Kathryn T. Anderson

The impact of cardiac risk factors on short-term outcomes for children undergoing a Ladd procedure

BACKGROUND/PURPOSE The purpose of this study was to describe the outcomes of children with and without congenital heart disease who undergo a Ladd procedure. METHODS The 2012-2014 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data were queried for patients undergoing a Ladd procedure. Utilizing NSQIP-P definitions, patients were categorized into four cardiac risk groups (none, minor, major, severe) based on severity of cardiac anomalies, previous cardiac procedure(s), and ongoing cardiac dysfunction. Ladd procedures were elective/non-elective. Outcomes included length of stay, adverse events, and mortality. RESULTS 878 patients underwent Ladd procedures. 633 (72%) patients had no cardiac risk factors and 84 (10%), 109 (12%), and 52 (6%) had minor, major, and severe cardiac risk factors, respectively. Children with congenital heart disease experienced increased morbidity and mortality and longer hospital stays (all p<0.05). Elective Ladd procedures were associated with similar morbidity but shorter length of stay and lower mortality than non-elective procedures. Older age at time of operation was associated with fewer adverse events. CONCLUSIONS Although overall mortality remains low, children with higher risk cardiac disease experience increased morbidity and mortality when undergoing a Ladd procedure. Older age at the time of the Ladd procedure was associated with improved outcomes in children.

Surgical site infection reporting: more than meets the agar

BACKGROUND/PURPOSE Surgical site infection (SSI) rate in pediatric appendicitis is a commonly used hospital quality metric. We hypothesized that surveillance of organ-space SSI (OSI) using cultures alone would fail to capture many clinically-important events. METHODS A prospective, multidisciplinary surveillance program recorded 30-day SSI and hospital length of stay (LOS) for patients <18years undergoing appendectomy for perforated appendicitis from 2012 to 2015. Standardized treatment pathways were utilized, and OSI was identified by imaging and/or bacterial cultures. RESULTS Four hundred ten appendectomies for perforated appendicitis were performed, and a total of 84 OSIs (20.5%) were diagnosed with imaging. Positive cultures were obtained for 39 (46%) OSIs, whereas 45 (54%) had imaging only. Compared to the mean LOS for patients without OSI (5.2±2.9days), LOS for patients with OSI and positive cultures (13.7±5.4days) or with OSI without cultures (10.4±3.7days) was significantly longer (both p<0.001). The OSI rate identified by positive cultures alone was 9.5%, whereas the clinically-relevant OSI rate was 20.5%. CONCLUSIONS Using positive cultures alone to capture OSI would have identified less than half of clinically-important infections. Utilizing clinically-relevant SSI is an appropriate metric for comparing hospital quality but requires agreed upon standards for diagnosis and reporting. LEVEL OF EVIDENCE II. TYPE OF STUDY Diagnostic study.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Palate: Analysis of the 2012-2014 NSQIP Database

Objective: To assess the risk of complication in patients undergoing cleft palate repair with congenital cardiac comorbidities in a large, national cohort. Design: Retrospective review. Patients/Setting: Using the 2012-2014 National Surgical Quality Improvement Program (NSQIP) Pediatric database, patients undergoing cleft palate repair were selected for analysis. Patients with cleft palate repairs were stratified based on the presence or absence congenital cardiac comorbidities. Univariate and stepwise forward logistic regression were conducted. Main Outcome Measures: It is hypothesized that risk of postoperative adverse events in patients with congenital cardiac comorbidities is higher than in patients without cardiac disease. Results: Nationally, between 2012 and 2014, 3240 patients underwent cleft palate repair, 422 (13.0%) with cardiac disease, and 2818 (87.0%) without cardiac disease. Patients with cardiac disease were smaller (10.5 [6.6] kg vs 11.6 [8.6] kg, P < .01) and more likely to be premature (4.6% vs 13.0%, P < .01) compared to those without cardiac disease. Postoperatively, patients with cardiac conditions were more likely to experience an adverse event (8.8% vs 4.2%, P < .01). Specifically, they were more likely to experience reintubation (1.7% vs 0.4%, P < .01), reoperation (2.1% vs 0.6%, P < .01), and longer length of stay (2.7 [7.0] vs 1.6 [2.8] days, P < .01). Rates of surgical site infection and dehiscence were not different. Conclusions: Cleft palate repair in patients with concurrent congenital cardiac defects is a safe procedure but carries elevated risk in the postoperative period as demonstrated in this analysis of the NSQIP-Pediatric database. Technical risks are equivalent. Additional anesthesia and surgical awareness of these potential complications is essential to minimize perianesthesia risks.

