09.18 Impact of Insurance and Economic status on care for Pyloric Stenosis

Posted on January 25, 2017

K. M. Herremans1, A. Yohann1, J. A. Taylor1, S. D. Larson1, D. Solomon1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Purpose: Hypertrophic pyloric stenosis (HPS) is a common condition in children with a 1:500 incidence. Patients typically present with forceful, repetitive emesis which leads to dehydration and failure to thrive. Delay in presentation is associated with a longer pre operative resuscitation and potentially longer hospital length of stay. The purpose of this study was to investigate the relationship between insurance and economic status with a delay in presentation for HPS.

 

Methods: A retrospective review of patients presenting with HPS was performed over a 5 year period. Patients who did not have the main procedure performed at our institution were excluded. Data regarding demographics, clinical history, time to presentation, and hospital course were collected. Insurance status was assessed, and patients without that information were excluded from final analysis. Zip code related census data was used as a proxy for economic status. The cohort was then divided by time to presentation and severity of hypochloremia. Students t test, Fisher’s exact test, and the Mann Whitney U test were used for comparative analysis.

 

Results: 167 patients were found, of which 155 met inclusion criteria. Overall, 84% patients had Medicaid. The cohort was divided into symptom duration less than or greater than 10 days, as well as by insurance status, and initial chloride level greater than or less than 95. There was no difference in racial or gender distribution among the groups, and the income data was not significantly different either. Commercial insurance patients had a shorter duration of symptoms than Medicaid cases (5.4 vs. 11.2 days), had higher chloride levels (99.4 vs. 91.5), were significantly younger (32.3 vs. 40.9 days), and spent half a day less in the hospital 3.27 vs. 3.85 days).

 

Conclusions: Patients with commercial insurance were significantly more likely to present earlier in the course, have a younger age, as well as a higher chloride level. In addition, patients with Medicaid tended to have more weight loss at presentation and stayed in the hospital longer. Despite the inability of census based income data to show any significance, these data would suggest that access to care may play an important role in timeliness of care for HPS. 

 

09.17 Factors affecting Complications in Tunnelled line Placement in Children

Posted on January 25, 2017

N. Laconi1, S. Islam1  1University Of Florida,Gainesville, FL, USA

 

Introduction:

A large number of children require long term central venous access for a variety of reasons. Tunneled lines are the most common kind of access used in these patients as they can last for longer duration. These catheters can be associated with complications and result in substantial morbidity. The purpose of this study was to better understand the factors associated with complications with tunneled central lines in children

Methods:

After obtaining IRB approval, the hospital database was searched for all central lines placed in patients aged 0-18 years of age over a 5 year period. Patients with PICC and non tunneled central lines were excluded. Data regarding demographics, indications, line type, complications and outcomes were collected and compiled. The cohort was divided into those who had any complication vs. those who did not. Students t test and fischers exact test were used where appropriate and a p value of less than 0.05 was considered significant.

Results:

594 children had tunneled lines placed. Overall mean age was 7.7 years, 52% were male and 43% were placed for cancer. A majority were placed in the subclavian vein and were single lumen. Completely subcutaneous ports were also the most common. 164 cases had a complication (27%), with 82 occlusions and 58 infections. Patients with complications were younger (p=0.002), and had a lower absolute neutrophil count at the time of line placement. Patients with complications were also more likely to have a non neoplastic diagnosis, more frequent access, and have Medicaid for their insurance. There was no difference in complications whether the subclavian or internal jugular were used, nor which service placed it

Conclusions:

In a large cohort of children with long term central access, there was a substantial overall complication rate. Younger patients, with a lower neutrophil count, and with a non neoplastic diagnosis were more likely to have a problem. Significantly more patients with complications had Medicaid for insurance, which is a proxy for poverty. This analysis will help to improve outcomes for children with long term central lines. 

09.16 Postoperative Complications in Children with Congenital Malformations – A NSQIP-Pediatric Analysis

Posted on January 25, 2017

C. L. Kvasnovsky1, J. Salazar1, J. Y. Chun1  1University Of Maryland Medical Center,Department Of Surgery,Baltimore, MD, USA

Introduction:  

Limited data exist to assess the increased risk conferred to children with congenital malformations (CM) undergoing abdominal surgery. Children with CM are presumed to have worse outcomes postoperatively. We sought to quantify the risk of postoperative complications in children with CM, after controlling for co-morbidities. 

Methods:  

The 2012-2014 National Surgical Quality Improvement Program-Pediatric (NSQIP-P) databases were queried to identify patients with and without CM, as defined by the American College of Surgeons, undergoing the 20 most common abdominal procedures in General Surgery. We assessed univariate associations between co-morbidities in patients with CM. Length of stay was compared using the Wilcoxon rank sum test.

 

Multivariate logistic regression to assess the odds of complication, controlling for co-morbid and operative conditions. We compared different wound classifications, using clean wounds as a reference. We assessed for collinearity between comorbidities by testing for variance inflation factors on linear regression. 

Results:

Over the study period, 46,368 children underwent abdominal surgery, including 7752 (16.7%) with a congenital malformation. Children with CM were more likely to have other pre-existing comorbidities, including cardiac risk factors (32.5% vs 6.6% of patients without CM, P<0.0001) and structural pulmonary disease (15.6% vs 2.3%, P<0.0001).

 

Patients with CM had a longer median hospital length of stay (median 3 days, interquartile range [IQR] 1-14, as compared with median 2 days, IQR 1-4, P<0.0001). The majority of patients, (59.0%) underwent urgent or emergent procedures, while patients with CM were more likely to undergo elective procedures (70.2%, P<0.0001).

