Implementation of a perioperative surgical home protocol for pediatric patients presenting for adenoidectomy

Incremental Societal Costs of Perioperative Complications Following Adult Elective Inpatient Major Therapeutic Surgery in the State of Florida: A Seven-Year Retrospective Epidemiological Analysis

Introduction There is an expanding role for anesthesiologists in the preoperative optimization and postoperative management of patients, often in the context of a so-called perioperative surgical home. Such efforts typically include enhanced recovery after surgery (ERAS) protocols and often an anesthesiologist-led team for perioperative management. Studies of the cost-effectiveness of such approaches have generally been conducted at single institutions, with most patients cared for by small numbers of surgeons. This limitation creates generalizability issues as to whether improvement was related mostly to organizational culture or the studied surgeons' practices (non-generalizable) versus the procedures (generalizable). We studied whether other organizations can rely on achieving similar benefits following the adoption of a studied process improvement strategy at a single institution. Methods All patients undergoing elective major therapeutic inpatient surgery discharged between October 2015 and June 2022 at non-federal hospitals in the state of Florida were included. For each discharge, the United States Medicare Severity Diagnosis-Related Group (MS-DRG) weighting factor (i.e., the multiplier for the hospital's base rate for admissions that determines reimbursement) and the Clinical Classification Software Refined (CCSR) code for the principal procedure were determined at admission and discharge from the state's inpatient healthcare database based on the diagnoses present at those time points. An increase in the weighting factor from admission to discharge represents societal costs from perioperative complications. Statewide, by hospital, and by surgeon, we calculated the total increase for each CCSR's weighting factor. Our primary hypothesis was that surgeon variability would be statistically greater than CCSR variability but that the incremental effect would be <5%. If CCSR and surgeon variability were comparable, this would be supportive of generalizability. In contrast, if there were a predominant effect related to the surgeon, results from one institution might not be applicable to others. Results Among the 1,482,344 discharges studied, the pooled (N=7 years) contributions to MS-DRG weighting factor increases from the upper 20% of surgeons were 2.8% more than from the upper 20% of CCSRs (95% CI 1.9%-3.9%, p=0.0006). Those CCSRs accounted for 85.5% (95% CI 79.4%-91.7%, p<0.0001) of the total increase in the MS-DRG weighting factor. The average contribution of the top two surgeons at each hospital to that hospital's increase in the weighting factor ranged among CCSRs from 68% to 97%. The median and 75th percentile of surgeons performing at least 10% of the total number of cases at each hospital was similar to those values for the contributions to the increases in the MS-DRG weighting factor, median 2.0 to 3.0, and 75th percentile 1.75 to 4.0. Conclusions Because variability among surgeons in their contributions to increases in the MS-DRG weighting factor only slightly exceeded the variability among CCSR surgical categories, perioperative surgical home and ERAS study research results involving single institutions and a small number of surgeons would likely be generalizable to other hospitals and healthcare systems. Funding agencies should not be hesitant to fund single-center perioperative surgical home studies and ERAS interventions based on concerns related to lack of generalizability.

Social Media Utilization in Otolaryngology: A Scoping Review

OBJECTIVE

Social media (SM) is an increasingly popular medium for the medical community to engage with patients, trainees, and colleagues. This review aimed to identify reported uses of SM in otolaryngology-head and neck surgery (OHNS), assess the quality of evidence supporting these uses, and identify gaps in the literature. With the relative lack of regulatory guidelines for the development of SM content, we hypothesized that the quality of content available on SM would be highly variable.

DATA SOURCES AND METHODS

A scoping review was performed of English-language peer-reviewed studies published to date discussing SM use in any form within OHNS. Three reviewers independently screened all abstracts. Two reviewers independently extracted data of interest from the full text of articles identified from the preliminary abstract screen.

RESULTS

171 studies were included, with 94 (54.9%) studies published between 2020 and 2022. 104 (60.8%) studies were conducted in the US. 135 (78.9%) used cross-sectional or survey-based methodology; only 7 (4.1%) were controlled studies. SM was most commonly employed for professional networking (n = 37 [21%]), and within subspecialties of otology (n = 38 [22%]) and rhinology/allergy (n = 25 [15%]). Facebook was most frequently used for study recruitment (n = 23 [13.5%]), YouTube for patient education (n = 15 [14.6%]), and Twitter for professional networking (n = 16 [9.4%]).

CONCLUSION

SM use within OHNS is increasing rapidly, with applications including patient education, professional networking, and study recruitment. Despite myriad articles, there remains a paucity of well-controlled studies. As SM becomes integrated into healthcare, particularly for applications directly impacting patient care, higher levels of evidence are needed to understand its true impact. Laryngoscope, 133:2447-2456, 2023.

