Impact of a Standardized Clinical Pathway for Suspected and Confirmed Ileocolic Intussusception.

INTRODUCTION: Clinical pathways for specific diagnoses may improve patient outcomes, decrease resource utilization, and diminish costs. This study examines the impact of a clinical pathway for emergency department (ED) care of suspected and confirmed pediatric ileocolic intussusception. METHODS: Our multidisciplinary team designed an intussusception clinical pathway and implemented it in a tertiary children's hospital ED in October 2016. Process measures included the proportion of patients who underwent abdominal radiography, had laboratory studies, received antibiotics, or required admission following reduction of intussusception. The primary outcome measure was the cost per encounter. Balancing measures included unplanned ED visits within 72 hours of discharge. Data analyzed compared 24 months before and 21 months following pathway implementation. RESULTS: After pathway implementation, the use of abdominal radiography in patients with suspected intussusception decreased from 50% to 12%. In patients with confirmed intussusception, laboratory studies decreased from 58% to 25%, antibiotic use decreased from 100% to 2%, and hospital admissions decreased from 100% to 12%. The average cost per encounter for confirmed intussusception decreased from $6,724 to $2,975. There was a small increase in unplanned returns to the ED within 72 hours but no increase in readmissions after pathway implementation. CONCLUSION: Implementation of a standardized ED pathway for the management of suspected and confirmed pediatric ileocolic intussusception is associated with a reduction in abdominal radiographs, improved antibiotic stewardship, reduction in laboratory studies, fewer inpatient admissions, and decreased cost, with no compromise in patient safety.

Unusual ultrasound appearance of small bowel intussusception and secondary bowel obstruction in a child with Peutz-Jeghers syndrome.

Small bowel intussusception (SBI) in pediatric patients resolves spontaneously in the majority of cases. Pathologic small bowel intussusception with a lead point is rare in children. Ultrasound (US) is the preferred initial imaging study for the diagnosis of intussusception. We report a case of long-segment SBI and secondary bowel obstruction caused by a large hamartomatous polyp. This case emphasizes unique, atypical ultrasound findings that may be encountered in small bowel intussusception, with correlative radiographic, CT (computed tomography) and intra-operative findings. Increased awareness of these atypical imaging features can lead to early diagnosis and decrease the risk of potential complications including mesenteric venous thrombosis, bowel ischemia and necrosis.

Factors associated with 30-day unplanned pediatric surgical readmission.

BACKGROUND: Unplanned readmissions are costly to family satisfaction and negatively associated with quality of care. We hypothesized that patient, operative, and hospital factors would be associated with pediatric readmission. METHODS: All patients with an inpatient operation from 10/1/2008 to 7/28/2014 at a freestanding children's hospital were included. A retrospective cohort study using multivariable forward stepwise logistic regression determined factors associated with unplanned readmission within 30 days of discharge. RESULTS: Among 20,785 patients with an operation there were 26,978 encounters and 3,092 readmissions (11.5%). Thirteen of 33 candidate variables considered in the stepwise regression were significantly associated with readmission. Patients with an emergency department visit within 365 days of operation, American Society of Anesthesiologists class 4 or greater, Hispanic ethnicity and late-day or holiday/weekend discharges were more likely to have an unplanned readmission (odds ratio [OR] = 1.96; 95% confidence interval [CI] = 1.76 to 2.19, OR = 2.00; 95% CI = 1.58 to 2.53, OR = 1.16; 95% CI = 1.04 to 1.29, OR = 2.27; 95% CI = 1.55 to 3.63. respectively). CONCLUSIONS: Patient and hospital factors may be associated with readmission. Day and time of discharge represent variability of care and are important targets for hospital initiatives to decrease unplanned readmission.

Pediatric magnet ingestions: the dark side of the force.

BACKGROUND: Pediatric magnet ingestions are increasing. Commercial availability of rare-earth magnets poses a serious health risk. This study defines incidence, characteristics, and management of ingestions over time. METHODS: Cases were identified by searching radiology reports from June 2002 to December 2012 at a children's hospital and verified by chart and imaging review. Relative risk (RR) regressions determined changes in incidence and interventions over time. RESULTS: In all, 98% of ingestions occurred since 2006; 57% involved multiple magnets. Median age was 8 years (range 0 to 18); 0% of single and 56% of multiple ingestions required intervention. Compared with 2007 to 2009, ingestions increased from 2010 to 2012 (RR = 1.9, 95% confidence interval 1.2 to 3.0). Intervention proportion was unchanged (RR = .94, 95% confidence interval .4 to 2.2). Small spherical magnets comprised 26.8% of ingestions since 2010; 86% involved multiple magnets and 47% required intervention. CONCLUSIONS: Pediatric magnet ingestions and interventions have increased. Multiple ingestions prompt more imaging and surgical interventions. Magnet safety standards are needed to decrease risk to children.

Too attractive: the growing problem of magnet ingestions in children.

