Introduction
Variation in the delivery of care and subsequent outcomes is known to exist in paediatric emergency surgery in the UK. This has been highlighted previously1–5, leading to significant reorganization of the provision of paediatric anaesthetic and surgical services, with a trend towards more centralized care in specialist paediatric centres.
A large proportion of paediatric surgical procedures take place outside of specialist centres2, and many challenges exist in improving paediatric surgical care and in reducing the incidence of perioperative morbidity3. It remains to be determined how the organization and processes involved in delivering paediatric emergency surgical care relate to outcomes. Paediatric emergency general surgery has been identified as a priority area for quality assurance and quality improvement6.
The Children’s Acute Surgical Abdomen Programme (CASAP) is a prospective observational cohort study with the aim of characterizing the care being delivered to children having emergency abdominal surgery in UK hospitals, and to understand factors that may influence outcomes in this patient group7. The Getting It Right First Time (GIRFT) initiative8 conducted a review of paediatric surgical provision in England in 2021, and identified several ways in which improvements in paediatric surgical care might be achieved. Improvements of particular relevance to the CASAP project are: use of newly established operational delivery networks to ensure that all children are treated by experienced teams with the right infrastructure and support; improving the care of children requiring emergency appendicectomy, including the use of a model pathway of care; and improving patient outcomes through strengthening how clinical data are collected, analysed, and shared.
CASAP comprises an organizational survey evaluating structural indicators of quality, and an observational cohort study looking at process and outcome indicators of quality. This categorization of quality is based on the Donabedian model for measuring quality in healthcare settings9. The model divides the measurement of quality into three main groups: structural indicators, such as organizational structure, staff, equipment, facilities, and guidelines; process indicators, for example time to first antibiotics, evidence-based interventions, and care bundles; and outcome indicators, including morbidity, mortality, duration of hospital stay, and patient-reported outcome measures.
Methods
This organizational survey was open from January 2019 to March 2020. The aim was to measure compliance against structural indicators of quality recommended in the current literature10 for hospitals in the UK that perform emergency abdominal surgery in children aged between 1 and 16 years. The survey is reported in Appendix S1.
Results
The authors identified 198 hospitals in the UK where emergency abdominal surgery is performed in children. A total of 134 completed surveys were received, representing a 67.6 per cent response rate (Fig. 1). Of these, 27 (20.1 per cent) were tertiary referral hospitals for paediatric abdominal surgery and 109 (79.8 per cent) were non-tertiary hospitals.
Survey data responses
Tertiary referral centres for paediatric abdominal surgery reported higher individual volumes of elective and emergency paediatric abdominal operations than non-tertiary hospitals, but collectively non-tertiary hospitals performed a larger proportion of the total elective and emergency procedures nationwide (Table 1).
Hospital characteristics
| Overall (n = 134) | Tertiary (n = 27) | Non-tertiary (n = 107) | |
|---|---|---|---|
| No. of paediatric inpatient beds | |||