Rural implementation of the perioperative surgical home: A case-control study

BACKGROUND

Perioperative surgical home (PSH) is a novel patient-centric surgical system developed by American Society of Anesthesiologist to improve outcomes and patient satisfaction. PSH has proven success in large urban health centers by reducing surgery cancellation, operating room time, length of stay (LOS), and readmission rates. Yet, only limited studies have assessed the impact of PSH on surgical outcomes in rural areas.

AIM

To evaluate the newly implemented PSH system at a community hospital by comparing the surgical outcomes using a longitudinal case-control study.

METHODS

The research study was conducted at an 83-bed, licensed level-III trauma rural community hospital. A total of 3096 TJR procedures were collected retrospectively between January 2016 and December 2021 and were categorized as PSH and non-PSH cohorts (n = 2305). To evaluate the importance of PSH in the rural surgical system, a case-control study was performed to compare TJR surgical outcomes (LOS, discharge disposition, and 90-d readmission) of the PSH cohort against two control cohorts [Control-1 PSH (C1-PSH) (n = 1413) and Control-2 PSH (C2-PSH) (n = 892)]. Statistical tests including Chi-square test or Fischer’s exact test were performed for categorical variables and Mann-Whitney test or Student’s t-test were performed for continuous variables. The general linear models (Poisson regression and binomial logistic regression) were performed to fit adjusted models.

RESULTS

The LOS was significantly shorter in PSH cohort compared to two control cohorts (median PSH = 34 h, C1-PSH = 53 h, C2-PSH = 35 h) (P value < 0.05). Similarly, the PSH cohort had lower percentages of discharges to other facilities (PSH = 3.5%, C1-PSH = 15.5%, C2-PSH = 6.7%) (P value < 0.05). There was no statistical difference observed in 90-d readmission between control and PSH cohorts. However, the PSH implementation reduced the 90-d readmission percentage (PSH = 4.7%, C1-PSH = 6.1%, C2-PSH = 3.6%) lower than the national average 30-d readmission percentage which is 5.5%. The PSH system was effectively established at the rural community hospital with the help of team-based coordinated multi-disciplinary clinicians or physician co-management. The elements of PSH including preoperative assessment, patient education and optimization, and longitudinal digital engagement were vital for improving the TJR surgical outcomes at the community hospital.

CONCLUSION

Implementation of the PSH system in a rural community hospital reduced LOS, increased direct-to-home discharge, and reduced 90-d readmission percentages.

The virtual pediatric perioperative home, experience at a major metropolitan safety net hospital

INTRODUCTION

Successes from anesthesiologist-led perioperative surgical homes in the adult patient population have inspired similar initiatives by pediatric hospitals. Typically the care coordination for these perioperative homes is run through hospital-funded, on-site, preanesthesia clinics. Preliminary data from pediatric perioperative homes have shown promising results in improved patient outcomes and decreased length of hospital stay. The majority of pediatric surgeries within the country are performed in nonpediatric hospitals. Such centers may not have the infrastructure or financial resources for a freestanding pediatric preanesthesia clinic. Faced with this situation at the largest safety net hospital in New England, the authors present their experience designing and implementing a "Virtual Pediatric Perioperative Home," a telemedicine-based triage and preanesthetic optimization for pediatric patients at Boston Medical Center, Boston, MA.

METHODS

A retrospective chart review of all pediatric anesthesia cases at Boston Medical Center from February 1, 2019, to January 31, 2020, as well as the number of pediatric cases canceled or postponed on the day of surgery for any reason during the same time period was conducted.

RESULTS

From February 1, 2019, to January 31, 2020, 1546 anesthetics were performed in children 18 years and under. Of those, 63 were designated as emergent and hence excluded from our analysis. 153 of the total 1483 (9.4%) of nonemergent bookings were canceled or postponed on the day of surgery. This represented a marked decline from our previous year's 13.7% same-day cancellation rate for pediatric patients. The most common reason for case cancellations (41.8%) was acute illness. Cancellation rates varied from month to month, with the highest cancellation rate of the year in September 2019 (18.8%). The departments of Podiatry and Gastroenterology represented the highest cancellation rates as a denominator of their case volumes, 15.4% and 15.2%, respectively. Younger children had 2.4 times the odds (95% CI: 1.720, 3.4) of cancellation compared to older children.

