Successful application of the innovation process to a case of Floyd Type I tracheal agenesis.

Background: Innovation is broadly defined as the act of introducing a new product, idea, or process. The field of surgery is built upon innovation, revolutionizing technology, science, and tools to improve patient care. While most innovative solutions are aimed at problems with a significant patient population, the process can also be used on orphan pathologies without obvious solutions. We present a case of tracheal agenesis, a rare congenital anomaly with an overwhelming mortality and few good treatment options, that benefited from the innovation process and achieved survival with no ventilator dependence at three years of age. Methods: Utilizing the framework of the innovation process akin to the Stanford Biodesign Program, 1) the parameters of the clinical problem were identified, 2) previous solutions and existing technologies were analyzed, newly invented solutions were brainstormed, and value analysis of the possible solutions were carried out using crowd wisdom, and 3) the selected solution was prototyped and tested using 3D modeling, iterative testing on 3D prints of actual-sized patient parts, and eventual implementation in the patient after regulatory clearance. Results: A 3D-printed external bioresorbable splint was chosen as the solution. Our patient underwent airway reconstruction with "trachealization of the esophagus": esophageotracheal fistula resection, esophagotracheoplasty, and placement of a 3D-printed polycaprolactone (PCL) stent for external esophageal airway support at five months of age. Conclusions: The innovation process provided our team with the guidance and imperative steps necessary to develop an innovative device for the successful management of an infant survivor with Floyd Type I tracheal agenesis. Article summary: We present a case of tracheal agenesis, a rare congenital anomaly with an overwhelming mortality and few good treatment options, that benefited from the innovation process and achieved survival with no ventilator dependence at three years of age.The importance of this report is to reveal how the innovation process, which is typically used for problems with significant patient population, can also be used on orphan pathologies without obvious solutions.

The APSA Board of Governors enthusiastically endorses the position paper ``Diversity, Equity, and Inclusion: A Strategic Priority for the American Pediatric Surgical Association''.

This Commentary by the APSA Board of Governors enthusiastically endorses the position paper "Diversity, Equity, and Inclusion: A Strategic Priority for the American Pediatric Surgical Association".

Contributions of Health Professions Students to Health System Needs During the COVID-19 Pandemic: Potential Strategies and Process for U.S. Medical Schools.

The COVID-19 pandemic poses an unprecedented challenge to U.S. health systems, particularly academic health centers (AHCs) that lead in providing advanced clinical care and medical education. No phase of AHC efforts is untouched by the crisis, and medical schools, prioritizing learner welfare, are in the throes of adjusting to suspended clinical activities and virtual classrooms. While health professions students are currently limited in their contributions to direct clinical care, they remain the same smart, innovative, and motivated individuals who chose a career in health care and who are passionate about contributing to the needs of people in troubled times. The groundwork for operationalizing their commitment has already been established through the identification of value-added, participatory roles that support learning and professional development in health systems science (HSS) and clinical skills. This pandemic, with rapidly expanding workforce and patient care needs, has prompted a new look at how students can contribute. At the Penn State College of Medicine, staff and student leaders formed the COVID-19 Response Team to prioritize and align student work with health system needs. Starting in mid-March 2020, the authors used qualitative methods and content analysis of data collated from several sources to identify 4 categories for student contributions: the community, the health care delivery system, the workforce, and the medical school. The authors describe a nimble coproduction process that brings together all stakeholders to facilitate work. The learning agenda for these roles maps to HSS competencies, an evolving requirement for all students. The COVID-19 pandemic has provided a unique opportunity to harness the capability of students to improve health.Other AHCs may find this operational framework useful both during the COVID-19 pandemic and as a blueprint for responding to future challenges that disrupt systems of education and health care in the United States.

Factors Associated With Hospital Decisions to Purchase Robotic Surgical Systems.

