14.02 Racial Disparities in Emergency General Surgery Go Beyond Hospital-Level and Geographic Factors

Posted on January 18, 2018

C. E. Sharoky1, M. M. Sellers1, J. H. Fieber1, C. J. Wirtalla1, G. E. Tasian2, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery, Center For Surgery And Health Economics,Philadelphia, PA, USA 2Perelman School Of Medicine,Center For Clinical Epidemiology And Biostatistics,Philadelphia, PA, USA

Introduction:  Racial disparities exist in the management of many acute medical conditions. Prior studies examining racial disparities in emergency general surgery (EGS) have pointed to hospital-level factors as major contributors. We sought to examine whether racial disparities in death and serious morbidity (DSM) after EGS exist independent of hospital-level and geographic factors.

Methods:  Using Florida inpatient hospital discharge claims (2010-2013), we identified all patients ≥18 with an EGS condition admitted through the emergency department who had an EGS operation ≤2 days from admission. Multivariable logistic regression with multilevel mixed effects to control for both the county and specific hospital where care was received was used to estimate the association between race and DSM in black patients (BL) compared to white patients (WH). Two subgroup analyses, one of urban counties and one of rural counties, were performed to examine geographic variation in the association between race and DSM. 

Results: A total of 154,377 patients were identified, of which 17,540 (11%) were BL. Compared to WH, BL had 16% increased odds of DSM (95%CI 1.10,1.25) after adjusting for patient comorbidities, severity of illness on presentation, EGS operation performed, county and hospital. In a subgroup of urban counties, BL had 23% increased odds of DSM (95%CI 1.11,1.36) compared to WH. In a subgroup of rural counties, BL had a 17% increased odds of DSM (95%CI 1.01,1.35) compared to WH.

Conclusion: Black race is associated with increased DSM after EGS, and this association holds true in both urban and rural regions. This suggests that racial disparities in EGS exist even when controlling for the county and hospital where patients receive care. Further research is needed to identify processes of care that underlie these associations to help improve racial disparities in EGS across hospitals and geographic regions. 

14.03 A Model for Spatio-Temporal Injury Surveillance

Posted on January 18, 2018

J. O. Jansen1, J. J. Morrison2, T. Cornulier3  1University Of Alabama At Birmingham,Division Of Acute Care Surgery,Birmingham, AL, USA 2University Of Maryland,R Adams Cowley Shock Trauma Center,Baltimore, MD, USA 3University Of Aberdeen,School Of Biological Sciences,Aberdeen, SCOTLAND, United Kingdom

Introduction:
The Centers for Disease Control and the World Health Organisation have promoted the concept of “injury surveillance”, to inform the provision of services. Such analyses tend to rely either on the evaluation of temporal trends or of geographical variations in case volume, both having important implications for trauma system configuration. However, spatial variation in these temporal trends (or changes in these distributions) are more difficult to estimate particularly in sparsely populated areas, and have received relatively little attention as a consequence. The aim of this study was to propose a model to facilitate the spatio-temporal surveillance of injuries, using Scotland as a case study.

Methods:
This is a retrospective analysis of five years’ of trauma incident location data, as collected routinely by the Scottish Ambulance Service, for incidents attended from 2009 to 2013. The source data was geocoded by postcode district (PCD), a medium-sized spatial unit. There are 444 PCDs in Scotland. We analysed the study population as a whole, as well as a number of predefined subgroups, such as those with abnormal physiological signs. Our analysis aimed at characterising the geographical distribution of expected incident numbers and identifying spatial variation in their temporal trends. In order to leverage sufficient statistical power to detect temporal trends in rare events over short time periods and small spatial units, we used a geographically weighted regression model, which assumed a Poisson distribution for the counts of incidents per PCD and per year, and used a Markov random field to condition estimates for each PCD on those from adjacent PCDs. The results are displayed as choropleth maps, showing percentage change per year, with hatched areas indicating statistically significant changes over 5 years.

Results:
There were 509,725 incidents. Overall, there were increases in case volume in the Glasgow area, the central Southern part of the country, the Northern parts of the Highlands, the North-East, and the Orkney and Shetland Islands. Statistically significant increases were largely restricted to major cities, with the notable exception of Edinburgh. Significant decreases in the number of incidents were seen in Western Scotland, Fife and Lothian, and the Borders. Subgroup analyses showed markedly different spatio-temporal patterns.

Conclusion:
This project has demonstrated the feasibility of population-based spatio-temporal injury surveillance. Even over a relatively short period, the geographical distribution of where injuries occur may change, and different injuries present different spatio-temporal patterns. These findings have potential implications for health policy and service delivery.
 

13.19 Computed Tomography Findings Predict the Need for Intervention in Children with Blunt Liver injuries

Posted on January 18, 2018

J. E. McMillan1,3, T. F. Boulden2, A. Gosain1, J. W. Eubanks1, R. F. Williams1  1University Of Tennessee Health Science Center,Surgery And Pediatrics,Memphis, TN, USA 2University Of Tennessee Health Science Center,Pediatric Radiology,Memphis, TN, USA 3University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA

Introduction:

A standardized method for classifying blunt solid organ injury in adults has existed for nearly three decades. However, there is not a standard approach for pediatric patients and management varies widely among centers. We hypothesize that radiologic findings in pediatric abdominal trauma can be used to predict the need for intervention.

Methods:

Following IRB-approval, a retrospective study was performed at an ACS-verified Level 1 Pediatric Trauma Center for 134 children (<18 years) who had sustained liver injuries. Radiologic findings were extracted from CT reports or, when missing, measured from original imaging. Radiologic variables included liver laceration size, number of Couinaud segments involved, presence of hemoperitoneum, hepatic vessel involvement, lobe involvement, and the presence of subcapsular or pericapsular hematoma.  Interventions included surgical intervention, angiography, or blood transfusion. Continuous variables were compared with a t-test, and a chi-square analysis was used for categorical variables.

