1. SUMMARY Type of facility on DCP3 classification) Level of Care1 Responsibilities Age Treated General Anesthesia OPTIMAL RESOURCES FOR CHILDREN’S SURGICAL CARE Quality and safety Human resources Required skills Infrastructure Equipment & supplies Community facility and primary health center I Screening for surgical disease Resuscitation Referral to higher levels of care All No Existing personnel Community Health Workers Basic assessment and treatment skills Existing infrastructure Wound care supplies CME/CPD Periodic supervision and mentoring First-level hospital I, II Emergency surgical care Diagnosis and treatment of common surgical diseases Referral to secondary or tertiary level All Yes, not including complex cases and minimal comorbidity (Limit of ASA I or II) Existing personnel Anesthesia provider Skills to treat emergency and essential childhood surgical conditions Children’s ward Functional operating room Emergency and essential surgical equipment & supplies for children CME/CPD Periodic supervision and mentoring M&M review Second- level hospital I, II, III 24/7 Emergency Surgical Care, Comprehensive surgical care for children2 All Yes, including some complex and comorbidities (Limit of ASA III) Specialists in some areas of children’s surgical care provided Advanced surgical and anesthesia skills in all majority of children’s surgical care Children’s wards, clinics, operating rooms, NICU, PICU Equipment and supplies to support services provided CME/CPD Periodic supervision and mentoring M&M review Trauma conference Tumor Board Third-level hospital I, II, III Comprehensive surgical care for children2 All Yes, including complex cases and comorbidities (All ASA) Specialists in all areas of children’s surgical care provided Pediatric anesthesia provider Advanced surgical and anesthesia skills in all areas of children’s surgical care Children’s wards, clinics, operating rooms, NICU, PICU, burn unit Equipment and supplies to fully support services provided CME/CPD Periodic supervision and mentoring M&M review Trauma conference Tumor Board National children’s hospital I, II, III Comprehensive surgical care for children, especially children who require multidisciplinary and chronic care All Yes, including complex cases and comorbidities (All ASA) Specialists in all of children’s surgical care provided Advanced surgical and anesthesia skills in all areas of children’s surgical care Wards, clinics, operating rooms, NICU, PICU, burn unit Equipment and supplies to support services provided CME/CPD Periodic supervision and mentoring M&M review Trauma conference
Infections Superficial abscess: drainage Infections Thoracic empyema: tube thoracostomy Appendectomy Laparotomy: typhoid complications, abscess Drainage of abscess: superficial, pyomyositis, perianal, anorectal, Septic arthritis: drainage Osteomyelitis: drainage, débridement Dental surgery: extraction, drainage of abscess, caries All All Tumors/cysts Tumors Excision of benign All tumors determined by available expertise All Others Rectal prolapse: reduction Foreign bodies: visible in ear, nose Others Central venous line Intestinal obstruction: intussusception, adhesion Foreign bodies: ear, nose, throat, swallowed All All
Groups of Conditions Specialty Conditions Degree of specialized training Specialty Procedures performed Specific infrastructure required Specific equipment required Allied staff requirements Additional requirements First-level Hospital All Congenital Anomalies Infections Minor Injuries Minor Burns Screening: Cleft lip/palate Craniofacial anomalies (ie. Apert’s syndrome, Pierre -Robin syndrome, etc.) Congenital hand anomalies (ie. syndactyly, radial club hand, amniotic bands, etc.) Brachial plexus palsy Infections (ie. septic arthritis, osteomyelitis, flexor tenosynovitis, deep hand space infections) Management: Fist degree burns Second degree burns Fractures, closed, (hand, finger, facial) Wounds/lacerations requiring dressings or simple sutures Stabilization of severe trauma (ie. amputation, injury, vascular injury) Physician Nurse Identification of brachial plexus Screening and appropriate triage Basic wound care for burns, wounds, lacerations Suturing of simple lacerations Splinting of simple fractures Stabilization of patients with severe limb and vascular trauma Stabilization of patients with infections Clean room for minor procedures Fully equipped, functional, operating theater Functioning cardiac monitors X-ray capabilities X-ray machine Functioning anesthetics machine Functioning Sterilizing equipment Basic wound dressing packs: sterile field, dressing tray, dressing towel, cotton balls/swabs, forceps Basic cesarean section set: Masson Needle Holder, TC Heaney Needle Holder, Foerster Sponge Serr, Mayo Dissecting Scissors, Mayo Dissecting Scissors, Phaneuf Forceps Angular, Jackson Vaginal Retractor, DeLee OB Forceps X-ray technician CME/CPD Access to CME from visiting specialist from the referral hospital Center Specific: Health professionals should be trained in feedings for infants with cleft/craniofacial abnormalities Health professionals should be trained to screen for common congenital abnormalities All healthcare professionals should be proficient in wound care Center should have ability to perform cesarean section safely
