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The Society for Pediatric Anesthesia (SPA) has developed the following statement due to increasingly frequent requests for advice and support regarding the nature of personnel and facilities required to provide various levels of pediatric anesthesia services. These requests have been directed to pediatric anesthesiologists at tertiary care and pediatric hospitals, as well as the SPA and other organizations. The questions come from multiple sources, including practicing anesthesiologists, pediatricians, surgeons, and other physicians, hospitals and other health care facilities, and parents and other members of the lay public. In particular, it is apparent that many anesthesiologists and pediatricians in the community feel under some significant amount of pressure to undertake the perioperative care of pediatric patients who, based upon factors including age, planned surgery, and/or co-existing medical conditions, seem inappropriate in their practice setting. This pressure has come from hospital administrators, HMOs and third-party payers, surgeons, and at times other members of the anesthesiologist’s practice group.

It is the position of its community and academic anesthesiologist members of the SPA that it is incumbent upon institutions and departments providing care for pediatric patients to prospectively establish what pediatric surgical and perioperative services the institution is capable of providing and define criteria for anesthesiologists’ and surgeons’ privileges. Furthermore, the members of the SPA maintain that there are certain aspects and types of pediatric anesthesia care, including perioperative care for infants and children with complex medical diseases and/or who are to undergo complex surgical procedures, that require unique skills and ongoing experience with such cases on the part of the anesthesiologist, as well as needing special resources within the institution.

The following statement is based upon deliberations of the Board of Directors and Executive Committee of the SPA, but also upon similar activities conducted by the California Society of Anesthesiologists (1), the Anesthesia and Pain Management Section of the American Academy of Pediatrics (2), a task force of the Committee on Pediatric Anesthesia of the American Society of Anesthesiologists (3), and a joint effort of the Anesthesia Patient Safety Foundation and the SPA, with the support of the ASA (4).

It is the position of the SPA that it is the duty and responsibility of local medical staffs to create and maintain appropriate policies and credentialing standards pertaining to the perioperative care of infants and children. The elements of this policy should include:

1. Perioperative Environment
A written policy, that defines perioperative care for pediatric patients in the institution should be established by the medical staff. This policy should define the nature of perioperative care of pediatric patients that can be appropriately provided within the institution. Overall, the institutional resources and environment need to be able to fully support the care of the pediatric patient throughout the perioperative period. This policy should be based upon patient and clinical factors such as age, surgical procedure, and risk assessment (including both the planned surgery and co-existing medical conditions). Necessary personnel include anesthesiologists, surgeons, pediatricians, and nurses who have appropriate experience in the perioperative care of pediatric surgical patients, as well as other health professionals with sufficient pediatric experience and expertise such as radiologists, respiratory therapists, pharmacists, and child life specialists. The institution must have the medical equipment, and other services such as blood bank and laboratory services, appropriate to the care being undertaken. An established relationship for consultation, referral, and transport to a specialized pediatric center should also exist.

2. Privileges
Anesthesia for pediatric patients can be provided directly or by direct and immediate supervision. The local medical staff, in conjunction with the facility’s department of anesthesiology, should establish criteria for the anesthetic care of pediatric patients. The facility and its department of anesthesiology should maintain a quality assessment and improvement process for pediatric cases. The facility and its department of anesthesiology should define patient and risk categories that are at increased risk for anesthetic and perioperative complications. Such patients require care by anesthesiologists with special clinical privileges, experience, and training. The facility and its anesthesia department should define the level of experience, training, and continuing education required to care for pediatric patients in “Regular Clinical Privileges” and “Special Clinical Privileges” categories. Requirements regarding minimal volumes and types of pediatric cases in each of these categories should be determined by the facility’s department of anesthesiology, and approved by the facility’s medical staff and governing board.

Regular Clinical Privileges
Extension of regular clinical privileges for pediatric anesthesia would be appropriate for anesthesiologists who are graduates of anesthesiology residence training programs that are accredited by the Accreditation Council for Graduate Medical Education or its equivalent. They should be board-eligible or board-certified in Anesthesiology. They should have documented current competence in the care of patients in this category in order to maintain these privileges.

Special Clinical Privileges
The facility’s department of anesthesiology is expected to designate categories of pediatric patients as being at increased risk for complications. Anesthesiologists caring for these patients should meet the requirements set forth above, and in addition should be credentialed by the department of anesthesiology for care in these increased risk categories. Graduation from an ACGME-accredited fellowship program in pediatric anesthesia, or its equivalent, is one criterion to be considered in the credentialing of anesthesiologists for “special clinical privileges for pediatric anesthesiology”. With or without prior fellowship training, granting of “special clinical privileges for pediatric anesthesiology” should include demonstration of current clinical competence and expertise in the care of such patients, as determined by the facility’s department of anesthesiology.

References

1. CSA Policy on Pediatric Anesthesia. Bulletin of the California Society of Pediatric Anesthesiologists 2003; July-September, 33-35.
2. Guidelines for the Pediatric Perioperative Environment. Pediatrics 1999;103:512-15.
3. Pediatric Anesthesia Practice Recommendations
4. Safety in Pediatric Anesthesia. (APSF videotape)