| < 25 | 51 (38.0) | 0 (0) | 51 (47.7) |
| 25–50 | 51 (38.0) | 6 (22) | 45 (42.1) |
| > 50 | 29 (21.6) | 21 (78) | 8 (7.5) |
| No Response | 3 (2.2) | 0 (0) | 3 (2.8) |
| Inpatient beds that are surgical (%) | |||
| 0 | 29 (21.6) | 0 (0) | 29 (27.1) |
| ≤ 25 | 74 (55.2) | 15 (56) | 59 (55.1) |
| ≤ 50 | 26 (19.4) | 11 (41) | 15 (14.0) |
| ≤ 75 | 1 (0.7) | 0 (0) | 1 (0.9) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| Designated paediatric transfer team | 122 (91.0) | 25 (93) | 97 (90.7) |
| Affiliated with a paediatric surgical network | 81 (60.4) | 19 (70) | 62 (57.9) |
| Affiliated with a paediatric anaesthetic/paediatric critical care unit | 94 (70.1) | 17 (63) | 77 (72.0) |
| No. of elective abdominal procedures per annum | |||
| < 50 | 91 (67.9) | 1 (4) | 90 (84.1) |
| 50–250 | 20 (14.9) | 9 (33) | 11 (10.3) |
| 251–500 | 10 (7.5) | 7 (26) | 3 (2.8) |
| > 500 | 9 (6.7) | 9 (33) | 0 (0) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| No. of emergency abdominal procedures per annum | |||
| < 25 | 22 (16.4) | 0 (0) | 22 (20.6) |
| 25–50 | 31 (23.1) | 1 (4) | 30 (28.0) |
| 51–75 | 28 (21.0) | 2 (7) | 26 (24.3) |
| 76–100 | 16 (11.9) | 3 (11) | 13 (12.1) |
| > 100 | 28 (21.0) | 18 (67) | 10 (9.3) |
| No Response | 9 (6.7) | 3 (11) | 6 (5.6) |
| Overall (n = 134) | Tertiary (n = 27) | Non-tertiary (n = 107) | |
|---|---|---|---|
| No. of paediatric inpatient beds | |||
| < 25 | 51 (38.0) | 0 (0) | 51 (47.7) |
| 25–50 | 51 (38.0) | 6 (22) | 45 (42.1) |
| > 50 | 29 (21.6) | 21 (78) | 8 (7.5) |
| No Response | 3 (2.2) | 0 (0) | 3 (2.8) |
| Inpatient beds that are surgical (%) | |||
| 0 | 29 (21.6) | 0 (0) | 29 (27.1) |
| ≤ 25 | 74 (55.2) | 15 (56) | 59 (55.1) |
| ≤ 50 | 26 (19.4) | 11 (41) | 15 (14.0) |
| ≤ 75 | 1 (0.7) | 0 (0) | 1 (0.9) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| Designated paediatric transfer team | 122 (91.0) | 25 (93) | 97 (90.7) |
| Affiliated with a paediatric surgical network | 81 (60.4) | 19 (70) | 62 (57.9) |
| Affiliated with a paediatric anaesthetic/paediatric critical care unit | 94 (70.1) | 17 (63) | 77 (72.0) |
| No. of elective abdominal procedures per annum | |||
| < 50 | 91 (67.9) | 1 (4) | 90 (84.1) |
| 50–250 | 20 (14.9) | 9 (33) | 11 (10.3) |
| 251–500 | 10 (7.5) | 7 (26) | 3 (2.8) |
| > 500 | 9 (6.7) | 9 (33) | 0 (0) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| No. of emergency abdominal procedures per annum | |||
| < 25 | 22 (16.4) | 0 (0) | 22 (20.6) |
| 25–50 | 31 (23.1) | 1 (4) | 30 (28.0) |
| 51–75 | 28 (21.0) | 2 (7) | 26 (24.3) |
| 76–100 | 16 (11.9) | 3 (11) | 13 (12.1) |
| > 100 | 28 (21.0) | 18 (67) | 10 (9.3) |
| No Response | 9 (6.7) | 3 (11) | 6 (5.6) |
Values are n (%).
Hospital characteristics
| Overall (n = 134) | Tertiary (n = 27) | Non-tertiary (n = 107) | |
|---|---|---|---|
| No. of paediatric inpatient beds | |||
| < 25 | 51 (38.0) | 0 (0) | 51 (47.7) |
| 25–50 | 51 (38.0) | 6 (22) | 45 (42.1) |
| > 50 | 29 (21.6) | 21 (78) | 8 (7.5) |
| No Response | 3 (2.2) | 0 (0) | 3 (2.8) |
| Inpatient beds that are surgical (%) | |||
| 0 | 29 (21.6) | 0 (0) | 29 (27.1) |
| ≤ 25 | 74 (55.2) | 15 (56) | 59 (55.1) |
| ≤ 50 | 26 (19.4) | 11 (41) | 15 (14.0) |
| ≤ 75 | 1 (0.7) | 0 (0) | 1 (0.9) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| Designated paediatric transfer team | 122 (91.0) | 25 (93) | 97 (90.7) |
| Affiliated with a paediatric surgical network | 81 (60.4) | 19 (70) | 62 (57.9) |
| Affiliated with a paediatric anaesthetic/paediatric critical care unit | 94 (70.1) | 17 (63) | 77 (72.0) |
| No. of elective abdominal procedures per annum | |||
| < 50 | 91 (67.9) | 1 (4) | 90 (84.1) |
| 50–250 | 20 (14.9) | 9 (33) | 11 (10.3) |