DISCUSSION

The virtual pediatric perioperative home (VPPH) may benefit quality of care while decreasing costs to pediatric patients, families, and hospital systems. While direct financial gains may be difficult to demonstrate, the VPPH has the potential to reduce OR delays and same day cancellations related to questions of medical optimization. In the context of a socioeconomically disadvantaged patient population, our VPPH's team of subspecialists created inroads for at risk children to establish or reestablish care for their comorbidities, while collaboration with the Department of Children and Families further streamlined communication and consent for pediatric patients in foster care.

CONCLUSIONS

The authors describe the design and successful implementation of a telemedicine-based pediatric preanesthesia triage and medical optimization service at a large safety net hospital. By creating a communication network of pediatric subspecialists, the anesthesiologists were able to, at minimal institutional cost, coordinate care for children with a variety of comorbidities leading up to the day of surgery. This yielded a 9.4% same day cancellation rate in a complex, socioeconomically disadvantaged pediatric patient population at a general hospital.

The association between pre-tonsillectomy education and postoperative emergency department returns: A retrospective cohort pilot study

INTRODUCTION

Tonsillectomy is the most common pediatric surgery in Canada. Post-tonsillectomy 30-day Emergency Department (ED) visit rates are higher than other pediatric day surgeries. To date, there have been no studies assessing whether additional preoperative education directed by Child Life Specialists impacts preventable ED visits. The primary aim of this study was to evaluate whether additional preoperative tonsillectomy education is feasible and is associated with fewer ED visits and admissions in the immediate postoperative period compared to standard care. The secondary aim of this study was to assess whether this education was associated with a lower ED visit rate for preventable causes.

METHODS

This is a retrospective chart review conducted in an academic tertiary pediatric hospital. Patients undergoing tonsillectomy surgery (from 2014 to 2019) were divided into three groups: consultation with a Child Life Specialist plus educational Booklet plus traditional surgeon-led education (CLS), educational Booklet plus surgeon-led education (Booklet), and traditional surgeon-led education (Traditional). The feasibility of the CLS education was assessed and the 30-day ED visit and admission rates were compared between groups. Visits included patients who returned to ED post-tonsillectomy and were not admitted, whereas admission included those who returned to ED and were admitted.

RESULTS

2081 patients undergoing tonsillectomy were included. 329 (15.8%) presented to the ED (within a median of 5 days), and 92 (4.4%) were admitted. ED visit/admission rates by group were: 14.7%/4.4% (CLS), 15.8%/4.1% (Booklet), and 16.2%/4.7% (Traditional) (p = 0.81/p = 0.84). The most common reason for return to ED was Hemorrhage (4.9%). Patients also returned to the ED for preventable reasons such as dehydration, pain, nausea/vomitting and fevers.

CONCLUSIONS

Additional preoperative tonsillectomy education is feasible but is not associated with fewer ED visits and admissions, or fewer ED visits for preventable causes. Further research is needed to identify the optimal intervention to address the high post-tonsillectomy ED visit rate.

The Perioperative Surgical Home in Pediatrics: Improve Patient Outcomes, Decrease Cancellations, Improve HealthCare Spending and Allocation of Resources during the COVID-19 Pandemic

Cancellations or delays in surgical care for pediatric patients that present to the operating room create a great obstacle for both the physician and the patient. Perioperative outpatient management begins prior to the patient entering the hospital for the day of surgery, and many organizations practice using the perioperative surgical home (PSH), incorporating enhanced recovery concepts. This paper describes changes in standard operating procedures caused by the COVID-19 pandemic, and proposes the expansion of PSH, as a means of improving perioperative quality of care in pediatric populations.

Perioperative Surgical Home Model Improves Outcomes in Crohn's Disease Patients Undergoing Disease-Related Surgery

Background

To evaluate Perioperative Surgical Home (PSH) practice model implementation in Crohn's disease (CD) patients undergoing disease-related surgery.

Methods

A retrospective analysis of CD patients requiring disease-related surgery in the Shanghai Ninth People's Hospital was undertaken. Subjects were divided into a non-PSH group consisting of 49 patients (June 2016 to November 2017) and a PSH group consisting of 72 patients (December 2017 until May 2019). Conventional treatment was used for the non-PSH group, while in the PSH group, a standardized pre- and postoperative management routine was employed. The postoperative lengths of stay and incidences of postoperative complications were analyzed.

Results

There were no significant differences in demographics, reasons for surgery, preoperative BMIs, and preoperative hemoglobin between the two groups (P > 0.05). The overall incidence of complications in the PSH group was dramatically lower than that in the non-PSH group (26.4% vs. 44.9%, P = 0.035). In the PSH group, postoperative length of stay was significantly shorter than that in the non-PSH group (11.5 ± 5.7 vs. 9.0 ± 6.8, P < 0.001).