 

On univariate analysis, the presence of a CM was associated with all complications. For instance, patients with CM had 1.9 the odds of readmission (CI 1.7-2.1, P<0.0001) and 2.7 the odds of wound dehiscence (CI 2.0-3.6, P<0.0001).

 

On multivariate logistic regression, the presence of a congenital malformation was a strong predictor of several complications, from urinary tract infection (P=0.01), post-operative sepsis (P=0.0002), need for reoperation during index stay (P<0.0001), and hospital readmission (P=0.0003, Table). There was no collinearity, allowing for complete analysis of complications. 

However, even after controlling for surgical contamination and other risk factors, there was no correlation between the presence of a congenital malformation and superficial wound infection (P=0.16), deep space infection (P=0.76), or post-operative bleeding episode (P=0.10). 

 

Conclusion:There was no increased postoperative risk conferred by CM for many important outcomes, such as bleeding and wound infection. Future work will focus on the risks associated with individual malformations, to further aid in preoperative risk assessment and family discussions. 

09.15 Non-Accidental Burns in Kids: What Are the Risk Factors?

Posted on January 25, 2017

R. P. Barker1, K. B. Savoie2, R. C. Passaro1, J. W. Eubanks2, R. F. Williams2  1Univeristy Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA 2Univeristy Of Tennessee Health Science Center,Department Of General Surgery And Pediatrics,Memphis, TN, USA

Introduction:
Non-accidental burns account for up to 20% of all non-accidental trauma and have been associated with increased septic complications, longer lengths of stay, more operations, and higher morbidity. Identification of these burns can be difficult; therefore, we sought to identify risk factors associated with non-accidental burns.

Methods:
After institutional review board approval, a retrospective chart study of all patients from 2011-2013 with confirmed or suspected diagnoses of non-accidental burns were identified through the institutional trauma data bank. These patients were then matched 2:1 with burn patients who had no suspicion for abuse based on gender, race, TBSA, and date of burn. Individual charts were reviewed and data was abstracted for basic demographics, injury characteristics, and parameters related to non-accidental trauma. Standard statistical analysis was performed.

Results:
A total of 94 patients were identified; 33 of these were either suspected or confirmed non-accidental cases. The remaining 61 were burn cases with no suspicion for abuse. Non-accidental cases presented at younger ages than accidental cases (median age 1.89 vs 8.42, p <0.0001) and were more likely to present with clinical signs of shock (median SBP 101 vs 124, p = 0.0004, median HR 133 vs 103, p = 0.004, median RR 28 vs 22, p = 0.001). Non-accidental cases were more likely to require ICU admissions (32% vs 7%, p = 0.05). Hospital length of stay was longer for non-accidental cases compared to accidental cases (median days 3 vs. 0, p <0.0001).  A surgery consultation was required for 87.9% of non-accidental cases vs. 50.8% of accidental cases (p <0.0004). Non-accidental cases were more likely to involve the perineum (36.4% vs. 8.2%, p =0.0007) and the feet (42.4% vs. 14.8%, p =0.0033) when compared to accidental burns.  Accidental burns were more likely to involve the upper extremities (37.7% vs. 18.2%, p =0.05) compared to non-accidental burns.  While only 47.5% of accidental cases required admission, 93.9% of non-accidental cases were admitted (p <0.0001). Non-accidental cases were more likely to have underlying social concerns when compared to accidental cases. These included a single parent (45.5% vs. 21.7%, p =0.02) and a previous Department of Children Services (DCS) encounter (27.3% vs. 1.7%, p <0.0001). Trauma activation was initiated in 24% of non-accidental cases and none of the accidental matched cases (p <0.0001).

Conclusion:
Suspected and confirmed non-accidental burn cases are overall more severe than accidental burn cases and require more hospital resources. Younger patients with burns to the perineum or feet who live in a single parent home or have a previous DCS encounter are at increased risk for non-accidental burns and may benefit from early social work consultation or transfer to a burn center for further evaluation. 
 

09.14 Bariatric Surgery in Adolescents: Factors Contributing to Type of Surgery and Treatment Cost

Posted on January 25, 2017

O. Nunez Lopez1, D. Jupiter2, D. Adhikari2, R. S. Radhakrishnan1,3, K. A. Bowen-Jallow1  1University Of Texas Medical Branch,Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Preventive Medicine And Community Health,Galveston, TX, USA 3University Of Texas Medical Branch,Pediatrics,Galveston, TX, USA

Introduction:

Despite the increasing epidemic rates of adolescent obesity, the use of bariatric surgery in adolescents has plateaued since 2003. Sex and race disparities contribute to the underutilization of bariatric surgery. The use of different types of bariatric surgery has changed over time. In order to better understand the underutilization of adolescent bariatric surgery, we set out to identify potential factors that can impact treatment cost and influence the type of bariatric procedure used in adolescents.

Methods:

We used the Kid’s Inpatient Database, a nationwide population-based survey from 2006, 2009, and 2012. Adolescents (age 10-19 years) with a primary diagnosis of obesity who underwent bariatric surgery were identified. Univariate and bivariate analysis were computed. Multinomial logistic and linear regression were used to determine the association of the predictor variables with type of bariatric procedure, treatment cost and length of hospital stay (LOS), respectively. Income was represented by quartiles (Q1-lowest, Q4-highest), self-pay status included self-pay/uninsured patients, other payer status included federal and non-federal programs.

