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McKie KA, Graham DA, Cramm SL, Saito JM, Rangel SJ. Population-Based Intraoperative Disease Severity Criteria for Pediatric Appendicitis. JAMA Surg 2024:2820788. [PMID: 38959019 PMCID: PMC11223053 DOI: 10.1001/jamasurg.2024.1759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/06/2024] [Indexed: 07/04/2024]
Abstract
Importance A standardized severity assessment approach is needed in children with appendicitis for postoperative adverse event estimation and severity adjustment for hospital-level comparative performance reporting. Objective To examine the association between the presence and number of National Surgical Quality Improvement Program (NSQIP) Pediatric-defined intraoperative criteria for complicated appendicitis and outcomes in a population-based sample of children. Design, Setting, and Participants This cohort study used data from the American College of Surgeons NSQIP Pediatric Appendectomy Procedure Targeted Participant Use Data File and General Participant Use Data File for children younger than 18 years who underwent appendectomy from January 1, 2019, through December 31, 2022, at 148 hospitals participating in NSQIP Pediatric. Exposure The presence of NSQIP Pediatric intraoperative criteria for complicated appendicitis (ie, visible perforation, intraperitoneal abscess, extraluminal fecalith, and diffuse fibrinopurulent exudate). Main Outcomes and Measures Adverse event outcomes included postoperative rates of any surgical site infection (incisional or organ space), percutaneous drainage, sepsis, and reoperation. Resource use outcomes included operative duration and hospital length of stay, and rates of postoperative imaging, parenteral nutrition use, and revisits. Multivariable regression was used to explore the influence of individual and combinations of intraoperative criteria on outcomes after adjusting for patient characteristics. Results Of 82 950 patients included, 23 221 (27.9%) had at least 1 finding of complicated appendicitis. Compared with cases without any criteria present, the presence of each finding of complicated appendicitis was independently associated with higher rates of any adverse events; adjusted odds ratios (AORs) by finding were 5.57 (95% CI, 5.04-6.15) for visible hole, 4.83 (95% CI, 4.17-5.59) for diffuse fibrinopurulent exudate, 7.06 (95% CI, 5.77-8.63) for abscess, and 6.62 (95% CI, 4.78-9.15) for fecalith. An increasing number of criteria was associated with a stepwise increase in risk of any adverse events; AOR by number of criteria met were 5.55 (95% CI, 5.09-6.05) for 1 criterion, 8.86 (95% CI, 8.16-9.62) for 2 criteria, and 16.65 (95% CI, 15.10-18.35) for ≥3 criteria. Similar patterns in criteria-specific and cumulative implications for outcomes were observed with each individual adverse event and resource use measure. Conclusions and Relevance This cohort study found that postoperative complications and increased resource use are associated with the presence and number of NSQIP Pediatric criteria for complicated appendicitis. These criteria should be considered the gold standard, evidence-based severity assessment framework for estimating risk of adverse events and resource use in children with appendicitis.
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Affiliation(s)
- Kerri A. McKie
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Donne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, Massachusetts
| | - Shannon L. Cramm
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jacqueline M. Saito
- Division of Pediatric Surgery, Washington University in St Louis, St Louis, Missouri
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Sogbodjor LA, Razavi C, Williams K, Selman A, Pereira SMP, Davenport M, Moonesinghe SR. Risk factors for complications after emergency surgery for paediatric appendicitis: a national prospective observational cohort study. Anaesthesia 2024; 79:524-534. [PMID: 38387160 DOI: 10.1111/anae.16184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 02/24/2024]
Abstract
Appendicectomy is a common procedure in children with a low risk of mortality, however, complication rates and risk factors are largely unknown. This study aimed to characterise the incidence and epidemiology of postoperative complications in children undergoing appendicectomy in the UK. This multicentre prospective observational cohort study, which included children aged 1-16 y who underwent surgery for suspected appendicitis, was conducted between November 2019 and January 2022. The primary outcome was 30-day postoperative morbidity. Data collected included: patient characteristics; comorbidities; and physiological status. Multivariable regression analysis was used to identify independent risk factors for poor outcomes. Data from 2799 children recruited from 80 hospitals were analysed, of which 185 (7%) developed postoperative complications. Children from black and 'other' minority ethnic groups were at significantly higher risk of poor outcomes: OR (95%CI) 4.13 (1.87-9.08), p < 0.001 and 2.08 (1.12-3.87), p = 0.021, respectively. This finding was independent of socio-economic status and type of appendicitis found on histology. Other risk factors for complications included: ASA physical status ≥ 3 (OR (95%CI) 4.05 (1.70-9.67), p = 0.002); raised C-reactive protein (OR 95%CI 1.01 (1.00-1.01), p < 0.001); pyrexia (OR (95%CI) 1.77(1.20-2.63), p = 0.004); and peri-operative oxygen supplementation (OR (95%CI) 4.20 (1.44-12.24), p = 0.009). In the UK NHS, which is a universally accessible healthcare system, ethnicity, but not socio-economic status, was associated with an increased risk of postoperative complications in children having surgery for acute appendicitis. Further evaluations and interventions are required to address this health inequality in keeping with NHS and international priorities.
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Affiliation(s)
- L A Sogbodjor
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Centre for Research and Improvement, Royal College of Anaesthetists, London, UK
| | - C Razavi
- Centre for Research and Improvement, Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - K Williams
- Centre for Research and Improvement, Royal College of Anaesthetists, London, UK
| | - A Selman
- Department of Anaesthesia, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S M Pinto Pereira
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK
| | - M Davenport
- Department of Paediatric Surgery, King's College London NHS Foundation Trust, London, UK
| | - S R Moonesinghe
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK
- Central London National Institute for Health Research Patient Safety Research Collaboration, London, UK
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3
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Fall F, Berman L. Antibiotic Use in Gangrenous, Suppurative, or Exudative Appendicitis. JAMA Surg 2024; 159:517-518. [PMID: 38324321 DOI: 10.1001/jamasurg.2023.7776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Fari Fall
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Loren Berman
- Nemours Children's Hospital Delaware, Wilmington, Delaware
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4
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Cramm SL, Chandler NM, Graham DA, Kunisaki SM, Russell RT, Blakely ML, Lipskar AM, Allukian M, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Cowles RA, DeFazio JR, Esparaz JR, Feng C, Griggs CL, Guyer RA, Hanna DN, Kahan AM, Keane OA, Lamoshi A, Lopez CM, Pace E, Regan MD, Santore MT, Scholz S, Tracy ET, Williams SA, Zhang L, Rangel SJ. Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis. Ann Surg 2023; 278:e863-e869. [PMID: 36317528 DOI: 10.1097/sla.0000000000005747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. BACKGROUND Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision. METHODS This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. RESULTS A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. CONCLUSIONS Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Robert A Cowles
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Cornelia L Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Richard A Guyer
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Anastasia M Kahan
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
- Department of Surgery, Mount Sinai Health System, New York, NY
| | - Olivia A Keane
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Carla M Lopez
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth Pace
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maia D Regan
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Stefan Scholz
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Sacha A Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Lucy Zhang
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Abstract
OBJECTIVE Although value-based healthcare (VBHC) views accurate cost information to be crucial in the pursuit of value, little is known about how the costs of care should be measured. The aim of this review is to identify how costs are currently measured in VBHC, and which cost measurement methods can facilitate VBHC or value-based decision making. DESIGN Two reviewers systematically search the PubMed/MEDLINE, Embase, EBSCOhost and Web of Science databases for publications up to 1 January 2022 and follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify relevant studies for further analysis. ELIGIBILITY CRITERIA Studies should measure the costs of an intervention, treatment or care path and label the study as 'value based'. An inductive qualitative approach was used to identify studies that adopted management accounting techniques to identify if or how cost information facilitated VBHC by aiding decision-making. RESULTS We identified 1930 studies, of which 215 measured costs in a VBHC setting. Half of these studies measured hospital costs (110, 51.2%) and the rest relied on reimbursement amounts. Sophisticated costing methods that allocate both direct and indirect costs to care paths were seen as able to provide valuable managerial information by facilitating care path adjustments (39), benchmarking (38), the identification of cost drivers (47) and the measurement of total costs or cost savings (26). We found three best practices that were key to success in cost measurement: process mapping (33), expert input (17) and observations (24). CONCLUSIONS Cost information can facilitate VBHC. Time-driven activity-based costing (TDABC) is viewed as the best method although its ability to inform decision-making depends on how it is implemented. While costing short, or partial, care paths and surgical episodes produces accurate cost information, it provides only limited decision-making information. Practitioners are advised to focus on costing full care cycles and to consider both direct and indirect costs through TDABC.
