SCOPE OF PRACTICE Function 24/7 emergency surgical care Diagnosis and treatment of common surgical diseases Referral to next of care Age of patients All ages Anesthesia Physician or non-physician provider with pediatric exposure. General anesthesia for all pediatric surgical procedures not requiring invasive monitoring or ventilation. Examples of types of conditions/ procedures Trauma/injuries Resuscitation with advanced life support measures Wound closure Intercostal drainage tube (thoracostomy) Trauma Laparotomy Closed fracture: reduction, traction Open fracture: irrigation, debridement, placement of external fixator Trauma-related amputation Escharotomy, fasciotomy 1st, 2nd degree, skin grafting, simple contractures Burr hole/craniotomy Congenital anomalies General pediatric surgery: Neonatal intestinal obstruction: laparotomy Anorectal malformation: colostomy, anoplasty Hirschsprung’s disease: colostomy Hernia/hydrocele repair: inguinal, umbilical Pediatric urology/gynecology: Relief of urinary obstruction: catherization, suprapubic cystostomy, Male circumcision: neonate, older child, phimosis, paraphimosis Meatal stenosis Orchidopexy: testicular torsion, palpable undescended testes Labial adhesion/agglutination Hydrocolpos/hydrometrocolpos: imperforate hymen, low vaginal septum Pediatric orthopedics: Club foot: non-operative manipulation Infections Infections Thoracic empyema: thoracostomy Appendectomy Laparotomy: typhoid complications, intra-abdominal abscess Drainage of abscess: superficial, pyomyositis, perianal, anorectal Septic arthritis: drainage Osteomyelitis: drainage, débridement Dental surgery: extraction, drainage of abscess, caries Tumors Tumors Biopsy Excision of benign tumors/cysts Others Others Central venous line Intestinal obstruction: intussusception, enteroclysis Foreign bodies: ear, nose, throat, swallowed (Table 5 continued on next page)
COMPLEX/ADVANCED SURGICAL CARE SCOPE OF PRACTICE Function 24/7 emergency surgical care Advanced diagnostic services Multidisciplinary specialized care Receive referral from other levels Training of human resources Research Develop standards of care Research and innovation Advocacy Age of patients All ages Anesthesia All types of anesthesia Conditions/ Procedures Trauma/injuries All Congenital anomalies All Infections All Tumors All Others All OPTIMAL RESOURCES Training & staffing Human resources Pediatric anesthetist Pediatric intensivist (pediatrician or anesthetist with additional training in intensive/critical care) General pediatric surgeon Pediatric cardiac surgeon Pediatric Ear, Nose & Throat (otorhinolaryngology) surgeon Pediatric neurosurgeon Pediatric ophthalmologist Pediatric oral and maxillofacial surgeon Pediatric orthodontist Pediatric orthopedic surgeon Pediatric plastic and reconstructive surgeon Pediatric urologist Support specialists and staff in relevant specialties (See appendices) Required skills Appropriate skills necessary to provide such specialized surgical care Management and administrative skills Physical resources Infrastructure See appendices Equipment & supplies See appendices Quality & Safety Quality improvement programs board Trauma conference CME/CPD Table 7. Children’s surgery package: procedures and levels of care TYPE OF PROCEDURE LEVEL OF CARE
Community facility/primary health center Primary referral hospital Secondary Hospital Tertiary hospital Children’s hospital Trauma/Injuries Resuscitation with basic life support measures Wound care: suturing, dressing Fracture: closed, non-displaced Burns: 1st degree Resuscitation with advanced life support measures Surgical airway Wound closure Intercostal drainage tube Trauma Laparotomy Closed fracture: reduction, traction Open fracture: irrigation, debridement, placement of external fixator Trauma-related amputation Escharotomy, fasciotomy 1st, 2nd degree, skin grafting, simple contractures Burr hole/craniotomy NOT ALL BURNS – up to 10% TBSA (excluding inhalation, face, H&N, flexural, perineal, neonatal, digital or hands) NOT ALL TRAUMA – Acute injury with acute limb or life threatening injury (stabilizing procedures, damage control operations) Colostomy and other abdominal emergency surgeries that can be performed by an adult general surgeon Hernia > 1 year-old All burns All trauma All Congenital anomalies Male circumcision: normal prepuce, using plastic guide device (e.g. Plastibel) General pediatric surgery: Neonatal intestinal obstruction: laparotomy Anorectal malformation: colostomy, anoplasty Hirschsprung's disease: colostomy Hernia/hydrocele repair: inguinal, umbilical Pediatric urology/gynecology: Relief of urinary obstruction: catherization, vesicostomy Male circumcision: neonate, older child, phimosis, paraphimosis Meatal stenosis Orchidopexy: testicular torsion, palpable undescended testes Labial adhesion/agglutination Imperforate hymen Pediatric orthopedics: Club foot: non-operative manipulation All corrective procedures determined by available expertise All All 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 tumors/cysts 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