94 results on '"Jonathan E. Kohler"'
Search Results
2. Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes.
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Abigail R. Wooldridge, Pascale Carayon, Peter Hoonakker, Bat-Zion Hose, David W. Shaffer, Thomas Brazelton, Ben L. Eithun, Deborah A. Rusy, Joshua Ross, Jonathan E. Kohler, Michelle M. Kelly, Scott R. Springman, and Ayse P. Gurses
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- 2024
- Full Text
- View/download PDF
3. Scenario-Based Evaluation of Team Health Information Technology to Support Pediatric Trauma Care Transitions.
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Peter L. T. Hoonakker, Bat-Zion Hose, Pascale Carayon, Ben L. Eithun, Deborah A. Rusy, Joshua Ross, Jonathan E. Kohler, Shannon M. Dean, Thomas B. Brazelton III, and Michelle M. Kelly
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- 2022
- Full Text
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4. Development and Feasibility Testing of a Decision Aid for Acute Appendicitis
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Joshua E. Rosen, Frank F. Yang, Joshua M. Liao, David R. Flum, Jonathan E. Kohler, Nidhi A. Agrawal, and Giana H. Davidson
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Surgery - Published
- 2023
5. Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care.
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Bat-Zion Hose, Peter Hoonakker, Abigail R. Wooldridge, Thomas Brazelton, Shannon M. Dean, Benjamin Eithun, James C. Fackler, Ayse P. Gurses, Michelle M. Kelly, Jonathan E. Kohler, Nicolette M. McGeorge, Joshua Ross, Deborah A. Rusy, and Pascale Carayon
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- 2019
- Full Text
- View/download PDF
6. Complexity of the pediatric trauma care process: implications for multi-level awareness.
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Abigail R. Wooldridge, Pascale Carayon, Peter Hoonakker, Bat-Zion Hose, Joshua Ross, Jonathan E. Kohler, Thomas Brazelton, Benjamin Eithun, Michelle M. Kelly, Shannon M. Dean, Deborah A. Rusy, Ashimiyu B. Durojaiye, and Ayse P. Gurses
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- 2019
- Full Text
- View/download PDF
7. Human-centered design of team health IT for pediatric trauma care transitions.
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Pascale Carayon, Bat-Zion Hose, Abigail R. Wooldridge, Thomas B. Brazelton III, Shannon M. Dean, Ben L. Eithun, Michelle M. Kelly, Jonathan E. Kohler, Joshua Ross, Deborah A. Rusy, and Peter L. T. Hoonakker
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- 2022
- Full Text
- View/download PDF
8. Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium
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John P. Marquart, Alexis N Bowder, Christina M. Bence, Shawn D. St. Peter, Samir K. Gadepalli, Thomas T. Sato, Aniko Szabo, Peter C. Minneci, Ronald B. Hirschl, Beth A. Rymeski, Cynthia D. Downard, Troy A. Markel, Katherine J. Deans, Mary E. Fallat, Jason D. Fraser, Julia E. Grabowski, Michael A. Helmrath, Rashmi D. Kabre, Jonathan E. Kohler, Matthew P. Landman, Amy E. Lawrence, Charles M. Leys, Grace Z. Mak, Elissa Port, Jacqueline Saito, Jared Silverberg, Mark B. Slidell, Tiffany N. Wright, and Dave R. Lal
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Pediatrics, Perinatology and Child Health ,Surgery ,General Medicine - Abstract
Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias.Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair.Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p 0.001), and less likely to have congenital heart disease (16% vs. 39%, p 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy.Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair.Level III.
- Published
- 2023
9. Evaluating the risk of peri-umbilical hernia after sutured or sutureless gastroschisis closure
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James A. Fraser, Katherine J. Deans, Mary E. Fallat, Michael Helmrath, Rashmi Kabre, Charles M. Leys, Troy A. Markel, Patrick A. Dillon, Cynthia Downard, Tiffany N. Wright, Samir K. Gadepalli, Julia E. Grabowski, Ronald Hirschl, Kevin N. Johnson, Jonathan E. Kohler, Matthew P. Landman, Grace Z. Mak, Peter C. Minneci, Beth Rymeski, Thomas T. Sato, Bethany J. Slater, Shawn D. St Peter, and Jason D. Fraser
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Gastroschisis ,Treatment Outcome ,Pediatrics, Perinatology and Child Health ,Infant, Newborn ,Humans ,Infant ,Surgery ,General Medicine ,Child ,Hernia, Umbilical ,Retrospective Studies - Abstract
We evaluate the incidence, outcomes, and management of peri‑umbilical hernias after sutured or sutureless gastroschisis closure.A retrospective, longitudinal follow-up of neonates with gastroschisis who underwent closure at 11 children's hospitals from 2013 to 2016 was performed. Patient encounters were reviewed through 2019 to identify the presence of a peri‑umbilical hernia, time to spontaneous closure or repair, and associated complications.Of 397 patients, 375 had follow-up data. Sutured closure was performed in 305 (81.3%). A total of 310 (82.7%) infants had uncomplicated gastroschisis. Peri-umbilical hernia incidence after gastroschisis closure was 22.7% overall within a median follow-up of 2.5 years [IQR 1.3,3.9], and higher in those with uncomplicated gastroschisis who underwent primary vs. silo assisted closure (53.0% vs. 17.2%, p0.001). At follow-up, 50.0% of sutureless closures had a persistent hernia, while 16.4% of sutured closures had a postoperative hernia of the fascial defect (50.0% vs. 16.4%, p0.001). Spontaneous closure was observed in 38.8% of patients within a median of 17 months [9,26] and most frequently observed in those who underwent a sutureless primary closure (52.2%). Twenty-seven patients (31.8%) underwent operative repair within a median of 13 months [7,23.5]. Rate and interval of spontaneous closure or repair were similar between the sutured and sutureless closure groups, with no difference between those who underwent primary vs. silo assisted closure.Peri-umbilical hernias after sutured or sutureless gastroschisis closure may be safely observed similar to congenital umbilical hernias as spontaneous closure occurs, with minimal complications and no additional risk with either closure approach.Level II.
- Published
- 2022
10. Acid suppression duration does not alter anastomotic stricture rates after esophageal atresia with distal tracheoesophageal fistula repair: A prospective multi-institutional cohort study
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Alexis N Bowder, Christina M. Bence, Beth A Rymeski, Samir K. Gadepalli, Thomas T. Sato, Aniko Szabo, Kyle Van Arendonk, Peter C. Minneci, Cynthia D. Downard, Ronald B. Hirschl, Troy Markel, Cathleen M. Courtney, Katherine J. Deans, Mary E. Fallat, Jason D. Fraser, Julia E. Grabowski, Michael A. Helmrath, Rashmi D. Kabre, Jonathan E. Kohler, Matthew P. Landman, Amy E. Lawrence, Charles M. Leys, Grace Mak, Elissa Port, Jacqueline Saito, Jared Silverberg, Mark B. Slidell, Shawn D. St Peter, Misty Troutt, Tiffany N. Wright, and Dave R. Lal
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Anastomosis, Surgical ,Infant ,Constriction, Pathologic ,General Medicine ,Cohort Studies ,Postoperative Complications ,Treatment Outcome ,Pediatrics, Perinatology and Child Health ,Esophageal Stenosis ,Humans ,Surgery ,Prospective Studies ,Esophageal Atresia ,Retrospective Studies ,Tracheoesophageal Fistula - Abstract
Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation.A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively.Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p0.01). There was no association between acid suppression duration and stricture formation.No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair.
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- 2022
11. Opioid prescribing to preteen children undergoing ambulatory surgery in the United States
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Jonathan E. Kohler, Randi Cartmill, Tony L. Kille, Yasmin S. Bradfield, Ruthie Su, Dou-Yan Yang, and Benjamin J. Walker
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medicine.medical_specialty ,MEDLINE ,Inappropriate Prescribing ,030230 surgery ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,Practice Patterns, Physicians' ,Medical prescription ,Child ,Pain, Postoperative ,Codeine ,business.industry ,Age Factors ,Infant ,Perioperative ,Ambulatory Surgical Procedure ,United States ,Surgery ,Analgesics, Opioid ,Ambulatory Surgical Procedures ,Otorhinolaryngology ,Opioid ,Child, Preschool ,030220 oncology & carcinogenesis ,Ambulatory ,business ,medicine.drug - Abstract
Background Overuse and misuse of opioids is a continuing crisis. The most common reason for children to receive opioids is postoperative pain, and they are often prescribed more than needed. The amount of opioids prescribed varies widely, even for minor ambulatory procedures. This study uses a large national sample to describe filled opioid prescriptions to preteen patients after all ambulatory surgical procedures and common standard procedures. Methods We analyzed Truven Health MarketScan data for July 2012 through December 2016 to perform descriptive analyses of opioid fills by age and geographic area, change over time, second opioid fills in opioid-naive patients, and variation in the types and amount of medication prescribed for 18 common and standard procedures in otolaryngology, urology, general surgery, ophthalmology, and orthopedics. Results Over 10% of preteen children filled perioperative opioid prescriptions for ambulatory surgery in the period 2012 to 2016. The amount prescribed varied widely (median 5 days’ supply, IQR 3–8, range 1–90), even for the most minor procedures, for example, frenotomy (median 4 days’ supply, IQR 2–5, range 1–60). Codeine fills were common despite safety concerns. Second opioid prescriptions were filled by opioid-naive patients after almost all procedures studied. The rate of prescribing declined significantly over time and varied substantially by age and across census regions. Conclusions We identified opioid prescribing outside of the norms of standard practice in all of the specialties studied. Standardizing perioperative opioid prescribing and developing guidelines on appropriate prescribing for children may reduce the opioids available for misuse and diversion.
