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To slow the spread of the 2019 novel coronavirus disease (COVID-19) and reduce the associated morbidity and mortality, the Children's National Hospital developed a multidisciplinary, collaborative vaccine program aimed at equitably and expeditiously vaccinating the pediatric population of the surrounding community. Interdepartmental collaboration, professional expertise, and community partnerships allowed for a dynamic and successful program design that began as large volume-centralized vaccine clinics and expanded to smaller volume ambulatory clinics. This strategy proved successful at meeting local vaccine demand; however, strategies to improve vaccine uptake in communities with high rates of hesitancy are still needed to maximize vaccine equity.

BACKGROUND Despite the growth of patient safety programs across the United States, errors and adverse events remain a source of patient harm. Many hospitals rely on retrospective voluntary reporting systems; however, there are opportunities to improve patient safety using novel tools like trigger programs. METHODS Children’s National Hospital developed a unique pediatric triggers program that offers customized, near real-time reports of potential safety events. Our team defined a measure to quantify clinical utility of triggers, termed “trigger signal,” as the percentage of cases that represent true adverse or near-miss events (numerator) per total triggers activated (denominator). Our key driver diagram focused on unifying the program structure, increasing data analytics, promoting organizational awareness, and supporting multidisciplinary end user engagement. Using the model for improvement, we aimed to double overall trigger signal from 8% to 16% and sustain for 12 months. RESULTS The trigger signal increased from 8% to 41% and sustained during the coronavirus disease 2019 pandemic. A balancing measure of time to implement a new trigger decreased. Key interventions to increase trigger signal were change in the program structure, increasing stakeholder engagement, and development of self-service reports for end users. CONCLUSIONS Children’s National Hospital’s triggers program highlights successful evolution of an iterative, customized approach to increase clinical utility that hospitals can implement to impact real-time patient care. This triggers program requires an iterative, customized approach rather than a “1-size-fits-all,” static paradigm to add a new dimension to current patient safety programs.

Objective While disparities in endometrial hyperplasia and endometrial cancer are well documented in Blacks and Whites, limited information exists for Hispanics. The objective is to describe the patient characteristics associated with endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer, and assess factors contributing to racial/ethnic differences in disease outcomes. Methods This single-center, retrospective study included women aged ≥50 years with ≥ two encounters for endometrial hyperplasia symptoms, endometrial hyperplasia with atypia and endometrial cancer between 2012 and 2016. Multivariate logistic regression models evaluated the predictors of endometrial cancer and hyperplasia. Results We included 19,865 women (4749 endometrial hyperplasia symptoms, 71 endometrial hyperplasias with atypia, 201 endometrial cancers) with mean age of 60.45 years (SD 9.94). The odds of endometrial hyperplasia symptoms were higher in non-Hispanic Blacks (Odds Ratio [OR] 1.56, 95% Confidence Interval [CI] 1.20–1.72), Hispanics (OR 1.35, 95% CI 1.22–1.49), family history of female cancer (OR 1.25, 95% CI 1.12–1.39), hypertension (OR 1.24, 95% CI 1.14–1.35), and birth control use (OR 1.29, 95% CI 1.15–1.43). Odds of endometrial cancer and atypical hyperplasia increased for ages 60–64 (OR 7.95, 95% CI 3.26–19.37; OR 3.66, 95% 1.01–13.22) and being obese (OR 1.61, 95% CI 1.08–2.41; OR: 6.60, 95% CI 2.32–18.83). Odds of endometrial cancer increased with diabetes (OR 1.68, 95% CI 1.22–2.32). Conclusion(s) Patients with obesity and diabetes had increased odds of endometrial cancer and hyperplasia with atypia. Further study is needed to understand the exogenous estrogen effect contributing to the increased incidence among Hispanics.

Objectives:To describe the incidence of seasonal respiratory viral infections (s-RVIs) before and during the coronavirus disease 2019 (COVID-19) pandemic and to compare virus-specific patient outcomes in pediatric patients.Design:A retrospective cross-sectional study including patient admissions to the Children’s National Hospital between October 1, 2015, and December 31, 2020.Results:Among 12,451 patient admissions between March 15 and December 31, 2020 (cohort 1), 8,162 (66%) were tested for severe acute respiratory coronavirus virus 2 (SARS-CoV-2), and 249 (2.0%) were positive. Among 10,986 patient admissions between April 1 and December 31, 2020 (cohort 2), 844 (8%) were tested for s-RV upon admission and 160 were positive. Thus, 1.5% of patient admissions were associated with laboratory-confirmed s-RVIs. Among the 49,901 patient admissions during a viral season between October 1, 2015, and March 31, 2020 (cohort 3), 7,539 (15%) were tested for s-RV upon admission and 4,531 were positive; thus, 9.0% of patient admissions were associated with laboratory-confirmed s-RVIs. hHRV/rENT was the most detected virus, but the detection rate decreased substantially (31% vs 18%; P < .001) during the COVID-19 pandemic. No patients had RSV, influenza, hMPV, hPIV, or hCoV detected upon admission after April 21, 2020. The 3 patient cohorts had no statistically significant difference in the percentage of ICU admissions (10.8% vs 15.0% vs 14.2%; P > .05) or death at discharge (0.8% vs 0.6% vs 0.5%; P > .05).Conclusions:Compared to COVID-19, s-RVI cases were associated with a higher proportion of inpatient admissions but were similar in ICU admission and death rates in hospitalized pediatric patients. Public health interventions for preventing COVID-19 were highly effective in preventing pediatrics s-RVIs.

