In-hospital Pediatric Endoscopic Retrograde Cholangiopancreatography Is Associated With Shorter Hospitalization for Children With Choledocholithiasis.

OBJECTIVES: Children with choledocholithiasis are frequently managed at tertiary children's hospitals that do not have available endoscopic retrograde cholangiopancreatography (ERCP) proceduralists. We hypothesized that patients treated at hospitals without ERCP proceduralists would have a longer hospital length of stay (LOS) than those with ERCP proceduralists. METHODS: Charts were reviewed for patients who underwent cholecystectomy and ERCP at 3 tertiary children's hospitals over 10 years. Trauma and complicated pancreatitis patients were excluded. Comparisons between patients requiring and not requiring transfer for ERCP were made using Wilcoxon rank-sum tests for continuous variables and Fisher's exact tests for categorical variables. RESULTS: One hundred and sixty-four children underwent ERCP for suspected choledocholithiasis: 79 (48%) in the transfer group and 85 (52%) in the no transfer group.Median LOS was longer for patients requiring transfer (7 vs 5 days, P < 0.0001). One-third (34%) of the transfer patients had magnetic resonance cholangiopancreatography compared to only 7% that did not require transfer (P < 0.0001). Among the 123 patients who underwent ERCP before cholecystectomy, 53% required (66/123) transfer and 47% (57/123) did not. Transfer group patients had longer median hospital LOS (P < 0.0001), more days between admission and ERCP (P < 0.0001), and more days between ERCP and surgery (P = 0.0004). CONCLUSIONS: Overall median LOS was significantly shorter for patients who underwent ERCP at the admitting facility. Patients who underwent ERCP before cholecystectomy at hospitals without available ERCP proceduralists incurred longer LOS. There is a need for more pediatric proceduralists appropriately trained to perform ERCP in children.

Disparity in Medicaid physician payments for vascular surgery.

OBJECTIVE: Medicare reimbursements are standardized nationwide on the basis of resource-dependent inputs of physicians' time, intensity, practice costs, and malpractice costs, whereas Medicaid payments vary and are determined by individual states. Our objectives were to determine Medicaid reimbursement to physicians for common vascular procedures for the seven states in the Northeast that compose the New England Society for Vascular Surgery and to compare Medicaid payments with Medicare. METHODS: Using publicly available data, we obtained Medicaid physician payments in Connecticut, Massachusetts, Maine, New Hampshire, New York, Rhode Island, and Vermont for 10 commonly performed vascular surgery procedures. For comparison, Medicare physician payments for these procedures were adjusted for regional differences using Medicare geographic payment cost indices. Descriptive statistics were calculated by state; Wilcoxon signed rank test was used to compare fees, and one-way analysis of variance was used to compare variance. RESULTS: Medicaid payments varied widely by state. Within individual states (except Vermont), there was no relationship between Medicaid and Medicare payments. Medicaid reimbursement for common vascular procedures ranged from 25% to 91% of Medicare rates and had up to a threefold variation in payment among states for a single procedure. The mean Medicaid payment was 60% of Medicare payment. The greatest state-to-state variance in payment was for open abdominal aortic repair (standard deviation, $227.31); the least was for femoral artery exposure (standard deviation, $31.86). For a Medicaid-based, frequency-weighted analysis of services, New Hampshire exhibited the lowest payments (43% Medicare) and Vermont the highest (80% Medicare). CONCLUSIONS: Among the seven Northeast states considered, with the exception of Vermont, there is no logical relationship between Medicaid and Medicare payments. Because Medicare payments are determined by the Centers for Medicare and Medicaid Services with consideration of resource-based inputs, we conclude that in six of the seven states, Medicaid payments bear no relationship to resource utilization. With Medicaid expansion, access to vascular procedures may be limited by payments insufficient to meet resource needs.

Nd:YAG laser therapy for rectal and vaginal venous malformations.

