Enhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized ...anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations.
To measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation.
The assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%).
The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers.
Higher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption.
Level III.
Mixed-methods survey.
•Enhanced recovery principles have low rates of implementation among pediatric surgeons.•Minimally invasive techniques (e.g. laparoscopy) have the highest utilization.•Enhanced recovery elements in the preoperative phase have the lowest utilization.•Elements requiring coordination between more than one department have low utilization.
Many children gained insurance with the 2014 Affordable Care Act's (ACA) Medicaid Expansion (ME), yet its impact on access to pediatric tertiary surgical care remains unknown. We examined the effect ...of ME on rates of elective, ambulatory surgery (EAS), especially among publicly-insured and ethnoracial-minority patients.
Surgical patients ≤18 years between 2012 and 2018 were identified using the Pediatric Health Information System. Interrupted time series analyses were conducted to predict the monthly proportion of publicly-insured patients and EAS rates in ME and nonexpansion states.
3,270,842 patients were included. Nonexpansion states demonstrated a 1.10% (p<0.05) increase in the proportion of publicly-insured patients at ACA implementation, which then plateaued. No immediate change was observed in ME states, but there was an annual 1.08% (p<0.01) decrease in subsequent years. Publicly-insured EAS rates decreased by 1.09% (p<0.01) in nonexpansion states; no change was observed in ME states. A 3.36% (p<0.01) increase in EAS rates was observed in nonexpansion and ME states. The gap in EAS rates increased between private and publicly-insured patients in nonexpansion, but not ME states.
Increased coverage for children in ME states was not associated with more access to tertiary pediatric surgical care; however, while nonexpansion states saw an increase in insurance-based disparities, ME states did not. Though insurance coverage is critical to access, other factors may be contributing to persistent disparities in access to pediatric surgical care.
OBJECTIVE:To examine the association between prolonged in-hospital time to appendectomy (TTA) and the risk of complicated appendicitis.
SUMMARY BACKGROUND DATA:Historically, acute appendicitis was ...treated with emergency appendectomy. More recently, practice patterns have shifted to urgent appendectomy, with acceptable in-hospital delays of up to 24 hours. However, the consequences of prolonged TTA remain poorly understood. Herein, we present the largest individual analysis to date of outcomes associated with prolonged in-hospital delay before appendectomy in children.
METHODS:Data from patients who underwent appendectomy within 24 hours of hospital presentation were obtained from the American College of Surgeons Pediatric National Surgical Quality Improvement Program Procedure Targeted Appendectomy database from 2016 to 2018. Appendectomy within 16 hours of presentation was considered early, whereas those between 16 to 24 hours were defined as late. The primary outcome was operative findings of complicated appendicitis. Secondary outcomes included 30-day complications and resource utilization.
RESULTS:This study consisted of 18,927 patients, with 20.6% undergoing late appendectomy. The rate of complicated appendicitis was significantly higher in the late group (Early26.3%, Late30.3%, P < 0.05). Additionally, the late group had longer operative times, increased need for postoperative percutaneous drainage, antibiotics at discharge, parenteral nutrition, and an extended hospital length of stay (P < 0.05). On multivariate analysis, late appendectomy remained a predictor of complicated disease (odds ratio 1.17 95% confidence interval, 1.08–1.27).
CONCLUSIONS:A significant proportion of pediatric patients with acute appendicitis experience prolonged in-hospital delays before appendectomy, which are associated with modestly increased rates of complicated appendicitis. Although this does not indicate appendectomy needs to be done emergently, prolonged in-hospital TTA should be avoided whenever possible.
Despite the frequency of acute appendicitis in children, there is no evidence-based consensus surrounding the urgency of the operation if a diagnosis is made after regular business hours. Although a ...modest delay in time to operation does not increase disease severity, postponing cases to the next calendar day may be associated with higher resource utilization. We aimed to evaluate the trend of delaying appendectomies to the next calendar day and its associated outcomes.
