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Not Just Individuals: The Importance of Collaborative Systems of Pediatric Surgical Care

Houck, Constance S. MD, MPH, FAAP; Oldham, Keith MD, FACS, FAAP; Uihlein, Marie Z.

doi: 10.1213/ANE.0000000000002039
Letters to the Editor: Letter to the Editor

Published ahead of print March 17, 2017.

ACS Children’s Surgery Verification Committee, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts,

ACS Children’s Surgery Verification Committee

Chair and Professor of Surgery, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin

Published ahead of print March 17, 2017.

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To the Editor

We read with interest the article by Muffly et al1 and found the distribution statistics both timely and relevant as pediatric surgical specialists work together to develop systems of pediatric surgical care. The vision of the American College of Surgeons Children’s Surgery Verification Quality Improvement Program (ACS CSV) is that “every child in need of surgical care in North America today will receive this care in an environment with resources optimal for his/her individual need.” It is a core principle of the Optimal Resources for Children’s Surgical Care standards ( that children who need the resources of a Level I children’s surgery center should have access to these resources regardless of their ability to pay or the distance from a pediatric resource-rich center. An essential component is the development of regional “systems” of pediatric surgical care that allow for the safe and effective transport of infants and children to a place that can provide the full range of pediatric specialty services for their particular need. To meet the standards as a Level I ACS CSV-verified center, hospitals must show that they provide leadership in education, research, and system planning, and they are expected to cooperate with all hospitals in the region caring for children with surgical needs. This includes caring for families with few resources who may be far from home by assisting them with managing their travel burden and providing psychologic, spiritual, and social support.

It is important to understand that the ACS CSV program is a voluntary program designed to assist providers, institutions, and families in making optimal choices for their children who need surgical care. The pediatric anesthesiology standards in the program are consensus professional recommendations, not regulations. In addition, the program defines alternative pediatric anesthesia training and experience such that the actual pool of pediatric anesthesiologists, alternative pathway pediatric anesthesiologists, anesthesiologists with pediatric expertise, and Certified Registered Nurse Anesthetists with pediatric expertise is substantially larger, and providers presumably more accessible than this analysis suggests.

It is also noteworthy that the most relevant established model of this concept is the ACS trauma center verification program developed during the last 40 years. This work toward trauma system development has demonstrably lowered trauma-related mortality in the United States at a population level.2 This positive outcome has been achieved despite the fact that 38.4 million Americans live more than 60 minutes from a trauma center.3

The ACS CSV standards were developed with input from multiple stakeholders in pediatric medicine and have been endorsed by the American Academy of Pediatrics and all of the major pediatric surgical and anesthesia organizations. The standards are designed to be “patient-centered” and to encourage “the right medical care to an individual patient at the right time.” The article by Muffly et al1 provides important information to members of the ACS CSV Committee as we continue to streamline the standards and will encourage careful review during the verification process of the regional systems of pediatric surgical care that each CSV-verified center is expected to provide.

Constance S. Houck, MD, MPH, FAAPACS Children’s Surgery Verification CommitteeDepartment of Anesthesiology, Perioperativeand Pain MedicineBoston Children's HospitalBoston,

Keith Oldham, MD, FACS, FAAPACS Children’s Surgery Verification Committee

Marie Z. UihleinChair and Professor of SurgeryChildren’s Hospital of WisconsinMilwaukee, Wisconsin

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1. Muffly MK, Medeiros D, Muffly TM, Singleton MA, Honkanen A. The geographic distribution of pediatric anesthesiologists relative to the US pediatric population. Anesth Analg. 2017; 125:261–267.
2. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al.A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366–378.
3. Hsia R, Shen YC. Possible geographical barriers to trauma center access for vulnerable patients in the United States: an analysis of urban and rural communities. Arch Surg. 2011;146:46–52.
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