52.20 Severity of Congenital Heart Disease and Timing of Non Cardiac Procedures

Posted on January 18, 2018

K. Weitzel1, D. L. Colon1, J. Philip1, M. S. Bleiweis1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction: Infants with severe congenital heart disease commonly have other abnormalities requiring general anesthesia and surgical intervention. In cases of elective or semi-elective procedures (non-cardiac), there is little data on when to perform these surgeries and what outcomes are associated with timing differences. The purpose of this study is to assess whether the severity of the condition correlated with any complications in other procedures.

 

Methods: Patients were identified as having cardiac surgical intervention (CI) within their first year using ICD codes and analyzed to identify those patients requiring other procedures with general anesthesia (non-cardiac interventions, NCI). Data regarding demographics, hospital course, CI, NCI, long-term complications and outcomes were collected. The cohort was divided by RACHS scores (risk adjustment for congenital heart surgery) as a proxy for severity of the heart condition. Comparative statistics were performed using the Student’s t test, the Mann Whitney u test, and Fisher’s exact test as appropriate, and a p value of less than 0.05 was considered significant.

 

Results: A total of 343 patients identified had CIs, of which 153 were included who had NCIs. This cohort was subdivided into patients with RACHS of 1-2 (N= 55) and patients with RACHS of 3-6 (N=79).  There were no differences in gender, race, prenatal diagnosis, chromosomal abnormalities, rhythm or other disturbances, type of major procedure, or infection rates between the two groups. There were differences found in gestational age (higher RACHS had higher gestational age), the higher RACHS had higher bypass times, higher RACHS had more major procedures and more inotropes were used after NCI. Complications or mortality were not different (see table please). We also separated the main cohort by the timing of the cardiac surgery (whether the CI was first or the NCI was first) and found no difference in outcomes.

 

Conclusion:  In this cohort of patients, there was no overall difference in morbidity or mortality based on the RACHS. Patients with higher scores were more likely to need inotropes after non-cardiac interventions. There were no differences in the morbidity or mortality when analyzed by the sequence of the procedure. Further analysis is needed to understand the potential differences of inter-stage procedures requiring general anesthesia and what support these patients require postoperatively to help decisions on the appropriate care and treatment of this unique class of patients. 

 

52.15 Racial and Ethnic Disparities in Hospital Resource Utilization Following Appendicitis in Children?

Posted on January 18, 2018

J. G. Ulugia1, T. L. Duncan1, E. R. Scaife1, B. T. Bucher1  1University Of Utah,Division Of Pediatric Surgery, Department Of Surgery,Salt Lake City, UT, USA

Introduction: We sought to assess the impact of race and ethnicity, among other factors, on post-discharge hospital resource utilization following the treatment of acute appendicitis in children.

Methods:  We performed a retrospective cohort study of 45 Children’s Hospitals from 2010-2015. Patients were included if they were diagnosed with acute appendicitis based on International Classification of Diseases, 9th edition, and were 18 years of age or less during the study timeframe. Patients were excluded if they expired during the encounter. The primary predictor was patient defined race and ethnicity, and grouped into non-Hispanic white (NHW), non-Hispanic Black (NHB), Hispanic/Latino (HL) or other. The primary outcome was 30-day post-discharge emergency department (ED) visit or inpatient readmission. Baseline characteristic differences were adjusted to account for disease severity including perforated appendicitis, procedure type, length of stay, and insurance type. The association of race and ethnicity on the primary outcome was assessed using univariate and multivariate logistic regression models computed in R (Version 3.4.0).

Results: Overall, 80,913 patients were identified as meeting inclusion criteria. The median age of our cohort was 11 years (IQR 8-13 years) and 60.3% of them were male. The majority (49.8%) of patients were NHW, 7.1% were NHB, and 32.4% HL. The rate of perforated appendicitis in our cohort was 13.3%, and 92% of children underwent a laparoscopic appendectomy. The overall rate of an ED visit within 30 days of discharge was 5.1%, and the overall rate of inpatient readmission within 30 days post-discharge was 3.9%. Compared to NHW, both NHB (p<0.0001) and HL (p<0.0001) children had a significantly increased rate of 30-day post-discharge ED visits (Table). However, there was not a corresponding increase in 30-day inpatient readmission in NHB (p=0.13) and HL (p=0.13) children compared to NHW. After adjusting for differences in baseline characteristics and disease severity, NHB and HL children had a significantly increased risk of 30-day ED visits. However, there was not a significantly increased risk of inpatient readmission in NHB and HL children (Table).

Conclusion: Compared to NHW children, NHB and HL children treated for appendicitis at US Children’s Hospitals are at a significantly increased risk of returning to the ED within 30 days post-discharge, without a corresponding increase in risk of inpatient readmission. This data suggests a racial and ethnic disparity in post-discharge care of children with appendicitis, and the preferential use of the ED for post-operative follow-up care in NHB and HL children.?

 

52.16 Facilitating Factors In Same-day Discharge After Laparoscopic Appendectomy

Posted on January 18, 2018

O. Cheng1, L. Cheng2, S. Burjonrappa2  1Stony Brook University Medical Center,Stony Brook, NY, USA 2Montefiore Medical Center,Bronx, NY, USA

Introduction:  Appendicitis has been cited to be the most common abdominal disorder that requires acute care surgery in the pediatric population. Enhanced Recovery After Surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining pre-operative organ function and reducing the profound stress response following surgery. Such protocols have been found to enhance quality of care for surgical patients, as well as improve recovery and shorten hospital stays. ERAS protocols have been proven to help colorectal surgeries but there are no protocols in place yet for appendectomies in the pediatric population. The purpose of this study is to determine the key factors that facilitate same-day discharge and early return to normal activities after laparoscopic appendectomies in children.

Methods: This is a single-center retrospective chart review of pediatric patients (<18 years old) who underwent appendectomies for acute appendicitis from January 2015 to April 2017. The patient population was divided into two groups: those with same-day discharge and those who were discharged one or more days after surgery. Same day discharge (SDD) was defined as discharge less than 24 hours of surgical admission. Patient factors, including pre-hospital, pre-operative, peri-operative, and post-operative factors, were compared and analyzed between the two groups and statistically evaluated using Fisher two-test for categorical data and student t-test for continuous variables.

