Surgeons, anesthesiologists develop resource standards for optimal pediatric care

The American College of Surgeons (ACS) has published new comprehensive guidelines that define the resources the nation’s surgical facilities need to perform operations effectively and safely in infants and children.  The standards—published in the March issue of the Journal of the American College of Surgeons—also have the approval of the American Pediatric Surgical Association and the Society of Pediatric Anesthesia.*  Representatives of these organizations as well as invited leaders in other pediatric medical specialties, known as the Task Force for Children’s Surgical Care, developed the consensus recommendations over the past three years.

“The intent of these recommendations is to ensure that all infants and children in the U.S. receive care in a surgical environment matched to their individual medical, emotional, and social needs,” said Keith T. Oldham, MD, FACS, task-force chair and the surgeon-in-chief at Children’s Hospital of Wisconsin, Milwaukee.

Many studies show better results—including fewer complications and shorter hospital stays—when newborns and children undergo surgical procedures in environments that have expert resources for pediatric patients, compared with non-specialized centers.

In its report, the Task Force for Children’s Surgical Care defined the proper surgical environment for children as one “that offers all of the facilities, equipment, and, most especially, access to the professional providers who have the appropriate background and training to provide optimal care.”

The task force assigned levels of resources, as the ACS has done for trauma centers for decades. The classification for children’s surgical centers is as follows:

  • Level I (highest level): Possesses adequate resources to provide comprehensive surgical care and perform both complex and noncomplex surgical procedures in newborns and children of all ages, including those with the most severe health conditions and birth defects.  Is staffed 24 hours a day, seven days a week with properly credentialed pediatric specialists, including pediatric and subspecialty surgeons, pediatric anesthesiologists, pediatric diagnostic and interventional radiologists, and pediatric emergency physicians. Has a Level IV neonatal intensive care unit (NICU), the highest level of critical care for newborns.
  • Level II: Possesses adequate resources to provide advanced surgical care for children of all ages, including those who have accompanying (“comorbid”) medical conditions. Operations would typically be performed by a single surgical specialty. Personnel include a board certified pediatric surgeon, pediatric anesthesiologist, and pediatric radiologist with other pediatric specialists readily available for consultation, and has an emergency physician and an intensive care unit that both have pediatric expertise. Has a Level III or higher NICU.
  • Level III: Possesses adequate resources to provide basic surgical care and perform common, low-risk surgical procedures in children older than one year who are otherwise healthy. Has a general surgeon, anesthesiologist, radiologist, and emergency physician, all of whom have pediatric expertise. Has a Level I NICU (well-newborn nursery) or higher.

Both Level II and III surgical centers must be able to stabilize and transfer critically ill children to a hospital with higher-level resources. All children’s surgical centers must have at least one pediatric surgical nurse, a pediatric rapid response team of critical care professionals available at all hours, and an in-house physician with Pediatric Advanced Life Support certification or equivalent qualifications. Furthermore, all areas of these centers must have the resources needed to perform pediatric resuscitation.

Additional guidelines for ambulatory, or outpatient, surgical centers include having preoperative and recovery areas dedicated to pediatric patients. Also according to the task force report, a pediatric anesthesiologist at an ambulatory surgical center should administer or supervise the administration of a general anesthetic or sedative to all infants younger than one year old.

Acknowledging that the standards are high, ACS Executive Director David B. Hoyt, MD, FACS, a member of the Task Force for Children’s Surgical Care, added, “I think many hospitals will rise to these new standards by adding resources.”

In designating the resources that children’s surgical centers need, the Task Force for Children’s Surgical Care reportedly relied on published scientific evidence and expert opinion. According to Dr. Oldham, supporting evidence included the success of the ACS’ nationwide classification and verification system for trauma centers. By helping ensure that injured patients receive care at the appropriate level, the trauma system has saved many lives, he noted.

Plans are under way to develop criteria for evaluating existing facilities that perform children’s surgical procedures. The ACS will oversee the site verification process, which Dr. Oldham anticipates will become available sometime this year.


*Optimal resources for children’s surgical care in the United States. J Am Coll Surg. 2014;218(3):479-487.e4.

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