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In all centres admitting children, one anaesthetist should be appointed as clinical lead (see glossary) for paediatric anaesthesia. Typically, they might undertake at least one paediatric list each week and will be responsible for co-ordinating and overseeing anaesthetic services for children, with particular reference to teaching and training, audit, equipment, guidelines, pain management, sedation and resuscitation.

The use of general anaesthesia, sedation and regional anaesthesia for procedures undertaken in the ED should be managed according to guidance from the Academy of Medical Royal Colleges and Royal College of Anaesthetists.^8,9,10,11

The majority of hip fracture patients are >65 years of age and often have multiple comorbidities, some of which may be undiagnosed. Decisions on their treatment should ideally be made using a multidisciplinary team that involves senior anaesthetists, perioperative physicians, orthopaedic surgeons and orthogeriatricians, all with a specific interest in this patient population.⁵⁰

There must be the ability to provide the patient with an appropriate chaperone, as per General Medical Council (GMC) guidance on intimate examinations and chaperones.⁴⁹ When examining a patient, anaesthetists must be sensitive to what the patient may consider as intimate. This could include any examination where it is necessary to touch or even be close to the patient.

There should be a dedicated trained assistant (i.e. an ODP, anaesthetic nurse or equivalent) who holds a valid registration with the appropriate regulatory body, immediately available in every location in which anaesthesia care is being delivered, whether this is by an anaesthetist or an AA.^39,112

The safe management of unstable patients depends on close liaison between emergency physicians and anaesthetists,^33,34 to ensure that clear guidelines are in place, emergency department support staff are trained to assist with tracheal intubation, and audit and discussion of complications is undertaken regularly.

A local training module should be provided for anaesthetists in training according to their grade, supervised by a nominated educational lead. This programme should develop understanding of the widespread nature of cardiovascular disease, optimisation and risk stratification, as well as perioperative management. The RCoA revised training curriculum (2010) provides explicit detail of the requirements.⁴²

Special considerations for younger children undergoing day case tonsillectomy/ adenoidectomy surgery should be made depending of expertise at the centre and current national guidelines. Skilled preoperative assessment services, including thorough assessment of children with obstructive sleep apnoea (OSA) and experienced anaesthetists and surgeon are required to deliver this safely. Surgery and perioperative care, including care on the post-anaesthetic care unit...

The Royal College of Anaesthetists has published guidance for audits and quality improvement projects in day surgery.⁶ Each day surgery unit should have a system in place for the routine audit of important basic clinical and organisational parameters such as:

• clinical: unplanned inpatient/overnight admissions following surgery, postoperative symptoms (e.g. pain, nausea and vomiting) 
• organisational: non-attendance rates, patients cancelled...

In non-specialist paediatric tertiary centres, having visiting consultant paediatric anaesthetists from specialist tertiary paediatric centres to attend operating lists to provide education and training updates should be considered. These may be part of the arrangements in place within a children’s surgery ODN. The Certificate of Fitness for Honorary Practice may facilitate such placements and provides a relatively simple system for...