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O'Guinn ML, Keane OA, Lee WG, Feliciano K, Spurrier R, Gayer CP. Clinical Characteristics of Avoidable Patient Transfers for Suspected Pediatric Appendicitis. J Surg Res 2024; 300:54-62. [PMID: 38795673 DOI: 10.1016/j.jss.2024.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/19/2024] [Accepted: 04/29/2024] [Indexed: 05/28/2024]
Abstract
INTRODUCTION Pediatric surgical care is becoming increasingly regionalized, often resulting in limited access. Interfacility transfers pose a significant financial and emotional burden to when they are potentially avoidable. Of transferred patients, we sought to identify clinical factors associated with avoidable transfers in pediatric patients with suspected appendicitis. METHODS We performed a single-center retrospective study at an academic tertiary referral children's hospital in an urban setting. We included children who underwent interfacility transfer to our center with a transfer diagnosis of appendicitis from July 1, 2021 to June 30, 2023. Encounters were designated as either an appropriate transfer (underwent appendectomy) or an avoidable transfer (did not undergo appendectomy). Encounters treated nonoperatively for complicated appendicitis were excluded. Bivariate analysis was performed using Mann-Whitney test and chi-square tests. RESULTS A total of 444 patients were included: 71.2% were classified as appropriate transfers and 28.8% as avoidable transfers. Patients with avoidable transfer were younger compared to those in the appropriate transfer cohort (median age 9 y, interquartile range: 7-13 versus 11 y, interquartile range: 8-14; P < 0.001). Avoidable transfers less frequently presented with the typical symptoms of fever, migratory abdominal pain, anorexia, and nausea/emesis (P = 0.005). Avoidable transfers also reported shorter symptom duration (P = 0.040) with lower median white blood cell count (P < 0.001), neutrophil percentage (P < 0.001), and C-reactive protein levels (P < 0.003). Avoidable transfers more frequently underwent repeat imaging upon arrival (42.9% versus 12.7%, P < 0.001). CONCLUSIONS These findings highlight the importance of clinical history in children with suspected appendicitis. Younger patients without typical symptoms of appendicitis, those with a shorter duration of symptoms, and lower serum inflammatory markers may benefit from close observation without transfer.
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Affiliation(s)
- MaKayla L O'Guinn
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - William G Lee
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Karina Feliciano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Ryan Spurrier
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Christopher P Gayer
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California.
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Stephens CQ, Ashok A, Gee A, Jafri M, Hamilton NA, Lehrfeld D, Newgard C, Krishnaswami S. Pediatric Trauma Care Standardization: A Statewide Survey of Trauma Providers and Program Managers. J Surg Res 2023; 288:178-187. [PMID: 36989834 DOI: 10.1016/j.jss.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/09/2023] [Accepted: 02/19/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Rural-urban disparities in pediatric trauma outcomes are well documented. However, few studies examine how differences in setting and resources impact rural providers' approach to trauma. We sought to understand the provider experience in managing injured children across our state and assess the potential for standardization of care. METHODS A statewide cross-sectional survey was distributed to trauma providers and program managers through the American College of Surgeons, the Oregon Medical Board lists, and the State Trauma Advisory Board. Topics included pediatric management processes, challenges, and transfer or admission procedures. Rural-urban commuting codes were used to categorize responses. RESULTS Of the 350 individuals who sent the survey, 68 responded (response rate 19%), representing 67% of trauma-verified hospitals and 72% of Oregon counties. Fifty-six respondents (82%) care for injured children, with 58% practicing rurally and 22% at critical access hospitals. Rural providers experienced lower trauma volumes (<1 patient/month, 63% versus 0%, P < 0.001), more difficulties obtaining pediatric-appropriate material resources (44% versus 30%), and challenges caring for infants/toddlers (25% versus 17%). Despite 77% of rural providers stating that <10% of patients had multisystem injuries, they described using full-body CT often (41% versus 10%, P = 0.007). Transfer interruptions were common (93%), with 44% having cancelled a transfer. The majority supported admission/transfer (85%) and imaging (82%) protocols. CONCLUSIONS Rural providers experience lower pediatric trauma volumes, greater material-resource issues, and discomfort with traumatically injured small children. Lack of care standardization may lead to reliance on full-body CT, and potentially complex/avoidable transfers. Adoption of standardized protocols could facilitate a state-wide collaborative approach to pediatric trauma management.
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Affiliation(s)
| | - Arjun Ashok
- New York Medical College, Valhalla, New York
| | - Arvin Gee
- Oregon Health and Science University, Portland, Oregon
| | - Mubeen Jafri
- Oregon Health and Science University, Portland, Oregon
| | | | | | - Craig Newgard
- Oregon Health and Science University, Portland, Oregon
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Lakshin G, Banek S, Keese D, Rolle U, Schmedding A. Telemedicine in the pediatric surgery in Germany during the COVID-19 pandemic. Pediatr Surg Int 2021; 37:389-395. [PMID: 33388961 PMCID: PMC7778404 DOI: 10.1007/s00383-020-04822-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The COVID-19 pandemic has led to an unprecedented expansion of telemedicine services worldwide. This study aimed to explore the practice of telemedicine in Pediatric Surgery in Germany, the impact of the pandemic on its development and parents' and surgeons' experiences with telemedicine. METHODS The study is a cross-sectional analysis using three surveys between 6/2020 and 10/2020: (1) all Pediatric Surgery departments of Germany reported whether they provide telemedicine services. (2) Members of the German Society of Pediatric Surgery and (3) families who participated in an outpatient visit by telephone or video with the Department of Pediatric Surgery and Pediatric Urology of the University Hospital Frankfurt completed an anonymous survey on their experience with telemedicine. RESULTS 21% of the Pediatric Surgery departments in Germany provided telemedicine, of which 57% started due to the pandemic. The lack of physical examination and face-to-face contact seem to be the major limitations to surgeons and parents. 48% of the parents answered that telemedicine is equal to or better than traditional appointments, while 33% thought that telemedicine is worse. CONCLUSIONS This study shows that families and doctors alike have had positive experiences with telemedicine and most will continue to use this format after the pandemic.
