EXECUTIVE SUMMARY

Surgery centers can provide a place for pediatric surgeries, helping their communities and giving families an affordable alternative to hospital inpatient procedures.

• Adding pediatric procedures requires preparation and additional skills sets.
• Surgery centers should know the risks of anesthesia for children and screen them for sleep apnea.
• With children as patients, it also is important to create a stress-free environment.

ASCs can provide space for some of the more common pediatric surgeries, including ear, nose, and throat (ENT) procedures, but it will require some flexibility and creative thinking.

“If you are trying to put kids into an existing place, then you have to see things from a different point of view to have it work well,” says Steven Butz, MD, professor of anesthesiology at the Medical College of Wisconsin. “It can work fine and can generate income, but you should be doing it for the right reasons — for the best interests of the kids, and start with that.”

One of the benefits to adding pediatric procedures to an ASC is that it is a service to the community, providing families with an affordable alternative for procedures that might otherwise take them to hospitals that are hours away, Butz offers. “Families can have a surgeon they are familiar with and who has been treating their child instead of being referred to a big city hospital that they’re not familiar with,” he says.

Surgery center administrators should keep in mind that adding pediatric procedures to the mix can involve some anesthesia challenges. For instance, common pediatric issues are respiratory infection, asthma, congenital heart disease, and sleep apnea.¹

“With anything in ambulatory surgery, you want to be prepared to do the things you are offering,” Butz says. “Pediatrics is different from adults. Surgery centers should train both physicians and nursing staff on pediatrics and also know how to pick their patients well.” It also is important to select services carefully. For instance, ASCs could handle ENT, general surgery, circumcisions, and tonsillectomies. Butz highlights some considerations for ASCs wishing to add pediatric surgeries:

• Define the population and assess risks. ASCs might focus heavily on ENT, but also include some dental work and orthopedic procedures. “If you’re doing tonsillectomies, then have special discussions about what the age cutoff will be,” Butz says.

Also, ASCs will need to know how to assess children for sleep apnea. The STOP BANG tool works well for adults with possible sleep apnea. But for children, a Snoring, Trouble Breathing, Un-Refreshed (STBUR) rating might work better.²

The STBUR screening addresses five questions: Does your child snore more than half the time? Is the snoring loud enough to hear through a door? While sleeping, does your child struggle to breathe? Does your child stop breathing during the night? Does your child wake up feeling unrefreshed in the morning?

• Meet accreditation agency standards. “You have to make sure that if you’re taking care of these children that you have the equipment to take care of them,” Butz says.

Equipment and instruments need to be designed for children’s size and airways. Also, nurses must be trained (with certification) on pediatric advanced life support, he adds. Some nurses are pediatric nursing care specialists with medical and social skills specific to dealing with children.

• Adjust medication. Smaller children cannot swallow tablets, so their medication will need to be given in liquid form by mouth, Butz says. “With kids, most doctors have them go to sleep with a mask,” he says. “There are different ways to numb the skin so you can start an IV and the child doesn’t feel it.”

• Think about all possibilities. “I recommend that people go into it with their eyes wide open so they can anticipate what kinds of things they will need to change,” Butz offers. “You should know what to do if you have a child wake up screaming in a small recovery area.”

Before adding pediatric cases, ASC leadership should visit another surgery center that already handles pediatric procedures to learn how they manage this service, Butz suggests. “Seeing how someone else does it gives you great ideas of what you think you’re comfortable with and what you need to tackle,” he says. “The more you see and think about before you start, the better you can plan.”

ASC administrators should think about how to establish the right medication, right equipment, right training, and even creating the right place for parents to wait while their children are in the operating room, Butz says.

• Create stress-free environment. “If you’re trying to make it a stress-free environment for kids, one thing that scares children is getting an IV,” Butz says. “This is why surgery centers should find a way to use numbing agents.”

Practitioners also should use devices to help them secure IVs in children so the young patients do not rip them out when they wake up. “Consult with a child life specialist; this can help a lot,” Butz suggests. Other techniques that might help make an ASC more welcoming to pediatric patients include using a cart in the shape of a racecar or spaceship to take children to the operating room. Let children bring a comfort item with them, such as pajamas, blanket, or stuffed animal, and allow a parent to come into the procedure room until the child is asleep. “Clinicians can treat the child’s anxiety with medication,” Butz says. “The big one is pre-op midazolam, a benzodiazepine that relaxes.”

Some surgery centers will ask parents to download a storytelling video on their cellphone or the child’s tablet that the child can watch before going to sleep. “It’s effective and easy to do,” Butz says. One reason ASCs should pay particular attention to how children are brought to sleep is because a stressful experience could lead to PTSD and other problems that could arise after children return home.

“If the child struggles with going to sleep or has bad memories of it, it can develop into a PTSD thing. The child could have nightmares or bedwetting issues,” Butz says.

REFERENCES

1. Butz SF. Pediatric ambulatory anesthesia challenges. Anesthesiol Clin 2019;37:289-300.
2. Tait AR, Voepel-Lewis T, Christensen R, O’Brien LM. The STBUR questionnaire for predicting perioperative respiratory adverse events in children at risk for sleep-disordered breathing. Paediatr Anaesth 2013;23:510-516.