Employee safety and the reduction of Days Away, Restricted, or Transferred are a focus of the Solutions for Patient Safety Network. One significant contributor to the Days Away, Restricted, or Transferred rate at Children's National Hospital is employee slips, trips, or falls.Children's National Hospital implemented a multidisciplinary quality improvement with executive leadership vision and support. We implemented quality techniques (including Key Driver Diagrams, Pareto Charts, and continuous Plan-Do-Study-Act) and designed novel Environmental Services interventions.Children's National Hospital achieved a 44.3% reduction in monthly average reported slips, trips, or fall events from baseline and sustained over a 2-year study period.A leadership-driven multidisciplinary approach to quality initiatives with team leaders capable of making and enacting real-time policy changes led to novel interventions and a successful reduction of employee slips, trips, and falls events over time, which are broadly generalizable.

Importance: Tracheotomy is one of the riskiest procedures for composite morbidity within pediatric otolaryngology. During the postoperative period, each time the tracheostomy tube is manipulated, there is opportunity for morbidity (e.g. a patient is vulnerable to accidental decannulation and airway loss). Objective: To identify areas of improvement in caring for "fresh tracheostomy" patients by determining the number of times a tracheostomy tube is manipulated from placement until discharge. The hypothesis is that the more a tracheostomy is manipulated, the higher probability of morbidity. Methods: A quality improvement initiative was conducted to map the care of patients who underwent tracheostomy placement over 12 months. Tracheostomy care and manipulation by all providers were reviewed. Complications, wound care, and respiratory treatments were also evaluated. Results: Patients were hospitalized for an average of 39 days (7–140) following tracheostomy. The first tracheostomy tube change occurred on average 6 days (5–10) following placement. Tracheostomy tubes were manipulated an average of 6 (2.5–11.9) times a day to amount to 216 (51–1091) times between placement and discharge. Bedside nurses and respiratory therapists were responsible for 95% of these actions; physicians accounted for 4%. There were 6 tracheostomy related complications. Three were accidental decannulations resulting in cardiopulmonary arrest. One of these caused long term patient morbidity. Patients with more than 4 manipulations per day during the 2 weeks following tracheostomy tube placement, were more likely to have a tracheostomy related complication than those with less than 4 (OR: 12.5; 95% CI: 1.2–130.6; P = 0.0349). Interpretation: While uncommon, complications related to tracheostomy can have serious long term effects and at best prolongs length of stay for patients. Reducing the number of tracheostomy manipulations may provide safer postoperative care ultimately reducing morbidity and potentially mortality; children on average have 6 tracheotomy manipulations/day with only 2% being by the physician. Key words: Complications; Management; Pediatric tracheostomy; Safety

Quality improvement (QI) and patient safety are essential to the practice of medicine. Specific training in these fields has become a requirement in graduate medical education, although there is great variation in how residency programs choose to approach trainee education in QI and patient safety. Residents have a unique vantage point into the operations of a health care system and can guide the development of system improvement initiatives. In this report, we (1) describe the context that led to the creation of a pediatric resident safety council (PRSC) in its current structure, (2) identify the organizational features implemented to best meet the objectives of this council, and (3) describe the local and institutional impact of the PRSC. A PRSC is a useful model to build resident engagement in safe and high-quality patient care within a residency program and health care system. A PRSC encourages the professional development of future pediatric safety leaders and facilitates experiential training in patient safety and QI science.

There has been tremendous attention and effort directed toward improving the safety and quality of healthcare in prior decades. There have been real gains, but also challenges, to the success and sustainment of improvement efforts. We know that our organizations, and those of our peers, are safer and deliver higher quality care than they ever have. To this end, this chapter demonstrates the need for a case-based approach toward patient safety and quality improvement. For our hospitals to overcome improvement plateaus and get to zero harm, we need to approach our work differently. Theoretical underpinnings have served us well; however, we need to present cases and real problems that have been amenable to the theoretical approaches. There is a myriad of issues we continue to struggle with, such as spreading learned best practices and sustaining improvement. This chapter uses catheter-associated urinary tract infections (CAUTIs) as an exemplar of how one organization employed their respective quality tools to reduce their CAUTI rate. The focus of this chapter will be on the Donabedian quality triad, the preventable harm index, and alignment of these concepts with an organization’s mission, vision, and values. This chapter is not intended to be a primer on how to reduce CAUTIs, but rather a framework for this textbook on how to embark and sustain a quality improvement initiative using a case-based approach.

Intubating critically ill patients is an extremely high-risk procedure with airway-related morbidity, and mortality significantly higher compared to that of controlled settings such as the OR. According to the fourth National Audit Project (NAP4) of the Royal College Of Anesthetics, airway-related mortality is 58 times more likely to occur per patient in the ICU than in the OR. These numbers tend to rise further when dealing with a septic patient. Within the critically ill population, intubation and airway management of a septic patient can be two of the most challenging interventions for providers. Identifying some of the factors that make this procedure so challenging will enable you to be better prepared to handle them in a smooth, safe, and efficient manner when the situation arises ….and it will!

