Luke R. Putnam

Multifaceted interventions improve adherence to the surgical checklist.

INTRODUCTION Adherence to surgical safety checklists remains challenging. Our institution demonstrated acceptable rates of checklist utilization but poor adherence to all checkpoints. We hypothesized that stepwise, multifaceted interventions would improve checklist adherence. METHODS From 2011 to 2013, adherence to the 14-point, pre-incision checklist was assessed directly by trained observers during three, 1-year periods (baseline, observation #1, and observation #2) during which interventions were implemented. Interventions included safety workshops, customization of a stakeholder-derived checklist, and implementation of a report card system. Chi-square and Kruskal-Wallis tests were utilized. RESULTS Checklist performance was assessed for 873 cases (baseline, n = 144; observation #1, n = 373; observation #2, n = 356). Total checkpoint adherence increased (from 30% to 78% to 96%; P < .001), as did cases with correct completion of all checkpoints (from 0% to 19% to 61%; P < .001). The median (interquartile range) number of checkpoints completed per case improved from 4 (3-5) to 11 (10-12) to 14 (13-14; P < .001). CONCLUSION A strategic, multifaceted approach to perioperative safety significantly improved checklist adherence over 2 years. Checklist content and process need to reflect local interests and operative flow to achieve high adherence rates. Successful checklist implementation requires efforts to change the safety culture, stakeholder buy-in, and sustained efforts over time.

Impact of a 24-hour discharge pathway on outcomes of pediatric appendectomy

BACKGROUND Clinical pathways for simple (nonperforated, nongangrenous) appendicitis potentially could decrease hospital length of stay (LOS) through standardization of patient care. Our institution initiated a simple appendicitis pathway for children with the goal of less than 24-hour discharge (same-day discharge, SDD) and evaluated its effectiveness. METHODS A prospective cohort of pediatric patients (<18 years of age) who underwent appendectomy for simple appendicitis after implementation of a SDD pathway were compared with a historic cohort of similar patients in this same large childrens hospital. Primary outcomes included LOS, surgical-site infections, and readmissions. Mann Whitney U test, Fischer exact test, χ(2) test, and logistic regression were used. RESULTS Between June 2009 and May 2013, 1,382 appendectomies were performed; 794 (57%) were for simple appendicitis (316 prepathway and 478 pathway). Hospital LOS decreased 37% after pathway implementation from a median (interquartile range) of 35 (20-50) hours to 22 (9-55) hours (P < .001). SDD increased from 13% to 58% (P < .001). Infectious complications were unchanged (1.6% vs 1.8%, P = .82), but readmissions increased (1.2% vs 4.2%, P = .02). CONCLUSION A standardized pathway for simple appendicitis that targets SDD can be achieved in children; however, a slight increase in readmissions was noted. High risk for readmission, cost effectiveness, and generalizability need to be further determined.

Congenital Diaphragmatic Hernia Defect Size and Infant Morbidity at Discharge

BACKGROUND AND OBJECTIVE: Survival for infants with congenital diaphragmatic hernia (CDH) has gradually improved, yet substantial burden of disease remains. Although larger CDH defect sizes increase mortality, the association between defect size and morbidity has not been reported. Our objective was to evaluate the association of defect size with pulmonary, neurologic, and gastrointestinal morbidity at the time of hospital discharge. METHODS: An international, prospective cohort study was performed. Patient demographics, intraoperative defect size, and clinical outcomes were reviewed. The primary outcome was morbidity at the time of discharge, which entailed supplemental oxygen requirement, abnormal neurologic clinical and radiographic findings, gastroesophageal reflux, supplemental nutrition, or pulmonary-, neurologic-, or gastrointestinal-related medications. RESULTS: A total of 3665 patients were included in the study cohort. Overall survival was 70.9%, and 84.0% of survivors were discharged from the hospital (16.0% transferred). Median age at discharge was 38 days (interquartile range [IQR] 23–69) and ranged from 22 (IQR 16–32) days for “A” (smallest) defects to 89 (IQR 64–132) days for “D” (largest) defects (P < .001). Of those discharged from the hospital, 1522 (74.2%) had pulmonary (n = 660, 30.2%), neurologic (n = 446, 20.4%), or gastrointestinal (n = 1348, 61.7%) morbidities, and multiple morbidities were diagnosed in 701 (34.7%) patients. On multivariable regression analyses incorporating key patient characteristics, defect size was consistently the greatest predictor of overall morbidity, hospital length of stay, and duration of ventilation. CONCLUSIONS: Infants with CDH are commonly discharged with ≥1 major morbidities. The size of the diaphragmatic defect appears to be the most reliable indicator of a patient’s hospital course and discharge burden of disease.