Results:

The mean age was 7.5 +/- 5.2 years with 59% male and 52% African-American.  Hemoperitoneum, length of liver laceration and number of Couinaud segments involved predicted the need for intervention in children with blunt liver injuries (table).  Normalizing continuous variables by age did not change the significance. However, the presence of hematoma and the proximity of the injury to the major hepatic vessels, important variables in the adult grading system, did not predict the need for intervention in children.

Conclusions:

Pediatric patients who present with liver injury from abdominal trauma with hemoperitoneum, larger laceration and more liver segments involved are more likely to require intervention. Contrary to the adult trauma guidelines, hematoma and proximity to the major hepatic vessels did not predict the need for intervention in children.  These findings build upon the expanding literature indicating the need for pediatric-specific guidelines for trauma management.

14.01 Location, Location, Location! Falling Short on Stepping Up to Reach Seniors for Fall Prevention?

Posted on January 18, 2018

S. Fantal1, K. Ladowski3, J. Vosswinkel3, R. Jawa3  1Stony Brook University,Program In Public Health,Stony Brook, NY, USA 3Stony Brook University Medical Center,Division Of Trauma,New York, NY, USA

Introduction:

Falls are the leading cause of injury-related morbidity/mortality in older adults. Despite demonstrated efficacy of fall prevention programs in randomized control trials, a gap remains between research and effective implementation and participant retention. The literature suggests interest in programs declines as distance, time, cost and effort to get to a class increase. Since 2012, our county has implemented community-based fall prevention programs. This study analyzed factors contributing to program completion.

Methods:

Evaluation was conducted on data from the Stepping On program, a multifaceted falls prevention program offered once/week, for 2 hours, over 7 weeks, free of charge. Program topics include exercise, vision, medication, and environmental risk factors. Variables examined include demographic data, program completion (≥5 classes), post program survey results, and census data.

Results:

Total of 869 participants mean age 80, white (94%), female (73%), married/widowed (82%), with high school diploma or higher (96%), enrolled in 41 programs, with mean class size of 21 participants. Overall program completion rate (CR) was 73% during the study period with 58% of participants completing the post program survey. Choropleth mapping was used to evaluate the relationship between participants' zip code to older adult population distribution. In multivariate logistic regression, Distance Traveled (OR=1.06 p=0.20), Age (OR=1.04 p=0.11), Gender (OR=0.52 p=0.17, ref=Female), Race (OR=1.25 p=0.90 ref=White), Education (Some College OR=1.95 p=0.18, ≤ High School OR=1.39 p=0.53, ref=≥College), and Marital Status (Divorced OR=0.60 p=0.38, Widowed OR=1.01 p=0.99, Single OR=0.52 p=0.43, ref=Married) were not significantly associated with program completion. There was a significant association between site type and program completion (8 Senior Centers n=170, CR=88%, 13 Libraries n=273, CR=76%, 1 Church n=21, CR=90%, 5 Assisted Living n=149, CR=83%, 12 Independent Living n=219, CR=86%, 2 Gyms n=37, CR=100%, p≤0.001). In univariate analysis, there were significant differences in completion rates between Senior Centers and Libraries (p=0.001) and Gyms and Libraries (p=0.002), but only Senior Centers remained significantly associated in multiple logistic regression analysis.

Conclusion:

The program was offered in areas of larger older adult populations. Estimated distance traveled to programs (mean=5.6 miles) did not significantly impact program completion. An association between site type and completion rates was noted. Senior Centers appear to be the best location to ensure program completion, as they explicitly serve an older adult population.

13.16 Stop the Radiation: Limiting Chest CT scans in the Pediatric Trauma Patient

Posted on January 18, 2018

S. Azari2, T. Hoover1, M. Browne1,2  1Lehigh Valley Health Network,Pediatric Surgical Specialties,Allentown, PA, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction: National attention has been drawn to decreasing pediatric radiation exposure with a push to “image gently”, however there are currently no national pediatric CT guidelines.  CT scans aid in the evaluation and treatment of pediatric patients; unfortunately, they expose the child to a considerable amount of radiation.  This creates a challenge for physicians, especially those caring for the acute pediatric trauma patient.  Due to the flexibility of the pediatric chest wall, the incidence of thoracic injury with blunt trauma is low.  We hypothesize that chest CT scans after a normal chest xray will not add clinically relevant information to justify the risk of the radiation.  

Methods:  A retrospective chart review of all level 1 trauma patients < 15 years of age who were evaluated at our pediatric trauma center between January 2013 and June 2016 was performed.  Using our database and chart review, patients who had a chest CT scan during their initial evaluation were reviewed for demographics, mechanism of injury, radiological results, and change in management based on those results.  Patients were excluded if their radiological evaluations were performed at an outside facility; no radiological chest evaluation was preformed; or if their mechanism of injury was drowning.

Results: There were 257 patients who met our inclusion criteria.  Eighty-two percent (211/257) had a chest xray.  Though 44% (114/257) had a chest CT scan; only 60% (68/114) of those patients had a chest xray prior to CT.  Of those patients, 74% (50/68) had a normal x-ray. Thirty percent (15/50) of the chest CTs done after a normal x-ray had an abnormal result.  Only 1 patient (2%) had a result which changed clinical management.

Conclusion: Though chest CT scans increase abnormal diagnoses, the chance of their results changing clinical management is very low.  Chest CTs should be consider unnecessary when the chest xray is normal.  

 

13.17 Pediatric Snakebites: comparing patients in two geographic locations in the United States

Posted on January 18, 2018

P. N. Chotai1, J. R. Watlington2, S. Lewis3, T. Pyo3, A. A. Abdelgawad4, E. Y. Huang5  1Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 2University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA 3Texas Tech University Health Science Center,School Of Medicine,El Paso, TX, USA 4Texas Tech University Health Science Center,Department Of Orthopedic Surgery,El Paso, TX, USA 5University Of Tennessee Health Science Center,Division Of Pediatric Surgery, Department Of Surgery,Memphis, TN, USA

Introduction:

Management of children with snakebites may vary based on subjective criteria and geographic and climatic factors. We reviewed the incidence and management of snakebite injuries in children at two tertiary referral centers in separate geographic and climatic location to assess differences in management and outcomes of these patients.