Coccidioidomycosis, a fungal infection caused by inhaling spores of Coccidioides immitis/posadasii, is endemic to the southwestern states of the United States, Northern Mexico and some parts of Central and South America. It is primarily a pulmonary infection with less than 0.5% of symptomatic cases showing dissemination. Skin, lymph nodes and bone are the commonest sites. Neurological involvement is rare and commonly presents as strokes, abscesses or meningoencephalitis. We present the case of a previously healthy 23-year-old African American male, presented with a four-month history of progressive right upper extremity weakness that initially started with right shoulder pain followed by worsening weakness and loss of muscle mass. Electromyography (EMG) demonstrated right brachial plexopathy with moderate-to-severe active denervation changes. MRI cervical spine revealed a 9-cm contrast enhancing extradural mass extending through the neural foramen from C4-T1 roots and forming a 4-cm right apical lung mass subsequently seen on MRI of the brachial plexus. All trunks, divisions and cords were thickened, hyperintense and showed contrast enhancement on MRI. Neuromuscular ultrasound (NUS) demonstrated enlargement of peripheral nerves. Differentials prior to biopsy of the mass ranged from neurofibromas to pancoast lung tumors. Coccidioidomycosis did not figure on the initial list of differentials. Patient underwent subsequent biopsy of the extradural and lung masses that showed coccidiodes. Serum coccidioides antibody titers were elevated. The patient was treated with high-dose intravenous fluconazole and aggressive mass debridement. His weakness improved on four months follow-up evaluation with significant resolution of EMG abnormalities and decreased swelling on NUS.

It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.

This cohort study compares the clinical features of coronavirus disease 2019 (COVID-19) with those of influenza A and B in US children., Key Points Question What are the similarities and differences in clinical features between coronavirus disease 2019 (COVID-19) and seasonal influenza in US children? Findings In this cohort study of 315 children with COVID-19 and 1402 children with seasonal influenza, there were no statistically significant differences in the rates of hospitalization, admission to the intensive care unit, and mechanical ventilator use between the 2 groups. More patients with COVID-19 than with seasonal influenza reported fever, diarrhea or vomiting, headache, body ache, or chest pain at the time of diagnosis. Meaning The findings suggest that prevention of both COVID-19 and seasonal influenza in US children is prudent and urgent for the well-being of this population., Importance Compared with seasonal influenza, the clinical features and epidemiologic characteristics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus 2019 (COVID-19) in US children remain largely unknown. Objective To describe the similarities and differences in clinical features between COVID-19 and seasonal influenza in US children. Design, Setting, and Participants This retrospective cohort study included children who were diagnosed with laboratory-confirmed COVID-19 between March 25 and May 15, 2020, and children diagnosed with seasonal influenza between October 1, 2019, and June 6, 2020, at Children’s National Hospital in the District of Columbia. Exposures COVID-19 or influenza A or B. Main Outcomes and Measures Rates of hospitalization, admission to the intensive care unit, and mechanical ventilator use and the association between underlying medical conditions, clinical symptoms, and COVID-19 vs seasonal influenza. Results The study included 315 patients diagnosed with COVID-19 (164 [52%] male; median age, 8.3 years [range, 0.03-35.6 years]) and 1402 patients diagnosed with seasonal influenza (743 [53%] male; median age, 3.9 years [range, 0.04-40.4 years]). Patients with COVID-19 and those with seasonal influenza had a similar hospitalization rate (54 [17%] vs 291 [21%], P = .15), intensive care unit admission rate (18 [6%] vs 98 [7%], P = .42), and use of mechanical ventilators (10 [3%] vs 27 [2%], P = .17). More patients hospitalized with COVID-19 than with seasonal influenza reported fever (41 [76%] vs 159 [55%], P = .005), diarrhea or vomiting (14 [26%] vs 36 [12%], P = .01), headache (6 [11%] vs 9 [3%], P = .01), body ache or myalgia (12 [22%] vs 20 [7%], P = .001), and chest pain (6 [11%] vs 9 [3%], P = .01). Differences between patients hospitalized with COVID-19 vs influenza who reported cough (24 [48%] vs 90 [31%], P = .05) and shortness of breath (16 [30%] vs 59 [20%], P = .13) were not statistically significant. Conclusions and Relevance In this cohort study of US children with COVID-19 or seasonal influenza, there was no difference in hospitalization rates, intensive care unit admission rates, and mechanical ventilator use between the 2 groups. More patients hospitalized with COVID-19 than with seasonal influenza reported clinical symptoms at the time of diagnosis.

Improvements in medical care and its delivery comes at a price. Quality professionals are tasked with assessing the value of the programs they implement and, for their superiors, whether that value is worth the cost of completing the program. They need to present the results in a convincing and clear way. The value of quality must be condensed into understandable and relatable economic terms that the organization and society as a whole will understand and accept. This chapter reviews the fundamentals of economics, finance, and politics of medical quality and illustrates how these three fields interact and can be used by the reader to prepare and defend the business case for quality. The information within this chapter is intended to introduce basic concepts that can be useful regardless of which direction the system will move in the next 5 years.