Evaluation of variability in inhaled nitric oxide use and pulmonary hypertension in patients with congenital diaphragmatic hernia

Importance Inhaled nitric oxide (iNO) is an expensive, commonly used therapy among patients with congenital diaphragmatic hernia (CDH); however, data to support its ongoing use in this patient population are lacking. Objective To describe the spectrum of iNO use among patients with CDH and its association with pulmonary hypertension (pHTN) and mortality. Design, Setting, and Participants A review was conducted of prospectively collected patient data in the Congenital Diaphragmatic Hernia Study Group registry between January 1, 2007, and December 31, 2014, from 70 participating centers in 13 countries. A total of 3367 newborn infants diagnosed with CDH and entered into the registry were reviewed. On the basis of echocardiogram data, pHTN was defined as right ventricular systolic pressure greater than or equal to two-thirds of the systemic systolic pressure. Propensity score and regression analyses were performed. Intervention Use of iNO. Main Outcomes and Measures Variability in iNO use and its association with pHTN and mortality. These outcomes were formulated prior to data evaluation. Results Sixty-eight (97.1%) centers used iNO. Of 3367 patients with CDH (1366 [40.6%] females; median estimated gestational age, 38 weeks; range, 23-42 weeks), a total of 2047 (60.8%) received iNO; the mean percentage of those receiving iNO per center was 62.3% (range, 0%-100%). Median iNO dose and duration were 20 (range, 0.1-80) ppm and 8 (range, 0-100) days. Of the 2174 infants with pHTN, 1613 infants (74.2%) received iNO. Of the 943 infants without pHTN, 343 infants (36.4%) were treated with iNO. Based on propensity score analysis incorporating 10 clinically relevant variables, iNO use was significantly associated with increased mortality (average treatment effect on the treated: 0.15; 95% CI, 0.10-0.20). Conclusions and Relevance Inhaled nitric oxide use is common but highly variable among centers, and 36% of patients without pHTN received iNO therapy. Based on data from 70 centers, iNO use in patients with CDH may be associated with increased mortality. Future efforts should be directed toward data-driven standardization of iNO use to ensure cost-effective practices.

Adherence to surgical antibiotic prophylaxis remains a challenge despite multifaceted interventions

BACKGROUND Adherence to prophylactic antibiotics guidelines is challenging and poorly documented. We hypothesized that a multiphase, multifaceted quality improvement initiative would engage relevant stakeholders, address known barriers to adoption, and improve overall adherence. METHODS From 2011 to 2014, a series of interventions were introduced in the pediatric operating rooms. After each interventional period, prospective assessments were performed to record the antibiotic type, dose, timing, and redosing according to the guidelines. Perioperative factors that may influence guideline adherence were analyzed. Spearmans rank correlation, analysis of variance, and χ(2) tests were performed. RESULTS A total of 1,052 operations were observed, and 629 (60%) required prophylactic antibiotics. Adherence to all 4 guideline components remained unchanged (54-55%, P = .38). Redosing significantly improved (7-53%, P = .02), but correct type decreased (98-70%, P < .01). The percentage of cases in which only one antibiotic guideline component was missed remained unchanged (35-34%, P = .46). Adherence to guidelines was not significantly associated with American Society of Anesthesiologists class, surgical specialty, patient weight, anesthesia provider, or surgical wound class. CONCLUSION Despite multiple interventions to improve antibiotic prophylaxis, overall adherence did not improve. Most interventions were directed at the point of administration in the operating room; future implementation strategies should focus on the perioperative setting.

Factors associated with early recurrence after congenital diaphragmatic hernia repair

BACKGROUND The purpose of this study was to identify patient and treatment characteristics associated with early (in hospital) hernia recurrence after congenital diaphragmatic hernia (CDH) repair. METHODS Data from the Congenital Diaphragmatic Hernia Study Group registry were queried from 2007 to 2015. Recurrence of the diaphragmatic hernia after initial repair and prior to death or discharge was determined at the time of reoperation. Minimally invasive surgery (MIS) approaches included laparoscopy or thoracoscopy, and open approaches consisted of laparotomy or thoracotomy. Multivariate regression analysis was performed. RESULTS Of 3984 patients, 3332 (84%) underwent CDH repair. 76 (2.3%) patients had an early recurrence. The rate of recurrence was less variable over time for patients undergoing laparotomy vs thoracoscopy (range: 1.1-3.7% vs 1.7-8.9% annually). Timing of repair, whether performed after, during, or before ECMO did not significantly alter recurrence rates (0% vs 4.2% vs 3.0%, p=0.116). Larger defect size (C: OR 4.3, 95% CI 1.2-15.4; D: OR 7.1, 95% CI 1.7-29.1) and an MIS approach (OR 3.2, 95% CI 1.7-6.0) were the only independent predictors of recurrence. CONCLUSION Larger defect size and an MIS approach were associated with higher rates of early recurrence, while ECMO use and timing of repair with ECMO were not. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE II.

