Reduction of prophylactic antibiotics for elective pediatric cholecystectomy: A QI initiative to promote antimicrobial stewardship.

Purpose: Antibiotic prophylaxis minimizes the risk of infection, but overtreatment leads to antimicrobial resistance. Adult studies suggest antibiotic prophylaxis for elective cholecystectomy may not be needed. Our quality improvement project aimed to decrease prophylactic antibiotic use for elective cholecystectomies from 100 % to ≤50 % and maintain that rate for one year.

An Electronic Health Record-integrated Web Application Augments a QI-directed Morbidity & Mortality Conference and Improves Quality of Care.

Background: In 2014, we developed a QI-directed Morbidity and Mortality (M&M) Conference, prioritizing discussion of individual and system failures, as well as development of action items to prevent failure recurrence. However, due to a reliance on individual electronic documents to store M&M data, our ability to assess trends in failures and action item implementation was hindered. To address this issue, in 2019, we created a secure electronic health record (EHR)-integrated web application (web app) to store M&M data.

Giant Omphaloceles-Morbidity, Mortality, and Financial Impact of Early Versus Delayed Repair.

Introduction: We compared strategy outcomes and financial impact over the first two years of life (F2YOL) for patients with giant omphaloceles undergoing early repair (ER) (primary or staged) versus delayed repair (DR).

Methods: A retrospective review of giant omphaloceles (fascial defect > 5 cm/> 50% liver herniation) at a tertiary children's hospital between 1/1/2010 and 12/31/2019 was performed. Survival, length of stay, age at repair, ventilation days (VD), time to full enteral feeds, readmissions during the F2YOL, incidence of major associated anomalies, and total hospitalization charges during the F2YOL were compared.

A Review of Covered Abdominal Wall Defects: Cord Hernias Are Associated With Major Anomalies.

Introduction: Covered abdominal wall defects (CAWD) can be categorized into giant omphaloceles (GOs), nongiant omphaloceles (NGOs), and umbilical cord hernias (UCHs). We sought to evaluate differences in management and outcomes of the different CAWD, treated at a large tertiary children's hospital, with regards to survival and association with other major congenital anomalies.

Methods: A retrospective review of CAWD patients between January 2010 and January 2021 was conducted.

Pediatric blunt cerebrovascular injuries: A national trauma database study.

Background: The incidence of blunt cerebrovascular injuries (BCVIs) in children is unknown. We aimed to determine the rate and consequences of BCVIs in pediatric blunt trauma patients.

Methods: We queried the National Trauma Data Bank (NTDB) for all blunt trauma patients between 2007 and 2014.

Improving Quality of Chest Computed Tomography for Evaluation of Pediatric Malignancies.

Introduction: Atelectasis is a problem in sedated pediatric patients undergoing cross-sectional imaging, impairing the ability to accurately interpret chest computed tomography (CT) imaging for the presence of malignancy, often leading to additional maneuvers and/or repeat imaging with additional radiation exposure.

Methods: A quality improvement team established a best-practice protocol to improve the quality of thoracic CT imaging in young patients with suspected primary or metastatic pulmonary malignancy. The specific aim was to increase the percentage of chest CT scans obtained for the evaluation of pulmonary nodules with acceptable atelectasis scores (0-1) in patients aged 0-5 years with malignancy, from a baseline of 45% to a goal of 75%.

Orientation in Perpetuity: An Online Clinical Decision Support System for Surgical Residents.

Background: Limiting variability is an essential element to improving quality of care. Frequent resident turnover represents a significant barrier to clinical standardization. Trainees joining new surgical services must familiarize themselves with the guidelines and protocols that direct patient care as well as their learning objectives and expectations.

Volume of Irrigation Does Not Affect Rate of Abscess in Perforated Appendicitis.

Although previous studies have evaluated whether use of irrigation decreases postoperative intraabdominal abscess (PO-IAA) formation, these studies treated irrigation as a dichotomous variable and concluded that no irrigation resulted in a decreased incidence of PO-IAA formation. However, a recent study found decreased incidence with small aliquots to a total volume of 6 L. We hypothesized that higher volumes of irrigation would result in a lower incidence of PO-IAA.

Safety and feasibility of skin-to-skin care for surgical infants: A quality improvement project.

Background: Skin-to-skin care (SSC) for infants improves physiologic stability, pain perception, brain development, parental bonding, and overall survival. Using quality improvement (QI) methodology, this project aimed to increase SSC for surgical infants in the neonatal intensive care unit (NICU).

Methods: A multidisciplinary working group composed of key NICU stakeholders instituted a needs assessment querying perceptions and concerns about SSC.

Gangrenous appendicitis: No longer complicated.

Background: Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections.

Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types.

Background: Trauma is a common indication for computed tomography (CT) in children. However, children are particularly vulnerable to CT radiation and its associated cancer risk. Identifying differences in CT usage across trauma centers and among specific populations of injured children is needed to identify where quality improvement initiatives could be implemented in order to reduce excess radiation exposure to children.

Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis.

Importance: The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals.

Objective: To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis.

Ambulatory pediatric surgery.