BACKGROUND AND OBJECTIVES: Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS: In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS: We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS: Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.

Causal analysis is a core function of safety programs. Although established protocols exist for conducting root cause analysis for serious safety events, there is limited guidance for apparent cause analysis (ACA) in health care. At our institution, through a novel facilitated ACA approach, we aim to improve safety culture and provide a clear approach to address precursor safety events and near-miss safety events. We define facilitated ACA as limited investigation (scope and duration) of a safety event that resulted in little to no harm. These investigations require fewer resources and focus on preventive strategies. Our facilitated ACA model, with an operational algorithm and structured process, was developed and implemented at our tertiary-care, freestanding, urban pediatric hospital in 2018. Sixty-four ACAs were completed, and 83% were identified with the algorithm. Process measures, including time from event reporting to ACA launch (median 3 days; interquartile range 2–6 days), are tracked. Patient safety consultants averaged 5 hours to complete a facilitated ACA. A median of 3 disciplines or departments participated in each facilitated ACA. Through an iterative process, we implemented a structured process for facilitated ACA, and the model’s strength includes (1) right event, (2) right team, (3) right analysis, and (4) right action plans. This novel facilitated ACA model may support organizational cause analysis and improve safety culture with higher-reliability processes.

We are inundated by data; healthcare is no different. The electronic medical record, the numerous patient care monitors, and the thousands of medications to be reconciled with specific dosing parameters are a few examples of the omnipresent and intimidating nature of data in healthcare. Across the world, healthcare without data does not exist. The data represent many forms but are quickly moving towards electronic formats. As ubiquitous as data are the near universal finding that such data are lagging. There is an urgent need for real‐time data in improving processes and ultimately outcomes in healthcare. If data lag by four to eight weeks, if not longer, then true change cannot occur and harm continues in that interval. This review article discusses the urgent need for real‐time data and demonstrates examples of how Children's National Medical Center in Washington, DC uses real‐time data to drive outcomes.

Objective To evaluate the efficacy of CO 2 laser cauterization with suspension microlaryngoscopy as a definitive surgical treatment for pediatric Congenital Pyriform Sinus Fistula (CPSF). Material and methods This is a cohort retrospective study. Thyroid function and cervical ultrasonography examinations were performed before operation. Enhanced magnetic resonance imaging (MRI) was performed on patients with a repeated infection (≥2 times) and/or if they had a prior open surgery. Patients were divided into two groups: the Results CO 2 laser cauterizations with suspension microlaryngoscopy were performed for 104 CPSF patients. No complications occurred. Three patients had a recurrence in the follow-up. The number of surgical cauterization operations was fewer than 3 in 85.1% of the patients. There was no significant difference in the number of cauterizations among the different age groups or between the initial treatment and retreatment groups ( P >0.05). Conclusion CO 2 laser cauterization with suspension microlaryngoscopy is a safe, effective, and minimally invasive approach to CPSF with optimal patient outcomes. Type of study Treatment Study. Level of evidence Level III.

“How would your perception of a patient change if you discovered that he or she had been convicted of a serious crime?” Medical students are typically posed with this scenario at some point during ...

The submental island flap was first described as a tool for facial reconstruction after tumor resection. It is now widely used for reconstructing numerous structures in the head and neck region of adults. Pediatric surgical reconstruction is a challenging task that continues to evolve over time. We describe two novel uses of this flap in the pediatric population. The submental island flap is an excellent option for reconstruction in pediatrics given its ease of elevation, excellent cosmetic outcomes, and low donor site morbidity.

Introduction This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program–Pediatric (NSQIP-P) database. Methods We performed a retrospective cohort study involving patients in the 2012–2015 NSQIP-P database who underwent ESS. Predictors included demographics, comorbidities and surgical acuity. Outcomes included 30-day complications, reoperations, and readmissions. Results Among 2,061 ESS cases identified, 1,829 (88.7%) were elective and 232 (11.3%) were urgent/emergent. There were 92 (4.5%) readmissions, 54 (2.6%) unplanned reoperations, and 61 (3.0%) complications. On multivariate analysis, readmission was associated with urgent/emergent procedures (OR 2.31, CI 1.36-3.93, p

Objective To report the results of a preliminary analysis of a quality improvement initiative aimed to identify potential latent systems defects. Methods A pilot study of an anonymous, voluntary, event reporting system made available to all members of the American Academy of Otolaryngology-Head and Neck Surgery was performed. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to classify error types. Descriptive statistics were used to summarize submissions to the database. Results In the 53 cases reported to the database over 22 months, the majority involved errors that had resulted in harm (n = 34, 64%), followed by errors that occurred and did not result in harm (n = 7, 13%). Errors occurred predominantly in the hospital (n = 23, 44%) and operating room (n = 19, 35%). Most entries were classified as either technical (n = 21, 39%) or related to postoperative care (n = 15, 30%). Discussion This preliminary descriptive analysis of a novel otolaryngology patient safety event reporting tool shows that this platform brings unique value to the identification of errors and adverse events in our specialty. Most reported events were classified as errors resulting in harm. The most common type of reported event was a technical error, most often resulting in a nerve injury. Implications for Practice This reporting tool will likely allow for identification and prioritization of improvement opportunities. This example may serve as a guide for other societies to create similar platforms as we strive for a standardized process for event reporting.

