Anesthesia Provider and Facility Practice Patterns in Ambulatory Surgical Centers Caring for Children: A Survey of the Society for Ambulatory Anesthesia

Ambulatory surgery centers (ASC) perform more than half of all outpatient surgeries in the United States [1]. The US ASC market is estimated to grow to $52–$55 billion this year, with outpatient procedural volume expected to increase by 15% by 2028. In pediatrics, over a quarter of outpatient procedures are performed in ASCs [2]. However, there is little reporting and outcomes data in ambulatory pediatric practice. We surveyed anesthesia providers caring for children in ASCs to understand clinician and facility practice patterns, hypothesizing that significant variability exists in this unique perioperative space. The electronic survey was distributed to Society for Ambulatory Anesthesia (SAMBA) members on August 27, 2024, with a reminder email on October 7, 2024, and closed to responses on November 21, 2024. The survey consisted of 20 closed-ended, multiple-choice questions divided into three sections by concept (Figure S1). The Johns Hopkins IRB (#00459329) approved the survey study with a waiver of informed consent. Participant demographics, practice characteristics, and answers to questions were characterized using frequencies and percentages or medians and interquartile ranges. Of 694 SAMBA members surveyed, 75 members participated (11%). Of these, 13 respondents were excluded because they did not work in an ASC (n = 10), did not care for children (n = 1), or did not complete the survey beyond agreeing to the instructions (n = 2). Therefore, the final cohort included 62 respondents. Summary characteristics are presented in Table 1. Most respondents were physician anesthesiologists (96.6%), though of these, only 39% had completed a fellowship and were board certified in pediatric anesthesiology. More than three-quarters of clinicians reported a mixed adult/pediatric practice at their ASC, while 24% had an exclusively pediatric practice. Most clinicians (69%) had been in practice for 15 years or longer. Most respondents (79%) worked in a free-standing ASC with standard same-day recovery capabilities. Over half (64%) worked in facilities with fewer than 1000 pediatric cases annually, and only 34% worked in an ASC that maintained a pediatric hospital affiliation. Additionally, 66% participated in physician-supervised care models (Figure 1). The minimum age most frequently reported to be eligible for care at an ASC was 6 months (41%), though this ranged broadly from 0 days to 12 years. The majority of respondents (59%) reported that their facility's age minimum considered a child's history of prematurity. Anesthesiologists were nearly always involved in setting minimum age guidelines for their facilities. Most respondents were unaware of insurance carriers' involvement in determining site of service (86%) or age minimums for ASC procedures (91%). This study identifies and highlights a wide variation in staffing, training, and policies in pediatric ambulatory anesthesia care. Most clinicians reported a mixed adult/pediatric practice, which presents challenges in providing safe, well-resourced pediatric care in primarily adult settings guided by financial and staffing considerations. These challenges are further compounded by ASC ownership models, often privately owned or operated by management companies [3]. This survey underscores the need for more data from pediatric ambulatory sites to inform how best to align a child's perioperative needs and risk profile with clinician competencies and facility resources. Notably, clinicians were unaware of insurance practices mandating case shifts to ASCs and lowering age minimums for common outpatient procedures [4]. Furthermore, only one-third of respondents worked in an ASC with a pediatric hospital affiliation. This raises concern that there may be situations where decisions regarding service site, increasingly disconnected from anesthesiologists, lead to care in ASCs inadequately supported by pediatric hospitals. Despite evidence that ambulatory surgery is safe for children, there is little data to guide eligibility criteria for infants, which our survey reinforces [5]. Discharge readiness criteria for infants under 6 months are also poorly defined [6]. Contributing factors include limited outcome data, implications of prematurity, varying local guidelines and practice volumes, and differing abilities to admit for extended observation. Robust data is needed to develop risk stratification tools for this vulnerable pediatric sub-population [7]. Most respondents had practiced for 15 years or more, with the most common supervision ratio being 1 MD to 4 CRNAs. This could indicate the high skill of pediatric ambulatory anesthesia teams, the lower acuity of outpatient surgeries, or a practice of leaner staffing for financial efficiency. More data is needed to determine ideal staffing models. This study's results are constrained by an 11% response rate, which is not uncommon for online surveys from specialty societies but limits its generalizability. Nevertheless, the issues voiced by respondents capture salient concerns in pediatric ambulatory anesthesia. Second, the results may be influenced by practice patterns of SAMBA members and may poorly reflect those of non-member providers. In summary, there exists significant variation in practice patterns among pediatric ambulatory anesthesia providers and the ASCs in which they work. Given the anticipated growth in pediatric ambulatory surgery, evidence-based guidelines are needed to delineate staffing ratios, eligibility criteria, and clinician competencies so that every child receives safe, consistent, efficient, and cost-effective care. The authors declare no conflicts of interest. The authors have nothing to report. Figure S1. Survey content. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.