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The increased attention on excessive healthcare spending and the need to improve the efficiency and quality of healthcare in the USA has prompted medical specialties such as otolaryngology to take the lead in quality improvement initiatives. These projects aim to reduce variation in certain health practices, improve patient outcomes, and stimulate further strides toward better overall healthcare in our country. Some tools that are commonly employed toward this goal are clinical practice guidelines and national administrative databases. The two methods are very dissimilar in their makeup and creation, but both can serve a common and shared purpose. This review provides the reader with an understanding of how our specialty can utilize these tools to improve healthcare.

Objectives To examine the rates and predictors of long-term opioid therapy in older cancer survivors. Design Retrospective cohort study. Setting Texas, United States. Participants Cancer survivors (5 years or more postcancer diagnosis) diagnosed from 1995 to 2008 and who were also Medicare Parts A, B, and D beneficiaries. Measurements We used Medicare Part D event data to calculate the proportion of cancer survivors with a prolonged opioid prescription (90-day or more supply of opioids/year). Adjusted odds ratios were calculated to identify predictors of prolonged opioid prescribing. All analyses were repeated with a subcohort of opioid-naive cancer survivors. Results The rate of prolonged opioid therapy for cancer patients diagnosed in 2008 was 7.1% prior to cancer diagnosis; it rose to 9.8% within a year of cancer treatments, and to 13.3% at 5 years postdiagnosis. The rate at the sixth year varied by cancer sites: 19.4% in lung cancer and 9.6% in prostate cancer. Among opioid-naive survivors, the rate increased from 1.4% to 7.1%, from 5 to 18 years postcancer diagnosis. Cancer survivors diagnosed in 2004 to 2008 had higher rates of opioid prescribing compared to those diagnosed in 1995 to 1998 and 1999 to 2003. Years since diagnosis, a later year of diagnosis, female sex, urban location, lung cancer diagnosis, disability as reason for Medicare entitlement, Medicaid eligibility, one or more comorbidity, and history of depression or drug abuse were predictors of prolonged opioid therapy. Among opioid-naive cancer survivors, diagnosis in 2004 to 2008 was the strongest predictor, while a history of drug abuse was the strongest predictor for all the survivors. Conclusion The rates of prolonged opioid prescribing for older cancer survivors remained high at 5 or more years after cancer diagnosis. Our findings have potential to inform the development of clinical guidelines and public policy to ensure safer and more effective pain treatment in older cancer survivors. J Am Geriatr Soc 67:945-952, 2019.

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children’s surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance. METHODS: Participating institutions included children’s units within general hospitals and free-standing children’s hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models. RESULTS: In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible. CONCLUSIONS: The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children’s surgery performance indicator. Programmatic improvements have resulted in actionable data.

There is controversy about which children should be admitted after adenotonsillectomy (TA) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after TA in tertiary care pediatric hospitals.Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database.There were 29,920 TAs performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions.Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-TA admission rates. Admission rates ranged from94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA.Post TA admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night.4.

An emerging focus on measurement and reporting of health care quality indicators calls for a sound evidence base that otolaryngologists can use to support clinical care decisions. In addition to traditional clinical trials, practitioners are heeding results of high-quality comparative-effectiveness and health services research analyses to better understand the complexity of disease epidemiology, care variation, health care costs, and surgical utilization for common conditions. Many national publicly available data sources exist for use in clinical research that may be of benefit for the academic and clinical otolaryngologist. The strength and value of these sources vary depending on the intended use or research question. The purpose of this commentary is to introduce and provide an overview of some major national and administrative databases, highlight potential strengths and limitations of these data, and suggest applications for use in advancing the care of our patients in otolaryngology.

Purpose The American College of Surgeons (ACS) National Surgical Quality Improvement Program Pediatric (NSQIP-P) expanded to beta phase testing with the enrollment of 29 institutions. Data collection and analysis were aimed at program refinement and development of risk-adjusted models for inter-institutional comparisons. Methods Data from the first full year of beta-phase NSQIP-P were analyzed. Patient accrual used ACS-NSQIP methodology tailored to pediatric specialties. Preliminary risk adjusted modeling for all pediatric and neonatal operations and pediatric (excluding neonatal) abdominal operations was performed for all cause morbidity (other than death) and surgical site infections (SSI) using hierarchical logistic regression methodology and eight predictor variables. Results were expressed as odds ratios with 95% confidence intervals. Results During calendar year 2010, 29 institutions enrolled 37,141 patients. 1644 total CPT codes were entered, of which 456 accounted for 90% of the cases. 450 codes were entered only once (1.2% of cases). For all cases, overall mortality was 0.25%, overall morbidity 7.9%, and the SSI rate 1.8%. For neonatal cases, mortality was 2.39%, morbidity 18.7%, and the SSI rate 3%. For the all operations model, risk-adjusted morbidity institutional odds ratios ranged 0.48–2.63, with 9/29 hospitals categorized as low outliers and 9/29 high outliers, while risk-adjusted SSI institutional odds ratios ranged 0.36–2.04, with 2/29 hospitals low outliers and 7/29 high outliers. Conclusion This report represents the first risk-adjusted hospital-level comparison of surgical outcomes in infants and children using NSQIP-P data. Programmatic and analytic modifications will improve the impact of this program as it moves into full implementation. These results indicate that NSQIP-P has the potential to serve as a model for determining risk-adjusted outcomes in the neonatal and pediatric population with the goal of developing quality improvement initiatives for the surgical care of children.

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 χ 2 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.

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.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.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.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.4. Laryngoscope, 2016 127:504-508, 2017.

To describe characteristics and outcomes of patients hospitalised for injuries occurring in industrial settings during a 1-year period.A retrospective analysis of hospital admissions in the USA in 2006 using the Nationwide Inpatient Sample was performed. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) code E849.3 (industrial place and premises) was used to identify work-related injury admissions.A total of 5826 patients were hospitalised with injuries sustained in industrial settings (weighted, 28,354 patients). The mean age was 42.9 years (82% were men). They were 48% Caucasian, 19% Hispanic and 6% African-American. The majority were admitted from the Emergency Department (72%). Further the majority of admissions were discharged home (79%; 9% with home healthcare) and 10.7% were transferred to another facility. The mean length of stay was 4.5 days (range 0-109 days). Mean total charges per admission was US$32,254 (median US$18,364, 90th percentile US$66,607). Common diagnoses included: orthopaedic injuries (including amputations) to: finger/hand (20.9%), foot/ankle (8.2%), leg (10.2%) and spine (8.4%); infection (10.8%), pulmonary diagnosis (6.6%), soft tissue injuries (3.6%) and burns to10% of the body (3.6%). Comorbidities included hypertension (17.0%) and diabetes mellitus (6.3%). Most common procedures performed included fracture reduction (17.6%), blood transfusions (3.1%) and spinal surgery (3%). A total of 194 (0.7%) patients died in the hospital.Injuries in industrial settings result in significant healthcare usage, morbidity and mortality on an annual basis in the USA. These admission levels facilitate development of targeted strategies to optimise the quality and economics of care for injuries in industrial settings.

