Understanding gaps in pediatric surgery care in rural environments and forging a path forward

Editor’s note: Portions of this manuscript were presented at the Northern Plains Rural Surgical Society 2019 Annual Meeting January 19, 2019, Denver, CO, and at a Panel Session: Surgery for Children: Who Can We Keep in the Rural Community? at the American College of Surgeons (ACS) Clinical Congress, October 30, 2019, San Francisco, CA.

The ACS Advisory Council for Rural Surgery, the ACS Advisory Council for Pediatric Surgery, and the American Pediatric Surgical Association (APSA) are united in an effort to understand and improve future surgical care for children who live in rural and underserved areas of North America. A first step is to examine the current status of existing surgical resources for children and perceived gaps in children’s surgical care in these geographic areas and environments. The ultimate goal is to sustain and improve fundamental children’s surgical care through training paradigms, improved transfer arrangements, continuing medical education (CME), and enhanced communication, including telemedicine.

Fundamental children’s surgical care, similar to trauma care, can be defined along a continuum. This care includes the ability of a prehospital emergency provider or first responder and the receiving hospital emergency department (ED) to be “pediatric ready,” as well as the ability of ED personnel to recognize that a child has a potential surgical condition and either call an appropriate consultant or use transfer protocols and guidelines to refer the child to a higher level of care after providing initial stabilizing care locally.^1-7 Some surgical conditions qualify as surgical emergencies and would benefit from the expertise of a local general surgeon. Other surgical conditions might be treated at the local level without transfer of the patient if a qualified surgeon, anesthesiologist, and surgical team are available to provide appropriate care.

Prior to implementation of the 80-hour workweek and the trend toward surgical subspecialization and an increase in pediatric surgery training programs, an average general surgery resident might have spent several months on a pediatric surgery rotation, often including senior rotations. Similarly, anesthesia residents rotated in children’s hospitals, and fewer advanced practice anesthesia professionals, such as certified registered nurse anesthetists (CRNAs), were practicing. We predicted that the comfort level of individual general surgeons and anesthesiologists taking care of children in rural hospitals might be reflective of the era in which they trained.

Survey methods

An Optimal Pediatric Surgical Care Task Force composed of members of the ACS Advisory Councils for Rural Surgery and Pediatric Surgery and the APSA solicited involvement from additional national stakeholders, including the American Board of Surgery, to develop a survey directed toward practicing rural and general surgeons in the U.S. who take care of some children in their practice or who evaluate and transfer children to a higher level of care. “Child” was defined as an individual younger than 18 years of age. The survey was validated by the ACS psychometrician at the time, Sara S. Hennings, PhD.

The survey was announced and sent via the ACS online Rural and General Surgery Communities and ACS NewsScope in January 2018. The initial response offered a reasonable snapshot of children’s surgical care, but the task force sought increased participation in two ways. Additional survey participation was solicited from the Northern Plains Rural Surgical Society in January and February 2019, and onsite at the regional Utah, Idaho, Montana-Wyoming ACS Chapter Meeting January 24–26, 2020, in Salt Lake City, UT. Surgeons were recruited to take the survey if they considered themselves to be in a rural practice.

An equivalent survey was developed through a collaboration of the ACS Advisory Council for Pediatric Surgery and the Canadian Association of Paediatric Surgeons. This survey was administered between April and July 2018 to Canadian general surgeons with a scope of practice that included children.

U.S. survey results

A total of 138 surgeons responded to the U.S. survey. Almost 60 percent of the respondents had been in practice for more than 15 years, and most identified their practice as rural, general surgery, or both. A few respondents were surgical specialists, such as colorectal, who provided care to some children. Surgeons in 37 states responded, and the states providing the highest responses included Montana (8.89 percent), Oregon (7.41 percent), Texas (6.67 percent), Idaho (6.67 percent), and Wisconsin (5.19 percent).

Seventy-eight percent of the respondents served communities of fewer than 100,000 people, and 62 percent served communities of fewer than 50,000. In addition, 57 percent worked in hospitals with fewer than 100 beds; 45 percent of surgeons were hospital employees, and 28 percent were in private practice; and 22 percent practiced in critical access hospitals, 47 percent in urban and rural community hospitals with limited specialty services, and 25 percent in tertiary referral centers with most specialty services available. Respondents reported that 70 percent of hospitals where they practice did not have a neonatal intensive care unit. Ninety-three percent of the respondents said they were full-time surgeons, and 73 percent were men.

Time spent on pediatric surgery during general surgery residency varied from one to more than nine months, with 74 percent of respondents saying they felt this was the right amount of training and 19 percent indicating it was insufficient. Of the respondents, 30 percent said that the experience was not valuable and added little to their overall training in general surgery, whereas 52 percent said they felt it was valuable, providing knowledge and skills that were useful in their practice. Among rural surgeons who care for children, fewer than half care for infants and toddlers younger than two years old, with increasing percentages caring for children in older age groups. Thirty-five percent said they wished they had more expertise in caring for surgical problems in children. Of those polled, most felt very comfortable or extremely comfortable taking care of children with appendicitis, umbilical hernia, inguinal hernia, and small bowel obstruction. Most felt uncomfortable taking care of children with pyloric stenosis or who needed central venous access, colorectal procedures, empyema treatment, or thyroglossal duct cyst excision.