Results: 248 patients were found under ICD-9 and ICD-10 codes for acute appendicitis. Of these, 63 were excluded due to perforated appendicitis, non-operative management, interval appendectomies, or misdiagnosis. The remaining 185 had laparoscopic appendectomies; 59.5% (n=110) were SDDs and 40.5% (n=75) stayed more than one day. No significant difference was found for time between ER arrival and surgical admission (5.27 vs 5.38 hours; p=0.8) but SDD patients had a significantly shorter time between surgical admission and operation (5.8 vs 11.4 hours; p<0.001). SDD patients also had fewer intra/post-operative complications (1.8% vs 13%; p<0.01) and patients with complications were more likely to stay. There was no significant difference in readmission rates between the two groups (2.73% vs 2.63%; p=1). Total hospital costs were significantly less for SDD ($29,200 vs $33,700; p<0.001). See table for more values.

Conclusion: Surgical leadership can be effective in facilitating same-day discharge without increasing readmission rates or complications, and helps reduce hospital costs, decreases chances of nosocomial infection, and increases patient and family satisfaction.

 

52.17 Socioeconomic Disparities of Children with Umbilical Hernia Presenting to the Emergency Department.

Posted on January 18, 2018

L. G. Souza Mota1, M. F. Nunez3, G. Ortega2,3, C. M. Smith1, D. S. Rhee4, D. D. Tran2,3  1Howard University College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Clive O. Callender, MD Howard-Harvard Outcomes Research Center/Department Of Surgery,Washington, DC, USA 4Johns Hopkins University School Of Medicine,Division Of Pediatric Surgery/Johns Hopkins Children’s Center,Baltimore, MD, USA

Introduction:  Children from lower socioeconomic status often experience longer wait times for elective surgery between diagnosis and the operating room, and are even less likely to undergo these procedures. The objective of this study is to investigate socioeconomic disparities among children with umbilical hernias presenting to the Emergency Department by analyzing a national dataset.

Methods:  A retrospective review utilizing the Nationwide Emergency Department Sample from 2009 to 2014 was performed. Patients under 18 with a diagnosis of umbilical hernia were selected. Hernias were categorized as uncomplicated and complicated. Insurance status and median household income were analyzed in unadjusted and adjusted models for the likelihood of presenting with an uncomplicated umbilical hernia to the emergency department.  

Results: A total of 31,327 pediatric patients with an umbilical hernia were identified. Of these patients 56.4% were male. Most of the patients were diagnosed with uncomplicated umbilical hernia (97%). Of which 20.3% had private insurance, 68.7% public, and 8.1% were uninsured. With respect to median household income (MHI), 42.1% were in the first quartile, 27.6% in the second, 19.2% in the third, and 11.2% in the fourth. Three percent of the population had a diagnosis of complicated umbilical hernia, of which 34.7% had private insurance, 56.0% public, and 6.5% uninsured. 34.9% were in the first MHI quartile, 26.3% in the second, 21.2% in the third, and 17.7% in the fourth. On multivariate analysis, uninsured patient and patients using public insurance were more likely to present to the emergency department with an uncomplicated umbilical hernia compared to private insurance, (OR 1.70 95%CI 1.22-2.38) and (OR 1.69 95%CI 1.40-2.04), respectively. Patients in the first and second MHI quartiles were also more likely to present with uncomplicated umbilical hernias compared to highest MHI quartile, (OR 1.42 95%CI 1.10-1.82) and (OR 1.40 95%CI 1.08-1.82), respectively. 

Conclusion: Pediatric patients who were uninsured, had public insurance, or of lower MHI were more likely to present to the emergency department with an uncomplicated umbilical hernia. This may represent a lack of access for publicly insured and uninsured pediatric patients resulting in utilization of the emergency department for non-emergent surgical care.
 

52.13 The Association of Healthcare Utilization with Readmission in Neonatal Intensive Care Unit Patients

Posted on January 18, 2018

K. J. Baxter1,2, H. T. Nguyen1,2, M. L. Wulkan1,2, M. V. Raval1,2  1Emory University School Of Medicine,Atlanta, GA, USA 2Children’s Healthcare Of Atlanta,Pediatric Surgery,Atlanta, GA, USA

Introduction:  After discharge from the neonatal intensive care unit (NICU), continuity through utilization of primary care is an important factor in coordination and readmission prevention.  Utilization in this complex population has not been well-characterized.  We sought to quantify utilization and to examine its association with readmission in these patients.

Methods:  The Truven MarketScan national insurance claims database was used to conduct a retrospective cohort study.  Inclusion criteria were patients with an initial admission to the NICU for ≥30 days and discharged to home.  We then measured the number and frequency over time of outpatient encounters after discharge, and readmission to the hospital within 90 days of discharge. Patient comorbidities were compared using chi square tests between those readmitted and non-readmitted.

Results:  We identified a total of 13,737 NICU patients.  Of these, 1,659 (12.1%) were readmitted within 90 days.  As the number of outpatient encounters per week increased, the percentage of patients readmitted increased substantially with an 85% readmission rate for patients with >3 visits/week (Figure).  However, these high-utilizers represent a small proportion of the overall cohort, as 98.1% had <2 outpatient visits/week.  Readmitted patients compared to non-readmitted patients were significantly more likely to have neuromuscular (7.7 vs. 4.5%, p<0.01), respiratory (17.9 vs. 13.4%, p<0.01), gastrointestinal (4.0 vs. 1.8%, p<0.01), hematologic (1.0 vs. 0.5%, p<0.01) and other congenital or genetic comorbidities (8.0 vs. 3.8%, p<0.01), but were less likely to have cardiovascular diagnoses (31.1 vs. 42.4%, p<0.01).

Conclusion:  We demonstrate that frequent outpatient healthcare utilization is a strong indicator of impending hospital readmission after NICU discharge.  However, the overall readmission rate for these children is relatively low given their high burden of comorbid conditions.  Cardiac patients were less likely to be readmitted, perhaps due to longer length of stay or specialized discharge strategies.  More study is needed to determine the optimal frequency of primary care visits in these complex patients.

 

52.14 Outcomes of Circumcision in Children with Single Ventricle Physiology

Posted on January 18, 2018

J. A. Sujka1, R. Sola1, A. Lay1, S. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:
Children with single ventricle physiology (SVP), especially hypoplastic left heart syndrome, have been shown to have a high morbidity and mortality after major non-cardiac surgical procedures. Elective circumcision, a cosmetic procedure, is one of the most common operations for infants and children with a very low morbidity with <1% of patients requiring readmission or reoperation. The purpose of our study was to review our institutional experience with SVP children undergoing circumcisions to determine the peri-operative course and outcomes.