BACKGROUND: Limited therapeutic options exist for rectal and vaginal venous malformations (VM). We describe our center's experience using Nd:YAG laser for targeted ablation of abnormal veins to treat mucosally involved pelvic VM. METHODS: Records of patients undergoing non-contact Nd:YAG laser therapy of pelvic VM at a tertiary children's hospital were reviewed. Symptoms, operative findings and details, complications, and outcomes were evaluated. RESULTS: Nine patients (age 0-24) underwent Nd:YAG laser therapy of rectal and/or vaginal VM. Rectal bleeding was present in all patients and vaginal bleeding in all females (n = 5). 5/7 patients had extensive pelvic involvement on MRI. Typical settings were 30 (rectum) and 20-25 W (vagina), with 0.5-1.0 s pulse duration. Patients underwent the same-day discharge. Treatment intervals ranged from 14 to 180 (average = 56) weeks, with 6.1-year mean follow-up. Five patients experienced symptom relief with a single treatment. Serial treatments managed recurrent bleeding successfully in all patients, with complete resolution of vaginal lesions in 40% of cases. No complications occurred. CONCLUSIONS: Nd:YAG laser treatment of rectal and vaginal VM results in substantial improvement and symptom control, with low complication risk. Given the high morbidity of surgical resection, Nd:YAG laser treatment of pelvic VM should be considered as first line therapy.

Optimal timing of appendectomy in the pediatric population.

BACKGROUND: No consensus has been reached on optimal timing for performing appendectomies. We compared immediate and delayed appendectomies in pediatric patients presenting with suspected acute appendicitis to determine differences in postsurgical complications and perforation rates. METHODS: A retrospective cohort study was performed of all children who underwent appendectomy during a 4-y period. Cutoffs used were 6, 8, and 12 h from admission to operating room (OR). The Student t-tests and chi-square tests were performed to compare continuous and categorical variables, respectively. A logistic regression model was fitted to determine predictors of appendiceal perforation. P values <0.05 were considered significant. RESULTS: Analysis included 484 patients with mean elapsed time from admission to OR of 394 min, with 262 subjects in the immediate and 222 subjects in the delayed >6 h groups. Surgical site infections (SSIs), perforations, and small bowel obstructions were similar between groups, and no statistically significant differences were found for SSIs in the nonperforated delayed versus immediate groups (P = 0.964). Time from admission to the OR did not predict perforation (P = 0.921), although white blood cell count at the time of admission was a significant predictor of perforation (odds ratio, 1.08; P < 0.001). CONCLUSIONS: For suspected acute appendicitis, delaying appendectomy after admission for >6 h demonstrated no differences in SSI or perforation rates compared with immediate appendectomy. Waiting to perform an appendectomy until the following day has equal outcomes to immediate surgical procedure and may improve overall quality of patient care by limiting surgeon fatigue.

An evaluation of trauma outcomes related to insurance status in patients requiring prehospital helicopter transport.

INTRODUCTION: Disparities in access to medical care and outcomes of medical treatment related to insurance status are documented. However, little attention has been given to the effect of health care funding status on outcomes in trauma patients. Hypothesis/Problem This study evaluated if adult trauma patients who arrived by air transport to a trauma center had different clinical outcomes based on their health insurance status. METHODS: A retrospective analysis was performed of all adult trauma patients arriving by prehospital flight services to a Level I Trauma Center over a 5-year period. Patients were classified as unfunded or funded based on health insurance status. Injury severity scores (ISS) were compared, while the end points evaluated in the study included duration of stay in the intensive care unit (ICU), duration of hospitalization, and mortality. RESULTS: A total of 1,877 adult patients met inclusion criteria for the study, with 14% (n = 259) classified as unfunded and 86% (n = 1,618) classified as funded. Unfunded patients compared to funded patients had a significantly lower average ISS (12.82 vs 15.56; P < .001) but a significantly higher mortality rate (16.6% vs 10.7%; P < .01) and a 1.54 relative risk of death (95% CI, 1.136-2.098). Neither mean ICU stay (3.44 days vs 4.98 days; P = .264) nor duration of hospitalization (11.18 days vs 13.34 days; P = .382) was significantly different when controlling for ISS. CONCLUSION: Unfunded health insurance status is associated with worse outcomes following less significant injury. Further investigation of baseline health disparities for identification and early intervention may improve outcomes. Additionally, these findings may have implications for the health systems of other countries that lack universal health care coverage.