Barriers to care for children at the local level included lack of pediatric resources, hospital equipment, and support from the pediatric community. Slightly less than half of the respondents reported that they rarely do pediatric procedures and, therefore, feel less comfortable doing them. Training and administrative support at the hospital were mentioned by 28 percent and 24 percent, respectively. CRNAs were reported to be present at 47 percent of the respondents’ hospitals, and 42 percent said a combination of CRNA and anesthesiologist were the predominant anesthesia presence. The number of annual pediatric cases varied from a handful to 50 or 60. A few individuals did more pediatric operations. When asked, “If you are nearing retirement age and have routinely taken care of children, do you have a succession plan (for example, training another surgeon to take your place)?” 83 percent responded “no.” Seventy-three percent of the respondents were at hospitals that had transfer agreements and protocols with a specific pediatric hospital; 65 percent of the respondents said they generally do not receive feedback for patients sent to a higher level of care.

Most of the respondents do not use telehealth as a means of communicating about pediatric patients but felt that it would be of value. The survey included a number of other questions regarding appropriate hospital resources for surgeons who will treat some children (see first sidebar), as well as pediatric topics that would be of value for CME (see second sidebar). The survey was used to guide a CME panel presentation at ACS Clinical Congress 2019 sponsored by the ACS Rural Surgery and Pediatric Surgery Advisory Councils.

Canadian survey results

The Canadian survey had 25 respondents from seven of 10 provinces, with 60 percent practicing in communities with populations of less than 100,000. Seventy-five percent of these respondents spent three months or less on a pediatric surgery rotation during residency, with most assessing it to be the right amount. Among these respondents, 60 percent took care of children as young as three years old. The five most common procedures performed were appendectomy, cholecystectomy, umbilical and inguinal hernia repair, and laparotomy for bowel obstruction. General anesthesia was administered by any adult anesthesiologist (74 percent), or by an adult anesthesiologist with an interest but no formal training in pediatric anesthesia (26 percent).

When a child needed transfer to a higher level of care, the surgeon rarely received feedback after transfer. Although more than 60 percent of respondents had telemedicine capability at their hospital, it was seldom used in support of pediatric surgical patients. Thirty percent of respondents were seeking pediatric surgical CME, and nearly 70 percent expressed interest in a technology-based educational offering (webinar, technical video, or simulation).

Both surveys had relatively low response rates and are subject to the usual limitations of selection and nonresponse bias. Nonetheless, they do provide a snapshot of children’s surgical care by community and rural general surgeons in North America and highlight current gaps and barriers to optimal care, which can be addressed through education, practice, and policy change.

Relevance of survey to rural children in North America

At present, an estimated 331 million people live in the U.S. According to the last decennial census in 2010, almost 60 million people (19.3 percent) lived in rural areas.8 Starting in 1910, the population threshold of 2,500 or less was adopted and considered rural, and this benchmark has not changed. Rural Americans reside in 80 percent of the total U.S. land area but comprise 20 percent of the population, and this also has changed very little since 1910, as most of the increase in U.S. population is attributed to urban growth.8 Nearly a quarter (22.3 percent) of individuals living in rural areas as of 2016 are children younger than 18 years old; 2.3 million of these children live in poverty, and 23.8 percent of rural households have no Internet access. Child poverty rates are 25 percent in rural areas with fewer than 10,000 people. More specifically, 14.1 million children in our country grow up in poverty, of which 11.8 million are urban and 2.3 million rural.⁹ Biologic distribution is approximately equal; 8.1 million are children of single mothers, 2.1 million of single fathers, and 4.5 million have parents who are married. In decreasing order, the racial mix are Latinx (5.1 million), Caucasian (4.3 million), African American (3.5 million), Asian (410,000), or Native American and Alaskan Native (240,000). There are geographic areas of distinction with 6.1 million children in the South, 3.2 million in the West, 2.7 million in the Midwest, and 2.0 million in the Northeast. Almost 1 million of these children have disabilities.⁹

Rural hospitals and their role in pediatric health care

Rural hospitals are an integral part of the rural health care system and may be classified as critical access hospitals by the Centers for Medicare & Medicaid Services.^10-11 These facilities often are a vital part of the local economy, but many are ill-equipped to care for children who are seriously ill or injured.¹² For those pediatric patients without easy access to tertiary pediatric care, both “pediatric readiness” of emergency medical services (EMS) and EDs is crucial.^1-6 According to the Health Resources and Services Administration Emergency Medical Services for Children Program, which funds programs in every U.S. state and territory, most nonpediatric centers see fewer than five pediatric patients a day and only approximately 10 percent of all EMS runs are for children—only a fraction of who are critically ill or injured.^1,13 Therefore, the exposure of an individual EMS or ED provider to a sick or hurt child will necessarily be low. A recent national assessment of pediatric readiness revealed that hospitals with low pediatric volume (defined as fewer than five pediatric visits daily) scored 61 out of 100 points on a readiness scale in contrast to 84 in a high-volume hospital (more than 27 pediatric visits per day).¹ The presence of a pediatric emergency care coordinator to champion pediatric education and quality improvement was associated with improved readiness and is now being championed for EMS, as well as hospital EDs.^4-6 The availability of transfer guidelines and protocols between hospitals, established relationships between providers at the local and regional level, and transport modes, including availability of pediatric transport teams are other ways to facilitate resuscitation and transfer of appropriate patients in a timely fashion. These protocols set the stage for timely and appropriate care.¹⁴