We queried the Pediatric Health Information System to analyze appendectomy patients younger than 18 y of age from 2010 to 2018. Same-day appendectomy and next-day appendectomy cohorts were created using admission hour and operative day. Healthcare cost, length of stay, surgical complications, and 30-day readmission rates were collected. Bivariate analyses and multivariable regressions were used to evaluate groups stratified by time of presentation.
During the study period, 113,662 appendectomies were performed, comprising 88,715 (78.1%) same-day appendectomies and 24,947 (21.9%) next-day appendectomies. A higher proportion of same-day appendectomies (80.5%) were performed during hours 12:00am to 5:00pm and 19.5% were performed during hours 6:00pm to 11:00pm. The trend of next-day appendectomies increased during the study period from 13.9% to 20.2%. This was primarily evident in the 6:00pm to 11:00pm period. The 5:00pm cutoff was most predictive of a next-day appendectomy. Next-day appendectomies had similar rates of surgical complications; however, they were associated with higher costs, longer lengths of stay, and higher readmission rates.
As the understanding of appendicitis urgency has changed, a more tempered approach of delivering surgical care has trended. Although short delays appear safe, postponement to the next calendar day is associated with higher resource utilization.
To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals.
We performed a cohort ...study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay.
In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons.
Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.
We conducted a scoping review to identify existing conceptual frameworks of postoperative recovery (PR) and assess their content.
PR is increasingly recognized by providers and third-party payers as ...a multidimensional phenomenon. Efforts to optimize PR and reduce complications and readmissions continue to evolve through changes in care (i.e., enhanced recovery protocols) and financial incentives. Delineating all factors affecting PR using a conceptual framework should aid in the design of effective interventions.
Web of Science and PubMed were queried to identify articles, between January 1980 and August of 2019, about conceptual frameworks of PR, using the search terms: “concept,” “model,” “framework,” “recovery after surgery,” “conceptual framework” “postoperative,” “surgery,” and “children.” Articles considering PR as a concept rather than an outcome were included. Articles were examined in accordance with Walker and Avant's method for the concept analysis. Concepts identified across articles were classified as domains and subdomains of PR.
The search yielded 183 unique articles; 8 met inclusion/exclusion criteria. Most articles defined PR as a period of days to weeks (n = 7) rather than days (n = 1). PR was mostly conceptualized as a process involving the patient and the health care system (n = 4) rather than the patient alone (n = 2). Physiological recovery (n = 8), activities of daily living (n = 8), pain (n = 5), cognitive/psychological recovery (n = 4), social recovery (n = 2), and patient perspective (n = 1) were the identified domains. Existing patient-reported outcome measures were used to assess most PR domains; however, definitions of domains and subdomains differed. None of the PR conceptual frameworks included were specific to children.
There are few conceptual frameworks of PR in adults, and the definitions of PR differ. No framework was specific to children. Consensus on a conceptual framework of PR in adults and development of a conceptual framework of PR specific to children are needed.
The presence of pain may interrupt sleep and impede normal postoperative recovery; however, no prior studies have quantified sleep loss due to pain in children undergoing inpatient surgery. Wearable ...accelerometers objectively measure sleep patterns in children. We aimed to quantify sleep loss associated with patient reported pain scores after a Modified Nuss operation.
Ten patients undergoing Modified Nuss operations were recruited during their inpatient stay. Children wore an Actigraph GT3X-BT accelerometer postoperatively during their hospital stay. Hourly sleep minutes were recorded using the Actigraph between 10 pm and 6 am. Patient reported pain scores were abstracted from patient charts. Mixed linear regression models, adjusting for within-subject random effects, were estimated to quantify the association between hourly sleep minutes and patient reported pain scores.
