Children with complex medical needs, a multidisciplinary challenge
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
- 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.
- 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.
- PATRN. PEACHY (PErioperAtive CHildhood obesity), 2018.
https://www.apagbi.org.uk/sites/default/files/paragraphs/files/
PEACHY%20Study%20Protocol.pdf (accessed 24/6/2021).
- 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).
- 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.