Optimal Resources for Children's Surgery 2: Tiered Recommendations for Minimum Essential Children's Surgical Procedures Across Health System Levels.

Abstract

In 2015 the World Health Assembly (WHO), based on recommendations by the Lancet Commission on Global Surgery, passed resolution (68:15) on strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage. However, children's surgery was not adequately represented and in response, the Global Initiative for Children's Surgery (GICS) published the Optimal Resources for Children's Surgical Care (OReCS) in 2019 providing insight into procedures which should be performed at different facility types. OReCS 2 addresses a gap in both policy and published literature to further define surgical conditions and procedural capabilities by hospital level. We performed a review of the literature to identify procedures routinely performed in a variety of settings. We then used an iterative Delphi like approach to identify specialty-specific procedures and nursing skills by hospital level. Participation was open to all members of GICS with representation from 21 working groups and more than 50 low-middle income countries (LMICs) and high-income countries (HICs). Data on essential procedures were collected for twelve specialty groups. Modifications of the recommendations provided by the working groups were made by the executive board based on firsthand knowledge of capabilities at lower-level facilities where subspecialists have less experience. Final recommendations were made based on greater than 75% agreement by respondents and review of the executive board of GICS. Procedures performed at health centers were limited to those not requiring anesthesia or sedation and were largely identified to help triage and stabilize patients for transfer to higher level care. Similarly, first level hospital procedures focused on stabilization and transfer to referral level hospitals for most specialties. Alternatively, specialties such as ophthalmology and dental surgery have identified definitive procedures for lower-level facilities. Procedures performed at the National Children's Hospital level include those requiring specialty providers and equipment such as transplantation, repair of congenital heart disease, and reconstructive surgery for complex trauma, congenital anomalies, and burns. This updated version of OReCS provides specific examples of procedural capabilities for twelve subspecialties at the health center, first, second, third, and referral level hospitals in LMICs. Whereas the list is not meant to be all inclusive, it provides a framework within which to define the minimum essential material resources, equipment, and personnel by hospital level.