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Affiliation(s)
- Maura Leusder
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Petra Porte
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Kees Ahaus
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Hilco van Elten
- Erasmus School of Health Policy & Management, Department Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Center for Corporate Reporting, Finance & Tax, Nyenrode Business Universiteit, Breukelen, The Netherlands
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Reduction of surgical site infections in pediatric patients with complicated appendicitis: Utilization of antibiotic stewardship principles and quality improvement methodology. J Pediatr Surg 2022; 57:63-73. [PMID: 34657739 DOI: 10.1016/j.jpedsurg.2021.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The rate of surgical site infection (SSI) after appendectomy for complicated appendicitis (CA) was high at our children's hospital. We hypothesized that practice standardization, including obtaining intra-operative cultures of abdominal fluid in patients with CA, would improve outcomes and reduce healthcare utilization after appendectomy. METHODS A quality improvement team designed and implemented a clinical practice guideline for CA that included obtaining intra-operative culture of purulent fluid, administering piperacillin/tazobactam for at least 72 h post-operatively, and transitioning to oral antibiotics based on intraoperative culture data. We compared outcomes before and after guideline implementation. RESULTS From July 2018-October 2019, 63 children underwent appendectomy for CA compared to 41 children from January-December 2020. Compliance with our process measures are as follows: Intra-operative culture was obtained in 98% of patients post-implementation; 95% received at least 72 h of piperacillin-tazobactam; and culture results were checked on all patients. Culture results altered the choice of discharge antibiotics in 12 (29%) of patients. All-cause morbidity (SSI, emergency department visit, readmission to hospital, percutaneous drain, unplanned return to operating room) decreased significantly from 35% to 15% (p=0.02). Surgical site infections became less frequent, occurring on average every 27 days pre-implementation and every 60 days after care pathway implementation (p=0.03). CONCLUSIONS Utilization of a clinical practice guideline was associated with reduced morbidity after appendectomy for CA. Intra-operative fluid culture during appendectomy for CA appears to facilitate the selection of appropriate post-operative antibiotics and, thus, minimize SSIs and overall morbidity.
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Sogbodjor LA, Singleton G, Davenport M, Walker S, Moonesinghe SR. Quality metrics for emergency abdominal surgery in children: a systematic review. Br J Anaesth 2021; 128:522-534. [PMID: 34895715 DOI: 10.1016/j.bja.2021.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children. METHODS We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications. RESULTS We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways. CONCLUSIONS This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis. CLINICAL TRIAL REGISTRATION PROSPERO CRD42017055285.
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Affiliation(s)
- Lisa A Sogbodjor
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Georgina Singleton
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Suellen Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond St Institute of Child Health, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
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8
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Kashtan MA, Graham DA, Anandalwar SP, Hills-Dunlap JL, Rangel SJ. Variability, outcomes and cost associated with the use of parenteral nutrition in children with complicated appendicitis: A hospital-level propensity matched analysis. J Pediatr Surg 2021; 56:2299-2304. [PMID: 33814183 DOI: 10.1016/j.jpedsurg.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/27/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND/PURPOSE To examine the influence of parenteral nutrition (PN) on clinical outcomes and cost in children with complicated appendicitis. METHODS Retrospective study of 1,073 children with complicated appendicitis from 29 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (1/2013-6/2015). Mixed-effects regression was used to compare 30-day postoperative outcomes between high and low PN-utilizing hospitals after propensity matching on demographic characteristics, BMI and postoperative LOS as a surrogate for disease severity. RESULTS Overall PN utilization was 13.6%, ranging from 0-10.3% at low utilization hospitals (n = 452) and 10.3-32.4% at high utilization hospitals (n = 621). Outcomes were similar between low and high utilization hospitals for rates of overall complications (12.3% vs. 10.5%, OR: 0.80 [0.46,1.37], p = 0.41), SSIs (11.3% vs. 8.8%, OR: 0.72 [0.40,1.32], p = 0.29) and revisits (14.7% vs. 15.9%, OR: 1.10 [0.75,1.61], p = 0.63). Adjusted mean 30-day cumulative hospital cost was 22.9% higher for patients receiving PN ($25,164 vs. $20,478, p < 0.01) after controlling for postoperative LOS. CONCLUSION Following adjustment for patient characteristics and postoperative length of stay, higher rates of PN utilization in children with complicated appendicitis were associated with higher cost but not with lower rates of overall complications, surgical site infections or revisits. Level of Evidence Level III: Treatment study - Retrospective comparative study.
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Affiliation(s)
- Mark A Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA
| | - Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Ingram MCE, Studer A, Schechter J, Martin SA, Patel M, Roben ECZ, Burjek NE, Birmingham PK, Raval MV. Implementing PDSA Methodology for Pediatric Appendicitis Increases Care Value for a Tertiary Children's Hospital. Pediatr Qual Saf 2021; 6:e442. [PMID: 34345755 PMCID: PMC8322485 DOI: 10.1097/pq9.0000000000000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: We used the plan-do-study-act (PDSA) framework to develop and implement an evidence-based clinical practice guideline (CPG) within an urban, tertiary children’s referral center. Methods: We developed an evidence-based CPG for appendicitis using iterative PDSA cycles. Similar CPGs from other centers were reviewed and modified for local implementation. Adjuncts included guideline-specific order sets and operative notes in the electronic medical record system. Outcomes included length of stay (LOS), 30-day readmissions, hospital costs, and patient and family experience (PFE) scores. Our team tracked outcome, process, and balancing measures using Statistical Process Charts. Outcome measures were compared over 2 fiscal quarters preimplementation and 3 fiscal quarters postimplementation, using interrupted time series, student t test, and chi-square tests when appropriate. Results: LOS for simple (uncomplicated) appendicitis decreased to 0.87 days (interquartile range [IQR] 0.87–0.94 days) from 1.1 days (IQR 0.97–1.42 days). LOS for complicated appendicitis decreased to 4.96 days (IQR 4.95–6.15) from 5.58 days (IQR 5.16–6.09). This reduction equated to an average cost-savings of $1,122/patient. Thirty-day readmission rates have remained unchanged. PFE scores increased across all categories and have remained higher than national benchmarks. Conclusion: Development and Implementation of a CPG for pediatric appendicitis using the PDSA framework adds value to care provided within a large tertiary center.
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Affiliation(s)
- Martha-Conley E Ingram
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Abbey Studer
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Jamie Schechter
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Sarah A Martin
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Manisha Patel
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Emily C Z Roben
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Nicholas E Burjek
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Patrick K Birmingham
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Mehul V Raval
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
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10
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Do-Wyeld M, Cundy TP, Court-Kowalski S, Dandie L, Cooper C, Burgoyne L, Cooksey R, Khurana S. Improving quality and efficiency of care for advanced appendicitis in children. ANZ J Surg 2021; 91:1497-1503. [PMID: 34013543 DOI: 10.1111/ans.16929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/04/2021] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Complicated appendicitis encompasses a spectrum of severity with heterogeneity in definition and substantial variation in care. Enhanced recovery after surgery or 'fast-track' protocols aim to reduce practice variation by standardizing care. These initiatives may improve quality and efficiency of care, preserve resources and expedite discharge. This study aims to evaluate the impact of a standardized Enhanced Recovery Pathway (ERP) on the post-operative recovery of children with a subset of complicated appendicitis termed 'advanced' appendicitis. METHODS We defined advanced appendicitis as gangrenous or suppurative appendicitis without perforation, contained iatrogenic perforation, or localized purulent fluid. Children with operative findings reflecting these criteria were enrolled in the ERP protocol. Key protocol components include early upgrade of diet, avoidance of intravenous analgesia, abridged intravenous antibiotics, early ambulation and standardized discharge criteria. The study period was May 2018 to June 2019. A historical cohort was used as the comparator group. RESULTS Outcomes for 44 children treated under the ERP were compared to 44 historical controls. There was a 20% reduction in median post-operative length of stay (1.80 vs. 2.24 days, p = 0.02). Intravenous analgesia was received by fewer patients (6.8% vs. 36.4%, p = 0.01) with significant reduction in antiemetic requirement (p = 0.03). No significant difference in 30-day complication rates was observed. CONCLUSION Reduced post-operative length of stay and reduction in practice variation were achieved after implementation of a 'fast-track' protocol for children with advanced appendicitis. Additional benefits of this protocol include reduced provision of intravenous morphine analgesia, decreased resource use and cost savings.