| 251–500 | 10 (7.5) | 7 (26) | 3 (2.8) |
| > 500 | 9 (6.7) | 9 (33) | 0 (0) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| No. of emergency abdominal procedures per annum | |||
| < 25 | 22 (16.4) | 0 (0) | 22 (20.6) |
| 25–50 | 31 (23.1) | 1 (4) | 30 (28.0) |
| 51–75 | 28 (21.0) | 2 (7) | 26 (24.3) |
| 76–100 | 16 (11.9) | 3 (11) | 13 (12.1) |
| > 100 | 28 (21.0) | 18 (67) | 10 (9.3) |
| No Response | 9 (6.7) | 3 (11) | 6 (5.6) |
| Overall (n = 134) | Tertiary (n = 27) | Non-tertiary (n = 107) | |
|---|---|---|---|
| No. of paediatric inpatient beds | |||
| < 25 | 51 (38.0) | 0 (0) | 51 (47.7) |
| 25–50 | 51 (38.0) | 6 (22) | 45 (42.1) |
| > 50 | 29 (21.6) | 21 (78) | 8 (7.5) |
| No Response | 3 (2.2) | 0 (0) | 3 (2.8) |
| Inpatient beds that are surgical (%) | |||
| 0 | 29 (21.6) | 0 (0) | 29 (27.1) |
| ≤ 25 | 74 (55.2) | 15 (56) | 59 (55.1) |
| ≤ 50 | 26 (19.4) | 11 (41) | 15 (14.0) |
| ≤ 75 | 1 (0.7) | 0 (0) | 1 (0.9) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| Designated paediatric transfer team | 122 (91.0) | 25 (93) | 97 (90.7) |
| Affiliated with a paediatric surgical network | 81 (60.4) | 19 (70) | 62 (57.9) |
| Affiliated with a paediatric anaesthetic/paediatric critical care unit | 94 (70.1) | 17 (63) | 77 (72.0) |
| No. of elective abdominal procedures per annum | |||
| < 50 | 91 (67.9) | 1 (4) | 90 (84.1) |
| 50–250 | 20 (14.9) | 9 (33) | 11 (10.3) |
| 251–500 | 10 (7.5) | 7 (26) | 3 (2.8) |
| > 500 | 9 (6.7) | 9 (33) | 0 (0) |
| No Response | 4 (3.0) | 1 (4) | 3 (2.8) |
| No. of emergency abdominal procedures per annum | |||
| < 25 | 22 (16.4) | 0 (0) | 22 (20.6) |
| 25–50 | 31 (23.1) | 1 (4) | 30 (28.0) |
| 51–75 | 28 (21.0) | 2 (7) | 26 (24.3) |
| 76–100 | 16 (11.9) | 3 (11) | 13 (12.1) |
| > 100 | 28 (21.0) | 18 (67) | 10 (9.3) |
| No Response | 9 (6.7) | 3 (11) | 6 (5.6) |
Values are n (%).
Eighty-one hospitals (60.4 per cent) participated in a coordinated paediatric surgical network, and 94 (70.1 per cent) participated in a coordinated anaesthetic/paediatric critical care unit (PCCU) network. Fifty-three hospitals (39.6 per cent) reported a locally agreed pathway for the perioperative care of children undergoing emergency abdominal surgery.
None of the tertiary referral hospitals reported a lower age or weight limit for operating on children. Of the non-tertiary hospitals, 75 (70.1 per cent) had a lower age limit, the most common age being 5 years; 39 reported age limits lower than this. Of those with a lower weight limit, the most common response was 10 kg. All tertiary centres had paediatric surgeons available 24/7, whereas 101 non-tertiary hospitals (94.4 per cent) had general surgeons who would undertake emergency abdominal surgery in children when specialist paediatric surgeons were not available.
Level 2 PCCU care was provided by 127 hospitals (94.8 per cent) on a temporary basis before transfer to a specialist hospital. Sixty-nine hospitals (51.5 per cent) had a permanent level 2 PCCU. Overall, 24-h access to radiology services for children was available in 124 hospitals (92.5 per cent), whereas 96 (71.6 per cent) provided a pain service that was able to address the needs of children.
Seventy-seven hospitals (57.5 per cent) routinely reviewed morbidity and near misses, with 24 (17.9 per cent) saying it would depend on the situation. Thirty-three hospitals (24.6 per cent) formally reviewed outcomes for paediatric abdominal surgery annually.
Discussion
Most hospitals that responded comply with structural indicators of quality care; however, the survey identified areas where the organization of care remains lower than the recommended standards.