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Affiliation(s)
- G Lakshin
- Department of Pediatric Surgery and Pediatric Urology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - S Banek
- Department of Pediatric Surgery and Pediatric Urology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - D Keese
- Department of Pediatric Surgery and Pediatric Urology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - U Rolle
- Department of Pediatric Surgery and Pediatric Urology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - A Schmedding
- Department of Pediatric Surgery and Pediatric Urology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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Nealeigh MD, Kucera WB, Artino AR, Bradley MJ, Meyer HS. The Isolated Surgeon: A Scoping Review. J Surg Res 2021; 264:562-571. [PMID: 33461780 DOI: 10.1016/j.jss.2020.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care. METHODS We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role. RESULTS From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, "rare-but-real" cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings. CONCLUSIONS This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.
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Affiliation(s)
- Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| | - Walter B Kucera
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anthony R Artino
- Department of Health, Human Function, & Rehabilitation Sciences, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Matthew J Bradley
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Holly S Meyer
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Musgrove KA, Abdelsattar JM, LeMaster SJ, Ballou MC, Kappel DA, Borgstrom DC. Optimal Resources for Rural Surgery. Am Surg 2020; 86:1057-1061. [PMID: 33049163 DOI: 10.1177/0003134820942142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Timely access to emergency general surgery services, including trauma, is a critical aspect of patient care. This study looks to identify resource availability at small rural hospitals in order to improve the quality of surgical care. METHODS Forty-five nonteaching hospitals in West Virginia were divided into large community hospitals with multiple specialties (LCHs), small community hospitals with fewer specialties (SCHs), and critical access hospitals (CAHs). A 58-question survey on optimal resources for surgery was completed by 1 representative surgeon at each hospital. There were 8 LCHs, 18 SCHs, and 19 CAHs with survey response rates of 100%, 83%, and 89%, respectively. RESULTS One hundred percent of hospitals surveyed had respiratory therapy and ventilator support, computerized tomography (CT) scanner and ultrasound, certified operating rooms, lab support, packed red blood cells (PRBC), and FFP accessible 24/7. Availability of cryoprecipitate, platelets, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) decreased from LCHs to CAHs. The majority had board-certified general surgeons; however, only 86% LCHs, 53% SCHs, and 50% CAHs had advanced trauma life support (ATLS) certification. One hundred percent of LCHs had operating room (OR) crew on call within 30 minutes, emergency cardiovascular equipment, critical care nursing, on-site pathologist, and biologic/synthetic mesh, whereas fewer SCHs and CAHs had these resources. One hundred percent of LCHs and SCHs had anesthesia availability 24/7 compared to 78% of CAHs. DISCUSSION Improving access to the aforementioned resources is of utmost importance to patient outcomes. This will enhance rural surgical care and decrease emergency surgical transfers. Further education and research are necessary to support and improve rural trauma systems.
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Affiliation(s)
- Kelsey A Musgrove
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | - Jad M Abdelsattar
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | - Stephanie J LeMaster
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | - Marguerite C Ballou
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | | | - David C Borgstrom
- 24041 Department of General Surgery, West Virginia University, Morgantown, WV, USA
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Tom CM, Friedlander S, Sakai-Bizmark R, Shekherdimian S, Jen H, DeUgarte DA, Lee SL. Outcomes and costs of pediatric appendectomies at rural hospitals. J Pediatr Surg 2019; 54:103-107. [PMID: 30389148 DOI: 10.1016/j.jpedsurg.2018.10.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Despite policy efforts to support rural hospitals, little is known about the quality and safety of pediatric surgical care in geographically remote areas. Our aim was to determine the outcomes and costs of appendectomies at rural hospitals. METHODS The Kids' Inpatient Database (2003-2012) was queried for appendectomies in children <18 years at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), cost) were analyzed with bivariate and multivariable regression analysis. RESULTS Rural hospitals performed 13.6% of appendectomies. On multivariable analysis, rural hospitals were associated with higher negative appendectomy rates (OR 1.49, 95% CI 1.39-1.60, p < 0.001), decreased appendiceal perforation rates (OR 0.86, 95% CI 0.83-0.89, p < 0.001), less laparoscopy use (OR 0.48, 95% CI 0.47-0.50, p < 0.001), higher complication rates (OR 1.29, 95% CI 1.19-1.39, p < 0.001), shorter LOS (IRR 0.90, 95% CI 0.89-0.91, p < 0.001), and slightly increased costs (exponentiated log$ 1.02, 95% CI 1.01-1.02, p < 0.001) CONCLUSIONS: Rural hospitals care for fewer patients with advanced appendicitis but are associated with higher negative appendectomy rates, lower laparoscopy use, and higher complication rates. Additional studies are needed to identify factors that drive this disparity to improve the quality of pediatric surgical care in rural settings. TYPE OF STUDY Treatment/Cost Study (Outcomes). LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Cynthia M Tom
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA
| | - Scott Friedlander
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA
| | - Rie Sakai-Bizmark
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA
| | - Shant Shekherdimian
- Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Howard Jen
- Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Daniel A DeUgarte
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA; Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA; Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA.
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Baxter KJ, Gale BF, Travers CD, Heiss KF, Raval MV. Ramifications of the Children's Surgery Verification Program for Patients and Hospitals. J Am Coll Surg 2018; 226:917-924.e1. [DOI: 10.1016/j.jamcollsurg.2018.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 10/18/2022]
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