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Pace D, Lopez ME, Berman L. Quality improvement dissemination in pediatric surgery: The APSA quality and safety toolkit. Semin Pediatr Surg 2023; 32:151279. [PMID: 37075657 DOI: 10.1016/j.sempedsurg.2023.151279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Shared experiential learning is critical in the field of pediatric surgery to support the translation of evidence into practice. Surgeons who develop QI interventions in their own institutions based on the best available evidence create work products that can accelerate similar projects in other institutions, rather than continuously reinventing the wheel. The American Pediatric Surgical Association (APSA) Quality and Safety Committee (QSC) toolkit was created to facilitate knowledge-sharing and thereby hasten the development and implementation of QI. The toolkit is an expanding open-access web-based repository of curated QI projects that includes evidence-based pathways and protocols, stakeholder presentations, parent/patient educational materials, clinical decision support (CDS) tools, and other components of successful QI interventions in addition to contact information for the surgeons who developed and implemented them. This resource catalyzes local QI endeavors by showcasing a range of projects that can be adapted to fit the needs of a given institution, and it also serves as a network to connect interested surgeons with successful implementers. As healthcare shifts towards value-based care models, quality improvement becomes increasingly important, and the APSA QSC toolkit will continue to adapt to the evolving needs of the pediatric surgery community.
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Affiliation(s)
- Devon Pace
- Department of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Monica E Lopez
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Monroe Carrell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States
| | - Loren Berman
- Department of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.
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Palchaudhuri S, Mccreary B, Davis J, Mcginnis B, Nyberg S, Mundi MS, Pham A. Discharged on Enteral Nutrition: What Now? The Poor State of Outpatient Support for Patients on Enteral Nutrition Support. Curr Gastroenterol Rep 2023; 25:61-68. [PMID: 36734991 DOI: 10.1007/s11894-023-00864-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW While the use of enteral nutrition (EN) has increased, and more medical centers have developed inpatient programs to address the unique needs of these patients, our collective experience at a few large institutions indicates that there is very little systemic support for patients after discharge. Here, we discuss what we have observed to be some of the barriers to providing outpatient follow up care, summarize the impact we have seen on patients, and propose some possible solutions. RECENT FINDINGS We have observed and identified some of the root causes to include financial barriers; uncoordinated care transitions; high complexity of care, including medication management; and diffuse leadership to a multidisciplinary problem. Systematic support for outpatient care for patients discharged on enteral nutrition is rare and limited, due to many root causes. There are a few tools and tips that we have summarized here for individual providers, and a few promising methods in development, but a systematic approach is in great need.
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Affiliation(s)
- Sonali Palchaudhuri
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
| | - Brigid Mccreary
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Brenna Mcginnis
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Susan Nyberg
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Angela Pham
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA
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Berman L, Baird R, Sant'Anna A, Rosen R, Petrini M, Cellucci M, Fuchs L, Costa J, Lester J, Stevens J, Morrow M, Jaszczyszyn D, Amaral J, Goldin A. Gastrostomy Tube Use in Pediatrics: A Systematic Review. Pediatrics 2022; 149:186999. [PMID: 35514122 DOI: 10.1542/peds.2021-055213] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Despite frequency of gastrostomy placement procedures in children, there remains considerable variability in preoperative work-up and procedural technique of gastrostomy placement and a paucity of literature regarding patient-centric outcomes. OBJECTIVES This review summarizes existing literature and provides consensus-driven guidelines for patients throughout the enteral access decision-making process. DATA SOURCES PubMed, Google Scholar, Medline, and Scopus. STUDY SELECTION Included studies were identified through a combination of the search terms "gastrostomy," "g-tube," and "tube feeding" in children. DATA EXTRACTION Relevant data, level of evidence, and risk of bias were extracted from included articles to guide formulation of consensus summaries of the evidence. Meta-analysis was conducted when data afforded a quantitative analysis. EVIDENCE REVIEW Four themes were explored: preoperative nasogastric feeding tube trials, decision-making surrounding enteral access, the role of preoperative imaging, and gastrostomy insertion techniques. Guidelines were generated after evidence review with multidisciplinary stakeholder involvement adhering to GRADE methodology. RESULTS Nearly 900 publications were reviewed, with 58 influencing final recommendations. In total, 17 recommendations are provided, including: (1) tTrial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth; (2) rRoutine contrast studies are not indicated before gastrostomy placement; and (3) lLaparoscopic placement is associated with the best safety profile. LIMITATIONS Recommendations were generated almost exclusively from observational studies and expert opinion, with few studies describing direct comparisons between GT placement and prolonged nasogastric feeding tube trial. CONCLUSIONS Additional patient- and family-centric evidence is needed to understand critical aspects of decision-making surrounding surgically placed enteral access devices for children.