Results:

1,799 adolescents underwent bariatric surgery. The majority of the subjects were female 77% (n=1,379). Mean age was 18 ± 1 years. Whites represented 60% (n=1,076), Blacks 13% (n=234), Hispanics 20% (n=359) and other races 7% (n=130). The most commonly performed procedure was gastric bypass (GB) (56%, n=993), followed by sleeve gastrectomy (SG) (23%, n=429) and adjustable gastric banding (AGB) (21%, n=377). Several sociodemographic characteristics are associated with specific type of bariatric procedure (Table 1). Hispanics were less likely to undergo AGB (OR 0.5; 95% CI 0.3-0.8); self-pay patients were less likely to undergo GB (OR 0.5; 95% CI 0.3-0.7), and patients with other payer type were more likely to undergo GB (OR 6; 95% CI 2.4-14.9) and AGB (OR 10.1; 95% CI 3.6-28.7), all as compared to SG. LOS was not affected by the variables analyzed. Overall, treatment cost was decreased by low income (Q1, Q2), teaching status and large hospital size. Stratification by type of surgery showed that GB cost was decreased by low income (Q1, Q2); AGB cost was reduced by female sex and large hospital size; and SG cost was reduced by large hospital size and teaching status.

Conclusion:

Primary payer, hospital region and teaching status play a role in the type of procedure performed. Income, teaching status, and hospital size are determinants of treatment cost. Understanding factors associated with the use of suboptimal procedures can identify opportunities for change of practice. Identifying factors that decrease treatment cost can improve access to surgical care.

09.13 Cardiovascular Risk Factors In Long-term Pediatric Burn Survivors

Posted on January 25, 2017

G. Hundeshagen1,4, R. P. Clayton1,4, V. N. Collins3, D. N. Herndon1,4, L. K. Branski1,4, M. P. Kinsky2  1University Of Texas Medical Branch,Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Anesthesiology,Galveston, TX, USA 3University Of Texas Medical Branch,School Of Medicine,Galveston, TX, USA 4Shriners Hospitals For Children,Galveston,Galveston, TX, USA

Introduction: There is little data describing long-term sequelae of pediatric burn injury on cardiovascular disease (CVD). A recent retrospective cohort analysis of more than 10.000 pediatric burn patients over 30 years showed increased admission rates and prolonged hospitalization times for cardiovascular and circulatory disease in this patient population1. In an ongoing prospective trial we are assessing cardiovascular risk factors of long-term pediatric burn survivors. The following data collection focuses on specific and potentially modifiable risk factors of CVD.

Methods:  Former pediatric burn patients greater than 3 years post injury were prospectively enrolled and screened for established CVD risk factors: elevated blood pressure is defined as >140mmg systolic or >90mmg diastolic, smoking is defined as smoking status at the time of survey, overweight is defined as BMI>25 and obesity is defined as BMI>30, total body fat percentage is measured using whole body bone densitometry (DEXA). All results are presented as mean ± SD or count and percentage.

Results: We included 64 patients (39male, 29 female) in this study. Age was 21±5 years, age at burn was 9±6 years, elapsed time between burn injury and assessment was 12±5 years, burn size was 62±19% total body surface area (TBSA). Four patients (6.25%) had evidence of hypertension (average prevalence in this age group, 5.4%), mean systolic blood pressure was 118±5mmg, mean diastolic blood pressure was 72±10mmg. Twenty-six patients (41%) were overweight (average prevalence in this age group 35%), 7 patients (11%) were obese (average prevalence in this age group 20%). While mean BMI was 24±5, mean total body fat percentage was 31±8% which is above the threshold for obesity in adolescents and adults. Six patients (9%) were actively smoking at the time of survey (average prevalence in this age group 27%). 

Conclusion: Our results to date suggest a similar incidence of hypertension. Interestingly, smoking risk was lower in this cohort. On the other-hand, despite only a moderate increase in BMI, total body fat percentage was higher than age match controls. The considerable prevalence of overweight and obesity in this patient collective raises questions about the long-term persistence of the burn-induced hyperdynamic state. Our results have limitations, other CVD risk factors e.g., hyperlipidemia was not measured and indices of systolic and diastolic dysfunction, which could impact hospitalization1, are not reported to date.

Reference: 1 Duke, Janine M., et al. "Long-term Effects of Pediatric Burns on the Circulatory System." Pediatrics 136.5 (2015): e1323-e1330.

 

09.12 Exploring Regional Variability in Utilization of Antireflux Surgery in Children

Posted on January 25, 2017

H. L. Short1, W. Zhu1, C. McCracken2, C. Travers2, L. Waller1, M. V. Raval1  1Emory University School Of Medicine,Pediatric Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Pediatrics,Atlanta, GA, USA

Introduction:  There is significant variation surrounding the indications, surgical approaches, and outcomes for children undergoing antireflux procedures (ARPs) resulting in differences in geographic utilization in the United States. Our purpose was to examine regional and state-level trends in utilization of ARPs and to determine if overall surgical utilization was correlated with use of laparoscopy. 

Methods:  A cross-sectional analysis of the 2009 Kid’s Inpatient Database was performed to identify patients <21 years old with one of the following diagnoses of interest: esophagitis, esophageal stricture, dysphagia, aspiration, apnea, failure to thrive, Barrett’s esophagus, gastroesophageal reflux (GERD), esophageal ulcer, or hiatal hernia. We then determined which of these patients underwent an ARP and the surgical approach utilized (laparoscopic versus open). A mixed effects model was used to determine which regions and individual states were high utilizers of surgery and to identify patient and hospital factors associated with open versus laparoscopic procedures.

Results: Of the 148,959 patients with one or more of the diagnoses of interest, 4,848 (3.3%) patients underwent an ARP with 2376 (49%) undergoing a laparoscopic procedure.  GERD was the most common indication (79%) for ARPs.  Older children (ages 11-20 years) had lower ARP utilization compared to children <1 year old (Odds Ratio (OR) 0.37; 95% Confidence Interval (CI) 0.33-0.40). The Northeast and Midwest had the lowest overall utilization of surgery (2.5%), compared to the West (3.8%) and South (3.8%).  After adjustment for age, case-mix, and surgical approach and allowing for state specific utilization rates, regional variation persisted with the West and the South demonstrating close to 2 times the odds of undergoing an ARP compared to the Northeast (Table).  Surgical utilization rates appeared to be independent of state-level case volume with some of the highest case volume states (Florida, New York and Ohio) having surgical utilization rates below the national rate.  In the West, the use of laparoscopy appeared to correlate with overall utilization of surgery, while surgical approach was not correlated with ARP use in the South. 