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Affiliation(s)
- Montgommery Do-Wyeld
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Stefan Court-Kowalski
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, University of Adelaide, Adelaide, South Australia, Australia
| | - Lynda Dandie
- Health Information and Decision Support, Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - Celia Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Laura Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Rebecca Cooksey
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Anandalwar SP, Graham DA, Kashtan MA, Hills-Dunlap JL, Rangel SJ. Influence of Oral Antibiotics Following Discharge on Organ Space Infections in Children With Complicated Appendicitis. Ann Surg 2021; 273:821-825. [PMID: 31274648 DOI: 10.1097/sla.0000000000003441] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To compare postdischarge rates of organ space infections (OSI) in children with complicated appendicitis between those receiving and not receiving oral antibiotics (OA) following discharge. SUMMARY BACKGROUND DATA Existing data regarding the clinical utility of extending antibiotic treatment following discharge in children with complicated appendicitis are limited. METHODS Retrospective cohort study of children ages 3 to 18 years undergoing appendectomy for complicated appendicitis from January 2013 to June 2015 across 17 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (n = 711). Multivariable mixed-effects regression was used to compare postdischarge OSI rates between patients discharged with and without OA after propensity matching on demographic characteristics and disease severity. A subgroup analysis was performed for high-severity patients (multiple intraoperative findings of complicated disease or length of stay≥6 d). RESULTS The overall rates of OA utilization and OSI following discharge were 57.0% (hospital range: 3-100%) and 5.2% (range: 0-16.7%), respectively. In the propensity-matched analysis of the entire cohort, use of OA was associated with a 38% reduction in the odds of OSI following discharge compared with children not discharged on OA (4.2% vs. 6.6%, OR 0.62 [0.29, 1.31], P = 0.21). In the high-severity matched cohort (n = 324, 46%), use of OA was associated with a 61% reduction in the odds of OSI following discharge (4.3% vs 10.5%; OR 0.39 [0.15, 0.96], P = 0.04). CONCLUSIONS Use of oral antibiotics following discharge may decrease organ space infections in children with complicated appendicitis, and those presenting with high-severity disease may be most likely to benefit.
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Affiliation(s)
- Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA
| | - Mark A Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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12
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Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols. J Pediatr Surg 2021; 56:663-667. [PMID: 33183744 DOI: 10.1016/j.jpedsurg.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis. MATERIAL AND METHODS A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant. RESULTS A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation. CONCLUSION Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted. LEVELS OF EVIDENCE Therapeutic study; Level 3.
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13
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Manworren RCB, Cooper J, Mishra T, Kaduwela N. Children's Pain at Home After Laparoscopic Appendectomy. Pain Manag Nurs 2021; 22:623-630. [PMID: 33744106 DOI: 10.1016/j.pmn.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hospitalized children experience moderate-to-severe pain after laparoscopic appendectomy, but knowledge of children's pain experiences after discharge home is limited. Accurate pain assessments are needed to guide appropriate pain treatment. AIMS To describe children's pain at home after laparoscopic appendectomy. DESIGN Prospective exploratory and descriptive METHODS: A convenience sample of 100 patients, aged 10-17 years, who spoke or wrote in English or Spanish, volunteered to complete 14-day pain diaries at home after laparoscopic appendectomy. Visual analytic techniques were used to analyze patterns of pain experiences. RESULTS Diaries were returned by 45 patients/parents, the majority of whom were White (64%), male (56%), adolescents (mean age 14 years) with no previous surgical history (70%), and whose appendix was inflamed (87%) but not perforated. More than 50% reported severe pain (4 or 5 on a 0-5 scale) on the first full day home after laparoscopic appendectomy. On day 7, 40% reported pain and on day 14, 16% were still reporting pain. Only rarely were pain scores not clinically significantly lower 1 hour after pain treatment, regardless of treatment type (e.g., nondrug, nonopioid, opioid). Reported pain intensity steadily decreased over time as did frequency of recorded pain scores. CONCLUSION Adolescents experience severe pain at home after laparoscopic appendectomy and some experience pain for 7 to 14 days after hospital discharge. Visual analytics better represent the dynamics of pain experiences than measures of central tendency.
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Affiliation(s)
- Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago 60611, Illinois; Northwestern University Feinberg School of Medicine, Chicago 60611, Illinois.
| | - Jessica Cooper
- University of North Carolina Health, Chapel Hill, North Carolina
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14
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Markham JL, Hall M, Goldman JL, Bettenhausen JL, Gay JC, Feinstein J, Simmons J, Doupnik SK, Berry JG. Readmissions Following Hospitalization for Infection in Children With or Without Medical Complexity. J Hosp Med 2021; 16:134-141. [PMID: 33617439 PMCID: PMC7929613 DOI: 10.12788/jhm.3505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/13/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the prevalence and characteristics of infection-related readmissions in children and to identify opportunities for readmission reduction and estimate associated cost savings. STUDY DESIGN Retrospective analysis of 380,067 nationally representative index hospitalizations for children using the 2014 Nationwide Readmissions Database. We compared 30-day, all-cause unplanned readmissions and costs across 22 infection categories. We used the Inpatient Essentials database to measure hospital-level readmission rates and to establish readmission benchmarks for individual infections. We then estimated the number of readmissions avoided and costs saved if hospitals achieved the 10th percentile of hospitals' readmission rates (ie, readmission benchmark). All analyses were stratified by the presence/absence of a complex chronic condition (CCC). RESULTS The overall 30-day readmission rate was 4.9%. Readmission rates varied substantially across infections and by presence/absence of a CCC (CCC: range, 0%-21.6%; no CCC: range, 1.5%-8.6%). Approximately 42.6% of readmissions (n = 3,576) for children with a CCC and 54.7% of readmissions (n = 5,507) for children without a CCC could have been potentially avoided if hospitals achieved infection-specific benchmark readmission rates, which could result in an estimated savings of $70.8 million and $44.5 million, respectively. Bronchiolitis, pneumonia, and upper respiratory tract infections were among infections with the greatest number of potentially avoidable readmissions and cost savings for children with and without a CCC. CONCLUSION Readmissions following hospitalizations for infection in children vary significantly by infection type. To improve hospital resource use for infections, future preventative measures may prioritize children with complex chronic conditions and those with specific diagnoses (eg, respiratory illnesses).
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
- Corresponding Author: Jessica L Markham, MD, MSc; ; Telephone: 816-302-3493; Twitter: @jmarks614
| | - Matt Hall
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Children’s Hospital Association, Lenexa, Kansas
| | - Jennifer L Goldman
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
| | - James C Gay
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Feinstein
- Department of Pediatrics, Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Children’s Hospital Colorado, Aurora, Colorado
- Department of Pediatrics, University of Colorado School of Medicine at Denver, Aurora, Colorado
| | - Julia Simmons
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
- Department of Pediatrics, Mercy Children’s Hospital St Louis, St Louis, Missouri
| | - Stephanie K Doupnik
- Division of General Pediatrics, PolicyLab, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jay G Berry
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Lane J, Schilling AL, Hollenbeak C, Rizk E. Cost of Chiari I Malformation Surgery: Comparison of Treatment at Children's Hospitals Versus Non-children's Hospitals. Cureus 2021; 13:e12866. [PMID: 33633895 PMCID: PMC7899285 DOI: 10.7759/cureus.12866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Chiari I malformation is a common entity in pediatric neurosurgery. Prior studies have shown that surgical treatment at children’s hospitals (CH) is associated with higher costs compared to non-children’s hospitals (NCH) for other diagnoses. Therefore, we hypothesized that costs would be increased for the treatment of Chiari I malformation at a CH. Data were extracted from the Agency for Healthcare Research and Quality’s (AHRQ) Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID). Patients who underwent surgery for Chiari I malformation were identified using International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis and procedure codes. Univariate statistical tests, multivariable linear regression models, and propensity score matching were utilized to determine differences in hospital length of stay (LOS) and costs between patients treated at CH versus NCH. Treatment at a CH was associated with significantly higher costs compared to treatment at an NCH while hospital LOS and mortality were similar. In the multivariable linear regression model, the adjusted average cost for surgical treatment of Chiari I malformation was $13,716, and treatment at a CH was associated with an additional $6,343 (p<0.0001). Similar results were seen after propensity score matching: costs for treatment at a CH were $6,047 higher than they were for treatment at an NCH (p<0.0001). In our analysis, a significant increase in cost was seen with treatment at a CH while controlling for patient demographics and hospital characteristics, as well as imbalanced covariates between the cohorts. Further investigation is warranted to determine the drivers of increased cost outside of the patient and hospital characteristics we analyzed in our study.
