Children with complex medical needs, a multidisciplinary challenge | Association of Anaesthetists
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Children with complex medical needs, a multidisciplinary challenge

Children with complex medical needs, a multidisciplinary challenge

illustration-it's-not-who-you-know

We are required to provide safe anaesthesia for children and young people with multiple co-morbidities for a wide range of procedures from MRI scans to major surgery, and they may therefore require input from a number of specialties for their peri-operative management. Through building our pre-operative care service at Sheffield Children’s Hospital, we have discovered ways to overcome some of these challenges.

The early bird catches the worm

In our experience, children with complex needs require early referral to pre-operative care to allow sufficient time for information gathering, optimisation and discussion, with referral at the point of booking being the best-case scenario. Many centres have a ‘one-stop shop’ model of pre-operative care, enabling the majority of the pre-operative screening to take place at this point.

Information, information, information

Information is the key for thorough assessment of a complex patient. In our organisation, a detailed health screening questionnaire completed by the carer or a health professional is the first port of call. This, along with a notes review, can usually provide most of the necessary information. However, these complex children may be treated at a number of different hospitals, so external notes are frequently required. We have found that access to SystmOne, the primary care IT system, can be an efficient method to access the latest clinic letters in cases where shared access is allowed. Recording of comorbidities that allows correct clinical coding also ensures that case complexity is reflected in hospital data, allowing comparisons with other centres and the potential to attract financial uplifts.

It’s not what you know, it’s who you know

Building good links with other specialities has been an incredibly important part of developing our pre-operative care service. We established early links with those with whom we were in regular correspondence, including the cardiology, haematology, endocrine and metabolic teams. Writing peri-operative guidelines in conjunction with the parent team(s) to promote consistency within the pathway was an excellent way to further build upon these links. Once each guideline was completed, the speciality consultant and/or specialist nurse presented at our education sessions to explain the guideline and the reasoning behind the guidance, thereby extending the links to the rest of the pre-operative team.

Multidisciplinary discussions are conducted via letter, email, telephone, video meeting or face-to-face. The majority are conducted over email, with a clear question asked of the parent specialty. All discussions must be recorded in the patient notes to follow GMC guidance.

Optimisation = marginal gains

Although published evidence is minimal, a number of conditions can be optimised before a procedure involving anaesthesia. Making use of a teachable moment when parents, carers and young people are motivated to adopt a behavioural change aims to improve not just the patient’s peri-operative health, but also long term health after the procedure.

Respiratory optimisation in asthma can be done using the Asthma Control Test, with a referral back to the GP, asthma nurse or respiratory consultant if required. Children who suffer recurrent chest infections may benefit from pre-operative antibiotics. Children who are exposed to environmental tobacco smoke are twice as likely to suffer a peri-operative respiratory adverse event [1]. We screen for these children in the health questionnaire and offer Very Brief Advice intervention to the smoker(s) in the family, aiming to trigger a quit attempt.

Children with anaemia may be more likely to have adverse peri-operative outcomes including death and blood transfusion [2]. Our surgeons request a full blood count when booking for a major procedure. Iron deficiency anaemia can be identified easily through the red cell indices and subsequent correction arranged via the GP with oral iron; however in some cases, intravenous iron may be appropriate.

Childhood obesity is a growing problem and the recent PEACHY (PErioperAtive CHildhood obesity) study has highlighted that surgical patients have a higher prevalence of obesity compared to the general population [3]. Paediatric weight management services across the country vary significantly, so it is important to get to know which local services are available and refer appropriately. Generic online resources are available via links such as ‘change4life’ and ‘Moving Medicine’.

‘Mini mouth care matters’ is a Health Education England initiative to address the appalling level of tooth decay in children. Dental decay has an impact on children’s wellbeing and school attendance, and has massive financial implications for the NHS [4]. The adult I COUGH programme has shown that, along with other inventions, improving oral care pre-operatively can reduce postoperative chest infections [5].

Improved pre-operative control of diabetes, in collaboration with the diabetes specialist team, has the potential to reduce peri-operative risk.

There is increasing investment to tackle the causes of preventable deaths in people with a learning disability and/ or autism. This will be facilitated by improving the uptake of the existing annual health check in primary care for people aged over 14 years with a learning disability. Pre-operative care services can encourage patients to engage in this process.

Before the pandemic, we were bound by the 18-week waiting time target. Currently most hospitals now have longer waits for less urgent procedures, so we can use this extra time in a positive way to optimise children’s health.

Consultation with the family

Families often provide feedback about how reassured they feel when they have been provided with all the relevant information and opinions. This can then lead to more productive discussions about the different treatment options and peri-operative risks, while re-emphasising the importance of pre-operative optimisation.

Peri-operative medicine communication skills courses promote the advanced communication skills required when dealing with shared decision making, risk communication and using the teachable moment.

Peri-operative plans

Once the date of the procedure has been confirmed, the peri-operative plan should be communicated with all stakeholders in the process: the family; the admission and post-operative ward(s); theatres and recovery; and other allied health professionals such as play specialists, dieticians and physiotherapists. This requires sometimes superhuman communication! Various systems to manage this flow of information can be employed, including ward diaries, emails and theatre IT systems, an area that we are currently improving at Sheffield Children’s Hospital.

In summary, children with complex needs require pre-operative screening, optimisation, consultation, planning and coordination to facilitate a safe peri-operative pathway, and we paediatric anaesthetists need to develop these systems.

Nadia Ladak
Consultant Paediatric Anaesthetist
Preoperative Care Clinical Lead Sheffield Children’s Hospital NHS Foundation Trust

References 

  1. Riley C, Ladak N. Reducing pediatric exposure to environmental tobacco smoke: the effects of pediatric exposure to environmental tobacco smoke and the role of pediatric perioperative care. Pediatric Anaesthesia 2020; 30: 1199-203. 
  2. Faraoni D, DiNardo JA, Goobie SM. Relationship between preoperative anemia and in-hospital mortality in children undergoing noncardiac surgery. Anesthesia and Analgesia 2016; 123: 1582-7. 
  3. PATRN. PEACHY (PErioperAtive CHildhood obesity), 2018. https://www.apagbi.org.uk/sites/default/files/paragraphs/files/ PEACHY%20Study%20Protocol.pdf (accessed 24/6/2021). 
  4. Health Education England. Mouth care matters. Children, 2019. https://mouthcarematters.hee.nhs.uk/about-the-programme/ children/#:~:text=Mini%20Mouth%20Care%20Matters%20 aims%20to%20encourage%20all,basic%20general%20health%20 care%20needs%20for%20all%20in-patients (accessed 24/6/2021). 
  5. Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surgery 2013; 148: 740-5.

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