Objective: To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. Background: Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision.Methods: This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. Results: A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P < 0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. Conclusions: Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.
Introduction:
Simulation offers multiple tools that apply to medical settings, but little is known about the application of simulation to pediatric trauma workflow changes. Our institution recently underwent significant clinical changes in becoming an independent pediatric trauma center. We used a simulation-based clinical systems testing (SbCST) approach to manage change-associated risks. The purpose of this study was to describe our SbCST process, evaluate its impact on patient safety, and estimate financial costs and benefits.
Methods:
SbCST consisted of the following steps: (1) change-based needs assessment, in which stakeholders developed relevant simulation scenarios; (2) scenario implementation; and (3) postsimulation failure mode and effects analysis (FMEA) to identify latent safety threats (LSTs). LSTs were prioritized for mitigation based on the expected probability and severity of adverse event occurrences. We calculated the costs associated with the simulation process. We conservatively estimated SbCST cost savings using 3 approaches: (1) FMEA-based avoidance of adverse events; (2) avoidance of trauma readmissions; and (3) avoidance of medical liability lawsuits.
Results:
We implemented 2 simulation scenarios prechange. FMEA revealed 49 LSTs, of which 9 were highest priority (catastrophic severity and high likelihood of occurrence). These were prioritized and mitigated using the hospital’s quality/safety framework. Cost-benefit analysis based on FMEA event avoidance demonstrated net cost savings to the institution ranging from $52,000−227,000 over the 3-month postchange period. Readmission-based and liability-based estimates also produced favorable results.
Conclusions:
The SbCST approach identified multiple high-impact safety risks and financially benefited the institution in managing significant pediatric trauma clinical process changes.
Introduction: Medical emergency response teams (MET), also known as code teams, consist of health care providers who respond to life-threatening clinical changes in hospitalized patients. The study objective was to determine whether the utilization of simulation-based clinical systems testing (SbCST) and failure mode and effects analysis (FMEA) would sufficiently assess operating room (OR) MET response systems. Methods: A multidisciplinary team of participants and observers collaborated in the SbCST to evaluate OR MET response to a simulated intraoperative code event, followed by FMEA. The primary outcomes were latent safety threats (LSTs), with mitigation strategies resulting from pre-/post-SbCST participant surveys, and debriefing. Risk priority numbers were calculated for each LST to denote priority; resultant scores of 8-16 were deemed significant on a scale of 1-16. Results: Participants and observers identified 19 LSTs, 14 of which were high priority. The FMEA further subcategorized LSTs into resource, systems, facility, and clinical performance issues. Pre-/post-survey responses were not significantly different. Participants reported that the SbCST provided a realistic and immersive experience, and effectively tested current OR MET responses. Conclusion: SbCST adequately recreated and tested an OR code situation; a significant but infrequent medical event. The use of FMEA highlighted potential LSTs that, in turn, could be rectified to enhance performance. All 19 study LSTs were addressed via training and systems improvements. These results demonstrate that clinical systems can be evaluated and ameliorated via the use of SbCST and FMEA.
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