Reverse shock index multiplied by the motor component of the Glasgow Coma Scale predicts mortality and need for intervention in pediatric trauma patients.

BACKGROUND: Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (rSIM) would perform equivalently to reverse shock index times the total Glasgow Coma Scale (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma. METHODS: The 2017-2020 National Trauma Data Bank datasets were used. We included all patients <16 years of age that had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic (ROC) curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the ROC curve (AUC) was used for comparison. Our primary outcome was mortality prior to hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) < 4 hours following hospital arrival and ICU admission. RESULTS: After application of exclusion criteria, 77,996 patients were included in our analysis. rSIM and rSIG performed equivalently as predictors of mortality in the 1-2 (p = 0.05) and 3-5 (p = 0.28) year categories, but rSIM was statistically outperformed by rSIG in the 6-12 (AUC: 0.96 vs. 0.95, p = 0.04) and 13-16 (AUC: 0.96 vs. 0.95, p < 0.01) year-old age categories. rSIM and rSIG also performed similarly with respect to prediction of secondary outcomes. CONCLUSION: rSIG and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage. LEVEL OF EVIDENCE: III, Diagnostic Tests or Criteria.

Rethinking pediatric trauma triage.

Despite advances in the delivery of trauma care, trauma remains the leading cause of death amongst the pediatric population within the United States and is one of the leading causes of death in children worldwide.  Accurately triaging pediatric trauma patients is essential to minimize preventable mortality without burdening the system by utilizing unnecessary resources.  This article will review the accuracy of current pediatric trauma triage practices and how it will evolve in the future including moving away from mechanism of injury towards physiologic scoring tools such as the pediatric age-adjust shock index, and intervention-based systems including. Need for Surgeon Presence and Need For Trauma Intervention. This paper will also present evidence regarding over-utilization of air transport for pediatric trauma patients and the associated unnecessary costs placed on the trauma system.

An evidence-based algorithm decreases computed tomography use in hemodynamically stable pediatric blunt abdominal trauma patients.

BACKGROUND: There are concerns about overuse of abdominopelvic-computed tomography (CTAP) in pediatric blunt abdominal trauma (BAT) given malignancy risks. This study evaluates how an evidence-based algorithm affected CTAP and hospital resource use for hemodynamically stable children with BAT. MATERIALS AND METHODS: This is a retrospective cohort study of hemodynamically stable pediatric BAT patients one year before and after algorithm implementation. We included children less than or equal to 14 years of age treated in a Level I pediatric trauma center. We compared CTAP rates before and after algorithm implementation. RESULTS: There were 65 in the pre- and 50 in the post-algorithm implementation group, and CTAPs decreased by 27% (p = 0.02). The unadjusted and adjusted odds ratio of receiving a CTAP after algorithm implementation were 0.3 (95% CI 0.1-0.6) and 0.2 (95% CI 0.1-0.7), respectively. There were no significant missed injuries in the post cohort. ED length of stay (LOS) decreased by 53 min (p = 0.03). CONCLUSIONS: An evidence-based algorithm safely decreased CTAPs for pediatric BAT with no increase in hospital resource utilization.

Clavien-Dindo Analysis of NSQIP Data Objectively Measures Patient-Focused Quality.

Current quality measures intended to drive improved clinical performance are perceived as an inappropriate administrative burden. Surgeon-constructed quality measures, including the NSQIP, are more closely aligned with provider performance and relevant outcome. We hypothesized that NSQIP participation would be associated with measurable improvement in surgical outcomes. Elective general surgical cases were compared by case volume and incidence of postoperative adverse events (AEs) from 2014 to 2017. Using the Clavien-Dindo severity scaling system, we summed the grades for each AE and defined the patient population burden of these AEs as this sum divided by case volume. Case volume samples increased 67 per cent from 2014 (n = 526, 30 day complete) to 2017 (n = 878). Ratio of patient burden to case volume improved from 0.92 (2014) to 0.73 (2017). Comparison of AE incidence was not significantly different; however, the majority decreased over time. Analysis of individual AE interval change identified sepsis-related respiratory care as the top priority performance improvement target. These data reflect improved performance for a growing volume of surgical procedures. The impact of perioperative morbidity and their associated burden on affected patients has decreased, demonstrating the value of combining NSQIP with Clavien-Dindo to measure the quality of surgical care in objective and patient-specific terms.