To evaluate parental knowledge regarding household food and non-food choking hazards.Cross Sectional Survey.Tertiary Care Children's Hospital.Parents presenting to a Pediatric Otolaryngology Clinic with a child4 years old.Parental survey asking which choking hazard foods (CHF) they allow their child to eat, previous instruction of CHF, knowledge of non-food choking hazards, and their knowledge sources.adjusted odds ratios (AOR) and logistic regressions.492 respondents. Adjusted for significant covariates associations between correct knowledge of CHF and correct parents actions of disallowing CHF: fruit chunks (prior instruction=42%; correct action=25%; AOR=3.51; P0.0001), hot dogs (59%; 28%; 1.75; 0.0178), raw vegetables (41%; 47%; 1.28; 0.198) popcorn (67%; 49% 2.64;0.0001), whole grapes (68%; 51%; 2.2;0.0001), nuts (73%; 66%; 2.47;0.0001), chunks of peanut butter (45%; 79%; 2.55; 0.0003), sticky candy (79%; 80%; 2.16;0.0033), gum (72%; 84%; 1.75; 0.028), seeds (65%; 87%; 1.4; 0.247), 76% always supervise meals, 57% always cut food, 62% know CPR. KNOWLEDGE OF NON-FOOD HAZARDS: Coins (97%), marbles (94%), small batteries (93%), small toy parts (93%), dice (92%), pen caps (92%), safety pins (85%), balloons (84%), syringes (40%). Sources of choking hazard knowledge: physicians (67%), family/friends (52%), books/magazines (40%), and the Internet (25%).Parental knowledge of CHF is incomplete. The consumption of CHF in children under 4 is significantly associated with decreased parental knowledge. Therefore, more parental education is needed.

Objectives/Hypothesis: To ascertain the surveillance and management practices for tracheotomy patients. Study Design: Survey of tracheotomy management. Methods: An electronically distributed 26-question survey was distributed under the auspices of the American Academy of Otolaryngology–Head and Neck Surgery Foundation. Results: There were 478 responses. The mean number of years in practice was 21.2 years (standard deviation [SD], 11.0 years). Sixty-five percent of respondents perform mainly adult tracheotomy. There is variation in surveillance patterns of immediate, postoperative, intermediate, and long-term surveillance. On average, respondents follow a fresh tracheotomy daily for about 6 days, monthly for about 3 months, and long-term surveillance every 4 months on average. Almost all respondents perform long-term surveillance during routine tracheotomy changes; 61.4% perform this surveillance with an endoscope, and a minority rely on history and examination. The mean frequency of tracheotomy tube changes was 2 months (SD, 2.2 months; median, 1.1 month; range, 0.06–12 months). Two hundred sixty-one respondents have or have used a decannulation algorithm. The vast majority, 96.2%, are comfortable with their current management practices. Over half of the respondents perceive value in a clinical practice guideline to help them with standardizing care, and 80% of respondents feel that it would assist other specialties in the care and surveillance of tracheotomy patients. Conclusions: There is marked variability in the surveillance and management of tracheotomy patients. There exists opportunity to improve care through standardization of surveillance and management of these patients. Laryngoscope, 122:46–50, 2012

Objectives/Hypothesis: To gather qualitative and semiquantitative information about catastrophic complications during and following tracheotomy. Study Design: National survey distributed to American Academy of Otolaryngology–Head and Neck Surgery members via the Academy weekly email newsletter during April and May 2011. Methods: A total of 478 respondents provided estimates of the number of four specific tracheotomy-related complications (innominate artery fistula, esophageal fistula, acute tracheotomy occlusion, and obstructing granuloma), all catastrophic events, and events resulting in death or permanent disability encountered during their careers. There were 253 respondents who provided 405 free-text descriptions of specific events. Results: The respondents experienced approximately one catastrophic event every 10 years and one event resulting in death or permanent disability every 20 years. More than 90% occurred more than 1 week after surgery. Categories of physicians who experienced more events per year included academic physicians and laryngologists. Pediatric otolaryngologists had twice as many innominate artery fistulas per year of practice as others. Qualitative (free-text) descriptions of the most serious events demonstrated that more of these events involved loss of airway and volume bleeds, usually from innominate or carotid artery erosion. Many of the events due to airway loss involved potentially correctable deficits in family education, nursing care, home care, and other structural factors. Conclusions: Even when we allow for selection bias, these data suggest that a substantial number of tracheotomy complications leading to death or permanent disability occur at a national level. The vast majority of events occur more than 1 week after the procedure. Many of the described events were caused by factors that should be amenable to prospective system improvement strategies. Laryngoscope, 122:30–37, 2012

Objectives We describe our use of balloon dilation to repair choanal atresia in a series of patients. Study design Case series. Methods We performed a retrospective review of patients who underwent repair of choanal atresia using dilation with high pressure, non-compliant airway balloons between January 2009 and September 2010. For primary cases, balloon dilation was used in conjunction with transnasal endoscopic puncture, and repair of bony stenosis with backbiting forceps and microdebrider drill. Results 5 patients underwent balloon dilation repair of choanal atresia or stenosis. 4 patients presented for primary repair, with a mean age of 2.9 months. 1 patient presented at 10 years of age for revision repair several years after previous attempts performed elsewhere. The average number of procedures was 3.6, with an average of 2 balloon dilations. There were no complications stemming from balloon dilation. Follow-up ranged from 3 to 24 months. All patients demonstrated choanal patency on last follow-up. Conclusions This is a novel use of high pressure, non-compliant balloons. We found success in dilating membranous stenoses, post-repair granulation, and scar tissue in revision cases. Balloon dilation is an effective adjuvant tool for use in the repair of choanal atresia and stenosis.