Background. Robotic surgical systems are expensive to own and operate, and the purchase of such technology is an important decision for hospital administrators. Most prior literature focuses on the comparison of clinical outcomes between robotic surgery and other laparoscopic or open surgery. There is a knowledge gap about what drives hospitals' decisions to purchase robotic systems. Objective. To identify factors associated with a hospital's acquisition of advanced surgical systems. Method. We used 2002 to 2011 data from the State of California Office of Statewide Health Planning and Development to examine robotic surgical system purchase decisions of 476 hospitals. We used a probit estimation allowing heteroscedasticity in the error term including a set of two equations: one binary response equation and one heteroscedasticity equation. Results. During the study timeframe, there were 78 robotic surgical systems purchased by hospitals in the sample. Controlling for hospital characteristics such as number of available beds, teaching status, nonprofit status, and patient mix, the probit estimation showed that market-level directly relevant surgery volume in the previous year (excluding the hospital's own volume) had the largest impact. More specifically, hospitals in high volume (>50,000 surgeries v. 0) markets were 12 percentage points more likely to purchase robotic systems. We also found that hospitals in less competitive markets (i.e., Herfindahl index above 2500) were 2 percentage points more likely to purchase robotic systems. Limitations. This study has limitations common to observational database studies. Certain characteristics such as cultural factors cannot be accurately quantified. Conclusions. Our findings imply that potential market demand is a strong driver for hospital purchase of robotic surgical systems. Market competition does not significantly increase the adoption of new expensive surgical technologies.

Determination of Sulfamethoxazole Degradation Rate by an in Situ Experiment in a Reducing Alluvial Aquifer of the North China Plain.

Effluents from wastewater treatment facilities are reclaimed for environmental and landscaping use, resulting in infiltration to groundwater. Trace organic contaminants in these effluents have raised concerns, including the antibiotic resistance contributor sulfamethoxazole (SMX) detected frequently at concentrations exceeding 0.01 µg/L. A push-pull study to evaluate in situ degradation of SMX was undertaken in a shallow alluvial aquifer at the Tongzhou groundwater experimental site in southeast suburban Beijing. Ambient groundwater (1000 L) extracted from an experimental well at a depth of 10 m was spiked with SMX and NaBr, and then injected back into the same well. SMX and Br were "stored" over 15 days and monitored in the experimental well and 4 multilevel (depth: 10, 15, 17.5, 20, 25, and 30 m) observation wells located within 2-3 m distance. The concentration of SMX decreased faster than that of Br in the experimental and one observation well at 10 m depth; samples from all other depths contained little Br and SMX. The half-life of SMX degradation is estimated to be 3.1 ± 0.2 and 6.5 ± 0.6 days in the experimental well and observation well, respectively, under suboxic/anoxic conditions.

Urban Stormwater to Enhance Water Supply.

The capture, treatment, and recharge of urban runoff can augment water supplies for water-scarce cities. This article describes trends in urban stormwater capture for potable water supply using examples from the U.S. and Australia. In water-limited climates, water supply potential exists for large scale stormwater harvesting and recharge, such as neighborhood-scale and larger projects. The beneficial use of urban stormwater to meet nonpotable water demands has been successfully demonstrated in the U.S. and internationally. However, in terms of potable water use in the U.S., the lack of a regulatory framework and uncertainty in treatment and water quality targets are barriers to wide-scale adoption of urban stormwater for recharge, which is not so evident in Australia. More data on urban stormwater quality, particularly with respect to pathogens and polar organic contaminants, are needed to better inform treatment requirements. New technologies hold promise for improved operation and treatment, but must be demonstrated in field trials. Stormwater treatment systems may be needed for large-scale recharge in highly urbanized areas where source control is challenging. The co-benefits of water supply, urban amenities, and pollution reduction are important for financing, public acceptance and implementation-but are rarely quantified.

Nutrient Removal during Stormwater Aquifer Storage and Recovery in an Anoxic Carbonate Aquifer.