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Affiliation(s)
- Jessica Lane
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Amber L Schilling
- Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | | | - Elias Rizk
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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16
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Park KY, Russell JI, Wilke NP, Marka NA, Nichol PF. Reducing cost and waste in pediatric laparoscopic procedures. J Pediatr Surg 2021; 56:66-70. [PMID: 33139028 DOI: 10.1016/j.jpedsurg.2020.09.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 09/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND In 2017 the healthcare cost in the United States accounted for 17.9% of the Gross Domestic Product (GDP). Furthermore, healthcare facilities produce more than 4 billion pounds of waste annually. Interhospital and intersurgeon variabilities in surgical procedures are some of the drivers of high healthcare cost and waste. We sought to determine the effect of a monthly surgeon report card detailing the utilization and cost of disposable and reusable surgical supplies on cost and waste reduction for pediatric laparoscopic procedures. METHODS Starting in July 2017, surgeons were provided with an individual report with supply cost per case, high cost, and disposable supply utilization, and clinical outcomes. Cost, utilization, and clinical outcomes six quarters before and after the intervention were compared. RESULTS A total of 998 pediatric laparoscopic procedures were analyzed. We reduced the median supply cost per case by 43% after the intervention with total cost savings of $71,035 for the first four quarters. We also reduced the use of disposable trocars by 56% and the use of disposable harmonics and staplers by 33%. CONCLUSIONS Using a periodic surgeon report card, we significantly reduced supply cost and utilization of disposable items for all pediatric laparoscopic procedures performed at the University of Wisconsin American Family Children's Hospital. TYPE OF STUDY Cost effectiveness study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Keon Young Park
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - James I Russell
- University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Nathan P Wilke
- University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Nicholas A Marka
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Peter F Nichol
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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17
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Anandalwar SP, Graham DA, Kashtan MA, Bachur RG, Barnewolt CE, Callahan MJ, Rangel SJ. Leveraging the Combined Predictive Value of Ultrasound and Laboratory Data to Reduce Radiation Exposure and Resource Utilization in Children with Suspected Appendicitis. J Surg Res 2021; 257:529-536. [DOI: 10.1016/j.jss.2020.07.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/01/2020] [Accepted: 07/11/2020] [Indexed: 11/28/2022]
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18
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Devin CL, D'Cruz R, Linden AF, English S, Vinocur CD, Reichard KW, Berman L. Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics. J Pediatr Surg 2020; 55:2591-2595. [PMID: 32482411 DOI: 10.1016/j.jpedsurg.2020.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population. METHODS We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol. RESULTS We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17). CONCLUSIONS These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Courtney L Devin
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA.
| | - Roshan D'Cruz
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Allison F Linden
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Sharon English
- Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Charles D Vinocur
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Kirk W Reichard
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Loren Berman
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA; Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
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Point-of-Care Ultrasound Diagnosis of Perforated Appendicitis in the Pediatric Emergency Department: A Case Series. Pediatr Emerg Care 2020; 36:606-608. [PMID: 32195980 DOI: 10.1097/pec.0000000000002082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Point-of-care ultrasound (POCUS) is being used for clinical decision making with increasing frequency across a broad range of indications in pediatric emergency medicine (PEM). We present a series of 4 patients in whom POCUS was used to facilitate a diagnosis of perforated appendicitis.
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20
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Yu D, Gu C, Zhang S, Yang H, Yao T. Ultrasound features and the diagnostic strategy of subhepatic appendicitis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1083. [PMID: 33145302 PMCID: PMC7575950 DOI: 10.21037/atm-20-5265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background This study aimed to compare the differences of ultrasound findings between subhepatic appendicitis and appendicitis at a normal position, then discuss the diagnostic strategies and improve the accuracy of diagnosis. Methods A retrospective analysis was performed in our hospital. One thousand five hundred ninety-one patients with appendicitis were diagnosed from January 2014 to January 2018. Eighteen patients with subhepatic appendicitis and 25 patients with appendicitis with regular positions were selected randomly as the control group. The difference in ultrasound features between the two groups was studied. Comparisons between the two groups showed statistically significant differences in the frequencies of the fishbone sign, enlarged appendix, appendicoliths, and hyperechoic omental cap (P<0.05). Results Statistical significance was not observed with the difference in the frequency of whether there was lymphadenectasis (P>0.05) in the abdominal cavity between the two groups. The Pareto chart was drawn to look for the main factors associated. The results of interpretation on the critical points of diagnosis for subhepatic appendicitis: (I) the fishbone sign of a dilated ileum in the right lower abdomen; and (II) the fishbone sign of a dilated ileum in the right lower abdomen + presence of an enlarged appendix in the right upper abdomen. Conclusions An abnormally dilated ileum in the right lower abdomen – the fishbone sign, is a vital sign leading to the diagnosis of subhepatic appendicitis. The fishbone sign of a dilated ileum in the right lower abdomen + whether there is a vermiform structure is an important diagnostic indicator for subhepatic appendicitis.
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Affiliation(s)
- Dong Yu
- Department of Radiology, Jizhong Energy Fengfeng Group Hospital, Handan, China
| | - Chenyao Gu
- Department of Radiology, Yancheng No. 1 People's Hospital, Yancheng, China
| | - Shuchen Zhang
- Department of Radiology, Yancheng No. 1 People's Hospital, Yancheng, China
| | - Hui Yang
- Department of Orthopaedic, Jizhong Energy Fengfeng Group Hospital, Handan, China
| | - Taotao Yao
- Rehabilitation Center, the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
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Utilization and Performance Benchmarking for Postoperative Imaging in Children With Complicated Appendicitis. Ann Surg 2020; 275:816-823. [PMID: 32657938 DOI: 10.1097/sla.0000000000004250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children. Ann Surg 2020; 271:962-968. [PMID: 30308607 DOI: 10.1097/sla.0000000000003059] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To characterize the influence of intraoperative findings on complications and resource utilization as a means to establish an evidence-based and public health-relevant definition for complicated appendicitis. SUMMARY OF BACKGROUND DATA Consensus is lacking surrounding the definition of complicated appendicitis in children. Establishment of a consensus definition may have implications for standardizing the reporting of clinical research data and for refining reimbursement guidelines. METHODS This was a retrospective cohort study of patients ages 3 to 18 years who underwent appendectomy from January 1, 2013 to December 31, 2014 across 22 children's hospitals (n = 5002). Intraoperative findings and clinical data from the National Surgical Quality Improvement Program-Pediatric Appendectomy Pilot Database were merged with cost data from the Pediatric Health Information System Database. Multivariable regression was used to examine the influence of 4 intraoperative findings [visible hole (VH), diffuse fibrinopurulent exudate (DFE) extending outside the right lower quadrant (RLQ)/pelvis, abscess, and extra-luminal fecalith] on complication rates and resource utilization after controlling for patient and hospital-level characteristics. RESULTS At least 1 of the 4 intraoperative findings was reported in 26.6% (1333/5002) of all cases. Following adjustment, each of the 4 findings was independently associated with higher rates of adverse events compared with cases where the findings were absent (VH: OR 5.57 [95% CI 3.48-8.93], DFE: OR 4.65[95% CI 2.91-7.42], abscess: OR 8.96[95% CI 5.33-15.08], P < 0.0001, fecalith: OR 5.01[95% CI 2.02-12.43], P = 0.001), and higher rates of revisits (VH: OR 2.02 [95% CI 1.34-3.04], P = 0.001, DFE: OR 1.59[95% CI 1.07-2.37], P = 0.02, abscess: OR 2.04[95% CI 1.2-3.49], P = 0.01, fecalith: OR 2.31[95% CI 1.06-5.02], P = 0.04). Each of the 4 findings was also independently associated with increased resource utilization, including longer cumulative length of stay (VH: Rate ratio [RR] 3.15[95% CI 2.86-3.46], DFE: RR 3.06 [95% CI 2.83-3.13], abscess: RR 3.94 [95% CI 3.55-4.37], fecalith: RR 2.35 [95% CI 1.87-2.96], P = < 0.0001) and higher cumulative hospital cost (VH: RR 1.97[95% CI 1.64-2.37], P < 0.0001, DFE: RR 1.8[95% CI 1.55-2.08], P = < 0.0001, abscess: RR 2.02[95% CI 1.61-2.53], P < 0.0001, fecalith: RR 1.49[95% CI 0.98-2.28], P = 0.06) compared with cases where the findings were absent. CONCLUSION AND RELEVANCE The presence of a visible hole, diffuse fibrinopurulent exudate, intra-abdominal abscess, and extraluminal fecalith were independently associated with markedly worse outcomes and higher cost in children with appendicitis. The results of this study provide an evidence-based and public health-relevant framework for defining complicated appendicitis in children.
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Cunningham ME, Zhu H, Hoch CT, DeMello AS, Gusman ND, Fallon SC, Lopez ME. Effectiveness of a clinical pathway for pediatric complex appendicitis based on antibiotic stewardship principles. J Pediatr Surg 2020; 55:1026-1031. [PMID: 32192736 DOI: 10.1016/j.jpedsurg.2020.02.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 02/20/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Outcomes and resource utilization were evaluated after implementing a novel complex appendicitis (CA) pathway limiting postoperative antibiotics based on clinical parameters. METHODS Children with intraoperative CA (gangrenous, perforated, or abscess) were treated with intravenous antibiotics postoperatively until clinical criteria were met, without utilizing CBC or oral antibiotics at discharge. An interrupted time series (pre-intervention, transition, post-intervention) was used to assess outcomes. Hospital length of stay (LOS) was analyzed using segmented regression. Intra-abdominal abscess and readmission rates were analyzed using non-inferiority and multivariate logistic regression. RESULTS Five hundred ten children were included with a median age of 10 [IQR7-12] years. There were no differences in postoperative LOS (slope - 0.008; p = 0.855), intra-abdominal abscess rate (5% vs. 8%; p = 0.135), or readmission rate (12% vs. 8%; p = 0.113) across time periods which remained true when adjusting for age, gender, and intraabdominal disease severity. Post-intervention outcomes were not inferior to pre-intervention, abscess rate (p = 0.002), or readmission rate (p < 0.001). Intraoperative findings of perforation (OR9.0; 95% CI1-71; p = 0.044) and perforation with abscess (OR18.2; 95% CI2-36; p = 0.005) were associated with a greater likelihood of postoperative abscess compared to gangrenous appendicitis. CONCLUSION A CA protocol based on clinical parameters is safe and effective, resulting in similar intra-abdominal abscess and readmission rates compared to more resource-intense regimens. LEVEL OF EVIDENCE III TYPE OF RESEARCH: Interrupted Time Series.