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Affiliation(s)
- Loren Berman
- Departments of Surgery.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert Baird
- Department of Pediatric General and Thoracic Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ana Sant'Anna
- Department of Pediatrics, Division of Gastroenterology and Nutrition, McGill University Health Center, Montreal, Quebec, Canada
| | - Rachel Rosen
- Aerodigestive Center, Division of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Petrini
- Pediatrics.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael Cellucci
- Pediatrics.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lynn Fuchs
- Neonatology.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joanna Costa
- Neonatology.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jennifer Lester
- Nutrition.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jenny Stevens
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Michele Morrow
- Therapy Services, Nemours Children's Health, Wilmington, Delaware.,Sidney Kimmel Medical School at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Joao Amaral
- Department of Diagnostic Imaging, Division of Interventional Radiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adam Goldin
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
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Skertich NJ, Lee TK, Grunvald MW, Sivakumar A, Tiglao RM, Madonna MB, Pillai S, Shah AN. The effect of standardized discharge instructions after gastrostomy tube placement on postoperative hospital utilization. J Pediatr Surg 2022; 57:418-423. [PMID: 33867152 DOI: 10.1016/j.jpedsurg.2021.03.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE Gastrostomy tube (GT) placement is a common pediatric procedure with high postoperative resource utilization. We aimed to determine if standardized discharge instructions (SDI) reduced healthcare utilization rates. METHODS We performed a retrospective cohort study comparing postoperative hospital utilization of patients who underwent initial GT placement pre- and post-SDI protocol implementation from 2014-2019. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression, adjusted Cox proportion hazard regression, and adjusted Poisson regression models when appropriate. RESULTS 197 patients were included, 102 (51.8%) before and 95 (48.2%) after protocol implementation. On primary analysis, SDI patients did not have significantly different total postoperative hospital utilization events at 30-days (48.0% vs. 38.9%, p = 0.25). On secondary analysis, SDI patients had lower rates of ED (8.4% vs. 19.6%, p = 0.026) and office visits (11.6% vs. 25.5%, p = 0.017) at 30-days. Non-SDIs patients had greater odds of ED visits (OR2.7, 95%CI 1.3-5.9, p = 0.01), office visits (OR3.7, 95%CI 1.7-8.1, p = 0.001) and phone calls (OR2.6, 95%CI 1.2-5.7, p = 0.016) at 1-year. The adjusted hazard ratio was 2.0 (95%CI 1.4-3.0, p < 0.001). Incident rate ratio were 1.8 (95%CI 1.2-2.5, p = 0.002) at 30-days and 1.9 (95%CI 1.5-2.4, p < 0.001) at 1-year post-discharge. CONCLUSIONS SDIs post-GT placement may reduce multiple aspects of postoperative hospital utilization.
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Affiliation(s)
- Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | | | - Miles W Grunvald
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | | | - Rona M Tiglao
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Srikumar Pillai
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA.
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Abstract
Premature infants or infants born with complex medical problems are at increased risk of having delayed or dysfunctional oral feeding ability. These patients typically require assisted enteral nutrition in the form of a nasogastric tube (NGT) during their NICU hospitalization. Historically, once these infants overcame their initial reason(s) for admission, they were discharged from the NICU only after achieving full oral feedings or placement of a gastrostomy tube. Recent programs show that these infants can be successfully discharged from the hospital with partial NGT or gastrostomy tube feedings with the assistance of targeted predischarge education and outpatient support. Caregiver opinions have also been reported as satisfactory or higher with this approach. In this review, we discuss the current literature and outcomes in infants who are discharged with an NGT and provide evidence for safe practices, both during the NICU hospitalization, as well as in the outpatient setting.