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- 2021
12. Contrast Challenge Algorithms for Adhesive Small Bowel Obstructions Are Safe in Children
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Ronald B. Hirschl, Tariku Jibat Beyene, Nathan S. Rubalcava, Christina M Bence, Jonathan E. Kohler, Kyle J. Van Arendonk, Amanda R Jensen, Grace Z. Mak, Irene Isabel P. Lim, Beth Rymeski, K. Elizabeth Speck, and Peter C. Minneci
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Retrospective review ,business.industry ,media_common.quotation_subject ,medicine.disease ,Predictive value ,Confidence interval ,Bowel obstruction ,Contrast (vision) ,Medicine ,Surgery ,Complication rate ,Nonoperative management ,Failure to progress ,business ,Algorithm ,media_common - Abstract
Objective The purpose of this study was to evaluate the safety of a water-soluble contrast challenge as part of a nonoperative management algorithm in children with an adhesive small bowel obstruction (ASBO). Background Predicting which children will successfully resolve their ASBO with non-operative management at the time of admission remains difficult. Additionally, the safety of a water-soluble contrast challenge for children with ASBO has not been established in the literature. Methods A retrospective review was performed of patients who underwent non-operative management for an ASBO and received a contrast challenge across 5 children's hospitals between 2012 and 2020. Safety was assessed by comparing the complication rate associated with a contrast challenge against a pre-specified maximum acceptable level of 5%. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of a contrast challenge to identify successful nonoperative management were calculated. Results Of 82 children who received a contrast challenge, 65% were successfully managed nonoperatively. The most common surgical indications were failure of the contrast challenge or failure to progress after initially passing the contrast challenge. There were no complications related to contrast administration (0%; 95% confidence interval: 0-3.6%, P = 0.03). The contrast challenge was highly reliable in determining which patients would require surgery and which could be successfully managed non-operatively (sensitivity 100%, specificity 86%, NPV 100%, PPV 93%). Conclusion A contrast challenge is safe in children with ASBO and has a high predictive value to assist in clinical decision-making.
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- 2021
13. Management of Pediatric Breast Masses: A Multi-institutional Retrospective Cohort Study
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Cynthia D. Downard, Jason D. Fraser, Dave R. Lal, Jonathan E. Kohler, Naila Merchant, Tiffany Wright, Amy E. Lawrence, Mercedes Pilkington, Patricia Lu, Grace Z. Mak, Troy A. Markel, Mary E. Fallat, Elle L. Kalbfell, Amanda Onwuka, Shawn D. St. Peter, Charles M. Leys, Maria E. Knaus, Cathleen M. Courtney, Tina Nguyen, Rashmi Kabre, Samir K. Gadepalli, Peter C. Minneci, Katherine J. Deans, Yara K. Duran, Julia Grabowski, Elissa Port, Thomas T. Sato, Alexis N. Bowder, Matthew P. Landman, Jacqueline M. Saito, and Beth Rymeski
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medicine.medical_specialty ,Adolescent ,Breast imaging ,medicine.medical_treatment ,Clinical Decision-Making ,Breast Neoplasms ,BI-RADS ,Mastectomy, Segmental ,Diagnosis, Differential ,Diagnostic Self Evaluation ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Phyllodes Tumor ,medicine ,Humans ,Breast ,Child ,Watchful Waiting ,Breast ultrasound ,Retrospective Studies ,medicine.diagnostic_test ,business.industry ,Lumpectomy ,Ultrasound ,Retrospective cohort study ,Pediatric Surgeon ,medicine.disease ,Fibroadenoma ,030220 oncology & carcinogenesis ,Practice Guidelines as Topic ,Feasibility Studies ,Female ,030211 gastroenterology & hepatology ,Surgery ,Biopsy, Large-Core Needle ,Ultrasonography, Mammary ,Radiology ,business - Abstract
Background The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. Materials and methods A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. Results Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. Conclusions Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.
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- 2021
14. Name the Diagnosis
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Robyn Huey Lao, Christina M. Theodorou, and Jonathan E. Kohler
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Medical–Surgical Nursing ,Surgery ,Pediatrics - Published
- 2022
15. Changing Patterns of Pediatric Trauma During the COVID-19 Pandemic
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Minna M. Wieck, Taylor Silva, and Jonathan E. Kohler
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Adult ,Trauma Centers ,SARS-CoV-2 ,Pediatrics, Perinatology and Child Health ,Communicable Disease Control ,COVID-19 ,Humans ,Child ,Pandemics ,Retrospective Studies - Abstract
The implementation of lockdown and social distancing policies at the beginning of the coronavirus disease 2019 (COVID-19) pandemic changed both the nature of pediatric traumatic injuries and how those injuries were managed by pediatric trauma centers. At the start of the pandemic, the number of injured children evaluated at trauma centers decreased. Trauma volumes have since rebounded, and a concerning increase in abuse-related injuries has been seen. Pediatric trauma systems responded to the pandemic with new approaches to protect health care providers, conserve critical resources, and assist adult trauma systems overburdened by patients with COVID-19. The widespread effect of COVID-19 continues to have significant repercussions on children's health, but the lessons learned and gaps exposed by the pandemic may be an opportunity to positively transform injury prevention and health care delivery. [ Pediatr Ann . 2022;51(7):e286–e290.]
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- 2022
16. Continued Prescribing of Periprocedural Codeine and Tramadol to Children after a Black Box Warning
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Jonathan E. Kohler, Jessica R. Schumacher, Elle L. Kalbfell, and Randi Cartmill
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Male ,medicine.medical_specialty ,Adolescent ,medicine.medical_treatment ,Inappropriate Prescribing ,Drug Prescriptions ,Perioperative Care ,03 medical and health sciences ,Wisconsin ,0302 clinical medicine ,Adenoidectomy ,Pediatric surgery ,medicine ,Humans ,Practice Patterns, Physicians' ,Medical prescription ,Child ,Contraindication ,Tramadol ,Drug Labeling ,Retrospective Studies ,Pain, Postoperative ,Codeine ,business.industry ,General surgery ,Infant ,Perioperative ,Tonsillectomy ,Ambulatory Surgical Procedures ,Child, Preschool ,030220 oncology & carcinogenesis ,Female ,030211 gastroenterology & hepatology ,Surgery ,business ,Administrative Claims, Healthcare ,medicine.drug - Abstract
Background Codeine and tramadol are commonly used analgesics in surgery. In 2013, the Food and Drug Administration (FDA) issued a contraindication to the use of codeine in tonsillectomy and adenoidectomy patients aged below 18 y. This warning was expanded in April 2017 to include tramadol and all children aged below 12 y. We sought to describe the prescribing of codeine and tramadol to contraindicated populations in Wisconsin before and after the release of the expanded FDA warning. Materials and methods Using a statewide Wisconsin claims database, we identified common pediatric ambulatory surgical procedures across the specialties of otolaryngology, urology, general surgery, orthopedics, and ophthalmology. For these procedures, we examined the rates of perioperative codeine and tramadol prescription fills and change in prescribing after the FDA contraindication. Results Surgeons in all of the specialties studied continued to prescribe codeine to pediatric patients after the contraindication, but tramadol was rarely prescribed. Procedures with relatively high rates of codeine fills were strabismus repair (65% of opioid fills), circumcision >1 yo (22%), and laparoscopic appendectomy (15%). Codeine fills significantly declined after the contraindication to 6% for circumcision >1 yo and 5% for orchiopexy and inguinal hernia repair. Otolaryngology, which was subject to the 2013 codeine contraindication, has low rates of codeine fills (under 2.5%) for the whole period studied. Codeine prescribing for strabismus repair showed no significant decline. Conclusions Codeine, and to a lesser extent tramadol, continue to be prescribed to contraindicated populations of children. This represents a target for future de-implementation interventions.
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- 2020
17. Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium
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Kristine S. Corkum, Patrick A. Dillon, Matthew P. Landman, Ronald B. Hirschl, Amy E. Lawrence, Jason D. Fraser, Kathryn H Wilkinson, Rashmi Kabre, Kevin N. Johnson, Madeline Scannell, Shawn D. St. Peter, Bethany J. Slater, Cynthia D. Downard, Katherine J. Deans, R. Cartland Burns, Charles M Leys, Peter C. Minneci, Julia Grabowski, Jonathan E. Kohler, Grace Z. Mak, Thomas T. Sato, Rachel M. Landisch, Beth Rymeski, Mary E. Fallat, Edward Hernandez, Michael A. Helmrath, Tiffany Wright, and Samir K. Gadepalli
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medicine.medical_specialty ,genetic structures ,Birth weight ,03 medical and health sciences ,Abdominal wall closure ,0302 clinical medicine ,030225 pediatrics ,Pediatric surgery ,Humans ,Medicine ,Prospective Studies ,Closure (psychology) ,Prospective cohort study ,Retrospective Studies ,Gastroschisis ,Sutures ,Wound Closure Techniques ,business.industry ,Abdominal Wall ,Infant, Newborn ,Gestational age ,Retrospective cohort study ,General Medicine ,medicine.disease ,Sutureless Surgical Procedures ,Surgery ,Treatment Outcome ,030220 oncology & carcinogenesis ,Pediatrics, Perinatology and Child Health ,business - Abstract
Purpose To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. Methods A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. Results Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. Conclusion Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. Level of Evidence Level III.