Introduction Perioperative services constitute a significant portion of the care delivery, the impact, and the potential risk in healthcare organizations. Tremendous attention has been paid towards hospital-acquired conditions; however perioperative services have not received similar attention. There is a need for a standardized manner to report on conditions in perioperative services which facilitates prioritization of quality improvement initiatives. Materials and methods Preventable harm and quality of care indicators were selected based on a review of the literature and available datasets, as well as from safety and quality measures in our organization. Metrics were derived from myriad national quality improvement initiatives and collaboratives. A structure was created to obtain the metrics in a near real-time manner and present the Perioperative Harm Index across the organization. Specific initiatives were targeted as necessitating immediate, short-term, or longer duration prioritization for improvement initiatives. Results A Perioperative Harm Index was created using 11 metrics that represent the spectrum of surgical care. The metrics facilitate prioritization of improvement initiatives and have resulted in improvement projects including perioperative normothermia in neonatal intensive care unit patients having procedures in the operating room, reduction of post-operative nausea and vomiting, and decrease in surgical site infections in selected procedures. Conclusions A Perioperative Harm Index facilitates immediate shared understanding of the harm resulting from the care of surgical patients. As such, this index enables rapid and rationale prioritization for improvement activities. Our harm index is shared, is broadly generalizable, and has facilitated prioritization of improvement opportunities and appropriate allocation of improvement resources at our organization. Levels of Evidence Level V.

Objectives Prior research has shown that airway reconstructive procedures comprise significant composite morbidity compared to the whole of pediatric otolaryngologic cases evaluated in the American College of Surgeon's National Surgery Quality Improvement Program-Pediatric (ACS-NSQIP-P) platform. We describe postoperative sequelae of pediatric airway reconstructive procedures and identify predictive factors for adverse events. Methods Current procedural terminology (CPT) codes were used to identify children undergoing included procedures in the 2012 to 2014 ACS-NSQIP-P public use files (PUF). Targeted variables included patient demographics and 30-day postoperative events (reoperation, readmission, and complications). Event rates were determined and compared within subgroups. Multivariate logistic regression was performed to identify predictive factors for major adverse events. Results In 3 years of PUF data (183,283 total cases), 198 cases (0.11%) were airway reconstructive procedures. The most common was laryngoplasty (CPT 31580, 31582; n = 111, 56.1%), followed by cervical tracheoplasty (CPT 31750; n = 47, 23.7%), tracheal resection (CPT 31780; n = 24, 12.1%), and cricoid split (CPT 31587, n = 16, 8.1%). There were 131 premature children (66.2%) and 94 children (47.5%) with history of bronchopulmonary dysplasia. Thirty-day postoperative sequelae included readmissions (n = 42, 21.2%), complications (n = 27, 13.6%), and reoperations (n = 14, 7.1%). On univariate analysis, children less than 3 years of age were more likely to undergo an unplanned reoperation. There were no significant predictive factors for readmission or complication. On multivariate analysis, there was a trend toward higher rates of unplanned reoperations in children less than 3 years of age. Conclusion The 30-day adverse event rate in pediatric airway surgery is high, with no identifiable predictors noted in the analysis of these data. Findings imply that systematic collection of variables and outcomes specific to pediatric airway surgery, in addition to standard NSQIP workflow, will be essential for NSQIP-P to truly effect quality improvement in these high-risk procedures. Level of evidence 4. Laryngoscope, 2016 127:504-508, 2017.

Objectives/Hypothesis To report otolaryngologists' reactions to errors and adverse events and determine if temporal changes in physician efforts to assume responsibility; ameliorate patients' conditions; or change personal, group-wide, or hospital practices have occurred. Study Design Mixed-methods analysis of survey entries detailing responses to errors and adverse events. Methods Members of the American Academy of Otolaryngology–Head and Neck Surgery were asked to report errors or adverse events. Responses to open- and closed-ended questions from a similar, previously distributed, anonymous national survey were included for analysis. Responses were enumerated and reported descriptively and then analyzed by reviewers using an interpretive phenomenological approach. Responses were compared to those from an identical survey distributed a decade prior. Results Otolaryngologists reported 226 adverse events. Responsibility was attributed to the physician surveyed in 74 cases (32.0%), to ancillary staff in 58 cases (25.1%), to consulting physicians in 24 cases (10.4%), and to trainees in 16 cases (6.9%). The undertaking of corrective actions was reported by 175 physicians (75.8%). These events led to changes in personal, group/departmental, and hospital practice in 78 (33.8%), 37 (16.0%), and 11 (4.8%) cases, respectively. Conclusion Following errors and adverse events, otolaryngologists continue to employ corrective actions to ameliorate harm. Responses are directed toward ameliorating the patient injury and also toward efforts to change personal practice and/or improve systems performance. Efforts to change personal practice are much more common than efforts to improve systems. Education about systems-based change represents a large opportunity for improvement in our specialty. Level of Evidence N/A Laryngoscope, 2016