Summary Background Access to effective surgical treatments such as breast reduction is often restricted on the grounds of patient obesity. However, there is a lack of unambiguous data on the surgical risks of obesity in patients undergoing breast reduction. The aim of this study was to assess the relationship between patient obesity, as determined by body mass index (BMI), and surgical outcome following bilateral breast reduction (BBR). Methods Retrospective review of case notes was conducted for 306 patients who underwent BBR in our unit over a 5-year period. BMI, resection weight, smoking history, technique, complications and outcomes were determined from records of follow-up assessment. Results Overall complication rate was 53.9%, with multiple complications of 22.9%. A significant increase in complications after BBR with increasing BMI was identified ( p =0.019 any complication, p =0.002 multiple complications). The effect of BMI on multiple complications was significant and independent of resection weight ( p =0.031) and reduction technique ( p =0.020). Smoking was associated with higher wound dehiscence and multiple complications. We developed a model for predicting risk of complications based on key variables. Despite higher complications, there was no significant difference in aesthetic outcome at follow-up between the BMI groups. Conclusions These findings add to the body of evidence that obesity is associated with an increased risk of post-operative complications. This has implications for surgeons and healthcare payers. However the majority of complications were minor and aesthetic outcomes were satisfactory in the majority of cases. The use of a ‘target' BMI as exclusion criteria should therefore be treated with caution.

Objectives To present case vignettes of unusual pediatric parotid pathologies and discuss management paradigms in the context of these lesions. Study design Retrospective case series. Setting Free-standing, academic tertiary care pediatric hospital. Methods All patients over the past 18 months undergoing parotidectomy for a parotid mass were reviewed (N = 5). Results Ages ranged from 17 months to 16 years. All presented with a remarkably similar clinical course, consisting of a persistent parotid mass for more than 3 months which was usually painless. Most (4/5 patients) had been treated with antibiotics prior to Otolaryngology consultation. Fine-needle aspiration (FNA) was performed on 3 patients and was diagnostic in one. Complete excision of the mass was performed in each child through a parotidectomy approach (3 total, 2 lateral lobe). The final pathology showed metastatic neuroblastoma (17 months old), undifferentiated primitive sarcoma (22 months old), mucoepidermoid carcinoma (11 years old), nodular fasciitis (12 years old), and hyperplastic lymph node (16 years old). The patient with neuroblastoma died from complications of bone marrow transplant. Conclusions The differential diagnosis for a persistent pediatric parotid mass is expansive and differs from that found in the adult population. As this series highlights, in many cases, it is impossible to discern the pathology, or rule out malignancy, based upon the clinical course, imaging, or FNA results. Surgical excision remains the standard for management of these patients and is both diagnostic and therapeutic. Our anecdotal case series highlights the importance of having a low threshold for parotidectomy in these children.

Objective To determine the scope of wrong-site sinus surgery. Study Design Electronic mail survey. Setting E-mailed via the American Academy of Otolaryngology–Head and Neck Surgery's weekly newsletter. Subjects and Methods Members were asked about wrong-site sinus surgery in an 11-item survey. Results A total of 455 members responded (response rate 19.8%). Forty-two (9.3%) have heard of a case of wrong-site sinus surgery occurring. Twenty-one cases were analyzed; of these, 10 (48%) implicated radiographic error, and the Universal Protocol was followed in one third. In seventeen reports (81%), there was disclosure to the family, one case with delayed disclosure; there was no disclosure in three cases. Sixty-one percent (n = 266) are concerned about operating on the wrong sinus or side. Forty-nine percent (n = 216) routinely use a checklist preoperatively. There is large variation in site marking for sinus surgery. Sixty-five percent (n = 282) routinely review the computed tomography scan prior to surgery. Conclusion Approximately 10 percent of survey respondents know of a case of wrong-site sinus surgery occurring; the majority of respondents are concerned about a wrong-sinus or wrong-sided surgery occurring in their practice. Otolaryngologists should be vigilant regarding the potential for inverted computed tomography images; there should be national efforts to address this latent systems defect. Surgeons should be trained in understanding the role of and engaging in disclosure and in other techniques that are of greatest support to the patient. Consideration of sinus-specific checklists should be led by the societies representing sinus surgeons.

Objectives/hypothesis To study national trends, variances, and outcomes in patients admitted with epiglottitis in the United States. We hypothesize that the incidence of epiglottitis has decreased, mortality has decreased, and that there has been a shift toward older patients being admitted with epiglottitis. Study design Retrospective review of a dataset for years 1998, 2000, 2002, 2004, and 2006. Methods The Nationwide Inpatient Sample was searched using ICD-9 CM codes for epiglottitis with obstruction (464.30) and without obstruction (464.31). Characteristics studied included patient demographics, hospital information, and admission variables. Weighted admissions were analyzed to facilitate national estimates. Results There was a trend toward decreasing admissions over the study period, from 4587.17 cases (1998) to 3772.49 cases (2006); the mean over the study period was 4062.52 cases/year. The mean age of a patient with epiglottitis has remained relatively constant at 44.94 years over the study period; there are less frequent admissions in the 18 years and younger age cohorts, with an increase in the ages 45 to 64 years old and in patients over 85 years old. Mean length of stay is 4.15 days. Mean total charges for an admission of epiglottitis was $17,204.02 (standard deviation, $5,894). There was a trend toward increased total charges for the management of epiglottitis from total charges of $10,738.60 (1998) to $25,071.62 (2006). The South had a predominantly higher proportion of epiglottitis admissions during the study period. The gender distribution remained consistent over the study years at approximately 60:40 for males:female. Mortality remained constant at approximately 36 cases per year for a national mortality rate from epiglottitis of 0.89%. The month with the highest percentage of admissions was December; April was the month with the lowest. The majority of admissions were via the emergency department; patients were transferred in 2.88% of admissions. Over two thirds of admissions were Caucasian patients. Hospital level measures included the majority of patients were treated in an urban hospital location (82%); a minority (41%) were treated at a teaching hospital. Insurance status was private insurance in 50.02%, Medicare 20.84%, and Medicaid 12.46%. The proportion of patients that were intubated was 13.18%; 3.62% underwent a tracheotomy. Additional diagnoses in admitted patients included concomitant cardiovascular (38.75%), infectious (27.17%), respiratory (22.88%), diabetes (13.26%), and substance abuse (18.86%) diagnoses. Conclusions An 8-year retrospective review of epiglottitis admissions revealed that epiglottitis continues to be a significant clinical entity in the United States. The portrait of a typical patient that will be admitted with epiglottitis is a mid-40-year-old, Caucasian, urban, male, with comorbid medical conditions, who will remain in the hospital on average for 4 days, resulting in total charges of $25,072 (2006 dollars). The majority of the mortalities are in adult patients. The majority of patients with epiglottitis has significant medical comorbid conditions and will be managed at the admitting hospital and not be transferred. This series identifies two newly recognized and uniquely vulnerable populations for epiglottitis: infants ( 85 years old).

Background In 2014, Children's National Health System's executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting. Methods Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting. Results Children's National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as "other" decreased from a baseline of 6% to 2%. Conclusions Children's National Health System's focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.

Objectives We describe our series in the surgical treatment of laryngomalacia using a microdebrider. Methods We performed a retrospective review of patients who underwent microdebrider-assisted supraglottoplasty for laryngomalacia between October 2004 and February 2008. Patients with neurologic conditions and secondary airway lesions were excluded. The main outcome measures included complications, pain, resolution of stridor, presence of aspiration, and need for revision surgery. Results Twenty-eight patients underwent microdebrider-assisted supraglottoplasty. The mean age at diagnosis was 109 days, and the mean age at the time of the procedure was 182 days. Nineteen patients (68%) had gastroesophageal reflux at diagnosis. The average operative time was 35.7 minutes (range, 11 to 65 minutes). No intraoperative complications or device problems occurred. Two patients remained intubated after the procedure. One patient required a tracheotomy, and 1 patient underwent revision supraglottoplasty. Three patients had aspiration that resolved. There was negligible pain from the procedure, as all patients immediately resumed a diet. All patients had immediate or eventual resolution of stridor. Conclusions This is the largest series of patients who underwent microdebrider-assisted supraglottoplasty for laryngomalacia. This procedure is relatively safe, with minimal pain, and effective in patients with laryngomalacia. Microdebrider-assisted supraglottoplasty is the method of choice for supraglottoplasty in our institution.

Objectives: We performed a retrospective review to determine the utility of bronchoscopy in patients with recurrent croup (RC). Methods: Bronchoscopy was performed on 30 patients with a diagnosis of RC (age, 14 months to 13.9 years) over a 2-year period. Results: One third of the patients (33.3%) were found to have airway disorders, including subglottic stenosis (7), subglottic edema (2), and a subglottic cyst (1). Patients with RC who were less than 3 years of age were more likely to have an airway abnormality found on endoscopy (9 of 14 or 64.2%) than were those older than 3 years (1 of 16 or 6.2%; χ2, p < 0.001). There was no statistically significant difference in abnormal findings 1) in patients with RC who had a history of prematurity or prior intubations (χ2, p = 0.17 and p = 0.052, respectively); 2) between infectious and spasmodic croup (χ2, p = 0.794); or 3) by number of croup episodes (χ2, p = 0.300). Two patients required surgical intervention (laryngotracheal reconstruction and marsupialization of a subglottic cyst). Conclusions: Of 30 patients who underwent bronchoscopy for RC, 33% had airway disorders — Mostly children less than 3 years old. We suggest a higher index of suspicion for finding airway disorders in children less than 3 years old with RC and having a lower threshold for performing diagnostic bronchoscopy in this population.

Objective Subglottic stenosis is found in 10% to 20% of patients with Wegener's granulomatosis, and at times, it may be the only indication of disease. This is particularly a problem in childhood-onset Wegener's granulomatosis, which is complicated 5 times more by subglottic and tracheal stenosis than in adult-onset disease. Because this is a rare disease that is often misdiagnosed as reactive airway disease in childhood, the discovery of subglottic stenosis is delayed until much of the chronic damage has already been done. This report discusses the diagnosis and management of a 12-year-old male with a severe, actively inflamed subglottis and trachea because of Wegener's granulomatosis. Method This study uses a retrospective case review. Results The study shows a successful symptomatic medical treatment of subglottic stenosis with resolution of tracheal inflammation and subglottic stenosis. Conclusion Treatment of an actively inflamed trachea with subglottic stenosis because of Wegener's granulomatosis should focus on medical therapy, including steroids, before making attempts at surgical intervention.

Objectives: Studies of medical error demonstrate that errors and adverse events (AEs) are common in hospitals. There are little data of errors on pediatric surgical services. Methods: We retrospectively reviewed 50 randomly selected inpatient admissions to the otolaryngology service at a tertiary care children's hospital. We used a “zero-defect” paradigm, recording any error or adverse event—from minor errors such as illegible notes to more significant errors such as mismanagement resulting in a bleeding emergency. Results: A total of 553 errors/AEs were identified in 50 admissions. Most (449) were charting or record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were present in 38% of admissions; there were no major AEs or permanent morbidity. Medication-related errors occurred in 22% of admissions, but only two resulted in minor AEs. There was a positive correlation between minor errors and AEs; however, this was not statistically significant. Conclusions: Multiple errors occurred in every inpatient pediatric otolaryngology admission; however, only 26 minor and eight moderate AEs were identified. The rate of errors per 1,000 hospital days (6,356 per 1,000 days) is higher than previously reported in voluntary reporting studies, possibly due to our methodology of physician review with a “zero-defect” standard. Trends in the data suggest that the presence of small errors may be associated with the risk of adverse events. Although labor-intensive, physician chart review is a valuable tool for identifying areas for improvement. Although small errors were common, there were few harms and no major morbidity. Laryngoscope, 2009

The purpose of this study was to determine resource utilization in managing subglottic stenosis.The Kids' Inpatient Database (KID) 2003 was analyzed.International Classification of Diseases, Ninth Revision code 478.74 was the inclusion criteria.Two thousand forty-six admissions with subglottic stenosis were sampled; there were 10 deaths (0.49%). States with the most admissions were Ohio, California, and Illinois; these did not have the highest spending per admission. Two hundred eighteen (10.7%) underwent a laryngeal graft procedure; states with the most were Ohio (35.8%), Texas, California, and Florida. Indicators of increased resource utilization include length of stay, nonelective admission, race, primary payer, hospital location, and type.For subglottic stenosis, three states account for 37% of admissions, and four states account for 56% of laryngeal graft procedures in 2003. The mean total charges were $53,787; 90% of admissions had total charges less than $139,253. Patients who underwent surgical procedures had total charges of $76,409.

Summary Objective To review the presentation and natural history of children with vascular rings and present management guidelines. Methods Retrospective study of tertiary care pediatric medical center charts from 1991 to 2002. Results There were 37 males and 27 females with a diagnosis of vascular rings. At presentation, 91% of patients had airway symptoms and 47% had esophageal symptoms. Airway symptoms included stridor (63%), recurrent respiratory infections (47%), respiratory distress (19%), and cough (17%). The most common esophageal symptom was dysphagia (27%). Pre-operative studies included: echocardiography (96%), chest X-ray (93%), barium swallow (75%), magnetic resonance imaging (MRI) (60%), and computerized tomography (CT) scan of the chest (59%). Surgical management included open (n = 25) and thoracoscopic (n = 39) approach. Complications included recurrent laryngeal nerve injury in five patients (8%). Conclusion Children with vascular rings present with respiratory and/or feeding difficulty. The evaluation should include chest X-ray, echocardiography, and barium swallow. Direct laryngoscopy and bronchoscopy are recommended to assess the degree of compression of the airway and/or esophagus, tracheomalacia, and vocal fold motion prior to intervention. Indication for surgical release is given when the diagnosis is made and can be assisted by advanced radiology studies. Surgical options include minimally invasive techniques involving either thoracoscopic or robotic-assisted repairs, as well as open procedures involving thoracotomy.

