Model of Care forms part of fashion. Surgery and Medicine, will be implemented. a much bigger picture.

A National Paediatric Steering Group could 9.18 Future planning of national paediatric incorporate a National Paediatric Peri-Operative services In Ireland ______Steering Group. These steering groups could take leadership roles in informing the design and potential The funding model needs to be reviewed. Certain impact of new service planning and service jurisdictions favour a central agency for delivery of reconfiguration. The National Paediatric Steering paediatric services with an independent budget. Group could also take a leadership role in the Some jurisdictions favour regional funding structures, dissemination of best practice policies, protocols and while others prefer funding to be allocated on a guidelines. The Group would need to be integrated local, unit-by-unit basis. Funding models need to be into the governance of the Acute Hospitals Office, reviewed and evaluated in order to ensure the best in order to allow for effective leadership in the interests of the patients being served. implementation of PPGs. As an interim measure, the National Paediatric Steering Group could be chaired It is our considered opinion that the paediatric by the National Lead in Paediatrics, until such time as budget, including the peri-operative services budget, a more permanent solution is found. should be separate in each Hospital Group.

The development of appropriate terms of reference Considerable work needs to be done in order to for a National Paediatric Steering Group and a clearly identify which units will provide paediatric National Paediatric Peri-Operative Steering Group care, and what types of facilities and appropriate would be a key first step in understanding the staffing are required. Such work needs to be carried potential roles and responsibilities of such bodies. out on a partnership basis, and needs to involve key However, it is clear that national leaders from the stakeholders in consultation with service users. This relevant clinical specialities would welcome such a work needs to be evidence based; it needs to use move; indeed, they are already strongly advocating the best and most reliable activity data, and it needs for the establishment of terms of reference. to take into account international best practice in the delivery of paediatric care. In time, it is expected that these clinical governance structures will be superseded by the structures put in Infants, and particularly neonates, undergoing place to deliver the roles and responsibilities of the anaesthesia have a significant increased risk. In New Children’s Hospital. 2013, in Ireland in 2013, more than 600 infants were The policy position adopted by the government anaesthetised in locations other than the three in June 2014, in approving the Project Brief for the children’s hospitals. All of these children should new children’s hospital, is for the New Children’s have been referred to a regional centre where Hospital to act as the central player in an integrated appropriately trained staff, including paediatricians, clinical network for paediatrics on the island of are readily available. Ireland. The Hospital Groups’ service delivery model will implement the service design modelled in the Details of what services (and in what speciality) will

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10. ABBREVIATIONS

AAGBI Association of Anaesthetists of Great Britain and Ireland M&M Morbidity and mortality ANZCA Australian & New Zealand College of Anaesthetists MDT Multidisciplinary team AORN Association of Operating Room Nurses MRI Magnetic resonance imaging APAGBI Association of Paediatric Anaesthetists of Great Britain and Ireland NAP National Audit Project APLS Advanced paediatric life support NCEPOD National Confidential Enquiry into Patient Outcome and Death ASA American Society of Anaesthesiologists NCH New Children’s Hospital BARNA British Anaesthetic and Recovery Nurses Association NCHD Non-consultant hospital doctor CAI College of Anaesthetists of Ireland NCPA National Clinical Programme in Anaesthesia CEO Chief executive officer NICU Neonatal intensive care unit CHICA Children’s Hospital Intensive Care Ambulance NIV Non-invasive ventilation CNM Clinical nurse manager NMBI Nursing and Midwifery Board of Ireland CNS Clinical nurse specialist NMTP National Transport Medicine Programme CPD Continuous professional development NNTT National Neonatal Transport Team CUHTS Children’s University Hospital Temple Street NPSA National Patient Safety Agency DNA Did not attend NRP Neonatal Resuscitation Programme DNV Det Norske Veritas NSAIDS Non-steroidal anti-inflammatory drugs DoH Department of Health NTMP National Transport Medicine Programme DOSA Day of surgery admission NTPF National Treatment Purchase Fund ECG Electrocardiograph OLCHC Our Lady’s Children’s Hospital Crumlin ECLS Extracorporeal life support PACU Post-anaesthetic care unit ECMO Extracorporeal membrane oxygenation PALS Paediatric advanced life support ENT Ear nose throat PCC Paediatric critical care ESA European Society of Anaesthesiology PCCU Paediatric critical care unit ESRI The Economic and Social Research Institute PEWS Paediatric early warning score ETT Endotracheal tube PICU Paediatric intensive care unit GA General anaesthesia PLS Paediatric life support HDU High dependency unit PONV Post-operative nausea/vomiting HIPE Hospital In-Patient Enquiry PPGs Policies, protocols and guidelines HIQA Health Information and Quality Authority PPOG Paediatric Peri-operative Group HSCP Health and social care professionals PTR Patient Treatment Register HSE Health Service Executive RCoA Royal College of Anaesthetists ICU Intensive care unit ROI Republic of Ireland IPAN Irish Paediatric Anaesthetic Network SAT Specialist anaesthesia trainee IPATS Irish Paediatric Acute Transport Service SOP Standard operating policy ISBAR Identify, situation, background, assessment and recommendation TORs Terms of reference IV Intravenous TPOT The productive operating theatre KPI Key performance indicator WHO World Health Organization LMA Laryngeal mask airway WTE Whole-time equivalent

