Adam M. Vogel

Surgical wound misclassification: A multicenter evaluation

BACKGROUND Surgical wound classification (SWC) is used by hospitals, quality collaboratives, and Centers for Medicare and Medicaid to stratify patients for their risk for surgical site infection. Although these data can be used to compare centers, the validity and reliability of SWC as currently practiced has not been well studied. Our objective was to assess the reliability of SWC in a multicenter fashion. We hypothesized that the concordance rates between SWC in the electronic medical record and SWC determined from the operative note review is low and varies by institution and operation. STUDY DESIGN Surgical wound classification concordance was assessed at 11 participating institutions between SWC from the electronic medical record and SWC from operative note review for 8 common pediatric surgical operations. Cases with concurrent procedures were excluded. A maximum of 25 consecutive cases were selected per operation from each institution. A designated surgeon reviewed the included operative notes from his/her own institution to determine SWC based on a predetermined algorithm. RESULTS In all, 2,034 cases were reviewed. Overall SWC concordance was 56%, ranging from 47% to 66% across institutions. Inguinal hernia repair had the highest overall median concordance (92%) and appendectomy had the lowest (12%). Electronic medical records and reviewer SWC differed by up to 3 classes for certain cases. CONCLUSIONS Surgical site infection risk stratification by SWC, as currently practiced, is an unreliable methodology to compare patients and institutions. Surgical wound classification should not be used for quality benchmarking. If SWC continues to be used, individual institutions should evaluate their process of assigning SWC to ensure its accuracy and reliability.

Acute coagulopathy in pediatric trauma

Purpose of review To summarize our current understanding of the pathophysiology, diagnosis, and management of acute traumatic coagulopathy in children. Recent findings Traumatic coagulopathy is a complex process that leads to global dysfunction of the endogenous coagulation system and results in worse outcomes and increased mortality. Although the cause is multifactorial, it is common in severely injured patients and is driven by significant tissue injury and hypoperfusion. Viscoelastic coagulation tests have been established as a rapid and reliable method to assess traumatic coagulopathy. Additionally, massive transfusion protocols have improved outcomes in adults, but limited studies in pediatrics have not shown any difference in mortality. Summary Prospective studies are needed to determine how to best diagnose and manage acute traumatic coagulopathy in children.

A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough? ☆ ☆☆ ★

BACKGROUND/PURPOSE Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions. METHODS A before-and-after study from 2011-2014 at eleven childrens hospitals was conducted. The SWC recorded in the hospitals intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohens weighted kappa and chi square. RESULTS Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution. CONCLUSIONS Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.

Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis

Introduction The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT). Methods We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard. Results Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = −0.050, p < 0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan. Conclusion As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.

BACKGROUND Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1–18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4–66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3–13 days) and regular diet at a median of 8 days (IQR 4–20 days). Median hospitalization length was 13 days (IQR, 7–24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE Therapeutic/care management, level V (case series).BACKGROUND Guidelines for non-operative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers in order to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (AAST grade III-V) pancreatic injuries treated with NOM between 2010-15. Data was collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range 1-18). The majority (73%) of injuries were AAST grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range 4-66). All patients had computed tomography (CT) scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. Endoscopic retrograde cholangiopancreatogram (ERCP) was obtained in 25%. An organized peri-pancreatic fluid collection present for at least 7 days following injury was identified in 59% (42/71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at median 6 days (IQR 3-13) and regular diet at median 8 days (IQR 4-20). Median hospitalization length was 13 days (IQR 7-24). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE IV (case series). STUDY TYPE Therapeutic/Care Management.

Acute procedural interventions after pediatric blunt abdominal trauma: A prospective multicenter evaluation

BACKGROUND Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant. RESULTS Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%. CONCLUSION Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.BACKGROUND Pediatric intraabdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization. METHODS We prospectively enrolled children <16 years following BAT at 14 Level-One Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared to those who did not receive an intervention using descriptive statistics and univariate analysis; p < 0.05 was considered significant. RESULTS 261 of 2188 patients (11.9%) had IAI. 45 IAI patients (17.2%) received an acute procedural intervention (38 operations, 7 angiographic embolization). The mean age for patients requiring intervention was 7.1+/-4.1 years and not different from the population. The majority of patients with IAI-I were normotensive (88.9%). IAI-I patients were significantly more likely to have a mechanism of MVC (66.7% vs. 38.9%), more likely to present as a level I activation (44.4% vs. 26.9%), more likely to have a GCS < 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical exam (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent CT scan before intervention. Operations consisted of laparotomy (n=21), laparoscopy converted to open (n=11), and laparoscopy alone (n=6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury (SOI), including 7 angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for SOI (59.2% vs. 7.6%). Post-operative mortality from IAI was 2.6%. CONCLUSIONS Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course, and have excellent clinical outcomes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

1557: CHARACTERISTICS AND PREDICTORS OF INTENSIVE CARE UNIT ADMISSION IN PEDIATRIC BLUNT ABDOMINAL TRAUMA.

Learning Objectives: The purpose of this study was to identify patient predictors for intensive care unit (ICU) admission in pediatric patients sustaining blunt abdominal trauma (BAT). Methods: Pediatric patients (age<16 years) who presented following BAT to 14 Level-One Pediatric Trauma Centers over a one-year period were prospectively identified. Patients were categorized as ICU or non-ICU. Descriptive statistics and binary logistic regression was performed. Results: 2182 children with a median age of 8 [4,12] years were included. 461 (21%) were admitted to the ICU. ICU patients had a higher rate of injury by assault (5.4% vs. 1.9%) and a lower rate of injury by motor vehicle crash (37.5% vs. 48.8%); all p<0.001. ICU patients were more severely injured (injury severity score (ISS); 17 [10,26] vs. 4 [1,9]), had a lower Glasgow coma score (GCS; 12 [4.5,15] vs. 15 [15,15]), increased hypotension (6.7% vs. 1.8%) and tachycardia (37.7% vs. 27.6%) for age, and were more anemic (hematocrit<30; 19.1% vs. 2.1%); all p<0.001. Severe (AAST>4) liver (4.5% vs. 0.2%) and spleen (3% vs. 0.1%) injuries were increased in the ICU cohort along with thoracic injury (35.9% vs. 10%), skull fractures (35.4% vs. 4.5%), facial fractures (24.4% vs. 5.8%), and cervical spine injury (9.3% vs. 1.3%); all p<0.001. ICU patients had higher rates of transfusion (5.6% vs. 0), ICP monitoring (13.6% vs. 0), craniotomy (8.2% vs. 0), and 30-day mortality (8% vs. 0.4%); all p<0.001). Severe trauma (ISS>15; OR 4.9, 95%CI [3.1,7.6]), initial GCS (OR 0.6, 95%CI [0.53,0.64]), cervical spine injury (OR 6.5, 95%CI [2.7,15.6]), anemia (OR 5.7, 95%CI [2.9, 11.7]) and skull fracture (OR 4.7, 95%CI [2.9,7.6]) in addition to severe solid organ injury (OR 14.7, 95%CI [4.7,45] were significantly associated with ICU admission. ICU admission was not influenced by center (p=0.09). Conclusions: Severe solid organ injury as well as traumatic brain injury and associated multisystem trauma drive ICU admission in pediatric patients sustaining BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization.