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Children with SARS-CoV-2 infection are at increased risk for postanesthesia complications. There is minimal data regarding how long that elevated complication risk persists beyond initial SARS-CoV-2 diagnosis.We investigated postanesthesia complications in children with SARS-CoV-2 infection within 90 days of diagnosis.We completed a single-center, retrospective, case-control study of pediatric patients with confirmed SARS-CoV-2 infection within 90 days undergoing anesthesia between January 3-October 7, 2020. Each SARS-CoV-2 positive patient was matched 1:2 by age and type of procedure with a non-SARS-CoV-2 cohort. The primary outcome was the rate of all postanesthesia complications within 30 days of the procedure, defined as unplanned escalations of care within 48 h, cardiac, respiratory, thrombotic, and hemorrhagic events within 30 days. Secondary outcomes were 30-day mortality and hospital length of stay.Of the 341 patients included, 114 patients were SARS-CoV-2 positive and 227 were SARS-CoV-2 negative. Patients with a positive test 0-7 days prior to anesthesia had an increased risk difference in all postanesthesia complications within 30 days (19.9, 95% CI [4.7, 35.1], p = .001) and increased risk difference in length of hospital stay (7.8, 95% CI [1.2, 14.4], p .001). Patients who underwent anesthesia greater than 42 days from SARS-CoV-2 diagnosis had an increased risk difference in cardiac complications within 30 days (4.3, 95% CI [0.9, 10.0], p = .029). There was no increased hospital length of stay among SARS-CoV-2 positive patients diagnosed greater than 8 days before anesthetic. There were no deaths within 30 days of anesthetic.Postanesthesia complications are higher in children who undergo anesthesia within 7 days of SARS-CoV-2 diagnosis. Additional cardiac risk may persist beyond the immediate period of initial diagnosis. Larger samples are needed to further evaluate the risk of delayed postanesthesia complications and guide optimal timing of surgery.

Background There are well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis. Aims We hypothesize that implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes. Methods This is a retrospective pre- and post-test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and number of spinal levels fused. The primary outcome was length of stay. Secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity. Results 424 patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 pre-pathway and 308 post-pathway). The median length-of-stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p=0.006) longer than White patients pre-pathway. Pre-pathway patients who self-identified as Other had a 1.2 (95% CI: 0.5, 1.9; p=0.004) higher median average pain score on postoperative day 1 compared to White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p=0.005) higher pain score compared to White patients pre-pathway. Post-pathway, there were no significant differences in outcomes by race/ethnicity. Conclusions Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.

Retrospective review of prospectively collected data. Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p

Children’s Hospitals’ Solutions for Patient Safety (SPS) is a network of over 140 children’s hospitals who share the vision of working together to eliminate serious harm across all pediatric hospitals. The SPS network is built on the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone. Each year, SPS hosts National Learning Sessions to which members are invited to submit abstracts describing relevant safety research or improvement work. The following abstracts were among the top submitted for the SPS Spring 2021 National Learning Session.

Objective To compare the incidence and severity of acute kidney injury following open heart surgery with cardiopulmonary bypass in children after administration of exogenous nitric oxide. Design Retrospective cohort study. Setting Single institution, university hospital. Participants: All children less than 18 years of age who underwent surgery with cardiopulmonary bypass. Interventions Medical records of all eligible patients between January 4, 2017 and June 28, 2019 were reviewed. Patients were divided into 2 groups based on whether they received exogenous nitric oxide. Measurements and Main results The primary endpoint was change in serum creatinine level as defined as the difference between the preoperative creatinine and peak postoperative creatinine. The secondary endpoint was the incidence and severity of post-operative acute kidney injury. A difference-in-difference method using fixed-effect multiple linear regression was carried out to compare difference in maximum serum creatinine changes between the control and intervention groups. 591 patients were included in the analysis: 298 (50.5%) in the control group and 293 (49.5%) in the intervention group. Control and intervention groups did not vary significantly in terms of baseline characteristics except for bypass time. After adjusting for all baseline variables, there was no statistically significant difference in increase in serum creatinine between the control and the intervention groups (0.01 [95% CI: -0.03, 0.05], p= 0.545). Conclusions This single center retrospective cohort study found no change in the incidence and severity of postoperative acute kidney injury after the administration of nitric oxide into the cardiopulmonary bypass circuit in children.