Patients were 30% female, with an average age of 15.7 years (range 13–22). The majority (70%) of patients were white non-Hispanic. All patients received a patient controlled analgesic pump. Average postoperative length of stay was 4.8 days (range 4.0–6.0; SD = 0.8). A total of 240 sleep hours and associated pain scores were analyzed. Patients slept on average 48 min per hour. Mixed model analysis predicted that a 1-point increase in pain score was associated with 2.5 min per hour less sleep time.
Increases in patient-reported pain scores are associated with sleep loss after a Modified Nuss operation. Objectively quantifying sleep loss associated with postoperative pain using accelerometer data may help clinicians better understand their patient's level of pain control. Our findings provide the basis for future studies aimed at more accurately titrating pain medication to optimize sleep and speed up recovery.
Case Series Without Comparison Group, Level IV.
Background
Image‐guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern ...biologic characterization of neuroblastoma.
Procedure
A multi‐institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3‐year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification.
Results
A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy.
Conclusions
PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real‐time pathology assessment of specimen quality.
In the midst of our national opioid crisis, recommendations have encouraged judicious stewardship of opioid prescription through the expanded use of non-opioid analgesic medications. This study aims ...to characterize trends in perioperative pain medication use for children undergoing ambulatory operations.
A cross-sectional, retrospective review was conducted using the Pediatric Health Information System. Patients younger than 18 years of age who underwent ambulatory surgery during 2010 to 2017 by one of five surgical subspecialties (otolaryngology, general pediatric, plastic or reconstructive, orthopedics, and urology) were included. Medications were identified using Current Procedural Terminology codes based on billing information for 18 commonly used analgesics along with the route of administration during their encounter.
A total of 1,795,329 patients with a median age of 10 years were identified, of whom 84.3% received an opioid or non-opioid analgesic. Opioid use in the perioperative setting for ambulatory procedures decreased during the study period from 74.9% to 66.9% as a proportion of total analgesic prescriptions. Among opioids commonly used, intravenous morphine decreased the most from 19.8% to 15.4%, and intravenous hydromorphone and oral oxycodone use remained largely unchanged. Conversely, non-opiate medications increased, specifically intravenous ketorolac from 8.4% to 13.6%, and intravenous acetaminophen use increased from 0% to 8.5%. Intravenous acetaminophen use more than doubled between 2013 and 2017 (3.4% to 8.2%) and was accompanied by a decrease in oral acetaminophen use (14.4% to 9.3%).
Overall, perioperative opioid utilization appears to be decreasing in favor of non-opioid analgesics. Other trends, such as increased intravenous acetaminophen, raise concerns for the cost effectiveness of perioperative analgesia and resource utilization.
In 2012, the American Academy of Pediatrics (AAP) concluded the health benefits of circumcision during the neonatal period outweigh the risks. This study describes recent trends in male circumcision ...in freestanding children's hospitals in the United States.
Using the Pediatric Health Information System (PHIS), male patients <18 years of age who were circumcised without any additional procedures between the years 2010 and 2017 were identified. Data included age at procedure (neonate: 0–30 days, infant: 31–365 days, early childhood: ≥1 to <5 years, and older child: ≥5 to<18 years), cost, and specialty performing the circumcision.
Of the 171,680 circumcisions performed, 85,270 (50%) were during neonatal period, 29,060 (17%) during infancy, 30,276 (18%) early childhood, and 26,355 (16%) thereafter. Circumcision in neonates increased from 39% to 58% (p < 0.001), and the proportion performed during infancy decreased over time. System level cost for ambulatory circumcision averaged $32 million USD annually, and median cost per ambulatory circumcision was $2892 USD. Obstetricians and Pediatricians are performing proportionally more circumcisions.
Since 2012, proportionally more neonates are undergoing circumcision in US children's hospitals. Perinatal specialties are performing an increasing proportion of circumcisions. Circumcision during the birth hospitalization in the neonatal period is more resource-effective than postponing until later in infancy.
Retrospective, cross-sectional analysis.
Level IV.
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