Gaps in care

Both surveys highlight several gaps that could be addressed with a combination of training, telehealth, directed CME, and selective mentoring. In this snapshot of pediatric surgical practice within the general and rural surgery community, a cadre of surgeons trained at a time when they became comfortable taking care of some children, and they continue to provide care to mostly older children, do routine cases with a limited scope of practice, and refer more complicated cases to a pediatric center with which they have a relationship. However, many surgeons lack a succession plan, and their respective hospitals will need either to recruit a replacement with similar expertise, which seems unlikely, or send all of the patients to a regional center, which may be difficult for families. In many cases, the hospital infrastructure does not support pediatric surgery well, perhaps because the average percentage of pediatric patients seen and cared for is sufficiently small to deter expending limited resources on this patient population. Our survey showed that few rural surgeons received feedback from the receiving pediatric institution when they sent their pediatric patients to a higher level of care. Such feedback could be a valuable source of education for the rural surgeon, and surgeons in tertiary centers should make providing this information a more structured part of the provision of care.

Other gaps not previously mentioned but relevant to this discussion include pediatric anesthesia services, which would include anesthesiologists who have consistently taken care of children in their practice or adequately trained CRNAs, to be further defined by our colleagues in pediatric anesthesia. The need for other routine pediatric surgical cases or management of conditions needs to be mentioned—including otolaryngology (ear tubes, tonsillectomy); orthopaedic surgery (simple fracture management); urologic surgery (circumcisions); and ophthalmology (lacrimal duct probing)—and whether or not these disciplines have rural and underserved community needs.

Pathways to additional pediatric training for rural general surgeons

Several pathways are available to individuals who want to receive additional training in general pediatric surgery. First is the flexibility in the training pathway. This pathway allows for additional rotations in the senior years of training with preapproval from the program director and the American Board of Surgery.¹⁵ Trainees could easily incorporate two to three months of pediatric surgery into the senior resident years if they were intending to take care of children in their practice. This approach easily could be incorporated into a rural surgery track. Another pathway is the ACS Mastery of General Surgery Program that is available after training is completed.¹⁶ Individuals in this fellowship can be treated as junior faculty in a children’s hospital, much like an apprenticeship, with appropriate supervision for cases where they need more experience and intend to incorporate these cases into their eventual scope of practice. Part of the year of experience would be spent in the hospital where they eventually will practice, building the needed infrastructure to take care of the planned age range of children. To date, children’s hospitals have not been able to participate in this program, although nothing precludes their involvement if they have the educational capacity.

Both of these models also will encourage young surgeons to develop relationships with mentoring pediatric surgeons who can provide lifelong advice and consultation under the appropriate circumstances.

Future work

Inherent to momentum is interest. A corollary survey has been developed for general surgery residents to determine interest in pediatric surgery electives among more senior general surgery residents with the intention to practice general surgery, particularly in rural environments. Some universities have a designated rural surgery residency track, which has a separate match through the matching program; however, it omits pediatric surgery from the core curriculum. The addition of pediatric surgery to the curriculum would improve the preparation of their residents to care for children more confidently.¹⁷

In addition, including some pediatric training in the acute care general surgery curriculum might help with pediatric trauma and emergency care for children in adult-predominant trauma centers that care for some children, where pediatric readiness often is still lacking.⁷ These may be opportunities for future consideration.

Targeted recruitment of medical students and surgery residents to a career in rural general surgery has the potential to fill some of the need for access. Including general surgeons in loan forgiveness programs by recognizing rural general surgery as a specialty in short supply is another. Unfortunately, many of our nation’s critical access hospitals have recently closed because of economic hardship.¹⁸

This year’s coronavirus (COVID-19) pandemic has highlighted the relatively untapped resource of telehealth, which can play a role in both pre- and postoperative care for children who need to travel to a regional pediatric center, but also can assist in communicating advice and expertise at a distance for simpler cases and in CME. Pediatric surgeons also can provide selective mentorship for general surgeons who are willing and have the expertise to care for some children locally and to assist small hospitals with understanding the minimum resources needed to take care of children. These facilities will see a return on their investment in the health, safety, and provision of local quality care.

Acknowledgment

The authors would like to acknowledge the assistance of Lindsey Gumer, MHA, for administrative assistance and the help of Rebecka Meyers, MD, FACS; Randall Zuckerman, MD, FACS; and Denis Bensard, MD, FACS, in administering the survey at the regional Utah, Idaho, Montana-Wyoming ACS Chapter Meeting.

References

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