Methods:
With IRB approval, we performed a retrospective review of children with SVP who underwent an elective circumcision from 2000 to 2017. Children with SVP include hypoplastic left heart syndrome, double outlet right ventricle, and tricuspid atresia. Children with non-single ventricle physiology congenital heart disease and those children undergoing circumcision in combination with another case were excluded from the study. Patient’s demographics, surgical characteristics and outcomes were analyzed. All means reported ± standard deviation.

Results:

There were 15 males who underwent elective circumcision from 2000 to 2017.  The mean gestational age at birth was 37.7 ± 2.65 weeks.  Their mean age at the time of their surgery was 1.39 ± 0.82 years old. Their mean weight was 9.7 ± 1.6 kg. Fourteen were Caucasian and one was African American.  Eleven of fifteen (73%) children were diagnosed with hypoplastic left heart syndrome, all had undergone their first stage procedure with 10 of 15 (66%) undergoing a Norwood Reconstruction as their first stage operation. 

All children underwent a circumcision due to uncomplicated phimosis. Thirteen (87%) of the children underwent a freehand circumcision.  Eighty four percent underwent their circumcision after their 2nd stage cardiac operation with only two patients having their circumcision after their 3rdstage cardiac surgery. 

The mean operative time was 20 ± 7 minutes and there was a mean total length of stay of 247 ± 98 minutes. None of the children were admitted after their circumcision. There were no intraoperative complications.  Post-operative complications included two (16.7%) hematomas with one requiring surgical intervention.  Both complications occurred in patients undergoing a freehand circumcision. There were no deaths within the first 30 days after surgery. There were no unplanned readmissions in one year after surgery.  

Conclusion:

Children with single ventricle physiology who undergo elective circumcision may have higher risk of complications, especially bleeding, compared to the general population.  Further investigations with more patients to better define the risk and allow for definitive recommendations are needed.

52.12 Symptom Resolution and Volumetric Reduction of Abdominal Lymphatic Malformations with Sclerotherapy

Posted on January 18, 2018

H. J. Madsen1,2,5, A. Annam2,3,5, R. Harned2,3,5, T. A. Nakano2,4,5, L. O. Larroque1,2, A. M. Kulungowski1,2,5  1Children’s Hospital Colorado,Divsion Of Pediatric Surgery,Aurora, CO, USA 2Children’s Hospital Colorado,Vascular Anomalies Center,Aurora, CO, USA 3Children’s Hospital Colorado,Interventional Radiology,Aurora, CO, USA 4Children’s Hospital Colorado,Center For Cancer And Blood Disorders,Aurora, CO, USA 5University Of Colorado,School Of Medicine,Aurao, CO, USA

Introduction:   Lymphatic malformations are congenital lesions that arise from errors in vascular embryogenesis.  Cystic lymphatic malformations are categorized based on the size of the lymphatic channels as microcystic, macrocystic, or combined.  Abdominal lymphatic malformations are rare.  Surgical resection of abdominal lymphatic malformations has been the mainstay of therapy but recurrence is high.  We sought to determine the effectiveness of sclerotherapy for the treatment of abdominal lymphatic malformation with regards to symptom resolution and volume reduction.  

Methods:   A single-center, retrospective review from 2014-2017 was conducted evaluating patients with abdominal lymphatic malformations.

Results:  Eight patients were included; 7 patients were male.  Macrocystic lymphatic malformation was the predominant type (n=7); one patient had microcystic disease.    The average age at time of first treatment was 6.8 years (range, 0-17 years). The most common presenting symptoms were distention (n = 7), abdominal pain (n = 6), infection (n = 2) and anemia (n = 1).  Preprocedural cross-sectional imaging was performed for all patients with an average pretreatment volume of 2983.7cm3 (± 4228.6 cm3).   Lymphatic malformations were accessed using ultrasonographic guidance followed by injection of opacified doxycycline.  Patients were treated with a mean of 7.75 cycles (range, 2-16 cycles) of doxycycline sclerotherapy.  Catheters were left in place for a median of 3 treatments (range, 1-7 treatments).  Complications included: intraperitoneal extravasation of doxycycline (n = 1) and infection of the abdominal lymphatic malformation (n=1).  The extravasation was managed conservatively and remained asymptomatic.  The infection was treated successfully with intravenous antibiotics and drainage.  One patient went on to surgical resection of the lymphatic malformation due to inability gain access to the lymphatic malformation.  Postprocedural imaging was available for 87.5% (7/8) patients; one patient is awaiting posttreatment imaging.  Magnetic resonance imaging was obtained after sclerotherapy for 6 patients with 83.3% (n = 5) showing resolution of the lymphatic malformation.  Lymphatic malformations’ volumes decreased by 97.1% after sclerotherapy.  The average remaining volume was 85.7 ± 226.7 cm3 (p = 0.07).  The patient undergoing surgical resection had follow-up abdominal ultrasonography that showed no recurrence.  All patients had resolution of presenting symptoms.  Follow-up duration was 11.8 months (range, 6-24 months).   

Conclusion: Initial results demonstrate that sclerotherapy is a safe and effective treatment for abdominal lymphatic malformations providing symptom resolution and volumetric reduction.

 

52.09 Surgeon Accuracy in Identifying Children with Simple Appendicitis

Posted on January 18, 2018

Y. R. Yu1,2, E. H. Rosenfeld1,2, S. Dadjoo1,2, M. E. Lopez1,2, S. R. Shah1,2, B. J. Naik-Mathuria1,2  1Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Surgery,Houston, TX, USA

Introduction:
Non-operative management (NOM) of simple appendicitis is a proposed alternative to traditional appendectomy. This study assessed the accuracy of surgeons’ prediction of appendicitis severity.

Methods:
From February to August 2016, pediatric surgeons prospectively predicted whether patients had simple or complex appendicitis before the operation based on clinical data, imaging, and general assessment at a single tertiary care pediatric hospital. Surgeon confidence in their prediction using a 5-point Likert scale was documented. Results were analyzed using receiver operating characteristic (ROC) curves to determine area under the curve (AUC) and optimal cut-off points of clinical findings for diagnosing simple appendicitis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) were also calculated. Predictions were compared to findings using χ2 . A p-value < 0.05 was considered statistically significant.

