The right stuff - Journal of Pediatric Surgery

Journal of Pediatric Surgery 49 (2014) 1–12
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Journal of Pediatric Surgery
journal homepage: www.elsevier.com/locate/jpedsurg
APSA Presidential Address
The right stuff
Keith T. Oldham, MD
a r t i c l e
i n f o
Article history:
Received 30 August 2013
Accepted 30 September 2013
a b s t r a c t
We will discuss a new initiative of the American College of Surgeons and the American Pediatric Surgical
Association to prospectively define optimal resource standards for children's surgical care.
© 2014 Elsevier Inc. All rights reserved.
Key words:
Children's surgery
Outcomes
Quality
Optimal resources
Dr. Sato, Members, Guests, Ladies and Gentlemen:
I am deeply honored to stand before you today in this role. This
possibility did not occur to me when I attended my first American
Pediatric Surgical Association (APSA) meeting as a senior fellow
30 years ago this month. I am indebted to all of you, the APSA
members for your trust in me and for the opportunity afforded by my
election to this position. Tom, I am grateful for that kind and personal
introduction. I am privileged to have met 40 of my 43 predecessors;
many have become friends. I am indeed humbled to join this group.
Like all of them I expect, this moment has been on my mind since I
learned of my election more than 2 years ago. By way of preparation, I
have read or listened to all of the available APSA presidential
addresses, as well as others. I conclude that I have license to talk
about the things most important to me. Many of you know that I am
generally careful to separate personal and professional interests, but
today with your indulgence, I plan to speak about the people closest to
me and about some issues I believe most important to us.
I will speak of friends, including colleagues and mentors; of family,
this will be difficult for me; and of children’s surgery, our shared
professional passion. With regard to children’s surgery and APSA, I
will outline a current initiative designed to optimize surgical
0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpedsurg.2013.09.021
resources to fulfill the vision that every child undergoing surgery
today receive care in the right environment to yield the best outcome;
the environment you would seek for your own child if necessary.
Some of you were at this morning’s APSA business meeting and know
of this, but many of you were not. I will present the rationale, selected
relevant data (some old, some new) and the proposal itself. I view this
as a process, actually a moment in a longer journey, and I would like us
to take a step together today at this 44th APSA Annual Meeting.
In my predecessors’ presidential addresses, many topics have been
discussed, sometimes many in a single address. Today, I would like to
provide a single and I hope memorable focus and agenda for each of
you and all of us. When Dr. Shamberger passed the gavel to me at this
meeting last year, I indicated that I had a specific vision. I think
surgeons are generally good at achieving clearly defined goals,
whether it means mastering an operation, becoming a pediatric
surgeon, or reaching some other finish line or mountaintop. I have
spent this presidential year in pursuit of the vision I noted a moment
ago and I hope to make it our collective goal.
To be clear, I know there will be something less than unanimity
regarding the initiative we will discuss. I am confident however that it
will benefit our patients demonstrably and also our members in the
long run. I believe therefore, it is the right thing to do.
1. Friends
This moment at the podium is not an individual achievement. Like
my predecessors, I have benefited enormously from many individuals
who have given kindly and generously of their time, personal
experience and wisdom to help me at every step in my professional
journey. Charles Scudamore [1] observed in his presidential address to
the North Pacific Surgical Association in 2011 that one trades one’s
youth to become a surgeon. I have been fortunate to make this trade
with the support and guidance of a remarkable group of mentors and
colleagues. It is not possible to acknowledge all if we're to complete
today’s activities on time; I would like to mention several however.
2
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
As a medical student, my first clinical rotation was on a surgery
service at the Hunter Holmes McGuire VA Hospital in Richmond,
Virginia, named to honor the Civil War surgeon who cared for
Stonewall Jackson after he was mistakenly shot by his own
Confederate troops. The historians in the audience will recall that
the outcome was death after a survivable wound treated in a
suboptimal environment. One of my attending surgeons was Dr.
Hunter H. McGuire, III, who for reasons that remain a mystery to me,
chose to become a mentor and also advocate on my behalf to the
newly appointed young Chairman of the Department of Surgery, Dr.
Lazar Greenfield. Both then and subsequent as a new and not quite as
young Chairman of Surgery at the University of Michigan where I was
on the faculty, Dr. Greenfield provided guidance, opportunity and
personal support for me. The advice and mentorship of both men
contributed critically at key moments in my journey here today.
During residency I was influenced by many people of course, but
none more than Dr. Kaj Johansen. Kaj, who is in the audience today, is
not a pediatric surgeon, rather a vascular surgeon. We first met at
Harborview Medical Center and the University of Washington in
Seattle when he joined the faculty and I was a junior resident. He
subsequently became the training program director and for years was
highly influential in the training of many surgeons, including a
number who are members of this organization. Kaj and I have shared
much and have run literally thousands of miles together. When
returning with Kaj on a Washington State ferry from one such race,
predictably competitive and a bit painful as I recall, we had a
conversation resulting in my decision to enter the pediatric surgery
match that year. Although we have both slowed, he more than I, he is
a best friend, an honest critic and always a competitor.
In fellowship, I was privileged to train with Dr. Lester Martin, APSA
President-elect at the time. The faculty included Drs. Martin, Jens
Rosencranz, Joe Cox and John Noseworthy; each of whom tolerated,
taught and supported me. John Noseworthy was a young faculty
member with whom I became close and Dr. Fred Ryckman was my
partner in fellowship the last year of my training, a year that I think we
collectively made the most difficult of Dr. Martin’s long and
remarkably distinguished career.