Methods:

An institutional review board approved, retrospective chart review was performed for patients ≤18-year-old with ICD-9/E-codes for snakebite injuries at emergency department (ED) of two American College of Surgeons verified trauma centers (2006-2013). One center is located in south-east US and experiences a sub-tropical climate whereas the other is located in south-west US and experiences a semi-arid climate. Demographic and clinical parameters were extracted. Descriptive bivariate analysis using chi-square or Fisher exact test for nominal variables and Mann-Whitney U test for continuous variables was performed.

Results:

A total of 108 patients(59% male), median age of 9y(1y-17 y), were included. Snake type was identified by bystanders in 55.5% cases; copperhead was the most common(37%) subtype. About 30% patients received antivenin. One quarter of all patients were discharged from ED. Of the 83 admitted, 81% were admitted to floor and 19% were observed in the intensive care unit (ICU). Two patients received surgical intervention in 48 hours after presentation (fasciotomy for lower extremity rattlesnake bite and blister removal on thumb from unidentified snake bite). There was one gastrointestinal complication (emesis), one cardiovascular (premature atrial contractions, benign) and one neurologic (paresthesia at bite site). All patients were discharged home with one 30-day re-admission for unrelated trauma. There were no fatalities. Compared to patients who sustained a snakebite in semi-tropical regions, patients in semi-arid areas had shorter bite-to-ED time, presented directly to the referral center, were more frequently bitten by a rattlesnake, had longer length of hospital stay, required antivenin more frequently and at higher doses, and were more frequently admitted to the ICU (table 1). No differences were seen in gender, age at presentation, severity of wound, location of bite, abnormalities in coagulation profile or rate of admission to hospital amongst the two sites.

Conclusion:

Patients sustaining snakebites in semi-arid climates were more commonly exposed to dangerous snake types, resulting in higher antivenin requirement, as well as longer hospital stays and need for intensive monitoring. Although no fatalities were reported in our study, our data support early transfer of snakebite victims to higher centers of care, especially in semi-arid or high-risk areas.

13.18 A Ten Year Review of Firework-Related Injuries Treated at a Regional Pediatric Burn Center

Posted on January 18, 2018

P. H. Chang2,4, D. Toplauffe1, S. Wang1, S. Romo1, K. Hannigan1, R. Sheridan1,3  1Shriners Hospitals For Children-Boston,Boston, MA, USA 2Shriners Hospitals For Children-Cincinnati,Cincinnati, OH, USA 3Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 4University Of Cincinnati,Division Of Plastics/Burn Surgery,Cincinnati, OH, USA

Introduction:
In 2015, 11,900 firework-related injuries were reported in the United States. Laws regulating the use of consumer fireworks vary from state to state in our region. However, it is common practice for consumers to cross state borders to purchase fireworks illegal in their state. The objective of this study is to describe the population of patients treated for injuries involving fireworks at a single regional pediatric burn center.

Methods:
A retrospective chart review was conducted to analyze all patients aged 0-18 years admitted to our regional pediatric burn hospital with a firework-related injury between 2006 and 2015. Data collected included demographics, total body surface area (TBSA) involved, location of burn, state in which the injury occurred, and whether sparklers, firecrackers, or aerial fireworks were involved. 

Results:
Of the 61 patients who met the inclusion criteria for review, four times as many patients were males than females. The mean age of the study sample was 10.53 ± 5.42 years (range: 0.52-17.9 years) and the mean TBSA was 3% ± 7%. More than half of these patients were from MA (66%), while the other injuries occurred in: NH (21%), VT (7%), and less than 4% in NY, CT, ME, and VA. Seventy-one percent of these patients had to be admitted as inpatients for treatment. At least 40% of injuries were to critical areas (i.e. face, hands, feet, genitalia). Aerial fireworks were involved in 46% of these injuries, while sparklers and firecrackers were each involved in 28%.  

Conclusion:
Fireworks pose a serious danger to children in every state, regardless of mandated state legislation pertaining to fireworks sales. Sparklers, which are legal in six of the seven states included in our review, were responsible for more than a quarter of the injuries treated. Moreover, preliminary data suggests that laws regarding firework sales are not being properly implemented. Fireworks are illegal in the state of MA; however, 40 of the patients referred to our facility due to firework-related injuries were injured in MA. Additionally, although firecrackers are illegal in all of the states in which these injuries occurred, they were involved in more than a quarter of the injuries reviewed.   Over the past ten years, our pediatric burn center has treated numerous children injured due to fireworks. Our research demonstrates a need for clinicians and lawmakers to work together to help enact legislation limiting the sales and use of fireworks.
 

13.14 Prevalence and Perceptions of Team Training Programs for Pediatric Surgeons and Anesthesiologists

Posted on January 18, 2018

A. Esce1, D. A. Rodeberg2,4, M. Browne4,5, D. H. Rothstein3,4, D. Wakeman1,4  5Lehigh Valley Health Network,Division Of Pediatric Surgical Specialties/Department Of Surgery,Allentown, PA, USA 4American Academy Of Pediatrics Section On Surgey,Delivery Of Surgery Committee,Elk Grove Village, IL, USA 1University Of Rochester School Of Medicine,Rochester, NY, USA 2East Carolina University Brody School Of Medicine,Greenville, NC, USA 3Women & Children’s Hospital Of Buffalo,Pediatric Surgery,Buffalo, NY, USA

Introduction: Team training programs adapt crew resource management principles from aviation to foster communication and prevent medical errors. Although multiple studies have demonstrated team training programs such as TeamSTEPPS® improve patient outcomes and safety across medical disciplines, limited data exist about their application to surgical teams. The purpose of this study was to investigate usage and perceptions of team training programs by pediatric surgeons and anesthesiologists. We hypothesized that team training programs are not widely available to pediatric surgical teams.