Results:

Of 125 cases, 73 (58%) were male and the median age was 9 years (range 1-18 years). Simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Surgeons were generally confident of their predictions (simple: 87% certainty, complex: 88% certainty). Predictions were accurate in 59 (77%) of simple cases and 45 (94%) of complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71% (Table).

Eighteen cases (14%) were inaccurately predicted as simple when they were actually complex.  Of these, 6 (33%) were gangrenous, 17 (94%) had focal/no abdominal tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound reported as simple appendicitis, 11 (61%) had ≤ 2 days of symptoms, and 8 (44%) were afebrile (<100.4 oF).

Lower WBC (<15.5×103/uL, AUC 0.61, p=0.05), afebrile (<100.4 oF, AUC 0.86, p<0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p<0.001) were associated with simple appendicitis. 

Conclusion:
Successful NOM for appendicitis works best in patients with simple appendicitis. While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, a significant error rate still exists. 

52.10 Gastrointestinal Outcomes in Congenital Diaphragmatic Hernia

Posted on January 18, 2018

M. A. Verla1,2, T. C. Lee1,2, C. C. Style1,2, P. E. Lau2, A. R. Mehollin-Ray1,3, C. J. Fernandes1,4, S. C. Fallon2, C. A. Ikedionwu2, S. G. Keswani1,2, O. O. Olutoye1,2  1Texas Children’s Hospital,Fetal Center,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Department Of Radiology,Houston, TX, USA 4Texas Children’s Hospital,Department Of Pediatrics – Newborn Section,Houston, TX, USA

Introduction:  Congenital diaphragmatic hernia (CDH) is a major anomaly with high mortality and significant long-term comorbidities. Survivors are at risk for developing gastrointestinal (GI) disorders, some requiring corrective abdominal surgical procedures. The purpose of this study was to examine the GI outcomes in CDH.

Methods:  This is a retrospective review of all infants evaluated for CDH at a single institution tertiary fetal center from April 2004 to March 2017. Data analyzed included prenatal imaging data and postnatal GI outcomes. Imaging features included liver position, stomach position, lung to head ratio, total fetal lung volume (TFLV), observed to expected total fetal lung volume (O/E TFLV) and laterality of defect. GI outcomes were defined as gastro-esophageal reflux disease (GERD), gastroparesis, and abdominal surgeries including fundoplication, gastrostomy tube (G-tube) placement, or exploratory laparotomy for bowel obstruction. Data were analyzed using chi-square, ANOVA, Mann-Whitney U test and student’s t-test as appropriate; a p-value of <0.05 was considered significant. Results are listed as percentages or median (interquartile range) unless otherwise stated.

Results: A total of 250 infants were evaluated over a thirteen year period. Of these, 55.2% were male (n=138). Seventy seven percent (n=192) had left sided CDH, 64% had an intrathoracic stomach, and 70% had an intrathoracic liver morphology prenatally. Postnatally, 78 neonates (31%) required ECMO (Extracorporeal Membrane Oxygenation). The cohort survival was 74% with a median age at repair of 3 days of life [3 – 6 days]. Of the 184 CDH survivors, 99% received total parental nutrition (TPN) for a median of 18 [14 – 28] days. After repair, enteral feeds were initiated at a median of 7 [5 – 10] days and full enteral feeds attained at a median of 11 [7 – 190] days. Of the survivors, 57% (n=105) had GERD requiring medication and 12% (n=21) had gastroparesis. Of those with GERD, 68% (n=71) had an intrathoracic stomach morphology prenatally and 27% (n=28) failed medical management requiring a fundoplication. Overall, 48% (n=89) of survivors had some form of abdominal surgery separate from the CDH repair. Neonates with unfavorable prenatal indices were more likely to require ECMO. There is a significant correlation between ECMO use and having a G-tube, GERD, gastroparesis, fundoplication, or need for other abdominal surgical intervention (p <0.05, Table 1).

Conclusion: A significant number of infants with CDH will have some form of GI morbidity postnatally. Those with severe CDH requiring ECMO are at an increased risk for needing a G-tube or other GI surgery. The results of our study may aid in pre- and postnatal counseling.

52.11 Assessment of Outcomes and Costs for Common Surgical Procedures at Children’s and Non-Children’s Hospitals

Posted on January 18, 2018

C. Tom1, R. P. Won1, E. Saab2, A. D. Lee2, S. Friedlander3, S. L. Lee1,2,3  1Harbor-University Of California Los Angeles Medical Center,Department Of Surgery,Torrance, CA, USA 2University Of California Los Angeles,Department Of Surgery,Los Angeles, CA, USA 3Los Angeles Biomedical Research Institute,Torrance, CA, USA

Introduction:  The benefits of managing children after pediatric surgical procedures or injury at children’s hospitals (CH) are well established. However, little is known about the outcomes and costs of managing common pediatric surgical procedures at non-children’s hospitals (NCH). The purpose of this study is to compare the outcomes and costs of appendectomy and cholecystectomy between CH and NCH.

Methods:  Using the Kids’ Inpatient Database (KID), we compared costs and outcomes for pediatric patients (< 18 years old) who underwent appendectomy and cholecystectomy in 2003, 2006, 2009, and 2012 at CH and NCH. We analyzed the patient demographics, complexity of disease, surgical management (rate of laparoscopy), length of stay (LOS), morbidity, and costs between CH and NCH. 

Results: The majority of appendectomies (NCH = 223,924 vs CH = 83,048) and cholecystectomies (NCH = 18,406 vs CH = 8,774) were performed at NCH. Overall, CH cared for younger children, had higher costs, and increased LOS compared to NCH. Results of the univariate analysis are summarized in the table. On multivariate analysis for appendectomies, CH treated younger children with higher rates of perforated appendicitis, and were associated with increased use of laparoscopy, longer LOS, lower complication rates, and higher costs. Conversely, multivariate analysis for cholecystectomy demonstrated that CH were associated with decreased use of laparoscopy, longer LOS, and higher costs with no difference in the complication rate compared to NCH. 

Conclusion: Variations in surgical management, outcomes, and costs related to common surgical procedures in children exist between CH and NCH. Appendectomies at CH are associated with improved outcomes and higher utilization of laparoscopy despite treating more advanced disease, but have longer LOS and higher costs.  Cholecystectomies at CH are associated with no difference in outcomes, but are less likely to utilize laparoscopy, have longer LOS, and higher costs. Opportunities exist at both CH and NCH to improve the quality of care and lower expenses for common surgical diseases in children.  