Recent changes in health care have begun to shift the industry from a volume-based to a value-based focus. This shift has led to standardized care pathways that decrease care variability, improve outcomes, and decrease cost. Although numerous studies have described standardized pathways for adolescent idiopathic scoliosis (AIS), few have demonstrated sustainability. We report the effectiveness and sustainability of a standardized care pathway for patients undergoing posterior spinal fusion for AIS.A standardized care pathway was developed and implemented (in March 2015) at our pediatric hospital for all patients undergoing posterior spinal fusion for AIS. This pathway was developed with use of the Lean process mapping technique to create an evidence-based protocol for preoperative, operative, postoperative, and post-discharge care. The 44 patients managed prior to implementation of the pathway (pre-pathway group) were compared with the 169 patients managed after implementation (post-pathway group). The post-pathway group was divided into 5 cohorts, each representing a 6-month time period. Clinical outcomes (pain scores, medication requirements, transfusions) and efficiency metrics (length of stay) were used to determine pathway sustainability.The pre-pathway group included patients managed in the 8 months prior to implementation (July 2014 to February 2015) and the post-pathway group included patients who underwent surgery from March 2015 to July 2017, divided into 5 cohorts representing 6 months each. Patients in the post-pathway group had lower postoperative pain scores, and used significantly less opioids at each time interval, compared with the pre-pathway group. Perioperative transfusion requirements and postoperative length of stay were significantly lower across all post-pathway cohorts compared with the pre-pathway group. There were no significant differences in clinical results among the 5 post-pathway cohorts.Implementation of a standardized care pathway developed with use of Lean process mapping demonstrated effective and sustained improvements to the care of patients with AIS, as well as decreased postoperative length of stay. These outcomes have been maintained over 2.5 years, indicating that high-quality care for patients with AIS undergoing spinal fusion can be achieved and sustained with use of a standardized care pathway.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinicians are at the frontline seeing the everyday challenges of providing high-quality care. This role uniquely positions us to engage in quality improvement (QI), a rigorous process that helps bridge the gap between what is happening and what patient care should be. From evidence-based practices in cystic fibrosis care to technological upgrades for anesthesia machines, QI can tackle all types of problems and incorporate all sorts of interventions. Like medicine, it is a team sport. Engagement of everyone involved in the process needing to be improved is crucial to make change possible and sustainable. And beyond teamwork, clinicians must also leverage important soft skills to be successful. It is often said that medicine is a combination of art and science – QI is the art and science of change. This chapter outlines how QI can be an effective tool for providers to implement meaningful, permanent change in healthcare delivery so that patients get the care they deserve every time.

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.

Introduction There is a myriad of factors that can lead to temperature derangements in anesthetized children undergoing magnetic resonance imaging (MRI). Temperature abnormalities in pediatric patients are associated with increased morbidity and mortality. Although some reports have looked at this topic, to our knowledge, no studies have continuously monitored temperature throughout the MRI scan. The purpose of this study is to determine the impact of MRI on body temperature for anesthetized children undergoing MRI using continuous temperature measurement, identify patient risk factors to develop temperature abnormalities, and determine the effect of temperature derangements on perianesthetic complications. Methods This retrospective, single-center study evaluated 285 pediatric outpatients from January 1, 2018, to March 31, 2018, who were less than 8 years old and underwent anesthesia for an MRI scan. Temperature, postanesthesia care unit length of stay, and demographic data were collected retrospectively using chart review and data extraction from electronic medical records. Statistical analyses included unpaired t test, chi-square test, and simple and multiple linear regressions. Results Sixty-three percent (179/285) of children in our study had a median temperature less than 36°C during their MRI scan. There were no patients who had a median temperature greater than 38°C during their MRI scan. There were no identifiable patient risk factors for the development of hypothermia. Those who developed hypothermia did not have an increased rate of perianesthetic complications. Conclusion MRI in anesthetized children is associated with hypothermia but does not correlate with any significant perianesthetic complications.

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 Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost. OBJECTIVE The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion. METHODS Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression. RESULTS For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0 mL/kg preperioperative surgical home vs 22.8 mL/kg postperioperative surgical home; mean difference = -0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4 mL/kg ± 20.4 mL/kg preperioperative surgical home vs 28.0 mL/kg ± 13.7 mL/kg postperioperative surgical home; log mean difference = 0.37 [95% CI 0.21-0.53], P