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11. NATIONAL CLINICAL PROGRAMME FOR ANAESTHESIA 12.  ACKNOWLEDGEMENTS

(NCPA) MODEL OF CARE FOR PAEDIATRIC On behalf of the National Clinical Programme for Anaesthesia, Dr Bairbre Golden and Dr Billy Casey would like to personally acknowledge the many considerable contributions made, and would like to thank Dr Aine Carroll, ANAESTHESIA STEERING/WORKING GROUP Director, Clinical Strategy and Programmes Division; Dr Tony O’Connell, Director, Acute Hospitals; Ms Aveen MEMBERSHIP Murray, Clinical Strategy and Programmes Division; Ms Carmel Cullen, National Communications Division ; Ms Maureen Flynn, Quality Improvement Division Lead; Dr Michael Shannon, National Director, Office of Nursing Model of Care for Paediatric Anaesthesia Steering Group and Midwifery Services Directorate; Ms Geraldine Shaw, Director of Nursing and Midwifery/National Clinical Dr Bairbre Golden, Clinical Director, National Clinical Programme of Anaesthesia (Chair) Programmes, IADNAM, DONMRG; Ms Rosemary Clerkin, CNF, Our Lady’s Children’s Hospital, Crumlin; Ms Deirdre Dr Billy Casey, Consultant Anaesthetist, Our Lady’s Children’s Hospital, Crumlin O’Shea, CNMII, Pain Medicine, National Children’s Hospital, Tallaght; Ms. Tuna Cassidy, CNMII, Children’s University Dr Kevin Bailey, Consultant Anaesthetist, AAGBI Representative Hospital, Temple Street Mr Fergal Quinn, Clinical Lead, Paediatric Surgery Programme Ms Helen Byrne, Head of Planning and Performance, Acute Hospitals, HSE Dr Jacinta McGinley, Consultant Anaesthetist, Our Lady’s Children’s Hospital, Crumlin Ms Suzanne Dempsey, Group Director of Nursing, Children’s University Hospital, Temple Street Ms Grainne Bauer, Divisional Nurse Manager, Children’s University Hospital, Temple Street Dr Cathy McMahon, Consultant Anaesthetist, Paediatric Critical Care, Our Lady’s Children’s Hospital, Crumlin Professor Alf Nicholson, Clinical Lead, Paediatric Clinical Programme Dr John Murphy, Clinical Lead, Neonatal Clinical Programme Dr Dermot Doherty, Clinical Lead, Paediatric Transport Dr Kevin Murray, General Surgeon, Kerry General Hospital Dr John Stokes, Ophthalmologist, Waterford General Hospital Ms Aileen O’Brien, Anaesthetic Nurse Lead, National Clinical Programme of Anaesthesia Ms Una Quill, Programme Manager, National Clinical Programme of Anaesthesia

Model of Care for Paediatric Anaesthesia Working Group Dr Billy Casey, Consultant Anaesthetist, Our Lady’s Children’s Hospital, Crumlin (Chair) Dr Bairbre Golden, Clinical Director, National Clinical Programme of Anaesthesia Dr Anthony Hennessy, Consultant Anaesthetist, South Infirmary Hospital, Cork Dr Wouter Joncker, Consultant Anaesthetist, Sligo General Hospital Dr Brendan McGarvey, Consultant Anaesthetist, Children’s University Hospital, Temple Street Dr Dara Diviney, Consultant Anaesthetist, Our Lady of Lourdes Hospital, Drogheda Dr Robert Whitty, Consultant Anaesthetist, Tallaght Hospital Dr Gerry Coughlan, Consultant Anaesthetist, Dr Marcella Lanzinger, Consultant Anaesthetist, South Tipperary General Hospital Dr Michael Callaghan, Consultant Anaesthetist, Galway University College Hospital Dr Branislav Mislovic, Consultant Anaesthetist, Our Lady’s Children’s Hospital, Crumlin Mr Paul Harding, CNMII, Hospital Design Coordinator, Children’s Hospital Group Ms Aileen O’Brien, Anaesthetic Nurse Lead, National Clinical Programme of Anaesthesia Ms Una Quill, Programme Manager, National Clinical Programme of Anaesthesia Dr John Chandler, Consultant Anaesthetist, Cork University Hospital Dr Klaus Pollmann-Daamen, Consultant Anaesthetist, Kerry General Hospital Dr Liam Claffey, Consultant Anaesthetist, APAGBI Dr Jennifer McElwain, Consultant Anaesthetist, Galway University College Hospital

