Tertiary Care Referrals for Fractures in Children.

PURPOSE: With limited local access to pediatric subspecialty care outside major metropolitan areas, tertiary care hospitals treat many children originally seen at outside facilities for relatively brief but urgent surgical procedures. This referral-based care imposes significant financial and psychological stress on the families. DESIGN: Prospective, survey methodology was used. METHODS: Families of children aged 0-18 years admitted to the St. Louis Children's Hospital for surgical repair of fractures were surveyed. The questionnaire was developed by the research team and measured a variety of fields. FINDINGS: The operative procedure in the majority of these children was relatively brief in both groups, often less than one hour. The time of injury to their discharge from our hospital, however, extended to 36 hours. Families missed several days of work. Many children were kept NPO longer than needed. CONCLUSIONS: Our preliminary evaluation suggests that a relatively minor unexpected surgery of a child can impose significant financial, organizational, and psychological burden on the family.

Difficult airway consultation service for children: steps to implement and preliminary results.

BACKGROUND: Failed airway management remains one of the most common causes of cardiopulmonary arrest in the pediatric population. Practice guidelines addressing the difficult airway (DAW) in adults provide anesthesiologists a framework for managing the airway during the perioperative period; however, similar consensus guidelines are lacking in the pediatric population. Many of the adverse events associated with difficult pediatric airway management occur outside the perioperative setting and often result in worse outcomes. The lower frequency of DAW management required in children, lesser awareness of pediatric health care professionals about DAW management, and the need for guiding principles led us to develop a DAW consultative service. This report outlines the steps to establish the Difficult Airway Service (DAS) and the initial experiences with this new consultation service. METHODS: The mission of the DAS is to identify children with known or anticipated DAWs, communicate the diagnosis and collaborate with referring medical and surgical services, and to manage children in those settings that airway management might be required in the context of the patient's ongoing medical care. RESULTS: The initial 3-month experience confirmed that a majority of pediatric DAW events are associated with congenital or acquired abnormalities. Through appropriate consultation and leadership, the DAS was able to physically and electronically identify pediatric patients with a DAW and provide management. Hospital-wide participation was instrumental in the success and exponential growth of DAS: planned preoperative tracheostomy in complicated posterior spinal fusion candidates, participation in EXIT procedures, standardization of airway carts, and implementation of education forums. CONCLUSION: In developing the DAS, our goal was to provide a more comprehensive approach to caring for a child with a DAW that included their entire hospital stay and follow-up care. We believe this approach has improved health care professional awareness as well as the safe management of routine and difficult pediatric airway. Additional studies are needed to determine whether measurable changes in morbidity and mortality are observed over time.