Twenty years of pediatric gunshot wounds in our community: Have we made a difference?

BACKGROUND/PURPOSE: Pediatric gunshot wounds (GSWs) carry significant incidence, mortality, and cost. We evaluated 20 years of GSW demographics at this level 1 trauma center and constructed a risk map triangulating areas of high incidence with risk factors. METHODS: Children 0-18 years suffering a GSW between 1996 and 2016 were identified via our trauma registry. Hospital charges, demographic, socioeconomic, and institutional variables were retrospectively reviewed. Multivariable logistic regression identified predictors of mortality. Geographic information system (GIS) mapping of incident location and residence identified areas of higher incidence. RESULTS: The cohort (n = 898) was 86.4% male. Mean age was 15.6 ±â€¯3.4 years. Median Injury Severity Score (ISS) was 9 (1-75). Procedural and/or operative intervention occurred in 52.9%. Intent included assault (81.5%) and unintentional injury (12.8%). Hospital charges showed significant annual increase. Annual incidence varied without trend (p = 0.89). Mapping revealed significant clustering of GSWs in known lower socioeconomic areas. Yearly and total GSWs were highest in one particular zip code. ISS was a significant predictor of mortality (n = 18) (OR 1.19, 95% CI 1.15-1.22, p < 0.001). CONCLUSIONS: Our impoverished neighborhoods have higher pediatric GSW incidence, unchanged over 20 years. Alternative community-based prevention efforts should involve neighborhood capacity building and economic strengthening. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: Level IV.

Suspected appendicitis pathway continues to lower CT rates in children two years after implementation.

BACKGROUND: We implemented a protocol to evaluate pediatric patients with suspected appendicitis using ultrasound as the initial imaging modality. CT utilization rates and diagnostic accuracy were evaluated two years after pathway implementation. METHODS: This was a retrospective observational study of patients <18 years evaluated for suspected appendicitis. CT rates were compared before and after implementation of the protocol, and monthly CT rates were calculated to assess trends in CT utilization. RESULTS: CT use decreased significantly following pathway implementation from 94.2% (130/138) to 27.5% (78/284; p < 0.001). Linear regression of monthly CT utilization demonstrated that CT rates continued to trend down two years after pathway implementation. Adherence to the pathway was 89.8% (255/284). Negative appendectomy rate was 2.4% (2/85) in the post-pathway period. CONCLUSIONS: Adherence to a pathway designed to evaluate pediatric patients with suspected appendicitis using ultrasound as the primary imaging modality has led to a sustained decrease in CT use without compromising diagnostic accuracy.

Risk factors for prolonged need for percutaneous endoscopic gastrostomy (PEG) tubes in adult trauma patients: Experience of a level 1 trauma.