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.Mixed-methods analysis of survey entries detailing responses to errors and adverse events.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.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.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.N/A Laryngoscope, 126:1999-2002, 2016.

Objective Given the low frequency of adverse events after tracheostomy, individual institutions struggle to collect outcome data to generate effective quality improvement protocols. The Global Tracheostomy Collaborative (GTC) is a multi-institutional, multi-disciplinary organization that utilizes a prospective database to collect data on patients undergoing tracheostomy. We describe our institution's preliminary experience with this collaborative. It was hypothesized that entry into the database would be non-burdensome and could be easily and accurately initiated by skilled specialists at the time of tracheostomy placement and completed at time of patient discharge. Methods Demographic, diagnostic, and outcome data on children undergoing tracheostomy at our institution from January 2013 to June 2015 were entered into the GTC database, a database collected and managed by REDCap (Research Electronic Data Capture). All data entry was performed by pediatric otolaryngology fellows and all post-operative updates were completed by a skilled tracheostomy nurse. Tracked outcomes included accidental decannulation, failed decannulation, tracheostomy tube obstruction, bleeding/tracheoinnominate fistula, and tracheocutaneous fistula. Results Data from 79 patients undergoing tracheostomy at our institution were recorded. Database entry was straightforward and entry of patient demographic information, medical comorbidities, surgical indications, and date of tracheostomy placement was completed in less than 5 min per patient. The most common indication for surgery was facilitation of ventilation in 65 patients (82.3%). Average time from admission to tracheostomy was 62.6 days (range 0–246). Stomal breakdown was seen in 1 patient. A total of 72 patients were tracked to hospital discharge with 53 patients surviving (88.3%). No mortalities were tracheostomy-related. Conclusion The Global Tracheostomy Collaborative is a multi-institutional, multi-disciplinary collaborative that collects data on patients undergoing tracheostomy. Our experience proves proof of concept of entering demographics and outcome data into the GTC database in a manner that was both accurate and not burdensome to those participating in data entry. In our tertiary care, pediatric academic medical center, tracheostomy continues to be a safe procedure with no major tracheostomy-related morbidities occurring in this patient population involvement with the GTC has shown opportunities for improvement in communication and coordination with other tracheostomy-related disciplines.

The incidence of obesity in the pediatric population is increasing. To date, data are limited regarding safety of adenotonsillectomy in this patient population. The purpose of this study is to assess perioperative outcomes of adenotonsillectomy in the obese pediatric patient.A review of the 2012 Kids' Inpatient Database (KID) was conducted to compare patients with clinical modification codes for adenotonsillectomy plus obesity to patients with clinical modification codes for adenotonsillectomy alone. Elements for comparison included patient demographics and concurrent discharge. An in depth review of risk factors associated with respiratory complications in obese patients was also conducted.A weighted total of 899 obese and 20,535 non-obese patients admitted after adenotonsillectomy were identified. When these two groups were compared, respiratory complications were found in 16.2% of obese and 9.6% of non-obese patients (p0.0001). A diagnosis of respiratory failure or pulmonary insufficiency was statistically more common in obese patients when compared to non-obese patients (5.0% versus 3.0%, p=0.007). In obese patients, respiratory complications were associated with male gender, low income, and concomitant asthma on multivariate analysis (p=0.01, 0.004, and 0.007 respectively).Performing adenotonsillectomy on the obese pediatric patient is safe. When performing adenotonsillectomy on this patient population, one must be aware that respiratory events are the most common type of complication and risk of respiratory complications is higher in males, patients of low socioeconomic status, and patients with comorbid asthma, regardless of race or insurance status.

The spotlight in the care of tracheotomy patients has turned in recent years onto multidisciplinary care, scrutinizing the patient journey from initial treatment decisions through tracheotomy to postprocedural care. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) conducted a national study into tracheostomy care in the United Kingdom, reporting the most comprehensive analysis of in-patient care to date. Key findings highlight recurrent deficiencies in the organization of care, staff training, and support and the inconsistent use of monitoring and safety equipment. The NCEPOD study findings are translatable to Western health care systems and serve to highlight important safety initiatives from exemplar institutions and national and international quality improvement projects. This commentary provides a forum to disseminate this essential information internationally.

The patient safety and quality improvement era began in 1999, and it has exploded in otolaryngology in the last decade. Although there have been some successes, it is not clear that, overall, otolaryngology is much safer than 15 years ago. We discuss why a prolonged lag between improvement efforts and improvements is not surprising and how the safety and quality movement is likely to evolve in the upcoming years.

Objectives: The objectives of this study were to describe otolaryngologists' emotional reactions to errors and adverse events, their efforts to take responsibility, and their attempts to implement improvements. Study Design and Methods: A retrospective, anonymous survey of 2,500 U.S. otolaryngologists who were members of the American Academy of Otolaryngology–Head and Neck Surgery about errors in their practice was conducted. Respondents were asked whether an error had occurred in their practice in the past 6 months and, if so, to describe the error, its consequences, and any corrective actions taken. Two aspects of these reports stood out, which were beyond the scope of the original study: the respondents' emotional responses and their corrective actions. Results: The response rate was 18.6%. Two hundred ten (45%) respondents reported a total of 212 analyzable error reports and 230 corrective actions. Corrective actions included disclosure to the patient (20 [9%]), ameliorating the consequences of the event to the patient (107 [50%]), personal practice changes (14 [7%]), improvements in the respondent's practice or department (60 [28%]), and hospitalwide or broader corrective actions (19 [9%]). Emotional reactions to errors and adverse events were reported by 22 (10%) otolaryngologists, including regret, embarrassment, guilt, anxiety, loss of temper, and irritation. Legal action was mentioned by five physicians (2%). Conclusions: Otolaryngologists took actions not only to treat their patients, but also to improve patient care in their practice, department, hospital, or community. Emotional reactions to errors and adverse events are common and need to be addressed in medical training and practice.