BACKGROUND: Small, powerful magnets are increasingly available in toys and other products and pose a health risk. Small spherical neodymium magnets marketed since 2008 are of particular concern. OBJECTIVE: The objective of this study was to determine the incidence, characteristics, and management of single and multiple-magnet ingestions over time. METHODS: Magnet ingestion cases at a tertiary children's hospital were identified using radiology reports from June 2002 to December 2012. Cases were verified by chart and imaging review. Relative risk regressions were used to determine changes in the incidence of ingestions and interventions over time. RESULTS: Of 56 cases of magnet ingestion, 98% occurred in 2006 or later, and 57% involved multiple magnets. Median age was 8 years (range, 0-18 years). Overall, 21% of single and 88% of multiple ingestions had 2 or more imaging series obtained, whereas no single and 56.3% of multiple ingestions required intervention (25.0% endoscopy, 18.8% surgery, 12.5% both). Magnet ingestions increased in 2010 to 2012 compared with 2007 to 2009 (relative risk, 1.9; 95% confidence interval, 1.2-3.0). Small, spherical magnets likely from magnet sets comprised 27% of ingestions, all ingested 2010 or later: 86% involved multiple magnets, 50% of which required intervention. Excluding these cases, ingestions of other magnets did not increase in 2010 to 2012 compared with 2007 to 2009 (relative risk, 0.94; 95% confidence interval, 0.6-1.4). CONCLUSIONS: The incidence of pediatric magnet ingestions and subsequent interventions has increased over time. Multiple-magnet ingestions result in high utilization of radiological imaging and surgical interventions. Recent increases parallel the increased availability of small, spherical magnet sets. Young and at-risk children should not have access to these and other small magnets. Improved regulation and magnet safety standards are needed.

Influence of surgeon experience, hospital volume, and specialty designation on outcomes in pediatric surgery: a systematic review.

IMPORTANCE: Analyses of volume-outcome relationships in adult surgery have found that hospital and physician characteristics affect patient outcomes, such as length of stay, hospital charges, complications, and mortality. Similar investigations in children's surgical specialties are fewer in number, and their conclusions are less clear. OBJECTIVE: To review the evidence regarding surgeon or hospital experience and their influence on outcomes in children's surgery. EVIDENCE REVIEW: A MEDLINE and EMBASE search was conducted for English-language studies published from January 1, 1980, through April 13, 2012. Titles and abstracts were screened in a standardized manner by 2 reviewers. Studies selected for inclusion had to use a measure of hospital or surgeon experience as a predictor variable and had to report postoperative outcomes as dependent response variables. Included studies were reviewed with regard to methodologic quality, and study results were extracted. FINDINGS: Sixty-three studies were reviewed. Significant heterogeneity was detected in exposure definitions, outcome measures, and risk adjustment, with the greatest heterogeneity seen in appendectomy studies. Various exposure levels were examined: hospital level in 48 (68%) studies, surgeon level in 11 (17%), and both in 9 (14%). Nineteen percent of studies did not adjust for confounding, and 57% did not adjust for sample clustering. The most consistent methods and reproducible results were seen in the pediatric cardiac surgical literature. Forty-nine studies (78%) showed positive correlation between experience and most primary outcomes, but differences in outcomes and exposure definitions made comparisons between studies difficult. In general, hospital-level factors tended to correlate with outcomes for high-complexity procedures, whereas surgeon-level factors tended to correlate with outcomes for more common procedures. CONCLUSIONS AND RELEVANCE: Data on experience-related outcomes in children's surgery are limited in number and vary widely in methodologic quality. Future studies should seek both to standardize definitions, making results more applicable, and to differentiate procedures affected by surgeon experience from those more affected by hospital resources and system-level variables.

Iatrogenic arteriovenous fistula in the arm in an infant: diagnostic and therapeutic considerations.

Iatrogenic arteriovenous fistulas (AVF) are well described in adults; however, this complication is rarely described and reported in infants. We report the case of a 3-month-old infant with complicated gastroschisis requiring multiple venipunctures who presented with signs and symptoms suggestive of traumatic arteriovenous fistula. Ultrasound imaging confirmed the presence of a wide-necked AVF between the brachial artery and vein. The fistula was surgically repaired. This case report describes the clinical imaging and treatment options for infants with iatrogenic AVF.

Implementation of a standardized procedural checklist in a children's hospital.

BACKGROUND: The aim of this study was to examine the implementation and sustainability of checklist use among procedural-based specialties in a pediatric hospital and to survey perceptions of checklist efficacy among staff members and physicians. METHODS: A modified World Health Organization procedural checklist was implemented. Percentage daily compliance was collected for all procedures over a 12-month period. Clinical staff members participated in a survey regarding the checklist. Associations among gender, clinical role, and years of experience were evaluated. RESULTS: Compliance at 12 months was significantly higher than at inception (94% vs 88%, P < .001) with average monthly compliance of 92%. Compliance deteriorated on weekends and holidays. Surgeons had more positive perceptions of using the checklist compared with nurses and anesthesiologists, independent of experience and gender (P = .001). CONCLUSIONS: The implementation of a procedural checklist can be sustained across specialties with high compliance. Off-hours utilization remains problematic. Perceptions of checklist efficacy are disparate among roles in the operating room.

