Shauna M. Levy

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.

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.

Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps

BACKGROUND Despite increased compliance with Surgical Care Improvement Project infection measures, surgical-site infections are not decreasing. The aim of this study was to test the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect implementation fidelity or adherence to guidelines as intended. METHODS A 7-week observational study of elective pediatric surgical cases was conducted. Adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics. RESULTS Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases (70%) in which antibiotic prophylaxis was indicated, compliance was documented in 100% cases in the electronic medical record, but only 48% of cases adhered to all 5 guidelines. Lack of adherence was due primarily to dosing or timing errors. CONCLUSIONS Lack of implementation fidelity in antibiotic prophylaxis guidelines may partly explain the lack of expected reduction in surgical-site infections. Future studies of Surgical Care Improvement Project effectiveness should measure adherence and implementation fidelity rather than just documented compliance.

Component separation for complex congenital abdominal wall defects: not just for adults anymore.

PURPOSE Operative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns. METHODS After IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large childrens hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications. RESULTS Nine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days-10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3-34 months). CONCLUSION CST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain.

What is the quality of reporting of studies of interventions to increase compliance with antibiotic prophylaxis

BACKGROUND Despite studies reporting successful interventions to increase antibiotic prophylaxis compliance, surgical site infections remain a significant problem. The reasons for this lack of improvement are unknown. This review evaluates the internal and external validity of quality improvement studies of interventions to increase surgical antibiotic prophylaxis compliance. STUDY DESIGN Three investigators independently performed systematic literature searches and selected eligible studies that evaluated interventions to improve perioperative antibiotic prophylaxis timing, type, and/or discontinuation. Studies published before the Surgical Infection Prevention project inception in 2002 were excluded. Each study was assessed based on modified criteria for evaluating quality improvement studies (Standards for Quality Improvement Reporting Excellence) and for facilitating implementation of evidence into practice (Reach-Efficacy-Adoption-Implementation-Maintenance). RESULTS Forty-six articles met inclusion criteria; 93% reported improvement in antibiotic prophylaxis compliance. Surgical site infections were evaluated in 50% of studies and 65% reported an improvement. Less than 5% of studies used randomization, allocation concealment, or blinding. Nine percent of studies described efforts to minimize bias in the design results and analysis and 13% described a sample size calculation. Approximately one-third of studies described participant adoption of the intervention (26%), factors affecting generalizability (33%), or implementation barriers (37%). Most studies (80%) used multiple interventions; no single intervention was associated with change in compliance. Studies with the lowest baseline compliance showed the greatest improvement, regardless of the intervention(s). CONCLUSIONS The methodology and reporting of quality improvement studies on perioperative antibiotic prophylaxis is suboptimal, and factors that would improve generalizability of successful intervention implementation are infrequently reported. Clinicians should use caution in applying the results of these studies to their general practice.

The impact of chylothorax on neonates with repaired congenital diaphragmatic hernia

PURPOSE Chylothorax is a known complication in neonates after congenital diaphragmatic hernia (CDH) repair. This report uses a large international registry to evaluate risk factors, treatment, morbidity, and survival associated with chylothorax in a prospective cohort of neonates after CDH repair. METHODS From January 2007 to January 2010, live-born neonates with repaired, unilateral CDHs were evaluated from a prospective database for chylothorax development. Chylothorax was diagnosed based on pleural fluid examination. Study variables included patient characteristics, CDH defect and disease severity characteristics, chylothorax treatment, and survival. In addition, the temporal relationship between timing of CDH repair and extracorporeal membrane oxygenation (ECMO) therapy was evaluated as a risk factor for chylothorax. Univariate and multivariate regression analyses were utilized. RESULTS Among the 1383 patients evaluated, chylothorax was diagnosed in 4.6% of the cohort. Patch repair and ECMO were statistically significant risk factors for chylothorax. The odds of developing a chylothorax were significantly increased in patients with CDH repair on ECMO (aOR 2.6; 95% CI: 1.3-4.9) or after ECMO (aOR 3.1; 95% CI: 1.7-5.8). Most chylothoraces (83.1%) were successfully treated without surgery. Chylothorax patients had significant morbidity including increased oxygen use at 30days and longer length of stay. Survival was not significantly affected by chylothorax. CONCLUSIONS Chylothorax is a known but uncommon complication of neonatal CDH repair. In this very large series of chylothorax in association with CDH, major risk factors appear to be related to increased disease severity with the highest risk in patients repaired on or after ECMO. Chylothoraces usually improve with conservative therapy and lead to significant morbidity but not increased mortality.

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.

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.