Conclusions

The PSH conditioning routine in CD patients undergoing disease-related surgeries suggests a trend of fewer postoperative complications and shorter lengths of hospital stay. The PSH model may have clinical advantages when applied to CD patients.

Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair

BACKGROUND

The Pediatric Perioperative Surgical Home (PPSH) model is an integrative care model designed to provide better patient care and value by shifting focus from the patient encounter level to the overarching surgical episode of care. So far, no PPSH model has targeted a complex airway disorder. It was hypothesized that the development of a PPSH for laryngeal cleft repair would reduce the high rates of postoperative resource utilization observed in this population.

METHODS

Institutional review board approval was obtained for the purpose of data collection and analysis. A multidisciplinary team of anesthesiologists, surgeons, nursing staff, information technology specialists, and finance administrators was gathered during the PPSH development phase. Standardized perioperative (preoperative, intraoperative, and postoperative) protocols were developed, with a focus on preoperative risk stratification. Patients presenting before surgery with ≥1 predefined medical comorbidity were triaged to the intensive care unit (ICU) postoperatively, while patients without severe systemic disease were triaged to a lower-acuity floor for overnight observation. The success of the PPSH protocol was defined by quality outcome and value measurements.

RESULTS

The PPSH initiative included 120 patients, and the pre-PPSH period included 115 patients who underwent laryngeal cleft repair before implementation of the new process. Patients in the pre-PPSH period were reviewed and classified as ICU candidates or lower acuity floor candidates had they presented in the post-PPSH period. Among the 79 patients in the pre-PPSH period who were identified as candidates for the lower-acuity floor transfer, 70 patients (89%) were transferred to the ICU (P < .001). Retrospective analysis concluded that 143 ICU bedded days could have been avoided in the pre-PPSH group by using PPSH risk stratification. Surgery duration (P = .034) and hospital length of stay (P = .015) were found to be slightly longer in the group of pre-PPSH observation unit candidates. Rates of 30-day unplanned readmissions to the hospital were not associated with the new PPSH initiative (P = .093). No patients in either group experienced emergent postoperative intubation or other expected complications. Total hospital costs were not lower for PPSH observation unit patients as compared to pre-PPSH observation unit candidates (difference = 8%; 95% confidence interval, -7% to 23%).

CONCLUSIONS

A well-defined preoperative screening protocol for patients undergoing laryngeal cleft repair can reduce postoperative ICU utilization without affecting patient safety. Further research is needed to see if these findings are applicable to other complex airway surgeries.

Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency.

METHODS

A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay.

RESULTS

Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001).

CONCLUSIONS

Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS.

LEVEL OF EVIDENCE

Level III.

Video Discharge Instructions for Acute Otitis Media in Children: A Randomized Controlled Open-label Trial

BACKGROUND

Thirty percent of children with acute otitis media (AOM) experience symptoms < 7 days after initiating treatment, highlighting the importance of comprehensive discharge instructions.

METHODS

We randomized caregivers of children 6 months to 17 years presenting to the emergency department (ED) with AOM to discharge instructions using a video on management of pain and fever to a paper handout. The primary outcome was the AOM Severity of Symptom (AOM-SOS) score at 72 hours postdischarge. Secondary outcomes included caregiver knowledge (10-item survey), absenteeism, recidivism, and satisfaction (5-item Likert scale).

RESULTS

A total of 219 caregivers were randomized and 149 completed the 72-hour follow-up (72 paper and 77 video). The median (IQR) AOM-SOS score for the video was significantly lower than paper, even after adjusting for preintervention AOM-SOS score and medication at home (8 [7-11] vs. 10 [7-13], respectively; p = 0.004). There were no significant differences between video and paper in mean (±SD) knowledge score (9.2 [±1.3] vs. 8.8 [±1.8], respectively; p = 0.07), mean (±SD) number of children that returned to a health care provider (8/77 vs. 10/72, respectively; p = 0.49), mean (±SD) number of daycare/school days missed by child (1.2 [±1.5] vs. 1.1 [±2.1], respectively; p = 0.62), mean (±SD) number of workdays missed by caregiver (0.5 [±1] vs. 0.8 [±2], respectively; p = 0.05), or median (IQR) satisfaction score (5 [4-5] vs. 5 [4-5], respectively; p = 0.3).

CONCLUSIONS

Video discharge instructions in the ED are associated with less perceived AOM symptomatology compared to a paper handout.