Conclusion: Significant regional variation in ARP utilization exists that cannot be explained entirely by differences in patient age, patient race/ethnicity, case-mix, and surgical approach.  In order to decrease variation in care and potentially improve care, further research is warranted to delineate local factors driving surgical utilization of ARP in children.  Consensus guidelines regarding indications and appropriateness for use are needed.     

 

09.11 Evaluation of Postoperative Fever in Children

Posted on January 25, 2017

K. S. Corkum1, J. E. Grabowski1, C. J. Hunter1, T. B. Lautz1  1Ann & Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery/Department Of Surgery,Chicago, IL, USA

Introduction: Early postoperative fever is an extremely common occurrence in both adult and pediatric patients. Adult data suggest that fever workup is unnecessary for most patients in the first 24-48 hours after a major operation. Data in the pediatric population is extremely limited, and as a result, many children with early postoperative fever may undergo unnecessary “pan-culturing”. The aims of this study were to describe the incidence of early postoperative fever following elective inpatient operations in children, determine current utilization of laboratory and radiologic tests in these children with fever, and assess the frequency with which early postoperative fever workup yields a positive result.

Methods: A retrospective analysis of all surgical subspecialty patients at our institution undergoing an inpatient or observational stay surgery between 2011 and 2015 was performed using our electronic medical record (EMR). The EMR query identified 18,612 distinct patient operative encounters of which 6,943 met our inclusion criteria of elective admission type, surgery performed on hospital day zero or one, and an identified wound class of I-IV. Of those encounters, 2,128 had a documented postoperative fever (>100.5 F within 0-2 days post procedure). The EMR was also queried for all blood cultures, urinalysis, urine cultures, respiratory viral panels (RVP) and chest radiographs during that time period and the generated data was then cross-referenced against our cohort of patient operative encounters based on medical record number and date of service using IBM SPSS.

Results: 2,128 patients (30.6%) developed an early postoperative fever, including 761 on POD0, 1422 on POD1, and 1157 on POD2. Urinalysis was tested in 450 (21.1%) and was positive in 89 (19.8% of patients tested and 4.2% of all with fever). Urine culture was tested in 479 (22.5%) and was positive in 72 (15.0% of patients tested and 3.4% of all with fever). Of patients with a positive urine culture, 90.2% (65/72) had an indwelling urinary catheter at the time of surgery. Blood culture was performed in 453 (21.2%), but only 3 patients, all with a central venous catheter, had clinically significant positive cultures. Overall, chest radiographs were performed in 853 (40.1%), and 26 (3.0%) were read as concerning for pneumonia, 326 (15.3%) non-infectious, 420 (19.7%) normal, and 81 (3.8%) were obtained to confirm line, tube or hardware placement. RVP was performed in 52 (3.1%) and was positive in 20 (38.5% of patients tested and 1.2% of all with fever).

Conclusion: Similar to adult patients, early postoperative fever is extremely common in the pediatric surgical population, and rarely associated with a positive blood, urine, respiratory culture and/or chest radiograph suggestive of an infectious source. Workup for early postoperative fever in the pediatric surgical population should be applied selectively, based on patient history, severity of illness, and clinical assessment.

 

09.10 Factors Influencing Replacing an Infected Central Line Catheter in Children

Posted on January 25, 2017

M. M. Nourian1, A. L. Schwartz1, A. Stevens1, E. R. Scaife1, B. T. Bucher1  1University Of Utah,Division Of Pediatric Surgery,Salt Lake City, UT, USA

Introduction:

The optimal time to reinsert Tunneled central venous catheters (tCVC) after a documented catheter related blood stream infection (CLABSI) is not well defined. In infants and children in particular, this leads to additional hospital stay and increased health care utilization. The goal of this study is to identify risk factors for children who develop persistent bacteremia after tCVC removal and therefore would not be a candidate for immediate tCVC replacement.

Methods:

We performed a retrospective cohort analysis of children with a tCVC associated CLABSI from the electronic medical records at a tertiary care children’s hospital from 2000-2016. All children with a tCVC (Broviac or Port-a-Cath) and documented CLABSI were included in our analysis. Our primary outcome was persistent bacteremia after removal of the tCVC as defined by positive blood cultures after tCVC removal. Salient patient demographic and clinical factors were extracted from the medical record. Statistical significance was defined as p<0.05.

Results:
From 2000-2016 there were 4,735 patients who had a tCVC placed. Of those patients 78 (1.6%) had a documented CLABSI and tCVC removed. The majority of patients were white (68%) and male (53%) with an average age of 6.5 years. Most of tCVC placed were Broviac catheters (82%) compared to Port-a-Cath, and the median (IQR) lifespan of the lines placed was 70 (30-167) days. The majority of patients had a history of malignancy (53%) and approximately 36% were treated with chemotherapy 30 days prior to the documented CLABSI. In addition, 42% of patients were placed on home TPN with a history of GI failure rate of 30%. The most common causative organism for a CLABSI was S. epidermidis (28%) followed by Pseudomonas species (15%). Sixteen patients (20%) had persistent bacteremia after line removal. Compared to patients who cleared the bacteremia, those with persistent bacteremia were similar in age, race, and history of malignancy. Patients with persistent bacteremia were more likely to have a history of GI Failure (57% vs 23%, p=0.01) and MRSA bacteremia (13% vs 0%, p=0.04). There was no significant difference between the cleared and persistent bacteremia in gram positive or negative, polymicrobial, or fungal CLABSIs. The majority (78%) of children required temporary CVC placement on average 3.9 days after removal of infected tCVC. 

