Finding a New Home: Approaching the Perioperative Care of Refugee Children
Samuel Percy MD and Debnath Chatterjee MD FAAP
Original Article
Kamath A, Gentry K, Dawson-Hahn E, Ross F, Chiem J, Patrao F, Greenberg S, Ibrahim A, Jimenez N. Tailoring the perioperative surgical home for children in refugee families. Int Anesthesiol Clin. 2023;61(1):1-7. PMID: 36409682
“The United Nations High Commissioner for Refugees (UNHCR) estimates that ~90 million people are currently forcibly displaced due to conflict, persecution, violence, human rights violations, public disorder, natural disasters, or famine. Of these, 27.1 million are refugees”.1 More than half of all refugees are children.2 Forcibly displaced persons face many barriers to access and receipt of health care services despite high health care needs. “Approximately three million surgical procedures annually are required to meet the surgical needs of refugees, internally displaced persons, and asylum seekers. Most displaced persons are hosted in countries with inadequate surgical care capacity”.3 Kamath et al.1 identify several health considerations specific to refugee children arriving and living in the United States and propose a refugee patient-centered perioperative surgical home care model (RPSH) that seeks to provide equitable perioperative care to this population. The elements of the RPSH will be discussed below.
Children in refugee families have varied prior interactions with the healthcare system, levels of health literacy, and institutional trust. “This variation includes whether or not their family was able to migrate together; if they or their family experienced or witnessed trauma; their opportunity to interact with health care systems; their privilege to access the school system; their families’ literacy and health literacy; and their level of trust for institutions”,1 Children from refugee families traveling to the United States are required to undergo a health assessment abroad following the Centers for Disease Control (CDC) and Prevention guidance. This helps identify conditions that might pose a public health risk or impact a child’s fitness to fly. The CDC recommends a comprehensive physical examination and laboratory investigations within 30 to 90 days of arrival.4
Surgical conditions present in children from refugee families vary widely and may include traumatic injuries or burns in patients migrating from conflict or disaster areas. Surgical effects of infectious diseases such as tuberculosis, amoebiasis, or hydatid disease may be encountered along with untreated congenital anomalies such as congenital heart disease or cleft lip and palate. Children from refugee families may also be experiencing malnutrition or anemia, which could impact their anesthetic and surgical care and recovery. Whatever the surgical condition a child from a refugee family presents with, all care should be provided in collaboration with their primary medical home and be performed with humility and cultural awareness.
The authors propose addressing gaps in perioperative care for refugee families using a refugee perioperative surgical home (RPSH) model. The RPSH care model focuses on the pillars of providing trauma-informed care, demonstrating cultural humility, and effective communication and providing multidisciplinary coordinated care (Figure 1). These pillars are based on the International Society for Social Pediatrics and Child Health (ISSOP) refugee care principles. These pillars are often present in the primary care setting but may be lacking in the perioperative environment.
The first pillar of providing trauma-informed care emphasizes safety, trustworthiness, collaboration, empowerment, and choice. In the perioperative setting, this may involve discussing with the patient and their family induction plans, plan for reuniting in the recovery area, and family support resources during a possible hospitalization. The second pillar of the RPSH involves focusing on cultural humility and communication. These skills are often emphasized at the primary community health level but may not be as ubiquitous in perioperative care. The perioperative environment should strive to build trust through preoperative encounters, involve culture navigators to provide context to providers regarding specific cultural or religious needs of patients, and emphasize the availability and use of appropriate interpreter services for all patient and family communications. Cultural humility should be emphasized and taught in residency training programs and continually refined throughout a career. The final RPSH pillar involves ensuring that children from refugee families receive multidisciplinary, coordinated care. This may be best achieved by close collaboration between the primary care team and pre-anesthesia clinics to establish trust and identify the roles of specialists for the patient and their families. Appointments should be bundled to respect transportation and work absence concerns, and the anesthesia team should seek to leverage and coordinate with the diverse set of hospital teams and resources that may be available including child life specialists, interpreters, and social workers.
The authors recognize that the complete RPSH model may only be able to be applied in tertiary care, high-resource environments, but that the pillars of trauma-informed care and cultural humility are applicable to any clinical encounter regardless of resources. Additionally, the RPSH model is not meant to create a one size fits all approach to the care of children from refugee families as these patients have varied and heterogenous backgrounds, clinical conditions, and experiences.
Please share any successes or challenges you have had in caring for children from refugee families and Myron will post them in a PAAD reader response.
References
1. Kamath A, Gentry K, Dawson-Hahn E, et al. Tailoring the perioperative surgical home for children in refugee families. International anesthesiology clinics. Jan 1 2023;61(1):1-7. doi:10.1097/aia.0000000000000387
2. Unicef. Uprooted: the growing crisis for refugee and migrant children. Accessed 02/24/2023, https://www.unicef.org/reports/uprooted-growing-crisis-refugee-and-migrant-children
3. Zha Y, Stewart B, Lee E, et al. Global Estimation of Surgical Procedures Needed for Forcibly Displaced Persons. World journal of surgery. Nov 2016;40(11):2628-2634. doi:10.1007/s00268-016-3579-x
4. Mitchell T, Weinberg M, Posey DL, Cetron M. Immigrant and Refugee Health: A Centers for Disease Control and Prevention Perspective on Protecting the Health and Health Security of Individuals and Communities During Planned Migrations. Pediatric clinics of North America. Jun 2019;66(3):549-560. doi:10.1016/j.pcl.2019.02.004