To describe the voice characteristics of pediatric unilateral vocal fold paralysis (UVFP).Retrospective series from a children's hospital, 1996 to present.Forty-two patients with a mean age of 7.1 years were diagnosed with UVFP in our voice clinic (prevalence = 5.4%). Paralysis was left sided in 88%, and was most commonly seen after cardiac surgery (28.5%) and prolonged intubation/prematurity (16.7%). Voice analysis showed a moderate degree of breathiness, mild-to-moderate hoarseness and straining, mild muscle tension, and soft loudness. Twenty-six percent of patients required surgical intervention, including injection into the paralyzed fold (7 patients) and medialization thyroplasty (4 patients). Pre-operatively, breathiness was worse (P.05) in patients undergoing surgical intervention.Voice characteristics of pediatric UVFP include increased breathiness, hoarseness, straining, muscle tension, and soft loudness. One-fourth of patients underwent surgical intervention; breathiness was the predominant abnormal voice characteristic in the operative cohort.The voice characteristics of pediatric patients with UVFP are described.C-4.

Importance Microlaryngoscopy and bronchoscopy procedures (MLBs) are short-duration, high-acuity procedures that carry risk. Poor case flow and communication exacerbate such potential risk. Efficient operative flow is critical for patient safety and resource expenditure. Objectives To identify areas for improvement and evaluate the effectiveness of a multidisciplinary quality-improvement (QI) initiative. Design, Setting, and Participants A QI project using the “Plan-Do-Study-Act” (PDSA) cycle was implemented to assess MLBs performed on pediatric patients in a tertiary academic children’s hospital. Forty MLBs were audited using a QI evaluation tool containing 144 fields. Each MLB was evaluated for flow, communication, and timing. Opportunities for improvement were identified. Subsequently, QI interventions were implemented in an iterative cycle, and 66 MLBs were audited after the intervention. Interventions Specific QI interventions addressed issues of personnel frequently exiting the operating room (OR) and poor preoperative preparation, identified during QI audit as areas for improvement. Interventions included (1) conducting “huddles” between surgeon and OR staff to discuss needed equipment; (2) implementing improvements to surgeon case ordering and preference cards review; (3) posting an OR door sign to limit traffic during airway procedures; and (4) discouraging personnel breaks during airway procedures. Main Outcomes and Measures Operating room exiting behavior of OR personnel, preoperative preparation, and case timing were assessed and compared before and after the QI intervention. Results Personnel exiting the OR during the MLB was identified as a preintervention issue, with the surgical technologist, circulator, or surgeon exiting the room in 55% of cases (n = 22). The surgical technologist and circulator left the room to retrieve equipment in 40% of cases (n = 16), which indicated the need for increased preoperative preparation to improve case timing and operative flow. The QI interventions implemented to address these concerns included education regarding break timing, improvements in communication, and improvements in ordering and preparation of equipment. After the QI intervention, the surgical technologist exiting rate decreased from 20% (n = 8) to 8% (n = 5), and the circulator exiting rate decreased from 38% (n = 15) to 27% (n = 17). In addition, the rate of surgeon exiting decreased significantly (from 25% [n = 10 of 40] to 9% [n = 6 of 66]) ( P = .03). The surgical technologist and circulating nurse remaining in the room were significantly associated with decreased operating time (1.84-minute decrease for surgical technologist [ P = .04] and 1.95-minute decrease for circulating nurse [ P = .001]). Conclusions and Relevance Gains were made in personnel exiting behavior and case timing after implementation of the QI interventions, potentially leading to decreased risk. This process is easily reproduced and is widely accepted by stakeholders.

A 51-year-old Hispanic woman with a history of Churg-Strauss syndrome (in remission for 20 years)–associated mesangial glomerulonephritis and end-stage renal disease with a recent renal transplant and previously cured cytomegalovirus (CMV) infection who was on a tapering dose of tacrolimus presented with sudden onset of lower extremity numbness. Symptoms progressed to complete paraplegia and sensory loss over 24 hours. The following day, ascending paresis extended to bilateral upper extremities, with high thoracic sensory level and complete blindness. Initial MRI revealed contrast enhancement of bilateral prechiasmatic optic nerve as well as T2 hyperintensities involving the central gray matter of the entire spinal cord with associated edema. CSF analysis documented neutrophilic pleocytosis (182 neutrophils per mm3) and increased total protein level (142 mg/dL) without oligoclonal banding. Bacterial, fungal, and mycobacterial cultures from the CSF were negative, as was PCR for CMV, Epstein-Barr virus, herpes simplex virus, human herpesvirus 6, and varicella-zoster virus. Serologic autoimmune assessment, including onconeuronal, anti-neutrophil cytoplasmic antibody, and other rheumatologic, Lyme, and aquaporin-4 (AQP4) antibody testing, was negative. Moreover, testing for sarcoidosis and HIV antibody was unrevealing. Nerve conduction studies (NCS) performed 2 weeks after symptom onset documented severe reduction in compound motor action potential amplitudes (worse in the lower extremities)

Objectives: Laryngeal dysfunction leading to incompetence and intractable aspiration can be a life-threatening problem. Laryngotracheal separation (LTS) can be used to prevent aspiration, but results in aphonia. The options for alaryngeal speech following LTS are limited. Methods: We performed tracheoesophageal puncture (TEP) and insertion of a Blom-Singer valve in 3 patients in an attempt to restore their voice after LTS for chronic aspiration. Results: Two patients had intractable aspiration (5 and 14 years) after full-course radiotherapy for laryngeal cancer, and 1 patient had aspiration after a stroke. In the first patient TEP was done as a secondary procedure, and in the other 2 patients it was done at the time of the LTS. The TEP was successful in providing these patients with phonation ability after their LTS procedure. There was no morbidity from these procedures. Conclusions: Creation of a TEP after an LTS procedure is relatively simple and relatively safe, and allows for the control of aspiration while maintaining vocal function.

In February 2013, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) released its list of 5 recommendations of diagnostic and therapeutic interventions that physicians and patients should question, as part of the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely campaign. This commentary outlines the impetus for the AAO-HNSF to join the campaign, our list of 5 recommendations, how they were developed, and our future involvement with the campaign. The AAO-HNSF's 5 recommendations are (1) don't order a computed tomography (CT) scan of the head/brain for sudden hearing loss, (2) don't prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea, (3) don't prescribe oral antibiotics for uncomplicated acute external otitis, (4) don't routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis, and (5) don't obtain CT or magnetic resonance imaging in patients with a primary complaint of hoarseness prior to examining the larynx.