Methods: We performed an online survey of Pediatric Surgery (General, Plastic, Urologic, Orthopedic, Otolaryngologic, and Ophthalmologic) and Anesthesiology members of the American Academy of Pediatrics. The survey inquired about completion and perceptions regarding efficacy of team-training programs. Simple descriptive statistics were used to interpret the data.

Results: 152 pediatric surgeons and 12 anesthesiologists completed the survey with a 10% response rate. Over half of the respondents were general pediatric surgeons. Home institutions offered TeamSTEPPS® or another team-training program in 39% of respondents. Of those with a program, 77% had completed training. Though most (76%) who participated in team training programs did so by requirement, 90% found it helpful. Of the 61% of surgeons who said their institution did not offer team-training programs, 60% said they would participate if one were offered and additional 32% said they might participate. The biggest barriers to participation were not enough free time or that the team training program was not offered to their department.

Conclusions: Team-training programs are considered beneficial amongst pediatric surgeons and anesthesiologists who have completed them. Unfortunately, despite substantial evidence showing training for team work improves team functioning and patient outcomes, many pediatric surgical teams do not have team training programs at their institutions. Further expansion of team-training programs may be valuable to improving a culture of safety in children’s hospitals.

13.15 Pediatric Surgical Risk Assessment Tools: A Systematic Review

Posted on January 18, 2018

D. Ji1, S. L. Goudy2, M. V. Raval3, N. P. Raol2  1Mercer University School Of Medicine,Savannah, GA, USA 2Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Division Of Pediatric Otolaryngology, Department Of Otolaryngology – Head And Neck Surgery,Atlanta, GA, USA 3Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Division Of Pediatric Surgery, Department Of Surgery,Atlanta, GA, USA

Introduction:  Currently used pediatric surgical risk assessment tools use patient and procedure-specific variables to predict postoperative complications following specific procedures. These tools assist clinicians in preoperative counseling and surgical decision-making. The objective of this systematic literature review was to compile and evaluate current pediatric surgical risk scores that are applicable across pediatric surgical specialties. 

Methods:  A systematic literature review was performed following PRISMA guidelines to identify relevant publications. Studies were independently screened by two reviewers by pre-defined eligibility criteria. Data was extracted from the selected manuscripts and the included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Studies were included if they met the following criteria: designed to develop a preoperative risk model predicting postoperative complications or mortality, applicable across various surgical specialties, and pertinent to the pediatric population. Studies with specialty- or procedure-specific risk scores and validation studies were excluded.

Results: Of 19 studies identified on initial title and abstract review, 4 studies (21%) comprising of 2,352,481 patients met inclusion criteria. Each study reported assessment of a novel, generally applicable pediatric surgical risk score to risk stratify children preoperatively. Risk variables evaluated across the models reflected the degree of resilience or fragility of the patient prior to surgery. Risk factors common to all studies were the presence of cardiovascular or neurological diseases. Three of the four included studies defined most risk factors in binary terms, whereas one study used a scale of severity of organ system disease when defining preoperative risk. Generated risk scores positively correlated with inpatient mortality or postoperative complications, with c-statistic values ranging from 0.77-0.98. 

Conclusion: Though a variety of risk assessment tools are available to reliably inform adverse events for children undergoing surgery, many of the characteristic risk factors were addressed in binary terms, limiting capture of differences in risk across gradients of preoperative condition and fragility. More study is needed to assess generalizability in all populations and procedures.

13.13 Examination of Postoperative Length of Stay Following Common Procedures in ACS-NSQIP Pediatric

Posted on January 18, 2018

D. Papandria1, Y. V. Sebastião1, K. J. Deans1, K. A. Diefenbach1, P. C. Minneci1  1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction:

Though frequently reported in comparative studies, there are few reports describing typical postoperative length of stay (LOS) associated with commonly performed operations in the pediatric population. The objective of this study was to identify ranges of postoperative LOS for common pediatric procedures using a large multi-institutional database.

 

Methods:

A retrospective analysis of the ACS-NSQIP Pediatric Public Use File (2013-2015) was performed. General surgical procedures were grouped using Current Procedural Terminology codes (CPTs). The most frequently performed procedures were identified and analyzed. These included: laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), laparoscopic gastrostomy (LG), laparoscopic esophagogastric fundoplication (LF), thoracoscopic repair of pectus excavatum (TPE), appendectomy (OA), enterostomy closure (OEC), gastrostomy closure (OGC), and bowel resection (OBR). Patients < 6 months or > 18 years of age and those receiving unrelated major concurrent surgical procedures were excluded, as were day-of-surgery discharges and inpatient deaths. Postoperative LOS was examined for each procedure, including multivariable analysis of patient preoperative risk factors for postoperative LOS > 75th percentile.

 

Results:

A total of 29, 557 cases were identified (median age: 7 years; 57% male; 73% white), and included procedure subgroups ranging from 505 (OBR) to 19,260 (LA) cases. Procedure-specific median postoperative LOS (75th percentile; 90th perecentile) were: LA 1d (2d; 5d); LC 1d (1d; 2d); LG 2d (2d, 4d); LF 3d (4d, 6d);  TPE 4d (5d, 6d);  OA 3d ( 6d, 9d);  OEC 4d (6d, 10d);  OGC 1d (1d, 2d); and OBR 6d (10d, 20d)(Fig. 1). Preoperative risk factors for high postoperative LOS varied by procedure and included patient demographics (age, race), admission factors (inpatient classification, admission from Emergency Dept.), case characteristics (emergent designation, ASA class III / IV), and comorbidities (sepsis, developmental delay, neurologic disease). No single risk factor reached statistical significance for more than six of the procedures.