As a young faculty member at the University of Michigan, I was
reunited with Dr. Greenfield who I have mentioned, but worked most
closely with Drs. Arnie Coran, Theo Polley and John Wesley. I learned a
great deal from each of them during a critical period of professional
transition from young and unfocused to a midcareer academic
pediatric surgeon. Dr. Coran, of course, became President of this
organization as well. All remain close friends and valued colleagues.
I would like to offer my thanks as well to two other pediatric
surgeons, both of whom also became Presidents of this organization,
neither of whom I worked with in the clinical realm. Dr. Marc Rowe,
for reasons that again remain obscure to me, concluded that I had
some potential in pediatric surgery and offered particular guidance
and support to me as a developing academic pediatric surgeon. The
other is Dr. David Tapper about whom I will say more in a moment.
Their personal mentorship and leadership by example were invaluable to me and I know to others here today.
Lastly, I want to recognize and thank our entire pediatric surgical
team at the Children’s Hospital of Wisconsin. The faculty members are
shown in Fig. 1. I am extremely fortunate and proud to have as
colleagues this group of talented, thoughtful and compassionate
surgeons. As important, each is a personal friend in whom I have
absolute trust and confidence: Drs. David Gourlay, Casey Calkins, Marj
Arca, John Densmore, Amy Wagner, Tom Sato, Dave Lal and John
Aiken. The training program we have built is a source of pride for all of
us. As you know, the relationship between faculty and trainees in
pediatric surgery is unique and lifelong. I have benefited enormously
from my association with our trainees over the years; they did the
work and I took the credit. I am confident of their individual skills and
proud to have had a role in the professional development of each.
Fig. 1. Drs. David Gourlay, Casey Calkins, Marj Arca, John Densmore, Amy Wagner, Tom
Sato, Dave Lal, and John Aiken.
2. Family
As Dr. Sato suggested, I grew up in a military family. My father was
an Army AirCorps and then Air Force pilot until I finished high school.
If I had to select a single person who has most influenced me, it is my
father. I am not the first to suggest that pilots and surgeons share
many traits, but I have known this for a very long time. A family’s
support is of course crucial to us all; mine was a very close nuclear
family as we moved about the world throughout my childhood. My
father is shown here at the time of his flight training in February 1942
(Fig. 2A), and then he with my mother (Fig. 2B) on the occasion of
their 50th wedding anniversary. Neither can be here today. My father
is in hospice care in Virginia and unable to travel. We lost my mother
about 4 ½ years ago. They were married 66 years, an extraordinary
relationship between two remarkable and remarkably different
individuals. Together they provided the foundation for me and for
my siblings, allowing us to both succeed and fail in a home of
unquestioned love and quiet support.
It has been observed that one’s personality is shaped more by
siblings than by parents. I don’t know whether that is true; I’m certain
it is not quantifiable. Regardless, I certainly learned from and was
influenced powerfully by my siblings. Ours was and is a highly
competitive but very close family. My older brother, Tim, is the
proverbial rocket scientist, a physics PhD who spent most of his career
with the Defense Department and NASA. My gentle sister Marilyn is
an architect who currently cares for our father. My precocious
younger brother Dwight and I graduated from medical school in the
same class. He is a now a senior medical oncologist in Virginia. My
youngest brother Mitch is most succinctly described as a computer
person.
Karen and I have two boys. Our oldest son Christian is here today, a
graduate of Davidson College and currently a graduate student in
environmental sciences. In recent years he has been my companion,
teammate, tentmate, ropemate on some adventures that I (and I think
he) will never forget (Fig. 3A). His younger brother Brian (Fig. 3B)
would love to be here with us, but to his distress is in the midst of final
exams in a premed undergraduate curriculum. Some of you may know
that OIdham is the name of an unappealing town near the epicenter of
the Industrial Revolution in England. It is our family’s ancestral home.
Mindful of this heritage and our current residence, I will repeat the
observation once made that in England the son is defined by the
father, but in America the father is defined by the son. I know this will
be true for Brian and I. I am immeasurably proud of both boys.
My wife, Karen Guice is known to many of you; she helped train
some of you in general surgery (Fig 4A/B). In many (perhaps most)
gatherings I am best known for being Mr. Guice. Karen has had an
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
3
Fig. 2. (A) Richard T. Oldham, February, 1942. (B) Richard T. and Gladys A. Oldham, 1992.
extraordinary career, first in academic surgery, becoming a Professor
of Surgery at Duke; currently in the Defense Department in
Washington, DC where her portfolio is the U.S. military health system.
Karen and I have spent almost 10 years of our marriage in different
cities, raising our boys, maintaining our relationship and adapting to
moderately complex professional and personal demands. While this
has had its moments, our marriage as residents in Seattle remains for
me the best decision I ever made. We will celebrate our 32nd wedding
anniversary 5 days hence. She has been a wonderful wife, mother,
companion, collaborator, partner, and friend without whom this
would be neither possible nor worthwhile for me.