Conclusion:

We have identified several risk factors for persistent bacteremia after tCVC removal including history of GI failure and MRSA bacteremia. This study supports the practice of early replacement of tCVC after removal for bacteremia in low risk patients. Early replacement could save on average a minimum of 2-3 hospital days in infants and children with tCVC associated CLABSI.

09.09 Trends in Neonatal Surgical Outcomes in Children’s Versus Non-Children’s Hospitals

Posted on January 25, 2017

H. L. Short1, A. Savinkina1, R. M. Patel2, M. V. Raval1  1Emory University School Of Medicine,Pediatric Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Neonatology,Atlanta, GA, USA

Introduction:  Newborns undergoing surgery represent one of the most fragile patient populations and require specialized care.  Our purpose was to examine trends in neonatal surgical outcomes between children’s and non-children’s hospitals (CH and NCH).

Methods:  A cross-sectional, retrospective review of the 2000, 2003, 2006, 2009 and 2012 Kid’s Inpatient Database (KID) was performed to identify all neonatal surgical cases of necrotizing enterocolitis (NEC), patent ductus arteriosis (PDA), esophageal atresia/tracheoesophageal fistula (EA/TEF), congenital diaphragmatic hernia (CDH), and gastroschisis/omphalocele (GAS/OMP).  Mortality rates, length of stay (LOS) and hospital costs at CH and NCH were compared.

Results: We identified 48,149 patients who underwent a surgical procedure to correct one of the diagnoses of interest during the neonatal period.  During the 12-year study period the incidence of all diagnoses increased.  The majority of patients (73%) were treated at NCH, however the proportion of children treated at CH increased 12%, from 18.4% to 30.3%, during the study period.  Overall mortality decreased from 14.9% in 2000 to 12.6% in 2012. This improvement is largely due to an improvement in mortality at CH from 17.2% in 2000 to 10.9% in 2012, while mortality in NCH remained stable at about 14% (Figure). Mortality was consistently lower at CH than NCH for 4 of 5 diagnoses, excluding NEC for all study years and CDH in 2006. From 2000 to 2012, overall mean LOS increased from 44 to 57 days and this trend was similar in CH and NCH.  However, when individual diagnoses were examined LOS was longer in CH than NCH every year for all diagnoses except PDA. After adjustment for inflation, there was a two-fold increase in cost per day for all diagnoses from $5,015/day in 2000 to $10,508 in 2012.  Cost per day was higher for each diagnosis at CH compared to NCH in each year. In 2000 these neonatal conditions cost $1.2 billion (22% at CH) and in 2012 cost increased to $7.6 billion (35% at CH).

Conclusion: Mortality among neonates undergoing surgery is improving at CH and is stable at NCH.  However, LOS and costs are consistently higher at CH than NCH.  In order to optimize outcomes and contain costs for these fragile patients the observed trends warrant further investigation.

 

09.08 Geographic Variation in Prompt Access to Care for Children Involved in Motor Vehicle Crashes

Posted on January 25, 2017

L. L. Wolf1,2, R. Chowdhury1, J. Tweed3, L. Vinson3, E. Losina4, A. H. Haider1,2, F. G. Qureshi3,5  1Center For Surgery And Public Health, Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Trauma, Burns, And Surgical Critical Care,Boston, MA, USA 3Children’s Medical Center Of Dallas, Part Of Children’s Health,Dallas, TX, USA 4Orthopaedic And Arthritis Center For Outcomes Research, Brigham And Women’s Hospital,Department of Orthopedic Surgery,Boston, MA, USA 5University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction: Unintentional injury is the leading cause of death in children 1-19 years and motor vehicle crashes (MVCs) are the most common cause of unintentional injury in this group. Previous research has demonstrated substantial variability in pediatric trauma resources at the state level. However, it is unclear how these differences in resources may affect actual access to care for pediatric trauma patients. We sought to examine the impact of state in which the crash occurred on prompt access to care for children involved in MVCs.

Methods: Using the 2010-2014 Fatality Analysis Reporting System, we assembled a cohort of child passengers (<15y) involved in a fatal MVC, defined as a crash occurring on a U.S. public road and resulting in ≥1 death (adult or pediatric) within 30 days. We included children requiring transport from the crash scene to a hospital for medical care for whom data on time of hospital arrival were available. Our primary outcome was time to first hospital, defined as a binary variable (>1h or ≤1h). We used multivariable logistic regression to establish the state-level variability of the percentage of children whose time to hospital was >1h, after adjusting for injury severity (no injury, possible injury, suspected minor injury, suspected severe injury, fatal injury, injury of unknown severity), mode of transport (Emergency Medical Services (EMS) air, EMS ground, other), and rural roads. We described variability by state, dividing states into quartiles according to the percentage of children delivered to the first hospital >1h after the fatal MVC.

Results: We identified 12,152 child passengers involved in a fatal MVC from 2010-2014; 4,672 (38.4%) required transport for medical care from the scene of the MVC. Of those not transported, 1,424 (19.0%) died at the scene. Of those transported, median time to first hospital was 1h (IQR: [1,1]; range: [0,87]). The percent of children that experienced transport times >1h varied significantly by state, from 0.0 in Rhode Island to 100.0 in Florida, Idaho, Indiana, and Michigan (p<0.001). While we observed striking state-level variation in transport times, there were no clear regional patterns (Figure).