 

Conclusion:

The range of postoperative LOS for commonly performed procedures varies considerably across procedures. Risk factors for high postoperative LOS also varied by procedure. These results may be a useful reference for benchmarking and resource utilization analyses at the institutional and health systems levels.

13.10 Approaches and Safety Profile of Surgical Treatment of Velopharyngeal Insufficiency Using NSQIP

Posted on January 18, 2018

A. D. Chen1, B. N. Tran1, Q. Z. Ruan1, 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: Velopharyngeal insufficiency (VPI) often manifests after cleft repair or adenoidectomy as a result of an occult palatal problem, which can result in hypernasal speech and nasal air emission. This study aims to study the outcomes of different techniques for VPI correction using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).  

Methods: VPI cases from 2012-2015 were identified.  Patients were subdivided in 4 unique cohorts: (1) palatoplasty, (2) pharyngeal flap and sphincter pharyngoplasty, (3) lengthening, and (4) others including tissue excision and rearrangement, dermal grafts or fillers. Group characteristics and postoperative outcomes were compared using chi-square test for categorical variables and one-way ANOVA for continuous variables.

Results:  There were 591 VPI cases identified, 83 in group1, 359 in group 2, 40 in group 3, and 109 in group 4. The average age of repair was 7.9 with palatoplasty and pharyngeal flap done at a later time. More Asian patients received lengthening compared to other techniques. The longest operating time (108 minutes) was noted in lengthening group while the longest length of stay (2 days) was seen in the palatoplasty group.  Pediatric plastics performed the majority of the palatoplasty and lengthening cases whereas pediatric ENT performed most of the pharyngeal flap and local tissue rearrangement. Overall complication rate was 2%, with palatoplasty group had the lowest rate. Subgroup analysis comparing flap and sphincter techniques showed more complications in the pharyngeal flap group, however, these trends were not statistically significant.

Conclusion: Repairing a VPI can be done safely and effectively using different surgical approaches depending on the extent of the defect. A small gap causing a mild VPI will probably require a secondary palatoplasty, local tissue rearrangement or lengthening while a wide gap mandates bringing extra tissue to narrow it. Timely correction is crucial to facilitate proper phonation in children of developmental age. 

13.11 Typhoid Intestinal Perforation: Burden & Outcomes of a Neglected Pediatric Surgical Disease in Uganda

Posted on January 18, 2018

M. Cheung1, J. M. Healy1, N. Kakembo2, A. Muzira2, P. Kisa2, J. Sekabira2, D. Ozgediz1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA 2Mulago Hospital, Makerere University,Surgery,Kampala, , Uganda

Introduction:  Typhoid ileal perforation comprises a substantial pediatric surgical burden in low-income countries, while in high-income countries it is rarely encountered and the mortality rate negligible. Mortality rates are 10-20-fold higher in low-income countries where surgical treatment ranges from repair of intestinal perforation to diverting enterostomy and interval ostomy reversal. There has been no prior analysis of pediatric typhoid perforation epidemiology and outcomes in Uganda despite the significant socioeconomic impact on these children and families.

Methods:  Review of a prospectively collected database of 3,289 pediatric surgical admissions to a tertiary referral hospital in Uganda from January 2012 to March 2016.

Results: 95 cases were identified: 79 new cases and 16 patients presenting for ostomy reversal   (excluded). The majority underwent operations (94.9%) with 56 (75%) requiring ostomy creation. Median age was 8 years with a range of 2-12 years.  Median distance traveled was 30 km with a range of 4-450 km, and duration of hospitalization ranged from 1–44 days, with a median of 9 days.  Geospatial mapping showed a majority of cases from the south central and west of the country (Figure 1). Post-operative courses ranged from 1–38 days with a median of 6 days.  Overall mortality was 19.0%.

Conclusion: Typhoid perforation preferentially affects vulnerable populations in low-income countries, and in Uganda a similar demographic is affected. Distance travelled approached the recommended 50 km set by the World Health Organization. While repair of perforation has been described, 75% of these children required diversion, suggesting more severe disease at presentation, and in Uganda ostomy creation has been associated with social isolation and impoverishment. The 19% case fatality rate is comparable to similar settings and underscores disease severity. More hospital and community-based data are needed for a more accurate national geospatial disease profile. This disease presents an opportunity for the global pediatric surgery community to promote disease prevention and access to emergency children’s surgical care in resource-poor areas.

 

13.12 Trends in Pediatric Electronic Burns

Posted on January 18, 2018

J. A. Cook1, S. E. Sasor1, S. P. Duquette1, M. P. Landman2, S. S. Tholpady1,3, M. W. Chu1,3  1Indiana University School Of Medicine,Division Of Plastic & Reconstructive Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 3R.L Roudebush VA Medical Center,Division Of Plastic & Reconstructive Surgery,Indianapolis, IN, USA

Introduction: The Consumer Product Safety Improvement Act (CPSIA) was passed in 2008 to improve testing and standardize the quality of manufactured products. Electronic toys and devices are common in today’s market and pose risks to the user. The purpose of this study is to characterize burn injuries caused by consumer devices in the pediatric population and to determine the impact of the CPSIA.

Methods: The National Electronic Injury Surveillance System (NEISS) database was used to collect data on pediatric burns between 2000 and 2015. Thermal and electric burns from cell phones, batteries, and electronic toys were included.  Age, gender, affected body part, mechanism of injury, and fire department involvement were recorded. Binary values were calculated using a Chi-square goodness-of-fit test.