 

52.07 Therapeutic Direction Versus Adverse Outcomes in Children Undergoing Lung Biopsy

Posted on January 18, 2018

J. Sobrino1, N. Le1, J. Sujka1, L. A. Benedict1, R. M. Rentea1, H. Alemayehu1, T. A. Oyetunji1, S. D. St.Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA

Introduction:

The indications for lung biopsy cover a wide array of pulmonary disease. While the morbidity of the procedure has decreased with the use of thoracoscopy, lung biopsy still holds substantial risk for the patients as they all have some degree of pulmonary dysfunction. Therefore we evaluated the likelihood of lung biopsies impacting treatment compared to complications.

Methods:

This is an IRB approved, single-institution, retrospective chart review of all patients less than 18 years of age undergoing lung biopsy as the primary operation between January 2010 and August 2016. Demographics were recorded, as well as details of patient presentation, pre-operative and post-operative management, operative course, peri-operative vital signs, pathology, adverse events, complications, and follow-up. Complications were defined as being related directly to the technical aspects of the lung biopsy, while adverse events were defined as clinical deterioration attributable to the overall process of lung biopsy and underlying lung disease. All values are reported as medians with interquartile range (IQR).

Results:

38 patients met criteria for inclusion in the study during the time period evaluated. The median age was 6.9 years old (IQR 1.5, 14.6 years) with a median weight of 18 kg (10.4, 52 kg). The median length of operation was 41.5 minutes (IQR 29.8, 55.5 minutes). The median length of follow up was 1.9 years (IQR 1.0, 3.5 years).[TO1]  87% (33) of biopsies were performed thoracoscopically, with a 3% conversion rate to thoracotomy.

Adverse events occurred in 21% (n=8) of cases including prolonged respiratory failure (18%, n=7) and cancellation of a planned joint procedure [TO2] due to acute respiratory failure (3%, n=1). Complications occurred in 16% (6) of cases including pneumothorax (13%, n=5) and cardiac arrest (3%, n=1). A third of these complications (33%, n=2) required re-operation, and both were urgent decompressions of tension pneumothoraces. There was a 10% (n=4) mortality rate during the same hospitalization.

The majority (68%, n=26) of cases were referred for lung biopsy with a working diagnosis of interstitial or diffuse lung disease. The pathology was definitive in 63% (n=24) of cases, yet it only changed the diagnosis in less than a third (29%). Treatment was changed 42% of cases, and in 5% of cases, a negative biopsy dictated subsequent management. There was no statistically significant difference between cases where pathology changed treatment in terms of age, weight, operative time, and length of follow-up.

Conclusion:

Lung biopsy for questionable pulmonary disease changed treatment in less than half of cases, with significant perioperative morbidity. Careful consideration should therefore be given to who would benefit most from lung biopsy.

52.08 Pediatric Single-Site Laparoscopic Appendectomy: Predictors of Conversion to Multiport Appendectomy

Posted on January 18, 2018

N. L. Gates1, R. D. Rampp1, S. D. Bhattacharya1  1University Of Tennessee College Of Medicine,Department Of Surgery,Chattanooga, TN, USA

Introduction:  Single-incision laparoscopic appendectomy (SILA) in the pediatric population has been well described in small case series and met analyses.  Our children’s hospital has adopted this modality for nearly all appendectomies since 2012.  In a review of 1000 consecutive cases from 2012-2017, we hoped to identify factors that portend conversion from SILA to multiport appendectomy.  We compared our cohort of conventional three port laparoscopic appendectomy (CLA) for outcomes including operative time, post-op length of stay, complications and readmission.

Methods:  A retrospective chart review of 1000 patients who underwent appendectomy from March 2012 to February 2017 at a single Children’s Hospital was performed. The type of appendectomy performed (single incision, conventional multiport, open), if the case was converted from single incision to multiport or open, and perforation status were recorded. Demographic data identified included age, sex, and BMI. Outcomes analyzed were operative time, length of stay, and postoperative complication/readmission rate. 

Results: Of 1001 appendectomies during the study period, 959 (95.9%) were initiated with plan for SILA,    35 (3.5%) were initiated CLA, and 6 (0.6%) were initiated via open approach.  Of those initiated SILA, 884/959 (92.2%) were able to be completed without additional port placement.   Cases initiated SILA for perforated appendicitis had a higher rate of conversion to multiport (22/169, 13%) than cases initiated SILA for non-perforated appendicitis (45/782, 5%; p<0.01).   Cases which were not able to be completed SILA were statistically significantly more likely to be older, male patients, or have increased BMI.  When compared to cases which were initiated CLA for perforated appendicitis, SILA- regardless of conversion- remained statistically similar for operative times and length of stay but had higher return to emergency department.  We found no statistically significant risk factors among any of the subgroups identified for increased morbidity such as small bowel obstruction, UTI, readmission, or abscess/reinterventions. 

Conclusion: Single incision laparoscopic appendectomy appears to be a safe and easily adopted modality for the treatment of appendicitis in pediatric populations with no increased morbidity.   Parents of children that are obese, males or present with perforation should be counselled regarding the possibility of additional port placement or considered for initiating conventional laparoscopic appendectomy.

 

52.05 Pre-Operative Factors and Response to Surgical Treatment of Achalasia in Pediatric Patients

Posted on January 18, 2018

R. J. Vandewalle1, C. C. Frye1, M. P. Landman1, J. M. Croffie2, F. J. Rescorla1  1Indiana University School Of Medicine,Department Of General Surgery, Division Of Pediatric Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Department Of Pediatrics, Division Of Gastroenterology,Indianapolis, IN, USA

Introduction:
Esophageal achalasia is an uncommon condition in children.  While many interventions exist for the management of this disorder, esophageal (Heller) myotomy offers one of the most durable treatments.  We reviewed patients undergoing Heller myotomy to ascertain pre-operative clinical factors that might predict post-operative outcomes.  

Methods:
All patients from 1/1/2007 to 12/31/2016 who underwent surgical treatment for achalasia at a tertiary pediatric hospital were identified and included in the study cohort.   Medical records for these patients were reviewed for clinical presentation variables, pre-operative high resolution manometry (HRM) data, non-surgical pre-operative treatment, surgical approach, response to surgery, and need for post-operative treatment for ongoing symptoms.