3. The right stuff
Tom Wolfe published a book entitled The Right Stuff in 1979, the
year of that ferry boat conversation I mentioned [2]. The book became
a best seller and in the year I finished pediatric surgery training, 1983,
was the basis for a popular movie about the Mercury 7 program and
astronauts, as I expect many of you know. It profiled the individuals in
some of their heroic and not so heroic moments, but it also detailed
the time, team, environment and culture surrounding this effort. We
are not going to discuss spaceflight today, but I have borrowed the
title because I believe it is relevant to today’s proposal. If you Google™
“The Right Stuff,” many references appear related to the book and the
movie. However, if you look a bit further into the Oxford Dictionary,
you will see “the right stuff” refers to the “necessary qualities for a
given task or job.” If you continue, you will find that the noun “stuff”
specifically refers to “matter, materials, articles” and lastly to “things
in which one is knowledgeable and experienced,” as in “he knows his
stuff.” All of these are essential aspects of our discussion today about
prospectively defining the optimal surgical environment for children.
Dr. Sato touched upon my personal travels and today I would like
to comment briefly about my time as a resident in Seattle. To be clear,
it was a time of transformation for me, as for most in this room from a
student and observer to a professional with personal accountability.
With the license this occasion permits, I will digress for a moment. For
me, this was also a time when my nascent interest in mountains and
mountaineering became a decades-long passion in which I still
Fig. 3. (A) Christian R. Oldham, 2006. (B) Brian T. Oldham, 2007.
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K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
Fig. 4. (A) Karen S. Guice MD, 1993. (B) Left to right: LTG Thomas Travis, Air Force Surgeon General; LTG Patricia Horoho, Army Surgeon General; Karen Guice MD, MPP, Principal
Deputy Assistant Secretary of Defense (Health Affairs); VADM Mathew Nathan, Navy Surgeon General, 2013.
indulge modestly, within the limits of life as a not so young pediatric
surgeon and father (Fig. 5). At that time in Seattle, there were many
famous and accomplished mountaineers, including a number in the
medical community, some of whom I got to know. In 1976, there was
a successful American expedition to Everest involving some Seattlebased physicians; in 1978 the first successful American ascent of K2
was led by Seattle climbers. Our own pediatric surgeon, Dr. Rob
Schaller at the Children’s Hospital in Seattle was an accomplished
Himalayan veteran and member of this successful 1978 K2 team [3].
Dr. Tom Hornbein, even then a legendary climber, was Chairman of
the Department of Anesthesia. For those of you who are interested,
50 years ago this month, he and Willie Unsoeld first climbed the West
Ridge of Everest with a summit traverse and bivouac that are today
still considered among the most remarkable mountaineering achievements in history [4]. Among trainees and young faculty, Dr. Bob
Schoene and others I knew went on to distinguished careers and
mountaineering legacies.
One of the stories I learned in those days resonates with me still
and does, I think, have commonality with our pediatric surgery world.
Although well known in the mountaineering community, I will guess
that some of you may not know of these events. Very briefly, in August
1953, just a few months after Edmund Hillary and Tenzing Norgay
summited Mt. Everest for the first time, an American team was high
on K2, the second highest, but widely believed to be the most difficult
and dangerous mountain on earth. The team was not far from the
summit under the leadership of Dr. Charles Houston, a remarkable
physician scientist himself [5]. One of the team members, Art Gilkey,
developed deep venous thrombosis, no doubt a consequence of the
polycythemia that accompanies high altitude adaptation. He collapsed, presumably from a pulmonary embolus at about 25,000 feet
and was no longer ambulatory. To be clear, individual self-sufficiency
in these circumstances is generally a prerequisite for survival. The
team came to his aid, abandoned the summit, endured a storm for
days, organized an evacuation and began to descend with Gilkey
belayed on an improvised litter over treacherous and steep terrain in
unbelievably difficult circumstances. Still near 25,000 feet, one of the
members fell, taking with him not only his own ropemate, but
eventually five individuals on three tangled ropes. As they accelerated
down the icy, precipitous slope, one of the team, Pete Schoening, saw
the unfolding events, recognized that tragedy was imminent and
acted. He plunged his ice ax into the snow and ice, anchored himself
behind a rock, and was alone able to arrest all of the five falling
members of the team, as well as hold Art Gilkey. The individuals
involved each fell between 150–300 feet and had a variety of injuries.
All survived with the exception of Art Gilkey, who although roped to
anchors, disappeared while the other team members were regrouping. To this day, it is unclear whether this was accidental or whether
this was an act of self-sacrifice to unburden his teammates and allow
them to survive themselves.
So in this brief story, we have the right training, the right
judgment, the right response to a life-threatening situation, the right
equipment for the environment and the right team working together
selflessly to adapt, improve and alter the outcome. It is doubtless
evident to you that I believe there are parallels in mountaineering and
this story to the surgical world in which we live. I submit that the right
combination of people, temperaments, acquired skills and equipment
is “the right stuff” in both worlds.
Most would acknowledge Drs. William Ladd and Robert Gross to
be the fathers of pediatric surgery in North America. The passage
below is from the introduction to their seminal text Abdominal Surgery
of Infancy and Childhood published in June, 1941 [6]. They point out
the suboptimal outcomes when the medical environment does not
recognize the specific needs of children undergoing surgery, noting
that “mortality rates in the young were extraordinarily high at the
turn of the previous century and that if improved results were to be
expected, the infant or small child could not be treated as though he
were a diminutive man or woman.” Although the care we offer
individuals today is very different than that available in 1941 and we
Fig. 5. Mt. Foraker, Alaska, 2008 (Christian R. Oldham).
