Ibrahim Abd El-Shafy

Closed-Loop Communication Improves Task Completion in Pediatric Trauma Resuscitation

BACKGROUND Pediatric trauma care requires effective and clear communication in a time-sensitive manner amongst a variety of disciplines. Programs such as Crew Resource Management in aviation have been developed to systematically prevent errors. Similarly, teamSTEPPS has been promoted in healthcare with a strong focus on communication. We aim to evaluate the ability of closed-loop communication to improve time-to-task completion in pediatric trauma activations. METHODS All pediatric trauma activations from January to September, 2016 at an American College of Surgeons verified level I pediatric trauma center were video recorded and included in the study. Two independent reviewers identified and classified all verbal orders issued by the trauma team leader for order audibility, directed responsibility, check-back, and time-to-task-completion. The impact of pre-notification and level of activation on time-to-task-completion was also evaluated. All analyses were performed using SAS® version 9.4(SAS Institute Inc., Cary, NC). RESULTS In total, 89 trauma activation videos were reviewed, with 387 verbal orders identified. Of those, 126(32.6%) were directed, 372(96.1%) audible, and 101(26.1%) closed-loop. On average each order required 3.85 minutes to be completed. There was a significant reduction in time-to-task-completion when closed-loop communication was utilized (p < 0.0001). Orders with closed-loop communication were completed 3.6 times sooner as compared to orders with an open-loop [HR = 3.6 (95% CI: 2.5, 5.3)]. There was not a significant difference in time-to-task-completion with respect to pre-notification by emergency service providers (p < 0.6100). [HR = 1.1 (95% CI: 0.9, 1.3)]. There was also not a significant difference in time-to-task-completion with respect to level of trauma team activation (p < 0.2229). [HR = 1.3 (95% CI: 0.8, 2.1)]. CONCLUSION While closed-loop communication prevents medical errors, our study highlights the potential to increase the speed and efficiency with which tasks are completed in the setting of pediatric trauma resuscitation. Trauma drills and systems of communication that emphasize the use of closed-loop communication should be incorporated into the training of trauma team leaders. LEVEL OF EVIDENCE This is a prospective observational study with intervention level II evidence.

Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis

INTRODUCTION Despite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge. METHODS We retrospectively reviewed 275 children, ages 4 to 17 years old, who underwent TULA for uncomplicated appendicitis in a single institution from August 2014 to July 2015. We compared those that received preincision bilateral RSB (n=136) with those who received LAI (n=139). The primary outcome was narcotic administration. Secondary outcomes included initial and mean scores, time from anesthesia induction to release, operative time, time to rescue dose of analgesic in the PACU and time to PACU discharge. RESULTS Total narcotic administration was significantly reduced in patients that underwent preincision RSB compared to those that received conventional LAI, with a mean of 0.112 mg/kg of morphine versus 0.290 mg/kg morphine (p<0.0001). Patients undergoing RSB reported lower initial (0.38 vs. 2.38; p<0.0001) and mean pain scores (1.26 vs. 1.77; p<0.015). Time to rescue analgesia was prolonged in patients undergoing RSB compared to LAI (58.93min vs. 41.56min; p=0.047). CONCLUSION Preincision RSB for TULA in uncomplicated appendicitis in children is associated with decreased opioid consumption and lower pain scores compared with LAI. As the addition of this procedure only added 6.67min to time under anesthesia, we feel that it is a viable option for postoperative pain control in pediatric single-incision laparoscopic surgery. RETROSPECTIVE COMPARATIVE STUDY LEVEL III EVIDENCE.

Simple diverticulectomy is adequate for management of bleeding Meckel diverticulum

PurposeIt is unclear whether simple diverticulectomy, rather than segmental bowel resection (SBR), is adequate treatment for gastrointestinal bleeding (GIB) secondary to Meckel diverticulum (MD). There is concern that ulcers in the adjacent bowel may continue to bleed if only the diverticulum is removed. This study seeks to determine if diverticulectomy is satisfactory treatment for bleeding MD.MethodsA multi-institution, retrospective review was performed for patients with a diagnosis of MD and GIB who underwent simple diverticulectomy or small bowel resection. Exclusion criteria were comorbid surgical conditions and other causes of GIB. The primary outcome was post-operative bleeding during the initial hospitalization. Secondary outcomes were bleeding after discharge, transfusion or additional procedure requirement, re-admission, and overall complications.ResultsThere were 59 patients who met study criteria (42 diverticulectomy, 17 SBR). One patient in the SBR group had early post-operative bleeding (p = 0.288). There was one re-admission (p = 0.288) and three total complications in the SBR group (p = 0.021). There were no cases of bleeding or other complications in the diverticulectomy group.ConclusionThis study suggests that simple diverticulectomy is adequate for treatment of GIB caused by MD. Furthermore, diverticulectomy appears to have a lower overall complication rate.

Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (TEF) is now offered at many pediatric surgery centers around the world. Focusing on the most common of the five types of TEF, this chapter briefly reviews the diagnosis of esophageal atresia and TEF, explores the operative technique in detail, and finally discusses standard postoperative care. A number of studies have reported equivalent outcome when compared with the open technique. Long-term studies are ongoing. Thoracoscopy offers the potential benefits of a reduction in scoliosis, muscle damage, postoperative pain, and improved appearance. Paramount in the application of thoracoscopy for TEF is appropriate patient selection, anesthesia team selection, and surgical expertise with neonatal minimally invasive surgery techniques. Future development of biologic grafts and novel techniques with magnets may further revolutionize the minimally invasive surgery approach to TEF repair.

Reduction of pediatric pedestrian hazardous road conditions in a school drop-off zone utilizing video review

BACKGROUND In 2012, 76,000 pedestrians were struck by motor vehicles. This resulted in 20% of all pediatric mortalities between the ages of 5 and 15. We hypothesize that children are exposed to increased risk as pedestrians to motor vehicle injury when arriving to school and that identification of these hazards would improve targeting of injury prevention efforts. METHODS Within a county containing 355 public schools, we identified a primary school with 588 students located in an urban setting with concerns for a high-risk traffic environment. Field surveys observed traffic patterns and established an optimal surveillance period 30 minutes before school. Three observation periods, from two discreet and blinded locations, were conducted from January to March 2016. Videos were evaluated by two independent reviewers to identify and score quantifiable hazards. Three controlled observations were conducted on non-school days, followed by three post-intervention observations from October to December 2016. Comparison was made using Student’s t test. Data was analyzed using SAS version 9.4 (SAS Institute Inc., Cary, NC). RESULTS We identified nine safety hazards including double parking (29.3 ± 5.5), dropping off in a bus stop (23.3 ± 7.6), and jaywalking (9.3 ± 3.1). Combining all hazards seen in each observation resulted in an overall hazard average of 83.0 ± 3.6 events/period. Comparing control periods to school observation identified significantly increased hazard events on school days (p < 0.0001). Targeted safety intervention demonstrated a 26% reduction in hazard events (p < 0.0005). CONCLUSION We identified the most common hazards associated with children arriving at a primary school in an urban setting, used our analysis to develop an intervention, and demonstrated the impact of our intervention. Our novel use of video review to identify hazards provides a metric against which the impact of pedestrian road safety interventions might be measured. LEVEL OF EVIDENCE Epidemiological, level II; Therapeutic, level IV.