Utility of standardized discharge criteria after appendectomy to identify pediatric patients requiring intervention after postoperative imaging

Background: The purposes of this study were to evaluate the efficacy of failure‐of‐discharge criteria and identify the cohort of pediatric patients after appendectomy in whom postoperative imaging would impact management. Methods: Pediatric patients who underwent an appendectomy from July 2009 to May 2017 were included. Complicated appendicitis was defined based on the intraoperative diagnosis. Postoperative imaging was recommended at postoperative days 5–7 for patients who met at least one criterion of failure of standard management: fever (>38°C), leukocytosis (white blood cell count >12,000/mm3), diet intolerance, or uncontrolled pain by oral analgesics at postoperative day 5. Primary outcomes included any intervention (reoperation, drainage procedures, or change in antibiotics). Results: In all, 3,276 pediatric patients undergoing appendectomy were identified. Of these patients, 12% met at least 1 discharge criterion of failure Most discharge failures (79%) underwent postoperative imaging, such as computed tomography (68%), ultrasonography then computed tomography (20%), or ultrasonography only (12%); 39% of imaging patients required intervention. On multiple logistic regression, 3 criteria (diet intolerance, fever, and leukocytosis), complicated disease, and age were associated with the need for intervention after imaging. The type of imaging modality did not discriminate need for intervention. Conclusion: Standardized criteria identifying failure of ability to discharge the patient after appendectomy limits the need for unnecessary imaging. In the management of pediatric appendicitis, a selective approach resulted in a high yield of complications requiring intervention after obtaining postoperative imaging.

Let the right one in: High admission rate for low-acuity pediatric burns

Background: The purpose of this study was to characterize emergency pediatric burn care triage at a tertiary childrens hospital to identify targets for quality improvement. Methods: A retrospective review of patients <18 years with primary burn injuries who presented to a childrens emergency department in 2016 was conducted. Demographic and injury characteristics were recorded. Low acuity was defined by size (<5% total body surface area burn), depth (not third degree), and no need for conscious sedation for debridement. Multiple logistic regression was used for analysis. Results: A total of 309 pediatric burn patients were triaged in the emergency department. Patients were typically young (median 3.3 years), male (59%), Hispanic (47%), publically insured (77%), and transferred in (65%). Scalding was the most common mechanism (59%). Though most burns were small (median 2% total body surface area), not deep (<third degree: 91%), and debrided without sedation (70%), most patients were admitted (80%). On regression, larger total body surface area, child protective services involvement, and in‐transfer, but not mechanism, location of injury, or time of day, were associated with observation admission (<24 hours) versus emergency department discharge. Conclusion: Though burns were low acuity, most children were admitted. Social factors may play an important role in triage decisions but there may be an opportunity for improved resource utilization.