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
routinely do things that Drs. Ladd and Gross could only dream of, I
suggest to you that even now in the 21st Century, when one looks
across our entire population, we do not uniformly match care in an
optimal environment with an individual child’s need.
I suspect everyone in this room has his or her individual
anecdotes. I’ll tell you one of mine briefly. Several years ago, we
received a child in transfer from another institution, a scenario we
all know. It was a toddler who had sustained blunt abdominal
trauma, seen initially in a good adult centered institution. The child
was awake, alert and physiologically stable. The evaluation at that
institution was positive for intraperitoneal blood which led to
laparotomy, uncontrolled hemorrhage and ultimately liver resection. There were systems issues I’ll not detail here today. He arrived
to us subsequent with an acquired hypoxic brain injury, severed
common bile duct and lesser issues, all of which he survived, but at
enormous cost and with a life permanently altered. We all recognize
issues in this story; most are not so dramatic. Perhaps it will never
happen again, but I submit to you that we can and should do better
in matching the needs of individual children to the right
environment for their surgical care.
Although we don't know the scope of this issue with precision, I
will show you some preliminary data that suggest it is not trivial. In
the interest of time, I have chosen one provocative bit of new data. I
am indebted to Drs. Li Ern Chen and Robert Haley for providing these
data; they are not yet published but soon will be [7]. Drs. Adam
Goldin, Fizan Abdullah, Shawn Rangel and others have contributed
additional important data supporting the initiative we will discuss.
These data are derived from the KID 2009 data set, a national sampling
of inpatient hospital discharges for infants and children in the United
States (Fig. 6). It has all the inherent limitations of a large
administrative dataset, including here, unproven assumptions about
available hospital resources. Very importantly, this analysis does
include prospective risk adjustment for patients using a novel
propensity scoring methodology. The study cohort is neonates who
underwent noncardiac thoracic and abdominal index operations
(tracheoesophageal fistula repair, necrotizing enterocolitis related
procedures and so forth, routinely performed by members of this
organization) with a projected mortality of N5%. Note by comparison,
that the ACS Pediatric NSQIP overall neonatal surgical mortality is
approximately 2.5% at 30 days, so this is a particularly high-risk
cohort at one end of the complexity spectrum.
On the vertical axis is the ratio of observed to expected
mortality. A value of one reflects expected performance, for our
golfers, par for the course; observed mortality is the same as that
expected. Above the line is not what you would want for your child,
excess mortality probability; below the line are better than
expected outcomes. On the horizontal axis are hospital type and
5
Fig. 7. Vision.
volume. On the left are (adult) general hospitals, in the center are
children’s units in general hospitals and on the far right are
children’s hospitals. Within each of these left to right, we move
from lower volume to higher volume as measured by annual
pediatric discharges. The assumption which I believe to be plausible,
is that low-volume adult general hospitals will have fewer
children’s specific resources than high-volume children’s units or
freestanding children’s hospitals. The resources are of course mostly
specialty trained people across the spectrum of contemporary care.
At the far left, in the lowest-volume general hospitals we have
substantial excess mortality over that expected. If you examine the
(green) statistical trend line, that effect is diminished somewhat but
still noteworthy. On the far right are children’s hospitals, where you
have significant survival advantage conferred.
Where would you have your newborn child or family member
receive this complex surgical care if needed?
Perhaps this observation is not a surprise to you, but let me show
you where neonates in this cohort actually received their care. Using
the same database, the same cohort and the same institutional
stratification as outlined above, approximately 35% of these infants
received their surgical care in 2009 in the environment with a
mortality probability higher than expected based on patient risk
factors. This is shown in Fig. 6 by the (red) oval.
I would like to propose today the vision that every child in need
of surgical care in North America be treated in an environment with
resources appropriate to his or her individual need. If we can do
that, it will become a model applicable elsewhere, perhaps
worldwide. It is an exceedingly simple vision that I believe is the
right thing for us to do (Fig. 7).
I’d like to turn once again to Dr. Tapper. Many of you in this
room knew David; he was APSA’s President in 2000–2001.
Although he trained in Boston and elsewhere, he was Surgeonin-Chief for most of his career at what is now Seattle Children’s
Hospital, from 1983 until his premature death. I came to know
David well because we served together in APSA. His presidential
address in May 2001 was entitled “The Achievement of Audacious
Goals” [8]. He discussed his remarkable personal journey through
illness and he spoke of pediatric surgery calling it “the business of
preserving and improving human life.” Audacious; he said “it grabs
you in the gut”…”everybody knows what it means”… bold, daring,
imprudent, venturesome. He went on to define 4 very specific
“audacious” goals.
Goal 1
■ All children with a presumed diagnosis of intussusception
should be rapidly transferred to a pediatric institution.
Goal 2
■ All children 7 years of age and younger should be operated on
only by specialty certified pediatric surgeons.
Goal 3
Fig. 6. O/E mortality for surgical neonates with intrinsic risk of mortality N5%.
■ All children under 4 years of age who require surgery should be
anesthetized by pediatric anesthesiologists or specialists
trained in pediatric anesthesia.
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K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
Goal 4
■ Health care for children is a right and should be funded. We
need to become loud, visible, forceful advocates for children at
local, regional and national levels.
While there are some differences in the details of these David
Tapper audacious goals and today’s proposal, both are absolutely
consistent with the concept of providing children’s care in the right
environment and with the right stuff. Let me suggest that today’s
proposal is a step in this journey begun by Drs. Ladd and Gross,
furthered by Dr. Tapper, and advanced by many others. It is the
process of improving children’s surgical care, a goal to which we are
all committed.
Let me rapidly summarize some data which in aggregate offer
compelling support for today’s proposal I think. Of necessity, I will be
brief and selective. I invite you to examine the original data which are
referenced.
4. Pediatric anesthesia
Specialized pediatric anesthesia is a crucial part of our contemporary care environment. This was the subject of a more robust
Education Day presentation from our Outcomes Committee in
which the question was posed, “Are pediatric anesthesiologists
required for better outcomes?” Their conclusion and mine is clearly
yes [9–27]. My personal view is that in many ways, an excellent
pediatric anesthesiologist offers a “Pete Schoening”-like lifeline for
our patients when things become chaotic as they frequently do in our
world.
To be clear, much of this is not new information. Going back
several decades to the work of Dr. Keenan, it’s been known that the
risk of anesthesia is disproportionately higher in younger patients
(Table 1). His original data show more than a 3-fold higher risk of
anesthesia-related cardiac arrest in pediatric patients, here defined as
children under the age of 12 years [27]. Today, the risk of anesthesiarelated cardiac arrest remains approximately 10-fold higher in a
neonate and 5-fold higher in an infant less than 1 year of age,
compared to an adult [15]. Furthermore, the risk of perioperative
death is approximately 25%–30% should this occur. A subsequent
report by Dr. Keenan demonstrated and others confirmed that this
risk could be significantly reduced by deployment of specialty trained
pediatric anesthesiologists. [19,9,24,25] (Table 2). To move to less
threatening but more common events, Mamie and colleagues [13]
from Geneva demonstrated meaningful reduction of perioperative
adverse respiratory events in children when pediatric anesthesiologists provide care (Fig. 8); they found this to be particularly
noteworthy for otolaryngology procedures, commonly performed by
nonspecialized providers today in the United States.
The 1989 National Confidential Enquiry into Perioperative Deaths
was a landmark system review by the National Health System (NHS)
in the UK [26]. The key relevant conclusion of that report for today’s
discussion was that “surgeons and anesthetists should not undertake
occasional pediatric care.” A more recent (2010) policy statement
from the Royal College of Anaesthetists offers different verbiage but a
similar conclusion; “anesthesia services for children require specialty
trained clinical staff together with equipment, facilities and environment” [24].
A report from France demonstrates a strong inverse correlation
between annual case volume and complication rates in pediatric
anesthesia [14]. Auroy and colleagues [14] demonstrate fivefold more
complications when fewer than 100 pediatric anesthetics were
performed annually compared to more than 200 annually (Fig. 9).
Their conclusion was, “we recommend a minimum case load of 200
pediatric anesthesia cases per year to reduce the incidence of
complications and improve the level of safety in pediatric practice.”
This is the basis for specific recommendation we will come to
momentarily.
I believe that the American Academy of Pediatrics (AAP) is one of
the most effective public policy voices in health care in the United
States and I think this is because advocacy for children has remained
their primary focus. The most recent statement from the AAP
regarding guidelines for the perioperative anesthesia environment
[10] states “The annual minimum case volume required to maintain
clinical competence in each patient care category should be
determined by the facility’s Department of Anesthesia.”
So what do you suppose has actually happened on this point in the
United States? While I do not have data here, I believe that significant
numbers of our population of infants and children receive care
without the levels of pediatric anesthesia training and experience we
know to be optimal.
5. Neonatal intensive care unit (NICU)
I’d like to touch quickly now on the NICU environment, an area I
believe all of us view as critical in the provision of contemporary
neonatal surgical care [28–34]. The most recent AAP policy statement
for the NICU environment was published about 9 months ago and
defines the resources recommended for an optimal care environment
in 4 levels of NICUs [33]. The recommendation is that neonatal
surgical patients receive care in a Level III or Level IV nursery,
characterized by functional capabilities within a regionalized system
of perinatal care. Level III designation requires access to pediatric
surgeons, pediatric anesthesiologists and pediatric ophthalmologists;
Table 1
Incidence of anesthetic cardiac arrest.27
No. of anesthetics
No. of arrests
Incidence (no./ 10,000)
Total
Adult vs. pediatric
< 12 yr
163,240
27
1.7
12,712
6
4.7
> 12 yr
Emergency vs. elective
Emergency
150,528
21
1.4
15,300
10
6.5
Elctive
Time
Daytime, Monday–Friday
147,940
17
1.1
124,100
19
1.5
39,140
8
1.8
P*
.014
.0001
.79
Other
*Determined by Fisher's exact probability test.
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
Level IV nurseries have a full range of pediatric surgical specialists and
perform surgical procedures for complex conditions. A meta-analysis
(Fig. 10) (based on the previous AAP guidelines in which Level III was
the highest level of care) clearly demonstrates improved survival for
very-low-birth-weight infants [34], including surgical infants, in a
specialized environment with access to appropriate resources; the
same is true for extremely low-birth-weight and very preterm infants.
