1
|
Arshad SA, Hebballi NB, Hegde BN, Avritscher EBC, John SD, Lapus RM, Tsao K, Kawaguchi AL. Early discharge after nonoperative management of intussusception is both safe and cost-effective. J Pediatr Surg 2022; 57:147-152. [PMID: 34756701 DOI: 10.1016/j.jpedsurg.2021.09.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE We implemented a quality improvement (QI) initiative to safely reduce post-reduction monitoring for pediatric patients with ileocolic intussusception. We hypothesized that there would be decreased length of stay (LOS) and hospital costs, with no change in intussusception recurrence rates. METHODS A retrospective cohort study was conducted of pediatric ileocolic intussusception patients who underwent successful enema reduction at a tertiary-care pediatric hospital from January 2015 through June 2020. In September 2017, an intussusception management protocol was implemented, which allowed discharge within four hours of reduction. Pre- and post-QI outcomes were compared for index encounters and any additional encounter beginning within 24 h of discharge. An economic evaluation was performed with hospital costs inflation-adjusted to 2020 United States Dollars ($). Cost differences between groups were assessed using multivariable regression, adjusting for Medicaid and transfer status, P < 0.05 significant. RESULTS Of 90 patients, 37(41%) were pre-QI and 53(59%) were post-QI. Patients were similar by age, sex, race, insurance status, and transfer status. Pre-QI patients had a median LOS of 23.4 h (IQR: 16.1-34.6) versus 9.3 h (IQR 7.4-14.2) for post-QI patients, P < 0.001. Mean total costs per patient in the pre-QI group were $3,231 (95% CI, $2,442-$4,020) versus $1,861 (95% CI, $1,481-$2,240) in the post-QI group. The mean absolute cost difference was $1,370 less per patient in the post-QI group (95% CI, [-$2,251]-[-$490]). Five patients had an additional encounter within 24 h of discharge [pre-QI: 1 (3%) versus post-QI: 4 (8%), p = 0.7] with four having intussusception recurrence [pre-QI: 1 (3%) versus post-QI: 3 (6%), p = 0.6]. CONCLUSIONS Implementation of a quality improvement initiative for the treatment of pediatric intussusception reduced hospital length of stay and costs without negatively affecting post-discharge encounters or recurrence rates. Similar protocols can easily be adopted at other institutions. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative treatment study.
Collapse
Affiliation(s)
- Seyed A Arshad
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Nutan B Hebballi
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Brittany N Hegde
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Elenir B C Avritscher
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Susan D John
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Robert M Lapus
- Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Akemi L Kawaguchi
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States.
| |
Collapse
|
2
|
Kelley-Quon LI, Arthur LG, Williams RF, Goldin AB, St. Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A, Smith CA, Miniati D, Sola JE, Valusek P, Berman L, Raval MV, Gosain A, Dellinger MB, Sømme S, Downard CD, McAteer JP, Kawaguchi A. Management of intussusception in children: A systematic review. J Pediatr Surg 2021; 56:587-596. [PMID: 33158508 PMCID: PMC7920908 DOI: 10.1016/j.jpedsurg.2020.09.055] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/30/2020] [Accepted: 09/24/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. METHODS The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. RESULTS A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. CONCLUSIONS Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. LEVEL OF EVIDENCE Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.
Collapse
Affiliation(s)
- Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles and the Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California,Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - L. Grier Arthur
- Division of Pediatric Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA
| | - Regan F. Williams
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Adam B. Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | | | - Alana L. Beres
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California, Davis, CA
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth J. Renaud
- Alpert Medical School at Brown University, Hasbro Children’s Hospital, Providence, RI
| | - Robert Ricca
- Division of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Mark B. Slidell
- Section of Pediatric Surgery, The University of Chicago Medicine, Comer Children’s Hospital, Chicago, Illinois
| | - Amy Taylor
- Texas Medical Center Library, Houston, TX
| | - Caitlin A. Smith
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children’s Center, Roseville, California
| | - Juan E. Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Patricia Valusek
- Pediatric Surgical Associates, Ltd., Children’s Minnesota, Minneapolis, MN
| | - Loren Berman
- Division of Pediatric surgery, Department of Surgery, Nemours-AI DuPont Hospital for Children and Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE
| | - Mehul V. Raval
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ankush Gosain
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN,Children’s Foundation Research Institute, Le Bonheur Children’s Hospital, Memphis, TN
| | - Matthew B. Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Stig Sømme
- Division of Pediatric Surgery, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Cynthia D. Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | | | - Akemi Kawaguchi
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children’s Memorial Hermann Hospital, Houston, TX
| |
Collapse
|
3
|
Impact of a Standardized Clinical Pathway for Suspected and Confirmed Ileocolic Intussusception. Pediatr Qual Saf 2020; 5:e298. [PMID: 32656466 PMCID: PMC7297403 DOI: 10.1097/pq9.0000000000000298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 04/15/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception. Methods: Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children’s hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation. Results: After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation. Conclusion: Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.
