Anesthesia Care and the Rural Pediatric Patient 2023

Safe access to pediatric surgery and anesthesia care in rural America is critical to having an equitable health care system. The American College of Surgeons (ACS) Children’s Surgery Verification (CSV) Quality Improvement Program provides standards defining “the resources believed necessary to achieve optimal patient outcomes for children’s surgical care regardless of location.” Years after the first institutions voluntarily certified under this program, what is the status of pediatric rural anesthesia care? Anesthesiologists working in rural locations face competing stressors and must make real-time decisions about the level of care required for both routine and urgent pediatric cases requiring anesthesia, all while hospital consolidation, transfer policies, and the availability of pediatric-trained physicians in rural locations potentially impact patient safety and access to care.

Pediatric surgical and inpatient care has consolidated over time, a trend likely accelerated by the ACS CSV program. The ACS issued a white paper in 2014 with guidelines to optimize surgical care for children, recommending centers provide either basic (level III), advanced (level II), or comprehensive (level I) care. The ACS defined the scope of pediatric surgical care based on ASA Physical Status Classification, need for intensive care, surgical risk, and interdisciplinary management of complex comorbidities. They delineated the minimum standards for level I, II, and III care. A requirement for any level is to always have a general pediatrician or pediatric hospitalist on staff and readily available, a prerequisite that may not always be possible at many rural hospitals. There is no specific requirement at level III pediatric surgery centers for a pediatric anesthesiologist, but an anesthesiologist with “pediatric expertise” must be on the medical staff and be available within 60 minutes. A pediatric anesthesiologist must serve as the primary anesthesiologist for all patients 2 years of age and younger, and they should serve as the primary anesthesiologist for all patients 3-5 years of age or with an ASA 3 or greater.

Hospital participation in the ACS CSV program is currently voluntary, yet future health care policy or insurance reimbursement changes could expand the scope of these guidelines by linking them to insurance payments or incorporating them into hospital system physician credentialing. The ACS CSV guidelines implicitly endorse physician-led anesthesia care, but in practice, rural hospitals are sometimes staffed exclusively with independently practicing CRNAs in states that allow such a practice arrangement. Making the situation worse, physician anesthesiologists can be prevented from practicing in hospitals with rural “pass-through” programs, which were originally designed to incentivize clinicians to practice in rural hospitals. Specifically, Medicare Part A funds can be used to cover anesthesia services provided in rural hospitals by AAs and CRNAs, but not for services provided by physician anesthesiologists. ASA has strongly advocated for legislation to expand the rural “pass-through” arrangement to include physician anesthesiologists, but efforts have been unsuccessful to date. This payment oversight could lead to even further consolidation of hospitals that care for pediatric surgical patients.

Children younger than 1 year have the highest incidence of morbidity and mortality under anesthesia, with increased risks of hypoxemia, bradycardia, and bronchospasm. Anesthetic risk decreases with increasing age, a reality reflected in the ACS guidelines. Subspecialty training in pediatric anesthesiology, hospital resources, and support staff are some of the most important safety factors to help mitigate these risks. European studies have shown that experience of the senior member of the anesthesia team was most beneficial in outcomes. Most of the North American outcome data related to pediatric anesthesia care are based on tertiary care centers reporting, potentially due to the prohibitive cost for smaller centers to participate in outcomes registries. The premise of the ACS guidelines, however, is that younger patients, especially those with comorbidities, can be more safely cared for in tertiary care centers with advanced resources readily available such as ECMO, supportive surgical specialties, and medical specialists.

Despite the seemingly natural argument that specialty care of children should be conducted by pediatric anesthesiologists, rural medical centers must frequently consider whether transferring a pediatric patient to a higher-level center is appropriate. The decision to transfer must weigh the risk of diagnosis and/or treatment delay against the potential benefits of treatment at a more specialized pediatric center. For example, appropriate care of an urgent or emergent medical condition, such as a teenager with testicular torsion, may necessitate keeping the patient in a rural center for surgery. These patients have a 2.5-times increased rate of testicular loss when transferred over 30 miles; the American Board of Urology considers surgical treatment of testicular torsion to be within the bounds of core urologic care. Similarly, care of an uncomplicated child presenting for relatively noncomplex surgery should likely be considered within core anesthesiology training and often affords the best chance for the best outcome for the patient.

According to a recent study, nearly 10 million children in the United States live greater than 50 miles from a pediatric anesthesiologist practice location. The clustering of pediatric anesthesiologists (and other specialists) reflects the underlying existing systems of pediatric care. As such, rural hospitals may not provide the full spectrum of pediatric services, like neurosurgery or general surgery, or may not staff intensive care units that can care for pediatric patients after surgery. Therefore, community and rural hospitals often create transfer agreements with specialized centers to facilitate the transfer of patients. However, this may create obstacles to health care access as the agreement may require the pediatric patient to be transferred to a specialized center much further away than a more local center that may still be able to treat a patient’s condition. These large distances can incur costs on both the health system and patients’ families and create inequity between rural and urban pediatric populations. A 2018 study examining pediatric transfers for abdominal pain in four states found that there were over 4,400 transfers to a higher-capability pediatric hospital, of which over half (52%) required surgery and about a third (29%) were discharged without further imaging or intervention. Given that nearly a third of those patients potentially did not require transfer, there may be room for improvement to reduce unnecessary travel by patients and families. Rural hospitals and higher-capability hospitals could create more standardized pediatric management protocols, establish and further the use of telemedicine, and improve interfacility coordination and information transfer.

Rural hospitals need anesthesiologists, surgeons, and nurses who maintain a baseline level of comfort and expertise with the care of pediatric patients. This is an argument for rural centers to perform at least some routine pediatric surgeries in order to maintain proficiency in overall pediatric perioperative care. Deliberate practice is a foundational need for the establishment and maintenance of skill and comfort in clinical care, and transfer of children at a high rate may prevent anesthesiologists from maintaining an important skill set necessary when an emergency occurs. Failure to use this skill set in a routine setting puts the team at risk of failure from lack of experience when a true emergency arises. Patient (and parent) centeredness is a critical pillar of health care quality and is also put at risk by requiring long distance transfer to regional centers when rural ones could also provide care. Patients who experience a longer time to evaluation and treatment by the ultimate treatment team are put into uncomfortable and vulnerable situations away from their home and support structures, often incurring a much higher cost of care that is not sustainable after the acute treatment is completed. When appropriate to do so, local care may be optimal to prevent delays in care and lessen financial challenges for pediatric patients and their families.

We have a duty to ensure pediatric patients in rural environments have access to safe and timely anesthesia and surgical care for both elective and emergent procedures. Every physician and hospital system makes decisions based on their own local realities. The ACS CSV program provides an excellent framework to champion safe surgical care for pediatric patients via minimum standards for level I, II, and III institutions. However, an unintended outcome of these guidelines may be further consolidation of care and worsening inequity for rural pediatric patients requiring anesthesia and surgery. Continued geographic outcomes research comparing transferred patients and surgeries of various acuities at low- versus high-volume pediatric centers is needed to ensure children living in rural areas are not subject to substandard care.