Surgical wound classification for pediatric appendicitis remains poorly documented despite targeted interventions

BACKGROUND/PURPOSE Surgical wound class (SWC) is used to risk-stratify surgical site infections (SSI) for quality reporting. We previously demonstrated only 8% agreement between hospital-based SWC and diagnosis-based SWC for acute appendicitis. We hypothesized that education and process-based interventions would improve hospital-based SWC reporting and the validity of SSI risk stratification. METHODS Patients (<18 years old) who underwent appendectomies for acute appendicitis between January 2011 and December 2013 were included. Interventions entailed educational workshops regarding SWC for perioperative personnel and inclusion of SWC as a checkpoint in the surgical safety checklist. Thirty-day postoperative SSIs were recorded. Chi-square, Fishers exact test, and kappa statistic were utilized. RESULTS 995 cases were reviewed (pre-intervention=478, post-intervention=517). Weighted interrater agreement between hospital-based and diagnosis-based SWC improved from 50% to 81% (p<0.01), and weighted kappa increased from 0.16 (95% CI 0.004-0.03) to 0.29 (95% CI 0.25-0.34). Hospital-based dirty wounds were significantly associated with SSI in the post-intervention period only (p<0.01). CONCLUSIONS Agreement between hospital-based SWC and diagnosis-based SWC significantly improved after simple interventions, and SSI risk stratification became consistent with the expected increase in disease severity. Despite these improvements, there were still substantial gaps in SWC knowledge and process.

Aggressive Surgical Management of Congenital Diaphragmatic Hernia: Worth the Effort?

Objective: The objectives of this study were (i) to evaluate infants with congenital diaphragmatic hernia (CDH) that do not undergo repair, (ii) to identify nonrepair rate by institution, and (iii) to compare institutional outcomes based on nonrepair rate. Background: Approximately 20% of infants with CDH go unrepaired and the threshold to offer surgical repair is variable. Methods: Data were abstracted from a multicenter, prospectively collected database. Standard clinical variables, including repair (or nonrepair), and outcome were analyzed. Institutions were grouped based on volume and rate of nonrepair. Preoperative mortality predictors were identified using logistic regression, expected mortality for each center was calculated, and observed /expected (O/E) ratios were computed for center groups and compared by Kruskal-Wallis ANOVA. Results: A total of 3965 infants with CDH were identified and 691 infants (17.5%) were not repaired. Nonrepaired patients had lower Apgar scores (P < 0.05) and increased incidence of anomalies (P < 0.0001). Low-volume centers (“Lo”, n=44 total, < 10 CDH pts/yr) and high-volume centers (“Hi”, n = 21) had median nonrepair rates of 19.8% (range 0%–66.7%) and 16.7% (5.1%–38.5%), respectively. High-volume centers were further dichotomized by rate of nonrepair (HiLo = 5.1–16.7% and HiHi = 17.6–38.5%), leaving 3 groups: HiLo, HiHi, and Lo. Predictors of mortality were lower birth weight, lower Apgar scores, prenatal diagnosis, and presence of congenital anomalies. O/E ratios for mortality in the HiLo, HiHi, and Lo groups were 0.81, 0.94, and 1.21, respectively (P < 0.0001). For every 100 CDH patients, HiLo centers have 2.73 (2.4–3.1, 95% confidence interval) survivors beyond expectation. Conclusions: There are significant differences between repaired and nonrepaired CDH infants and significant center variation in rate of nonrepair exists. Aggressive surgical management, leading to a low rate of nonrepair, is associated with improved risk-adjusted mortality.

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.

The utility of the contrast enema in neonates with suspected Hirschsprung disease

BACKGROUND/PURPOSE The contrast enema (CE) is commonly utilized for suspected Hirschsprung disease (HD) patients. We set out to determine the utility of the CE in the newborn for clinically suspicious HD. METHODS All CEs performed for suspicion of HD in neonates from January 2004 to December 2013 were reviewed by two pediatric radiologists who were blinded to the original interpretations and final diagnoses. A standardized scoring sheet was utilized to document essential radiographic findings. Definitive diagnoses were determined by pathology. Descriptive statistics, likelihood ratios, and interrater agreement were determined. RESULTS 158 CEs were reviewed. Interrater agreement was 89% with kappa (95% CI) of 0.63 (0.47-0.76). Common indications for CE were similar between non-HD and HD groups. The positive, inconclusive, and negative likelihood ratios (95% CI) were 38 (10-172), 3.2 (1.3-9.1), and 0.15 (0.06-0.47), respectively, leading to posttest probabilities for positive, inconclusive, and negative tests of 83%, 32%, and 2.5%, respectively. CONCLUSIONS Although radiographic positive CE for HD portends a high probability of HD, inconclusive studies still represent a significant increased risk. In clinically suspicious infants for HD, those with inconclusive studies may benefit from a lower threshold to perform follow-up rectal biopsy.