Results: A total of 126 pediatric burns were identified. The majority of patients were male (60.3%) and mean age was 8.3 years. Thirty-eight pediatric burn cases were identified before 2008; 88 cases were identified after 2008. The proportion of contact burns before 2008 (0.18) was significantly less than the proportion of contact burns after 2008 (0.44), X2 = 7.68, p < 0.01. Before 2008, the leg was the most affected body part (0.39); after 2008, the proportion of leg burns significantly decreased (0.17), X2 = 7.359, p = 0.01. Hand injuries significantly increased after 2008 (0.50) as compared to before 2008 (0.26), X2 = 6.08, p = 0.01. The proportion of cell phone injuries before 2008 (0.16) was significantly less than the proportion of cell phone injuries after 2008 (0.39), X2 = 6.39, p = 0.01. A significantly smaller proportion of powered scooter burns occurred after 2008 (0.09) as compared to before (0.36), X2 = 14.18, p < 0.01. The proportion of cases admitted to the burn unit did not differ before (0.03) or after 2008 (0.08), X2 = 1.27, p = 0.26.

Conclusions: The overall incidence of pediatric burns caused by electronic devices was low, both before and after 2008. The enactment of the Consumer Product Safety Information Act has not affected the severity of burns based on the number of patients requiring hospital admissions. However, the mechanism of burn and affected area did change significantly. Providers should be aware of these patterns in pediatric patients and should educate guardians about these risks.

13.08 Put a Ring on it: Better Pediatric Pre-Induction Checklist Adherence Observed with Parent Engagement

Posted on January 18, 2018

D. N. Supak1,2, M. A. Bartz-Kurycki1,2, K. T. Anderson1,2, S. N. Wythe1,2, G. M. Garwood1,2, R. F. Martin1,2, R. Gutierrez1,2, A. L. Kawaguchi1,2, K. P. Lally1,2, K. Tsao1,2  1McGovern Medical School, University Of Texas Health Sciences Center At Houston,Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction:  Patient and parent engagement in healthcare has been shown to improve compliance and outcomes in many medical disciplines, but no literature exists regarding parent engagement in the perioperative process. The World Health Organization surgical safety checklist (SSC) recommends including the parents of pediatric patients in checklist completion. At our children’s hospital, the pre-induction SSC is conducted in pre-operative holding with anesthesia, nursing and often with parents. We hypothesized that better checklist compliance would be observed when parents were engaged in checklist performance.

Methods:  An observational study of pre-induction checklist adherence during non-emergent pediatric operations was performed from 2016 to 2017 during two separate 8-week periods. Adherence was defined as verbalization of each checkpoint with or without parent confirmation. Six of 13 checkpoints (patient identification, procedure, surgical site marked, weight, allergies and NPO status) containing information relevant to parental knowledge were evaluated for staff confirmation with parents. Trained observers assessed parent engagement based on: parents off their phones, not distracted, positive body language, eye contact and demonstrating an understanding of the checkpoint. Chi-square test and linear regression were used for analysis. P-value <0.05 was significant.

Results: Over the study period, 459 pre-induction checklists were observed with at least partial completion in 93.3% of cases with kappa >0.7. The mean proportion of checkpoints completed was 64.6% ± 31.1% and the proportion of fully completed pre-operative checklists was only 18.3%. Parents were present in 82% of cases and at least 1 checkpoint was confirmed with parents in 79% of checklists. Pre-induction checklist adherence was better when parents were present compared to when absent (p<0.001 for all checkpoints). Linear regression demonstrated a 1.2 (95%CI 1.0-1.3) increase in pre-induction adherence for every unit increase in parent engagement (Figure). Furthermore, meaningful completion of checkpoints by staff confirmation with parents differed significantly based on parent engagement with 93.9-100% of staff confirmation of checkpoints occurring with engaged parents compared to 0.3-6.1% in parents deemed not engaged (p<0.001).

Conclusion: Pre-induction SSC performance remains a challenge, as less than one-fifth of checklists were completed in full. However, dramatic improvement in compliance and staff confirmation of checkpoints was observed when parents were present for and engaged in the checklist process. Creating a process and training operative teams how to engage parents may increase checklist compliance and improve patient safety.

 

13.09 Surgical safety checklists in children’s surgery: Surgeon’s attitudes and a review of the literature

Posted on January 18, 2018

J. Roybal3, K. Tsao1,9, S. Rangel4,7, M. Ottosen2, D. Skarda6,8, L. Berman5  1UTHealth Medical School,Pediatric Surgery,Houston, TX, USA 2UT Houston-Memorial Hermann,Center For Healthcare Quality And Safety,Houston, TX, USA 3Ochsner Hospital For Children,Pediatric Surgery,New Orleans, LA, USA 4Boston Children’s Hospital,Pediatric Surgery,Boston, MA, USA 5Nemours/Alfred I. DuPont Hospital For Children,Pediatric Surgery,Wilmington, DE, USA 6Primary Children’s Hospital,Pediatric Surgery,Salt Lake City, UT, USA 7Harvard Medical School,Pediatric Surgery,Boston, MA, USA 8University Of Utah,Pediatric Surgery,Salt Lake City, UTAH, USA 9Children’s Memorial Hermann,Pediatric Surgery,Houston, TX, USA

Introduction:  Safety initiatives, such as peri-operative checklists, aim to create a safe environment for patients undergoing surgery.  Attitudes toward and adherence to the checklist among providers affect its ability to prevent harm.   The pediatric surgeon’s perception of the importance of the surgical checklist, and its perceived role in improving patient safety, is unknown.  We designed a survey to assess safety knowledge, attitudes and perceptions of North American pediatric surgeons, and to specifically gauge the “buy-in” of the American Pediatric Surgical Association (APSA) membership on checklists.

Methods:  An online survey of APSA members was conducted to evaluate utilization of and attitudes towards surgical safety checklists (SSCs). Surgeons’ perceptions of SSC’s, including the components that make them effective as well as barriers to participation, were measured.   Closed and open-ended questions were designed to quantify surgeon participation in the pre-induction, pre-incision, and post-operative debriefing checklists, and to describe surgeons’ attitudes about the effectiveness of checklists.  Standard frequency analyses were performed, and content analysis was used to evaluate open ended responses.  In addition to the survey, a literature search was carried out to identify systematic reviews of safety checklists in surgery and any studies focusing on the use of checklists in the pediatric surgical population.

