Surgical site infections (SSIs) cost an estimated $27,288 per case. An analysis of the National Surgical Quality Improvement Program data at the University of Rochester Medical Center suggested that rates of SSIs could be lowered in comparison with both peers and baseline. The aim of this study was to reduce the number of SSIs to zero through the implementation of a "bundle" or a combination of practices. Meetings were held with the multidisciplinary care team that includes surgeons and staff from pediatric pharmacy, pediatric infectious diseases, anesthesia, and nursing to create a care bundle for all pediatric orthopaedic surgery patients. Bundle elements included use of chlorhexidine gluconate wipes the night before surgery and the day of surgery, use of preoperative nutrition screens, development and use of a prophylactic antibiotic dosing chart, use of methicillin-resistant Staphylococcus aureus screening, maintenance of normal patient temperature, and use of nasal swabs in the operating room. The SSI rate dropped from a baseline figure of 4% in 2013 (n = 154) and 3.2% in 2014 (n = 189) to 0.0% (n = 198) in 2015 after the bundles were implemented. Both compliance with the bundle and SSI rates must be monitored monthly. Staff and providers should be offered monthly feedback on SSI rates and care bundle compliance. If an SSI does occur, a root-cause analysis is performed with the multidisciplinary care team using a standardized review form.
Introduction The pediatric perioperative surgical home (PPSH) is a population health management model designed to provide a seamless experience for children and their families undergoing surgical procedures. The purpose of this quality improvement project is to evaluate the feasibility and utility of implementing a PPSH at an academic medical center. Method A multidisciplinary team was formed, composed of representatives from nursing, surgery, anesthesiology, and perioperative medicine. This group developed a comprehensive preoperative screening tool designed for early identification of patient barriers before elective surgery. The screening tool was developed with input from multiple pediatric subspecialists. At the initial surgical visit, patients and families are encouraged to complete this screening tool. The screening tool was piloted to 74 patients (46 completed) in a pediatric orthopedic clinic for an 8-month period. Existing tools in the electronic medical record system were identified to assist with care coordination perioperatively. Result In comparing our baseline period (2016, n = 174) with the early implementation phase of our PPSH (2017, n = 188), unplanned readmission rates decreased from 4.0% to 2% (p = .011), and surgical site infections decreased from 3.5% to 2.3% (p = .002), whereas unplanned return to operating room and average length of stay remained the same. Conclusion Information obtained within a PPSH informs the entire team of important factors that could influence perioperative care. A PPSH serves to make the health care team more efficient and may also be associated with a reduction in complications, cost, and time spent in the hospital.
Background: Inpatient surgical teams are challenged with treating complex patients, communicating across disciplines, educating trainees, and transitioning between the operating room, clinic, and inpatient unit. Systematic approaches to rounds are needed to perform these tasks effectively. Prior studies on nonsurgical units have shown that rounding checklists improve patient safety and trainee education. However, few studies have investigated the utility of checklists on surgical rounds.Objective: The purpose of this article is to synthesize the evidence regarding rounding checklists on inpatient surgical units, with a focus on structure, content, utilization, outcomes, and educational value.Methods: A narrative review was completed after a search of PubMed, Embase, and Cumulative Index of Nursing and Allied Health Literature in November 2020 using the following index terms and keywords: pediatrics, operative surgical procedures, surgery, perioperative period, teaching rounds, rounds, checklist, rounding tool, and rounding list. Results:We identified 11 relevant studies. Six were conducted on inpatient surgical units (54%), and five were conducted on medicine or critical care units (46%). The structure and content of checklists were varied, with most integrating subjective and objective findings. These studies show that rounding checklists improve the organization and completeness of rounds, interdisciplinary communication, documentation, adverse event rates, and educational opportunities. However, they also increase rounding time and require reinforcement for sustained compliance. Conclusions:The existing literature suggests rounding checklists can help create a culture of safety in which every team member, from nurse to attending, actively participates in improving patient care. We provide strategies to develop rounding checklists for pediatric surgical units.