Stormwater harvesting coupled to managed aquifer recharge (MAR) provides a means to use the often wasted stormwater resource while also providing protection of the natural and built environment. Aquifers can act as a treatment barrier within a multiple-barrier approach to harvest and use urban stormwater. However, it remains challenging to assess the treatment performance of a MAR scheme due to the heterogeneity of aquifers and MAR operations, which in turn influences water treatment processes. This study uses a probabilistic method to evaluate aquifer treatment performance based on the removal of total organic C (TOC), N, and P during MAR with urban stormwater in an anoxic carbonate aquifer. Total organic C, N, and P are represented as stochastic variables and described by probability density functions (PDFs) for the "injectant" and "recovery"; these injectant and recovery PDFs are used to derive a theoretical MAR removal efficiency PDF. Four long-term MAR sites targeting one of two tertiary carbonate aquifers (T1 and T2) were used to describe the nutrient removal efficiencies. Removal of TOC and total N (TN) was dominated by redox processes, with median removal of TOC between 50 and 60% at all sites and TN from 40 to 50% at three sites with no change at the fourth. Total P removal due to filtration and sorption accounted for median removal of 29 to 53%. Thus, the statistical method was able to characterize the capacity of the anoxic carbonate aquifer treatment barrier for nutrient removal, which highlights that aquifers can be an effective long-term natural treatment option for management of water quality, as well as storage of urban stormwater.

An Interprofessional Curriculum to Advance Relational Coordination and Professionalism in Early-Career Practitioners.

Introduction: We created a curriculum to help new physicians and nurses develop skills in interprofessional collaboration. This modular, team-based curriculum for early practitioners delivered training in the five following skill areas: listening for meaning, soliciting another's perspective, negotiating a transparent plan of care, attending to nonverbal communication and microaggression, and speaking up the hierarchy. Methods: We brought first-year medical and surgical residents and new nurses together for a 2-hour session monthly for 5 months. Each session began with an interactive large-group presentation, followed by small-group activities covering one of the five skill areas above, which had been identified as critical to interprofessional collaboration by national organizations. We measured relational coordination (RC), a validated measure of how well teams work together, before and after the curriculum was administered. We also obtained qualitative data from participant interviews and end-of-session evaluations. Results: Participants reported that the program helped them gain an understanding of each other's roles and workflow challenges. They felt that the curriculum allowed for the cultivation of professional relationships outside the clinical environment, which improved collegiality via gains in rapport and empathy towards each other. Nurses noted increased approachability of their physician colleagues after participation. RC scores improved for the entire cohort (p = .0232). Nurses had statistically higher RC gains than interns did (p = .0055). Discussion: Curriculum participants demonstrated improved RC scores and reported increased rapport with and empathy for each other. Curriculum development in this area is important because it may lead to better team-based patient care.

Understanding readmissions in children undergoing surgery: A pediatric NSQIP analysis.

BACKGROUND: Readmission is increasingly being utilized as an important clinical outcome and measure of hospital quality. Our aim was to delineate rates, risk factors, and reasons for unplanned readmission in pediatric surgery. MATERIALS AND METHODS: Retrospective review of pediatric patients (n=130,274) undergoing surgery (2013-2014) at hospitals enrolled in the Pediatric National Surgical Quality Improvement Program (NSQIP-P) was performed. Logistic regression was used to model factors associated with unplanned 30-day readmission. Reasons for readmission were reviewed to determine the most common causes of readmission. RESULTS: There were 6059 (n=4.7%) readmitted children within 30days of the index operation. Of these, 5041 (n=3.9%) were unplanned, with readmission rates ranging from 1.3% in plastic surgery to 5.2% in general pediatric surgery, and 10.8% in neurosurgery. Unplanned readmissions were associated with emergent status, comorbidities, and the occurrence of pre- or postdischarge postoperative complications. Overall, the most common causes for readmission were surgical site infections (23.9%), ileus/obstruction/gastrointestinal (16.8%), respiratory (8.6%), graft/implant/device-related (8.1%), neurologic (7.0%), or pain (5.8%). Median time from discharge to readmission was 8days (IQR: 3-14days). Reasons for readmission, time until readmission, and need for reoperative procedure (overall 28%, n=1414) varied between surgical specialties. CONCLUSION: The reasons for readmission in children undergoing surgery are complex, varied, and influenced by patient characteristics and postoperative complications. These data inform risk-stratification for readmission in pediatric surgical populations, and help to identify potential areas for targeted interventions to improve quality. They also highlight the importance of accounting for case-mix in the interpretation of hospital readmission rates. LEVEL OF EVIDENCE: 3.

Perceptions of mistreatment among trainees vary at different stages of clinical training.