This is the latest in a series of such recommendations that have
been made periodically since 1976 by the AAP. It is noteworthy that
the initial response to regionalize NICU efforts and optimize resources
in the 1980s and 1990s has stalled or even regressed in certain areas of
the country. Unfortunately, the fiscal reality of current NICU
reimbursement policies encourages proliferation of small NICUs and
some “deregionalization” has occurred. This is in spite of what you see
here, that outcomes are demonstrably superior if these resource
recommendations are followed. APSA is on record in support of
neonatal surgical teams and multidisciplinary centers in a 2008
position paper by Dr. Stolar and our Workforce Committee, published
in the Journal of Pediatric Surgery [31]. In addition to pediatric surgeons,
this statement speaks of intimate involvement and availability of other
specialty trained professionals including neonatologists, perinatal
specialists, pediatric anesthesiologists, pediatric radiologists and
others relevant working together as a team in an appropriate
facility…the right environment…the right stuff, once again.
In reality, neither the AAP nor the APSA policy efforts created a
mechanism to verify and document adherence to their recommendations; hence the impact to date is limited.
6. Pediatric intensive care units (PICU)
Let me move now to the pediatric intensive care unit environment
[35–40]. The data in Table 3 were published in 1997 in the Lancet
comparing pediatric intensive care units in Trent, north central
England, with those in Victoria, a state in southeastern Australia [38].
The report reflects a period when the Australian health care system
had a formal system of transfer policies in place for critically ill
children, effectively regionalizing such care. Trent did not; it was left
to the judgment of providers and families to select the location of care.
The analysis is based upon a physiologic score assigned each patient at
presentation which was predictive of mortality risk. In Victoria, the
number of expected deaths and actual deaths observed was identical.
On the other hand, Trent had 32 excess deaths, about 75% more than
expected based on the physiologic status of patients at presentation.
The authors concluded at that time that “if Trent is representative of
the whole country, there are several hundred deaths a year in the UK
(not a third world environment), that are probably caused by
suboptimal results from pediatric intensive care.” Notably, this report
did effect change in NHS policies and practice. Although the system
remains imperfect, it is unlikely the results would be the same in the
U.K. today.
In the United States today, we of course have no formal system to
assign a facility based on an individual child’s need in this
circumstance. The point of care is selected by families, payors,
Table 2
Distribution of cases with and without anesthetic cardiac arrest.
Group
No arrest
Arrest
Total
Nonpediatric
anesthesiologist
2029
4
2033
Pediatric
anesthesiologist
2310
0
2310
Total
4339
4
4343
P = .048 (Fisher's exact test).
Data from Keenan RL, et al. J Clin Anesth, Vol 3, Nov/Dec 1991.
7
Fig. 8. Incidence and risk factors of perioperative respiratory adverse events in children
undergoing elective surgery.
providers and others for a variety of reasons, similar to Trent at the
time of this study. The population of the United States is about 5 times
that of the UK.
In January 2000, a pediatric-specific task force assembled by the
American Academy of Pediatrics (AAP) and the Society of Critical Care
Medicine (SCCM) concluded that evidence supporting regionalized
care for critically ill children was sufficiently strong to recommend its
implementation [35]. Dr. Watson presented data for the United States
shortly thereafter concluding that “a growing body of evidence
suggests that many hospitalized and critically ill children with fatal
outcomes in the United States never received the highest level of care
available” [40].
To be clear, some planned and some defacto regionalization occurs
in the PICU environment, but it is variable and inconsistent if assessed
at a national population level.
7. Congenital heart surgery
Congenital heart surgery is largely done by individuals not represented
here today. I will say a word about it however, because I think it is
illustrative of high complexity procedures in high-risk infants and children
and the data are more clear here than elsewhere at present [41–45].
California, like most states, has more congenital heart programs
than one would likely create if asked to plan prospectively. Dr. Chang
evaluated their performance in a provocative report published in 2002
in which a 2-year experience with congenital heart surgery in the
state of California was analyzed [45]. For better or worse, 30-day or inhospital mortality for congenital heart surgery is a meaningful,
dichotomous variable reliably recorded. It is clear for congenital
heart surgery that low-volume centers generally have higher
mortality probability and higher volume is associated with lower
mortality on a risk-adjusted basis. I will note here that we (the
Children’s Hospital Association and the Organization of Children’s
Hospitals Surgeons-in-Chief) recently commissioned a Cochrane
Response Rapid Review on this general subject [46]. This concludes
that higher volume is generally effective in reducing hospital
mortality after congenital heart surgery. The Cochrane standard is
rigorous, more than two-thirds of published studies show positive
correlation between higher volume and lower morbidity, although
the magnitude of the effect is uncertain because of disparate
methodologies.
To return to Dr. Chang’s report, low-volume centers are theoretically closed and patients moved, theoretically again, to the next
nearest center. As one moves from left to right on the graph in Fig 11,
progressively moving patients to the next nearest center, there is little
8
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
Fig. 9. Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics.
change in the number of avoidable deaths for the first several centers
closed. As you close more centers moving to the right, statewide
mortality is reduced until you are left with five high-volume centers
where no further benefit is apparent. More than 80 lives are saved
annually in this population-based analysis; one state, congenital heart
disease only.
Interestingly the authors also performed concurrent analysis of the
travel burden such a strategy would impose on families. The average
travel distance was 45.4 miles for a child here, and this was increased
by 12.7 miles when all surgeries were referred to high-volume centers
as outlined. These are averages, obviously there are some for whom it
is much more. We will discuss this briefly again in a moment.