Conclusions: Time to hospital varied greatly by U.S. state for children requiring transport for medical treatment from the scene of a fatal MVC. State-level resources for EMS services and the availability of pediatric trauma care may contribute to the availability of prompt trauma care for children involved in fatal MVCs. These results provide critical data to inform state-level trauma care planning.

09.07 Pediatric Falls in the Greater Los Angeles Area: Targeting Populations for Injury Prevention

Posted on January 25, 2017

J. A. Zagory1, M. Mallicote1, H. Arbogast1, J. Upperman1, M. Fenlon1, A. Jensen1  1Children’s Hospital Los Angeles,Surgery,Los Angeles, CA, USA

Introduction:  Children suffering fall related injury sustain significant morbidity and mortality and require significant resource utilization. Currently, there are no injury prevention programs in the greater Los Angeles area targeted to prevent pediatric falls. We aim to identify injury patterns, resource utilization, and complication rates in children sustaining falls. We hypothesize that falls from significant height occur in children as they become mobile, and an at-risk age can be identified for injury prevention targeting.

Methods:  We conducted a 10-year retrospective review (2004-2014) of a prospectively collected countywide trauma database for children (age <18y) who sustained injury related to a fall mechanism.  Mechanism codes were utilized to identify <15 ft/low-risk (LR) and >15ft/high-risk (HR) falls for comparison.  Statistical analysis was conducted with independent t-test or χ2 as appropriate.

Results: 4451 children sustained LR and 229 HR falls. HR falls were more likely to be younger (4.3±3.7 v 5.6±4.4) , non-white (11.3% v 12.2%), have greater Injury Severity Score (ISS)(7±7.5 v 6±4.2), and sustain injury to their head (skull/facial fracture, intracranial hemorrhage, closed head injury)(70% v 43%)(p<0.001). Of all falls in children under 1y, less than 1.5% were HR, while in children 1-4y 8% of falls were HR. Children 1-4y represent 62% of all HR falls. Resource utilization (computed tomography, length of stay, Intensive Care Unit admission, intubation) and complications (decubitus ulcer, need for respiratory support, pneumonia) were higher in HR (p<0.0001) (Table). Two deaths were in LR and due to non-accidental trauma.

Conclusion: Non-white children 1-4y are at especially high risk for falls from a significant height, with higher ISS, resource consumption, and complications. Injury prevention education should be part of well-child visits as children begin to ambulate, and structured targeted community-based programs should be developed and paired with health policy efforts.

 

09.06 Venous Thromboembolism in Pediatric Trauma: More Thrombus Than Embolism?

Posted on January 25, 2017

C. M. Schneider1, M. Jackson1, M. Harting1, B. Cotton1, C. Cox1  1University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction:  Venous thromboembolism (VTE) is a major source of morbidity and mortality among adult trauma patients, and pulmonary embolism (PE) was once the leading cause of preventable in-hospital adult deaths. These data drove the initiation of guidelines for VTE prophylaxis. Comparatively, the incidence of VTE among pediatric trauma patients is lower than that of their adult counterparts despite aggressive implementation of VTE prophylaxis in adults. The aim of this study is to evaluate the risk factors and outcomes of VTE after injury in children admitted to our level-1 pediatric trauma center. 

 

Methods:  All pediatric trauma patients (15 and younger) admitted to a Level-1 Pediatric Trauma Center from January 2005 to August 2016 were screened for VTE. VTE events were defined as the documentation of deep venous thrombosis (DVT) detected by duplex ultrasonography and/or PE detected by helical computed tomography angiography (CTA) of the chest during the hospital stay or readmission. We evaluated the incidence, risk factors, and adverse events of VTE.

Results: A total of 14,018 pediatric trauma patients ≤ 15 years old were evaluated between 2005-2016, of which 1,842 patients were admitted as level-1 trauma team activations. Of those patients admitted, only 19 patients experienced VTE: 17 patients with DVT alone, 1 patient with PE alone, and 1 patient with both a DVT and PE. All 17 patients with DVT-alone were related to a central venous catheter (CVC) or a peripherally inserted central catheter (PICC). The two patients who experienced PE were 15 years old and both presented > 1 week after hospital discharge. One patient had a history of bilateral long-bone fracture repair, and the other was suspected to have embolized from a previous IV site.

Conclusion: Multiple previous studies have shown VTE rates among pediatric trauma patients to be lower than adult trauma patients.  Unlike adult trauma patients, whose DVT burden is primarily in the calves or pelvic veins, pediatric trauma patients nearly universally develop DVT at catheter-related sites. The only PE identified were in older children (15 years old) whose risk of VTE transitions toward adult risk, as shown in previous studies. These data suggest that VTE prophylaxis of pediatric trauma patients without a CVC is unwarranted.

 

09.05 Socioeconomic Status Affects Time to Treatment of Pediatric Well-Differentiated Thyroid Cancer

Posted on January 25, 2017

E. F. Garner1, I. I. Maizlin1, K. W. Gow2, M. Goldfarb3, M. Langer4, M. V. Raval5, J. G. Nuchtern6, S. A. Vasudevan6, J. J. Doski7, A. B. Goldin2, E. A. Beierle1  3John Wayne Cancer Institute/Providence St. John’s Medical Center,Department Of Sugery,Santa Monica, CA, USA 4Maine Medical Center,Division Of Pediatric Surgery,Portland, ME, USA 5Emory University School Of Medicine,Division Of Pediatric Surgery/Department Of Surgery,Atlanta, GA, USA 6Baylor College Of Medicine,Division Of Pediatric Surgery/Department Of Surgery,Houston, TX, USA 7University Of Texas Health Science Center At San Antonio, San Rosa Children’s Hospital,Division Of Pediatric Surgery/Department Of Surgery,San Antonio, TX, USA 1University Of Alabama,Division Of Pediatric Surgery/Department Of Surgery,Birmingham, Alabama, USA 2University Of Washington,Division Of Pediatric Surgery/Department Of Surgery,Seattle, WA, USA

Introduction:  Well-differentiated thyroid cancer (WDTC) is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in adults undergoing thyroidectomy. However, few studies have looked at the effects of socioeconomic status on the management of pediatric thyroid cancer. We sought to determine if children with lower socioeconomic status experience delays in diagnosis and management of their thyroid cancer. 