BACKGROUND: Mistreatment of trainees remains a frequently reported phenomenon in medical education. One barrier to creating an educational culture of respect and professionalism may be a lack of alignment in the perceptions of mistreatment among different learners. Through the use of clinical vignettes, our aim was to assess the perceptions of trainees toward themes of potential mistreatment at different stages of training. METHODS: Based on observations from external experts embedded in the clinical learning environment, six thematic areas of potential mistreatment were identified: verbal abuse, specialty-choice discrimination, non-educational tasks, withholding/denying learning opportunities, neglect and gender/racial insensitivity. Corresponding clinical vignettes were created and distributed to 1) medical students, 2) incoming interns, 3) residents/fellows. Perceptions of the appropriateness of the interactions depicted in the vignettes were measured on a 5-point Likert scale. Scores were categorized into neutral or appropriate (≤3) or inappropriate (i.e. mistreatment) (>3) and compared using chi-squared tests. RESULTS: Four hundred twenty seven trainees participated (182 students, 120 interns, 125 residents/fellows). Proportions of students perceiving mistreatment differed significantly from those of interns and residents/fellows in domains of verbal abuse, specialty discrimination and gender/racial insensitivity (p < 0.05). In scenarios comparing interns to residents/fellows, no significant differences were noted in perceptions of mistreatment in the domains of non-educational tasks, withholding learning and neglect. CONCLUSIONS: Perceptions of mistreatment differ at different developmental stages of medical training. After exposure to the clinical learning environment, perceptions of incoming interns did not differ from those of residents/fellows, implicating clinical rotations as a key period in indoctrinating students into the prevailing culture. More longitudinal studies are needed to confirm or better examine this phenomenon.

Costs of Clostridium difficile infection in pediatric operations: A propensity score-matching analysis.

BACKGROUND: The purpose of this analysis was to assess the burden of Clostridium difficile infection in the hospitalized pediatric surgical population and to characterize its influence on the costs of care. METHODS: There were 313,664 patients age 1-18 years who underwent a general thoracic or abdominal procedure in the Kids' Inpatient Database during 2003, 2006, 2009, and 2012. Logistic regression was used to model factors associated with the development of C difficile infection. A propensity score-matching analysis was performed to evaluate the influence of C difficile infection on mortality, duration of stay, and costs in similar patient cohorts. Population weights were used to estimate the national excess burden of C difficile infection on these outcomes. RESULTS: The overall prevalence of C difficile infection in the sampled cohort was 0.30%, with an increasing trend of C difficile infection over time in non-children's hospitals (P < .001). C difficile infection was associated with younger age, nonelective procedures, increasing comorbidities, and urban teaching hospital status (P < .001). An estimated 1,438 children developed C difficile infection after operation. After propensity score matching, the mean excess duration of stay and costs attributable to C difficile infection were 5.8 days and $12,801 (P < .001), accounting for 8,295 days spent in the hospital and $18.4 million (2012 USD) in spending annually. CONCLUSION: C difficile infection is a relatively uncommon but costly complication after pediatric operative procedures. Given the increasing trend of C difficile infection among hospitalized surgical patients, there is substantial opportunity for reduction of inpatient burden and associated costs in this potentially preventable nosocomial infection.

Aligning perceptions of mistreatment among incoming medical trainees.

BACKGROUND: Learner mistreatment has been a long-standing example of unprofessional behavior in medical training. Alignment of perceptions of professional behavior is a critical component of developing a defined organizational culture. Clinical vignettes addressing learner mistreatment can help to achieve this goal. Our aim was to determine whether using clinical vignettes to address learner mistreatment during onboarding can reduce variability in the perceptions of mistreatment. MATERIALS AND METHODS: External experts in the field of labor and employment relations embedded in the clinical learning environment identified six thematic areas of potential mistreatment. Corresponding clinical case vignettes were developed and presented to incoming trainees during the onboarding process, followed by facilitated discussion. Perceptions of mistreatment before and after discussion were assessed on a Likert scale, with results compared using F-test and t-test. RESULTS: There were 145 participants. Most participants reported previously witnessing or experiencing episodes of mistreatment before matriculation (84%), with the majority reporting multiple events. The most common offenders were faculty (57%), residents/fellows (49%), and nurses (33%). Only 10% of incoming trainees reported a previous incident of mistreatment. Postintervention scores demonstrated decreased variability (P < 0.05) in perceptions of mistreatment in all but one vignette (withholding learning opportunities). Two vignettes demonstrated higher perception of mistreatment after intervention (noneducational tasks and gender or racial discrimination, P < 0.05). CONCLUSIONS: Mistreatment remains a prevalent phenomenon in medical training involving a wide cross-section of healthcare providers. Trainees arrive with discordant definitions of mistreatment. Alignment of individuals' definitions can be achieved through the use of carefully crafted clinical vignettes and facilitated discussion.