BACKGROUND: Percutaneous endoscopic gastrostomy tubes are a means of providing an alternative enteric route of nutrition. This study sought to identify risk factors for the prolonged need of a percutaneous endoscopic gastronomy tube (≥90 days) in adult trauma patients. METHODS: The trauma database of a level 1 trauma center was queried retrospectively to identify patients who had percutaneous endoscopic gastronomy tubes placed. RESULTS: A total of 9,772 charts were reviewed with 282 patients (2.9%) undergoing successful percutaneous endoscopic gastronomy tube placement. On review of discharged living patients, 195 had adequate clinical documentation to allow for analysis. The mean age was 57.5 years, admission serum albumin was 3.7 g/dL, and Charlson Comorbidity Index score was 1.1. The first recorded mean Glasgow Coma Scale was 10.7, and their Injury Severity Score was 23.2. The mean duration of total hospital stay was 23.8 days, intensive care unit stay was 16.5 days, and in-hospital ventilator days was 11.5. Of the 272 patients, 77 (41.4%) required percutaneous endoscopic gastronomy tubes for >90 days. Statistically significant characteristics on univariate analysis included increasing age, a greater Charlson Comorbidity Index score, and a greater number of in-hospital ventilator days. On logistic regression, a Charlson Comorbidity Index score >1 (odds ratio 1.27, 95% confidence interval 1.03-1.56, P = .02) and greater in-hospital ventilator days (odds ratio 1.05, 95% confidence interval 1.02-1.09, P < .01) were predictive of the need for prolonged percutaneous endoscopic gastronomy tube placement. CONCLUSION: A Charlson Comorbidity Index score >1 and prolonged in-hospital ventilator days were risk factors for the necessity of a percutaneous endoscopic gastronomy tube for ≥90 days after placement. This observation may assist patients/surrogates in decision-making when needing alternative routes for nutrition.

Pediatric vascular trauma practice patterns and resource availability: A survey of American College of Surgeon-designated pediatric trauma centers.

BACKGROUND: Variation exists in pediatric vascular trauma management. We aim to determine practice patterns for vascular trauma management at American College of Surgeons verified pediatric trauma centers and evaluate the resources available for management of vascular trauma at both freestanding children's hospitals (FSCH) and pediatric hospitals within general adult hospitals. METHODS: Pediatric surgeons and trauma medical directors at American College of Surgeons designated pediatric surgery trauma centers completed a survey designed to evaluate anticipated management of traumatic arterial injuries and resource availability. Hospital setting comparisons were made using Fisher exact tests and t tests. Binomial tests were used to compare pediatric and vascular surgeons' responses to clinical vignettes. p Values of 0.05 or less were significant. RESULTS: One hundred seventy-six (42%) of 414 pediatric surgeons participated. Vascular surgeons are more likely to operatively manage vascular trauma at all anatomic sites except subclavian artery when compared to pediatric surgeons, regardless of hospital setting (p <0.001). Forty-eight percent of the pediatric trauma medical directors completed their portion of the survey. At FSCHs, 36% did not have a fellowship-trained vascular surgeon on-call schedule, 27% did not have endovascular capabilities, and 18% did not have a radiology technologist always available. CONCLUSION: Vascular surgeons are more likely to manage pediatric vascular trauma regardless of hospital setting. However, FSCH have fewer resources available to provide optimal care. LEVEL OF EVIDENCE: Care management, level IV.

Review of bedside surgeon-performed ultrasound in pediatric patients.

PURPOSE: Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS. METHODS: PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation. RESULTS: There are no standards for the practice of PSPBUS. CONCLUSIONS: As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management. TYPE OF STUDY: Review Article. LEVEL OF EVIDENCE: Level III.

Meta-analysis of surgeon-performed central line placement: Real-time ultrasound versus landmark technique.

BACKGROUND: Major health care agencies recommend real-time ultrasound (RTUS) guidance during insertion of percutaneous central venous catheters (CVC) based on studies in which CVCs were placed by nonsurgeons. We conducted a meta-analysis to compare outcomes for surgeon-performed RTUS-guided CVC insertion versus traditional landmark technique. METHODS: A systematic review of the literature was performed, identifying randomized controlled trials (RCT) and prospective "safety studies" of surgeon-performed CVC insertions comparing landmark to RTUS techniques. Searches were conducted in MEDLINE, Cochrane, and Web of Science, with additional relevant articles identified through examination of the bibliographies and citations of the included studies. Two independent reviewers selected relevant studies that matched inclusion criteria, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A meta-analysis was conducted using random effects models to compare success and complication rates. RESULTS: Three RCTs were identified totaling 456 patients. The RTUS guidance was associated with better first attempt success (odds ratio [OR], 4.7; 95% confidence interval [CI], 1.5-14.7, p = 0.008) and overall success (OR 6.5, 95% CI: 2.7-15.7, p < 0.0001). However, there were no differences in overall complication (OR 1.9 (95% CI, 0.8-4.4, p = 0.14)) or arterial puncture (OR 2.0 (95% CI, 0.7-5.6, p = 0.18) rates between the two methods. CONCLUSION: Despite many studies involving nonsurgeons, there are only three RCTs comparing RTUS versus landmark technique for surgeon-performed CVC placement. The RTUS guidance is associated with better success than landmark technique, but no difference in complication rates. No study evaluated how RTUS was implemented. Larger studies examining RTUS use during surgeon-performed CVC placements are needed. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

