Search

Importance: Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric demonstrated that the highest contribution to composite morbidity in otolaryngology is seen in children younger than 2 years undergoing tracheostomy., Objective: To determine predictive factors for complications following tracheostomy placement in patients younger than 2 years that, if targeted for reduction in quality initiatives, might result in improved surgical outcomes., Design, Setting, and Participants: The NSQIP Pediatric reports predefined 30-day postoperative outcomes for surgical cases from participating institutions for quality improvement. All 206 cases of elective tracheostomy performed in children younger than 2 years from 2012 to 2013 among 61 participating institutions and documented in the NSQIP Pediatric public use file were included. Data analysis was conducted from December 1, 2014, to June 30, 2015., Interventions: Surgical placement of tracheostomy in children younger than 2 years., Main Outcomes and Measures: Demographics and clinical and perioperative characteristics for children who did and did not experience a major complication from elective tracheostomy were compared. Continuous variables were compared using Wilcoxon rank sum tests and categorical variables were compared using Pearson χ2 tests or Fisher exact tests where appropriate. A logistic regression model was fit to identify adjusted odds ratios (aORs) with 95% CIs of preoperative factors predictive of occurrence of a major complication., Results: Of the 206 children younger than 2 years who underwent tracheostomy, 50 (24.3%) experienced a major complication within 30 days. The most common complications were pneumonia (16 [7.8%]), postoperative sepsis (12 [5.8%]), death (12 [5.8%]), and deep or organ space surgical site infections (8 [3.9%]). Neonatal age (aOR, 2.38; 95% CI, 1.06-5.37; P = .04), intraventricular hemorrhage (aOR, 2.72; 95% CI, 1.01-7.32; P = .048), and comorbid cardiac risk factors (relative to none: minor risk factors, aOR, 2.94; 95% CI, 1.19-7.24; major or severe risk factors, aOR, 1.31; 95% CI, 0.44-3.84; P = .04 for all cardiac risk factors) were independently predictive of major complications., Conclusions and Relevance: Young children undergoing tracheostomy tube placement have high rates of morbidity. This analysis identifies the need for additional procedure-specific outcome variables and improved variable definitions to incorporate into a detailed module for NSQIP Pediatric that will more effectively promote national, specialty-specific targeted quality improvement efforts.

Background: Preoperative risk assessment is standard in adult surgery, but often these risk assessments cannot be applied to children. Previous studies emphasize the differences between pediatric and adult populations and variability by surgical procedure types., Objective: We investigated preoperative risk factors for several outcomes in children undergoing major urologic surgery using the National Surgical Quality Improvement Program (NSQIP) Pediatric., Study Design: A cohort of 2-18-year-old children who underwent major urologic surgery was identified by Current Procedure Terminology (CPT) codes in the 2012-2013 NSQIP-Pediatric. The NSQIP-Pediatric prospectively collects standardized and validated data from 61 sites on preoperative, operative, and 30-day postoperative variables. Urologic surgeries involving dissection of the peritoneal or extraperitoneal space were included. Patients undergoing pure genitourinary surgery were analyzed separately from those with bowel involvement to improve homogeneity. Postoperative outcomes including hospital length of stay and 30-day infective complications, non-infective complications, unplanned reoperation and readmissions were evaluated by fitting multivariable logistic regression models., Results: A total of 2601 patients were identified, of whom 399 (15.3%) underwent bowel-involved surgery and 2202 (84.7%) underwent pure genitourinary surgery. Patients in the bowel-involved group were significantly older with more comorbidity. Postoperative complications, unplanned return to operating room, hospital length of stay and readmission rates were all significantly worse in the bowel-involved group. In the pure genitourinary group, older age and white race improved some outcomes, while American Society of Anesthesia (ASA) class ≥ 3, total operation time, obesity, pulmonary risk factors, preoperative renal disease, developmental delay, structural central nervous system abnormality, and supplemental nutrition independently predicted at least one negative outcome (Table)., Discussion: Consistent with previous research on reconstructive surgery, we identified a significant difference in patient age, surgery details, comorbidity, and increased complications for patients undergoing urologic surgery with bowel involvement compared with pure genitourinary surgery. Focusing solely on pure genitourinary surgery, we identified predictors of outcomes. Identification of these factors in pediatric urology is novel and only recently possible with the availability of the NSQIP-Pediatric., Conclusion: Using the NSQIP-Pediatric, we confirmed differences in complication rates for major urologic surgeries, with and without bowel involvement in a national sample. Preoperative risk characteristics were also identified for patients undergoing pure genitourinary surgery. Further investigation into these relationships is necessary to better elucidate their clinical significance with the goal of improving surgical planning, postoperative care, and family counseling., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Surgical treatments of soft-tissue abscesses (STAs) include packing and ring drain (RD) and straight drain (SD) placement. Potential benefits of SDs include a single incision, less scarring, and no need for a follow-up appointment. We used a multidisciplinary quality improvement (QI) process to promote surgeon adoption of an STA drainage technique to improve efficiency and quality of care., Subjects and Methods: Outcome measures included the proportion of STAs drained using SDs, the number of postoperative clinic visits, the proportion of patients requiring follow-up with a pediatric surgeon and other providers, and the postoperative complication rate, defined as need for an additional drainage procedure., Results: After beginning the QI initiative, the proportion of STAs drained by SDs increased from 23% to 78% (P < .00001) and the proportion of patients requiring a surgical follow-up clinic appointment decreased from 71% to 32% (P < .00001). The mean number of surgical clinic visits per patient decreased from 0.79 to 0.39 visits per patient (P < .00001). Complication rates were similar between drain types (RD: 2.4%; SD: 1.7%; P = .57). This QI initiative produced a rapid sustained shift in surgeon practice with increased use of SDs, decreased number of follow-up visits, and no increase in complications.