Methods:  Patients <21 years of age with well-differentiated thyroid cancer (WDTD) were reviewed from the National Cancer Data Base (NCDB) from 1998-2013. Three socioeconomic surrogate variables were identified: insurance type, median income in the patient’s ZIP code, and percent of people with no high school degree in the patient’s ZIP code. Chi-square and pool-variance t-tests were then used to compare tumor characteristics, intervals from diagnosis to staging and diagnosis to treatment, as well as clinical outcome variables within each of the socioeconomic surrogate variables, while controlling for the effect of age, race and gender.

Results: A total of 9585 children with WDTC were reviewed; 8696 (90.72%) with papillary thyroid cancer and 889 (9.28%) with follicular thyroid cancer. 7914 (82.6%) were female. In multivariate analysis, lower income (p = 0.041, Hazard Ratio [HR] = 1.98, 1.88 and 1.68 in each successive quartile compared to highest one), lower educational quartile (p<0.001, HR=1.86, 1.50 and 1.12, compared to highest quartile) and insurance status (p < 0.001, HR = 2.26 for uninsured and HR = 1.46 for government insurance, as compared to private insurance) were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment (p <0.002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared to those with government (19 days) or private (18 days) insurance (p < 0.001). However, despite diagnosis at a higher stage and requiring longer time between diagnosis and treatment, there was no significant difference in either overall survival or rate of complications (demonstrated by unplanned readmission rates) based on any of the socioeconomic surrogate variables.  

Conclusion: Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their WDTC. These patients also presented with higher stage disease. These data suggest that a disparity exists in access to care for children from low-income families.  Although these findings did not translate into worse outcomes for WDTC, future efforts should focus on reducing these differences. 

 

09.04 Patient and provider factors associated with ultrasound visualization in pediatric appendicitis

Posted on January 25, 2017

B. L. Vey1, H. E. Arnold1, R. P. Cutts1, A. U. Patel1, C. Travers3, J. Loewen2, K. Braithwaite2, K. E. Applegate2, K. Heiss1, M. V. Raval1  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Division Of Pediatric Radiology, Department Of Radiology And Imaging Sciences,Atlanta, GA, USA 3Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA

Introduction:
When indicated, ultrasound (US) is the preferred diagnostic imaging modality for children with possible appendicitis. Unfortunately, in over half of studies US fails to visualize the appendix. Factors such as study duration, time of day, gender, obesity, and technologist experience have all been implicated as influencing US visualization rates. The purpose of this study was to identify which factors are associated with emergency room US visualization rates in a pediatric center with 24-hour US availability.

Methods:
Single-center retrospective review of all US studies obtained from January 1 to March 31, 2016 for children ages 5-18yo in the emergency room. Each US was assessed for duration, technologist experience, time of day, and patient factors including age, sex, and obesity.  Technologists were considered ‘low experience’ with less than one year of experience in a dedicated pediatric setting. Regression models were used to examine association of patient and study factors with visualization.

Results:
649 US studies were identified as direct assessments of the appendix for cases of potential appendicitis. Overall, the appendix was fully visualized in 271 (41.8%) of studies. Compared to older patients, younger children (ages 5-9) were more likely to have the appendix visualized (Odds Ratio (OR) 3.09, 95% Confidence Interval (CI) 1.97-4.85). Males were more likely to have visualization compared to females (OR 1.96, 95%CI 1.42-2.71). Patient obesity, defined as greater than 95th percentile weight for age, did not significantly impact visualization rates (42.1% vs 41.7%, p=0.93). There were 28 US technologists and 194 studies (30%) were performed by technologists with low experience. Technologists’ experience did not significantly impact visualization rate (OR 1.09, 95%CI 0.76-1.56). Visualization rates were higher during the weekday nighttime hours of 10pm to 8am and weekends compared to daytime hours (46.1% versus 37.1%, P=0.02). There was slight decrease in the visualization rate in the early evening hours (Figure).

Conclusion:
Overall, complete appendix visualization on US in a pediatric emergency setting remains low. Visualization is highest in males and younger patients and is not compromised by obesity.  Efforts are needed to understand how best to improve US performance overall and in older children and females. Visualization does not appear to be associated with technologists’ experience and is not compromised on nights and weekends. Pediatric centers with available highly trained technologists may provide after-hours US coverage for appendicitis evaluation without sacrificing quality.
 

09.03 Viscoelastic Monitoring in Pediatric Trauma: A Survey of Pediatric Trauma Society Members

Posted on January 25, 2017

R. T. Russell1, I. I. Maizlin1, A. M. Vogel2  1University Of Alabama At Birmingham, Children’s Of Alabama,Department Of General Surgery, Division Of Pediatric Surgery,BIrmingham, AL, USA 2Washington University, St. Louis Children’s Hospital,Department Of General Surgery, Division Of Pediatric Surgery,St. Louis, MO, USA

Introduction: Viscoelastic monitoring (VEM), including TEG® (thromboelastography) and ROTEM® (rotational thromboelastometry) in the setting of goal directed hemostatic resuscitation has been shown to improve outcomes in adult trauma. The American College of Surgeons (ACS) Committee on Trauma recommends that “thromboelastography should be available at Level I and Level II trauma centers”. The purpose of this study is to determine the current availability and utilization of VEM in pediatric trauma.