Reassessing the utility of CT angiograms in penetrating injuries to the extremities.

BACKGROUND: Computed tomography angiography has become routine in the management of penetrating trauma to the extremity. Our objective was to evaluate the efficacy of physical examination findings compared with computed tomography angiography for detection of clinically significant vascular injuries associated with penetrating trauma to the extremity. METHODS: This was a retrospective chart review of patients presenting to a single level 1 trauma center from January 2013-June 2016. Patients with penetrating trauma to the extremity and no hard signs of vascular injury were included. Physical examination and computed tomography angiography findings were analyzed, with particular focus given to missed injuries. RESULTS: We identified 393 patients with penetrating trauma to the extremity without hard signs of vascular injury. Computed tomography angiography was performed in 114 patients (29%). Four patients with distal pulses documented on their initial trauma surveys were found to have vascular injuries on computed tomography angiography, although 3 of these injuries were identified on repeat physical examination. One additional patient had a delayed presentation of a pseudoaneurysm. No mortality or limb loss resulted from these injuries. Total hospital charges for computed tomography angiography amounted to over $700,000. CONCLUSION: Patients with penetrating trauma to the extremity and no hard signs of vascular injury do not require computed tomography angiography for identification of clinically relevant vascular injuries that require emergent operative repair. Serial physical examination appears to provide accurate detection of vascular injury requiring procedural intervention.

How Safe Is the Safety Net? Comparison of Ivor-Lewis Esophagectomy at a Safety-Net Hospital Using the NSQIP Database.

BACKGROUND: Recent data suggest that surgical outcomes at hospitals caring for low-income, vulnerable populations are suboptimal compared with outcomes from nonsafety-net hospitals. Therefore, the purpose of our study was to compare outcomes for patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital with the National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN: We retrospectively reviewed the medical records of consecutive patients who underwent an Ivor-Lewis esophagectomy, between September 2013 and January 2017, at a single safety-net hospital. Patient characteristics and outcomes were compared with the 2013 to 2015 NSQIP database. Continuous variables were compared using Student's t-test, and categorical variables were analyzed using chi-square tests. Values of p < 0.05 were considered significant. RESULTS: We identified 78 patients from the safety-net hospital and 1,825 patients in the NSQIP database who underwent an Ivor-Lewis esophagectomy. Baseline characteristics were similar, except the safety-net hospital patients were more likely to have COPD (19.2% vs 8.1%; p = 0.001) and be current smokers (42.3% vs 26.0%; p = 0.001); patients in the NSQIP group had a higher BMI (28 kg/m2 vs 26 kg/m2; p = 0.001). There were no differences between groups for mortality, readmission, discharge destination, or mean operative time. Safety-net hospital patients had significantly fewer complications (16.7% vs 33.3%; p = 0.003), fewer reoperations (6.4% vs 14.5%; p = 0.046), and shorter hospital length of stay (10.3 vs 13.1 days; p = 0.001). CONCLUSIONS: Patients who underwent an Ivor-Lewis esophagectomy at a safety-net hospital had fewer complications and reoperations, and a shorter hospital length of stay compared with a national cohort. These findings illustrate the value of clinical pathways in optimizing the patient outcomes at safety-net hospitals and providing excellent care to their vulnerable patient population.

Resource utilization and indications for helicopter transport of head-injured children.

