Marisa A. Bartz-Kurycki

Approaching zero: Implications of a computed tomography reduction program for pediatric appendicitis evaluation

PURPOSE Because of awareness of iatrogenic radiation exposure, there is a national trend of diminishing computed tomography (CT) use for pediatric suspected appendicitis. The purpose of this study was to evaluate the effects of a CT reduction program for evaluation of appendicitis. METHODS A multidisciplinary group (emergency medicine, radiology, and surgery) at a childrens hospital developed a reduction program which included: ultrasound (U/S) first (2012), magnetic resonance imaging (MRI) second (2014), and standardized U/S reports (2016). Imaging modality, negative appendectomy rate, time from first image to incision, and imaging costs were evaluated over time. RESULTS Of the 571 patients evaluated from 2012 to 2016, there was a significant decrease in CT use and increase U/S and MRI use over the study period (all p<0.01). CT use approached zero in 2016. Time from first image to incision (median 10.7h, IQR 5.6-15.5) and negative appendectomy rate (mean 3.7±0.2%) did not change. Median imaging costs (

Decreasing intraoperative delays with meaningful use of the surgical safety checklist

88, IQR

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

52-

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

169) and radiology percent of total costs (range 0.8%-3.9%) increased over time (both p<0.01). CONCLUSION Approaching zero CT use for evaluation of pediatric appendicitis is possible through a multidisciplinary protocol without impacting clinical outcomes. However, increased MRI use led to higher costs. Cost-effectiveness of replacing CT with MRI warrants further study. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.

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

Background Purposeful completion (fidelity) more than simple adherence to items in the surgical safety checklist may improve operating room efficiency and patient safety. The purpose of this study was to evaluate intraoperative delays and correlate them with adherence and fidelity to the preincision surgical safety checklist. Methods Trained observers evaluated surgical safety checklist compliance during 3 observation periods from 2014–2016. Degree of adherence, checkpoint verbalization, fidelity, and meaningful completion were assessed. Delays were categorized as missing or malfunctioning equipment, staff error, and medication issues. Descriptive statistics, analysis of variance, logistic regression, χ2 and Student t test were used to analyze results. Results Of the 591 cases observed, 19% (n = 110) had at least one documented, intraoperative delay. The majority of delays were related to missing (50%) or malfunctioning (30%) equipment. Compared with cases without delays, cases with delays did not have a different mean degree of adherence (96.3 ± 7.6% vs 95.6 ± 5.8%, P = .36). Degree of fidelity was different between cases with and without delays (mean fidelity 77.1 ± 14.9% vs 80.5 ± 7.14.2%, P = .03). Conclusion The preincision SSC is a communication tool offering an opportunity to discuss potential concerns and anticipated intraoperative needs. Fidelity rather than adherence to the surgical safety checklist seems to diminish intraoperative delays.

Advances in perioperative quality and safety

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.

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

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.

Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe?

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.

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

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.

Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients

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.