Collapse
|
4
|
Sujka JA, Dalton B, Gonzalez K, Tarantino C, Schroeder L, Giovanni J, Oyetunji TA, St Peter SD. Emergency department discharge following successful radiologic reduction of ileocolic intussusception in children: A protocol based prospective observational study. J Pediatr Surg 2019; 54:1609-1612. [PMID: 30309734 DOI: 10.1016/j.jpedsurg.2018.08.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Pediatric intussusception's first line treatment consists of fluoroscopic guided air enema reduction. Postprocedure, these patients are usually admitted overnight for observation. The purpose of our study was to document the results of emergency department (ED) observation and discharge protocol after successful reduction of ileocolic intussusception. METHODS A prospective observational study was conducted after implementation of an ED protocol for ileocolic intussusception from 10/2014 to 7/2017 and compared these patients to a historical cohort immediately prior to protocol initiation (10/2011-9/2014). Data collected included demographics, total time in the ED and hospital, enema reduction, recurrence, and requirement for operative intervention. Results reported as means with standard deviation and medians reported with interquartile ranges (IQR). RESULTS 115 patients were treated with the prospective protocol and were compared to a 90 patient historical cohort. Reduction was successful in 84%-89% of cases. Median hospital time after enema was shorter in the protocol group [4.8 h (4.25, 14.97) versus 19.7 h (13.9, 33.45), p < 0.01]. Only 33% of patients were admitted following the protocol; the most common admission reason was persistent abdominal discomfort. CONCLUSION ED observation and discharge after successful air enema reduction in children with ileocolic intussusception are safe, facilitate early discharge, and reduce hospital resource utilization. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Joseph A Sujka
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108.
| | - Brian Dalton
- Department of Surgery, UF College of Medicine, Jacksonville.
| | | | - Celeste Tarantino
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108.
| | - Lisa Schroeder
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108.
| | - Joan Giovanni
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108.
| | | | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108.
| |
Collapse
|
5
|
Intussusception Protocol Implementation: Single-Site Outcomes With Clinician and Family Satisfaction. J Surg Res 2019; 244:122-129. [PMID: 31284141 DOI: 10.1016/j.jss.2019.06.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/02/2019] [Accepted: 06/07/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to evaluate clinical outcomes, costs, and clinician and parent satisfaction after implementation of a protocol to discharge patients from the emergency department (ED) after successful reduction of uncomplicated ileocolic intussusception. MATERIALS AND METHODS In March 2017, an intussusception management protocol was implemented for children presenting with ultrasound findings of ileocolic intussusception. Those meeting inclusion criteria were observed after successful radiological reduction in the ED and discharged after 6 h with resolution of symptoms. Retrospective chart review was completed for cases before and after protocol implementation for clinical outcomes and costs. Clinicians and parents were surveyed to assess overall satisfaction. RESULTS Charts were reviewed before (42 encounters, 37 patients) and after (30 encounters, 23 patients) protocol implementation. After implementation, admission rates decreased from 95% (40/42) to 23% (7/30; P < 0.001) and antibiotic use was eliminated (91% to 0%, P < 0.001). There was no difference in recurrence rates (17% versus 23%, P = 0.44). Median total length of stay decreased from 18.87 to 9.52 h (P < 0.001), whereas median ED length of stay increased from 4.37 to 9.87 h (P < 0.001). In addition, there was an overall hospital cost saving of over $2000 ($9595 ± 3424 to $7465 ± 3723; P = 0.009) per encounter. Clinicians and parents were overall satisfied with the protocol and parents showed no changes in patient satisfaction with protocol implementation. CONCLUSIONS An intussusception protocol can facilitate early discharge from the ED and improve patient care without increased risk of recurrence. Additional benefits include decreased hospital- and patient-related costs, elimination of antibiotic use, and parent as well as clinician satisfaction.
Collapse
|
6
|
Okumus M, Emektar A. Pediatric intussusception and early discharge after pneumatic reduction. Acta Chir Belg 2019; 119:162-165. [PMID: 29947299 DOI: 10.1080/00015458.2018.1487190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The success of non-operative reduction methods is extremely high in pediatric intussusceptions. Recurrent intussusceptions are also well-known entities in the pediatric age group after non-operative and operative reduction. Historical recommendations include a 24- to 48-h observation period after reduction. This situation often leads to unnecessary time loss. We aimed to show that early discharge does not pose a significant risk. METHODS The medical records of patients who presented to our hospital between January 2008 and June 2017 were retrospectively reviewed. Data collected included age, clinical presentation, procedural information, surgical intervention, hospital stay, and presence of recurrence. RESULTS A total of 62 patients were included the study. Non-operative reduction was successful in 58 of 62 patients (93.5%). Four patients with failed non-operative reduction underwent subsequent surgical procedures. All patients were allowed oral intake within 2-4 h (mean: 2.6 h) after successful non-operative reduction and discharged within 5-8 h (mean: 6.2 h) after reduction. There were five episodes of recurrence and none occurred in the first 48 h after reduction. All recurrences were treated with non-operative reduction as in the first attempt. There were no problems detected in short- or long-term follow-ups. CONCLUSION Pneumatic reduction is a safe and effective method in pediatric intussusception. If one is confident about treatment success, patients can be discharged without a long observation period. Early discharge is also cost-effective and reduces time loss.
Collapse
Affiliation(s)
- Mustafa Okumus
- Department of Pediatric Surgery, Yeniyüzyıl University, Faculty ofMedicine, Gaziosmanpaşa Hospital and Bahat Hospital, Istanbul, Turkey
| | - Ali Emektar
- Department of Radiology, Bahat Hospital, Istanbul, Turkey
| |
Collapse
|