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Appendix A – Sample Quality Improvement Project Record Sheet References Campling, E.A., Devlin, H.B. & Lunn, J.N. (1990) Report of the National Confidential Enquiry into Perioperative Deaths 1989. NCEPOD, London. ______Lunn, J.N. (1992) Implications of the National Confidential Enquiry into Perioperative Deaths for Paediatric Anaesthesia. Paediatric Anaesthesia 2, 69-72. ______Arul, G.S. & Spicer, R.D. (1998) Where should paediatric surgery be performed? Archives of Disease in Childhood 79, 65-72. ______RCoA (2002) President’s letter to colleagues. Royal College of Anaesthetists, 8 August 2002. ______BAPS (2006) Joint statement on General Paediatric Surgery provision in District General Hospitals. Retrieved from wwwbaps.org.uk/index.html ______ANZCA (2008) Statement on Anaesthesia Care of Children in Healthcare Facilities without Dedicated Paediatric Facilities. Australian and New Zealand College of Anaesthetists, Melbourne. ______RCSENG (2013) Standards for Children’s Surgery. Children’s Surgical Forum of the Royal College of Surgeons of England, London. ______Wilkinson, K.A., Brennan, L.J. & Rollin, A.M. (2014) Guidelines for the provision of paediatric anaesthesia services. Retrieved from www.rcoa.ac.uk/gpas2014 on ______Getting the right start. National service framework for children: standard for hospital services. DH, London 2003) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Consultations/Closedconsultations/ DH_4085150 ______Delivering a healthy future. An action framework for children and young people’s health in Scotland. Scottish Executive, 2007 (www.scotland.gov.uk/Resource/Doc/165782/0045104.pdf). ______National service framework for children, young people and maternity services. Welsh Assembly Government, 2004 www.wales.nhs.uk/sites3/Documents/441/EnglishNSF_amended_final.pdf ______Surgery for children: delivering a first class service. R Col Surg Eng, London 2007 (www.rcseng.ac.uk/publications/docs/CSF.html 2012) Report of the children and Young People’s Health Outcomes Forum. ______Scottish Executive (2009) General Surgery of Childhood. National Steering Group for Specialist Children’s Services. Scottish Executive, Edinburgh. ______NHS Wales (2008) All Wales Universal Standards for Children and Young People’s Specialised Healthcare Services. National Health Service, Wales. ______DHSSPS (2010) Improving Services for General Paediatric Surgery – policy and standards of care for general paediatric surgery. Department of Health, Social Services and Public Safety, Northern Ireland. ______RCoA (2013) The CPD Matrix. Royal College of Anaesthetists, London. ______RCSENG (2010) Ensuring the provision of general paediatric surgery in the District General Hospital: guidance for commissioners and service providers. Children’s Surgical Forum of the Royal College of Surgeons of England, London. ______NCEPOD (2011) Surgery in children: Are we there yet? A review of organisational and clinical aspects of children’s surgery. NCEPOD, London 2011. ______Welsh Government (2009) Children and young people’s specialised services project (CYPSSP): All Wales anaesthesia and surgery standards for children and young people’s specialised healthcare services. Welsh Government. Diagram above - Institute for Healthcare Improvement (IHI) Plan-Do-Study-Act (PDSA) Worksheet (http://www.ihi.org/IHI/Topics/Improvement/ ______ImprovementMethods/Tools/Plan-Do-Study-Act+(PDSA)+Worksheet.htm accessed 29February 2012