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- 2020
18. Age-Dependent Costs and Complications in Pediatric Umbilical Hernia Repair
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Caprice C. Greenberg, Randi Cartmill, Dou Yan Yang, Sara Fernandes-Taylor, and Jonathan E. Kohler
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Male ,medicine.medical_specialty ,Adolescent ,Revision procedure ,Convenience sample ,Age dependent ,Insurance claims ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Risk Factors ,030225 pediatrics ,Pediatric surgery ,medicine ,Umbilical hernia repair ,Humans ,030212 general & internal medicine ,Child ,Herniorrhaphy ,business.industry ,General surgery ,Age Factors ,Infant, Newborn ,Infant ,Health Care Costs ,Emergency department ,Cross-Sectional Studies ,Child, Preschool ,Pediatrics, Perinatology and Child Health ,Current Procedural Terminology ,Female ,business ,Hernia, Umbilical - Abstract
To characterize regional variation in the age of patients undergoing umbilical hernia repair to determine costs and subsequent care.We performed a cross-sectional descriptive study using a large convenience sample of US employer-based insurance claims from July 2012 to December 2015. We identified children younger than 18 years of age undergoing uncomplicated (not strangulated, incarcerated, or gangrenous) umbilical hernia repair as an isolated procedure (International Classification of Diseases, Ninth Revision procedure codes 53.41, 53.42, 53.43, or 53.49, International Classification of Diseases, Tenth Revision procedure code 0WQF0ZZ, or Current Procedural Terminology procedure codes 49580 or 49585).In all, 5212 children met criteria for inclusion. Children younger than age 2 years accounted for 9.7% of repairs, with significant variation by census region (6% to 14%, P .001). Total payments for surgery varied by age; children younger than 2 years averaged $8219 and payments for older children were $6137. Postoperative admissions occurred at a rate of 73.1 per 1000 for children younger than age 2 years and 7.43 for older children; emergency department visits were 41.5 per 1000 for children younger than age 2 years vs 15.9 for older children (P .001).Umbilical hernias continue to be repaired at early ages with large regional variation. Umbilical hernia repair younger than age 2 years is associated with greater costs and greater frequency of postoperative hospitalization and emergency department visits.
- Published
- 2020
19. Managing multiple perspectives in the collaborative design process of a team health information technology
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Bat-Zion Hose, Pascale Carayon, Peter L.T. Hoonakker, Joshua C. Ross, Benjamin L. Eithun, Deborah A. Rusy, Jonathan E. Kohler, Thomas B. Brazelton, Shannon M. Dean, and Michelle M. Kelly
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Patient Care Team ,Humans ,Physical Therapy, Sports Therapy and Rehabilitation ,Human Factors and Ergonomics ,Safety, Risk, Reliability and Quality ,Child ,Engineering (miscellaneous) ,Medical Informatics ,Article - Abstract
We need to design technologies that support the work of health care teams; designing such solutions should integrate different clinical roles. However, we know little about the actual collaboration that occurs in the design process for a team-based care solution. This study examines how multiple perspectives were managed in the design of a team health IT solution aimed at supporting clinician information needs during pediatric trauma care transitions. We focused our analysis on four co-design sessions that involved multiple clinicians caring for pediatric trauma patients. We analyzed design session transcripts using content analysis and process coding guided by Détienne’s (2006) co-design framework. We expanded upon Détienne (2006) three collaborative activities to identify specific themes and processes of collaboration between care team members engaged in the design process. The themes and processes describe how team members collaborated in a team health IT design process that resulted in a highly usable technology.
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- 2022
20. A Video-Based Consent Tool: Development and Effect of Risk-Benefit Framing on Intention to Randomize
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Alex Lois, Jonathan E. Kohler, Sarah E. Monsell, Kelsey M. Pullar, Jesse Victory, Stephen R. Odom, Katherine Fischkoff, Amy H. Kaji, Heather L. Evans, Vance Sohn, Lillian S. Kao, Shah-Jahan Dodwad, Anne P. Ehlers, Hasan B. Alam, Pauline K. Park, Anusha Krishnadasan, David A. Talan, Nicole Siparsky, Thea P. Price, Patricia Ayoung-Chee, William Chiang, Matthew Salzberg, Alan Jones, Matthew E. Kutcher, Mike K. Liang, Callie M. Thompson, Wesley H. Self, Bonnie Bizzell, Bryan A. Comstock, Danielle C. Lavallee, David R. Flum, Erin Fannon, Larry G. Kessler, Patrick J. Heagerty, Sarah O. Lawrence, Tam N. Pham, and Giana H. Davidson
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Surgery - Abstract
Nearly 75% of clinical trials fail to enroll enough participants, and cohorts often fail to reflect the clinical and demographic diversity of at-risk populations. Effective recruitment strategies are critically important for successful clinical trials. Framing treatment risks are known to affect medical decision-making for both physicians and patients but has not been rigorously studied in surgical trials. We sought to examine the impact of a high-quality video-based consent tool and the effect of risk-benefit framing on patient willingness to participate in a surgical clinical trial.A standardized video consent was shown to all potential participants in the Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial, a randomized controlled trial comparing antibiotics and surgery for acute appendicitis. We report (1) differences in recruitment between two versions of a video-based tool that differed in production quality and (2) the impact of risk-benefit framing on participant randomization rates. The reasons for declining randomization were also assessed.Of 4697 eligible patients approached to participate in the CODA trial, 1535 (33% [95% confidence interval (CI): 31%-34%]) agreed to randomization; this did not change from video version 1 to version 2. There was no difference in participation between positively framed videos (32% [95% CI: 30%-34%]) versus negatively framed videos (33.0% [95% CI: 30.8-35.2]). The most common reason for declining participation was treatment preference (72% for surgery and 18% for antibiotics).Neither the change from video 1 to video 2 nor the positive versus negative framing affected participant willingness to randomize. The stakeholder-informed video-based consenting tool used in CODA was an effective strategy for the recruitment of a heterogeneous patient population within the proposed study period.
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- 2022
21. Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation
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Michael A. Helmrath, Charles M Leys, Nicholas Marka, Mary E. Fallat, Peter C. Minneci, Amy E. Lawrence, Ninette Musili, Grace Z. Mak, Samir K. Gadepalli, Brad W. Warner, Shawn D. St. Peter, Beth Rymeski, Devin R. Halleran, Rashmi Kabre, Matthew P. Landman, Cynthia D. Downard, Ronald B. Hirschl, Jacqueline M. Saito, R. Cartland Burns, Linda Cherney-Stafford, Michelle Knezevich, Jason D. Fraser, Dave R. Lal, Thomas T. Sato, Daniel J. Ostlie, Julia Grabowski, Jonathan E. Kohler, and David S. Foley
- Subjects
Male ,medicine.medical_specialty ,Adolescent ,Thoracentesis ,medicine.medical_treatment ,Pilot Projects ,03 medical and health sciences ,0302 clinical medicine ,Predictive Value of Tests ,Recurrence ,030225 pediatrics ,medicine ,Humans ,Prospective Studies ,Treatment Failure ,Child ,Thoracic Surgery, Video-Assisted ,business.industry ,Pneumothorax ,General Medicine ,Primary spontaneous pneumothorax ,Pigtail catheter ,medicine.disease ,Management algorithm ,Surgery ,Test (assessment) ,Chest tube ,Chest Tubes ,030220 oncology & carcinogenesis ,Pediatrics, Perinatology and Child Health ,Persistent air leak ,Female ,Level iii ,business - Abstract
Purpose Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. Methods A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children’s hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. Results Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P = 0.028]. Conclusion Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. Type of study Prospective pilot study Level of evidence Level III.
- Published
- 2020
22. Team Cognition as a Barrier and Facilitator in Care Transitions: Implications for Work System Design
- Author
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Bat Zion Hose, Pascale Carayon, Ayse P. Gurses, Ben Eithun, Deborah A. Rusy, Abigail R. Wooldridge, Shannon M. Dean, Thomas B. Brazelton, Joshua Ross, Michelle M. Kelly, Jonathan E. Kohler, and Peter Hoonakker
- Subjects
Pediatric intensive care unit ,Inpatient care ,business.industry ,Team cognition ,digestive, oral, and skin physiology ,05 social sciences ,Emergency department ,medicine.disease ,050105 experimental psychology ,Medical Terminology ,Work system design ,Facilitator ,Medicine ,0501 psychology and cognitive sciences ,Medical emergency ,business ,050107 human factors ,Care Transitions ,Medical Assisting and Transcription ,Pediatric trauma - Abstract
Inpatient care of pediatric trauma patients includes care transitions, including from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU, which are important to patient safety and quality of care. Previous research identified work system barriers and facilitators in these transitions; the most common related to team cognition. We conducted interviews with 18 healthcare professionals to better understand how work system design influences team cognition barriers and facilitators. Using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling, we identified when each barrier/facilitator occurred. The ED to OR transition had more barriers in transition preparation, while OR to PICU had more facilitators in the transition. Future research should explore solutions to support team cognition early in the ED to OR transition, such as designing a technology to be used by distributed teams.
- Published
- 2019
23. Development of a Decision Support Tool for Acute Appendicitis
- Author
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Joshua M. Liao, Giana H. Davidson, David R. Flum, Joshua Eli Rosen, and Jonathan E. Kohler
- Subjects
Decision support system ,medicine.medical_specialty ,business.industry ,Best practice ,Stakeholder engagement ,Context (language use) ,Certification ,Checklist ,law.invention ,Randomized controlled trial ,law ,Design process ,Medicine ,Medical physics ,business - Abstract
BackgroundMultiple randomized controlled trials have shown that it is safe and effective to treat appendicitis with antibiotics or surgery. There are no tools available to assist surgeons and their patients in choosing the optimal treatment for each individual patient. Here we describe the development of a new decisions support tool (DST) for acute appendicitis and place it in the context of international guidelines for decision aid development.MethodsThe stakeholder engagement and development process for the DST is described. The DST and its development process are placed in the context of the International Patient Decision Aid Standards (IPDAS) and the DEVELOPTOOLS checklist for a user-centered design process.ResultsA diverse group of over 60 stakeholders were involved in the needs-assessment, development, and evaluation of the DST. The development process met 11/11 of the scored items on the DEVELOPTOOLS checklist. Of the 34 applicable IPDAS items, the current version of the DST meets 31 of them including 6/6 qualifying criteria, 6/6 certification criteria, and 18/22 quality criteria.ConclusionsThe novel appendicitis DST was developed with the input of multiple stakeholders. The development process and the tool itself complies with best practices recommended by the IPDAS.