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Affiliation(s)
- Anna Ermarth
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Con Yee Ling
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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Addressing ethical clinical dilemmas with quality improvement methodology. Semin Pediatr Surg 2021; 30:151105. [PMID: 34635285 DOI: 10.1016/j.sempedsurg.2021.151105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Application of Quality Improvement methodology to nuanced clinical scenarios may be useful to ensure consistent delivery of equitable and comprehensive care. The purpose of this article is to inform the pediatric surgical readership of opportunities where quality improvement methodology may aid in navigating ethical nuances of complex surgical care. We present three case scenarios and discuss how quality improvement methodology could be utilized to address issues of provider autonomy, patient autonomy, and justice.
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Lagatta JM, Uhing M, Acharya K, Lavoie J, Rholl E, Malin K, Malnory M, Leuthner J, Brousseau D. Actual and Potential Impact of a Home Nasogastric Tube Feeding Program for Infants Whose Neonatal Intensive Care Unit Discharge Is Affected by Delayed Oral Feedings. J Pediatr 2021; 234:38-45.e2. [PMID: 33789159 PMCID: PMC8238833 DOI: 10.1016/j.jpeds.2021.03.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/21/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare healthcare use and parent health-related quality of life (HRQL) in 3 groups of infants whose neonatal intensive care unit (NICU) discharge was delayed by oral feedings. STUDY DESIGN This was a prospective, single-center cohort of infants in the NICU from September 2018 to March 2020. After enrollment, weekly chart review determined eligibility for home nasogastric (NG) feeds based on predetermined criteria. Actual discharge feeding decisions were at clinical discretion. At 3 months' postdischarge, we compared acute healthcare use and parental HRQL, measured by the PedsQL Family Impact Module, among infants who were NG eligible but discharged with all oral feeds, discharged with NG feeds, and discharged with gastrostomy (G) tubes. We calculated NICU days saved by home NG discharges. RESULTS Among 180 infants, 80 were orally fed, 35 used NG, and 65 used G tubes. Compared with infants who had NG-tube feedings, infants who had G-tube feedings had more gastrointestinal or tube-related readmissions and emergency encounters (unadjusted OR 3.97, 95% CI 1.3-12.7, P = .02), and orally-fed infants showed no difference in use (unadjusted OR 0.41, 95% CI 0.1-1.7, P = .225). Multivariable adjustment did not change these comparisons. Parent HRQL at 3 months did not differ between groups. Infants discharged home with NG tubes saved 1574 NICU days. CONCLUSIONS NICU discharge with NG feeds is associated with reduced NICU stay without increased postdischarge healthcare use or decreased parent HRQL, whereas G-tube feeding was associated with increased postdischarge healthcare use.
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Affiliation(s)
- Joanne M. Lagatta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Uhing
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Krishna Acharya
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Julie Lavoie
- Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Erin Rholl
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathryn Malin
- Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Margaret Malnory
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jonathan Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Brousseau
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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Ruffolo LI, McGuire A, Calderon T, Wolcott K, Levatino E, Martin H, Foito T, Pulhamus M, Wakeman DS. Emergency department utilization following pediatric gastrostomy tube placement is driven by a small cohort of patients. J Pediatr Surg 2021; 56:961-965. [PMID: 32900509 DOI: 10.1016/j.jpedsurg.2020.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/23/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Pediatric gastrostomy tubes (G-tubes) are associated with frequent postoperative problems and consumption of healthcare resources. We hypothesized that a small cohort of patients disproportionately drives healthcare resource utilization after G-tube insertion. This study aimed to characterize this population in order to implement evidence-based pathways to reduce healthcare utilization after G-tube insertion. METHODS All surgically placed pediatric G-tubes at a quaternary care center between March 2011 and June 2018 were retrospectively reviewed. Healthcare utilization including radiographic studies, emergency department (ED) visits, hospital admissions, procedures, and diagnoses was abstracted. Encounter specific charges based on CPT codes were collected. Statistical analyses were performed with Mann Whitney U, Fisher's Exact Test, and multivariate nominal logistic regression. Institutional review board approval was obtained. RESULTS During the study period, 189 patients underwent G-tube insertion; 24% of patients presented to the ED two or more times and accounted for 82% of ED visits. This cohort of high ED utilizers was more likely to present with G-tube dislodgement [both within the first three months (early) and after three months (late)], required more radiographic studies, and accrued significantly more charges compared to low ED utilizers. Multivariate analyses demonstrated high ED utilization was significantly associated with non-Caucasian race and the surgeon performing the procedure. CONCLUSIONS At our institution, a significant proportion of healthcare utilization following G-tube placement is consumed by a relatively small cohort of children. Future efforts will target patients with two or more G-tube related ED visits or an early G-tube dislodgement for additional education and integration with outpatient resources. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Luis I Ruffolo
- University of Rochester Medical Center, Department of Surgery, Rochester, NY.