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Resuscitation Council (UK) (2013) Suggested Equipment for the Management of Paediatric Cardiopulmonary Arrest (0-16 years) (excluding resuscitation at birth). Resuscitation Council (UK), London. ______AAGBI (2010) The Anaesthesia Team 3. Association of Anaesthetists of Great Britain and Ireland, London. PICS (2010) Standards for the care of critically ill children (4th edn). Paediatric Intensive Care Society, London. ______Standards of Practice. AAGBI (2007) Recommendations for standards of monitoring during anaesthesia and recovery (4th edn). BARNA (2012) British Anaesthetic and Recovery Nurses Association, London. An Bord Altranais (2000) Scope of Nursing and Midwifery Practice Framework. An Bord Altranais, Dublin. Association of Anaesthetists of Great Britain and Ireland, London. ______National Consent Policy. MHRA (2013) Codeine: restricted as an analgesic in children and adolescents after European Safety Review. HSE (2013) Retrieved from http://www.hse.ie/eng/about/Who/ Drug Safety Update 11, (6). Medicines and Healthcare Products Regulatory Agency, London. qualityandpatientsafety/National_Consent_Policy/consenttrainerresource/trainerfiles/ ______NationalConsentPolicyM2014.pdf RCoA (2014) Guidance on the provision of anaesthesia services for acute pain management. Royal College of ______National Policy and Procedure for Safe Surgery. Anaesthetists, London. HSE (2013) Retrieved from http://www.hse.ie/eng/about/Who/ ______qualityandpatientsafety/safepatientcare/safesurg14june.pdf Pharmaceutical Press (2013) British National Formulary for Children 2013-2014. Pharmaceutical Press, London. ______WHO (2009) WHO Guidelines for Safe Surgery. World Health Organization, Geneva. APAGBI (2012) Good practice in Postoperative and Procedural Pain (2nd edn). Association of Paediatric ______Anaesthetists of Great Britain and Ireland, London. Press Room. Association of Perioperative Registered Nurses Partners with Elsevier to Publish AORN Journal. ______Retrieved from www.nursingconsult.com/about/pressroom/pr_may_01_06.html BADS (2007) Issues in paediatric day surgery. British Association of Day Surgery, London. ______National Patient Safety Agency (28th March 2007). Promoting safer use of injectable medicines. Patient Safety RCPCH (2012) Standards for Children and Young People in Emergency Care Settings (3rd edn). Royal College Alert 20. of Paediatrics and Child Health, London. ______www.ismp.org/tools/guidelines/smartpumps/printerversion.pdf Department of Health UK (2009) Toolkit for High-Quality neonatal services (Gateway reference 12753). Department of Health, London. ______What is Quality Improvement and How can it Transform Healthcare Quality & Safety in Healthcare February Department of Health UK (2005) The acutely or critically sick or injured child in the District General Hospital: A 2007 16(1)2-3 team response. Department of Health, London. ______RCoA (2010) Joint statement from the Society of British Neurological Surgeons and the Royal College of Institute for Healthcare Improvement (IHI) Plan-Do-Study-Act (PDSA) Worksheet (http://www.ihi.org/IHI/Topics/ Anaesthetists regarding the provision of emergency paediatric neurosurgical services. Royal College of Improvement/ImprovementMethods/Tools/Plan-Do-Study-Act+(PDSA)+Worksheet.htm accessed 29 February Anaesthetists, London. ______2012 RCoA (2013) Continuing Professional Development: Guidance for doctors in anaesthesia, intensive care and pain medicine. Royal College of Anaesthetists, London. ______RCoA (2013) Raising the standard: a compendium of audit recipes for continuous quality improvement in anaesthesia (3rd edn). Royal College of Anaesthetists, London. ______GMC (2013) Good medical practice. General Medical Council, London. ______RCPCH (2000) Guidelines for the ethical conduct of medical research involving children. Archives of Disease in Childhood 82, 177-182. ______RCoA Safety in Anaesthesia. Royal College of Anaesthetists, London. ______RCoA (2012) Patient Safety Update – January 2012 to March 2012. Royal College of Anaesthetists: Safe Anaesthesia Liaison Group (SALG). Retrieved from www.rcoa.ac.uk/node/588 on ______AAGBI (1995) The National Survey of Paediatric Anaesthetic Practice in General Hospitals in the Republic of Ireland, Association of Anaesthetists of Great Britain and Ireland, London. ______ESRI (2011) Activity in Acute Public hospitals in Ireland: Annual Report 2010. Economic and Social Research Institute, Health Research and Information Division, Dublin. ______Jonker, W.R., Hanumanthiah, D., Ryan, T., Cook, T.M., Pandit, J.J., O’Sullivan, E.P. & NAP 5 Steering Panel (2014) Who operates when, where and on whom? A survey of anaesthetic-surgical activity in Ireland as denominator of NAP5. Anaesthesia 69, 961–8.

http://www.ntpf.ie/home/nwld.htm http://www.ntpf.ie/home/PDF/ChildAdult%20Waiting%20Times.pdf http://www.ntpf.ie/home/PDF/GI%20Endoscopy%20Hospital%20Trend%20Analysis.pdf http://www.ntpf.ie/home/PDF/Hospital%20Trend%20Analysis%20of%20Waiting%20Times.pdf

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MODEL OF CARE FOR PAEDIATRIC ANAESTHESIA

NATIONAL CLINICAL PROGRAMME FOR ANAESTHESIA