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Each hospital should have a written definition of age thresholds and the types of procedure for elective and emergency work, including imaging, which can be provided locally. Complex children, e.g. ASA 3 with significant comorbidity, should be discussed with the carers and referred to a tertiary centre if the local infrastructure cannot meet their needs.^21,22

In each hospital providing neuroanaesthesia, a neuroanaesthetist should be appointed as the clinical lead (see glossary) to manage service delivery. Adequate time for this role should be included in the lead’s job plan.

Children should be separated from, and not managed directly alongside adults throughout the patient pathway including in waiting rooms, preassessment clinic rooms and theatre areas, including anaesthetic and recovery areas, as far as possible.¹⁹ These areas should be child-friendly.

Hospitals should define the extent of emergency surgical provision for children and the thresholds for transfer.

Emergency paediatric surgical care should be provided within a network of secondary and tertiary care providers. Networks should agree standards of care and formulate care pathways for emergency surgery. Departments should participate in regular network audits of emergency surgical work.^{120,121,122,123}

Children with severe comorbidity who require emergency anaesthesia should be treated in a specialist paediatric centre. However, if transfer is not feasible, the most appropriately experienced senior anaesthetist should provide anaesthesia and support resuscitation and stabilisation, as part of the multidisciplinary team.^124,125

Transfer of children to specialist centres is usually undertaken by regional paediatric emergency transfer services. Time critical transfers such as neurosurgical emergencies may need to be transferred by the referring hospital. Local guidelines should be in place for the management of such transfers and the most experienced anaesthetist with appropriate skills, together with a trained assistant, should accompany the child.¹²⁶

In the elderly, anaesthesia and surgery should be undertaken by senior staff with experience and expertise in this area in order to limit the duration of the operation and its physiological impact to a minimum.⁷  

Poor or inadequate analgesia contributes to postoperative morbidity in the elderly. Pain is poorly assessed and treated in the elderly, particularly in those patients who suffer with cognitive impairment. Specific algorithms for the assessment of pain, and postoperative analgesia protocols, are recommended in the elderly.⁷

Perioperative delirium/confusion is common and often under recognised. Hospitals should have policies to recognise and manage perioperative delirium/confusion.^7,9,117