Newsletter

Quality Quarterly, Pediatric Surgery Quality Collaborative

March 2025
Volume 4, Issue 1

 

Happy Spring! Lots of activity within PSQC. Our research resident, Jeannette Joly, has been invited to present on the antibiotic dura-tion post appendectomy for complicated appendicitis at the American Surgical Association (ASA) the end of April. We believe the work done around this project is of great significance to the pediatric surgery community and are quite excited the work has been recognized by the ASA. Next steps on this project will be focused on how best to scale-up across as many pediatric hospitals as possible.

As mentioned previously, the ACS is developing a collaborative on opioid stewardship. Given the ACS has better access to specialty providers (orthopedics, plastics, ENT), their collaborative can be more successful than the PSQC in this realm. General surgery is not the service line with high utilization of opioids but our membership is predominately general surgeons. We are very happy the ACS has taken this challenge on. Expect to hear more about this collaborative at the Quality and Safety conference in July.

We are in the planning stages for our next in-person meeting at the conference in July. You have received a save the date from Terry for the afternoon of July 17th at The Embassy Suites, about 2 blocks from the conference hotel. We would like to hear from you what topics you’d like featured at the meeting.

Thank you for your continued interest in Quality via the PSQC. If you have any questions about anything PSQC, please reach out to Terry.

Kevin Lally, MD, MS, FACS PSQC Executive Director
Surgeon-in-Chief, Children’s Memorial Hermann Hospital Houston, TX

 

PSQC Projects

Pilot Projects:

Antibiotic Duration post Appendectomy for Complicated Appendicitis

This project aimed to assess the effect an antibiotic protocol of 4 days (+/- 1) , based on the STOP-IT trial, would have on patients undergoing an appendectomy for complicated appendicitis. Of primary interest was what effect a shortened course might have on rates of SSIs and readmis-sions. 36 hospitals participated in this project, with 21 adopting the pro-tocol and 15 continuing usual care. Each participating hospital submitted data to PSQC on a quarterly basis.

Our analysis of a cohort of patients between July 1, 2023 and June 30, 2024, demonstrates that patients who receive a shorter course (median 5 days) did not have a higher propensity for SSIs or readmissions. The protocol patients and usual care patients (median 8 days of antibiotics) had no significant difference in their rates of SSIs, readmissions or ED visits.

Our next steps on this project will be an assessment of best approaches to adoption and how to scale-up the adoption of this protocol across children’s hospitals.

Colorectal Checklist Bundle

This project launched with the intent to demonstrate a reduction in SSIs among colorectal surgery patients with an anastomosis using an 11 item checklist. Use of the checklist among 10 hospitals in the Western Pediatric Surgery Research Consortium (WPSRC) showed that utilization did reduce the incidence of SSIs. The PSQC project focused on checklist compliance and an association with SSIs.

Our analysis does demonstrate that compliance with checklist utilization can be achieved, however, the effect on SSI incidence and related length of stay (LOS) is not significant. Compliance has been too low among participating hospitals to say with any confidence that their utilization of the checklist resulted in a decrease in SSIs.

The efficacy of checklist use, when adhered to with high fidelity, has been shown to re-duce SSIs and other adverse outcomes in the literature. However, this project did not demonstrate that effect. We think there may be opportunity for us to analyze the barriers to high fidelity utilization, but are not pursuing at this time.

Antibiotic Stewardship

This project is in beginning stages. A baseline survey of participating hospitals ‘ operationalization of their SAP SAR reports has yielded high variability across sites. Next steps for this project are to conduct qualitative interviews and compile a guide on best practices and strategies to improve utilization of this tool.

G-Tube

This project is in the formative stage, with the composition of a workgroup occurring now. Participating sites will provide their Gastronomy Pilot Report, if they participated in the pilot, to allow the workgroup an opportunity to identify areas of high variability which may lend themselves to a quality improvement approach.

Specifically, dislodgments, both in-house and out, as well as identifying which patients are truly appropriate for g-tube placement , will be a likely focus. We also feel the utilization of upper GI series prior to placement may not be necessary in most cases. We will explore that question as well.

If your hospital is interested in participating in this project, please reach out to Terry.

PSQC Organization Update

The ACS has formed a QI collaborative called the Children’s Surgery Clin-ical Collaborative (CSCC) with its first project focused on opioid steward-ship. ACS will provide details around joining at the July meeting. The ad-vantage the ACS can bring to this collaborative is the engagement of ser-vice lines outside of general surgery-like orthopedics and plastic surgery. Having this type of engagement would be a challenge for the PSQC since we are comprised primarily of general surgery. Look for more information on this from the College.