8. Trauma
Our adult trauma colleagues have effectively although not
perfectly addressed this issue of triaging patients to receive care in
the right environment [47–52]. In 1976 the Committee on Trauma of
the American College of Surgeons first published a document which
became Resources For Optimal Care of the Injured Patient [48]. Program
characteristics were defined prospectively for various levels of trauma
centers, with particular emphasis on the providers required. Importantly, this program included a verification process administered by
the American College of Surgeons. As most of you know, if an
institution elects to be verified as a trauma center, periodic site visits
by representatives from the ACS verification team confirm that the
resources delineated in this regularly updated document are actually
in place. I will note that this has been a useful mechanism for
providers to obtain necessary resources. It has taken several decades,
and even though nearly 50 million Americans live over 1 hour away
from a high level trauma center [52], it has been a demonstrably
successful effort. Ellen McKenzie, PhD, demonstrated significant
improvement in mortality outcomes if care is provided in the right
environment, a trauma center, with survival advantage of about 20%–
25% conferred for adults with similar serious injuries [47]. A report
from Australia last year shows that similar trauma system
Fig. 10. Survival for very-low-birth-weight infants.
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
Table 3
Regionalization of PICU Services Reduces Mortality.
Victoria
Trent
n
Deaths
Expected
n
Deaths*
1194
60
deaths*
Total
1014
74
42.3
Expected
deaths*
60.0
Interpretation: If Trent is representative of the whole country, there are 453 (200-720)
excess deaths a year in the UK that are probably due to suboptimal results from
paediatric intensive care [38].
development and regionalization demonstrably improved not just
survival, but functional outcomes for seriously injured patients as
well [51].
I conclude that the preponderance of evidence supports the
hypothesis that children undergoing complex procedures and those
who are at high risk because of certain patient factors such as young
age or comorbidities, have better outcomes in a specialized environment. Not that many individual patients will not do well in our
current system; but if considered on a population basis, I believe that
too many infants and children currently receive care in an
environment deficient in support elements we know to be associated
with better outcomes.
I call your attention to the Articles of Incorporation for APSA.
When the organization was founded, we committed ourselves to
“establishing standards of excellence in the surgical care of infants
and children” [53].
In our current strategic plan, again briefly discussed this morning
at our business meeting, seven strategic directions are enumerated
[54] (Table 4). To be clear, these are substantially unchanged from
earlier versions of this document, although the specific goals and tasks
are updated. I highlight now and for the remainder of our time, the
9
first of these directions; “Define standards for optimal health care for
children that promote the quality and safety of pediatric surgery in an
efficient and cost conscious manner that provides value for our
patients and the health care community.”
I will briefly summarize the proposal that we shared electronically
with the entire membership April 1, 2013 and discussed briefly earlier
today [55]. Just over 1 year ago, with the support and sponsorship of the
Children’s Hospital Association and the American College of Surgeons,
we convened an ad hoc group which we called the Task Force for
Children’s Surgical Care. It included leadership from various pediatric
surgical groups, including APSA, the AAP Section on Surgery, the
Advisory Council for Pediatric Surgery of the American College of
Surgeons, and also the leadership from the pediatric surgery training
program directors, the Pediatric Surgery Board of the American Board of
Surgery, as well as other disciplines, notably pediatric anesthesia,
neonatology, cardiology and neurosurgery. The intent was to have it
small enough to be functional, but large enough to be representative.
Participants are documented carefully in the proposal. It is fair to say we
have had several groups come forward subsequent to seek inclusion and
we have done so. The focus was to stratify infants and children by
clinical need and to define the optimal surgical environment; the right
people, the right facilities and the right systems. We recognized that this
will necessarily be a data-driven process. We outlined and assigned
individual tasks for data development to examine medical quality
(outcomes), as well as financial impact, travel burden and manpower
needs. Some of the data I have shared today result from work assigned
then and done in the last 12 months. The Task Force utilized the best
available data and consensus that was presumably expert when data
were lacking [56,57].
To be clear, I view this current proposal as a first edition that will
be regularly modified via processes we must yet create.
The proposal that I am advocating for today is entitled “Optimal
Resources for Children’s Surgical Care, (we said) in the United States,”
Fig. 11. Effect of theoretical closure of low volume-high mortality congenital heart programs in California. Reproduced with permission from Pediatrics 109(2):173-181, 2002 by the
AAP.
10
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
Table 4
Strategic directions; American Pediatric Surgical Association.
1. Define standards for "optimal health care for children" that promote the quality and safety
of pediatric surgery in an efficient and cost conscious manner to provide value for our
patients and the health care community.
2. Promote education and facilitate certification for pediatric surgeons throughout their
careers, from trainee to senior surgeon.
3. Encourage the discovery and dissemination of new knowledge.
4. Become a respected resource for information on new technology and innovation in the
field.
5. Become a trusted source for in-depth educational information for patients and their
families.
6. Formulate public policy and become an effective voice that advocates nationaly for
"optimal health care for children."
7. Lead discussions on the workforce and economic environment of the field and implement
necessary change.
but it is more widely applicable I think. It represents the work product
from this group. It was our initial intent to develop the document and
publish it as an opinion piece from the individual members of the Task
Force, seeking subsequent formal approval from the various relevant
organizations, as we know this can be a quite lengthy process. As we
moved forward, key organizations asked that we obtain organizational approval prior. I will discuss that a bit more momentarily.