With respect to where paediatric abdominal surgery is performed, having fewer centres undertaking higher volumes of procedures may be desirable, but this poses several problems related to capacity at specialist sites, accessibility for parents and children when centres are located far away, and the deskilling of staff in non-tertiary hospitals. Coordinated paediatric surgical and anaesthetic/PCCU networks provide better communication between hospitals, coordination of care, sharing of resources, and benchmarking of standards of care. This survey reflected lower than expected participation in these networks.
Protocolized pathways for the care of children undergoing emergency appendicectomy are associated with reduced duration of hospital stay and fewer readmissions10–12. An easily adaptable pathway for children with emergency surgical presentations is set out in the Royal College of Surgeons of England (RCS) Standards for Non-specialist Emergency Surgical Care of Children11.
Local restrictions on the age and size of children managed in institutions is largely governed by the skill set of available personnel. Tertiary centres reported no limits, and variation was noted in non-tertiary centres. The RCS Standards for Children’s Surgery suggest that all hospitals performing paediatric abdominal surgery should have a permanent level 2 PCCU, but only around half do. For the National Emergency Laparotomy Audit (NELA) study13, the availability of radiological services is an important structural indicator. Pain management is particularly important for children, with ineffective pain management affecting patient experience and outcome. An acute pain service that can effectively accommodate the needs of children may help mitigate this14–16.
A forum in which to discuss near-misses, morbidity, and mortality allows hospitals to identify successes and areas of care that require improvement. Reviewing outcome data to determine how children’s surgical services will be shaped in the future was one of the major recommendations of the GIRFT review8.
As a national perioperative research study, the survey response rate of 69 per cent demonstrates a high level of engagement, although this does not provide a complete picture of paediatric emergency surgical services. Having engagement from major stakeholders is another strength as was their input in the survey design process.
Despite being designed and undertaken before the COVID-19 global pandemic, which led to some subsequent reorganization of paediatric surgical services, the data highlight important structural indicators and areas where compliance can be improved. Regular evaluation of these indicators and sharing of resources (such as pathways and business cases) between hospitals may support improved adherence to standards in general.
In conclusion, this national survey, which included almost 70 per cent of hospitals delivering paediatric emergency surgery, identified challenges in adhering to national recommendations surrounding the structural aspects of high-quality paediatric care. Lessons learned from NELA over many years indicate that such structural challenges are both linked to patient outcomes and prove harder to address than many patient-level processes. Evaluation of patient-level processes and outcomes will be available soon through the recently completed CASAP study, and will provide further information on the quality of paediatric emergency surgical care.
Funding
There was no direct funding for this project. The lead author’s Master of Science in Perioperative Medicine was funded by the Department of Perioperative Medicine at University College London Hospitals, for which this project formed the dissertation.
Author contributions
Andrew Selman (Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing—original draft, Writing—review & editing), Lisa Sogbodjor (Conceptualization, Methodology, Project administration, Writing—review & editing), Karen Williams (Project administration), Mark Davenport (Writing—review & editing), and Ramani Moonesinghe (Conceptualization, Methodology, Supervision, Writing—review & editing).
Disclosure
The Royal College of Anaesthetists provided meeting rooms and lunch for the CASAP Project Team Meetings. The research sponsors for the CASAP Project were the Health Services Research Centre (HSRC), the Association of Paediatric Anaesthetists of Great Britain and Ireland, and the British Association of Paediatric Surgeons (BAPS). S.R.M., Chair of the HSRC, chaired the CASAP Project Team Meetings at which the design of the survey was formally discussed, and was involved in reviewing the final manuscript. L.A.S., HSRC Fellow, was also involved in the design of the survey and in reviewing the final manuscript. M.D., previously President of BAPS, was involved in reviewing the final manuscript. Data collection, analysis, and presentation of data was undertaken by A.M.R.S. alone. The authors declare no other conflict of interest.
Supplementary material
Supplementary material is available at BJS online.
Data availability
The data for this Short Report will be available as follows. Survey questions are appended as supplementary material. Raw data for answers to the survey questions will be made available as a Microsoft® Excel spreadsheet (Microsoft, Redmond, WA, USA) if requested.
References
Author notes
A summary of the survey data was presented to the Association of Paediatric Anaesthetists of Great Britain and Ireland Annual Scientific Meeting, Cardiff, UK, May 2022; published in abstract form as Pediatric Anesthesia 2022. https://doi.org/10.1111/pan.14595