INTRODUCTION: Helicopter emergency medical services (HEMS) have provided benefit for severely injured patients. However, HEMS are likely overused for the transportation of both adult and pediatric trauma patients. In this study, we aim to evaluate the degree of overuse of helicopter as a mode of transport for head-injured children. In addition, we propose criteria that can be used to determine if a particular patient is suitable for air versus ground transport. MATERIALS AND METHODS: We identified patients who were transported to our facility for head injuries. We included only those patients who were transported from another facility and who were seen by the neurosurgical service. We recorded a number of data points including age, gender, race, Glasgow Coma Score (GCS), and intubation status. We also collected data on a number of imaging findings such as mass effect, edema, intracranial hemorrhage, and skull fractures. Patients undergoing emergent nonneurosurgical intervention were excluded. RESULTS: Of the 373 patients meeting inclusion criteria, 116 (31.1%) underwent a neurosurgical procedure or died and were deemed appropriate for helicopter transport. The remaining 68.9% of patients survived their injuries without neurosurgical intervention and were deemed nonappropriate for helicopter transport. Multivariable logistic regression identified GCS 3-8 and/or presence of mass effect, edema, epidural hematoma (EDH), and open-depressed skull fracture as appropriate indications for helicopter transport. CONCLUSIONS: The majority of patients transported to our facility by helicopter survived their head injury without need for neurosurgical intervention. Only those patients meeting clinical (GCS 3-8) or radiographic (mass effect, edema, EDH, open-depressed skull fracture) criteria should be transported by air. LEVEL OF EVIDENCE: Level III (Diagnostic Study).

Resource savings and outcomes associated with outpatient laparoscopic appendectomy for nonperforated appendicitis.

BACKGROUND: Postoperative admission for acute appendicitis utilizes health care system resources. We evaluated outcomes and hospital charges for children with nonperforated appendicitis who underwent outpatient laparoscopic appendectomy. METHODS: A retrospective chart review was performed for patients ≤18years old who underwent laparoscopic appendectomy for acute appendicitis in 2015. Patients were categorized into discharge from postanesthesia care unit (PACU) (outpatient), admission for <24-h, and admission for >24-h. Continuous variables were compared using analysis of variance and categorical variables were compared using chi-square test, with p<0.05 considered significant. RESULTS: Of the 171 patients identified, 63 (37%) were discharged from the PACU, 94 (55%) were admitted <24-h, and 14 (8%) were admitted >24-h. There were no differences in postoperative emergency department/clinic visits, complications, or readmissions. Hospital charges for admission <24-h and >24-h were $1007 and $2237 more per patient than the PACU-discharge group, respectively. Outpatient laparoscopic appendectomies became more common over time, occurring in only 20% of patients with acute appendicitis in the first quarter of the year versus 49% of patients in the last quarter. CONCLUSION: Outpatient laparoscopic appendectomy for nonperforated appendicitis in children is a safe practice that decreases length of stay and hospital charges. Adoption of an outpatient strategy allows for better standardization of care and can lead to savings in health care resources. LEVEL OF EVIDENCE: III (Treatment: retrospective comparative study).

Pediatric vascular injuries: Are we preparing trainees appropriately to meet our needs?

BACKGROUND: There is no required competency for pediatric vascular injury in surgical training. We sought to describe changes over time for surgical specialists operating on pediatric vascular trauma injuries at a pediatric trauma center. METHODS: Charts were retrospectively reviewed for vascular trauma injuries at a freestanding children's hospital between 1993 and 2015. Data were collected on mechanism, injured vessel(s), operation(s) performed, and specialists performing operation. Surgical specialists were compared over time. RESULTS: Ninety-four patients (median age = 12) underwent 101 pediatric vascular trauma operations. There were significant differences in frequency of types of operations (primary repairs, graft repairs, and ligations) performed by pediatric, vascular, and orthopedic surgeons (P < .001). The proportion of operations performed by vascular surgeons increased and those performed by pediatric surgeons decreased significantly over time. CONCLUSIONS: Various surgical specialists manage pediatric vascular trauma. With expansion of integrated residency programs, surgical specialists managing these patients in the future should be trained in both pediatric and vascular surgery.