Biofouling potential and material reactivity in a simulated water distribution network supplied with stormwater recycled via managed aquifer recharge.

The injection of stormwater into aquifers for storage and recovery during high water demand periods is a promising technology for augmenting conventional water reserves. Limited information exists regarding the potential impact of aquifer treated stormwater in distribution system infrastructure. This study describes a one year pilot distribution pipe network trial to determine the biofouling potential for cement, copper and polyvinyl chloride pipe materials exposed to stormwater stored in a limestone aquifer compared to an identical drinking water rig. Median alkalinity (123 mg/L) and colour (12 HU) in stormwater was significantly higher than in drinking water (82 mg/L and 1 HU) and pipe discolouration was more evident for stormwater samples. X-ray Diffraction and Fluorescence analyses confirmed this was driven by the presence of iron rich amorphous compounds in more thickly deposited sediments also consistent with significantly higher median levels of iron (∼0.56 mg/L) in stormwater compared to drinking water (∼0.17 mg/L). Water type did not influence biofilm development as determined by microbial density but faecal indicators were significantly higher for polyvinyl chloride and cement exposed to stormwater. Treatment to remove iron through aeration and filtration would reduce the potential for sediment accumulation. Operational and verification monitoring parameters to manage scaling, corrosion, colour, turbidity and microbial growth in recycled stormwater distribution networks are discussed.

Timing of postoperative infections after colectomy: evidence from NSQIP.

BACKGROUND: We studied whether risk factors for infectious complications differed between inpatient (IP) and postdischarge (PD) periods in patients undergoing colon surgery. METHODS: Among partial colon resection patients in the National Surgical Quality Improvement Program (2005 to 2010), we identified risk factors for superficial and deep (D-SSI) surgical site infections and urinary tract infections in the IP and PD phases of care. RESULTS: Obesity was associated with higher risk of both IP superficial surgical site infections and D-SSI (odds ratio [OR] 1.41, P < .0001 and OR 1.28, P < .0001) and increasing to OR 1.73 (P < .0001) and OR 1.83 (P < .0001), respectively, in the PD period. Smoking was associated with development of D-SSI, and this risk increased from IP to PD phases of care (OR 1.15, P = .02 to OR 1.54, P < .0001). CONCLUSIONS: Risk factors for infections differ between IP and PD phases of care in colon surgery patients. Earlier discharge from the hospital may shift recognition of an SSI to the outpatient setting.

Measuring Surgical Site Infections in Children: Comparing Clinical, Electronic, and Administrative Data.

BACKGROUND: Surgical site infections (SSIs) are an important end point and measure of quality of care. Surgical site infections can be identified using clinical registries, electronic surveillance, and administrative claims data. This study compared measurements of SSIs using these 3 different methods and estimated their implication for health care costs. STUDY DESIGN: Data were obtained from 5,476 surgical patients treated at a single academic children's hospital (January 1, 2010 through August 31, 2014). Surgical site infections within 30 days were identified using a clinical registry in the NSQIP Pediatric, an electronic surveillance method (Nosocomial Infection Marker; MedMined), and billing claims. Infection rates, diagnostic characteristics, and attributable costs were estimated for each of the 3 measures of SSI. RESULTS: Surgical site infections were observed in 2.24% of patients per NSQIP Pediatric definitions, 0.99% of patients per the Nosocomial Infection Marker, and 2.34% per billing claims definitions. Using NSQIP Pediatric as the clinical reference, Nosocomial Infection Marker had a sensitivity of 31.7% and positive predictive value of 72.2%, and billing claims had a sensitivity of 48.0% and positive predictive value of 46.1% for detection of an SSI. Nosocomial Infection Marker and billing claims overestimated the costs of SSIs by 108% and 41%, respectively. CONCLUSIONS: There is poor correlation among SSIs measured using electronic surveillance, administrative claims, and clinically derived measures of SSI in the pediatric surgical population. Although these measures might be more convenient, clinically derived data, such as NSQIP Pediatric, may provide a more appropriate quality metric to estimate the postoperative burden of SSIs in children.