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Affiliation(s)
- Megan E Cunningham
- Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030
| | - Huirong Zhu
- Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030
| | - Connor T Hoch
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Annalyn S DeMello
- Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030
| | - Nakada D Gusman
- Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030
| | - Sara C Fallon
- Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030
| | - Monica E Lopez
- Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030.
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Leveraging the Incidence, Burden, and Fiscal Implications of Unplanned Hospital Revisits for the Prioritization of Prevention Efforts in Pediatric Surgery. Ann Surg 2020; 271:191-199. [PMID: 29927779 DOI: 10.1097/sla.0000000000002885] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To characterize procedure-level burden of revisit-associated resource utilization in pediatric surgery with the goal of establishing a prioritization framework for prevention efforts. SUMMARY OF BACKGROUND DATA Unplanned hospital revisits are costly to the health care system and associated with lost productivity on behalf of patients and their families. Limited objective data exist to guide the prioritization of prevention efforts within pediatric surgery. METHODS Using the Pediatric Health Information System (PHIS) database, 30-day unplanned revisits for the 30 most commonly performed pediatric surgical procedures were reviewed from 47 children's hospitals between January 1, 2012 and March 31, 2015. The relative contribution of each procedure to the cumulative burden of revisit-associated length of stay and cost from all procedures was calculated as an estimate of public health relevance if prevention efforts were successfully applied (higher relative contribution = greater potential public health relevance). RESULTS 159,675 index encounters were analyzed with an aggregate 30-day revisit rate of 10.8%. Four procedures contributed more than half of the revisit-associated length of stay burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.4%), gastrostomy (13.4%), uncomplicated appendicitis (13.0%), and fundoplication (9.4%). Four procedures contributed more than half of the revisit-associated cost burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.8%), gastrostomy (14.6%), fundoplication (10.4%), and uncomplicated appendicitis (10.2%). CONCLUSIONS AND RELEVANCE A small number of procedures account for a disproportionate burden of revisit-associated resource utilization in pediatric surgery. Gastrostomy, fundoplication, and appendectomy should be considered high-priority targets for prevention efforts within pediatric surgery.
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Anandalwar SP, Cameron DB, Graham DA, Melvin P, Dunlap JL, Kashtan M, Hall M, Saito JM, Barnhart DC, Kenney BD, Rangel SJ. Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis. JAMA Surg 2019; 153:1021-1027. [PMID: 30046808 DOI: 10.1001/jamasurg.2018.2085] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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. Design This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children's hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014. Main Outcomes and Measures Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals. Results A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P < .001), and higher hospital cost (rate ratio, 1.35; 95% CI, 1.19-1.53; P < .001). Significant differences were found among different combinations of intraoperative findings for all outcomes, including a 3.6-fold difference in rates of surgical site infection (range, 7.5% for fecalith alone to 27.2% for all 4 findings; P = .002), a 2.6-fold difference in revisit rates (range, 8.9% for exudate alone to 22.9% for all 4 findings; P = .001), a 2.2-fold difference in length of stay (range, 4.0 days for exudate alone to 8.9 days for all 4 findings; P < .001), and a 2.4-fold difference in mean cumulative cost (range, $13 296 for exudate alone to $32 282 for all 4 findings; P < .001). Conclusions and Relevance More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource use. Severity adjustment may be needed to ensure fair reimbursement and comparative performance reporting, particularly at hospitals treating underserved populations where more severe presentations are common.
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Affiliation(s)
- Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle B Cameron
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts
| | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan L Dunlap
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Jacqueline M Saito
- Division of Pediatric Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Douglas C Barnhart
- Division of Pediatric Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Brian D Kenney
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Tessler RA, Graves JM, Vavilala MS, Goldin A, Rivara FP. Hospital factors associated with higher costs in pediatric blunt abdominal trauma: A national study. J Pediatr Surg 2019; 54:1621-1627. [PMID: 30773396 PMCID: PMC7477749 DOI: 10.1016/j.jpedsurg.2018.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/14/2018] [Accepted: 12/14/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND/PURPOSE Our objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma. METHODS We queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18 years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics. RESULTS The 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children's = $6575 [$4333-$10,862], nonchildren's $7027 [$4230-$12,219] p = 0.47) and high-grade (children's = $10,984 [$6211- $20,007] nonchildren's $10,156 [$5439-$18,404] p = 0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CR = 2.35 95% CI 2.02, 2.74, high-grade CR = 2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status. CONCLUSION Hospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert A. Tessler
- University of Washington, Harborview Injury Prevention and Research Center, 401 Broadway, 4th floor, Seattle, WA 98122,University of Pittsburgh, Department of Surgery, UPMC Presbyterian Hospital F1281, 200 Lothrop St., Pittsburgh, PA, 15213
| | - Janessa M. Graves
- Washington State University College of Nursing, 103 E Spokane Falls Blvd, Spokane, WA 99202,Washington State University, Community Health Analytics Project (CHAP), Washington State University, Pullman, WA
| | - Monica S. Vavilala
- University of Washington, Harborview Injury Prevention and Research Center, 401 Broadway, 4th floor, Seattle, WA 98122,University of Washington Department of Anesthesiology and Pain Medicine, 1959 NE Pacific Street, BB-1468, Seattle, WA 98195,University of Washington Department of Pediatrics, 1959 NE Pacific Street, Box 356320, Seattle, WA 98105
| | - Adam Goldin
- Seattle Children's Hospital, Division of General and Thoracic Surgery, 4800 Sand Point Way NE, Seattle, WA 98105.
| | - Frederick P. Rivara
- University of Washington, Harborview Injury Prevention and Research Center, 401 Broadway, 4th floor, Seattle, WA 98122,University of Washington Department of Pediatrics, 1959 NE Pacific Street, Box 356320, Seattle, WA 98105
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Bonasso PC, Dassinger MS, Wyrick DL, Smith SD, Burford JM. Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis. Am J Surg 2019; 217:1099-1101. [PMID: 30639131 DOI: 10.1016/j.amjsurg.2018.12.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
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Anderson KT, Bartz-Kurycki MA, Kawaguchi AL, Austin MT, Holzmann-Pazgal G, Kao LS, Lally KP, Tsao K. Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe? J Am Coll Surg 2018; 227:247-254. [PMID: 29680415 DOI: 10.1016/j.jamcollsurg.2018.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
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Kharbanda AB, Christensen EW, Dudley NC, Bajaj L, Stevenson MD, Macias CG, Mittal MK, Bachur RG, Bennett JE, Sinclair K, McMichael B, Dayan PS. Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis. Acad Emerg Med 2018; 25:785-794. [PMID: 29427374 DOI: 10.1111/acem.13387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/01/2018] [Accepted: 02/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.
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Affiliation(s)
- Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Eric W Christensen
- Health Services Management, College of Continuing and Professional Studies, University of Minnesota, Minneapolis, MN
| | - Nanette C Dudley
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO
| | | | - Charles G Macias
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Manoj K Mittal
- Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jonathan E Bennett
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Jefferson Medical College, Wilmington, DE
| | - Kelly Sinclair
- Division of Emergency Medicine, Children's Mercy Hospital, Kansas City, MO
| | - Brianna McMichael
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, MN
| | - Peter S Dayan
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
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Yousef Y, Youssef F, Homsy M, Dinh T, Stagg H, Petroze R, Baird R, Larberge JM, Poenaru D, Puligandla P, Shaw K, Emil S. Appropriate use of total parenteral nutrition in children with perforated appendicitis. J Pediatr Surg 2018. [PMID: 29525273 DOI: 10.1016/j.jpedsurg.2018.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Total parenteral nutrition (TPN) is often used in children with perforated appendicitis, despite the absence of clear indications. We assessed the validity of specific clinical indications for initiation of TPN in this patient cohort. METHODS Data were gathered prospectively on duration of nil per os (NPO) status and TPN use in a cohort of children treated under a perforated appendicitis protocol during a 19-month period. TPN was started in the immediate postoperative period in patients who had generalized peritonitis and severe intestinal dilatation at operation, or later per the discretion of the attending surgeon. At discharge, TPN was considered to have been used appropriately, according to consensus guidelines, if the patient was NPO≥7days or received TPN≥5days. RESULTS During the study period, TPN was initiated in 31 (25.4%) of 122 patients operated for perforated appendicitis. Sixteen (51.6%) received TPN per operative finding indications and 15 (48.4%) for prolonged ileus. The operative indications demonstrated 47% sensitivity, 86% specificity, a positive predictive value (PPV) of 35%, and a negative predictive value (NPV) of 91%, when adherence to TPN consensus guidelines was considered the gold standard. CONCLUSION Patients without severe intestinal dilatation and generalized peritonitis at operation should not be placed on TPN in the immediate postoperative period. Refinement of selection criteria is necessary to further decrease inappropriate TPN use in children with perforated appendicitis. TYPE OF STUDY Diagnostic Test. LEVEL OF STUDY II.