Introduction: The association between hypothermia in the neonatal intensive care unit (NICU) patients and morbidity and mortality is well described. Neonates are at higher risk of perioperative hypothermia when compared to older children. Previous studies showed that quality improvement tools reduced postoperative hypothermia in NICU patients, but none showed sustained improvement at incidence rates of

Background Surveillance plays a pivotal role in the surgical-site infections (SSIs) prevention through identifying infections, monitoring changes in infection rates, and evaluating the effectiveness of intervention strategies. Methods This retrospective study reviewed SSI surveillance systems implemented at the Children's National Health System in 3 phases between 2007 and 2016 including all surgical procedures. The targeted surveillance was conducted in cardiovascular, spinal fusion, and ventricular shunt surgeries and required an infection preventionist (IP) to review all procedures, to identify SSIs that meet the CDC's National Healthcare Safety Network definition. SSIs in the remaining surgical procedures were identified through the review of positive microbiology reports daily and followed by full chart review if the specimen type and/or patient location were suggestive of a surgical history. Timely feedback of SSI to stakeholders was the primary mode of intervention, with additional interventions implemented for the 3 targeted surveillance procedures. Data collected between 2013 and 2016 were analyzed to account for a definition change in 2013. Results For the 3 targeted surveillance procedures, IP reviewed 2,255 procedures and identified 43 SSIs. For the remaining procedures, IPs identified 123 SSIs confirmed by one or more pathogens. The overall SSI rate had a 31% decrease. The cardiovascular and spinal fusion SSI rate had a 61% and 84% decrease, respectively. The ventricular shunt SSI rate increased 29% due to 2 episodes of recurrent infections in 2 patients. Conclusions It is prudent for hospitals to continue monitoring SSI by establishing surveillance programs with optimal approaches.

Endoscopic management of pediatric subglottic stenosis (SGS) is common, however no multi-institutional studies have assessed its perioperative outcomes. The American College of Surgeon's National Surgical Quality Improvement Program - Pediatric (ACS-NSQIP-P) represents a source of such data.Current procedural terminology (CPT) codes were queried for endoscopic or open airway reconstruction in the ACS-NSQIP-P Public Use File (PUF). Demographics and 30-day events were abstracted to compare open to endoscopic techniques and to assess for risk factors for varied outcomes after endoscopic dilation.National database.Patients with data reported in the 2015 ACS-NSQIP-P PUF.Length of stay (LOS), 30-day rates of reintubation, readmission and reoperation.171 endoscopic and 116 open procedures were identified. Mean age at endoscopic and open procedures was 4.1 (SEM = 0.37) and 5.4 years (SEM = 0.40) respectively. Mean LOS was shorter after endoscopic procedures (5.5 days, SEM = 1.13 vs. 11.3 days SEM = 1.01, p = 0.0003). Open procedures had higher rates of reintubation (OR = 7.41, p = .026) and reoperation (OR = 3.09, p = .009). In patients undergoing endoscopic dilation, children1 year were more likely to require readmission (OR=4.21, p=0.03) and reoperation (OR=4.39, p=0.03) when compared to older children.Open airway reconstruction is associated with longer LOS and increased reintubations and reoperations, suggesting a possible opportunity to improve value in healthcare in the appropriately selected patient. Reoperations and readmissions following endoscopic dilation are more prevalent in children less than one year.

Otitis media (OM) is a common diagnosis in the pediatric population that is usually managed on an outpatient basis. A small proportion of children are admitted due to a complex disease course. The aim of this study was to investigate the demographics of those patients and the resources utilized during their admissions.Retrospective review based on the 2009 Kids' Inpatient Database.Nationwide administrative database.A review based on the 2009 Kids' Inpatient Database was conducted. Inclusion criteria were clinical modification codes for OM (ICD-9 code 382). Data recorded included patient demographics, concurrent discharge diagnosis codes, length of stay, total charges, and frequency of procedures performed.There were 61,783 (92,548 nationally weighted) admissions with OM, which were analyzed. The average age (SD) for the patients was 2.18 (3.49) years, and the average length of stay was 2.88 days. The majority (80.75%) of patients did not have to undergo a procedure during admission, whereas a small proportion (5.4%) underwent a major operating room procedure. There were 21 deaths recorded (0.03%). A diagnosis of mastoiditis, meningitis, venous sinus thrombosis, or intracranial abscess was associated with significantly increased length of stay, incidence of procedures, and total cost of admission.Complicated pediatric OM remains of concern requiring prompt and thorough management. Major complications include mastoiditis and meningitis, and unfortunately, fatalities still occur in patients with OM. An understanding of resource utilization and socioeconomic implications can identify and drive opportunities for targeted quality improvement.

