Many pediatric procedures, especially those in ENT and urology, can be profitable, but there's a lot to consider. Anesthesia providers need to be comfortable and proficient with children, and parents need to feel that their children are in a safe, reassuring environment. Whether you're planning a pediatric surgery center or just thinking of adding pediatric cases to your case mix, here are eight issues to consider.

1. Beware "The Gowns"
Small communities seldom have adequate pediatric case volume to support a pediatrics-focused surgery center. Large metro areas with a children's hospital and a large number of pediatric surgeons tend to be the best locations. When assessing whether there's a significant population of appropriately aged patients in your market, ask these questions:

• Where are pediatric cases currently performed?
• Can these cases be safely performed in an outpatient setting?
• Are local physicians dissatisfied with the current services in the hospital?

When recruiting physician-partners and physicians who'll bring cases to your center, be aware that you might encounter the "Town vs. Gown" conflict. Often, children's hospitals are associated with universities. In these institutions, the "teaching" approach includes residents who work with attending surgeons (The Gowns). These surgeons are often more focused on creating an environment conducive to learning than to bringing volume to their institution. This approach may not blend well with the profit goals of the local high-volume physicians in private practice (The Town). The local children's center can be a blessing or a curse, depending on whether management of the hospital will consider a joint venture with the ASC.

2. Orthopedics? Maybe not
The surgical specialties best suited to the pediatric ASC environment include otolaryngology, urology, dentistry, general surgery, plastic surgery, ophthalmology and gastroenterology. While orthopedics is a possibility, it's usually challenging to perform those cases in an outpatient environment because of patients' post-op pain control needs. Most orthopedic patients require extra recovery time and sometimes hospitalization for pain control. The high cost of orthopedic equipment coupled with potential low volumes of procedures could be prohibitive. However, orthopedics may be successful if you attract an orthopedic surgeon who hasn't already invested in another surgical facility and who sees a high volume of sports injuries requiring arthroscopy.

3. Set an age limit
You'll need to determine the age range of the patients you'll serve and clearly delineate this for your state license and accreditation purposes. Follow your state regulations, but be aware that some states allow patients up to 21 years old, and even older in certain circumstances such as adults with mental handicaps.

Work with an anesthesia provider to determine your admission criteria. An age limit is the most important parameter to establish. This will help you frame your policies regarding pre-existing medical conditions and what conditions may prevent a patient from being a good candidate for a procedure at the facility.

Standard age criteria usually begin at one month, unless the patient was born prematurely. Premature babies are usually not seen in an ASC setting until they reach at least six months. Patients with health issues such as cerebral palsy and conditions that may result in airway difficulties are often best treated at the hospital.

4. The right staff and anesthesia services
Search for anesthesia providers with pediatric training and current pediatric experience. Having a pediatric trained professional not only satisfies safety aspects, but it also goes a long way in terms of patient and parent satisfaction. Pediatric anesthesia specialists can also help with surgical start and turnover times. When developing procedures for the anesthesia team, work with an anesthesia provider to determine:

• appropriate NPO guidelines;
• when pre-op medications are given and how they're administered;
• whether to let parents into the OR during induction; and
• when to let parents come into the PACU.

In pediatrics, it's best to perform procedures throughout the day in order of youngest child to oldest. At the same time, don't let yourself get caught up in the cycle of not using the center in the afternoons. By following proper NPO guidelines, surgery can continue throughout the day for all age groups.

Depending on the situation, one or two family members may be allowed to come into the PACU as soon as the child is awake. This can comfort the child and make providing comfort easier for the nurse. Another effective measure for pain and comfort? Give the child an acetaminophen suppository before they awake from anesthesia and are transfered to the PACU. Older children may benefit from receiving an intramuscular injection of pain medication before transfer. It is also best to start IVs on young children and infants after induction.

5. What about your space?
Keeping the child's and parent's needs in mind are important when designing the facility. Encourage all members of the care team to use their imagination to create a child-focused environment. Consider adding the following to your design:

• play areas in the registration and waiting rooms to keep children distracted before surgery;
• private rooms for the adolescent and non-compliant children, particularly in the PACU, where private rooms are best for patients needing extended recovery time;
• a separation room, where the child and the parent part ways until they're reunited in the PACU;
• an area with age-appropriate toys, where the child can select a gift before moving into the surgery suite and leaving his parents, which can serve as a good distraction for younger children;
• a wagon ride for transport to surgery; and
• an induction room, where parents can be with their child while the patient is put under anesthesia.

Some facilities let parents come into the OR suite rather than limiting them to a separate room. Other physicians and centers prefer to keep the child and parent apart during the induction phase.

6. The people you hire must love kids
Prior pediatric experience is preferable, along with strong IV and excellent communication skills. Employees must have certification in PALS, take IV access training specifically for pediatric patients and complete annual pediatric age-specific competencies.

Staff will also deal with families, many of which are multiple-parent families. Issues sometimes arise regarding custody and legal authority to sign for the child, or involving feuding parents who are separated or divorced. In these situations, the staff needs to maintain a cool head and reiterate to the parents that the focus should be on the child.

A staff well-versed in caring for children knows plenty of innovative techniques geared to the pediatric patient, such as letting a compliant child sit in the anesthesia provider's lap during induction, singing to the patient during induction and giving a loving scalp massage as the child goes to sleep.

A pre-surgery visit will help familiarize children with the staff and facility and alleviate the anxiety of both the parent and the patient. Acquaint patients with the perioperative routine through storybooks depicting a child's surgical experience or a Web site featuring a virtual tour. Letting the child pick her anesthesia "flavor" (flavored oils applied to the anesthesia mask) is a crowd-pleaser.

7. Equipment needs
Equipment and supplies must be the appropriate size and age-specific. This includes anesthesia equipment and consumable supplies such as electrosurgery pads, sutures, surgical instruments and telescopes. You'll need a mix of cribs, small beds and stretchers. Depending on anesthesia and surgeon preference, consider heat lamps, warming blankets and forced air blankets for keeping children warm on more invasive and longer procedures.

8. Partner with the local children's hospital
A relationship or partnership with the local children's hospital can be a recipe for success, since most are well-known brands in a community. When your facility has the hospital's support, it eases much of the competition for pediatric business. It's also important to engage local pediatricians for referrals and market to them as well as the surgeons. Throughout the community, promote the fact that the center is family-friendly and kid-friendly. Place additional focus on the ability to be back home resting quickly, while achieving this in a safe environment. Emphasize that the staff, especially the anesthesia team, specializes in pediatric care.