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Affiliation(s)
- Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fouad Youssef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael Homsy
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Trish Dinh
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Hayden Stagg
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robin Petroze
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Martin Larberge
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Poenaru
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pramod Puligandla
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kenneth Shaw
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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Abstract
BACKGROUND Complicated appendicitis, characterized by perforation and/or peritonitis, is common in children, and late infectious complications are frequent. The best antibiotic treatment approach is unknown, resulting in substantial variation in care. We evaluated the effects of 2 successive interventions, an antimicrobial stewardship program (ASP) and a condition-specific clinical practice guideline (CPG), on antimicrobial utilization and patient outcomes in these patients. METHODS The ASP at our institution was begun in March 2012. The CPG, a standardized antibiotic treatment, was implemented in July 2013. We reviewed every case of complicated appendicitis managed with early appendectomy between January 2011 and October 2014. Patients were thus divided into 3 eras based on their exposure to the following: (1) neither intervention, (2) ASP only or (3) both ASP and CPG. We compared measures of antibiotic utilization and clinical outcomes among the 3 eras. RESULTS A total of 313 patients were included in the study: 91 exposed to neither intervention; 100 exposed to only the ASP; and 122 exposed to both interventions. With ASP implementation, there were declines in the use of unnecessarily broad or toxic antibiotic regimens. With CPG implementation, there was a decrease in total antibiotic utilization and discharges with intravenous antibiotics. Compliance with CPG-recommended antibiotics exceeded 90%. There was no significant change in overall adverse events; there was a decline in the incidence of surgical-site infections in patients exposed to both interventions. CONCLUSIONS Complicated appendicitis is an important target for antimicrobial stewardship and quality improvement efforts. A condition-specific CPG can improve both antimicrobial utilization and clinical outcomes.
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Clarkson E, Zutty J, Raval MV. A Visual Decision Support Tool for Appendectomy Care. J Med Syst 2018; 42:52. [PMID: 29404704 DOI: 10.1007/s10916-018-0906-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022]
Abstract
Appendectomy is the most common abdominal surgical procedure performed in children in the United States. In order to assist care providers in creating treatment plans for the postoperative management of pediatric appendicitis, we have developed a predictive statistical model of outcomes on which we have built a prototype decision aid application. The model, trained on 3724 anonymized care records and evaluated on a separate set of 2205 cases from a tertiary care center, achieves 97.0% specificity, 25.1% true sensitivity, and 58.8% precision. We have also built an interactive decision support tool augmented with simple visualization techniques designed for clinicians to use in the course of making care decisions (e.g., discharge) and in patient/stakeholder communication. Its focus is on end-user ease of use and integration into existing clinician workflows, and is designed to evolve its predictions as more and better data become available.
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Affiliation(s)
- Edward Clarkson
- Electro-Optical Systems Lab, Georgia Tech Research Institute, 925 Dalney St., Atlanta, GA, 30332-0834, USA.
| | - Jason Zutty
- Electro-Optical Systems Lab, Georgia Tech Research Institute, 925 Dalney St., Atlanta, GA, 30332-0834, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, 30322, USA
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Markham JL, Hall M, Bettenhausen JL, Myers AL, Puls HT, McCulloh RJ. Variation in Care and Clinical Outcomes in Children Hospitalized With Orbital Cellulitis. Hosp Pediatr 2017; 8:28-35. [PMID: 29208694 DOI: 10.1542/hpeds.2017-0040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe variation in the care of children hospitalized with orbital cellulitis and to determine associations with length of stay (LOS), emergency department (ED) revisits, and hospital readmissions. METHODS By using the Pediatric Health Information System, we performed a multicenter, retrospective study of children aged 2 months to 18 years with a primary International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code for orbital cellulitis from 2007 to 2014. We assessed hospital-level variation in the use of diagnostic tests, corticosteroids, and antibiotics individually and in aggregate for association with outcomes (LOS, ED revisits, readmissions) after risk-adjusting for important clinical and demographic factors. RESULTS A total of 1828 children met inclusion criteria. Complete blood cell counts (median [interquartile range]: 81.8% [66.7-89.6]), C-reactive protein levels (57.1% [22.2-84.0]), blood cultures (57.9% [48.9-63.6]), and computed tomography imaging (74.7% [66.7-81.0]) were the most frequently performed diagnostic tests, with significant variation observed across hospitals (all P < .001). Corticosteroids were used in 29.2% of children (interquartile range: 18.4-37.5). There was significant variation in antibiotic exposure across hospitals (P < .001). Increased total diagnostic test usage was associated with increased LOS (P = .044), but not with 30-day ED revisits (P = .176) or readmissions (P = .403). CONCLUSIONS Children hospitalized with orbital cellulitis experience wide variation in clinical management. Increased hospital-level usage is associated with increased LOS. Our findings highlight a critical need to identify treatment strategies that optimize resource use and outcomes for children hospitalized with orbital cellulitis.
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Affiliation(s)
| | - Matthew Hall
- Divisions of Pediatric Hospital Medicine and.,Children's Hospital Association, Lenexa, Kansas
| | | | - Angela L Myers
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
| | | | - Russell J McCulloh
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
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Serres SK, Graham DA, Glass CC, Cameron DB, Anandalwar SP, Rangel SJ. Influence of Time to Appendectomy and Operative Duration on Hospital Cost in Children with Uncomplicated Appendicitis. J Am Coll Surg 2017; 226:1014-1021. [PMID: 29155269 DOI: 10.1016/j.jamcollsurg.2017.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/01/2017] [Accepted: 11/03/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND The goal of this study was to examine the influence of time to appendectomy (TTA) and operative duration (OD) on hospital cost as surrogate measures of perioperative efficiency. STUDY DESIGN We conducted a retrospective cohort analysis of 2,116 children undergoing appendectomy for uncomplicated appendicitis at 16 children's hospitals from January 2013 to December 2014. Time to appendectomy (emergency department presentation to incision) and OD were obtained from the NSQIP Pediatric Appendectomy Pilot Database and merged with cost data from the Pediatric Health Information System Database. Multivariate regression was used to examine the influence of TTA and OD (categorized by quartiles of hospital-level means) on hospital cost, adjusting for patient and hospital-level characteristics. RESULTS Median TTA and OD across all patients was 7.3 hours (interquartile range 4.4 to 12.4 hours) and 36 minutes (interquartile range 26 to 49 minutes), respectively. The longest quartile of OD was associated with 38% higher total cost ($2,512/case; rate ratio [RR] 1.38; 95% CI 1.27 to 1.5; p < 0.001) and 27% higher operating room-associated cost ($960/case; RR 1.27; 95% CI 1.22 to 1.34; p < 0.001) compared with the shortest quartile. The longest quartile of TTA was associated with 23% higher total cost ($1,589/case; RR 1.23; 95% CI 1.14 to 1.32; p < 0.001) and 53% higher room-associated cost ($906/case; RR 1.53; 95% CI 1.35 to 1.74; p < 0.001) compared with the shortest quartile. The influence of TTA and OD were independent but potentiating effects, with median cost for hospitals in both the longest quartiles of TTA and OD being 79% higher than those in the shortest quartiles. CONCLUSIONS Longer TTA and OD were independently associated with increased hospital cost, with OD being the most significant driver of cost variation across hospitals. Identification of best practices from high-efficiency hospitals might provide a high-yield strategy for improving value in appendicitis care.
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Affiliation(s)
- Stephanie K Serres
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Center for Applied Quality Analytics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Charity C Glass
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Danielle B Cameron
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Abstract
OBJECTIVES Emergency department (ED) visits and hospital readmissions are common after gastrostomy tube (GT) placement in children. We sought to characterize interhospital variation in revisit rates and explore the association between this outcome and hospital-specific GT case volume. PATIENTS AND METHODS We conducted a retrospective cohort study from 38 hospitals using the Pediatric Health Information System database. Patients younger than 18 years who had a GT placed in 2010 to 2012 were assessed for a GT-related (mechanical or infectious) ED visit or inpatient readmission at 30 and 90 days after discharge from GT placement. Risk-adjusted rates were calculated using generalized linear mixed-effects models accounting for hospital clustering and relevant demographic and clinical attributes, then compared across hospitals. RESULTS A total of 15,642 patients were included. A median of 468 GTs were placed in all the 38 hospitals during 3 years (range: 83-891), with a median of 11.4 GT placed per 1000 discharges (range: 2.4-16.7). Median ED visit for each hospital at 30 days after discharge was 8.2% (range: 3.7%-17.2%) and 14.8% at 90 days (range: 6.3%-26.1%). Median inpatient readmissions for each hospital at 30 days after discharge was 3.5% (range: 0.5%-10.5%) and 5.9% at 90 days (range: 1.0%-18.5%). Hospital-specific GT placement per 1000 discharges (rate of GT placement) was inversely correlated with ED visit rates at 30 (P = 0.007) and 90 days (P = 0.020). The adjusted 30- and 90-day readmission rate and the adjusted 30- and 90-day ED return rates decreased with increasing GT insertion rate (P < 0.001). CONCLUSION Higher hospital GT insertion rates are associated with lower ED revisit rates but not inpatient readmissions.