| | - Anna McGuire
- University of Rochester Medical Center, Department of Surgery, Rochester, NY
| | - Thais Calderon
- University of Rochester Medical Center, Department of Surgery, Rochester, NY
| | - Kori Wolcott
- Rochester Regional Health, Quality and Safety Institute, Rochester, NY
| | - Elizabeth Levatino
- University of Rochester Medical Center, Department of Surgery, Rochester, NY
| | - Heather Martin
- University of Rochester Medical Center, Department of Emergency Medicine, Rochester, NY
| | - Theresa Foito
- University of Rochester Medical Center, Department of Surgery, Rochester, NY
| | - Marsha Pulhamus
- University of Rochester Medical Center, Department of Surgery, Rochester, NY
| | - Derek S Wakeman
- University of Rochester Medical Center, Department of Surgery, Rochester, NY
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Ruffolo LI, Pulhamus M, Foito T, Levatino E, Martin H, Michels J, Schriefer J, Wolcott K, Wakeman D. Implementation of a gastrostomy care bundle reduces dislodgements and length of stay. J Pediatr Surg 2021; 56:30-36. [PMID: 33168177 DOI: 10.1016/j.jpedsurg.2020.09.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/22/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Pediatric gastrostomy tubes (G-tubes) are associated with considerable utilization of healthcare resources. G-tube dislodgement can result in tract disruption and abdominal sepsis. We aimed to reduce early G-tube dislodgement by 25%. METHODS An interdisciplinary team convened to identify key drivers of G-tube dislodgement and implement initiatives to reduce this complication. A G-tube care bundle was implemented in 2018. Rates of early G-tube dislodgement (within 90 days of insertion) were tracked. 15 months of cases after bundle implementation were compared to 20 months of cases before implementation. Length of stay (LOS, balancing measure) and bundle compliance (process measure) were tracked. RESULTS G-tube dislodgements decreased 47% after bundle implementation. Overall, dislodgements after G-tube insertion decreased from 43% to 19% dislodgements per tube inserted, p = 0.004. Reductions were observed for dislodgements occurring in both the inpatient (14% vs. 1.5%) and outpatient (29% vs. 18%) settings. Median LOS was reduced from 15.3 to 7.1 days following implementation, p = 0.004. Process measures demonstrated 75% or greater compliance one year after implementation. CONCLUSION An interdisciplinary team using quality improvement science methodology can significantly reduce G-tube dislodgement and improve value after pediatric gastrostomy tube insertion. TYPE OF STUDY Longitudinal cohort study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Luis I Ruffolo
- University of Rochester, Department of Surgery, Division of Pediatric Surgery, Rochester, NY, USA.
| | - Marsha Pulhamus
- University of Rochester, Department of Surgery, Division of Pediatric Surgery, Rochester, NY, USA
| | - Theresa Foito
- University of Rochester, Department of Surgery, Division of Pediatric Surgery, Rochester, NY, USA
| | - Elizabeth Levatino
- University of Rochester, Department of Surgery, Division of Pediatric Surgery, Rochester, NY, USA
| | - Heather Martin
- University of Rochester, Department of Emergency Medicine, Rochester, NY, USA
| | - Julie Michels
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Jan Schriefer
- Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Kori Wolcott
- Quality and Safety Institute, Rochester Regional Health, Rochester, NY, USA
| | - Derek Wakeman
- University of Rochester, Department of Surgery, Division of Pediatric Surgery, Rochester, NY, USA
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