- Published
- 2021
24. Driving Time to Trauma Centers for Children Living in Wisconsin
- Author
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Keon Young, Park, Benjamin L, Eithun, Jeffrey, Havlena, Jessica, Draper, Randi S, Cartmill, Michael K, Kim, and Jonathan E, Kohler
- Subjects
Wisconsin ,Trauma Centers ,Humans ,Wounds and Injuries ,Child - Abstract
Trauma is the number 1 cause of death among children. Shorter distance to definitive trauma care has been correlated with better clinical outcomes. There are only a small number of pediatric trauma centers (PTC) designated by the American College of Surgeons, and the resources available to treat injured children at non-PTCs are limited. To guide resource allocation and advocacy efforts for pediatric trauma care in Wisconsin, we determined the precise distance to trauma centers for all children living in the state.The 2010 US Census data was used to determine ZIP-centroid geolocation. The Wisconsin Department of Health Services trauma classification database was used to identify trauma facilities in Wisconsin. SAS routines invoking the Google Maps application programming interface were used to calculate the driving distance to each of the trauma facilities. We quantified the percentage of children living within 30- and 60-minute driving distances of level I-IV trauma centers.Just 31.3% of Wisconsin children live within a 30-minute drive of a level I PTC; 32.7% live within 30 minutes of a level II center; 81.3% within 30 minutes of a level III center; and 74.6% within 30 minutes of a level IV center.Two-thirds of children in Wisconsin live beyond a 30-minute driving distance of a level I PTC, but most children live within 30 minutes of level III and IV trauma centers. As the closest hospitals for most children, smaller trauma centers should be adequately resourced to provide pediatric trauma care.
- Published
- 2021
25. It's the message not the medium: Ethics in pediatric surgery communication
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Kevin M. Riggle, Jonathan E. Kohler, and Mary E. Fallat
- Subjects
medicine.medical_specialty ,Medical education ,ComputingMilieux_THECOMPUTINGPROFESSION ,business.industry ,Communication ,education ,Pediatric Surgeon ,Medical care ,Experiential learning ,Patient care ,Pediatrics, Perinatology and Child Health ,Pediatric surgery ,medicine ,Text messaging ,Humans ,Surgery ,Social media ,Empathy ,business ,Child ,Medical ethics ,Aged - Abstract
New communication technologies and generational differences in communication techniques create ethical challenges for pediatric surgeons. Using two hypothetical cases we explore the ethics of modern communication in pediatric surgery. The first case explores the ethics of text messaging with patients and families and of social media posts, both of which have useful ethical analogues in older communication technologies. The second case explores ways that generational experiential differences in learning can foster misunderstandings between team members at different levels of training and potentially impact important medical care decisions. The ethical rules that govern the delivery of patient care also apply to what we say and how we say it. Effective, ethical and compassionate communication will often be the aspect of therapy most appreciated by the patient and family.
- Published
- 2021
26. Care transition of trauma patients: Processes with articulation work before and after handoff
- Author
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Jonathan E. Kohler, Scott Springman, Joshua Ross, Pascale Carayon, Ben Eithun, Tom Brazelton, Deborah A. Rusy, Shannon M. Dean, Katherine Schroeer, Michelle M. Kelly, Abigail R. Wooldridge, Peter Hoonakker, Bat-Zion Hose, Rima Rahal, and Ayse P. Gurses
- Subjects
Adult ,Patient Transfer ,Operating Rooms ,media_common.quotation_subject ,Physical Therapy, Sports Therapy and Rehabilitation ,Human Factors and Ergonomics ,Interview data ,Patient safety ,medicine ,Humans ,Safety, Risk, Reliability and Quality ,Child ,Engineering (miscellaneous) ,Care Transitions ,media_common ,Teamwork ,business.industry ,Transition (fiction) ,digestive, oral, and skin physiology ,Patient Handoff ,medicine.disease ,Intensive Care Units ,Handover ,Work (electrical) ,Medical emergency ,Patient Safety ,Articulation (phonetics) ,business - Abstract
While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) and administered the AHRQ Hospital Survey on Patient Safety Culture items about handoffs, care transitions and teamwork. Care transitions are complex, spatio-temporal processes and involve work during the transition (i.e., handoff and transport) and preparation and follow up activities (i.e., articulation work). Physicians defined the transition as starting earlier and ending later than nurses. Clinicians in the OR to adult ICU transition without a team handoff reported significantly less information loss and better cooperation, despite positive interview data. A team handoff and supporting articulation work should increase awareness, improving quality and safety of care transitions.
- Published
- 2021
27. Can fecal continence be predicted in patients born with anorectal malformations?
- Author
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Cynthia D. Downard, Marc A. Levitt, Jennifer S. McLeod, Jennifer N. Cooper, Katherine J. Deans, Shawn D. St. Peter, Jonathan E. Kohler, Thomas T. Sato, Amin Afrazi, Michael A. Helmrath, Peter C. Minneci, Peter F. Ehrlich, Beth McClure, Daniel L. Lodwick, Beth Rymeski, Samir K Gadepalli, Rashmi Kabre, Richard J. Wood, Charles M. Leys, Matthew P. Landman, Jacqueline M. Saito, Constance Lee, Casey M. Calkins, Kristine S. Corkum, Grace Z. Mak, Devin R. Halleran, Rachel M. Landisch, Jason D. Fraser, and Rodrigo A. Mon
- Subjects
medicine.medical_specialty ,Fistula ,Bowel management ,Logistic regression ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,Humans ,Medicine ,Fecal continence ,In patient ,Prospective Studies ,Child ,Prospective cohort study ,business.industry ,General Medicine ,medicine.disease ,Anorectal Malformations ,Perineal fistula ,Surgery ,Logistic Models ,030220 oncology & carcinogenesis ,Pediatrics, Perinatology and Child Health ,business ,Fecal Incontinence ,Cohort study - Abstract
Purpose The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM). Methods We performed a multi-institutional cohort study of children born with ARM in 2007–2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥ 4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression. Results Among 144 ARM patients with a median age of 7 years (IQR 6–8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001). Conclusion Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM. Type of Study Prospective Cohort Study. Level of Evidence II.
- Published
- 2019
28. Information flow during pediatric trauma care transitions: things falling through the cracks
- Author
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Ayse P. Gurses, Michelle M. Kelly, Deborah A. Rusy, Bat Zion Hose, Thomas B. Brazelton, Abigail R. Wooldridge, Jonathan E. Kohler, Pascale Carayon, Peter Hoonakker, Shannon M. Dean, Ben Eithun, and Joshua Ross
- Subjects
Patient Transfer ,medicine.medical_specialty ,Interprofessional Relations ,media_common.quotation_subject ,Population ,030204 cardiovascular system & hematology ,Pediatrics ,Article ,Interviews as Topic ,03 medical and health sciences ,Patient safety ,0302 clinical medicine ,Surveys and Questionnaires ,Anesthesiology ,Internal Medicine ,Humans ,Medicine ,030212 general & internal medicine ,Information flow (information theory) ,education ,Qualitative Research ,media_common ,Pediatric intensive care unit ,Teamwork ,education.field_of_study ,business.industry ,Communication ,Transitional Care ,Continuity of Patient Care ,medicine.disease ,Falling (accident) ,Emergency Medicine ,Wounds and Injuries ,Medical emergency ,medicine.symptom ,business ,Pediatric trauma - Abstract
Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Every year, nearly 10 million children are evaluated in emergency departments (EDs) for traumatic injuries, resulting in 250,000 hospital admissions and, unfortunately, 10,000 deaths. Pediatric trauma care in hospitals is distributed across time and space and involves a large and fluid care team. Several clinical teams (including emergency medicine, surgery, anesthesiology, and pediatric critical care) converge to help support trauma care in the ED; this co-location in the ED can help to support communication, coordination and cooperation of team members. The most severe trauma cases often need surgery in the operating room (OR) and are admitted to the pediatric intensive care unit (PICU). Care transitions in pediatric trauma can result in loss of information or transfer of incorrect information, which can negatively affect the care a child will receive. In this study, we interviewed 18 clinicians and asked questions about communication and coordination during care transitions between the ED, operating room and PICU. After the interview was completed, clinicians completed a short questionnaire about patient safety during transitions. Results of our study show that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, often important patient care information is lost when transitioning patients between units. To safely manage the transition of this fragile and complex population, we need to find ways to better manage the information flow during these transitions by, for instance, providing technological support for shared mental models.
- Published
- 2019
29. National variation in opioid prescribing after pediatric umbilical hernia repair
- Author
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Dou-Yan Yang, Randi Cartmill, Sara Fernandes-Taylor, and Jonathan E. Kohler
- Subjects
Pediatrics ,medicine.medical_specialty ,Adolescent ,MEDLINE ,Pharmacy ,030230 surgery ,Drug Prescriptions ,Opioid prescribing ,03 medical and health sciences ,0302 clinical medicine ,Umbilical hernia repair ,Humans ,Medicine ,Hernia ,Practice Patterns, Physicians' ,Medical prescription ,Child ,Gangrene ,Pain, Postoperative ,business.industry ,Infant, Newborn ,Infant ,medicine.disease ,Analgesics, Opioid ,Opioid ,Child, Preschool ,030220 oncology & carcinogenesis ,Surgery ,business ,Hernia, Umbilical ,medicine.drug - Abstract
Pediatric umbilical hernia repair is a common procedure that requires minimal tissue disruption. We examined variation in opioid prescription fills after repair of uncomplicated umbilical hernias to characterize the types and doses of medication used and persistent postsurgical use.Using the Truven Health Analytics MarketScan© Research Database for June 2012-September 2015, we identified pediatric patients undergoing umbilical hernia repair. We excluded patients with obstruction, gangrene, an earlier repair or a concurrent surgical procedure, and those without available pharmacy claim data. Analyses describe filled outpatient prescriptions by age, geographic region, drug type, quantity, and second prescriptions/refills.Of 4,407 procedures performed, 2,292 patients (52%) filled a prescription for postoperative opioids (age 0-1 years: 21.6%, age 2-3 years: 51.5%, age 4-5 years: 54.3%, 6 years or older: 57.9% [P.0001]). In the northeast United States, 42% of patients filled narcotic prescriptions, compared with 59% of patients in the south (P.0001). Hydrocodone/acetaminophen was most commonly prescribed (51%), followed by codeine/acetaminophen (30%). Durations were ≤3 days (50%), 4-10 days (46%), and10 days (4%). A total of 6% of patients filled a second opioid prescription within 30 days.Although many patients do not require opioids for umbilical hernia repair, most pediatric patients fill opioid prescriptions, including for prolonged courses and refills. Guidelines for appropriate prescribing of opioids after common, simple procedures, such as umbilical hernia repair, could improve the quality of care for children and impact the US epidemic of opioid abuse.