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Partain KN, Patel AU, Travers C, Short HL, Braithwaite K, Loewen J, Heiss KF, Raval MV. Improving ultrasound for appendicitis through standardized reporting of secondary signs. J Pediatr Surg 2017; 52:1273-1279. [PMID: 27939802 PMCID: PMC5459678 DOI: 10.1016/j.jpedsurg.2016.11.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation. METHODS A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate. RESULTS We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p<0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p<0.001) with US, overall CT use (8.5% vs 7.0%, p=0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p=1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, p=0.002) and admissions for observations decreased (21.5% vs 15.3%, p=0.02). Test characteristics of RLQ US for appendicitis also improved in the posttemplate period. CONCLUSION A focused QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT use and fewer admissions for observation. Study of a Diagnostic Test Level of Evidence: 1.
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Affiliation(s)
- Kristin N Partain
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Adarsh U Patel
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kiery Braithwaite
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jonathan Loewen
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Affiliation(s)
- Rebecca M Rentea
- Deparment of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Pediatric Surgical Fellowship and Scholars Programs, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Serres SK, Cameron DB, Glass CC, Graham DA, Zurakowski D, Karki M, Anandalwar SP, Rangel SJ. Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children. JAMA Pediatr 2017; 171. [PMID: 28628705 PMCID: PMC5710637 DOI: 10.1001/jamapediatrics.2017.0885] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events. OBJECTIVE To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied. EXPOSURES The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices. MAIN OUTCOMES AND MEASURES The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits). RESULTS Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable analyses, increasing TTA was not associated with risk of complicated appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02). The odds ratios of complicated appendicitis for late vs early TTA across hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a statistically significant increase in their late TTA group (odds ratio, 9.63; 95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days; P < .001) but was not associated with increased risk of any of the other secondary outcomes. CONCLUSIONS AND RELEVANCE Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.
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Affiliation(s)
- Stephanie K. Serres
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle B. Cameron
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charity C. Glass
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dionne A. Graham
- Center for Applied Quality Analytics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mahima Karki
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seema P. Anandalwar
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Short HL, Parakati I, Heiss KF, Wulkan ML, Sweeney JF, Raval MV. Challenge of balancing duration of stay and readmissions in children's operation. Surgery 2017; 162:950-957. [PMID: 28709646 DOI: 10.1016/j.surg.2017.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgeons balance competing interests of minimizing duration of stay with readmissions. Complications that occur early after discharge often result in readmissions. This study examines the relationship between duration of stay, timing of complications, and readmission risk. METHODS Cases from the 2012-2014 National Surgical Quality Improvement Project-Pediatric were organized into 30 procedural groups. Procedures where duration of stay approximated the median day of complication were identified. A theoretical model was applied to minimize readmissions by extending duration of stay. RESULTS From 30 procedure groups, 3 were identified where duration of stay approximated median day of compilations: complicated appendectomy, antireflux operation, and abdominal operation without bowel resection. The complicated appendectomy readmission rate drops from 12.2% to 8.2%, increasing duration of stay from 3 to 8 days at the cost of 16,428 additional hospital days among 4,740 patients (3.5 days/patient). Readmission optimization tapers after duration of stay of 8 days. Similar findings were observed for antireflux operation and abdominal operation without bowel resection with readmission optimization at duration of stay of 5 days (2.6 days/patient) and 7 days (5.3 days/patient), respectively. CONCLUSION Our theoretical model aimed at balancing readmissions by extending duration of stay to capture early complications results in a substantial increase in hospital days illustrating the conflict between competing quality metrics and limited resources.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Isaac Parakati
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
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Rangel SJ. Moving the needle toward high-quality pediatric surgical care: How can we achieve this goal through prioritization, measurement and more effective collaboration? J Pediatr Surg 2017; 52:669-676. [PMID: 28190557 DOI: 10.1016/j.jpedsurg.2017.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 11/26/2022]
Abstract
Over the past decade, the American College of Surgeons Pediatric National Surgical Quality Improvement Program (NSQIP-Pediatric) has greatly improved upon our ability to measure, benchmark and compare outcomes as they relate to pediatric surgical care. Several factors have served to mold the program's evolution and data collection paradigm over time. These have included a broader understanding of what quality measures should be captured and compared from the perspectives of different stakeholders, identification of conditions where quality and process improvement efforts may have the greatest relative impact from a public health perspective, and increasing evidence in support of collaborative networks to accelerate quality improvement through the dissemination of best practices. The purpose of today's lecture is to review these factors in the context of a comprehensive road map for optimizing the quality of pediatric surgical care, and the role that NSQIP-Pediatric has and will continue to play as the foundation supporting this road map.
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Affiliation(s)
- Shawn J Rangel
- Department of Surgery, Boston Children's Hospital - Harvard Medical School, Boston, MA.
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Anderson KT, Putnam LR, Caldwell KM, B. Diffley M, A. Hildebrandt A, Covey SE, Austin MT, Kawaguchi AL, Lally KP, Tsao K. Imaging gently? Higher rates of computed tomography imaging for pediatric appendicitis in non–children's hospitals. Surgery 2017; 161:1326-1333. [DOI: 10.1016/j.surg.2016.09.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/12/2016] [Accepted: 09/30/2016] [Indexed: 11/30/2022]
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Otero HJ, Crowder L. Imaging Utilization for the Diagnosis of Appendicitis in Stand-Alone Children's Hospitals in the United States: Trends and Costs. J Am Coll Radiol 2017; 14:603-608. [PMID: 28223114 DOI: 10.1016/j.jacr.2016.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe the imaging utilization patterns for the diagnosis of appendicitis among children's hospitals in the United States over the last 10 years (2005-2014). METHODS All patients with a primary discharge diagnosis of appendicitis included in a large administrative database of 45 pediatric institutions in the United States between 2005 and 2014 were selected. Demographics, imaging utilization, and costs were described. RESULTS In all, 96,786 children with appendicitis (59% boys, 41% girls; mean age: 9.9 years) were studied. The average length of stay decreased from 5.0 days in 2005 to 3.4 days in 2014 (P < .01). The percentage of patients undergoing CT increased between 2005 and 2007 from 59.1% to 62.6%, respectively, followed by a decrease from 62.6% to 32.7% in 2014 (r2 = 0.93). Radiograph utilization decreased from 14.2% in 2005 to 3.6% in 2014 (r2 = 0.93), and ultrasound and MRI increased from 25% and 0.03% in 2005 to 61% and 1.0% in 2014 (r2 = 0.97 and 0.64), respectively. The mean total hospital costs increased from $11,700 in 2005 to $16,500 in 2014; imaging costs increased only slightly from $3,205 to $3,259. The imaging fraction of hospital costs decreased from 27.5% to 19.8%. CONCLUSION There has been a significant decrease in utilization of CT and radiographs for the management of appendicitis in children, and ultrasound has continued to increase. Imaging costs have remained stable in comparison to rising hospital costs, generating a drop in the fraction of costs related to imaging.
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Affiliation(s)
- Hansel J Otero
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC.
| | - Lauren Crowder
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC
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Manworren RCB, McElligott CD, Deraska PV, Santanelli J, Blair S, Ruscher KA, Weiss R, Rader C, Finck C, Bourque M, Campbell B. Efficacy of Analgesic Treatments to Manage Children's Postoperative Pain After Laparoscopic Appendectomy: Retrospective Medical Record Review. AORN J 2016; 103:317.e1-11. [PMID: 26924376 DOI: 10.1016/j.aorn.2016.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 01/02/2015] [Accepted: 01/21/2016] [Indexed: 11/19/2022]
Abstract
Knowledge of the effectiveness of multimodal analgesic treatments to manage children's postoperative pain during hospital stays is limited. Our retrospective chart review of a convenience sample of 200 pediatric surgical patients' pain experiences during the first 24 hours after laparoscopic appendectomy demonstrates the benefits of a multimodal analgesic approach. We found that pediatric patients who received perioperative IV ketorolac in addition to opioids reported statistically significantly lower mean pain intensity (n = 134, mean [M] = 2.9, standard deviation [SD] = 1.7) during the first 24 hours after surgery when compared with the pain intensity of patients who did not receive perioperative IV ketorolac (n = 66, M = 3.7, SD = 1.7, t = 3.14, P = .002). Patients who received perioperative IV ketorolac (M = 0.94, SD = 0.71) also received significantly fewer morphine equivalents of postoperative opioids during the first 24 hours after surgery than those who did not (M = 1.21, SD = 0.78, t = 2.41, P = .02). We will use data from these patients to introduce the potential for a personalized medicine approach to postoperative pain.