Groups of Conditions Specialty Conditions Degree of specialized training Specialty Procedures performed Specific infrastructure required Specific equipment required Allied staff requirements Additional requirements Second-level hospital All Congenital Anomalies Infections Injuries Screening: Cleft lip/palate Craniofacial anomalies (ie. syndrome, Pierre -Robin syndrome, etc.) Congenital hand anomalies (ie. syndactyly, radial club hand, amniotic bands, etc.) Brachial plexus palsy Management: Fist degree burns Second degree burns Fractures, closed, (hand, finger, facial) Wounds/lacerations requiring dressings or simple sutures Stabilization of severe trauma (ie. amputation, nerve injury, vascular injury) Infections (ie. septic arthritis, osteomyelitis, flexor tenosynovitis, deep hand space infections) General Surgeon (Physician with formal training in general surgery) Orthopedic surgeon (Physician with formal training in orthopedic surgery) (Physician with formal training in Pediatrician (Physician with formal training in pediatrics) Nurse Dedicated surgical nurses Burn care (surgical and resuscitation) care for burns, wounds, lacerations Splinting of simple fractures Stabilization of patients with severe limb and vascular trauma Vascular to preserve inflow to amputated extremity if salvageable Revision amputation in extremity injury Debridement of acute hand infections Repair of complex lacerations Fully equipped, functional, operating theater Functioning cardiac monitors X-ray capabilities Pediatric ward Functioning X-ray machine Functioning anesthetics machine Functioning Sterilizing equipment Skin mesher Humbly/Watson handles and knives wound dressing packs: sterile dressing tray, dressing towel, cotton balls/swabs, forceps Basic cesarean section set: Masson Needle Holder, TC Heaney Needle Holder, Foerster Sponge Serr, Mayo Dissecting Scissors, Mayo Dissecting Scissors, Phaneuf Forceps Angular, Jackson Vaginal Retractor, DeLee OB Forceps Plastic surgery set: Hartmann Mosquito Forceps, Crile-Murray, Ryder Micro, Reynolds Sciss, X-ray technician CME/CPD Access to CME from visiting specialist from the referral hospital Center Specific: Health professionals should be trained in feedings for infants with cleft/craniofacial abnormalities Health professionals should be trained to screen for common congenital abnormalities All healthcare professionals should be proficient in wound care Center should have ability to perform cesarean section safely
Hospital All Congenital Anomalies Infections Injuries Burns Traumas Screening: Brachial plexus palsy Management: Severe Cleft lip/cleft palate Common congenital hand anomalies (ie. syndactyly, amniotic band release, polydactyly) Craniofacial abnormalities Severe trauma (ie. fracture fixation, neurovascular repair, amputation, nerve injury, vascular injury) Infections (ie. septic arthritis, osteomyelitis, flexor tenosynovitis, deep hand space infections) Hypospadias/ Epispadias Plastic Surgeon (physician with formal training in plastic surgery) Anesthesiologist (Physician with formal training in anesthesiologist) Pediatrician (Physician with formal training in pediatrics) Pediatric Surgeon (Physician with formal training in pediatric surgery) Nurse Dedicated surgical nurses Burn care (surgical and resuscitation Soft-tissue coverage (ie.grafts, local flaps, free tissue transfer) Skin Graft Tissue Transfer Flaps repair of lip/cleft palate management of craniofacial abnormalities of common congenital hand anomalies (ie. syndactyly, amniotic band release, polydactyly) management of severe trauma (ie. fixation for complex fracture, , neurovascular repair for severe limb and vascular equipped, functional, operating theater Functioning cardiac monitors X-ray capabilities Fluoroscopy capabilities Pediatric ward Intensive Care Unit Functioning X-ray machine Tourniquet Doppler Functioning anesthetics machine Functioning Sterilizing equipment Skin graft mesher Electric dermatome /Watson handles and knives Operating microscope/ Magnifying loups Microsurgery instruments set: Instruments specific to hand and craniofacial surgery: Basic wound dressing packs: sterile field, dressing tray, dressing towel, cotton balls/swabs, forceps cesarean section set: Masson Needle Holder, TC Heaney Needle Holder, Foerster Sponge Serr, Mayo Dissecting Scissors, Mayo Dissecting Scissors, Phaneuf Forceps Angular, Jackson X-ray technician with fluoroscopy capabilities Occupational therapy Physiotherapy Speech Language Pathologist
Groups of Conditions Specialty Conditions Degree of specialized training Specialty Procedures performed Specific infrastructure required Specific equipment required Allied requirements Additional requirements National children’s hospital All Congenital Anomalies Infections Injuries Burns Traumas Management: Severe burns Brachial plexus palsy Complex craniofacial abnormalities (ie. Craniosynostosis, frontonasal dysplasia) Complex vascular malformations Complex congenital hand anomalies (ie. radial club hand, Apert’s syndactyly, thumb hypoplasia) Craniofacial abnormalities Severe trauma (ie. fracture fixation, neurovascular repair, amputation, nerve injury, vascular injury) Infections (ie. septic arthritis, osteomyelitis, flexor tenosynovitis, deep hand space infections) Hypospadias/ Epispadias Pediatric Plastic Surgeon (physician with formal training in pediatric plastic surgery) Pediatric Anesthesiologist (Physician with formal training in pediatric anesthesiology) Neonatologist Pediatric Critical Care Pediatric Surgeon (Physician with formal training in pediatric surgery) Pediatric maxilla-facial surgeon (Physician with formal training in pediatric maxilla-facial surgery) Pediatric orthopedic Burn care (surgical and resuscitation Brachial plexus exploration Nerve transfer and grafting Soft-tissue coverage (ie.grafts, local flaps, free tissue transfer) reconstruction following tumor excision Skin Graft Tissue Transfer Flaps management of complex craniofacial abnormalities (ie. Cranial vault surgery) of complex congenital hand anomalies (ie. equipped, functional, operating theater Functioning cardiac monitors X-ray capabilities Fluoroscopy capabilities Pediatric Plastic Surgery specific ward Pediatric Intensive Care Unit Neonate Intensive Care Unit Functioning X-ray machine Tourniquet Doppler Functioning anesthetics machine Functioning Sterilizing equipment Skin graft mesher Electric dermatome /Watson handles and knives Operating microscope/ Magnifying loups Microsurgery instruments set: Instruments specific to hand and craniofacial surgery: Basic wound dressing packs: sterile field, dressing tray, dressing towel, cotton balls/swabs, forceps cesarean section set: Masson Needle Holder, TC Heaney Needle Holder, Foerster Sponge Serr, X-ray technician with fluoroscopy capabilities Occupational therapy Physiotherapy Speech Language Pathologist