Adherence to the Pediatric Preinduction Checklist Is Improved When Parents Are Engaged in Performing the Checklist

Background: The World Health Organization recommends including the parents in completion of the pediatric surgical safety checklist. At our hospital, the preinduction surgical safety checklist is conducted in the preoperative holding with anesthesia, nursing, and often with the parents of children undergoing an operative procedure. We hypothesized that adherence to the preinduction checklist is better when parents are engaged in surgical safety checklist performance. Methods: An observational study of adherence to the preinduction checklist for nonemergent pediatric operations was performed (2016–2017). Adherence was defined as verbalization of checkpoints. Only checkpoints (patient identification, procedure, site marking, weight, allergies, and NPO status) relevant to parental knowledge were evaluated. Parental engagement was based on: positive body language, eye contact, lack of distractions, and understanding of checkpoints. Results: 484 preinduction surgical safety checklists were observed (interrater reliability >0.7). Partial completion occurred in 55% cases; only 41% checklists were fully completed. Parents were present for 81% of checklists, and more checkpoints were performed when parents were present (5, IQR 4–6) versus absent (2, IQR 1–3, P < .001). Increased preinduction adherence was associated with increased parent engagement by linear regression analysis (1.20, 95%CI 1.05–1.33). Staff confirmed more checkpoints with engaged parents (28–78%) versus when parents were not engaged (1–9%, P < .001 for all checkpoints). Conclusion: Overall preinduction surgical safety checklist performance was poor (less than half of checklists fully completed). In contrast, checklist adherence improved with parental presence and engagement during performance of the checklist.

Advances in perioperative quality and safety

For decades, safe surgery focused on intraoperative technique and decision-making. The traditional hierarchy placed the surgeon as the leader with ultimate authority and responsibility. Despite the advances in surgical technique and equipment, too many patients have suffered unnecessary complications and suboptimal care. Today, we understand that the conduct of safe and effective surgery requires evidence-based decision-making, multifaceted treatment approaches to prevent complications, and effective communication in and out of the operating room. In this manuscript, we describe three significant advances in quality and safety that have changed the approach to surgical care: the National Surgical Quality Improvement Program, evidence-based bundled prevention of surgical site infections, and the Surgical Safety Checklist.

Highs and Lows of Discharge Opioid Prescribing in Common Pediatric Surgical Procedures

Methods Using the American College of Surgeons – National Surgical Quality Improvements Project’s database, patients who underwent lower extremity amputations were identified. Major and minor covariates were determined with 30-day readmission as the primary outcome. Risk factors for readmission were examined using bivariate and multivariate analysis within all cases, as well as between surgical subspecialties and between elective and emergent cases.

Room for “Quality” Improvement? Validating National Surgical Quality Improvement Program-Pediatric (NSQIP-P) Appendectomy Data

INTRODUCTION Accurate data are essential for the validity of clinical registries. This study aimed to validate NSQIP-P data, assess representativeness, and evaluate risk-adjusted predictive ability at a single institution. METHODS A prospective appendectomy-specific pediatric surgery research database (RD) maintained by clinical researchers was compared to the NSQIP-P data for appendectomies performed in 2016 at a tertiary childrens hospital. NSQIP-P sampled data collected by trained surgical clinical reviewers (SCRs) were compared to matched RD patients. Both datasets used NSQIP-P definitions. Using χ2, datasets were compared by patient demographics, disease severity (simple vs. complicated), and outcomes. RESULTS 458 appendectomies for acute appendicitis were performed in 2016, of which 250 (55%) were abstracted by SCRs and matched to RD patients. Patient demographics were similar between datasets. Disease severity (NSQIP-P:50% complicated vs RD:31% complicated) and composite morbidity (NSQIP-P:6.0% vs RD:14.4%) were significantly different (both p < 0.01). Demographics and outcomes were similar between matched (n = 250) and unsampled patients in the RD (n = 208). NSQIP-Ps risk-adjusted predicted morbidity was significantly lower than morbidity observed in all (n = 458) RD patients (NSQIP-P:9.9% vs RD:14.2%, p < 0.01). CONCLUSIONS Though constituting a representative sample, NSQIP-P appendectomy data were inconsistent with department data. Discrepancies appear to be the result of underreporting of outcome variables and disease misclassification. TYPE OF STUDY Retrospective comparative review. LEVEL OF EVIDENCE Level III.

Hospital type predicts computed tomography use for pediatric appendicitis

BACKGROUND Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildrens hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.