Results:
Twenty-six patients were included in the study and all underwent myotomy with partial fundoplication [median age: 14.4 years (IQR 11.6-15.5).  Twenty patients had HRM data available for review. At a median follow up of 9.75 months (IQR 3.5-21), 16 (61.5%) patients self-reported complete/near-complete resolution of their dysphagia symptoms with surgery alone.  Eight patients (30.8%) required additional treatment for achalasia, with 5 (19.2%) undergoing additional operative/endoscopic interventions.  Patients who had pre-operative dilation did not have self-reported complete/near-complete resolution of their dysphagia (n=2; p=0.037).  There was a statistically significant association for patients with pre-operative dilation undergoing post-operative dilation (p=0.0010).  None of these patients underwent pre-operative manometry.  There was a statistically significant difference in the ages of patients who required post-operative treatment to improve dysphagia and those that did not (14.1 vs. 15.2 years old; p=0.043), respectively.  When comparing patients who reported good response of GERD/reflux type symptoms to surgical intervention, there was a statistically significant difference in pre-operative HRM lower esophageal residual pressure (29.1 vs. 18.7mmHg; p=0.018) and upper esophageal mean pressure (66.6 vs. 47.8mmHg; p=0.050) and those that did not, respectively.  3 patients who underwent reversal of their fundoplication for ongoing dysphagia had available HRM data.  There was a significant difference in distal contractile integral (4374.2 vs. 1573.5mmgHg-cm-sec; p= 0.030), upper esophageal sphincter mean residual pressure (14.3 vs. 3.8mmHg; p=0.025), and effective contractions (10% vs. 0%; p=0.010) between those that had their fundoplication reversed and those that did not, respectively.

Conclusion:
Current analysis suggests that pre-operative dilation may either indicate a higher likelihood of disease difficult to treat surgically or make achalasia difficult to treat itself.  Older patients appear to have a better response to surgery.  Additionally, pre-operative HRM may aid in determining if fundoplication should be completed at the time of myotomy.  Further research is needed to delineate these factors.

52.06 Improving Imaging Strategies for Pediatric Appendicitis

Posted on January 18, 2018

L. Schoel1, I. I. Maizlin1, T. Koppelmann1, M. Shroyer1, A. Douglas1, R. T. Russell1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA

Introduction: Appendicitis represents the most common surgical emergency in children, yet it can often be difficult to differentiate from other causes of acute abdominal pain. Diagnostic imaging modalities, such as computed tomography (CT) and ultrasonography (US), are often employed to assist with the diagnosis of acute appendicitis in children. The American College of Radiology recommends ultrasound as the first line imaging study for children with suspected appendicitis. Data from the American College of Surgeons NSQIP-Pediatric Appendectomy pilot identified our facility as a high outlier for CT utilization. We performed a quality improvement effort to reduce this utilization in favor of US-based diagnoses through creation of an appendicitis algorithm.

Methods: An evidence-based algorithm was created by a multidisciplinary team incorporating the Pediatric Appendicitis Score to direct surgical consultation and imaging recommendations for all patients presenting directly to our facility. We evaluated data from a two-year period, including one year preceding and one year following institution of the protocol, to assess changes in imaging strategies for pediatric appendicitis. Patients transferred from referring facilities with prior imaging were excluded. Standard statistical methods were utilized.

Results: A total of 227 patients (117 pre-/110 post-protocol initiation) were primarily evaluated in our Emergency Department and diagnosed with appendicitis during the period in question. There were no differences in gender, age, race, or BMI between the groups. There was a significant reduction in the utilization of CT following introduction of the protocol (Fig 1) and a concurrent increase in the utilization of US. Importantly, there were no differences in length of stay (p=0.27), post-operative complications (p=0.19), or negative appendectomy rates (p=0.40) between the two periods. Based on estimated imaging charges for US and CT, this reduction saves an estimated $109, 400 in health care costs for this population.

Conclusion: Based on NSQIP-Pediatric Appendectomy data, we initiated and experienced success in a quality improvement project to decrease the utilization of CT scans for diagnosis of pediatric appendicitis. This paradigm shift led to significant health care cost savings without negatively affecting post-operative outcomes. NSQIP data provide a useful framework on which to build collaborative quality improvement efforts.

 

52.03 Evaluation of Disparity in Healthcare for Perforated Appendicitis in a National Health Care System

Posted on January 18, 2018

L. M. Fluke1, A. Peruski2, C. Shibley2, B. Adams2, S. Stinnette2, R. Ricca1  1Naval Medical Center Portsmouth,Pediatric Surgery,Portsmouth, VA, USA 2Navy And Marine Corps Public Health Center,Health Analysis Department,Portsmouth, VA, USA

Introduction:
Disparity in healthcare due to bias caused by racial differences and socioeconomic status has been reported in the management of appendicitis. Passage of the Affordable Care Act has improved access to healthcare across the United States. TRICARE is a nationwide managed care program for the military that provides equal access to healthcare independent of race or socioeconomic status. Perforated appendicitis (PA) in children is used as an index for barriers to care as it is thought to result from delays in treatment. We evaluated the effect of racial and socioeconomic differences on the likelihood of PA to determine if a disparate level of care exists in an equal access national healthcare system. 

Methods:
Retrospective review of pediatric patients who underwent appendectomy from October 2010 through September 2015 was performed after Institutional Review Board approval was obtained. Data was collected from the Military Health System Data Repository. TRICARE patients aged 6 months to 17 years who underwent appendectomy in the continental United States were included. Logistic regression was used to examine the association between ethnicity, age, gender, marital status and deployment status of the active duty parent, distance from child’s home to facility performing the appendectomy, type of facility and type of admission with the odds of having a perforated appendix.

Results:
A total of 3,124 children met inclusion criteria. The majority of children were non-Hispanic white, males with an average age of 10.5 years, and had sponsors who were married, senior enlisted, and not deployed at the time of their appendicitis diagnosis. Most children were admitted based on a referral from another source (e.g. clinic). One-third of patients had the diagnosis of PA. There was no difference in odds of having a perforated appendix based on ethnicity. Children of a single active duty parent or admitted from another institution had significantly higher odds of perforated appendicitis. Additionally, there is a decrease in the odds of having a perforated appendix for every year increase in the child’s age for enlisted personnel and senior officers (Table 1).

Conclusion:
In a national healthcare system, no healthcare disparity was found based upon race with regards to perforated appendicitis. Increased odds of perforated appendicitis persist in younger patients with lower socioeconomic status despite equal access to care. Preventive efforts focused on ease of access should be explored. 