Our proposal is based on age criteria presently, not specific
procedures; that level of detail and complexity was judged prohibitive. The choice of age thresholds is for utility but also reflects the
important relationship between age and anesthesia outcomes we
discussed earlier at some length. We recommend designations at
Table 5
Optimal resources by center designation.
three levels and somewhat arbitrarily call these “comprehensive,”
“advanced” and “basic.” In addition, we included congenital heart
programs. With regard to the latter, there are already reasonably
detailed resource guidelines through the AAP; we made no effort to
modify these [41].
We recommend that children less than 1 year of age receive
optimal care in a “comprehensive” environment. Between the ages of
1 and 6 years an “advanced” environment is recommended and above
the age of 6 years a “basic” environment is recommended. This will
undoubtedly be refined and modified as we move forward.
We defined resources; examples are shown in Table 5. To be clear,
not every child under the age of 1 year will need every resource such
as an NICU or PICU that is required for a comprehensive center, but
access must be available when needed. We do not have time to review
all of the details today, but the entire proposal is disseminated to our
members and available on our Website. It is mostly access to the right
team members and to the right resources at the right time.
As I trust I have made clear, the pediatric anesthesia component of
this is a major point. Let me go through that one example with you
quickly. We defined a pediatric anesthesiologist as someone certified
or eligible for certification in pediatric anesthesia by the American
Board of Anesthesia or equivalent, AND who has an anesthesia case
log of 200 or more patients less than 18 years of age annually,
including 10 or more infants less than 1 year of age. We also defined
availability. For a comprehensive center, two or more pediatric
anesthesiologists must be on staff and one must be available to
respond to the bedside and provide care within 60 minutes.
Verification is a very important issue, as has been demonstrated
clearly by the AAP process of recommending guidelines without this
feature. Beyond acknowledgement of this point, we have not made
specific recommendations about this at present. It will be a subject of
discussion at the next Task Force meeting which is later this month. To
be frank, without a mechanism for verification an initiative such as
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
11
Fig. 12. Newspaper articles regarding congenital heart surgery outcomes in Bristol, U.K..
this will have little impact I expect. Please recall the ACS-Trauma
Center process and experience. It is a voluntary program, not a
directive. Participation (verification) is driven by providers and
communities interested in improving the quality of care and outcomes for injured patients. It has demonstrably made a difference.
In summary, we have become quite facile at caring for individual
patients and for certain groups in the various regions we serve. Our
challenge now is less what we can do for an individual patient, but
what we might do for all children. This proposal is directed at
improving children’s surgical care for our entire population. The
intent is improved surgical outcomes for all of our patients; it will
discomfort some providers.
Much work remains to be done. The proposal does not address the
issue of differential outcomes in specific complex procedures such as
repair of congenital diaphragmatic hernia, biliary atresia and others. As
we consider less complex procedures (appendicitis, pyloric stenosis
and the like) and lower-risk patients, benefit is less apparent and more
data are clearly needed. I do think that his proposal defines basic
infrastructure necessary for safety and is a relatively “low bar”
supported by existing data. I think it can assist our members in
working with hospitals, other institutions and other providers to
obtain necessary resources. Although good care generally yields higher
value, data will need to be developed related to economic impact as
well as training, manpower and access/travel burden. We will need to
Fig. 13. Hospitals with higher neonatal surgery volume have better patient outcomes 2012 APSA Member Survey (unpublished).
12
K.T. Oldham / Journal of Pediatric Surgery 49 (2014) 1–12
develop better methods to share information and export best practices
where possible. Implementation will require buy-in from many and
organizational processes will need to be developed.
Lastly, let me note that there is ever more public scrutiny of what
we do. Fig. 12 reflects the British tabloid response (on the left) when
the NHS report on excess mortality in the Bristol congenital heart
surgery program was made public in 2001. More recently (on the
right), you see a headline and comment on the NHS and the
professional resistance to recommended change over the intervening
decade. Neither is what we seek professionally. There are a number of
unique issues here that in the interest of time, we cannot discuss. My
point is simply that I think the public will hold us accountable if we do
not do what we know or believe to be best for our patients.
Fig. 13 reflects what you, the APSA members thought when
queried in a survey by Dr. Chen about 1 year ago on the question of
neonatal regionalization and surgical outcomes. More than 70% of you
indicated agreement or strong agreement with the statement that
hospitals with higher neonatal surgery volume have better patient
outcomes. Fewer than 10% disagreed [58].
To conclude, I have offered a rationale and a vision. I have
summarized some data and made a proposal. I’ve said that this is a
journey, perhaps uphill, begun by others long ago. The APSA Board of
Governors has unanimously approved this optimal resources proposal
as did an overwhelming majority of our members this morning. It is a
part of our current strategic plan. We have the next Task Force
meeting later this month as I noted. Presentation to the Regents of the
American College of Surgeons is next month. There will be many more
steps before it is reality. It will be ongoing and at times hard work. I do
believe strongly that it will benefit infants and children with surgical
needs. I am confident that we will get there, to see that all infants and
children receive what they need, the right stuff.
I will close by simply saying thank you for your attention today. I
would especially like to thank the Board of Governors and all of the
members who have expressed their support for this initiative. I thank
all of you for the singular opportunity to serve as your President this
past year.
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