Objective To describe the epidemiology, natural history, and treatment of epiglottitis in the Hemophilus influenzae type B (Hib) vaccine era. Design Ten-year retrospective study. Setting Tertiary-care children's hospital. Patients Nineteen patients with a discharge diagnosis of epiglottitis. Intervention As indicated by the presentation of the patient, including direct laryngoscopy, intubation, intravenous antibiotics, and steroids. Main outcome measures Presentation, management, and microbiology. Results Presenting symptoms included fever, drooling, and hot potato voice. Patients' ages ranged from 15.8 months to 17.5 (mean 8.9) years. From 1992 to 1997, the mean age was 5.8 years; from 1998 to 2002, the mean age was 11.6 years. Sixty-eight percent of patients were transferred from an outside hospital. A lateral neck radiograph was recorded in 84% of patients. Mean leukocyte count was 16,600. Direct laryngoscopy with intubation was performed in 79%; intubation was for an average of 3.5 days. H. influenzae was cultured in six patients, five of which had up-to-date immunizations. The most commonly administered antibiotics were ampicillin/sulbactam and ceftriaxone. Steroids were administered to 63% of patients. Complications included deep neck space infection (2), seizure (1), recurrent illness (1), and vocal granuloma (1). There were no deaths. Conclusion The demographics, causative organisms, and natural history of epiglottitis have changed substantially in the Hib vaccination era. The clinician evaluating and treating patients with epiglottitis should be aware of current trends.

Introduction Apparent cause analysis (ACA) is a process in quality improvement used to examine events. A baseline assessment of completed ACAs at a tertiary care free-standing pediatric academic hospital revealed they were ineffective due to low-quality analysis, unreliable action plans, and poor spread, leading to error recurrence. The goal of this project was to increase ACA action plan reliability scores while maintaining or decreasing turnaround time. Methods The Model for Improvement served as the framework for this quality improvement initiative. We developed a key driver diagram, established measures, tested interventions using plan- do-study-act cycles, and implemented the effective interventions. To measure reliability, we created a high reliability toolkit that links each action item/intervention to a level of reliability and scored each ACA action plan to determine overall reliability score. Action plans scored as low level of reliability required revision before implementation. Results Average ACA action plan reliability scores increased from 86.4% to 96.1%. ACA turnaround time decreased from a baseline of 13 days to 8.6 days. Stakeholders reported a subjective increase in satisfaction with the revamped ACA process. Conclusions Incorporating high reliability principles into ACA action plan development increased the effectiveness of ACA while decreasing turnaround time. The high reliability toolkit was instrumental in providing an organizational resource for approaching this subset of cause analyses. The toolkit provides a way for safety/quality leaders to connect with stakeholders to design highly reliable solutions that improve safety for patients, families, and staff.

Introduction The "July Effect" suggests an increase in patient adverse events in July compared with other months due to the introduction of new providers throughout the training continuum. The aim of this initiative was to analyze reported pediatric trainee medical errors from May through September 2015 at a tertiary care free-standing academic children's hospital to determine if there were more reported medical errors and more adverse events from those errors in July. Methods An error surveillance system is used to report and track near misses, adverse events, and medical errors. Three of the authors reviewed each report, which was electronically collected in the institution during the time period of interest. The reported medical error incidence per 1,000 trainee-days was compared against those in July for a significant difference. Results There are a total of 282 trainees (86 pediatric residents, 81 nonpediatric residents, and 115 fellows) who are clinically active in the hospital at any given month. Pediatric residents had more reported medical errors in July (31) compared with May (16; P = 0.015), June (16; P = 0.019), and August (19; P = 0.046). There was no significant difference in the number of adverse events from reported medical errors by trainees in July (7) compared with May (5), June (8), August (4), or September (8; P > 0.2). Conclusion In this single-center evaluation, there is an increase in reported medical errors involving pediatric residents in July compared with the months surrounding July. However, there is no difference in numbers of adverse events from those errors between these months.

Program Description:Quality improvement (QI) activities emphasize systems to prevent or detect inevitable errors by fallible humans. Aside from intentional misconduct or impaired judgment, human errors often are attributed to system factors, deemphasizing the role of individual decision making as a potential cause of error. Convincing data show that cognitive and motivational biases affect how providers collect and apply clinical data. Our purpose is to increase audience awareness of cognitive “traps” in medical decision making. We will discuss illustrative case studies, practical ways to incorporate these concepts into QI and patient safety activities, and uses of “debiasing” and other strategies to improve individual decision making.Educational Objectives:(1) Describe the importance of individual cognitive processes in medical decision making and error and situations in which these processes might be either beneficial or harmful. (2) Describe cognitive processes, heuristics, and biases that play a role ...

Objectives:Tonsillotomy has been presented as a less-invasive alternative to the traditional tonsillectomy. The decreased pain and recovery time after tonsillotomy have been well established, but questions regarding tonsil regrowth remain. It has been assumed that parents would prefer tonsillotomy because of its recovery advantages. The objective of this study is to (1) directly sample the opinion of typical parents who would be considering tonsillotomy versus tonsillectomy. (2) Assess the role of age, educational level, and risk aversion in this parental choice.Methods:Parents in a busy pediatric otolaryngology waiting room were approached and asked to hypothetically choose either tonsillectomy or tonsillotomy for their child via a written survey. Each procedure was described in basic terms listing basic risks and benefits including pain, recovery, regrowth, and incidence of complications. Parents were also asked simple questions regarding age range, educational level, and risk tolerance. Data analysis i...

Objectives:There is a paucity of data regarding postoperative complications associated with pediatric otologic procedures. We describe safety and postoperative sequelae of these procedures using data from the largest quality improvement initiative in pediatric surgery, the American College of Surgeons National Surgery Quality Improvement Program-Pediatric (NSQIP-P). This study is the first to assess safety of pediatric otologic surgery using NSQIP-P data.Methods:We identified children who underwent outpatient otologic surgery using current procedural terminology codes. Variables of interest included patient demographics and 30-day unplanned postoperative events including reoperation, readmission, and wound complication. Adverse event rates were determined and prevalence of events was compared by procedure type and within patient subgroups.Results:Of 37,319 pediatric surgical cases, 2410 were otologic procedures. The most common procedure was tympanoplasty (N = 836, 34.7%), followed by myringoplasty (N = 7...