52.04 Inter-rater Reliability of a Grading System for Congenital Diaphragmatic Hernia Defect Size is Fair

Posted on January 18, 2018

C. E. Hunter1, Z. M. Saenz1, D. Nunez1, L. Timsina2, B. W. Gray1  1Indiana University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Center For Outcomes Research In Surgery, Department Of Surgery,Indianapolis, IN, USA

Introduction:
The Congenital Diaphragmatic Hernia Study Group (CDHSG) registry is a vital multi-institutional tool to help track outcomes of CDH patients to improve prognosis and patient care. The CDHSG asks surgeons to categorize each patient’s diaphragmatic defect size as grade A, B, C, or D based on published guidelines. A reliable grading system of these defects is important for individual patient prognosis and clinical research. The reported size of the defect has been correlated with patient outcomes, such as survival. However, the inter-rater reliability of this system has not been evaluated. The goal of this study was to evaluate the inter-rater reliability of the CDHSG grading system.

Methods:
The operative notes from patients that underwent surgical repair of a unilateral CDH at a single institution between 2010 and 2016 were collected. Forty-six operative notes were cropped to include only the information necessary to grade the hernia defect A-D based on the CDHSG grading system guidelines. The defects were graded by 9 pediatric surgeons of differing experience levels, and the inter-rater reliability was determined by calculating a Cohen’s kappa (κ). The following cutoffs were used to interpret κ: ≤ 0 – no agreement, 0.01-0.20 – none to slight agreement, 0.21-0.40 – fair agreement, 0.41-0.60 – moderate agreement, 0.61-0.80 – good agreement, 0.81-1.00 – very good to perfect agreement.  Data was also collected on intraoperative findings (liver up vs. down, ECMO status, need for patch repair) and patient outcomes (length of stay, survival).

Results:

Overall, there was 57.49% agreement across all raters, corresponding to a fair level of agreement (κ=0.395, p<0.001). Between any two raters, agreement ranged from no agreement (21.74% agreement, κ= -0.027) to good agreement (82.61% agreement, κ= 0.7543). All 9 of the surgeons agreed in only 2 of the 46 patients, both of which were assigned an “A” grade. Four patients received 3 different grades: 3 received grades A, B, and C, and 1 received grades B, C, and D. No patients were given all four grades. Overall, there was 87% survival (n=40). Inter-rater agreement was similar despite different operative findings and outcomes (p > .05): survival yes/no (κ=0.3690, κ=0.3518), need for ECMO yes/no (κ=0.3323, κ=0.3362), patch repair yes/no (κ=0.2050, κ=0.1916), and liver up/down (κ=0.2941, κ=0.4404).

Conclusion:
This single institution study shows that while the CDHSG grading system is not random, it produces only a fair amount of agreement between pediatric surgeons when grading the severity of hernia defects. Patient outcomes and intraoperative findings do not affect levels of agreement. Future research will examine intra-rater reliability of this system and will work to provide a more reliable system for grading the severity of CDH defects. 

52.02 The Disproportionate Cost of Surgery and Congenital Anomalies in Infancy

Posted on January 18, 2018

J. C. Apfeld1,6,7, Z. J. Kastenberg1,2, F. S. Jazi1, C. S. Phibbs4,5, H. C. Lee3,4,6, K. G. Sylvester1,2,3,4  1Stanford University School Of Medicine,Department Of Surgery,Palo Alto, CA, USA 2Stanford University School Of Medicine,Center For Health Policy/Center For Primary Care And Outcomes Research,Stanford, CA, USA 3Lucile Packard Children’s Hospital,Center For Fetal And Maternal Health,Palo Alto, CA, USA 4Stanford University School Of Medicine,Department Of Pediatrics,Palo Alto, CA, USA 5Veterans Affairs Palo Alto Healthcare System,Health Economics Resource Center And Center For Implementation To Innovation,Menlo Park, CA, USA 6Stanford University,California Perinatal Quality Care Collaborative (CPQCC),Palo Alto, CA, USA 7Cleveland Clinic,Department Of General Surgery,Cleveland, OH, USA

Introduction:
Congenital anomalies are one of the leading causes of infant deaths and pediatric hospitalizations, but existing estimates of the associated healthcare costs are either cross-sectional survey studies or economic projections. This study sought to determine the percent of total healthcare expenditures attributable to major anomalies requiring surgery within the first year of life. 

Methods:
Utilizing comprehensive California state-wide data from 2008-12 and validated selection criteria, cohorts of major surgery, birth defect, and surgical anomalies were constructed alongside referent groups of non-surgical/non-defect newborns. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first-year-of-life; with additional stratifications by birthweight, gestational age, and involved organ system.  

Results:
In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n=32,614) or had a diagnosis of a severe congenital anomaly (n=57,793), comprising $7.7 of $18.9 billion (40.7%) of total first-year of life hospitalization costs/expenditures, $7.1 billion (49.3%) of costs for infants with long birth hospitalizations (5+ days; n=211,791), $5.2 billion (57.8%) of total NICU admission costs. More specifically, infants with surgical anomalies (n=14,296) totaled $3.7 billion (19.6%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases comprised most admission costs secondary to major surgery or congenital anomalies.   

Conclusion:
Considering the medical costs of all newborns, infants with congenital surgical anomalies consume a disproportionate cost within the US healthcare system. The care and associated costs of these infants, which are covered to a significant degree by Medicaid, represent a particular focus in an era of healthcare payment reform.

52.01 Management of Long Bone Metastasis from Malignant Solid Tumors in Children

Posted on January 18, 2018

M. W. Lu1,2, L. Van Houwelingen1, M. D. Neel1, A. M. Davidoff1, M. J. Krasin1, B. N. Rao1, I. Fernandez-Pineda1  1St. Jude Children’s Research Hospital,Surgery,Memphis, TN, USA 2University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA

Introduction:
Management of long bone metastasis from pediatric solid tumors and skeletal-related events (SREs) – including severe bone pain, immobility, and pathological/impending fracture – have not been widely described in children with cancer. We aimed to investigate the clinical presentation, SREs, management, and outcomes of pediatric solid tumor patients with long bone metastasis treated at our institution.

Methods:
Medical records of pediatric solid tumor patients with long bone metastasis treated at our institution between 2005 and 2015 were retrospectively reviewed. Variables analyzed included demographics, primary diagnosis, patterns of bony metastatic disease, management, and outcomes.