Ambulatory pediatric surgery has become increasingly common in recent years, with greater numbers of procedures being performed on an outpatient basis. This practice has clear benefits for hospitals and healthcare providers, but patients and families also often prefer outpatient surgery for a variety of reasons. However, maximizing the potential opportunities requires critical attention to patient and procedure selection, as well as anesthetic choice.

Hospital variation in rates of concurrent fundoplication during gastrostomy enteral access procedures.

Background: This study aimed to determine whether (1) the propensity for concurrent fundoplication during gastrostomy varies among hospitals, and (2) postoperative morbidity differs among institutions performing fundoplication more or less frequently.

Methods: Children who underwent gastrostomy with or without concurrent fundoplication were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P). A hierarchical multivariate regression modeled the excess effects that hospitals exerted over propensity for concurrent fundoplication adjusting for preoperative clinical variables.

Effective methods to decrease surgical site infections in pediatric gastrointestinal surgery.

Background: Gastrointestinal (GI) surgeries represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. Previous studies have shown that perioperative bundles reduce SSIs, but few have focused on pediatric GI operations. We hypothesized that a GI bundle would decrease SSI rates, length of stay (LOS), and hospital charges.

Identifying Adverse Events in Pediatric Surgery: Comparing Morbidity and Mortality Conference with the NSQIP-Pediatric System.

Background: Recent improvements to morbidity and mortality (M&M) conference have focused on the case review system. However, case selection occurs by physician reporting, which is limited by selection bias. We compared the effectiveness of our M&M conference with the NSQIP-Pediatric (NSQIP-P) system for identifying adverse events.

Resource use in pediatric blunt and penetrating trauma.

Background: Trauma is one of the leading causes of pediatric morbidity and mortality with significant patient and economic impacts that necessitate constant study. Significant differences in outcomes and resource use exist between blunt and penetrating mechanisms.

Methods: The National Trauma Data Bank was analyzed for patients aged 0-18 y with International Classification of Diseases, 9th Revision injury codes for blunt and penetrating trauma from 2007-2012.

Variation in intraoperative and postoperative red blood cell transfusion in pediatric surgery.

Background: Intraoperative and postoperative red blood cell (RBC) transfusions are relatively frequent events tracked in the American College of Surgeons' National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P). This study sought to quantify variation in RBC transfusion practices among hospitals.

Study Design And Methods: This is an observational study of children older than 28 days who underwent a general, neurologic, urologic, otolaryngologic, plastic, or orthopedic operation at 50 hospitals in participating in the ACS-NSQIP-P during 2011 to 2012.

Essentials of navigating and teaching surgical quality improvement.

Quality improvement (QI) has become a focus of contemporary surgical practice. The purpose of this review is to provide a framework of working knowledge regarding QI for the practicing surgeon. QI design, implementation methods, measurement tactics, statistical analysis, and presentation tools based on the Institute of Healthcare Improvement model are reviewed.

Postoperative timing of computed tomography scans for abscess in pediatric appendicitis.

Background: One-quarter to one half of pediatric appendicitis patients present with ruptured appendicitis and about 3%-25% go on to form postoperative intra-abdominal abscesses. The optimal timing of postoperative imaging for suspected abscess formation has been a subject of debate.

Methods: All patients who underwent appendectomy for complex appendicitis and were not discharged before postoperative day (POD) #5 from April 2012-October 2014 were identified.

Improving Quality and Efficiency for Intussusception Management After Successful Enema Reduction.

Objectives: The purpose of this project was to implement a protocol facilitating discharge from the emergency department (ED) after successful radiologic ileocolic intussusception reduction in a pediatric referral center.

Methods: A multidisciplinary team identified drivers for successful quality improvement including educational brochures, a standardized radiologic report, an observation period in the ER with oral hydration challenges, and follow-up phone calls the day after discharge. Patient outcomes were tracked, and quarterly feedback was provided.

Estimating Adverse Events After Gastrostomy Tube Placement.

Objective: Gastrostomy feeding tube placement in children is associated with a high frequency of adverse events. This study sought to preoperatively estimate postoperative adverse events in children undergoing gastrostomy feeding tube placement.

Methods: This was an observational study of children who underwent gastrostomy with or without fundoplication at 1 of 50 participating hospitals, using 2011-2013 data from the American College of Surgeons' National Surgical Quality Improvement Program Pediatric.

Using quality improvement methods to change surgical practice: a case example of pediatric soft-tissue abscesses.

Background: Surgical treatments of soft-tissue abscesses (STAs) include packing and ring drain (RD) and straight drain (SD) placement. Potential benefits of SDs include a single incision, less scarring, and no need for a follow-up appointment. We used a multidisciplinary quality improvement (QI) process to promote surgeon adoption of an STA drainage technique to improve efficiency and quality of care.

A risk calculator predicting postoperative adverse events in neonates undergoing major abdominal or thoracic surgery.

Purpose: This study sought to demonstrate the feasibility of a risk calculator for neonates undergoing major abdominal or thoracic surgery with good discriminative ability.

Methods: The American College of Surgeons' National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) 2011-12 data were queried for neonates who underwent major abdominal or thoracic surgery. The outcome of interest was the occurrence of any adverse event, including mortality, within 30-days postoperatively.