Results:  The survey response rate was 38% (353/928). Use of the SSC was reported by 93.6% of respondents, but only 54.7% felt that checklists improve patient safety, and only 62.6% would want it used in their own child’s operation.  Being in a safety position was the only respondent characteristic that correlated with believing that checklists improve patient safety or wanting the checklist used in one’s own child’s operation.  Reasons most commonly cited for skepticism around checklist efficacy included length of the checklist process, distraction from thoughtful patient care, and lack of data to support use.   For the literature review, 10 manuscripts met inclusion criteria and were reviewed in detail.  Only one study addressed pediatric surgery patients.  

Conclusion:  Most pediatric surgeons participate in surgical safety checklists at their institutions, but many question their benefit.   While data is lacking on the morbidity and mortality benefit of surgical safety checklists in the pediatric population, checklists have been shown to improve communication, promote teamwork, and identify errors. Checklists should be regarded as key elements in improving peri-operative safety culture.  

 

13.05 Blunt Renal Injury in Children: Do National Trends in Management Follow Recent Literature?

Posted on January 18, 2018

R. Sola1, T. A. Oyetunji1, K. D. Graziano2, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 2University Of Arizona,College Of Medicine/ Department Of Surgery,Phoenix, AZ, USA

Introduction:  Published prospective observational data suggest children with blunt renal injury can be managed without bedrest, the use of catheters or antibiotics, and follow up imaging can be reserved to those with urinary extravasation. We wanted to investigate the current practice patterns of major children’s’ hospital to identify variation and areas for improvement with the use of evidence based protocols. 

Methods:  Data from 2006 to 2015 were requested from the Pediatric Health Information System. Patients were included based on the International Classification of Disease Ninth Revision (ICD-9) coding for blunt renal injury. Children were excluded if they had concomitant major thoracic or abdominal injury, diagnosis of renal injury without computerized tomography (CT) imaging confirmation, length of stay greater than seven days, underwent laparotomy and those that were intubated. Demographics, need for further imaging, and hospital outcomes were analyzed.

Results: During the study period, 1487 children were found to have a blunt renal injury. A total of 638 children were identified after excluding those that did not meet our inclusion criteria.  Median age was 12 years old (8,14). There were 474 (74%) males and 386 (61%) were white.  Median length of stay was 3 days (2,4).  Foley catheters were placed in 93 (15%) children and 157 (25%) were given antibiotics during their hospital course.  Two or more CT scans were performed in 376 (59%) children during their hospitalization.  

Conclusion: Children with blunt renal injury appear to be utilizing excess healthcare resources compared to published recommendations.  Further studies implementing an evidence based protocol would allow for the reduction of Foley catheters, antibiotics and CT scans. 

 

13.06 Hurry Up and Wait: Pre-Incision Time in the OR Associated with Pre-Induction Checklist Adherence

Posted on January 18, 2018

S. N. Wythe1, K. T. Anderson1,2, M. A. Bartz-Kurycki1,2, D. N. Supak1, R. F. Martin1, G. M. Garwood1, R. Gutierrez1, A. L. Kawaguchi1,2, M. T. Austin1,2, K. P. Lally1,2, K. Tsao1,2  1McGovern Medical School, University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction: Delays in surgery impact patient care and resource utilization.  Operating room (OR) delay metrics are often defined when the patient enters the OR, but may not reflect in-room inefficiencies prior to incision. We hypothesized that low adherence to the pre-induction surgical safety checklist (SSC) may be associated with pre-OR delays or longer pre-incision times. 

Methods: An observational study of a convenience sample of scheduled, elective pediatric surgical cases in a tertiary care children’s hospital was performed over a 12-week period by trained observers. Specialties included general and thoracic, urology, neurosurgery, ophthalmology, orthopedics, otorhinolaryngology (ENT), and plastic & reconstructive surgery. Performance of the pre-induction checklist in the pre-operative area between nursing staff, anesthesia staff and patient/parents was observed. Degree of adherence to the pre-induction SSC was the proportion of checklist items completed. Pre-OR delays are institutionally defined as cases in which the patient enters the OR more than 5 minutes after scheduled case start. Pre-incision time was calculated as the difference between scheduled case start or room entry, whichever occurred first, and incision time. Cases were classified by scheduled order in the day (first start vs. later case). Descriptive statistics, chi2, t-tests, ANOVA and linear regression were performed. Inter-rater reliability was determined before the start of study using Cohen’s kappa.

Results:Interrater reliability for SSC performance was 0.70 (95%CI 0.68 – 0.72) for 5 observers. Of the 197 observed cases, 33% had pre-OR delay. Median total pre-incision time was 38 minutes (IQR 23-52). Median pre-induction adherence was 85% (IQR 69-100%) and did not vary by specialty (p=0.73). Pre-induction adherence to the SSC (p=0.91) and specialty (p=0.17) were not associated with pre-OR delays. First cases of the day were more likely to be on time (p<0.01). Longer total pre-incision times were associated with specialty (p<0.01) and worse pre-induction checklist adherence (p<0.01). After adjustment for specialty, case order, and adherence to SSC, first cases (p<0.01), ENT specialty (p<0.01), and higher pre-induction checklist adherence (p<0.01) remained associated with shorter pre-incision times (figure).

Conclusion:While pre-OR delays are tracked and audited, total pre-operative time, including time in the OR prior to surgery is not usually captured. Trying to achieve one metric of timeliness and efficiency may drive the necessary preparations to the OR, where costs may be higher. Pre-operative readiness may be reflected by meaningful pre-induction SSC performance and better measured by total pre-operative time. 
 

13.07 The Effect of Hospital Volume on Patient Outcomes for Pyloric Stenosis

Posted on January 18, 2018

C. Tom1, C. Niino2, A. D. Lee2, E. Saab2, 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: For many surgical operations, there is a well-established relationship between surgical volume and outcome.  In the field of pediatric surgery, this has been shown to be true for conditions requiring complex operations, however, for common conditions this relationship is less clear. This study investigated the relationship between hospital volume and surgical outcomes for infants affected by hypertrophic pyloric stenosis. 

