Optimization of care for the pediatric surgical patient: Why now?

Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals

OBJECTIVE

To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals.

STUDY DESIGN

We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay.

RESULTS

In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons.

CONCLUSIONS

Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.

Use of nursing technologies for safe perioperative pediatric care

OBJECTIVE

To understand the nursing team's perception about the use of technology for safe perioperative pediatric care, through photographs.

METHOD

A qualitative study using the theoretical framework of Nietsche Specific Nursing Technology, with a total of 18 perioperative nursing professionals from a general hospital in southern Brazil. Data collection occurred from June to August 2018, from a semi-structured interview and photograph production. They were analyzed through the Thematic Content Analysis. Approved by the Research Ethics Committee of the Federal University of Santa Catarina.

RESULTS

The Nursing Technologies category used for the safety of the pediatric patient in the perioperative period, with 250 photographs illustrating facts, situations and artifacts considered nursing technologies used in safe care.

CONCLUSIONS

In the team's perception, patient safety involves the use of technologies integrated to perioperative care and structural, physical and input aspects.

Geographic distance to pediatric surgical care within the continental United States

PURPOSE

Geographic proximity to pediatric surgical care has not been evaluated using the Decennial Census nor have racial, ethnic, gender, or urbanization variations been reported. This study's aim is to describe proximity of children living in the continental U.S. to a pediatric surgeon with respect to these variations.

METHODS

The 2010 American Pediatric Surgical Association member file and the 2010 Decennial Census were used to calculate straight-line distances between pediatric surgeons' zip code centroids and census block centroids.

RESULTS

In 2010, 716 practicing pediatric surgeons were identified, 6,182,882 populated Census blocks were identified, and 73,690,271 children were enumerated. Of white non-Hispanic children, 30.1% lived greater than 40 miles from care. Of Native American children, 40.5% lived more than 60 miles from care. Among children 0-5 years of age, the median (IQR) miles to closest pediatric surgeon was 14.2 (6.2, 39.6), and 3,010,698 of these children lived more than 60 miles from care.

CONCLUSION

More than 10 million children lived greater than 60 miles from a pediatric surgeon in 2010. Racial, ethnic, age, and urbanization variations in proximity to pediatric surgeons were present. This method is feasible to describe distance-to-care with the upcoming 2020 Decennial Census and may benefit future allocation of pediatric surgeons.

LEVEL OF EVIDENCE

IV.

Minimally invasive surgical exposure among US and Canadian pediatric surgery trainees, 2004-2016

BACKGROUND

Minimally invasive pediatric surgery has increased in breadth and complexity over the past several decades, with little data on minimally invasive surgery (MIS) training in US and Canadian pediatric surgery fellowship programs.

METHODS

We performed a time series analysis of Accreditation Council for Graduate Medical Education pediatric surgery fellow case logs from 2003 to 2016. Proportions of cases performed in an MIS fashion as well as per-fellow MIS case averages were recorded over time.

RESULTS

There was a 30.9% increase in average number of MIS cases per fellow over the study time period. Twenty-three recorded procedures included MIS and open options (17 abdominal, three thoracic, and three genitourinary). The proportion of cases performed using a minimally invasive approach increased by an average of 29.0%, 14.6%, and 47.0% for each of these categories, respectively. Significant variability was observed in specific cases such as laparoscopic and open inguinal hernias, ranging from 0 to 85 and nine to 152 per trainee, respectively, in the final year of data collection. When examining pyloromyotomy, a high-volume procedure with a known increase in the MIS approach, the proportion of cases performed MIS increased by 83.3%. The minimum and maximum number of cases per fellow recorded ranged from 0 to 114 during the eight years in which MIS pyloromyotomy was recorded.

CONCLUSIONS

MIS case exposure among graduating US and Canadian pediatric survey fellows increased substantially during the study period. More granular data, however, are needed to better define the current operative experience and criteria for determination of competency in advanced MIS.

Surgical protocol violations in children with renal tumors provides an opportunity to improve pediatric cancer care: a report from the Children's Oncology Group

BACKGROUND

The purpose of this study was to evaluate the frequency and characteristics of surgical protocol violations (SPVs) among children undergoing surgery for renal tumors who were enrolled on the Children's Oncology Group (COG) renal tumor biology and classification study AREN03B2.

METHODS

AREN03B2 was opened in February 2006, and as on March 31, 2013, there were 3,664 eligible patients. The surgical review forms for 3,536 patients with unilateral disease were centrally reviewed for SPVs. The frequency, type, number of violations, institutional prevalence, and quartiles for SPVs were assessed.

RESULTS

Of the 3,536 patients, there were a total of 505 with at least one SPV (564 total SPVs reported), for an overall incidence of 14.28%. The types of SPVs included a lack of lymph node sampling in 365 (64.7%), avoidable spill in 61 (10.8%), biopsy immediately before nephrectomy in 89 (15.8%), an incorrect abdominal incision in 32 (5.7%), and unnecessary resection of organs in 17 (3.0%). The SPVs occurred in 163 of 215 participating institutions (75.8%). For centers with at least one SPV, the mean number of SPVs reported was 3.10 ± 2.39 (mean ± standard deviation). The incidence of protocol violation per institution ranged from 0 to 67%. Centers with an average of ≤1 case/year had an incidence of SPVs of 12.2 ± 3.8%, those with an average of >1 to <4 cases/year had an incidence of SPVs of 16.4 ± 3.6%, and those with an average of ≥4 cases/year had an incidence of SPVs of 12.6 ± 5.5% (P > 0.05).

CONCLUSIONS

SPVs that potentially result in additional exposure to chemotherapy and radiation therapy are not uncommon in children undergoing resection of renal malignancies.

Quality improvement in pediatric surgery

PURPOSE OF REVIEW

The goal of this review is to provide updates on the evolution of conceptual definitions as they relate to quality in healthcare, existing measurement platforms for performance benchmarking in pediatric surgery, and available tools for quality improvement that are relevant to care of the pediatric surgical patient.

RECENT FINDINGS

The American College of Surgeon's National Surgical Quality Improvement Program-Pediatric has continued to evolve, now providing risk-adjusted safety outcomes data to over 70 hospitals and broadening its scope of quality measurement to include resource utilization and value-based metrics. Increasing use of checklists and other team-based communication tools show potential for making surgical care safer for children, and thoughtful application of quality improvement methods such as Lean methodology, six-sigma and others are helping to improve efficiency and increase healthcare value. Finally, efforts to define minimal resource standards for pediatric surgical care holds promise to improve outcomes for neonates and other children with complex surgical needs.

SUMMARY

Over the past decade, significant progress has been made in our ability to measure, benchmark and improve quality in pediatric surgery. Future efforts will need to facilitate broader participation in benchmarking programs and knowledge-sharing collaboratives, and to develop multidisciplinary, 'disease-specific' longitudinal care models where quality measurement extends before and beyond the 'traditional' 30-day perioperative period.