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Imaging trends in suspected appendicitis-a Canadian perspective. Emerg Radiol 2016; 24:249-254. [PMID: 27933409 DOI: 10.1007/s10140-016-1472-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/25/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of our study was to assess trends in the imaging of suspected appendicitis in adult patients in emergency departments of academic centers in Canada. METHODS A questionnaire was sent to all 17 academic centers in Canada to be completed by a radiologist who works in emergency radiology. The questionnaires were sent and collected over a period of 4 months from October 2015 to February 2016. RESULTS Sixteen centers (94%) responded to the questionnaire. Eleven respondents (73%) use IV contrast-enhanced computed tomography (CT) as the imaging modality of choice for all patients with suspected appendicitis. Thirteen respondents (81%) use ultrasound as the first modality of choice in imaging pregnant patients with suspected appendicitis. Eleven respondents (69%) use ultrasound (US) as the first modality of choice in patients younger than 40 years of age. Ten respondents (67%) use ultrasound as the first imaging modality in female patients younger than 40 years of age. When CT is used, 81% use non-focused CT of the abdomen and pelvis, and 44% of centers use oral contrast. Thirteen centers (81%) have ultrasound available 24 h a day/7 days a week. At 12 centers (75%), ultrasound is performed by ultrasound technologists. Four centers (40%) perform magnetic resonance imaging (MRI) in suspected appendicitis in adult patients at the discretion of the attending radiologist. Eleven centers (69%) have MRI available 24/7. All 16 centers (100%) use unenhanced MRI. CONCLUSIONS Various imaging modalities are available for the work-up of suspected appendicitis. Although there are North American societal guidelines and recommendations regarding the appropriateness of the multiple imaging modalities, significant heterogeneity in the first-line modalities exist, which vary depending on the patient demographics and resource availability. Imaging trends in the use of the first-line modalities should be considered in order to plan for the availability of the imaging examinations and to consider plans for an imaging algorithm to permit standardization across multiple centers. While this study examined the imaging trends specifically in Canada, there are implications to other countries seeking to streamline imaging protocols and determining appropriateness of the first-line imaging modalities.
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Tan J, Liu L, Xie J, Hu L, Yang Q, Wang H. Cost-effectiveness analysis of ultrasound-guided Seldinger peripherally inserted central catheters (PICC). SPRINGERPLUS 2016; 5:2051. [PMID: 27995028 PMCID: PMC5130933 DOI: 10.1186/s40064-016-3698-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 11/18/2016] [Indexed: 12/30/2022]
Abstract
Background Ultrasound-guided cannulation of deep mid-arm veins by a modified Seldinger (US-Seldinger) technique has been demonstrated to yield better puncture success rates and lower postoperative complication rates than direct cannulation of superficial veins near the elbow with a short peripheral cannula and peripherally inserted central catheter (PICC) insertion through the cannula (non-US conventional method). Economic factors have been evaluated across different operators (i.e. nurses, radiologists, and general practitioners) and different venous catheter types (i.e. PICCs vs. central venous catheters). However, to our knowledge, data describing the economic evaluation on the aforementioned modified Seldinger technique are lacking. Hence, the aim of this study was to evaluate the cost-effectiveness of US-Seldinger technique (experimental group) compared with that of the non-US conventional method based on direct vein visualization (control group). Results A cohort of 360 subjects were assigned randomly to the experimental and control groups. Cost-effectiveness ratio (CER) analyses indicated that the effectiveness index (EI) for the experimental group was 89.29% (final CER = 3732.75), whereas that for the control group was 59.18% (final CER = 2492.98). Conclusion The US-Seldinger technique was found to be more cost-effective than the non-US conventional method. These findings support the use of the former in place of the traditional latter technique as a routine puncture technique and suggest that the update would improve intravenous therapy treatment for patients needing PICCs. This study should serve as a reference for national healthcare policy. Trial registration ChiCTR-TRC-14004993 Electronic supplementary material The online version of this article (doi:10.1186/s40064-016-3698-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jianghong Tan
- Nursing College of Central South University, Zhuzhou Central Hospital, Room 210, Administration Building, Zhuzhou, 410007 Hunan China ; Zhuzhou Central Hospital, Zhuzhou, 410007 Hunan China
| | - Liping Liu
- Zhuzhou Central Hospital, Zhuzhou, 410007 Hunan China
| | - Jing Xie
- Zhuzhou Central Hospital, Zhuzhou, 410007 Hunan China
| | - Lingli Hu
- Zhuzhou Central Hospital, Zhuzhou, 410007 Hunan China
| | - Qiaolan Yang
- Nursing College of Central South University, Yuelu District Tongzipo Road, Changsha, 410013 Hunan China
| | - Honghong Wang
- Nursing College of Central South University, Zhuzhou Central Hospital, Room 210, Administration Building, Zhuzhou, 410007 Hunan China ; Nursing College of Central South University, Yuelu District Tongzipo Road, Changsha, 410013 Hunan China
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Cundy TP, Gent R, Frauenfelder C, Lukic L, Linke RJ, Goh DW. Benchmarking the value of ultrasound for acute appendicitis in children. J Pediatr Surg 2016; 51:1939-1943. [PMID: 27670963 DOI: 10.1016/j.jpedsurg.2016.09.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study appraises the diagnostic quality of ultrasound for acute appendicitis in children and consequently challenges the perception of inferior accuracy and suitability compared to computed tomography (CT). METHODS Radiologist reports for consecutive "query appendicitis" ultrasound studies were retrieved from a hospital database for the study period 2009-2014. Children who subsequently underwent appendicectomy were identified. Corresponding operative and histopathology findings were evaluated. Diagnostic accuracy of ultrasound was determined by analyzing overall accuracy, sensitivity, specificity, predictivity, and likelihood ratios. RESULTS A total of 3799 ultrasound examinations were evaluated. Mean age was 11.5±3.8years. The proportion of patients investigated with preoperative ultrasound was 59.9% (1103/1840). Appendix visualization rate was 91.7%. Overall diagnostic accuracy was 95.5%. Sensitivity and specificity values were 97.1% (95.9-98.1; 95% CI) and 94.8% (93.9-95.6; 95% CI), respectively. Separate analysis of only ultrasound positive and negative examinations (i.e., excluding nondiagnostic examinations) confirmed sensitivity and specificity values of 98.8% and 98.3%. CONCLUSION In this largest reported single institution series of ultrasound examinations for appendicitis, we report benchmark standard quality of diagnostic accuracy and visualization rates. Given the radiation and cost implications of CT, there is a strong argument to recommend ultrasound as the primary imaging modality. Diagnostic Study-Level II.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia; Discipline of Surgery, University of Adelaide, South Australia.
| | - Roger Gent
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Claire Frauenfelder
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia
| | - Laura Lukic
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Rebecca J Linke
- Department of Radiology, Women's and Children's Hospital, South Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia; Discipline of Paediatrics, School of Medicine, University of Adelaide, South Australia
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Partain KN, Patel A, Travers C, McCracken C, Loewen J, Braithwaite K, Heiss KF, Raval MV. Secondary signs may improve the diagnostic accuracy of equivocal ultrasounds for suspected appendicitis in children. J Pediatr Surg 2016; 51:1655-60. [PMID: 27039121 PMCID: PMC5018916 DOI: 10.1016/j.jpedsurg.2016.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improve diagnostic accuracy in equivocal US studies. METHODS Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated. RESULTS 530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% confidence interval (CI) 2.1-82.8), hyperemia (OR=2.0, 95%CI 1.5-95.5), free fluid (OR=9.8, 95%CI 3.8-25.4), and appendicolith (OR=7.9, 95%CI 1.7-37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy. CONCLUSION Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide clinicians and reduce unnecessary CT and admissions.
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Affiliation(s)
| | - Adarsh Patel
- Emory College, Emory University, Atlanta, GA, USA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Jonathan Loewen
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kiery Braithwaite
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F. Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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González del Castillo J, Ayuso FJ, Trenchs V, Martinez Ortiz de Zarate M, Navarro C, Altali K, Fernandez C, Huckins D, Martín-Sánchez FJ. Diagnostic accuracy of the APPY1 Test in patients aged 2–20 years with suspected acute appendicitis presenting to emergency departments. Emerg Med J 2016; 33:853-859. [DOI: 10.1136/emermed-2015-205259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 07/09/2016] [Accepted: 08/20/2016] [Indexed: 12/29/2022]
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Cundy TP, Sierakowski K, Manna A, Cooper CM, Burgoyne LL, Khurana S. Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study. ANZ J Surg 2016; 87:271-276. [PMID: 27599307 DOI: 10.1111/ans.13744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children. METHODS Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach. RESULTS Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057. CONCLUSION Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.
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Affiliation(s)
- Thomas P Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kyra Sierakowski
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Alexandra Manna
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Celia M Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Laura L Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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