Methods:  Kid’s Inpatient Database (KID) was used to identify patients with congenital hypertrophic pyloric stenosis who underwent pyloromyotomy for years 2003, 2006, 2009, and 2012. Surgical outcomes were measured by length of stay (LOS), complication rates, mortality, and cost. Hospitals were stratified based on case volume. Low-volume hospitals had the lowest quartile of patients treated per year, medium-volume hospitals had the middle two quartiles, and high-volume hospitals had the highest quartile of patients. 

Results: A total of 2,234 hospitals treated 51,792 patients with pyloric stenosis. The majority of hospitals were low-volume (n=1,834), while only 51 were high-volume. The overall mortality rate was 0.1% and the median length of stay was 2 days. Females were associated with higher complication rates. Results of multivariate analysis are summarized in table. High-volume hospitals were associated with lower complication rate and increased cost compared to medium- or low-volume hospitals. There were no differences in mortality or LOS. 

Conclusion: Using national data, we found that patients with hypertrophic pyloric stenosis treated at high-volume hospitals have improved outcomes despite higher costs. This indicates a benefit to receiving treatment for pyloric stenosis at a high-volume hospital. 

 

13.04 Pediatric Trauma Outcomes in the Obese.

Posted on January 18, 2018

R. Duran1, R. Barry1, M. Modarresi1, E. Thimpson1, J. Sanabria1  1Marshall University Schoool Of Medicine,Department Of Surgery,Huntington, WV, USA

Introduction:
 

Obesity affects one in four adults in the West, and this epidemic has extended to the young patient. The aim of this study is to assess the effects of obesity in the pediatric population affected by blunt trauma at a Global, Country, State and local medical center level. 

Methods:

The incidence, prevalence and mortality rates of blunt trauma by age, sex, cause, BMI, year, and geography were found using datasets from i) the Global Burden of Disease (GBD) group, where the epidemiological data obtained were modelled in DisMod-MR 2.1, a Bayesian meta-regression tool which pools data-points from different sources and adjusts for known sources of variability and iii) the local level II trauma registry at where data was modelled by JMP methods. GBD data was extracted from 284 country-year and 976 subnational-year combinations from 27 countries in North America, Latin America, Europe, and New Zealand from 1990 to 2015. Outpatient encounter data was also available from the USA, Norway, Sweden, and Canada for 48 country-years. There were 1026 pediatric patients admitted to the local trauma service who were evaluated (2014 to 2016). 

Results:

The Global, USA and State (WV) mortality on pediatric patients from transport related injuries has decreased (from 55, 64 and 49% to 46, 58 and 41%, respectively) as well as from falls (from 43, 55 and 41% to 30, 52 and 25 %, respectively) from 1990 to 2015.  The local cohort of pediatric patients included 880 non-obese (85.8%) and 146 obese (14.2%) patients. There was no significant difference in mortality rate, length of stay, ventilator support days, Glasgow Coma Scale score, presence of comorbidities or injury Severity score. The obese cohort, however, had a significantly longer ICU LOS. The average ICU LOS in our non-obese population was 2.46 vs 4.97 days in the obese group (p<0.05).

Conclusion: In the pediatric population, obesity is not a risk factor for fatality but for an increased ICU length of stay. Protocols engaging patients and parents aimed to pediatric weight control are being implemented.

 

13.03 The Role of LFTs in the Evaluation of Blunt Trauma in Pediatric Trauma Patients: Are They Necessary?

Posted on January 18, 2018

S. F. Rosati1, B. A. Borg1, P. Kato1, A. Husseini1, L. Donoghue1, C. Shanti1  1Children’s Hospital Of Michigan,Pediatric Surgery,Detroit, MI, USA

Introduction:  Injury is the leading cause of morbidity and mortality in children over one year; over 90% are the result of blunt trauma. Diagnostic aids to detect intra-abdominal injuries (IAIs) of the liver and spleen include abdomen/pelvis CT scans (AP CT) and liver function tests (LFTs). Historically, elevated LFTs have been used as a marker for when to obtain AP CTs. Our objectives were to evaluate the number of clinically significant injuries (defined as Grade IV or V) found using AP CT, and if there was a correlation to elevated LFTs.

Methods:  This is a retrospective review of pediatric patients (<18 years) evaluated at our Pediatric Level I trauma center from 1/1/15-12/31/16, who suffered blunt trauma. Variables included age, gender, injury severity score (ISS), LFTs, AP CTs and IAI with grades. 

Results: 1138 children were evaluated: 63% male, 37% female, with ages from 6 wks – 18 yrs (mean 5.25 yrs) and ISS from 0-45 (mean 5.4).  38% of patients (pts) had LFTs, 5% had an AP CT, 37% had IAI (1.8% overall). In the 62% of pts without LFTs, there were 16 AP CTs, 4 IAI, 0 significant; in pts with LFTs 0-100 (33%), there were 27 AP CTs, 7 IAI, 1 significant; in pts with LFTs 101-200 (2.8%), there were 7 AP CTs, 1 IAI, not significant; in pts with LFTs 201-300 (0.8%), there were 6 AP CTs, 5 IAI, 0 significant; in pts with LFTs 301-400 (0.4%), there were 2 AP CTs, 1 IAI, significant; in pts with LFTs 401-500 (0.01%), there was 1 AP CT, 1 IAI, not significant; in pts with LFTs > 500 (0.7%), there were 8 AP CTs, 2 IAI, 0 significant. 

Conclusion: In this limited review, a fraction of pts required an AP CT. While 33% of them were found to have IAI on CT, only 1% was clinically significant. Elevated LFTs do not correlate with the severity of IAI. LFTs alone may be a poor screening lab to determine need for an AP CT. We propose developing a different screening approach to our pts besides LFTs to determine need for AP CT.

 

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