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Units without inpatient paediatric beds should have a formal arrangement with a neighbouring unit, to ensure that practical assistance is available should a child require transfer.⁹ Protocols should be in place for the rapid assessment and transfer of patients to the local specialist unit within the network.¹³

Onsite ICU and HDU services should be appropriate to the type of surgery performed and the age and comorbidity of patients, and should be available to support the delivery of more complex postoperative analgesic techniques.

In hospitals with no onsite paediatric high dependency and critical care facilities, there should be the facilities and expertise to initiate critical care prior to transfer/retrieval to a designated regional PICU/HDU facility. This may involve short-term use of adult/general ICU facilities.¹³

A well-designed preoperative service should minimise patient delays through the journey to surgery, while allowing appropriate time for initiation of interventions likely to improve patient outcome. By optimising planning of patient care, with the right staff and resources available, cancellations can be reduced and the efficiency of operating lists improved.⁷³

There should be ready access to evidence based guidelines that are appropriate for children on the following topics:

management of pain, nausea and vomiting

• fluid fasting⁶⁷
• intravenous fluid management¹⁸
• prevention of perioperative venous thromboembolism⁶⁸
• death of the child in theatre
• protocols for anaesthetic emergencies, including:
  • anaphylaxis⁶⁹
  • malignant hyperthermia
  • difficult airway management
  • airway obstruction...

When infants and children undergo procedures under sedation alone, recommended published guidance for the conduct of paediatric sedation should be used.^71,72

Guidance on preprocedure pregnancy testing in female patients should be followed.⁷¹

Quality indicators, such as unplanned inpatient admission following day case surgery, readmission within 28 days, or unanticipated admission to PICU following surgery, should be measured, collated and analysed, and can be compared within regional networks. A number of suggested audit topics specifically relating to paediatric anaesthesia are set out in the RCoA document ‘Raising the standard: a compendium of audit...

Regional networks could provide agreed quality standards for the perioperative care of infants, children and young people, and units could be encouraged to participate in regular collation of data relating to these standards. Participation in national audit should also be encouraged.⁵

Quality improvement projects in relevant areas of paediatric anaesthetic practice should be agreed and implemented.^1,70