Background While radiographs are a critical component of diagnosing musculoskeletal (MSK) injuries, they are associated with radiation exposure, patient discomfort, and financial costs. Our study initiative was to develop a system to diagnose pediatric MSK injuries efficiently while minimizing unnecessary radiographs. Methods This was a quality improvement trial performed prospectively at a single level one trauma center. A multidisciplinary team with leaders from pediatric orthopedics, trauma surgery, emergency medicine, and radiology created an algorithm delineating which x-rays should be obtained for pediatric patients presenting with MSK injuries. The intervention was performed in the following 3 stages: stage 1: retrospective validation of the algorithm, stage 2: implementation of the algorithm, and stage 3: sustainability evaluation. Outcomes measured included number of extra radiographs per pediatric patient and any missed injuries. Results In stage 1, 295 patients presented to the pediatric emergency department with MSK injuries. A total of 2148 radiographs were obtained, with 801 not indicated per the protocol, for an average of 2.75 unnecessary radiographs per patient. No injuries would have been missed using the protocol. In stage 2, 472 patients had 2393 radiographs with 339 not indicated per protocol, averaging 0.72 unnecessary radiographs per patient, a significant reduction from stage 1 (P < 0.001). There were no missed injuries identified on follow-up. In stage 3, improvement was sustained for the subsequent 8 months with an average of 0.34 unnecessary radiographs per patient (P < 0.05). Conclusions Sustained reduction of unnecessary radiation to pediatric patients with suspected MSK injuries was accomplished through the development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach, widespread education of pediatric providers, and standardized order sets improved buy-in and is generalizable to other institutions. Level of Evidence: III
Background Quality improvement efforts in pediatric surgery can positively impact both outcomes and cost. Purpose The use of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)–Pediatrics was essential in determining where to focus our efforts. Methods Utilizing risk-adjusted outcomes data is the key driver behind our successes as a multidisciplinary team. This team, which now includes a parent representative, meets at least monthly to review data, identify trends and problems, propose new change ideas, identify barriers to change, and celebrate success. Detailed agendas and minutes are circulated to all team members to ensure a shared mental model. Results Since initiation in 2011, our efforts have resulted in a decrease in multiple morbidities, including surgical site infections, blood transfusions, preoperative Computerized Tomography use for patients undergoing appendectomy, unplanned reintubations, shorter lengths of stay, and fewer readmissions. Our improvement efforts resulted in an estimated cost savings of $1.5 million over a 2-year period (2015–2016). Conclusions Our team used NSQIP data to direct and guide quality improvements in patient care. Implications The business case for surgical quality comes from getting a return on investment in NSQIP with multidisciplinary teams led by surgeons and nurses.
Background: Children are more vulnerable to ionizing radiation which increases health risks later in life including cancer. An interdepartmental team developed an algorithm to guide providers ordering extremity radiographs in pediatric patients with musculoskeletal (MSK) injuries. Purpose: Reduce unnecessary pediatric radiation/extremity radiographs through development and implementation of an interdepartmental designed algorithm. Determine utility, safety, and efficacy of the algorithm through retrospective and prospective analysis. Methods: Our study was performed at an academic pediatric trauma center. An interdepartmental committee including pediatric orthopedic surgery, emergency medicine, trauma, and radiology providers created a MSK injury imaging algorithm (Figure 1). We retrospectively validated the algorithm for efficacy and safety through chart review of pediatric patients seen in the ED with MSK extremity injury, identified through CPT code, from 6/24/2016 through 8/31/2016. We determined the number of extra radiographs per patient and identified if injuries would be missed utilizing our protocol. After retrospective validation, guideline implementation was undertaken through multidisciplinary education. The imaging guideline was prospectively implemented in the pediatric ED from 6/24/2018 through 8/31/2018. We continued to prospectively evaluate through selecting one week every month over the following eight months to determine sustainability of the implemented algorithm. Results: Our interdepartmental team in 2016 developed a pediatric MSK radiograph protocol (Figure 1). A retrospective chart and radiograph review of 295 pediatric patients between 6/24/2016 through 8/31/2016 was analyzed correlating physical examination to appropriate radiographs. Utilizing the protocol, the review revealed an average of 2.75 extra radiographs per patient. No injuries were missed. Providers including orthopedic and emergency medicine attendings, mid-levels, and residents were educated through meetings, emails, and having the protocol posted and easily accessible. Our protocol was implemented 6/24/18 and underwent prospective enrollment and review through 8/31/18 which revealed a reduction to 0.72 radiographs per patient (P-value <0.001) (Figure 2). Eight month follow up revealed a sustainable reduction in extra radiographs per patient (Figure 3). Conclusion: Reduction of unnecessary radiation to pediatric patients with MSK extremity injuries was accomplished through development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach combined with widespread education of pediatric providers improved buy-in driving a sustainable system improvement. [Figure: see text][Figure: see text][Figure: see text]
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