Methods: After IRB and Pediatric Trauma Society (PTS) approval, a survey was administered to the current members of the PTS via Survey Monkey®. The survey collected demographic information, hospital and trauma program type, volume of trauma admissions, and use and/or availability of VEM for pediatric trauma patients.

Results: We received 107 responses representing 77 unique hospitals. Survey respondents were: 61% physicians, 29% nurses, 6% trauma program managers, and 4% NPs/PAs. Over half of providers worked in a free standing children’s hospital. Seventy-nine percent of respondents were from hospitals that had > 200 trauma admissions/year, 42% were providers at ACS Level 1 pediatric trauma centers, and 77% practiced at State Level 1 designated centers.  VEM was available to 63% of providers, but only 31% employed VEM in pediatric trauma patients. For those who had no VEM available, over 75% would utilize this technology if it was available. Most providers continue to rely on traditional coagulation studies (CCT) to monitor coagulopathy in pediatric trauma patients after admission (Figure 1).

Conclusions: While a growing body of evidence demonstrates the benefit of viscoelastic hemostatic assays in management of adult traumatic injuries, VEM during active resuscitation is infrequently used by pediatric trauma providers, even when the technology is readily available. This represents a timely and unique opportunity for quality improvement in pediatric trauma.

09.02 Influence of Discharge Timing and Diagnosis on Outcomes of Pediatric Laparoscopic Cholecystectomy

Posted on January 25, 2017

S. B. Cairo1, D. H. Rothstein1,2  1Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA 2State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA

Introduction:

The purpose of this study was to evaluate the influence of discharge timing (same-day vs other) on 30-day hospital readmissions following laparoscopic cholecystectomy in pediatric patients. We also compared wound complication and readmission rates among patients with different indications for operation.

Methods:

The National Surgical Quality Improvement Program-Pediatric database (2012-2014) was queried for patients who underwent laparoscopic cholecystectomy. Variables examined included age, gender, body-mass index, race/ethnicity, diagnosis (cholecystitis vs other), presence of hematologic disorders or diabetes, pre-operative hospital length of stay, and American Society of Anesthesiology (ASA) Physical Status classification. Same-day discharge was defined as zero days between surgery and discharge and was compared to patients discharged within 2 days. The primary outcome was hospital readmission within 30 days after surgery; secondary outcomes included surgical site infections and other wound complications. Forward stepwise logistical regression was used to determine odds ratios for factors contributing to hospital readmissions and wound complications.

Results:

During the study period, 2,825 patients underwent cholecystectomy (74.6% female; median age 13.8 years). Of these, the post-operative diagnosis was gallstone disease (67.4%), cholecystitis (12.9%) and biliary dyskinesia (19.8%). Same-day discharge occurred in 567 patients (20.2%).  Among variables measured, only ASA class 3 (compared to ASA class 1) was associated with increased odds of 30-day hospital readmission (OR 1.70, 95% C.I. 1.03-2.81). Same-day discharge was in fact associated with a decreased risk of readmission (OR 0.49, 95% C.I. 0.25-0.96) when compared to discharge within 2 days. A variety of reasons for readmission was identified but did not differ between the same-day and longer discharge groups. When examining wound complications, again only ASA class 3 was associated with increased risk of wound infection or breakdown (OR 4.98, 95% C.I. 1.06-23.4). 

Conclusion:

In pediatric patients undergoing laparoscopic cholecystectomy, same-day discharge is associated with no increase in 30-day hospital readmission rates or wound complications when compared to discharge in 1 or 2 days. Specific indications for surgery are also not associated with increased readmission rates or wound complications. Same-day discharge appears safe and therefore may reduce hospital costs and other resource utilization, and serve as an applicable quality indicator for pediatric patients undergoing laparoscopic cholecystectomy.

09.01 Members of the American Pediatric Surgical Association Demonstrate Career-Long Academic Productivity

Posted on January 25, 2017

D. P. Milgrom1, H. Abduljabar2, B. Kiel2, N. Valsangkar1, L. G. Koniaris1  1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:  The American Pediatric Surgical Association (APSA) is a prestigious organzition dedicated to promoting excellence in the field of pediatric surgery.  The membership is comprised of university-based and non-university based surgeons.   We sought to evaluate the academic productivity of the members of the (APSA) with respect to their affiliation.

Methods:  Academic metrics including numbers of publications, citations, and NIH funding history were determined for the 705 members of the APSA, using SCOPUS, NIH RePORT, and the grantome© online databases. 

Results:  APSA membership included 365 non-university and 340 university members.  Among the APSA, publications (P), citations (C), three-year citations (3YC), and H-index (H) for university members were P: 61.6±64.8, C: 1353.9±1884.1, 3YC: 315.6±494.0, and H: 16.7±11.0 compared with P±SD: 31.8±40.2, C: 803.8±2670.5, 3YC: 147.8±394.8, and H: 11.48±9.7 for non-university members, p < 0.05 [Table 1]. University positions were associated with increased rates of NIH funding, with 15.3% of university members having NIH funding, compared to 4.9% of non-university members. The most common grant type among non-university members was an F32, comprising 35% of grants for non-university members.  Among the university members, assistant professors most commonly had F32s comprising 33% of their grants, associate professors most commonly had R21 grants, comprising 31% of their grants, and professors most commonly had R01 grants, comprising 39.3% of their grants.  Professors were most likely to have NIH funding (23.3%), followed by associate professors (13.4%), assistant professors (8.8%), and finally non-university members (4.9%).

Conclusion:  While university members of the APSA have overall higher levels of academic productivity than non-university members, non-university continue to be productive and obtain extramural funding, including NIH funding.

 

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