Results:
Ninety-nine patients (57 males, 42 females), median age at primary solid tumor diagnosis of 42 months (range, 1.5 – 247 months), were identified. Primary diagnoses included neuroblastoma (82), rhabdomyosarcoma (7), retinoblastoma (2), and other solid tumors (8). Seventy-five (76%) patients had both upper and lower extremity involvement; 22 (22%) had lesions limited to the lower extremities and 2 (2%) to the upper extremities. Eight (8%) patients had metastasis to a single long bone; 91 (92%) had metastasis to multiple long bones. Eighteen (18%) patients were diagnosed with long bone metastasis non-synchronous with their primary diagnosis with a median length of time to long bone metastasis diagnosis of 30.5 months (range, 3 – 60 months). Seventy-five (76%) patients presented with or experienced at least one SRE (67 patients had severe bone pain, 42 had immobility, and 14 had pathological fracture), of which 42 had more than one discrete SRE. Among patients with an SRE – 43 (57%) patients required only observation for their long bone metastasis; 27 (36%) patients required radiation, of which 21 were indicated for palliation; 12 (16%) patients required cast immobilization; and 4 (5%) patients required surgery: one had bony metastatic resection and 3 had prophylactic fixation for impending fracture. One patient had closed reduction of a pathological fracture. All 24 patients that did not experience an SRE required only observation. 

Conclusion:
The most common pattern of long bone metastasis from pediatric solid tumors involves both upper and lower extremities with multiple bones affected. Neuroblastoma is the most common primary diagnosis. Most pediatric solid tumor patients with long bone metastasis are managed well with observation alone. Cast immobilization and palliative radiation are considered for patients who fail to improve with conservative management. Impending high-risk fracture is managed with prophylactic fixation; otherwise, surgery is rarely indicated. Although SREs are commonly seen among these patients, most are managed conservatively. 
 

51.18 Outcomes of Atypical Genitalia Surgery for Disorder of Sexual Development in Pediatric Population

Posted on January 18, 2018

A. F. Doval1, B. N. Tran1, B. T. Lee1, O. Ganor2  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA 2Boston’s Children Hospital,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction: Infants with a congenital discrepancy between external genitalia, gonadal, and chromosomal sex are classified as having a disorder of sexual development.  The most common form of DSD with atypical genitalia is 46 XX with congenital adrenal hyperplasia; as such feminizing genitoplasty is the standard surgical correction. We examined the trends and outcomes of atypical genitalia surgery for DSD in pediatric population using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

Methods: Infants with DSD were identified from NSQIP 2012-2015 using ICD 9 and 10 codes.  Descriptive data about patients’ demographics, types of procedures, surgical specialty performing the surgery, and perioperative complications including bleeding, infection, wound dehiscence, unplanned reoperation, unplanned intubation, and readmission were obtained.

Results: 46 cases of DSD were identified. Most surgical correction occurred at 3-4 years of age in genetically female patients (65%).  Types of reconstructive surgery included feminizing procedures (45.7% including vaginoplasty, clitoroplasty), masculinizing procedures (28.3% including laparoscopic procedure on testis, laparoscopic vaginal hysterectomy, penile repair, vaginectomy, laparoscopic TAH-BSO), or undetermined (26% including adjacent diagnostic laparoscopy, tissue transfer, excision of penile lesions, and enterostomy and external fistulization of intestines).  Postoperative complications detailed 2 incidences of bleeding requiring transfusion, 1 of unplanned intubation, and 1 of prolonged hospitalization.

Conclusion: This study reaffirms the rising awareness of surgical intervention for disorders of sexual development. Most patients were genetically female with congenital adrenal hyperplasia and the most common reconstructive surgery was feminizing genitoplasty. Interestingly, the mean age of reconstruction reflected early genital surgery. Postoperative complications showed that atypical genitalia surgery is safe for pediatric population. 

 

51.19 Evaluation of current practices and presence of advanced providers in pediatric surgery

Posted on January 18, 2018

B. R. Beaulieu-Jones1, D. P. Croitoru2, R. M. Baertschiger2  1Geisel School Of Medicine At Dartmouth,Hanover, NH, USA 2Dartmouth Hitchcock Medical Center,Pediatric Surgery, Department Of Surgery,Lebanon, NH, USA

Introduction:

The shortage of physician providers, resident work hour limitations and the demonstrated positive impact of advanced providers (AP, nurse practioners, NP, physician assistants, PA and clinical nurse specialists, CNS) on the quality and efficiency of care in numerous specialties have led to broader integration of AP in healthcare organizations. With regard to pediatric surgery, some tertiary centers have successfully implemented 24/7 NP coverage for their inpatient services. However, pediatric surgery practices vary throughout North America and the broader presence and function of AP among all practice types and settings has not been characterized previously. The purpose of this survey is to conduct a descriptive evaluation of current pediatric surgical practices in North America with regard to AP coverage and their impact on patient care, as well as patient and surgeon satisfaction.

Methods:
A fourteen item online survey, approved by the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee, was distributed to all full APSA members (N=1189, opening rate of 56%), representing the vast majority of pediatric surgeons in North America. The survey investigated the practice characteristics of the responding surgeon, the presence and role of AP in their practice and their impact on patient care. Descriptive statistics were performed to characterize the function of AP in pediatric surgery practices. 

Results:
A total of 266 pediatric surgeons completed the survey (response rate 22% and 40% considering “email send out” and “e-mail opening” rates respectively), with 47.6% employed at free standing children’s hospitals and 41.1% employed at a children’s hospital within an adult hospital. Nearly all respondents (N=244, 91.7%) reported the presence of AP in their practice, with NP (N=216) and PA (N=101) most represented. The majority of AP (N=189, 77.8%) covered both general surgery and trauma patients. AP worked nearly equally in the out- (N=219, 89.8%) and in-patient settings (N=232, 95.1%), and less often in the neonatal (N=131) or pediatric (N=126) intensive care units. 15% of surgeons (N=40) reported that AP provided 24/7 coverage within their practice. Surgeons reported that AP had a very positive (75%) or positive (21%) impact on their practice, with none reporting a negative impact. AP also had a very positive (74%) or positive (21%) impact on patient satisfaction. The main area in which surgeons reported the most significant impact of AP was continuity of care (N=77), efficiency of service (N=66) and education of parents and patients (N=53).

Conclusion:

Pediatric surgical practices of all types are broadly utilizing AP. The integration of AP across inpatient and outpatient settings has positively impacted care, advancing both continuity of care and efficiency of service. AP likely represent part of the solution to delivering quality care in current delivery systems.

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