Importance Pediatric laryngotracheal trauma is rare but can carry considerable morbidity and health care resource expenditure. However, the true cost of these injuries has not been thoroughly investigated. Objective To use a national administrative pediatric database to identify normative data on pediatric laryngotracheal trauma, specifically with regard to cost and resource utilization. Design and Participants Retrospective medical record review using the Kids’ Inpatient Database (KID) 2009. Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification , codes for fractures or open wounds of the larynx and trachea. Main Outcomes and Measures Among many data analyzed were demographic information and admission characteristics, including length of stay, diagnoses, procedures performed, and total charges. Results There were 106 admissions that met inclusion criteria. Patient mean (SE) age was 15.9 (0.45) years, and 79% were males. The mean (SE) length of stay (LOS) was 8.4 (1.1) days; more than 50% of patients had a LOS longer than 4 days. The mean number of diagnoses per patient was 6.9 (0.6); other traumatic injuries included pneumothorax (n = 18). More than 75% of patients underwent more than 2 procedures during their admission; 60.2% underwent a major operative procedure. The most common procedures performed were laryngoscopy (n = 54) and operative repair of the larynx and/or trachea (n = 32). Tracheostomy was performed in only 30 patients. The mean (SE) total charge was $90 879 ($11 419), and one-third of patients had total charges more than $100 000. Conclusions and Relevance Pediatric laryngotracheal trauma remains a relatively rare clinical entity. These injuries primarily affect older children and are associated with long hospitalizations, multiple procedures, and high resource utilization.

This study seeks to synthesize evidence-based findings related to patient satisfaction as a process measure in pediatric surgical care.PubMed, CINAHL, Scopus, and the Cochrane Central Register of Controlled Trials.We queried 4 standard search engines (1992-2013) for studies specific to pediatric surgical fields in which patient or parent satisfaction or experience of care was a primary outcome measure. Data were systematically analyzed to determine study characteristics, setting, parent or patient focus, measure of experience, and bias. Two independent investigators independently reviewed all articles.The initial search yielded 4748 publications (1503 duplicates), of which 170 underwent full-text review. Thirty-five were included for analysis; the majority (24/35,77%) were published in the last 5 years. Studies examined experience of the child (3/35), parent (23/35), or both (9/35). Experience and satisfaction were evaluated either by validated self-assessment instruments (8), by satisfaction tools (8), or by nonstandard institutional or author-developed tools (19). Experience was measured in the outpatient (7), preoperative (11), operative (14), and postoperative (3) care settings. Specific findings were unique to setting; however, in many studies higher satisfaction correlated with education/information giving, health care provider interpersonal behaviors, and facile/efficient care processes.The patient experience of care is a valuable quality measure that is being more frequently evaluated as a mechanism to improve pediatric surgical care processes. Findings related to patient satisfaction and experience of care may be limited due to lack of measurement using validated tools. Findings from this review may bear significance as patient experience measures become routinely integrated with quality and reimbursement.

A decade ago, a survey study identified areas of risk and proposed a classification schema for otolaryngology errors. The objective of the present study is to obtain current data for comparison using a similar methodology.Survey study.An anonymous online survey was distributed via the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) weekly email.Members of the AAO-HNS were asked to describe any event in their practice that they felt should not have happened. Events were classified using the prior schema with minor modifications.Of 681 respondents, 445 (66%) reported an event within the past 6 months, from which 222 reports were extracted. The mean age of the affected patients was 41 ± 24 years. An adverse consequence occurred in more than half of events, with corrective action taken in 82.8%. Of the respondents, 68% subsequently changed their practice patterns. The domains with the most reported errors were technical (27.9% of all events, 71% with major morbidity), administrative (12.2%, 3.7%), diagnostic testing (10.8%, 8.3%), and surgical planning (9.9%, 45.5%). There were 8 wrong-site surgeries, 23 cranial nerve injuries (91.3% major morbidity), and 9 errors during endoscopic sinus surgery (55.6% major morbidity). There were 4 deaths.There has been disappointingly little overall change. Otolaryngologists remain vulnerable to errors and related adverse events. The domains with the greatest risk for error-related major morbidity have changed little and include errors in technical, administrative, diagnostic testing, surgical planning, and surgical equipment. Awareness of high-risk areas may help to focus preventive efforts in these domains.

Acute epiglottitis is an exceedingly rare, potentially deadly disease. Since the introduction of the Haemophilus influenzae type B (HiB) vaccine in the mid-1980s, its incidence has decreased dramatically. With the decrease in the incidence of epiglottitis attributed to HiB came a relative increase in epiglottits caused by other pathogens. These atypical pathogens often present in an atypical manner, confusing the clinical picture and often delaying diagnosis and treatment. As the immunized portion of the population increases, atypical non-HiB epiglottis will become the rule rather than the exception. Successful management of this disease poses a particularly difficult challenge to physicians who have been trained in the post-HiB era, in which epiglottitis is both rare and deceptive in presentation.

Objective To describe mediastinitis in infants. Study Design Case series. Setting Tertiary-care, academic, pediatric hospital. Subjects Four infants managed during eight months. Results Patients were eight months (two patients), nine months, and 18 months old. They had retropharyngeal phlegmons and were started on clindamycin/cephalosporin. Interval imaging scans revealed abscess formation with mediastinal extension. All retropharyngeal abscesses were drained; three patients required video-assisted thoracoscopic debridement. Methicillin-resistant Staphylococcus aureus (two patients) and methicillin-sensitive Staphylococcus aureus (two patients) were cultured. Peak white blood cell counts were 15,000, 18,400, 30,200, and 44,900. The patients survived without long-term morbidity. Conclusions In infants with pediatric deep neck space infections, increased vigilance should be maintained for progression to mediastinal extension. Optimal management includes imaging of the neck and chest as indicated, broad-spectrum antibiotic coverage, and aggressive surgery as warranted to clear the neck space infections with appropriate surgical consultants to manage the mediastinal process. Despite high morbidity and mortality in adult mediastinitis, infant mediastinitis may be a different disease process as all patients survived without sequelae.

Objectives:Synthesize evidence-based findings related to patient satisfaction as a quality indicator in pediatric surgical care.Methods:We conducted a qualitative systematic review, querying 4 standard search engines (1992-2013) for studies specific to pediatric surgical fields in which patient/parent satisfaction or experience-of-care was a primary outcome measure. Data were systematically analyzed to determine study characteristics, setting, parent/patient focus, measure of experience, and bias. Two independent investigators independently reviewed all articles.Results:The initial search yielded 4678 publications (1433 duplicates) of which 170 underwent full text review. Thirty-five were included for analysis; the majority (24/35,77%) were published in the last 5 years. Studies examined experience of the child (4/35), parent (19/35), or both (12/35). Experience and satisfaction were evaluated either by validated self-assessment instruments (9) or satisfaction tools (13), or by non-standard institutional ...