The news we want to share is that we will be sending out a new DUA to all our members in the coming days. This DUA will encompass any QI project we’d like to pursue for the foreseeable future with the PSQC evolving into a largely general surgery focused QI collaborative. The College has not shared data with PSQC since July 2021, so that DUA is essentially nonfunctional as the ACS collaborative won’t need it. The new DUA will be between your hospital and the University of Texas and will define membership in the PSQC. It will be a standing DUA meaning your hospital can opt to participate in any QI project that PSQC launches or not. There is no requirement to participate. This is completely voluntary. But we do hope you will. We are finding that work done by this collaborative is having a significant impact on care patterns in general surgery.

If you have any questions, please reach out to Terry.

 

 

Welcome New Members!

Please contact Terry Fisher to request the full list of our new members!

 

 

 

 

 

 

 

 

PSQC In-Person Meeting
Thursday, July 17th
1-5pm PDT
Embassy Suites
Monterrey Ballroom
601 Pacific Highwy
San Diego, CA

 

 

 

 

Recent Publications of Interest by Our Members

Neighborhood deprivation is a risk factor for severe child physical abuse: A multicenter cohort investigation
Our purpose was to investigate whether neighborhood deprivation is associated with outcomes in a multicenter population of children with suspected or confirmed child physical abuse. We hypothesized that community level social determinants of health are associated with worse outcomes following child physical abuse. This large multicenter experience demonstrates a dose-dependent relationship between socioeconomic disadvantage and child physical abuse. We further demonstrate that disadvantage is associated with worse outcomes, including increased mortality, in child physical abuse. These findings provide objective data and lead to suggestions for interdisciplinary and multiscale approaches to primary prevention of child physical abuse.

Reduction of Pediatric Gastrostomy Tube Healthcare Utilization and Socio-economic Disparities: Longitudinal Benefits of Quality Improvement
Disparities in emergency department (ED) utilization after gastrostomy (G-) tube placement were previously demonstrated at our children’s hospital. We aimed to reduce postoperative G-tube dislodgements and ED visits with a particular focus on socially vulnerable children. A longstanding quality im-provement initiative has led to sustained reductions in overall G-tube-related health care utilization. Care standardization and improvement may mitigate outcome disparities related to socioeconomic advantage.

Identifying Quality Improvement Targets After Pediatric Gastrostomy Tube Insertion: A NSQIP-Pediatric Pilot Study
Gastrostomy tube (GT) placement is one of the most common procedures performed by pediatric surgeons; however, no current national clinical data registry exists to assess GT-specific care processes and morbidity. The American College of Surgeons (ACS) National Surgical Quality Improvement Pro-gram-Pediatric (NSQIPPed) GT Pilot was created to provide participants with these data. This study aims to analyze these data to identify variability in perioperative practices and post-operative morbidity in pediatric GT operations and to provide targets for future quality improvement (QI) interventions. Within pediatric GT placement, high variability exists in preoperative UGI use and high postoperative GT-related morbidity, including ED visits and dislodgements among pediatric facilities. The results of this analysis can in-form prioritization of future GT QI interventions and research which aim to standardize clinical practice and reduce the incidence of these complications.

Racial Disparities in Pediatric Anesthesia: An Updated Review
Health care disparities affect care across all medical fields, including pediatric anesthesia. Recent studies have revealed differences in pediatric perioperative care especially in anesthetic and analgesic choices. Additionally, Black children face higher 30 day postoperative mortality and more serious adverse events compared to White children. While strategies to address these disparities have been proposed, significant work is still needed.

Machine-learning-assisted Preoperative Prediction of Pediatric Appendicitis Severity
This study evaluates the effectiveness of machine learning (ML) algorithms for improving the preoperative diagnosis of acute appendicitis in children, focusing on the accurate prediction of the severity of disease. Prediction of appendiceal perforation outperforms prediction of the continuum of appendicitis grades. The variables our models primarily rely on to make predictions are consistent with clinical experience and the literature, suggesting that the ML models uncovered useful patterns in the dataset. Our model outperforms the other pediatric ap-pendicitis prediction tools. The ML model developed for grade prediction is the first of this type, offering a novel approach for assessing appendicitis severity in children preoperatively. Following external validation and silent clinical testing, this ML model has the potential to enable personalized severity-based treatment of pediatric appendicitis and optimize resource allocation for its management.

Surgical Risk, Operative Time, and Anesthesia Time Associated With Combining Tracheostomy and Gastrostomy Tube Placement Under a Single Anesthetic
Pediatric patients may need both tracheostomy and gastrostomy tube (G-tube) placement to satisfy both oxygen and nutritional requirements for sustaining life. It is unclear if combining both procedures under one anesthetic is associated with reductions in total operative time or surgical risk, compared to performing the two procedures separately. Combined procedures are theorized to reduce risks associated with prolonged exposure to anesthesia. We found a reduction in total anesthesia time associated with combining tracheostomy and G-tube place-ment under one anesthetic, and lower risk of complications, but no change in total operative time relative to performing 2 separate surgeries.

 

*Please contact Terry Fisher to request the full newsletter.

 

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