- Published
- 2019
30. Practice Variation in Umbilical Hernia Repair Demonstrates a Need for Best Practice Guidelines
- Author
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Tiffany Zens, Jonathan E. Kohler, Randi Cartmill, Sara Fernandes-Taylor, Bridget L. Muldowney, and Peter F. Nichol
- Subjects
Male ,medicine.medical_specialty ,Adolescent ,medicine.medical_treatment ,Best practice ,New York ,Article ,03 medical and health sciences ,Postoperative Complications ,Wisconsin ,0302 clinical medicine ,030225 pediatrics ,Pediatric surgery ,medicine ,Umbilical hernia repair ,Humans ,Hernia ,030212 general & internal medicine ,Practice Patterns, Physicians' ,Child ,Herniorrhaphy ,business.industry ,General surgery ,Infant ,medicine.disease ,Umbilical hernia ,Delayed repair ,Cross-Sectional Studies ,Ambulatory Surgical Procedures ,Child, Preschool ,Practice Guidelines as Topic ,Pediatrics, Perinatology and Child Health ,Ambulatory ,Florida ,Female ,business ,Hernia, Umbilical ,Watchful waiting - Abstract
OBJECTIVE: Umbilical hernias are a common diagnosis in young children. To our knowledge, no formal practice guideline exists to guide timing of operative repair for asymptomatic pediatric umbilical hernias, which often resolve spontaneously. To evaluate and better understand variations in practice patterns, we analyzed ambulatory surgery claims data from three demographically diverse states to assess the relationship between age at umbilical hernia repair and patient, hospital and geographic characteristics. STUDY DESIGN: We performed a cross-sectional descriptive study of uncomplicated hernia repairs performed as a single procedure in 2012–2014, using the State Ambulatory Surgery and Services databases (SASD) for Wisconsin, New York and Florida. Age and demographic characteristics of umbilical hernia repair patients are described. RESULTS: The SASD analysis included 6551 patients. Across three states, 8.2% of hernia repairs were performed in children
- Published
- 2019
31. Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction
- Author
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Grace Z. Mak, Manish T. Raiji, Jessica J. Kandel, Jonathan E. Kohler, Erica M Carlisle, Allison F. Linden, J. Carlos Pelayo, and Kate A. Feinstein
- Subjects
Male ,medicine.medical_specialty ,Adolescent ,Contrast Media ,Tissue Adhesions ,Nasogastric Decompression ,Enteral administration ,Young Adult ,Intestine, Small ,Humans ,Medicine ,Nonoperative management ,Child ,Diatrizoate Meglumine ,Retrospective Studies ,business.industry ,Medical record ,Infant ,Health Care Costs ,General Medicine ,Length of Stay ,medicine.disease ,Surgery ,Hospitalization ,Bowel obstruction ,Water soluble ,Child, Preschool ,Pediatrics, Perinatology and Child Health ,Female ,Level iii ,business ,Group outcomes ,Intestinal Obstruction - Abstract
Background/purpose We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO). Methods Medical records were reviewed retrospectively for all children admitted with ASBO between November 2010 and June 2017. Those admitted between November 2010 and October 2013 received nasogastric decompression with decision for surgery determined by surgeon judgment (preprotocol). Patients admitted after October 2013 (postprotocol) received water-soluble contrast early after admission, were monitored with serial examinations and radiographs, and underwent surgery if contrast was not visualized in the cecum by 24 h. Group outcomes were compared. Results Twenty-six patients experienced 29 admissions preprotocol, and 11 patients experienced 12 admissions postprotocol. Thirteen (45%) patients admitted preprotocol underwent surgery, versus 2 (17%) postprotocol patients (p = 0.04). Contrast study diagnostic sensitivity as a predictor for ASBO resolution was 100%, with 90% specificity. Median overall hospital LOS trended shorter in the postprotocol group, though was not statistically significant (6.2 days (preprotocol) vs 3.6 days (postprotocol) p = 0.12). Pre- vs. postprotocol net operating cost per admission yielded a savings of $8885.42. Conclusions Administration of water-soluble contrast after hospitalization for pediatric ASBO may play a dual diagnostic and therapeutic role in management with decreases in surgical intervention, LOS, and cost. Type of study Retrospective comparative study. Level of evidence Level III.
- Published
- 2019
32. Age-dependent outcomes in asymptomatic umbilical hernia repair
- Author
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Daniel J. Ostlie, Randi Cartmill, Andrew P. Rogers, Bridget L. Muldowney, Tiffany Zens, Jonathan E. Kohler, and Peter F. Nichol
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Asymptomatic ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,030225 pediatrics ,Pediatric surgery ,Umbilical hernia repair ,Humans ,Medicine ,Hernia ,Child ,Herniorrhaphy ,Retrospective Studies ,Surgical repair ,business.industry ,Incidence ,Age Factors ,General Medicine ,medicine.disease ,United States ,Umbilical hernia ,Surgery ,Child, Preschool ,Asymptomatic Diseases ,Pediatrics, Perinatology and Child Health ,Female ,030211 gastroenterology & hepatology ,medicine.symptom ,business ,Complication ,Hernia, Umbilical ,Watchful waiting - Abstract
Umbilical hernias are common in young children. Many resolve spontaneously by age four with very low risk of symptoms or incarceration. Complications associated with surgical repair of asymptomatic umbilical hernias have not been well elucidated. We analyzed data from one hospital to test the hypothesis that repair at younger ages is associated with increased complication rates.A retrospective chart review of all umbilical hernia repairs performed during 2007-2015 was conducted at a tertiary care children's hospital. Patients undergoing repairs as a single procedure for asymptomatic hernia were evaluated for post-operative complications by age, demographics, and co-morbidities.Of 308 umbilical hernia repairs performed, 204 were isolated and asymptomatic. Postoperative complications were more frequent in children 4 years (12.3%) compared to 4 years (3.1%, p = 0.034). All respiratory complications (N = 4) and readmissions (N = 1) were in children 4 years.Age of umbilical hernia repair in children varied widely even within a single institution, demonstrating that timing of repair may be a surgeon-dependent decision. Patients 4 years were more likely to experience post-operative complications. Umbilical hernias often resolve over time and can safely be monitored with watchful waiting. Formal guidelines are needed to support delayed repair and prevent unnecessary, potentially harmful operations.
- Published
- 2018
33. Risk factors for perioperative hypothermia and infectious outcomes in gastroschisis patients
- Author
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Shirli Tay, Shilvi Joshi, Shawn D. St. Peter, Christina M Bence, Rachel M. Landisch, Charles M. Leys, Joseph B. Lillegard, Amy J. Wagner, Ruizhe Wu, Jason D. Fraser, Aimee G. Kim, Mary T. Austin, Aniko Szabo, Erin E. Perrone, Brad W. Warner, Kathryn McElhinney, and Jonathan E. Kohler
- Subjects
Hypothermia ,Logistic regression ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,030225 pediatrics ,medicine ,Humans ,Surgical Wound Infection ,Child ,Retrospective Studies ,Gastroschisis ,business.industry ,Infant, Newborn ,Infant ,General Medicine ,Odds ratio ,Perioperative ,medicine.disease ,Increased risk ,Treatment Outcome ,030220 oncology & carcinogenesis ,Anesthesia ,Pediatrics, Perinatology and Child Health ,Cohort ,Surgery ,medicine.symptom ,business ,Surgical site infection - Abstract
Prior data suggest that infants with gastroschisis are at high risk for hypothermia and infectious complications (ICs). This study evaluated the associations between perioperative hypothermia (PH) and ICs in gastroschisis using a multi-institutional cohort.Retrospective review of infants with gastroschisis who underwent abdominal closure from 2013-2017 was performed at 7 children's hospitals. Any-IC and surgical site infection (SSI) were stratified against the presence or absence of PH, and perioperative characteristics associated with PH and SSI were determined using multivariable logistic regression.Of 256 gastroschisis neonates, 42% developed PH, with 18% classified as mild hypothermia (35.5-35.9 °C), 10.5% as moderate (35.0-35.4 °C), and 13% severe (35 °C). There were 82 (32%) ICs with 50 (19.5%) being SSIs. No associations between PH and any-IC (p = 0.7) or SSI (p = 0.98) were found. Pulmonary comorbidities (odds ratio (OR)=3.76, 95%CI:1.42-10, p = 0.008) and primary closure (OR=0.21, 95%CI:0.12-0.39, p0.001) were associated with PH, while silo placement (OR=2.62, 95%CI:1.1-6.3, p = 0.03) and prosthetic patch (OR=3.42, 95%CI:1.4-8.3, p = 0.007) were associated with SSI on multivariable logistic regression.Primary abdominal closure and pulmonary comorbidities are associated with PH in gastroschisis, however PH was not associated with increased risk of ICs. Independent risk factors for SSI include silo placement and prosthetic patch closure.