Laparoscopic management of neonatal paraesophageal hernia with intrathoracic gastric volvulus.

Intrathoracic gastric volvulus associated with neonatal paraesophageal hernia is very rare in the newborn period. We report a case of a 3-week-old term infant who presented to the hospital with a history of non-bilious vomiting. Workup for hypertrophic pyloric stenosis eventually revealed the presence of a congenital hiatal hernia and intrathoracic gastric volvulus requiring urgent surgical management. The infant underwent successful laparoscopic repair. We discuss the diagnosis and management of this extremely rare surgical cause of neonatal nonbilious emesis.

Mesothelial cyst presenting as an irreducible inguinal mass.

Inguinal hernias are common in the pediatric population. We describe a 10-year-old child who presented with signs and symptoms suggestive of an incarcerated inguinal hernia. Ultrasound examination demonstrated an aperistaltic multicystic inguinal mass of uncertain origin. The mass was resected, and the adjacent hernia was repaired. Histologic examination identified the mass as a mesothelial cyst. Mesothelial cysts are rare groin lesions in children that can masquerade as an incarcerated inguinal hernia in a child.

Optimizing your operating room: or, why large, traditional hospitals don't work.

INTRODUCTION: Caring for patients in traditionally designed, large teaching hospitals is often frustrating. Attempts at decreasing internal costs and inpatient length of stay are universally undertaken in order to address dwindling reimbursement, and patient care becomes more specialized and fractionated. These attempts have proven to be myopic, at best, and injurious to patient care and professional job satisfaction, at worst. This manuscript attempts to characterize the operational processes of our university operating room facility as well as make suggestions for operational improvements that can be applied to all hospitals. METHODS: Through a step-by-step approach, we analyze the patient's journey from the surgeon's office through the day of surgery to discharge. Using this approach, a series of studies designed to identify operational shortcomings and inefficiencies are undertaken, and the results of these shortcomings are elucidated. RESULTS: In our operating room, the peri-operative services are composed of multiple departments, each accountable to their own administrative silo. We found this to result in fragmented goals and objectives confounded by individualized and conflicting incentives. Consequently, we conclude with a recommendation that veers from process modification to a disruptive innovation of the hierarchical organization. CONCLUSION: Nowhere in the hospital is this drive for cost containment and increased patient volume more evident than in the operating theatre. Long-term improvements must embrace radical reduction of OR costs and increased operative patient through-put, (i.e. per 8 h day; per fiscal year) by re-engineering the processes of operative patient care. In the end, the ultimate goal of safe and high-quality patient care must not be compromised.

Simultaneous gastric and small intestinal trichobezoars.

Bezoars are conglomerates of food or fiber in the alimentary tract of humans and certain animals, mainly ruminants. A trichobezoar represents a mass of accumulated hair. Trichobezoars may present as an isolated gastric mass, as an extension into the small intestine, or as an independent fragmented mass in the small intestine. The presence of discrete coexisting gastric and ileal trichobezoars has been reported only rarely in the literature. This is a case report of a 9-year-old girl presenting with small-bowel obstruction secondary to synchronous trichobezoars in the stomach and ileum. The case highlights the role of imaging and importance of complete evaluation of the gastrointestinal tract at the time of surgical evacuation.

Isolated torsion of the fallopian tube in a menarchal 11-year-old girl.

Isolated torsion of the fallopian tube is a rare cause of an acute lower abdominopelvic pain in adolescent females that is difficult to recognize preoperatively. This is a case report of an 11-year-old girl who presented with a right lower quadrant abdominal pain, nausea, and vomiting secondary to isolated torsion of the right fallopian tube 2 days after the onset of her first menses. In this report, the patient's clinical course is discussed with special emphasis on diagnostic imaging and management strategy of adnexal torsion in pubertal and adolescent girls.

Temporary occlusion of the gastroesophageal junction: a modified technique for stabilization of the neonate with esophageal atresia and tracheoesophageal fistula requiring mechanical ventilation.

Management of newborn infants with esophageal atresia and tracheoesophageal fistula that require mechanical ventilation is challenging. Without rapid control of the fistula, these patients develop profound respiratory failure and massive distention of the gastrointestinal tract. We present the case of a newborn who upon intubation exhibited respiratory failure and cardiovascular collapse, and in whom traditional intra-operative techniques to gain control of the tracheoesophageal fistula were unsuccessful. We describe a technique that temporarily occludes the gastroesophageal junction, and allows for stabilization of the neonate and definitive repair of the tracheoesophageal fistula.