Children’s surgery: room for improvement

 The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is calling for UK-wide clinical networks to enhance the quality of the care received by children, following a recent study that, for the first time, included a wide-ranging organisational survey of hospitals carrying out surgery on children. The case-based study, which focused on children who died after surgery, concluded that there was room for improvement in the care of 26% of these patients, despite the considerable advances made in the delivery of surgical services for children in the last 20 years. The aims of the study were to explore remediable factors in the processes of care of children aged 17 and younger, including neonates, who died prior to discharge and within 30 days of surgery. This included looking closely at the organisational structure of services currently provided and the quality of care received by individuals. The study involved a multidisciplinary group, both in its design and to review its findings. All National Health Service hospitals in England, Wales and Northern Ireland, as well as hospitals in the independent sector and public hospitals in the Isle of Man, Guernsey and Jersey were expected to participate in the study, if they undertook surgery in children aged 17 and younger. From these hospitals all patients aged 17 and younger, who had died within 30 days of a surgical procedure (including interventional procedures or radiology either in the operating theatre or elsewhere) between 1 April 2008 and 31 March 2010 were included in the study. After reviewing all aspects of care provided in the 378 cases identified, 71% of cases reviewed were judged by advisors as having received good care, demonstrating that there is a high level of good quality care on both a clinical and organisational level, being delivered to children undergoing surgery. This figure probably reflects that fact that the majority of the sample cases came from specialist centres. In 20% of the sample there was believed to be room for improvement in clinical care, 2% in organisational care, and 2% in both clinical and organisational care. Three per cent of patients were deemed to have received care which was less than satisfactory.

 Raising concerns

Co-author of the report, NCEPOD clinical co-ordinator and consultant paediatric anaesthetist, Dr Kathy Wilkinson, has expressed concern regarding the findings of the report, that care could have been better in over a quarter of the children included in the study. She did, however, also stress the importance of noting the improvements that have occurred in children’s surgery, with 71% receiving good care. “However, there still much to be done to improve care for the rest of these patients,” she said. The report reviewed the time taken between the decision to transfer sick children with complex health needs and their admission to a specialist centre for surgery. “In many cases the transfer of these critically ill children from district general hospitals to specialist paediatric centres took more than six hours to organise and implement. While this is often to be expected, perhaps to allow for stabilisation, Trusts must be better prepared to admit, assess and, when necessary, transfer these children as quickly as possible. Documentation about the transfer should also be included in the case notes,” said Dr Wilkinson. “There needs to be national standards for the transfer of children who require surgery and hospitals must develop robust policies for this.” The report found that parents and carers of the children looked at in the study were often provided with limited information about the diagnosis and treatment, which resulted in inadequate consent procedures. The report also identified that there had been little discussion and documentation about the risk that a child might die following surgery, and when this became inevitable, end of life care planning was lacking in many cases.