- Published
- 2021
34. Does Use of a Feeding Protocol Change Outcomes in Gastroschisis? A Report from the Midwest Pediatric Surgery Consortium
- Author
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Michael A. Helmrath, Bethany J. Slater, Kevin N. Johnson, R. Cartland Burns, Samir K. Gadepalli, Jonathan E. Kohler, Ronald B. Hirschl, Katherine J. Deans, Cynthia D. Downard, Grace Z. Mak, Julia Grabowski, St Shawn D Peter, Edward Hernandez, Amy E. Lawrence, Tiffany Wright, Charles M. Leys, Peter C. Minneci, Charlene Dekonenko, Patrick A. Dillon, Thomas T. Sato, Kristine S. Corkum, Matthew P. Landman, Rachel M. Landisch, Beth Rymeski, Rashmi Kabre, Jason D. Fraser, and Mary E. Fallat
- Subjects
medicine.medical_specialty ,Peripherally inserted central catheter ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,Surgical site ,Pediatric surgery ,medicine ,Humans ,030212 general & internal medicine ,Child ,Retrospective Studies ,Protocol (science) ,Gastroschisis ,business.industry ,Infant, Newborn ,Infant ,Retrospective cohort study ,Length of Stay ,medicine.disease ,Hospitals, Pediatric ,Surgery ,Treatment Outcome ,VIA protocol ,Pediatrics, Perinatology and Child Health ,Cohort ,business - Abstract
Introduction Gastroschisis feeding practices vary. Standardized neonatal feeding protocols have been demonstrated to improve nutritional outcomes. We report outcomes of infants with gastroschisis that were fed with and without a protocol. Materials and Methods A retrospective study of neonates with uncomplicated gastroschisis at 11 children's hospitals from 2013 to 2016 was performed.Outcomes of infants fed via institutional-specific protocols were compared with those fed without a protocol. Subgroup analyses of protocol use with immediate versus delayed closure and with sutured versus sutureless closure were conducted. Results Among 315 neonates, protocol-based feeding was utilized in 204 (65%) while no feeding protocol was used in 111 (35%). There were less surgical site infections (SSI) in those fed with a protocol (7 vs. 16%, p = 0.019). There were no differences in TPN duration, time to initial oral intake, time to goal feeds, ventilator use, peripherally inserted central catheter line deep venous thromboses, or length of stay. Of those fed via protocol, less SSIs occurred in those who underwent sutured closure (9 vs. 19%, p = 0.026). Further analyses based on closure timing or closure method did not demonstrate any significant differences. Conclusion Across this multi-institutional cohort of infants with uncomplicated gastroschisis, there were more SSIs in those fed without an institutional-based feeding protocol but no differences in other outcomes.
- Published
- 2020
35. Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula
- Author
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Cathleen M. Courtney, Jared T Silverberg, Julia Grabowski, Ruchi Amin, R. Cartland Burns, Elissa Port, Tiffany Wright, Michael A. Helmrath, Shawn D. St. Peter, Misty Troutt, Mark B. Slidell, Matthew P. Landman, Cynthia D. Downard, Thomas T. Sato, Katherine J. Deans, Christina M Bence, Ronald B. Hirschl, Jacqueline M. Saito, Rashmi D Kabre, Samir K. Gadepalli, Beth Rymeski, Linda Cherney-Stafford, Jonathan E. Kohler, Sarah K. Walker, Grace Z. Mak, Charles M. Leys, Jason D. Fraser, Dave R. Lal, Amy E. Lawrence, Peter C. Minneci, and Mary E. Fallat
- Subjects
Leak ,medicine.medical_specialty ,Tracheoesophageal fistula ,Anastomosis ,03 medical and health sciences ,0302 clinical medicine ,Postoperative Complications ,Suture (anatomy) ,030225 pediatrics ,medicine ,Humans ,Inverse correlation ,Child ,Esophageal Atresia ,Retrospective Studies ,business.industry ,Infant ,General Medicine ,Perioperative ,medicine.disease ,Surgery ,Treatment Outcome ,030220 oncology & carcinogenesis ,Bundle ,Atresia ,Pediatrics, Perinatology and Child Health ,business ,Tracheoesophageal Fistula - Abstract
This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF).Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively.One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029).Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes.Level II.Treatment Study.
- Published
- 2020
36. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis
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Charles M. Leys, Jonathan E. Kohler, Jennifer N. Cooper, Samir K. Gadepalli, Rashmi Kabre, Dave R. Lal, Christa Fox, Thomas T. Sato, Matthew P. Landman, Erinn M. Hade, Grace Z. Mak, Ronald B. Hirschl, Yuri V. Sebastião, Jacqueline M. Saito, Katherine J. Deans, Amy E. Lawrence, Peter C. Minneci, Mary E. Fallat, and Michael A. Helmrath
- Subjects
Male ,medicine.medical_specialty ,Adolescent ,Psychological intervention ,Appendix ,01 natural sciences ,03 medical and health sciences ,0302 clinical medicine ,Quality of life ,Antibiotic therapy ,Internal medicine ,medicine ,Appendectomy ,Humans ,Uncomplicated appendicitis ,030212 general & internal medicine ,0101 mathematics ,Nonoperative management ,Laparoscopy ,Child ,Propensity Score ,Selection Bias ,Ultrasonography ,medicine.diagnostic_test ,business.industry ,010102 general mathematics ,General Medicine ,medicine.disease ,Appendicitis ,Anti-Bacterial Agents ,Treatment Outcome ,Propensity score matching ,Acute Disease ,Quality of Life ,Female ,business ,Tomography, X-Ray Computed ,Follow-Up Studies - Abstract
Importance Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery. Objective To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis. Design, Setting, and Participants Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children’s hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study. Interventions Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698). Main Outcomes and Measures The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments. Results Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor’s degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%;P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, −4.3 days (99% CI, −6.17 to −2.43;P Conclusion and Relevance Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met. Trial Registration ClinicalTrials.gov Identifier:NCT02271932
- Published
- 2020
37. Outcomes in gastroschisis: expectations in the postnatal period for simple vs complex gastroschisis
- Author
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Peter C. Minneci, Amy E. Lawrence, R. Cartland Burns, Jonathan E. Kohler, Ronald B. Hirschl, Cynthia D. Downard, Shawn D. St. Peter, Kevin N. Johnson, Katherine J. Deans, Bethany J. Slater, Patrick A. Dillon, Charles M. Leys, Charlene Dekonenko, Jason D. Fraser, Beth Rymeski, Thomas T. Sato, Kristine Corkumd, Matthew P. Landman, Rashmi Kabre, Grace Z. Mak, Julia Grabowski, Mary E. Fallat, Rachel M. Landisch, Edward Hernandez, Samir K. Gadepalli, Michael A. Helmrath, and Tiffany Wright
- Subjects
Gastroschisis ,medicine.medical_specialty ,Motivation ,Obstetrics ,business.industry ,Infant, Newborn ,Obstetrics and Gynecology ,Retrospective cohort study ,Length of Stay ,medicine.disease ,Hospitals, Pediatric ,Statistics, Nonparametric ,03 medical and health sciences ,0302 clinical medicine ,Treatment Outcome ,030225 pediatrics ,Pediatrics, Perinatology and Child Health ,Cohort ,medicine ,Humans ,030212 general & internal medicine ,business ,Retrospective Studies - Abstract
To provide generalizable estimates for expected outcomes of simple gastroschisis (SG) and complex gastroschisis (CG) patients from a large multi-institutional cohort for use during counseling. A retrospective study of 394 neonates with gastroschisis at 11 children’s hospitals from January 2013 to March 2017 was performed. Analysis by Fisher’s exact tests and Wilcoxon rank sum tests were performed. Outcomes of complex and simple gastroschisis are reported. There were 315 (80%) SG and 79 (20%) CG. CG had increased time from birth to closure (6 vs 4.4 days), closure to goal feeds (69 vs 23 days), ventilator use (90% vs 73%), SSIs (31% vs 11%), NEC (14% vs 6%), PN use (71 vs 24 days), LOS (104.5 vs 33 days), and mortality (11% vs 0%). This study provides generalizable estimates for expected outcomes of patients with both SG and CG that can be utilized during counseling. CG has significantly worse in-hospital outcomes.
- Published
- 2020
38. PD09-09 EVALUATION OF POSTOPERATIVE OPIOID PRESCRIBING FOLLOWING COMMON UROLOGIC PROCEDURES IN THE STATE OF WISCONSIN
- Author
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Kyle A. Richards, Tudor Borza, Aravind Viswanathan, Jessica R. Schumacher, Edwin Jason Abel, Jonathan E. Kohler, Elise H. Lawson, Manasa Venkatesh, Caprice C. Greenberg, Tracy M. Downs, and David F. Jarrard
- Subjects
medicine.medical_specialty ,business.industry ,Urology ,Emergency medicine ,Medicine ,Opioid naive ,business ,Opioid prescribing - Abstract
INTRODUCTION AND OBJECTIVE:Postoperative opioid prescribing is associated with a 6% new persistent use rate in previously opioid naive patients and accounts for significant supply available for div...
- Published
- 2020
39. Work System Barriers and Facilitators in Inpatient Care Transitions of Pediatric Trauma Patients
- Author
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Bat Zion Hose, Jonathan E. Kohler, Joshua Ross, Pascale Carayon, Thomas B. Brazelton, Peter Hoonakker, Ayse P. Gurses, Michelle M. Kelly, Abigail R. Wooldridge, Benjamin Eithun, Shannon M. Dean, and Deborah A. Rusy
- Subjects
Male ,Patient Transfer ,Operating Rooms ,Systems Analysis ,Health Personnel ,Staffing ,Physical Therapy, Sports Therapy and Rehabilitation ,Human Factors and Ergonomics ,Intensive Care Units, Pediatric ,Article ,Workflow ,03 medical and health sciences ,Patient safety ,0302 clinical medicine ,Nursing ,Medicine ,Humans ,0501 psychology and cognitive sciences ,Safety, Risk, Reliability and Quality ,Child ,Engineering (miscellaneous) ,050107 human factors ,Care Transitions ,Pediatric intensive care unit ,Patient Care Team ,Inpatient care ,business.industry ,05 social sciences ,Emergency department ,medicine.disease ,030210 environmental & occupational health ,Female ,Ergonomics ,business ,Work systems ,Emergency Service, Hospital ,Pediatric trauma - Abstract
Hospital-based care of pediatric trauma patients includes transitions between units that are critical for quality of care and patient safety. Using a macroergonomics approach, we identify work system barriers and facilitators in care transitions. We interviewed eighteen healthcare professionals involved in transitions from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU. We applied the Systems Engineering Initiative for Patient Safety (SEIPS) process modeling method and identified nine dimensions of barriers and facilitators - anticipation, ED decision making, interacting with family, physical environment, role ambiguity, staffing/resources, team cognition, technology and characteristic of trauma care. For example, handoffs involving all healthcare professionals in the OR to PICU transition created a shared understanding of the patient, but sometimes included distractions. Understanding barriers and facilitators can guide future improvements, e.g., designing a team display to support team cognition of healthcare professionals in the care transitions.