To report patient/family experiences and outcomes after tracheostomyInternational survey of patients and families with tracheostomy.Collaboration of the Patient Safety and Quality Improvement Committee of the American Academy of Otolaryngology-Head and Neck Surgery and the Global Tracheostomy Collaborative.A 50-item survey was developed with multistakeholder collaboration. The survey was disseminated via international social networks used by patients with a tracheostomy and their families. Qualitative and quantitative data were analyzed.Of 220 respondents, 90% cared for a pediatric patient with a tracheostomy. Only 48% of respondents felt "very prepared" at time of discharge, and 11% did not receive emergency preparedness training prior to discharge. Home nursing needs were inadequately met in 17% of families, with resulting difficulties shortly after discharge; 14% sought emergent care within 1 week of discharge. Nearly half of respondents indicated a desire to have met with a patient with a tracheostomy prior to surgery but were not offered that opportunity. Fragmented care or limited teamwork was reported by 32% of respondents, whereas tracheotomy care was described as "integrated" or "maximally integrated" for 67%.While many families report satisfaction with tracheostomy care, opportunities remain for improving care. This study highlights the importance of teaching, teamwork, and smoothing transition from the hospital. Potential quality improvement areas include standardizing tracheostomy teaching for routine and emergency needs and optimizing postdischarge support and coordination. Prior to surgery, connecting families to people with a tracheostomy may also be beneficial.

Describe safety and postoperative sequelae of pediatric otologic surgery and identify predictive factors for postoperative events.Retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database.Data pooled from the 2012 NSQIP-P public use file (50 institutions).Current procedural terminology codes were used to identify children who underwent otologic surgery. Variables of interest included demographics and 30-day postoperative events grouped as reoperation, readmission, and complication. Event rates were determined and prevalence of events compared by procedure type and within patient subgroups according to chi-square analysis. Multivariate logistic regression evaluated predictive factors for postoperative events.Of 37,319 pediatric operations, 2556 (6.8%) were otologic procedures. The most common procedure was tympanoplasty (n = 893, 34.9%), followed by myringoplasty (n = 741, 30.0%), cochlear implantation (n = 464, 18.2%), and tympanomastoidectomy (n = 458, 17.9%). There were 9 reoperations (0.4%), 32 readmissions (1.3%), and 18 complications (0.7%). Children undergoing tympanomastoidectomy or cochlear implantation were more likely to be readmitted irrespective of other factors (odds ratio = 5.5, P = .010; odds ratio = 3.5, P = .083). Children3 years old were 4 times more likely to be readmitted than older children (odds ratio = 4.4, P.001).Pediatric otologic procedures are common and have low rates of global 30-day postoperative events. Tympanomastoidectomy and cochlear implantation have the highest risk of 30-day readmission. Young children (3 years) are more likely to be readmitted following these procedures. Further optimization of the NSQIP-P to include specialty and procedure-specific variables is necessary to assess complete, actionable outcomes of pediatric otologic surgery, however the present study provides a foundation to build upon for safety and quality improvement initiatives in pediatric otology.

Objective To directly sample the preference of representative parents who would be hypothetically considering tonsillotomy versus tonsillectomy for their child and assess the role of parental age, educational level, and risk aversion in making this choice. Methods Parents in a pediatric otolaryngology waiting room were asked to complete an anonymous survey which presented hypothetical scenarios for their child and described the specifics of tonsillectomy and tonsillotomy in terms of post-operative recovery, tonsil regrowth rates, and future strep throat risk. Other questions gathered parental demographic data and assessed risk tolerance. Results Two hundred and thirty-four parents completed the survey. A large majority of parents (201 of 234, 85.9%) preferred tonsillectomy over tonsillotomy for their child. Parental education and age were not associated with procedural preference. An increasing self-reported risk aversion score ( p = 0.003, Fisher's exact test) and a classification as risk averse using validated questions ( p = 0.034) were both associated with a preference for tonsillectomy over tonsillotomy. Conclusion Parents of pediatric Otolaryngology patients strongly prefer tonsillectomy over tonsillotomy when described in general terms. This parental choice appears to correlate with risk aversion of the possible long-term complications of tonsillotomy including the need for future treatment of streptococcal pharyngitis and/or regrowth of the tonsils and subsequent revision tonsil surgery.

Education in patient safety (PS) and quality improvement (QI) helps both medical students and residents understand the health care environment in the United States, where these concepts are now incorporated into virtually every aspect of patient care. The Accreditation Council of Graduate Medical Education has made PS/QI a mandatory component of resident education, and a number of specialties have published their experiences with incorporating PS/QI into their training programs. In otolaryngology-head and neck surgery, a strong curriculum can be built by teaching residents about the principles of PS/QI through both didactic and experiential learning, and morbidity and mortality and QI conferences can serve as the cornerstone of this curriculum. Understanding the potential challenges in PS/QI education can allow training programs to plan their strategy effectively for successful incorporation into their existing curricula.

Erbium-doped fiber amplifier (EDFA) plays crucial role in future optical networks. The Gain two-dimensional EDFA plays a serious role for contemporary WDM optical application. We have done simulation of WDM Optical Network by changing pump power and length. The system is simulated victimization Optisystem package to realize noise figure, BER (Bit error rate), and gain flatness of EDFA through optimized pump power and fiber length. The gains are two-dimensional at intervals 25dB from 1546 to 1568 nm range of wavelength, keeping bit error rate (BER)