Comparing 30-day outcomes between thoracoscopic and open approaches for resection of pediatric congenital lung malformations: Evidence from NSQIP.

BACKGROUND/PURPOSE: Thoracoscopic surgery has been increasingly utilized in treating pediatric congenital lung malformations (CLM). Comparative studies evaluating 30-day outcomes between thoracoscopic and open resection of CLM are lacking. METHODS: There were 258 patients identified in pediatric NSQIP with a CLM and pulmonary resection in 2012-2013. Comparisons of patient characteristics and outcomes between surgical approaches were made using standard univariate statistics. In addition, a propensity score match was performed to evaluate outcomes in similar patient cohorts. RESULTS: One-hundred twelve patients (43.4%) received thoracoscopic resections and 146 patients (56.6%) received open resections. Patients undergoing open resections were more likely to be less than 5 months of age and have a comorbidity/preoperative condition (47.3% vs. 25.0%, p<0.001). The extent of resection was a lobectomy in 84.8% of thoracoscopic and 92.5% of open resection patients. Median operative time was similar between both groups (thoracoscopic 172 vs. open 153.5 minutes). On univariate analysis, thoracoscopic resection was associated with decreased postoperative complications (9.8% vs. 25.3%, p=0.001) and LOS (3 vs. 4 days, p<0.001). However, after adjusting for similar patient and operative characteristics, no significant differences were encountered between techniques. CONCLUSIONS: Thoracoscopic and open resection provide comparable 30-day outcomes and safety in the management of congenital lung malformations.

Length of Stay and Readmissions in Mastectomy Patients.

Interest is growing in preventing readmissions as payers start to link reimbursement to readmission rates. The purpose of this study was to assess factors that contribute to 30-day readmission rates for women undergoing mastectomy for breast cancer. Data from the Pennsylvania Health Care Cost Containment Council were queried for women undergoing mastectomy for breast cancer during 2011 (n = 2,919). The outcomes measured were length of stay (LOS) and 30-day readmission. Univariate comparisons between characteristics of readmitted (n = 172) and nonreadmitted patients were performed using t-tests and chi-square tests. Readmission was modeled using logistic regression; LOS was modeled using linear regression and controlled for potential confounders. In multivariate analyses, patients with peripheral vascular disease were more likely to be readmitted (OR 4.36, p = 0.002). Increased LOS was also associated with increased odds of readmission (OR 1.26, p = <0.0001). Since LOS was an important predictor of readmission we also estimated determinants of LOS using linear regression. The occurrence of reconstructive surgery (p = <0.0001) and renal disease (p < 0.0001) were highly predictive of longer LOS. This study showed peripheral vascular disease and longer lengths of stay were associated with higher odds of readmission in women undergoing mastectomy. Clinicians should be cognizant that optimizing a patient's vascular status before mastectomy may lead to lower rates of readmission. Additional research is needed to determine whether the relationship between readmissions and length of hospital stay is a causative versus associative phenomenon since LOS is a modifiable factor that may lead to lower readmissions.

Reframing Surgical Care: Understanding Complexity and Promoting Teaming.

Reframing healthcare delivery in terms of the principles of complex adaptive systems has practical implications for addressing the challenges in improving surgical care. In an Integrated Practice Unit (IPU) - such as a surgical service line, a surgical in-patient floor, or an acute care unit - a diverse group of caregivers must interact in a highly interdependent fashion in an environment characterized by ambiguity, uncertainty, and time constraints. Understanding of the concept of teaming and the tenets of relational coordination are crucial to the promotion of a successful patient-centric approach to surgical care.