- Published
- 2020
40. Complexity of the pediatric trauma care process: implications for multi-level awareness
- Author
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Abigail R. Wooldridge, Benjamin Eithun, Ashimiyu B. Durojaiye, Jonathan E. Kohler, Joshua Ross, Pascale Carayon, Peter Hoonakker, Michelle M. Kelly, Deborah A. Rusy, Shannon M. Dean, Thomas B. Brazelton, Ayse P. Gurses, and Bat Zion Hose
- Subjects
Coping (psychology) ,Sociotechnical system ,business.industry ,media_common.quotation_subject ,05 social sciences ,medicine.disease ,Clinical decision support system ,Article ,050105 experimental psychology ,Computer Science Applications ,Human-Computer Interaction ,Interdependence ,Philosophy ,Patient safety ,Nursing ,Health care ,medicine ,0501 psychology and cognitive sciences ,Industrial and organizational psychology ,business ,Psychology ,050107 human factors ,media_common ,Pediatric trauma - Abstract
Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, we combine interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e. safety in complex systems. We discuss three levels of awareness (individual, team and organizational) and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration and decision making. A challenge to team awareness is inadequate "non-technical" skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, by using process modeling or simulation.
- Published
- 2018
41. Screening practices and associated anomalies in infants with anorectal malformations: Results from the Midwest Pediatric Surgery Consortium
- Author
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Jason D. Fraser, Thomas T. Sato, Rodrigo A. Mon, Richard J. Wood, Devin R. Halleran, Constance Lee, Katherine J. Deans, Beth Rymeski, Jonathan E. Kohler, Casey M. Calkins, Amin Afrazi, Grace Z. Mak, Samir K. Gadepalli, Rachel M. Landisch, Charles M. Leys, Daniel L. Lodwick, Michael A. Helmrath, Rashmi Kabre, Shawn D. St. Peter, Jennifer N. Cooper, Peter C. Minneci, Marc A. Levitt, Beth McClure, Peter F. Ehrlich, Matthew P. Landman, Jacqueline M. Saito, and Cynthia D. Downard
- Subjects
Male ,medicine.medical_specialty ,Pediatrics ,Standard of care ,Screening test ,Fistula ,Rectum ,Midwestern United States ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,Pediatric surgery ,medicine ,Humans ,Abnormalities, Multiple ,Practice Patterns, Physicians' ,Child ,Retrospective Studies ,business.industry ,Incidence ,Incidence (epidemiology) ,Infant ,Retrospective cohort study ,General Medicine ,medicine.disease ,Anorectal Malformations ,Perineal fistula ,medicine.anatomical_structure ,Child, Preschool ,030220 oncology & carcinogenesis ,Pediatrics, Perinatology and Child Health ,Female ,Surgery ,business - Abstract
This study evaluates screening practices and the incidence of associated anomalies in infants with anorectal malformations (ARM).We performed a multi-institutional retrospective cohort study of children born between 2007 and 2011 who underwent surgery for ARM at 10 children's hospitals. ARM type was classified based on the location of the distal rectum, and all screening studies were reviewed.Among 506 patients, the most common ARM subtypes were perineal fistula (40.7%), no fistula (11.5%), and vestibular fistula (10.1%). At least 1 screening test was performed in 96.6% of patients, and 11.3% of patients underwent all. The proportion of patients with ≥1 abnormal finding on any screening test varied by type of ARM (p0.001). Screening rates varied from 15.2% for limb anomalies to 89.7% for renal anomalies. The most commonly identified anomalies by screening category were: spinal: tethered cord (20.6%); vertebral: sacral dysplasia/hemisacrum (17.8%); cardiac: patent foramen ovale (58.0%); renal: hydronephrosis (22.7%); limb: absent radius (7.9%).Screening practices and the incidence of associated anomalies varied by type of ARM. The rate of identifying at least one associated anomaly was high across all ARM subtypes. Screening for associated anomalies should be considered standard of care for all ARM patients.Multi-institutional retrospective cohort study.III.
- Published
- 2018
42. Need for Consensus Guidelines in Pediatric Umbilical Hernia Repair
- Author
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Peter F. Nichol, Randi Cartmill, and Jonathan E. Kohler
- Subjects
medicine.medical_specialty ,business.industry ,General surgery ,Pediatrics, Perinatology and Child Health ,Umbilical hernia repair ,medicine ,business - Published
- 2019
43. Intestinal Perforation in Children as an Important Differential Diagnosis of Vascular Ehlers-Danlos Syndrome
- Author
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Jonathan E. Kohler, Kara G. Gill, and Keon Young Park
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Perforation (oil well) ,Uterine perforation ,030204 cardiovascular system & hematology ,Diagnosis, Differential ,03 medical and health sciences ,Ileostomy ,Colonic Diseases ,0302 clinical medicine ,medicine ,Humans ,Child ,Colectomy ,business.industry ,General Medicine ,Articles ,medicine.disease ,Surgery ,Stercoral ulcer ,Ehlers–Danlos syndrome ,Intestinal Perforation ,030220 oncology & carcinogenesis ,Ehlers-Danlos Syndrome ,Differential diagnosis ,business ,Complication ,Constipation - Abstract
Patient: Male, 6 Final Diagnosis: Colonic perforation secondary to vascular Ehlers Danlos Syndrome Symptoms: Abdominal pain • constipation Medication: — Clinical Procedure: Loop colostomy followed by total colectomy and ileostomy Specialty: Surgery Objective: Unusual clinical course Background: Ehlers-Danlos Syndrome (EDS) is a group of connective tissue disorders with heterogeneous clinical features associated with varying genetic mutations. EDS type IV, also known as vascular EDS (vEDS), is the rarest type but has fatal complications, including rupture of major vasculature and intestinal and uterine perforation. Intestinal perforation can be spontaneous or a consequence of long-standing constipation, a common symptom among patients with EDS. Case Report: We present a case of a 6-year-old boy with the previous diagnosis of vEDS who presented with colonic perforation from a stercoral ulcer. He underwent diagnostic laparoscopy and loop colostomy, with an uneventful postoperative course. Unfortunately, he developed a second colonic perforation 14 months after the initial episode and underwent total abdominal colectomy with end ileostomy. Conclusions: Intestinal perforation is a well-documented and devastating complication of vEDS. However, spontaneous intestinal perforation is extremely rare in a young child. Therefore, the diagnosis of vEDS should be included in the differential diagnosis if a child presents with intestinal perforation. There is no clear guideline available for surgical management of colonic perforation in patients with vEDS, but total abdominal colectomy appears to provide the best chance of preventing recurrent perforation.
- Published
- 2019
44. Factors Associated With Management of Pediatric Ovarian Neoplasms
- Author
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Jonathan E. Kohler, Charles M. Leys, Peter C. Minneci, S. Paige Hertweck, Rashmi Kabre, Joseph A. Sujka, Jason D. Fraser, Julia Grabowski, Amy E. Lawrence, Dave R. Lal, Mary E. Fallat, Patrick A. Dillon, Madeline Scannell, Thomas T. Sato, Grace Z. Mak, Dani O. Gonzalez, Robert C. Burns, Ronald B. Hirschl, Matthew P. Landman, Amanda Onwuka, Christina M Bence, Geri Hewitt, Katherine J. Deans, Jennifer H. Aldrink, and Peter F. Ehrlich
- Subjects
Pediatrics ,medicine.medical_specialty ,Adolescent ,Ovariectomy ,medicine.medical_treatment ,Unnecessary Procedures ,Malignancy ,Risk Assessment ,Midwestern United States ,Ovarian disease ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,medicine ,Humans ,Young adult ,Child ,Retrospective Studies ,Ovarian Neoplasms ,business.industry ,Age Factors ,Oophorectomy ,Retrospective cohort study ,Pediatric Surgeon ,Hospitals, Pediatric ,medicine.disease ,Child, Preschool ,Pediatrics, Perinatology and Child Health ,Cohort ,Medicine ,Female ,Risk assessment ,business ,Organ Sparing Treatments - Abstract
BACKGROUND: Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children’s hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions. METHODS: A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children’s hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy. RESULTS: Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%–49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (P = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (P = .02), preoperative suspicion for malignancy (P < .0001), larger lesion size (P < .0001), and presence of solid components (P < .0001). Preoperative findings independently associated with malignancy included increasing size (P < .0001), solid components (P = .003), and age (P < .0001). CONCLUSIONS: The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.