This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database.We performed a retrospective cohort study involving patients in the 2012-2015 NSQIP-P database who underwent ESS. Predictors included demographics, comorbidities and surgical acuity. Outcomes included 30-day complications, reoperations, and readmissions.Among 2,061 ESS cases identified, 1,829 (88.7%) were elective and 232 (11.3%) were urgent/emergent. There were 92 (4.5%) readmissions, 54 (2.6%) unplanned reoperations, and 61 (3.0%) complications. On multivariate analysis, readmission was associated with urgent/emergent procedures (OR 2.31, CI 1.36-3.93, p0.01) and history of bleeding disorder (OR 2.24, CI 1.12-4.44, p = 0.02), reoperation was associated with urgent/emergent procedures (OR 5.78, CI 3.24-10.34, p0.01), and complications were associated with urgent/emergent procedures (OR 3.81, CI 2.13-6.82, p0.01) and history of bleeding disorder (OR 5.30, CI 2.74-10.20, p0.01). Bleeding requiring transfusion was associated with urgent/emergent procedures (OR 9.61, CI 2.90-31.80, p0.01), history of bleeding disorder (OR 14.16, CI 4.41-45.45, p0.01), and age3 years (OR 3.92, CI 0.99-15.61, p = 0.05). Black children were significantly more likely to undergo urgent/emergent surgery than white children (19.7% vs. 9.6%, p0.01).This multi-institutional study confirms that while pediatric ESS is largely safe, urgent/emergent procedures carry the greatest risk of postoperative adverse events, and black children are significantly more likely to undergo higher acuity surgery than white children. Regardless of procedure acuity, young age and bleeding disorder are associated with higher risk of 30-day adverse events.

Upcoming mobile communication systems are more complex and comprise of sophisticated functionality to enhance their performance. To expedite their time to market, the RTL development and verification cycle time has to be improved. This paper puts an emphasis to improve the prototyping phase by using Model Based Design technique comprising of Simulink HDL coder, HDL verifier and rapid FPGA prototyping utilizing FPGA in loop co-simulation. As a case study, the MIPI Low Latency Interface (LLI) layer protocol is implemented. The results conferred in this paper illustrates the acceleration in hardware development cycle by reducing the RTL development time and simulation time required for verification of the design under test. In this paper comparison of the automatic generated HDL code from the Simulink HDL coder to that of manual handwritten code is performed. The comparison targets the time to market, area, power and timing constrains for the Data Link Layer (DLL) of MIPI LLI for both the procedures. The automatic HDL code generated from the Simulink Model using MATLAB R2016b, and the manual hand-written Verilog code for the Data Link Layer are synthesized for CMOS 45nm standard cell ASIC technology. The comparison result shows that time to market value is reduced by more than half with significant decrease of 11% to 17% in the operating speed, the area and power consumption is also increased by 25% and 29% respectively.

To compare the performance of ibuprofen vs codeine for postoperative pain management after tonsillectomy as measured by need for emergency department (ED) treatment for pain and/or dehydration.Retrospective case series with chart review.Tertiary children's hospital.Consecutive series of patients who underwent tonsillectomy with or without adenoidectomy at a tertiary children's hospital. Patients were categorized based on the type of postoperative pain management (acetaminophen with codeine vs acetaminophen and ibuprofen). The main outcome measure was the proportion of patients requiring ED visits or inpatient admissions for inadequate pain control or dehydration. Secondary measures included antibiotic use, postoperative hemorrhage, need for return to the operating room, vomiting, and oral diet tolerance.Patients in the ibuprofen/acetaminophen group were younger than those in the codeine/acetaminophen group (6.2 vs 8.1 years, P.05). Patients in the codeine/acetaminophen group were more likely to use antibiotics in the postoperative period (50.3% vs 5.9%, P.05). The proportion of patients requiring ED visits or inpatient admission for dehydration was not significantly different between the groups (5.1% for codeine, 2.7% for ibuprofen, P = .12). Multivariable analysis controlling for age and antibiotic use showed no difference in ED visits or admission for dehydration (P = .09). There was no difference between the groups for any of the secondary measures.Ibuprofen with acetaminophen represents a safe and acceptable analgesic alternative to codeine and acetaminophen in patients undergoing pediatric tonsillectomy.

The objective of this study was to describe the incidence of complications in children with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) at a tertiary pediatric hospital and to identify predictive factors for their occurrence. A retrospective chart review of 110 patients born in or transferred to Sydney Children's Hospital with EA/TEF between January 1999 and December 2010 was done. Univariate and multivariate regression analyses were performed to identify predictive factors for the occurrence of complications in these children. From univariate analysis, early esophageal stricture formation was more likely in children with 'long-gap' EA (odds ratio [OR] = 16.32). Patients with early strictures were more likely to develop chest infections (OR = 3.33). Patients with severe tracheomalacia were more likely to experience 'cyanotic/dying' (OR = 180) and undergo aortopexy (OR = 549). Patients who had gastroesophageal reflux disease were significantly more likely to require fundoplication (OR = 10.83) and undergo aortopexy (OR = 6.417). From multivariate analysis, 'long-gap' EA was a significant predictive factor for late esophageal stricture formation (P = 0.007) and for gastrostomy insertion (P = 0.001). Reflux was a significant predictive factor for requiring fundoplication (P = 0.007) and gastrostomy (P = 0.002). Gastrostomy insertion (P = 0.000) was a significant predictive factor for undergoing fundoplication. Having a prior fundoplication (P = 0.001) was a significant predictive factor for undergoing a subsequent aortopexy. Predictive factors for the occurrence of complications post EA/TEF repair were identified in this large single centre pediatric study.