- Published
- 2019
45. Rural health, telemedicine and access for pediatric surgery
- Author
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Jonathan E. Kohler, Richard A. Falcone, and Mary E. Fallat
- Subjects
Rural Population ,medicine.medical_specialty ,Telemedicine ,Specialty ,Rural Health ,Health Services Accessibility ,Specialties, Surgical ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,Pediatric surgery ,medicine ,Humans ,Child ,business.industry ,Rural health ,Trauma care ,medicine.disease ,United States ,030220 oncology & carcinogenesis ,Pediatrics, Perinatology and Child Health ,Medical emergency ,Rural Health Services ,Rural area ,business - Abstract
Access to care for children requiring pediatric general or specialty surgery or trauma care who live in rural areas remains a challenge in the United States.The expertise of specialists in tertiary centers can be extended to rural and underserved areas using telemedicine. There are challenges to making these resources available that need to be methodically approached to facilitate appropriate relationships between hospitals and providers. Programs, such as the National Pediatric Readiness Project and the HRSA Emergency Medical Services for Children Program enhance the capability of the emergency care system to function optimally, keep children at the home hospital if resources are available, facilitate transfer of patients and relationship building, and develop necessary transfer protocols and guidelines between hospitals.Telehealth services have the potential to enhance the reach of tertiary care for children in rural and underserved areas where surgical and trauma specialty care is not readily available, particularly when used to augment the objectives of national programs.
- Published
- 2019
46. Reply to: Confounding factors on the analysis of opioid prescription after pediatric umbilical hernia repair
- Author
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Randi Cartmill, Dou-Yan Yang, Sara Fernandes-Taylor, and Jonathan E. Kohler
- Subjects
medicine.medical_specialty ,Pain, Postoperative ,business.industry ,Confounding ,Analgesics, Opioid ,Prescription opioid ,Internal medicine ,medicine ,Umbilical hernia repair ,Humans ,Surgery ,Practice Patterns, Physicians' ,business ,Child ,Hernia, Umbilical ,Herniorrhaphy - Published
- 2019
47. Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care
- Author
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James C. Fackler, Joshua Ross, Jonathan E. Kohler, Abigail R. Wooldridge, Nicolette M. McGeorge, Michelle M. Kelly, Peter Hoonakker, Ben Eithun, Deborah A. Rusy, Thomas B. Brazelton, Shannon M. Dean, Ayse P. Gurses, Pascale Carayon, and Bat Zion Hose
- Subjects
020205 medical informatics ,Problem list ,Health Informatics ,02 engineering and technology ,Pediatrics ,03 medical and health sciences ,Patient safety ,0302 clinical medicine ,Health Information Management ,Trauma Centers ,Physicians ,Surveys and Questionnaires ,0202 electrical engineering, electronic engineering, information engineering ,Physician perception ,medicine ,Electronic Health Records ,Humans ,030212 general & internal medicine ,Medical diagnosis ,Past medical history ,business.industry ,Attitude to Computers ,Human factors and ergonomics ,Guideline ,medicine.disease ,Computer Science Applications ,Policy ,Medical emergency ,business ,Pediatric trauma - Abstract
Objective To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma. Methods We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospital's PL etiquette document of guideline. Results We identified five goals of the PL (to document the patient's problems, to make sense of the patient's problems, to make decisions about the care plan, to know who is involved in the patient's care, and to communicate with others), seven characteristics of the PL (completeness, efficiency, accessibility, multiple users, organized, created before arrival, and representing uncertainty), and 22 patient-related information elements (e.g., injuries, vitals). Physicians' suggested criteria for a PL varied across services with respect to goals, characteristics, and patient-related information. Conclusion Physicians involved in pediatric trauma care described the electronic PL as ideally more than a list of a patient's medical diagnoses and injuries. The information elements mentioned are typically found in other parts of the patient's electronic record besides the PL, such as past medical history and labs. Future work is needed to evaluate the optimal design of the PL so that users with emergent cases, such as pediatric trauma, have access to key information related to the patient's immediate problems.
- Published
- 2019
48. Proactive Risk Assessment of Team Health IT for Pediatric Trauma Care Transitions (T3)
- Author
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Jonathan E. Kohler, Jordan C. Ramsey, Pascale Carayon, Julie A. Nieman, Deb A. Rusy, Bat Zion Hose, Deb J. Soetenga, Ben Eithun, Megan M. Reisman, Joshua Ross, Kristen S. Koffarnus, Peter Hoonakker, and Michael K. Kim
- Subjects
Teamwork ,Process (engineering) ,business.industry ,media_common.quotation_subject ,Affect (psychology) ,medicine.disease ,Patient safety ,Nursing ,medicine ,Risk assessment ,business ,Care Transitions ,media_common ,Pediatric trauma - Abstract
Children suffering from trauma are vulnerable during care transitions. We designed a teamwork transition technology (T3) to support team activities in the emergency deoartment (ED) and help the care teams prepare for transition(s). The introduction of a new technology in an existing process can create new risks. To assess these risks we conducted a proactive risk assessment (PRA) with experts in pediatric trauma before implementation of the technology. Results showed that the experts were able to identify several risks that could negatively affect patient safety, and to formulate strategies to address those issues in the design and implementation of T3.
- Published
- 2019
49. Diagnostic performance of standardized ultrasound protocol for detecting perforation in pediatric appendicitis
- Author
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Randi Cartmill, Blake C. Weber, Kara G. Gill, Jonathan E. Kohler, Matthew W Shore, Erica L. Riedesel, Daniel J. Ostlie, and Charles M Leys
- Subjects
Male ,medicine.medical_specialty ,Adolescent ,Perforation (oil well) ,Risk Assessment ,Severity of Illness Index ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,medicine ,Appendectomy ,Humans ,Radiology, Nuclear Medicine and imaging ,Pediatric appendicitis ,Registries ,Child ,Neuroradiology ,Retrospective Studies ,Observer Variation ,business.industry ,Ultrasound ,Echogenicity ,Ultrasonography, Doppler ,medicine.disease ,Appendicitis ,Hospitals, Pediatric ,Magnetic Resonance Imaging ,Appendix ,United States ,Clinical trial ,medicine.anatomical_structure ,Treatment Outcome ,Intestinal Perforation ,Child, Preschool ,Pediatrics, Perinatology and Child Health ,Acute Disease ,Female ,Radiology ,Emergencies ,business ,Follow-Up Studies - Abstract
Recent clinical trials in adults and children have shown that uncomplicated acute appendicitis can be successfully treated with antibiotics alone. As treatment strategies for acute appendicitis diverge, accurate preoperative diagnosis of complicated appendicitis and appendiceal perforation has become increasingly important for clinical decision-making. To examine diagnostic performance of ultrasound for detecting perforated appendicitis in a single institution using a standardized technique. In this retrospective single-center study we evaluated 113 ultrasounds from pediatric patients who underwent appendectomy between November 2014 and December 2015. All ultrasounds were performed using a standardized US protocol including still and cine images of all four abdominal quadrants, with more targeted evaluation of the right lower quadrant (RLQ) using graded compression technique. We compared US findings to intraoperative diagnosis of non-perforated or perforated acute appendicitis. The standardized image protocol generated a reproducible set of ultrasound images in all cases. The most common primary appendiceal finding on US in perforated appendicitis was appendix wall thickening >3 mm (54%, 171/314) and most common secondary finding was echogenic mesenteric fat (75%, 237/314). Thinning of the appendix wall and loculated fluid collection in the right lower quadrant were both highly specific (>90%) for perforation. The diagnostic performance of ultrasound using a standardized US technique was similar to that reported in prior studies for detecting perforated appendicitis. Despite low sensitivity, individual ultrasound findings and overall diagnostic impression of “evidence of appendix perforation” remain highly specific.
- Published
- 2018
50. Addition of Dornase to Intrapleural Fibrinolytic Therapy Is Not Superior to Fibrinolytic Therapy Alone for Otherwise Healthy Children Hospitalized With Empyema
- Author
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Jonathan E. Kohler and Michelle M. Kelly
- Subjects
medicine.medical_specialty ,business.industry ,MEDLINE ,medicine.disease ,Recombinant Proteins ,Empyema ,Tissue Plasminogen Activator ,Internal medicine ,Pediatrics, Perinatology and Child Health ,medicine ,Deoxyribonuclease I ,Humans ,Well child ,Thrombolytic Therapy ,Fibrinolytic therapy ,Child ,business ,Empyema, Pleural ,Original Investigation - Abstract
IMPORTANCE: Clinical guidelines recommend that children with pleural empyema be treated with chest tube insertion and intrapleural fibrinolytics. The addition of dornase alfa (DNase) has been reported to improve outcomes in adults but remains unproven in children. OBJECTIVE: To determine if intrapleural tissue plasminogen activator (tPA) and DNase is more effective than tPA and placebo at reducing hospital length of stay in children with pleural empyema. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, parallel-group, placebo-controlled, superiority randomized clinical trial included children diagnosed as having pleural empyema requiring drainage aged 6 months to 18 years treated at 6 tertiary Canadian children’s hospitals. A total of 379 children were assessed for eligibility; 281 were excluded and 98 were randomized. One child was excluded after randomization for not meeting the inclusion criteria. Data were collected from March 4, 2013, to December 13, 2017. INTERVENTIONS: Participants underwent chest tube insertion and 3 daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). Participants, families, clinical staff, and members of the study team were blinded to allocation. MAIN OUTCOMES AND MEASURES: The primary outcome was hospital length of stay from chest tube insertion to discharge. Secondary outcomes included time to meeting discharge criteria, time to chest tube removal, mean fever duration, additional pleural drainage procedures, hospital readmissions, and total health care cost. RESULTS: Of the 97 analyzed children with pleural empyema, 52 (54%) were male, and the mean (SD) age was 5.1 (3.6) years. A total of 49 children were randomized to tPA and DNase and 48 were randomized to tPA and placebo. Treatment with tPA and DNase was not associated with decreased hospital length of stay compared with tPA and placebo (mean [SD] length of stay, 9.0 [4.9] vs 9.1 [5.3] days; mean difference, −0.1 days; 95% CI, −2.0 to 2.1; P = .96). Similarly, no significant differences were observed for any of the secondary outcomes. Of the 14 adverse events in the tPA and DNase group, 6 (43%) were serious; of the 21 adverse events in the tPA and placebo group, 8 (38%) were serious. There were no deaths. CONCLUSIONS AND RELEVANCE: The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01717742
- Published
- 2020
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